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Thyroid us

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  • 1. Anatomy of thyroid glandAnatomy of thyroid gland
  • 2. What are the indications for thyroidWhat are the indications for thyroid ultrasound?ultrasound?  Diffuse enlargement on physical examinationDiffuse enlargement on physical examination  A palpable massA palpable mass  A non palpable mass seen on otherA non palpable mass seen on other imaging( CT-MRI- nuclear scan)imaging( CT-MRI- nuclear scan)  Abnormal thyroid function testsAbnormal thyroid function tests
  • 3. Thyroid diseasesThyroid diseases DiffuseDiffuse  Grave's diseaseGrave's disease  Hashimoto thyroiditisHashimoto thyroiditis  De Quervain's thyroiditisDe Quervain's thyroiditis FocalFocal  SolitarySolitary  multinodularmultinodular
  • 4. Solitary thyroid noduleSolitary thyroid nodule  BenignBenign  malignantmalignant
  • 5. General features of the solitary noduleGeneral features of the solitary nodule  Solid / cysticSolid / cystic  Comet tail signComet tail sign  MarginsMargins  CalcificationCalcification  Color flow imagingColor flow imaging
  • 6. Solid/CysticSolid/Cystic  Nodules with large cysticNodules with large cystic components are usuallycomponents are usually benign nodules that havebenign nodules that have undergone cysticundergone cystic degeneration or hemorrhage ,degeneration or hemorrhage , however about 20-30% ofhowever about 20-30% of papillary carcinomas alsopapillary carcinomas also have a cystic component,have a cystic component, indicating that not all cysticindicating that not all cystic thyroid nodules are benign.thyroid nodules are benign.
  • 7. Comet tail signComet tail sign One highly specific sign ofOne highly specific sign of a benignity of a thyroida benignity of a thyroid nodule is the presence ofnodule is the presence of comet tail sign, signifyingcomet tail sign, signifying a benign colloid nodule.a benign colloid nodule. This sign is neverThis sign is never encountered in aencountered in a malignant lesionmalignant lesion
  • 8. EchogenecityEchogenecity  Hyperechoic noduleHyperechoic nodule  malignant in 4%malignant in 4%  Isoechoic noduleIsoechoic nodule  malignant in 26%malignant in 26%  Hypoechoic noduleHypoechoic nodule  malignant in 63%malignant in 63%
  • 9. MarginsMargins  Peripheral halo ofPeripheral halo of decreased echogenecity isdecreased echogenecity is seen around the nodule.seen around the nodule.  a complete halo is 12a complete halo is 12 times more likely totimes more likely to indicate benign lesionindicate benign lesion  An incomplete halo is 4An incomplete halo is 4 times more likely benigntimes more likely benign than malignantthan malignant
  • 10. CalcificationCalcification  Peripheral rim calcification and large areas ofPeripheral rim calcification and large areas of coarse shadowing calcifications are morecoarse shadowing calcifications are more frequently seen in benign nodules’frequently seen in benign nodules’  Fine punctate calcifications due to calcifiedFine punctate calcifications due to calcified psammoma bodies are more frequently seen inpsammoma bodies are more frequently seen in malignant nodulesmalignant nodules
  • 11. Color flow imagingColor flow imaging  There are three general patterns of vascular distributionThere are three general patterns of vascular distribution of the thyroid nodule:of the thyroid nodule:  Type 1Type 1 : complete absence of flow signal within the: complete absence of flow signal within the nodule.nodule.  Type 2Type 2 : exclusive perinodular arterial flow signal: exclusive perinodular arterial flow signal ““type 1 and 2” are more common with benign nodulestype 1 and 2” are more common with benign nodules  Type 3Type 3 : intranodular flow with or without significant: intranodular flow with or without significant perinodular flow and this type isperinodular flow and this type is generally associatedgenerally associated with malignant nodules.with malignant nodules.
  • 12. Although none of the ultrasoundAlthough none of the ultrasound features above isfeatures above is BY ITSELFBY ITSELF pathognomonic for malignancy, BUTpathognomonic for malignancy, BUT when it usedwhen it used IN COMBINATIONIN COMBINATION they are very useful in differentiatingthey are very useful in differentiating malignant from a benign nodulemalignant from a benign nodule
  • 13. What are the features of a benignWhat are the features of a benign thyroidthyroid nodulenodule?? 1- completely or nearly completely cystic,1- completely or nearly completely cystic, especially with echogenic foci with comet tailespecially with echogenic foci with comet tail artifactartifact 2- echogenic or isoechoic to normal tissue2- echogenic or isoechoic to normal tissue 3- a complete halo3- a complete halo 4- well described margin4- well described margin 5- rim or large coarse calcifications5- rim or large coarse calcifications 6- hypovasculrity6- hypovasculrity
  • 14. What are the features ofWhat are the features of malignantmalignant thyroidthyroid nodule?nodule? 1- microcalcifications1- microcalcifications 2- irregular margin2- irregular margin 3- marked hypoechogenecity3- marked hypoechogenecity 4- hypervascularity4- hypervascularity
  • 15. Examination of adjacentExamination of adjacent structuresstructures  (1)-(1)- CCA and internalCCA and internal jugular veinjugular vein : the: the presence of thrombuspresence of thrombus within CCA or IJV inwithin CCA or IJV in association with a thyroidassociation with a thyroid nodule is a clue to thenodule is a clue to the malignant nature of themalignant nature of the nodulenodule
  • 16.  (2) –(2) – spread to adjacent structuresspread to adjacent structures;; extrathyroid spread including involvement ofextrathyroid spread including involvement of esophagus, trachea, strap muscles, recurrentesophagus, trachea, strap muscles, recurrent laryngeal nerve is another clue to the malignantlaryngeal nerve is another clue to the malignant nature of the nodulenature of the nodule
  • 17.  (3)-(3)- cervical lymphadenopathycervical lymphadenopathy  The LNs commonly involved are the pretrachealThe LNs commonly involved are the pretracheal , paratracheal and nodes along internal jugular, paratracheal and nodes along internal jugular vein.vein.
  • 18. MULTINODULAR THYROIDMULTINODULAR THYROID ultrasound features:ultrasound features:  Solid nodules, frequently isoechoicSolid nodules, frequently isoechoic  well defined marginswell defined margins  Cystic component in 60 %Cystic component in 60 %  Heterogeneous internal echopattern with multipleHeterogeneous internal echopattern with multiple septa , solid and cystic portions.septa , solid and cystic portions.  On color flow imaging the nodules either show typeOn color flow imaging the nodules either show type 1 or type 2 pattern1 or type 2 pattern
  • 19.  It is generally believed that malignancy isIt is generally believed that malignancy is common in a solitary nodule and thatcommon in a solitary nodule and that multinodularity is usually associated with benignmultinodularity is usually associated with benign disease,disease, HOWEVERHOWEVER 10 – 20 % of papillary10 – 20 % of papillary carcinoma may be multicentriccarcinoma may be multicentric
  • 20. DIFFUSE THYROIDDIFFUSE THYROID DISEASESDISEASES • Grave's diseaseGrave's disease • Hashimoto thyroiditisHashimoto thyroiditis • De Quervain’s diseaseDe Quervain’s disease
  • 21. GRAVE’S DISEASEGRAVE’S DISEASE  Diffuse enlarged glandDiffuse enlarged gland  Color Doppler study is pathognomonic for theColor Doppler study is pathognomonic for the disease , revealing hypervascularity which isdisease , revealing hypervascularity which is called “thyroid inferno”.called “thyroid inferno”.  the peak systolic velocity is more than 100the peak systolic velocity is more than 100 cm/sec “normal up to 25 cm / sec”cm/sec “normal up to 25 cm / sec”
  • 22. ..
  • 23. HASHIMOTO THYROIDITISHASHIMOTO THYROIDITIS Three stages:Three stages:  Acute: enlarged in size and increased vascularity.Acute: enlarged in size and increased vascularity.  Chronic: enlarged gland with multiple linear brightChronic: enlarged gland with multiple linear bright echoes throughout the hypoechoic parenchyma as wellechoes throughout the hypoechoic parenchyma as well as multiple small hypoechoic nodules.as multiple small hypoechoic nodules.  Atrophic; end stage : small atrophic gland. avascularAtrophic; end stage : small atrophic gland. avascular with heterogenous echoes.with heterogenous echoes.
  • 24. ..
  • 25. DE QUARVAN’SDE QUARVAN’S THYROIDITISTHYROIDITIS  The inflammation does not involve the entireThe inflammation does not involve the entire gland but infiltrates the gland in a nongland but infiltrates the gland in a non homogenous pattern.homogenous pattern.  The sonographic correlate is a disorderedThe sonographic correlate is a disordered pattern of hypoechoic and hypervascular areaspattern of hypoechoic and hypervascular areas
  • 26. Evaluation of nodulesEvaluation of nodules incidentally detected by U/Sincidentally detected by U/S  Nodules under 1.5 cm are followed upNodules under 1.5 cm are followed up by u/sby u/s  Nodules over 1.5 cm are furtherNodules over 1.5 cm are further evaluated by FNAevaluated by FNA
  • 27. ILLUSTRATEDILLUSTRATED CASESCASES