for Thyroidologists
Durr-e-Sabih
Why
o Accurate depiction of neck anatomy
o Clarifies doubtful findings
o Differentiates thyroid from non-thyroidal
masses
o Detection of non-palpable disease
o Follow-up of focal disease
o Guides FNA/therapy
o Suggests probable benign/malignant for
stratification of further workup
The section
The section
Surroundings
Sternohyoid
Sternothyroid
Sternocleidomastoid
Trachea
Thyroid
Oesophagus
Cervical Vertebra
C-6
Longus coli
Scalenus anterior
Surroundings
Surroundings
Sternohyoid
Sternothyroid
Sternocleidomastoid
Trachea
Thyroid
Oesophagus
CCA
Cervical Vertebra Longus coli
C-6
Size
o Each lobe 4-6 cm in cranio-caudal extent
o <1.8 cm in maximum depth, isthmus <6mm
in thickness
o Volume 7-14ml, calculated for each lobe
and add
Size
4-6 cm
<0.6cm
<1.8cm
<1.8cm
4-6 cm
Volume; 7-14 ml. Calculate for
each lobe and add
<1.8cm
Texture
o Medium to high density
echoes, homogenous
o Thin capsule occasionally
seen might become
calcified in uraemia
o Muscles are hypoechoic
o Texture can appear different
with different equipment
use same equipment for
follow-up
o Parathyroids not visible
unless enlarged
My thyroid
Xario
Nemio
Aplio
Blood supply
o Superior thyroid artery and vein at the
upper pole of each lobe
o Inferior thyroid vein at the lower pole
o Inferior thyroid artery is posterior to the
lower third of each lobe
Mid
th.
vein
Inf th.
vein
Parenchymal vascularity
Isoechoic, Hyperechoic
Hypoechoic
Markedly hypoechoic
Content
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
Calcification
<1mm, no shadowing
Colloid crystals
Reverberating echogenicities
Margin
Smooth/irregular
Orientation
Vascularity
Nodes
Features
Tall/Wide
Contents
Echogenicity
Halo
Margins
Calcification
Doppler
Feature
Benign
Malignant
+++
++
++++
Purely cystic
++++
+++
Mixed Solid/cystic
+++
++
Purely solid
+++
++
+++
Hyperechoic
++++
Isoechoic
+++
++
Hypoechoic
+++
+++
Markedly hypoechoic
++++
Thin
++++
++
Thick
+++
Absent
+++
Well defined
+++
++
Poorly defined
++
+++
Spiculated
++++
Eggshell
+++
++
Coarse
+++
Micro
++
++++
Peripheral
+++
++
Internal flow
++
+++
Thyroid nodules
Thyroid Nodules
o Is it in the thyroid or outside it?
Hyperplastic, Adenomatous or
Colloid Nodule
o Cellular hyperplasia, microndule nodule,
macronodule formation
o Liquefactive degeneration with
accumulation of serous fluid, blood and
colloid material
o Calcification, often coarse and peripheral
o Can be hypo functioning, normally
functioning or hyperfunctioning
Colloid Nodules
Follicular Neoplasm
o Follicular adenoma is a true neoplasm with
compression of adjacent tissue and fibrous
capsulation
o Capsular/vascular invasion is the hallmark
of follicular carcinoma, that can be seen on
histology and not cytology
Follicular Neoplasm
o FNA does not differentiate between benign
follicular adenoma and carcinoma (capsular
and vascular invasion)
o Usually solid
o Hypo, iso or hyperechoic
o Thin or thick halo
o Peripheral rim of vessels, sometimes extending
inwards in spoke-wheel pattern
Follicular Neoplasm
Colloid Nodule
Hypoechoic
Microcalcification
Hypervascular
Cervical nodes with possible
microcalcification or cystic degeneration
Papillary Carcinoma
Other Carcinomas
o Medullary
o Part of the MEN-II syndrome, tends to be multicentric or
bilateral
o Similar to papillary carcinoma on ultrasound
o Calcifications tend to be coarse
o Anaplastic
o Large, hypoechoic, encase or invade blood vessels and muscles
o Lymphoma
o In most there is pre-existing Hashimotos and hypothyroidism,
rapidly growing mass
o Extremely hypoechoic, lobulated, areas of cystic necrosis
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rt
Score
Study
Score
Interpretation
1 feature: 81%
sensitivity.
>2 features FNAB
> 2 biopsy
threshold,
sensitivity of 80.3%
specificity of 72.3%
Pattern
Pattern
Significance
Benign
Unpredictable
Pattern
Spongiform without hypervascularity
Cyst with avascular colloid plug
Giraffe pattern (skin, not the neck)
White knight (uniform hyperechogenicity)
John A. Bonavita, Jason Mayo, James Babb et al. Joseph Yee. Pattern Recognition of Benign Nodules at Ultrasound of
the Thyroid: Which Nodules Can Be Left Alone? AJR 2009; 193:207213.
Pattern
Red light (intense hypervascularity)
Intense hypoechogenicity
Isoechogenic without halo
Isoechogenic with halo
isoechogenic with peripheral vascularity
(Ring-of-fire )
Other
John A. Bonavita, Jason Mayo, James Babb et al. Joseph Yee. Pattern Recognition of Benign Nodules at Ultrasound of
the Thyroid: Which Nodules Can Be Left Alone? AJR 2009; 193:207213.
Yes
Yes
Yes
?Yes
?Yes
?
Hyperplasia
Thyroiditis
Graves disease
Colloid goitre
Thyroid Hyperplasia
o Hyperplasia of cells or acini, followed by
micro and then macronodule formation
o Hyperplastic nodules can undergo
liquefaction with accumulation of serous
fluid, blood and colloid
Ultrasound Surprises
Hashimotos Thyroiditis
o Enlarged, hypoechoic, hypervascular,
coarse
o Micronodular, nodules are hypoechoic,
intervening bands can be echogenic.
o Very high flow to very low flow
Thyroiditis
Thyrotoxicosis
Thank you