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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5797_Библиотеки_им_академика_М_И_Перельмана.pdf
Removable trolley
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1 Overview ofSkin Ultrasound
11
• Color Doppler ow imaging and power
Doppler ultrasound can be used to detect small
blood vessels in skin.
1.3 Layout ofExamination Room
The facilities for the skin ultrasound examination
room are as follows.
1.3.1 Room Requirement
The room area is recommended to be greater than
18m2. A window is required to facilitate ventilation, and a door with a big size is required to
facilitate the access of sickbeds and wheelchairs.
1.3.2 Equipment
It is equipped with color Doppler ultrasound
device, transducers with various frequencies,
examination bed, ultrasound report system
(including computer, printer, and writing desk),
and image collector.
hand sanitizing gel will be equipped. In addition,
it is particularly important to protect the privacy
of patients during the examination, so there must
be screens or isolation curtains in the ultrasound
room.
1.3.4 Disinfection Equipment
In order to protect various ultrasound equipment
and keep the examination room dry and clean, the
room needs to be ventilated and avoid light, and
it is recommended to install sterilization and disinfection equipment such as ultraviolet lamps.
The layout in the examination room is equally
important. Generally, the examination bed is
placed on the right side of the ultrasound device,
and the computer and writing desk are placed on
the left side. When the operator is left-handed,
the above orientations are changed from left to
right. Figure1.17 shows the equipment and layout of the ultrasound examination room.
1.4 Preparation forExamination
1.4.1 Preparation
1.3.3 Materials
Ultrasound examination of the skin is convenient
and easy to perform. Patients do not need special
There shall be garbage cans and sink in the room,
and if necessary, a movable trolley for placing
gel, alcohol, medical gloves, paper tissues, and
Computer
Printer
Ultrasound device
Medical waste garbage can
Examination
bed
Report workstation
Fig. 1.17 The equipment and layout of the ultrasound examination room. (a)Layout of skin ultrasound examination
room. (b)Washing sink, removable trolley, and other materials placement
preparations such as fasting or holding back
urine. They only need to fully expose the lesion.
If the lesion is ulcerated, simple hemostasis and
Washing sink
Gel
Hand
sanitizer gel
Sanitary wipes
Gloves
Paper tissues
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H.-X. Xu et al.
debridement should be performed rst, and the
hand of the examiner, ultrasound transducer and
normal skin around the lesion should be protected and isolated. It is not recommended to
examine immediately when there is active
bleeding.
Physicians should carefully inquire about the
patient’s medical history before the examination,
including the time of the initial presentation, the
growth speed of the lesion, number of lesions,
symptoms (pain, itching, etc.), history of trauma,
history of infectious diseases and history of treatment and other clinical information. After the
examination, attention should be paid to cleaning
the transducer and discarding the waste according to relative regulations.
1.4.2 Position
Sitting position can be selected when the lesion is
located on the scalp, dorsum of the hands, and
dorsum of the feet. Supine position can be selected
when the lesion is located on the frontal face,
anterior chest wall or abdominal wall, upper and
lower extremities. Prone position can be selected
when the lesion is located on the back and buttocks. Lateral position can be selected when the
lesion is located on the lateral waist. Lithotomy or
lateral position can be selected when the lesion is
located on the perineum. In general, the appropriate position should be exibly selected based on
the location of the lesion (Fig.1.18).
1.4.3 Selection andAdjustment
ofUltrasound Device
1.4.3.1 Selection ofUltrasound Device
The devices for skin ultrasound mainly include
conventional ultrasound devices and ultrasound
biomicroscopy (UBM).
The conventional ultrasound device is
equipped with an ultrasound transducer with a
frequency≤20MHz to carry out skin ultrasound.
The function is similar to that of a conventional
ultrasound device. It can realize the imaging of
multi-modal imaging such as gray-scale, color
Doppler, power Doppler, and elastography.
The UBM is equipped with an ultrasound
transducer with a frequency≥50MHz. At present, most UBM only have a single gray-scale
imaging function, but can clearly display very
supercial structures of skin layers (especially
for the epidermis and supercial dermis).
In addition, laptop and hand-held ultrasound
devices are increasingly used to meet bedside
needs (Fig.1.19).
1.4.3.2 Selection, Application
ofUltrasound Transducer,
andImage Interpretation
Selection ofUltrasound Transducer
The ultrasound transducers are divided into lowfrequency transducers (1~8MHz), conventional
high-frequency transducers (HFUS)
(9 ~ 20 MHz), ultrahigh-frequency transducers
(20~50MHz), and UBM (≥ 50MHz).
Unlike other organs, the ultrasound transducer
used for skin disease has a large frequency range.
The most common transducers are ultrahighfrequency ultrasound transducers and UMB
transducers.
However, when the skin lesions are too large
and deep to be presented completely, it is necessary to select the low-frequency ultrasound transducer for evaluation.
In the skin ultrasound examination, it is recommended to preferentially select the transducer
with the frequency of 20~25MHz for preliminary evaluation, and then select the transducer
with other frequencies according to the imaging
status and clinical need. The appearance and
scope of application of ultrasound transducers
with different frequencies are as follows:
(1) Low-frequency ultrasound transducer
(Frequency: 1~8 MHz, Fig. 1.20): convex
arrays, generally used for abdominal examination, rarely used in skin diseases, only recommended when the skin lesion is large,
deep or suspected of deep organs, or abdominal lymph node metastasis.
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1 Overview ofSkin Ultrasound
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Fig. 1.18 Examination position. (a) The patient is exam-
ined in prone position (lesion located on the back). (b)The
patient is examined in supine position (lesion located on
the face). (c)The patient is examined in a sitting position,
and he sits on one side of the examination bed (lesion
located on the palm of the hand). (d)The patient is examined in sitting position (lesion located on the leg)
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H.-X. Xu et al.
Fig. 1.19 Skin ultrasound devices. (a) Conventional
ultrasound devices (MyLab Twice, Esaote, Italy), with a
high-frequency ultrasound transducer (Frequency:
22 MHz), can realize the examination of skin diseases.
(b) Ultrasound biomicroscopy (Frequency: 50 MHz) is
dedicated to the examination of skin diseases (Tianjin
Meda, model MD-310SII, China). (c)A laptop ultrasound
device (Kolo, model Paragon XHD, China) with a highfrequency ultrasound transducer (Frequency:
22~38MHz) can realize the examination of skin diseases.
(d) Hand-held wireless ultrasound device (Frequency:
5/7/10MHz) can realize the examination of skin diseases
(Healcerion, model Sonon 300 L, Korea) [Image cited
from Li XL et al, AUDT, 2020, 02: 050-056]
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1 Overview ofSkin Ultrasound
15
(2) Conventional HFUS transducer (Frequency:
9~20MHz, Fig.1.21): linear arrays, often
used for examinations of supercial organs,
blood vessels, and pediatric abdomen. It
can also be used for skin diseases when a
higher frequency ultrasound transducer is
lacking.
(3) Ultrahigh-frequency ultrasound transducer
with frequency≥20MHz (Fig.1.22): linear
array, mostly used for the examination of
skin lesions in supercial location, which
can clearly display the internal details of the
lesion.
(4) Ultrasound transducer with fre-
quency ≥ 50 MHz, known as “ultrasound
biomicroscopy” (UBM), the spatial resolution reaches submillimeter level, which can
display tiny structures such as epidermis and
skin appendages. The preparations before
examination are as follows (Fig.1.23).
Fig. 1.20 Low-frequency convex arrays ultrasound
transducer (Esaote CA431, Italy; Frequency: 1~8MHz)
Utilization oftheUltrasound Transducer
andImage Interpretation
(1) Operator posture: During the examination,
the operator can sit or stand on the right
side of the patient. The operator can hold
the transducer with the right hand and operate the control panel with the left hand.
When the transducer is small, pen-holding
method can be adopted, and when the transducer is large, it can be grasped by the
thumb and the remaining four ngers are
opposite (Fig.1.24). The transducer is held
rmly throughout the examination. When
the operator is left-handed, the above orientations are changed.
(2) Transducer placement: Before examination,
the operater should observe the lesion (Fig.
1.25A), apply sufcient gel to completely
embed the lesion to form an isolation zone
(Fig. 1.25B), take care to eliminate large bubbles in the gel. When the lesion is in the epidermis, the operater should place the transducer
on the surface of gel isolation zone to keep a
gap between the transducer and the lesion surface (Fig. 1.25C). When the lesion is in the
subcutaneous tissue, the transducer could
touch the body surface without pressure.
(3) Image orientation: The ultrasound image
shows the skin structure longitudinally with
the epidermis anteriorly and the deep tissue
posteriorly. All transducers have a raised
Fig. 1.21 Conventional high-frequency linear array ultrasound transducer. (a)Esaote SL1543, with a frequency range
of 6~13MHz (Italy). (b)Supersonic Imagine SLH20–6, with a frequency range of 6~20MHz (France)
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H.-X. Xu et al.
c
Fig. 1.22 High-frequency linear array ultrasound transducer. (a) GE L10–22-RS, with a frequency range of
10~22MHz (USA). (b)TOSHIBA i24LX8, with a fre-
mark at the lateral side to orient the image
(arrow on Fig.1.26). There is a mark (gener-
quency range of 16~24 MHz (Japan). (c)Kolo Paragon
XHD L38–22, with a frequency range of 22~ 38 MHz
(China)
1.4.3.3 Adjustment ofUltrasound
Devices
ally a trademark of the device manufacturer)
on the upper left corner of the ultrasound
image, indicating that this direction corresponds to the raised mark on the lateral side
of the transducer (Fig.1.26).
Adjustment ofGray-Scale Ultrasound
(1) Gain: Gain is one of the most commonly
used buttons on the operator panel of ultrasound devices, which mainly adjusts the
brightness of the image. The higher the gain,
Key Points
• The devices for skin ultrasound include conventional ultrasound device and ultrasound
biomicroscopy.
• In the skin ultrasound examination, it is recommended to preferentially select the transducer with a frequency of 20~ 25 MHz for
preliminary evaluation, and then select the
transducers with other different frequencies as
needed.
the brighter the image, while the lower the
gain, the darker the image. Improper adjustment of gain can affect the display and diagnosis of lesions, so the gain is often adjusted
to obtain a clear image during the examination (Fig.1.27).
(2) Time gain compensation (TGC): Ultrasound
is attenuated as propagating deep into tissue.
The deeper the detected tissue, the more the
ultrasound attenuation, and the weaker the
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1 Overview ofSkin Ultrasound
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17
Fig. 1.23 Preparations before UBM examination.
(a)Step 1: Transducer preparation includes a transducer
and a silicone waterproof sac. (b)Step 2: Stick the special
waterproof PU lm at the front end of silicone waterproof
sac tightly without water leakage. (c) Step 3: Inject an
appropriate amount of distilled water (not normal saline)
into the silicone waterproof sac, so that the transducer can
be immersed. (d)Step 4: Install the marks on both sides of
silicone waterproof sac in line with the marks on transducer handle. After the examination, remove the waterproof sac, discard the water and place the waterproof sac
separately from the transducer to keep the transducer dry
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Fig. 1.24 Holding method of ultrasound transducer. (a)Pen-holding method. (b)Grip holding method
H.-X. Xu et al.
a
b
c
Fig. 1.25 Diagram of transducer placement.
(a) Supercial lesion on dorsum of right foot (arrow).
(b)The lesions are embedded with gel prior to examination to create an isolation zone (arrow). (c)Place the trans-
ducer over the surface of the gel and keep a distance from
the lesion (take another hand lesion as an example)
(arrows point to the gel)
a
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1 Overview ofSkin Ultrasound
Fig. 1.26 Image orientation. The raised mark on the transducer corresponds to the orientation mark on the ultrasound
image (arrow)
19
b
Gain
Fig. 1.27 Adjustment of gain. (a) Gain button on the operator panel (red circle). (b)Gain is too high. (c)Gain is too
low. (d)Gain is proper (lesion indicated by arrows)
ultrasound wave signal received by the
transducer. Therefore, the ultrasound wave
signal of deep tissue is weaker than that of
supercial tissue, which corresponds to deep
tissue showing darker than the supercial tissue on gray-scale ultrasound image. TGC corrects and compensates for image attenuation
due to increased depth, allowing the brightness of the image to be adjusted evenly from
shallow to deep (Fig.1.28). It is also feasible
to adjust the image brightness of a specic
depth by changing the TGC of that depth.
(3) Depth: It is adjusted by the Depth button on
the operator panel. The target lesion should
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TGC
c
H.-X. Xu et al.
Fig. 1.28 Adjustment of TGC.(a) TGC buttons on the operator panel (red circle). (b)Improper TGC adjustment, such
as local gain is too high (arrows). (c)Proper TGC adjustment, the image gain is even
normally be displayed in the center of the
image. The depth scale is usually on the
right side of the ultrasound image, and the
unit is cm usually. When the depth is
adjusted too deep, too much irrelevant deep
tissue is incorporated, causing the reduction and off- center of the target. When the
depth adjustment is too shallow, it may
result in incomplete display of the target,
even part of the target located outside the
screen. In general, it is appropriate to take
the lesion in the center of the screen
(Fig.1.29).
screen, which can be adjusted up and down with
the Focus button (Fig.1.30).
In general, the focus marker should point to
the center of the lesion as possible. When the target is large, the number of foci can be increased
so that the focal zone contains the lesion and its
adjacent tissue as much as possible. However, it
should be noted that excessive foci will lead to
the reduction of image frame rate, causing the
image lagging. Skin lesions are generally thin
and supercial, so it is recommended to select
one focus and place it at the upper side of the
screen.
(4) Focus: This parameter is related to the lateral
resolution, which reects the differentiation
between the lesion from its peripheral tissue
at the same depth.
(5) Output: The output of ultrasound power is
adjusted to optimize the image, with the
adjusted range of 0~100%. The greater the
output power, the stronger the ultrasound
On most ultrasound devices, the focus is dis-
played as a special marker on the right side of the
penetration and the more ambiguous the
image display. On the contrary, the lower the