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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5802_Библиотеки_им_академика_М_И_Перельмана.pdf
Supercial structures
136
Lymph nodes in the neck
PREPARATION
None.
POSITION
Supine.
TRANSDUCER
7.0–14.0 MHz linear transducer.
METHOD
Use the thyroid as a landmark and assess the anterior and posterior
aspects of both aspects of the neck.
APPEARANCE
Ultrasound features that should be assessed include:
1. Lymph node shape: Assessed by measuring the longitu-
dinal (L) and transverse (T) diameter on the same image
and calculating the L/T ratio. This is normal when L/T
>2; that is, when the shape is oval. Another method is to
measure the ratio of the minimum to maximum diameter
of a node in the transverse plane. A ratio of more than
0.55 yields the highest accuracy when predicting malignancy with ultrasound.
2. Nodal hilus: This should be of high reectivity and wide.
The presence of hilar narrowing or cortical widening
(either concentrically or eccentrically) should be regarded
with suspicion for malignancy.
3. Nodal size: Ultrasound is not a reliable criterion for dif-
ferentiating benign from malignant lymph nodes.
4. Calcication: Calcication is found in a signicantly
lower number of malignant nodes.
5. Doppler waveforms: The Resistance Index can be mea-
sured, with a cutoff of 0.70 for differentiating benign
(<0.70) from malignant, but with considerable overlap in
recordings.
Lymph nodes in the neck
Longitudinal image through an oval lymph node demonstrating features of benign disease.
Longitudinal (L) and transverse (T) diameter on the same image, calculating the L/T ratio.
137
Level classication of lymph nodes of the neck.
Supercial structures
138
MEASUREMENT
Classication of position of neck lymph nodes
Level Lymph node group Ultrasound boundaries
IA Submental Between anterior bellies of diagastric
muscle
IB Submandibular Posterior to diagastric muscle below
mandible
II Upper jugular Skull base to inferior border of hyoid
bone
A: anterior to spinal accessory nerve
B: posterior to spinal accessory nerve
III Middle jugular Inferior border of hyoid to inferior
border of cricoid cartilage
IV Lower jugular Inferior border of cricoid cartilage to
clavicle
V Posterior
triangle
VI Anterior
compartment
Superior boundary is the convergence of
the sternomastoid and trapezius muscles
to the clavicle
A: Above the plane of the inferior cricoid
cartilage
B: Below the plane of the inferior cricoid
cartilage
Superior boundary hyoid bone to
suprasternal notch
VII Superior
mediastinum
Between carotid arteries at the top of
manubrium superiorly to innominate vein
inferiorly
FURTHER READING
Na DG, Lim HK, Byun HS, Kim HD, Ko YH, Baek JH.
Differential diagnosis of cervical lymphadenopathy: Usefulness
of color Doppler sonography. AJR Am J Roentgenol. 1997;
168:1311–1316.
Lymph nodes in the neck
Robbins KT, Shaha AR, Medina JE, Califano JA, Wolf GT, Ferlito
A, Som PM, Day TA. Consensus statement on the classication
and terminology of neck dissection. Arch Otolaryngol Head
Neck Surg. 2008; 134:536–538.
Takashima S, Sone S, Nomura N, Tomiyama N, Kobyashi T,
Nakamura H. Nonpalpable lymph nodes of the neck: Assessment
with US and US-guided ne needle aspiration biopsy. J Clin
Ultrasound. 1997; 25:283–292.
Vassallo P, Wernecke K, Roos N, Peters PE. Differentiation of benign
from malignant supercial lymphadenopathy: The role of high
resolution US. Radiology. 1992; 183:215–220.
139
Supercial structures
140
Orbits (extraocular muscles)
PREPARATION
None.
POSITION
Supine in a reclining position with the eyelid closed.
TRANSDUCER
10.0–14.0 MHz linear transducer.
METHOD
Transverse and longitudinal planes of the four recti are obtained and
appear as low-reective areas.
APPEARANCE
Well-circumscribed, round, low-reective uid-like structure, with
linear structures posteriorly located corresponding to the intraocular
muscles.
Axial image through the orbit, demonstrating the diameter of the medial rectus muscle
(between cursors).
Orbits (extraocular muscles)
MEASUREMENTS
Diameters of extraocular muscles in normal population
Muscle Mean (mm) SD (mm) Median (mm)
Superior rectus 5.3 0.7 5.4
Lateral rectus 3.0 0.4 3.1
Inferior rectus 2.6 0.5 2.6
Medial rectus 3.5 0.6 3.6
FURTHER READING
Byrne SF, Gendron EK, Glaser JS, Feuer W, Atta H. Diameter
of normal extraocular recti muscles with echography. Am J
Opthalmol. 1991; 112:706–713.
141
Supercial structures
142
Orbits (optic nerve)
PREPARATION
None.
POSITION
Supine in a reclining position, with eyelid closed.
TRANSDUCER
10.0–14.0 MHz linear transducer.
APPEARANCE
Tubular structure. Homogenous, low-reective, parallel nerve ber
bundle surrounded by a highly reective dural sheath.
Axial image through the orbit demonstrating the optic nerve (between cursors).
MEASUREMENTS
Optic nerve width: 2.4 mm–3.4 mm
Median of 2.9 mm and no more than 0.3 mm between the two nerves.
FURTHER READING
Atta HR. Imaging of the optic nerve with standardized echography.
Eye. 1988; 2:358–366.
PERIPHERAL
7
VASCULAR
(ARTERIAL)
Colin R. Deane and
Paul S. Sidhu
Upper limbs (peripheral arteries) 144
Abdominal aorta and common iliac
arteries 148
Lower limbs (peripheral arteries) 152
Lower limbs (peripheral artery
bypass grafts) 156
Hemodialysis access stulas and
grafts 160
Extracranial arteries 164
Transcranial Doppler (TCD)
ultrasound 172
Peripheral vascular (Arterial)
144
Upper limbs (peripheral arteries)
PREPARATION
Patient should rest in a supine position. If accurate physiological
changes are to be measured, then the subject should rest for 15 minutes
in a room where the temperature is 21°C to avoid vasoconstriction.
POSITION
Supine.
TRANSDUCER
3.0–10.0 MHz linear transducer for subclavian and axillary arteries, higher frequency (8.0–15.0 MHz) linear transducer for brachial,
radial, and ulnar arteries.
METHOD
Examination of the upper extremity usually starts at the level of the
subclavian artery followed by the axillary artery, brachial artery, and
radial and ulnar arteries. The radial and ulnar arteries are imaged with
the arm in supination, and slightly abducted. The vessels should be
examined in the longitudinal axis.
APPEARANCE
The arteries appear as noncompressible, pulsating tubular structures.
At rest, ow waveforms show a high peripheral resistance spectral
Doppler waveform with a typical tri- (or greater) phasic ow pattern,
consisting of a steep systolic upslope, a systolic peak, a reverse ow
component, forward ow in late diastole, and pre-systolic zero. The
ow waveform is dependent on environmental factors and changes
markedly if the hand is subjected to cold or heat.
Arterial disease. Arms suffer less from atherosclerotic disease than do
legs. Occlusions, for example from thrombus or injury, are evident
as absent ow in arteries with damped ow distally. Stenoses or arterial compression are evident as local increases in velocity with damped
ow distally if the disease is severe.
Upper limbs (peripheral arteries)
Radial artery ow waveform at rest. The ow waveform shows high-resistance pulsatile
ow.
145
With the hand placed in cold water, velocities are reduced and there is increased reverse
ow indicating distal vasoconstriction.