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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5793_Библиотеки_им_академика_М_И_Перельмана.pdf
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Y. K. Aleksandrov and Y. N. Patrunov
a
b
Fig. 8.12 (a) Infected median neck cyst. Grayscale US.Transverse scan. (b) Infected median
neck cyst with dense contents after conservative treatment
The capsule of the cyst is usually easily identied as the echogenic linear avascular margin of the thickness up to 1–2 mm (depending on whether the cyst is
infected). Inammation leads to cyst dilation with much suspension, clots, and
changes in the capsule. The capsule of the cyst becomes thicker or thinner (and
sometimes cannot be differentiated). Edema and inltration of the surrounding tissues may accompany the inammation in some cases. This is sonographically
observed as a decrease or increase in echodensity, protruding heterogeneity, and a
blurring of the differentiation of the structure. Lymph node enlargement associated
with inammation may occur.
8 Ultrasound oftheParathyroid Glands andNeck Masses
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Neuroectodermal tumors of the neck are represented by paragangliomas (chemodectomas, glomus tumors). These form part of the extra-adrenal neuroendocrine
system. There are two main location-specic types of neck paraganglioma: carotid
and vagal paragangliomas. Carotid paragangliomas—also called carotid body glomus tumors—are the most common of the head and neck paragangliomas. They
occur at the bifurcation of the CCA and arise from the tissue of the normal carotid
body. Vagal paragangliomas are the least common of the head and neck paragangliomas. Paragangliomas are more often observed in women 40–45years old. They
usually appear as solitary lesions, although multiple lesions at multiple sites may be
a
b
Fig. 8.13 (a) Lateral neck cyst. (a) Grayscale US.Transverse scan. (b) Grayscale US.Longitudinal
scan. (c) CDI. (d) PDI
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Y. K. Aleksandrov and Y. N. Patrunov
c
d
Fig. 8.13 (continued)
seen in 3–5% of cases. The vast majority of glomus tumors are benign and slow to
grow. In rare cases they may become active and secrete catecholamines, which can
lead to clinical manifestations similar to pheochromocytoma. Carotid paragangliomas are found at the site of CCA bifurcation and are tightly connected to the vessels. The tumor is sonographically represented by a large lesion (up to 10cm) of
oval or roundish shape, iso- or hypoechoic homogeneous structure, with accurate
regular contours (Fig.8.14). It shows very limited mobility and appears dense upon
compression by the US probe. Because it is part of the neuroendocrine system, this
tumor is highly vascularized. A large amount of arterial and venous vessels is rather
characteristic. Doppler examination is also necessary in such patients to assess both
8 Ultrasound oftheParathyroid Glands andNeck Masses
a
b
177
Fig. 8.14 Right carotid paraganglioma. (a) Grayscale US, transverse scan. (b) PDI, longitudinal
scan
the anatomical course and hemodynamic changes in the carotid artery. In cases of
malignant tumor, metastases in regional lymph nodes are possible.
US permits the differentiation of malignant pathology of the larynx. Laryngeal
cancer is the most common malignancy of the larynx (50–60%), and one that
mainly affects men 40–70years old. Larynx sarcomas are most often represented by rhabdomyosarcomas, liposarcomas, brosarcomas, and angiosarcomas. Carcinosarcomas are rare. Malignant tumors of the larynx show different
clinical signs that complicate the differential diagnosis. They exhibit sonographic features similar to cancers of other neck organs (e.g., the thyroid or
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Y. K. Aleksandrov and Y. N. Patrunov
a
b
Fig. 8.15 Laryngeal cancer. (a) Grayscale US. (b) PDI
salivary glands), and are characterized by lesions in the projections of median
structures of the neck with the following features (Fig.8.15):
• Decreased echodensity
• Irregular shape
• Indistinct contours
• Heterogeneous structure often with echogenic inclusions
• Immobility, incompressibility, painlessness with compression
• Heterogeneous disorganized vascularity with CDI and PDI in large-sized
tumors
• Frequent enlargement of regional lymph nodes.
8 Ultrasound oftheParathyroid Glands andNeck Masses
179
CT of the larynx is always needed in order to assess the lesion more precisely.
Hodgkin’s lymphoma is a type of malignancy originating from lymphocytes. It
affects cervical lymph nodes in 60–70% of cases. It commonly arises in combination with abnormal axillary, mediastinal, inguinal, retroperitoneal, or other groups
of lymph nodes. The disease is more often observed in males and exhibits two peaks
in incidence: at 20–30years and over 60years of age. During the initial stage of the
disease, the lymph nodes show the following US picture (Fig.8.16):
• Enlarged size of 1–3cm
• Roundish, oval, or irregular shape
• Regular or irregular accurate margins
• Decreased echodensity
• Frequent heterogeneity of echostructure
a
b
Fig. 8.16 Enlarged neck lymph node in Hodgkin’s disease. (a) Grayscale US and CDI. (b)
Grayscale US and PDI. (c) Compression US elastography, high strain ratio. (d) CEUS
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Y. K. Aleksandrov and Y. N. Patrunov
c
d
Fig. 8.16 (continued)
• Hypovascularization or hypervascularization with a hypertrophic hilar blood
ow pattern with CDI and PDI
• Low mobility, incompressibility, painlessness with compression
• Dense with compression US elastography and elastometry
• CEUS reveals fast regular grainy contrast enhancement of the medulla and
cortex.
Further development of the disease is characterized by conglomerations of lymph
nodes of various sizes and densities. The natural course of the disease is characterized by spontaneous remissions and ares. As the disease progresses, new groups of
8 Ultrasound oftheParathyroid Glands andNeck Masses
181
lymph nodes become affected and the disease generalizes. Abnormal lymphatic
nodes in Hodgkin’s disease are differentiated from metastases of thyroid cancer or
malignant tumors of other head and neck organs.
Abnormalities of submandibular salivary glands may be identied in the upper
neck area. Inammatory diseases (sialadenitis), salivary gland stones, and tumors
(e.g., adenoma, Fig.8.17) are most common conditions.
Cervical esophageal diverticulum is a rare diagnostic nding with US (Fig.8.18).
Esophageal diverticulum is a diversely shaped evagination of the esophageal wall
that is connected with the esophageal lumen. True and false types of diverticula can
be distinguished. The walls of the rst type contain all of the layers of the normal
a
b
Fig. 8.17 Pleomorphic adenoma of a salivary gland. (a, b) Grayscale US. (c) CDI. (d) PDI
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Y. K. Aleksandrov and Y. N. Patrunov
c
d
Fig. 8.17 (continued)
esophageal wall. The walls of the latter type consist of the mucosa that outpouches
through the defect in the muscular layer. Esophageal diverticulum may have a congenital or acquired origin. The latter develop due to the following mechanisms:
pulsion (appears with an increase in pressure within the esophagus resulting from a
disturbance to its motility or distal stenosis), traction (arises as a result of adhesion
between the esophageal wall and the surrounding structures due to an inammatory
process, etc.), and pulsion-traction (mixed). Diverticula may exist in any part of the
esophagus and be solitary or multiple. Esophageal diverticulum is sonographically
visualized as a roundish isoechoic or hypoechoic lesion of regular shape with accurate margins and a length of 0.5 to 2–3cm that is avascular in CDI and PDI.It
8 Ultrasound oftheParathyroid Glands andNeck Masses
a
b
183
Fig. 8.18 Grayscale US (a) Cervical esophageal diverticulum. (b) Esophageal achalasia
contains heterogeneous, mostly hyperechoic, inclusions in the central part that are
similar to those of a microcalcication or an arc-shaped calcication, and which
move and change shape upon swallowing. The lesion may change in size and content depending on the patient’s head or body position. The esophageal wall is most
often differentiated as a hypoechoic boundary structure up to 2mm thick that surrounds the lesion. The echodensity and echostructure of the wall may differ from
homogeneous and hypoechoic to heterogeneous and mostly hyperechoic depending
on the morphological structure and the type of diverticulum. Careful examination
can reveal its connection with the adjacent esophageal wall. Esophageal diverticula
can easily be misdiagnosed as thyroid nodules, since they often occur on the