Apm HOm.~y lu d~g for lliepmpoSJes ofr·eSJearrn or pm.ralte smdy, or 'criticism or review, ,i:iI:SpemI:Jit1h:dMdier ili;eUK Copyrig}\lt ][JieSJigns. ,~d jp:ll:itenrlts. Act 1988, iliItiispj[]bJffica1!ioF:lm1l!j' Flot.be w:epfochoedl" ssored, m 1tr~ed,many fOmJI or by any means, \vi!~0l!li1: tlJiepriorp erMscsiioo ill writillg .of 'ihe])ll]!bJ1isJl.ets.,. orm ilie ease ofmepmglfa:p11illc teproc:m:01t1on. omly m[jj)cootdmoe "viil:lh the :ite:l:l!HS of ~el&Oe1iroes ~sS:lIToo.by ilieOi!:ppi:opri<il:~elEtepmrnro1t1on :Rights. OrgrulliMim1l5 olliitside lOOe UK_ &qrnies oQ!Flc:~greplfornrc:1tiarn1J ontsmde ilie 1te:rnB8SJt1lL:itedl ]],eresJloIIil!dlbe :s:emt ~o lOOeplillib1llishers. at &e lOFldorn1J ;<iI!dJcheSlsprin1ted a'boC)i\.'le_
Thepl.!l!blli~efmHes Florept.es;oota1tiion, express Of .impJliedl, wi!ili.regardl to the :1IDCOlaI:<il:CY of the iiMofm:~l'tion. oon1tmoo. m t:lThiisboo:kud crumot acoept ;<my ]eglilr,es;porulmrlty orlli&biilllrlty for m1yerrors Of Om:lS810l'l!S: ilialma!}'bem1itde_
Page .... ·
,C OIU.te:nts,
CfuJaplbe:r 1
i'\n:a:lbomy:mdl 'fecfuMiqure RMEvam
3
4
6<
Chaplber2. S~ID)' H]1ll1d)s
lVJ1Jmdley
19
21
.21
.25
26
26
3.i
Chaplber3
The Th:vm:oid aad f:m:,;jJ:l:hvroiidis
, '~. ., ~
A TAhuja
37
37
39
43
46
48
49
50
511.
53
55
55
58
59
Cfu<i!p1ter 4- Lymph. Nodes R.UEvam
61
68
74
Cfu<i!p1tef :5
LmJl'psgd BmJl]J.8 m{i]e Bei!l:d.<md. Neck A .TAhuja
87
89
94
97
Wi
Cl1uap1ter6 The Lm:}'lWl: .E Loveday
W7
108
109
uo
Cl1uap1ter7
\Nllijl!E the SmgeOl!TIi Neem to Km:ow, :iiIl!J!d. \Vhy DWPat.t:on, K C Sil'l1est;er
lH
122
112
U7
Ch::ilplter S-
iF me- Needille Aspira1tiou Oil! GOlfe Biopsy? NJ A Cozens, L Berman
131
Chapter 9'
Cam1tiidlOimd Ve:l1eJbrali. U]tr@so~oy.apihy S No, C lYe,tri~eli
147
153
153
fu1:d!ex
167
C ontr.ibutors
Anjill, 'f ,MiuW<1ll!vmBS (Bom) ~, (Bom) meR iF~CR lIFHKANll
Associate jp\[O£essor.
Uepl1l:litm;e:rJt of Di!1iI!g:I]osilllc Rad!i!o:bgy aad Org[JfJJ kIlliaiging
CI1imese UMrie:!"Sil[y of HO!l1Jg Kong jp'rmoe of Wailles HO::1p1!-tlil
S~a1t:iillJJ, HOlThg Kong
Glm1ilJ,
Laereaee Berm[M1JJ, ilFRef' FRCR
CQmim~imt R~dID]ogiist lJ5c:mre:r/BO!l1JOf,ill)' CQmim~iIDt U~eFsjJ1t}, BeparfimetJt of R[lJ;rnomogy
Uepii!l:l1tm:ent of Or§:]. ;omdi. Muofl1ciall Sm,gery MomsIon Ho.s:;pitail.
Moms;~on" Swaasea
\Vailles, UK.
Intrn duetien
'Ve h§!;Vle iliepffiiille,ge of wor11cingMdI. m,-mg dJrnrIDg <1I.1tiim:e oflimpreoedJentred. tedIDo]ogica:ll. aWruloes ill ,dlii<il!g:I1iostic medicine_ 'fills a;ow meMS ili:§t for .~ onedliiat.g:l'los1tl!cPHyMe:m we ~,jl!:'i,~~ot omy .}][ilveonemeiliod. of oo~gbll~mi:lliJJyme1hodls .i:ilLv.d);iMe 1!OllJ!S_ Wi5euSie of ilie YrulOlillS ltedIDo]ogies clictMes :!hat 1tfue most nOrnillJaWe,£eas,t fu!mTI!llfuill,most ei§iSJ!l~~<ilLvaiilla'b]eMdl1Ieast expe:l1i~e tred:miquxes :sli:omd.be e:1'I1Ipbyedimst
Wiili. ilie:m:Wa]. of CT ,. ~, ·l!lmltrMomdi.Md. fll.!illderu- merncme in merncO]] .. OO<ligIDg, ili new era. of dtiiiilg:l1iQsticudJenltmdllil1g of the he:ad.Md l1ec:k iIl:&S f]!oW'el:·ed
J!n 'lhesolFlI 1!l!s5lITeS of ilie .l1edk:,mlimY of 1the ,m~osticp~X)iJb.]ems iliiiltpreSJent lto 1the cllitmci<ilfl. canbemill1:<ligied \w1thm~aJJ ,efficiMCYl!l!sIDgrntri[fiOl!IDdL Sm-prisiinJg1~., despite 1thepiiooeeri:liJJg of neck.wtriiill50md by iBnmettol1.<iIf!I!di. Solibii1lilli, ii§[ ~iifge nIleher of neck. ex::m1il1[jlti!o~s are s:1tiill].hemgpffiDrmedl1!]!si!r:lg fll!l!clem mewcDe,. C'F :mJ!d ~_ OlJ!e nllight lwiilVie tI1ol!JigM iliillili flecklllilltriiISJol!l!n1dwowd ~e .m. ThJ:oSpllta1!s: m. whim. Gfill1dlpilrtiicllll1!arlY, NOO :a!·e li]Qtr.ea;CMy i<ilLvIDll<ifMe_. M&s, i1tS!eenJ!siliOlt IDOSit ,dilliici;rn;s wo1.!1!l!di.prefer to let 1tfucirpa1ti~ts. WmiliSie\i\eEiiIiI w,eeks for ThOOmldl. '!he:l1i. ll()t~et iOJ! S:atisf@ldorymsw'BI",raflher 'lhoo o!b1tm .. 1llJI.'lllillItr'Mol.!1fldi.s:c;m.q;lliick1o/ HOm. a.1lmo\v]edg~b]eproID'e8sio:l1!ali.1illd. h§:;V'e .iMli. aocma~e i;mSWefSiOOner_
There are severa] t'e;ll:ES on. D<iI!giElg of ilie Ewe<il!d amdi.neckI,llbnE lOOeSie :<iI:lfepredJom:an!tliy Cl' .<md ~ oriefllta:~ed_Ap.art H·om. dhaptrers m. SoIDbliaEi. MOl. llizz;jj:1t1to"s. boolk} iliere ~s: "\f.ery .1li1t1tl!ehdpfull ooor.ma:1tl!oo. ~o .en[i[b]e '!he f<il:dilloillogiist ill> i[jj[b1!]!sy general hospir1t;irll ~o ccme lin grips v.'lith.lIlilltriliSiOoodi. of ilie heiildli!l:l1d1 fleck_ Ths ~s1iIDfOl-m:1:ll.1a~e- Climte<ilP,mH.om ilie1iJ!slIJ!ali. \V,el!I.-UOWll. a:wOMlt<ilg,es oflllilittr<MiOl.!1fld in the fueadmd.l1:eck, it isre:m1ll."ka:lblIy11ocmate .Mdl e1ID5J!ef to .:app~y ~m CT ,and. NllU_
Tms. book ilierefOfe~s. ~o ::fiilliI. iliat g:1lp_. The Itext is. mWe:lli.d.ed.i§iS.~pr.iilc1tl!ca1l.grndJeand. bem.rn book; n is tobe :I1;oped ~<lI!ll i~ will. ·enDomi<ilgeMYOlle \wlttl1! fiI. reaso:l1!<l'ble .kI1owledJge ofl!l!lJtrasJol.!md tOp1cli:::. up '!he (appropriate ,!) li:l:'ansrnroefiMl:di. stmSic~g Iili:e neckclIecwe1ym'l:her 1tllli1ll1 siimp:1Y'ge] spreaemg'_ lt is m~end!ed Ito bdp 'lher·ea;d!er It.obe able lto ul:[ild1J<li.11illSiefuru]. Op6oo ill '90'% of theproMe:ms tl\i:ilt arise m da:iillyplf.ac1tioe_ The tel1lJ<~g l '0% \\i1!lI ~iitVie trobe ]e.m1It »omperSiOl1'a:] .~pmenoe <illdgreOl:lter m-de;p1illl re<lid!IDg_ By the jp'Oll[·edopmcip]e, E[ymg tro OOVle:Ji" ili1lt 10% wo1!1illd.pfi()ibablY qil!]l~dlrnp]e :l:fue~e of;ttbjs 'hoo~., so do l!1!ot expeot tlilllS book to lTh,iEve t11eusw.er to ev~g_
B esiidJes olililirlillil1g t,aritnes we :h1l:ve .;!ISioiil::voidedmytths-fLo.Sie;:meotroWil'Ji\l:clhi' 1tlliat.kleep teappe:aring m.ltex1tbooksa:l1:di. 'ex~a:fu!0ns but. wmoh one .ne"ilie;l: sees inmI. diiilliyprao1tioe_
TheboO:k oont~s ~e SiOrt of wOfmatiof:l. ili1il:1!: we '!Mis.}] we oolllilldJ. l]"ilIvie l],<lid whem.. we stmed.l;1leckSJc~g wOO years ago_ MlITcl!. of '!he i!rno:lD1a!tUon is §:;v:ml!;[Jbille m.li:l\i:e l!ilterau·e but is :S:C<il.tler·ed!_ Her,e the most uSJefiut]. wormafu!on_ ~sg"<il:th,er.ed to~et]weribypoopille who <iLOm~ySicafl;. the 'Th;1tJter -laud' h<il!S 1tfuerefo!l:e beoo. w,eeded. ont
jp~.BiDe fl;o.~e that &lis. boO:k is mtremlied. for '!hose Who wilill adill!dy sean. n depends on i1ll1 mil!e:r.aoWe appm<IDcJ]_ lt. is flot'meant :IDor Iili:e CjpR. (ooUlCih.potatro :l:"iil:wologJist) who slltsbiilc:k<lll!d. meES otlielfS :penorm the ·SJcamI. ia:l1d. tlloo. 'repoo:s:1!:he ~r" _ W.eSitronglYheThieVie 1i:hat IihlJs is flOlt the way ltoprilofu!oemk<ilOOlilllld. W eare also strong beThie\'iefsm 1t'I1e opmOOJ iliat (good~1!l!1kmol!md is llot'operatror d!epe11!d!enf', all ]eOliSl no more SiQ ilirulJ.'N.][R][, CT Of, {or iliatmatle:r, smge:ry mpa'lho]ogy _ The d11iim. iliatmMMOml:d is .operator dfllend!ent is mere1JYiil. feeble meofdJefenoefor CjpRs Who :arem1~g tor.olJl·up '!heir sIJeevesiill1l!d. ]eiID'l bow to do ilie jolbproper]y'r
lIF'or 1tfuyroiid nodl!l!l!e:s,. we CH now malbe i[jj[rnarg:l1oSJIs 'i.-vlhl\lwumol!rn:dl1tllli1l1! C1rnJ Ibemoref!ei~b]e &1iL1iJJ.me-flee:dllie[fiptralli~. c)1oDogy (lFNAC) md.rMmore 'l!]s.ernJi. tIlli<lll!.scin1il!graphy., whim. smpris.mg1~ ~S sti1il. mentiCWlOO. in tl]e texts as
Page Kii
Wi'lh. m:.ecik: ]ymphm:odles we C;]Il1I!. llliOW '~e thcirV.MGI]illiMi1ty, 'I1:ot Druly wi'l:lh CQi]o.low aI1!dpower il)oppillerbl!lJtmo wir[!]. 3D'i,~omemCm:I!a;]ys.B_ The detd. &~tt canbe seea m lo/mpfll1:odJesis sllillperim to ;<mdlmofe c1iru)c.~~ l!lJS!ffiJ!lI.1!han.thil:tt oh1tam:ed.'by ei!~e:1f Cl' Of~_
The cl1;ai:&c~eriS<iltioN!Md EocmIDS;l,iItioN! of sdvmy .g]Md rumoms: ~s simpDeMd easy WJi1i:hDnt ilie need. ~o mffiect oontrMJt or cruwiulilla~e ilie dl!l:c:ts_ Even '1:lhose m¥s:lteriom. Wp,s .1ll1dlbrumps t1hiil1t do El!oll.S!eeJilil. ~oJb.el!OFl!g to tile ,expededl orgi1ID5pevea] 1!hdr secrets tolililltr:,Molil!lil!dL
:m Nruwy cases oee is ;~b]e :Ito .rnmlbe ill coNIidioot db!~oSJ!s before lFN.AcC or hi81tO;]ogy,hl!]t ill tltoSie cases where :lhis~ rus. s1tiiml. mrncia:ltedl.1ll'l1kMomdrus. tlJre
Despite ~ts ml!1!lJtrip.DernuiliDfship 1Jhiisbook ~§lS a. $eeJ:ing of OOmIlIDof:l.p1!1mpoSJemdi ] wo1!1!lJd Jlile ~o iliIDl, '!,\:ri!1!:h oonsiidJerab]epriidJe,.iliiilll. 1tl1iis ~s. iliefeS'l!1!lJI: of ,iij; OOliIlWOO. origin fOlfse¥eralJ of :ihe:aJl!lJ1illors_ lRhodri. iEv,1llJ!5,~e lBrad!ljeyW1:d Eric Lovecillay hillLVie :d.pas8ed. WOl!JJgh. my depar1tm.ent m. tile Cmne&e UlWeJr,siiry of Hoog Kong at 1tfue 'lmOe of '~.irles HospiiltiiiJI_ ]t: was here ~alt they ]eiilTIlt ilie .imTh1!1tiirn:ll :sJk:illills1ll1:d h<ilLvebe;oo.<lb]e ~orlt.e ~eSie brndk: ~o ElI][ope 0: belllieve 'lhlltBri1tam is oOFl!sidered,. by some, EO be part ofEm:ope in. aperipher;1llI.sort ofwa~'!I) and. to deve]op 1tll:e:rnfmflllier_
Most of theial!]ilholf:S .h<ilLve triJil!J!ght at the Morris:lto!ll He1IDd::wd!. Neck Uilihiil!Slol!l!t1d Workshops_ As: ltN,e Momston eourse eyo~ed, itthocame d,em lIhEil:E lliere .I!s ;<iIllfe1il1l 'I1:eed.£OfillL co-ordloo<il~edl. ;[jIppro<il'rn. ~o the .heiil!d1illdl neck. 'Thills :ltex1tsillio1ffiilid .• :ruJI.1tfu!<ilt need, Tfue 5pec1tnlllll1l!Ji. of 1tOp'~.c:.:.S.dill8cllsSied.sho.mdp'foviid!e ~e fleoess:arybackgmmdfof ,~ones;trru::tri!:lg owt mhern:dru1:d. necl:1i!1!lJtrMOl!l!fHi
The Morrist,.on. OOl.!lfl:Sle has lJiOlt.SJO far not:. mcmdJed. <li. ,Sleccttron on. cmottiditmdi.\,'imehmJ!.uaillfu;,asolil!lil!dlI'Dlopp]er.; howeViel:, it was:re!l~ ~a1t thJ!s is ;1m! eSi:>enfulaJJ oompO!n1oott of neckm1tr,illiSiOIl!l!lld1lldi. F!<iIiS thereE:m:ebeefl.1ilidded_ The SiOrn'l!O]ogiiSt Dr :SiOmDgrapher w}llio deaJis, '!,'!,:riri:fu the fueadmd! n1:eck mIDllstlhe oOMpe1teFli1t. Fl!ot o~ mgreY-Sic<rl!em1trooom1d.l1}1!l!t oalow Il!oW1mdJ.pllills:ed. BoppFer as wellli. m 'lfte fleck. we b<il\!ie ilie oppo:l1iiID1Jty of1!J!mg every new :lteclmiique that the mW;lli<cJI!I!n1!d dJes;iigners 'cru:lgEv.el!lJ5!~
It isgratti}riJn'I!g to ]e1itm. th<illt the ElI][opeiim ASS10ci<ll1tfoo. nf Radllio]ogy h1ll5 nowrecognised :I1e1ilidMd llledk: oo<llgmg as .i1iI. sl!I!bspeciiil!1'tym. lts D"~. right, ;~ongsid!e SlITciI. dd!er womes as nem,ora'.rno]ogy 'Mdpa:edi!amcradio]ogy_
Ths 1bext is ilieresmt OKi:iI. tJeam. dfoll_'\.Ve iliae$oreS<lY ";jhm yOM;~O tlhe tJeam_ We wouilldp.M1t!olilll!ru-l~' llillliJe to ilim'jProf M; Jor giv-mg1!J!sboili. Ole oppo'l1l!miJ1ty 1bo deve1)op om .m~aest ill l1eOl!dMdI. neckM!lIltr,[tiomdL We aliso owe ,ElL large debt ofgraltiim:d!e 1bo om oolilletilguresllldl SEm of omresp eCIDrre hospi1t~5" l1I'ruE;e]ly:: The JP'Moe of W~e5 Hospi1t~, ShiilM,. Hoog Kco'l'lg; Momston. Hospi1t;m]i" SWMSe1ID.Md. Neiilili. Gel1ier<i!ll. H05pi1t~ lor ilieil:gel1iefoUS ~llpport,l!itot_ilust iIl1 the r"vriliIDgarJ!oJ ,e~g of ~ 1bextbl!JJtMOMrn 1ihe OlfEi<i!liJ,iLsirl1lg.mdJ.~g of ~eMrn-risJ~on.WlOtkskops_
On.<i!J. morepersMa!li. ]evd. wem1!J!s,t <i'C!uO'I.v]edge the dOSJe sllP'port. ;;md fuclp]:J.fOviided:Oy omf<m!1iilli:es_ jF"Of . .lUM'I.1tl];iS ~s"mpru1ticwm., his "WIDe Cl1uru. W;;ai Po, ms m01J1e:r and. ms ]iil1be failie:r. O!l1i iIUlooo.'spm. _iOio]c}\);. ynm\;w i Lynee, Ca:trm, lB e1tfl:u. ,<ill G\V}'EJ!' _
AN1L AND RHOnlEU
1-,
An,ato:DlY and. T1echnique
E~qlllpmemd a:u,d, l' eC]l:wque Anatom.y: Introdndlon U.krasJOililld An,a,tomy
P.age3
'Ov-;er 1ili:e :P<illSll ID.VO d!erndies,.r,apidi smd!es mlllllitr.§lSiol!m!cl (US) tecmo]Dgyimd mpa:rtiicm<ll ~e de\iiel!opment .of lTh1!.g]1J. f,esorurttiiO:l1! US h2lVie led ~o <lJ.greEiLlte:rro]e :Worll.lill"ItI::&5D1!l!I1d m. ti1:e<ll!Ssess.nJient of ilie 'exltraCfaru<irl!. fieildtmd neck. The wcrea:sed. :spafuJa:l!.resomltion. <iJ!crne\iied.1hy ~e ]a~est gooer.illtioo 'ofmil.rnm:esal1d kiilil1lsrnroe:rsa:ll!ows exoeE!eflt neiilill :frdd.meS!OimtiO>11J. '\Vl1en. one oo~d.ers, 1!h@t iliem~jiDrirjty of s,1tI:l.!JJc1tm"es and <ilISSiodartted. p.m:I1!o]ogy m tfue :!leek llUe om¥ bemeeJ!l. oneud fuie oooTIlne1tres bel!ow 1tl1:e ~. sm:£1IDoe,Mdl.gYefI. ilie S;1mperfor resoimtion that fuJigllli.resom!J!ltron US ean i!1~ it ~s nDtsm-prismg thrnt US ~s E'i(Ji;nmg mpDplflillmrtty .Im. tlle IilleIid ofhe<iLd.ru'I!d neck E<iI!gmg .. As it ~srd<il:mdymexpen~,e (m Radliomogy lteml1!5) ;ru<d ~ :rlea~ ,llIvd2lb£e.,. liIe1lJ!SJe of US- \V1iiIill lConwMe Ito mcre2ls.e.
One crilticism. of US ~s that ~t is "operator dependent'. WMe ~ere em he El!O argmnel1t ,.,,~ili iliat :s.1talte:l'llJ:ent, it is not 1:11. cri1ticism.1illIrnt~s m<1l:de of oilier iilnaging 1te~qll:es" wihicll.ill,e ,eq1'J!dri operaltor d.epeJ1:d~t W,eilooeplt tll[jjjt· c}'lto]ogy ~s: Ooperaltor dependent we .blOW Iillat slmrgery .~ operaltDr dependiel1t,SiD why is'operaltor depelllidelThf a. crilticism. iliat is OOOWlllrn:lll}, heOlJfdl w'llen US is .diis.'C1'J!Sis;edi? Most me.dlUcEe 1S operatoe dependent m O:I1eForm. or oilier.; the ml}1:h :!hat US ~s mor,e'qpera.1tor depell:denf th:m. olher tedniquess:fuolillilld he ]OJidi torest.lff one is ,enthJ!]SJi@!SlticMd wiiIilli:ng to ~eam,t11;e ]e~g cmve ill US is FlD .s.lteep'ef "!hillJj. ~a1tillllim<wgn5ticreSi~1iIl1I!oeE<iI!giilliug ~" OOmpl!]iltedl ~Dmogra;phy (eT), or i1ftly oilierbmncll. OhiiLd1!olDgy.
Thelk!ey lio IDl.wdersltiMllidmg OK ilie ned!::,1iI'5 ill d. oilier areas of iHIDQli:O]Ogy, is a.SlDmd.l\:now]edge IQf IDlJa~omry. The .illrnJ of 1tI\u1s rnaplter is~oprovi)dle ilim know]edge as at basis for ·1mdJe:rS.1tru1dliwlg1!1!lJ1trrlliomd of ~e neck.
A slt1i'lte-of':'~e-m l1ligh.r,esomnon USma.c.lillrne is .d!emab]e bot not ,esseE1tiiaJi .. A dediicalted.lulgh.reSto'mtron. USmilcrune .is. ,1iI' mmy:WDr mosft or ~Ds.e who work mbJ!]sy US depm.tm:en1ts; howe'ilie:J[, mo.strepult<1l.bEemml~ctio1Ji m<iLcMles m:ow hatV'e s.lillifficienll hlignre50mtllolFl! lllimd\ville,SiofuvmeiIDdJprdbes Ito ,allliDwadeq1lJ!1ll!e ,ex~llfllon IQf ~e l1:e1iLdud neck. A bear 7.5-101 Rv.l[Hzpm:be wiil:h. @H:!llaltweJlysmallll. ''fODtprint, ie. a s.m§J!l. ooo1t<1l:ct is;m:Ea\Oe area, is Oop_&]. IF:Iigher Y,eqllJ!oocyprOlbes:, i.'e. loIJI i!v.IiHz<lll:d .rni!b{);\ile, dow :SJaPeriorfJeStorufulo:IJI.for :SJaPemciaJi :snc'lh!liresibnu 1i:l];er'e is .iiI. tradJe-oif iI1J. ]liI:ck. of deplth. pene1tl:a1tloll1. Be ;iil.wru:e iliat a.prDbe OK ItOD Jillillgfu @»eq1ITency, i.e. 1.1Ci'-13 il'clHz, CialiJ. ,de&lliltdybe ODl!]I1IlterpfOrnxcm~e when. ]e~g~fDr ilie beg:ltrnter, IDlJ apprecia1tiion. OK [he o\iierd.a11211tornry is m1!])c:h more easill~ dhltUtedJ!]smg ~Dw>e:rl&etpIToocypmbes. There ~s a. r,o]e :£00£ .5 &1Hzprohes in. assessiag deep ]eslblW cSllWOO. ,1lI!5 ilioSJe m 1tl\Le deep Dobe of iliepm:01tl!d. CoEom:lIlJow;fthl!cili1tiies are now :sltru.dMd. 'on mJiOSJ[ .mlild~mes;, udl. wmIJeprefer,<1I:Me :lheyme nDt neoess~ esS!en~alI. ThehegI:Mer \viiIill.Md itt easier ~opid: out 1tlb:e ·v~c1!J!ll<iLrMaltomy of tfue ~ed:.1!]!smg ODb.!lIl:" nDW, bUIt ~ere ,."vi1IiIhe less: dependienoe osee :1famiim"ly ~th&e ana1tDmy :hasheen. <il:1tE~ed_ JP'owerlIl!ow ~p]iCi\l.fu!oosar,e desirable for assessieg ]]!owpafie:l"l!JiS, fDr '~3miIp]e ill ]ymp,fu. nodes <mdl :ili}'f()~d nDrnies. The begim:ermiilty be de1be:rred.from GaH}.ng out ;<iIlmopsym, tile .heiitd1il:l1dl neck .if 100]0« EagiiFJJg is regmID:'l¥1!J!sed. MMY head.mdl. l1:eck IDiIlIlo_s<ilf:ld.lJymph nodes fu,:~I!:'i!ie spedac1!l!l!ar oDlomlIJ!owlD'e1iImes:bl!1~ oorebiopsY1illld.fine-~eedille<1liS1piirationbiiopsy (JFNAB) C<ll1I.SJ1!:illill. be smelly carriedl o1tl!ItT
One eSSien1tl1al1. pieoe ,af e~menlt is. .i:1I. rugll q1!J!a:lIirlry, ad~stllb]e oodmo1b1ille taMe. ~t is irnzpocltMt iliat :fOf US ,and US .~.dled.pmoedim:es m 'ilie fleck, 1tfle ,e;:;~er.is ·oormforEaMe. Amo<1b:iille ~aMe that canbe ,e;msj[iy posi1ti:ooeds.o1!hrnt tfuepa:tien1i's l1:eok is ]evd \viltth.IDe USmooiwm: ;Md \VJ!~:!he Gperaltors sc~gr<mge ~s eSSJentnaJLMDst operaltors md ilie most ooWortaMepDcsiittioo to be, one m w~ch. ffuepafllffit's neck lis ]evel] Vlirl:h.1OOe~er"s thillgh or bees .. Wltel1i. ~g ouubiopsy ~edWg;lWes: the Dperaltor .l!iI!11!J!stbe pDsittruoned. SiD ~<ilt 1the mcft1tor c1iI:liI.be wewed oomfoftrn:b]y ~rlhol]tmooe s,ltr,etcimg or twiis1tIDg. A IDOl'I!l!ltor Dlil.<iIl IDMOel!IDvmJbEe .;mr]J. is ideorlL ThepiiLMen1i's ,neck. 'slli:ouilld he :51ilIfficien1t1y close SiD ilialtboth. t11:e .hMdl }1o]d!iing 1tI1epfOlbeud.1tI1e TI:<M<d [I1olc:lli!l'JJgilie needrue mmopsy .gml!.orr.e in ar,e!l!m!!edpo5litiofl, agUil \viiI:1lol!J!tmooeSJtretclMing Oor ti.v1500g. Thepmlbe, needile, moWl:O:I"Mdp1l:1!l)ml shomdbe in i<ill ugh! or a:CU"IDe nel!d ofv:iew r()iD: op~<irl!.posi"l:iomng. C060rt. of Dp e:raltormd.pafulent ,."viililll',ernmeprOoM.eJOOs \vfu:en fi",ee-hmd.1biopsies <H,epeiformedl.m1!d!er re§].-m:ne US iQonltml.WhlI!e :l:fuJjsiilppears to be ~o mOore oommOil1l. sense, most OK :fuepmMems enwm1teredi.by1i:fueauiliOf \vhen.1teiitd1ir!iJ!gfree-ffil!Md biDPSy ltec.laruq1!])es are De topDorposi1t:ioomg QfboiliraJrno~og;ustMdpa1tiient.
Thepilfuiwt .sl1:ouailidbeposirtiooed ,."villi ili.e .~.ed{. ,ex1t.endl.ed!,<iIlpillIDow hehmd. :!he .sl1:ouaili.ders and!. Fower neckliLfllowmg "lhepafulent to adopt at oonio!l1aMe
~ow~edge of ltlb:e ;iml1'1tomry of just 1hli.eemililJ!S!des.- :!he stenTI!odemdioffl<fuS,trncl, dlUg,&s,mcmdi. ()mo:fuyoiJd-rus ilie JilJey t01lilllldJerst<ID~g ilie m~gl!es of the :I1!eck_ The slten1odcidiomas.toid, wmch rnrI')!S -from. ~e m<ms.ltoiidi.proDess to lihe di<lliv-rdJeorn:d.s1ben1l1Jm,OOriides 1tl1:e neck. into two ~<ltI"ge manglJes;: <mlteno!l"<ll:ldi. 'P0s.ltmrn_
mlto Mle 51!l!1bmen1ta!li. ;<mdislllibmMd!bl!l!l!ar m1ll1Jg1!es_ The ilma:l1y,o&d.pm11iorll. is ,dlNiidled.1by ilie s;1mperrorbeJllr-r of :!:he omohy,o&d. musde m1io mllSlc1!J!liarmd, lG11[otrd mm1lg]es_ Theposlteriollfudily of dffigilSmc mrrrh thesilllpe;rlorborde:r of the ,cm:oillid. m<IDg]e_
Theposlterror m~gl!e. ~s de:llliilfC1illtBdby 1ihepas.lterrorbmder of sltenTI!.Dm<il!5ltrndi1lIDltmodYud, ilie<ilJ!1IDeri:O!f.border. of1trapeoos,postrerib!l:lly _ The apex ~5 :mom:led,by Mle OCcipll1t ...vUe 1ili:eb<ilt5e of tlteltriMgl!e is formed by 1tll:e d:mwcille_ The manglJe isfm::ilier 'sl!l!1brnvrdiedby ilie po<errorbelllY of ilie omoill1yord, mllSiGle, fo~g H. occipirlt;m:] mrulglJe ,SJLr]p,eriorl~ ;1ilI1d <]IL~:mpr<ld[itvicmlrr mrulglJefieriody_ Thed!Evl!smoEl. oK;!:he neckb}' the S1i!en'1DrniillSlOiid. OfienpOSle5 <iI. d~eJillIll[il. inmI. ilia1t a .. maslS deep Ito 1t'I1e Sl~enTI!omi!l:s.:1to&d is no!!: :Somctllym ilie afIlteriOf Of thepOiSoteriof mrulglJe" the pos.:1!eriofho!l"deJ! OK 's,1!enTDm~-
Theiilfficent 'Of C'f ,i:iI.li1dl l!vffiJ hfJiSmol!]lght:a:bol!l~<iI!,fe<llppfmal!,bYfarlJ)d]o~sts: of lOOeW1!1i~omy of tlhe 'e;ll:fur;jLCf,amaJJ:heiildi,1lI1d neck. Th.eml!lmttlp~W1!W: capilJb.iillifuies of 1\00 mpncl.!l!1lru: ,fuJ<I;;V1e e:I'l!:abled],iiiI, fM bene:!" apprecm1tiilll of ilie Oomp]ex'ilf):[il~omy of tlhillsmegloiI'l. The "spaces' OO:l1oept h<lliS beoo, her~d!ed as ilielbey to .fiIl beimerllillndler$t;m:dllll1lg of ilie ru'l!atoB'lI)' Mdi,pOl.ilid]ogy of tlle ~.eadM,di neck. Rrn:dlid]ogiis1ts, ID,pru1iolill!l!:ar Hrul1iS:berger,3"';§ b<ilVie deV'eJ)oped .a dernIruld,pr<lc1ticaill m~od, ofusmg 1tlb:e spaces Goooept to irula;]yseThtmd Hal nec;k,p<lIiliology (Figm-'es: 1.3, D.. 4). Ahov·e tllJe:l\iyoidi1bone lthe sprn:oes concept works: welil,md 1b1:ow]ed~e of ilieslI]])mfu!}'ord&p.iiloes aidsassessarest r"villi,ml.iltrasiOwd, ,hOWeVief 1fhe same is not De wfien,rn:sSJeSJs.mg ilie nr..mryoiidineck.
"W1lliere do ill start?' iis ,@f1ll1Lliillliarp]eOll whoo atltelNpoog1Llilltr@SJomdi. of ilhe beiilidal1:d. ~.eck. :lit ~S es~~1tiiaJI. ~o b<ilVie an. e~lyrep]ica:ted sysltemml:1tl!csfur.&'l:egy:IDol: '!:he ,e)!;ruilil~1!ation. of ~e ,ex1tl::ocraruia'l l1ead and. neck. 'I'hisdows key :~1!!I1J:c1tmes, Itolbe rdientmedMd. efl~lb]es .atS:&es.smel'1I of 1tlTI:e whoDe neck The .~ of thlis chapter .~5 1topresioo1! a.s.trmegy ilia1! mJ)ows 'iheSiolll!og:l:aphe:l" or md:i!o]oglst to qrucl\clly <M1!d ·sys1temil1tIca:lll.ly ,ex;~e 1tfu:e fleck.
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Thebm:d.ers >of lOOes1!limnen1ta]. m1mglleme eMiThY demedi. (lm:JJ ·mtrmolllil1:di_ The El!.oor ~ :Formedl.by themy~ol1r-:r"oidml!1LSicl!e,.1lI1d. thea:pex of the mMg]eby the :sym;p~sis .men1tiis, the base .of. &.e m::mg]ebemgIDormoo. by 1he hryol1d bone_ Thei'm~erim:bel!l~ of ilie m§<il®mGmI!J!Slcl!e5r,epre~e:I"It t:he :smd!es of t:he miil1l!glle_ These cMI.be folillowed down. m trmsve:l:seSJectioo. !to Iili:e furyomd_ The o:l1!l.ly oootem:JJ1i's Oif llo~ene theslliI!1bmoo1taJJ ~h node gro1!IDp_
The geruOgl!osSiIiliS Md. geWofulJ'oid~llSdes form. ilieroot of the tonguJ!e_ T.ogetther wi1th. iliehyoglhsSil!lLs mlilisde they malbe .Mp the mrnej:olf extrimic ml!JlSJdes of :!he !toogru:e_ Them~l]oilhry.ol1dml!J!sde ~s.s}'Nic:m:ymol!l!s \VJ!ili.1heflJom: OfmCFIJJtfl, fo~g :<iI.ml!l!scw1lJfsllliilgbe1b.v'flie:l'l. the .mernaJJ :~ed of IDem<rndhlbwm- bomes_ lP'asteriodty iliemy£OIfuylOJid fuJas, OlJ.free ~ck. hmdJer :;md is 1!:hiooer<m~eriiml5t where it is attached. to ilie .m1terior m~dti!b]e .mor Ito ilie ori~s .of ~e gem<irll mlllsicles (gemogl!o8sI!illSMd.geNoThJ.rylOJid). TheMilteriorportrc:m . .of ltfue .my]ohry.ol1d 'C&I'I be dITfficm~ 1to de:IDl»Is1tl::a~e,mdJ mSiOme m1talThoes ir1! ~s deffiicient :iiill.rtteriorl~' _
The1lfirlgI!l!<I1l may CM. be e1liS.i!l1y pickedJ .1!l!p1illJs.mg ooIo_ illJ!ow itrnJ~g,mdi is a.lfe&m1}rreoogmSJedJ F<mdlrn,nk_ n~sjinillst mern<I1l. to ~e :I1YOgi'O-SISIiliS ml!illsde_ Di[erel1lfui~oobemreel'l.1the ·rntryIOi!b,yoidMd. furyoglo.S<slilismIiliSic1!es caffiI.heal1dfidi.bysl~g m 1ihe oOlfOllla:lJp~Me, whiille :~g 1i:lTI:epa1ti!el1IE !tomO'i1if: the ~ongL!lle from :side ltoSJidJe_ The mryillo;l\tryo~d~sf!eJl<il1t:ivd¥ .iimmo1b1ille wmlle ilie lThYOgDOS81]JS is idru1tIDled[ <lI!cltivelly OOOIT<lI!c1!::iing (see JF'lgm:el_61b, c)_Contractruoil1!. of 1t11:e fuyog1!O!ssl!Jls ml!J!sdediepresses the 1t000gJJ!e_ L:alter.a:ll. to tlte hyogJlossl!l!s, ~e s1!l!1bmMdulbmru: ;(]ud Glilbe iidienlliiied./,.partlolllillm'lly if ilt is dlilllaltedi. (see JFigm:e :t6d)_ Tai'e care .iI1!olt Ito oDl1fl:J!s;e ~e .ooclt 'Wiith. ilie .lllingJiillaJI. Vlei:rJJ Vimm silts ruolllg:s.iidie 1hepmm~. sl!l!bmaFl!cJlJI1bmiliam- diad; oo]om-fl!ow oo[jl~gl!]s:l!illaltlly lidmltiifies the veW:!_ TheSI!l!'lbmlimidlbiill;u dl!il:ot ~sS:Mdf",richedi. 'ioviil:lh. :!the :sil!l!bllillgEJ'al.g1iMdhenveen the byog]osSil!]S :Mdilill!)']ohY1oiidi mliliSides_ It llies jJ!st Silil]Jerior :Md ]atera] 'Ito the mgJrn<itl.mery.,.whid-!. canbe ~defl1!iIffiiedi mema] ~o the hyog]ossWlsml!J!sdle (iFig 1l._6b).
The s:J.!]ib_gJlJla:ll gl!mdl is~ rudJen1tIDed . .on. U,aJlJiS\iyerSie or :aOO;<1!!I.SiOOfuJOmlatS. :an. donga:lted .. lli!yper,echorc: :SJ1tI:l!J:crnr,e,. l!alte:r<I1l ~o fuyOgl!OSS71iliS. ]It is mnd!. ]i:ilrger than ~s. Fjem:JJera:l!l1y :<iiP:PfIBCl1il:1tedt :mlteriim1)r ilti:i!Wos;t ~olIT&es the symphysl1smen1llis .mdlpo.s~eri:o.t11y it :[]'bl9Jts ilie deep smforoe oj[ ttfie sllillbm<iOO&lhma:[ gl!udi_ The :S:l!J!bmmdubmm ooct oien.r,oowes <lI!. large aooesSioryooctrromilie i:iIIIltoom :part Oif lOOesll!blIDgJ!J!al!. g]):IDdl (Bru:1!1JJ()illffiiS ood)_ The SiIili1bIingJ!]&1!.g];;md ma~be ilomedi to the :slil!bman.dub1J!l!w:g]mdi. ~0lForm.i!iI .. ]mge,stigIe sll!blli11!gL!l!<fr-SJllillbmandllbw1lJf oomp]ex_.
Themy~Oi:l\t!ylordimlilisde ~s the lk!ey Ito diIDeren1tiiaoog \v}\];ether Olf not i1iI. ]es.iol1 ~s m the :Slil!bMgL!lI;rl ors;lilibmMrnbmJru-spa:ce_ Lesices deep ltomy]o!b,Y1CJrdl are Vlirfthi'rrJJ. ~e sl!libhgJl]allspa:.oe; ifm nes-rOl1 iis .sHperllicii:i!:ll.1to my]oh~oid)jt llies '!,\~. theSJl!J!bmmdublllillrn- spaee (see iF~gl!lfI:e 1_4)_ .Amnd thepos'lteriol[ border.of :!hemy]o-
iI1feri0r1~ _ Cl!i!rnca1tly, iliepos,1teflDrhel!lI}' of ilie dJigiilt5mcml!J!sclemm:'ks the ,dlWJisiion.be'hv'een, iliesl!ll1bmMdlllH!lilli:ilf womglJe :1lI1I1te1"liodly,.d, ftfle CallofuJd.wMg]e mmepos~eflody _ To ~dJ.e11LiliY i1t,a:l!i,gI]! [;fu;eprohe ]JrnSJtM~erior to 1ihe matSJ~ord 'Jlifoc:es:s:, cmecmg dO\VFI.~D\-V:ru:ds the fuy;ord Thepos1te:ITOf belli)' of dlig~mc wil. herdJentmed e:lne:rgil'lig deep tos"l!e:m:oma:sttoiid l1IJJl!J!sde to abut ~e ~a:illI, .of thepm:otid_ It is <l!.s,1ape:mciorl. soe:wemdl OOl!Jf..Sies at apP1fOxDa1te11y
(6) .Exlle:mal! caJ!o,fidiart,ery-. No"!:e the 1lll1ion of the paIofidaadi s:urnlHINdfb'llJb" glland!s (nOfll'lal! '!i/:a:!liaat)..
45 degrees to, ilieplme of tlle nor1th-sol!J!tlJJ :ms, of 1thepMo1tiid. gEancl 1!llere1troIDm1:ow"bwM ~ffi1d1. its oomoo1tfo!l1! 1t'O 1tll:e ex1tenl!a1i.~gmilin .~. c<ll1J,.be seea ptlSsmg :supem.ci<i!!l. to it Ths is the ()~lm<lLjor V;iiliSJcwE:llisnct"me ilia1t issupe:mci1aJ!.1to tthe ·pos,1terio\£:beID.¥ of dlig"01Smc.
By ~g iliepfobe :sill:ig]'1il:1y illIDooo:r1}r ,,uO!l1!g the Me ·of tI1epos1terio!lf belilly ·of d)igiiliSmc ilie vessels deep "1\0 .itMe seea. Fml!'11l.pos1teriO!lf ~o1m1terior ,ilieyru:e '!he in1tema1i.~gm!l!M·~.m1temJa!li.ca:ro1ti!dme1).ffi1d1. exl1e:rn<llill. cMotrud.mery (lFigrurre L HJ).
'The keY!I"cliafioaslhips ,ofllie posierioifbe11yo,f.d!igasbic tlll!lscle ..
Wl1!ere does 1i:l1elilP'pe:r oBlVi.rnJ! r.eg:UotlJ. end aad ~e n:Midl oe:rvi:ca:ll,regio.flI, hegWI! The oBlVicaJl, r.e,g:Uot1J is dM!d!ed, m~ol!lipper .andlrJru!d,pomom, hy the fuyord bD:ne_ The criCDid cW[ilge dWiid!esadlfrom ]ower ]JomooK
The omo:fuyo1diml!J!SJde ~s. an lmpodoot ,Sil!lillgtcaJI ~<m~ru:lk:_ Thes.lilpeflO:l:bel!1y of omofuyoiidldliviidJes tlhe imfahyordpomcm oftfu:e IDLterior mugEe m~o. carotid!, :mdml!J!scmru- m<illgl!es whiill:s.t 1i:l1epo.s~erior ormeriDr heM!y dWiides 1iDepo.s.~erior m<illgl!e ,m~o oocip1i1tal1,~d, :S;I!l!bcill!fuviian_1tri~glles_ Mru'l!~r" mmDlililfS are trea!Dedi.
The oOmo:fuyo1diooSJes. i:om llieM!Deriorp.olNOO of iliebo~ of :!he hyoidboil'1ebefore~g dblillql!J!eJ:y ~o CfOS8[i1f1tenOf. Ito. ilie OOml!I);O:ll c1lfo1tid :a:l1eryMd
As.Siessmeflt is 'e<iI!Syiif it isr<5l11lteJ1l'lbered. tfu,3l:1: iliepos.1!eriior m:amglle is ;[jJJEilllt -lEilll!ed.:Mpe:rliicia:1l s,Bcllilre. Thep'n~e be1tweoo.'lhe sl!]]}emcia1l.sl:.e:m:OOlliatS-1toiid.ru:td trapez:ms ID1iJ!SlciJJesMd[ the deeper IDl!J!sdes. of 1tl1eposteflm: m:H:Igllefl!oOll' is ~d~t:ffiedlMd ~SicamIDg iismd!er1tnen. ill ;§L trmSVieJfCSiep]Me Homm~1tord 1t:ip,_ i,e .. ste::m:omasto£d -origin!, ~ommdlllla:1bera:ll diil!viid.e. RemeJ1l]jbeJf ~;jL1t 1Ililie spm;a]iilooessory l!1e:IV-e (IDld 1Ililie <il!ooompu~g ]ymph node .d1!aiin)nI!IiIS HOm. a.pomt il!mv:til.ry he1tJ.veenl1!he ID&s:1toidJpmoessmd.<iIl!JIglle ofmmdllHe 1:0 &e Olilli~eJf tl'm:d. of &e d~[vide;mmt~g tfue[IJ\l:d1be m tllat he \viilllI. 1e:n1iSJW"<e ~at ~e 1te:rn1tmy of '!he spm::rl. accessory .cham is oOVier-edt. On. fu:ID1SVie:n'Sie scans, tlilie 1t:ips of 1tl1:e 1trID')!wers;e prooesses of 1tlh:everltdmae m<:l)' beseea <IDS ec:hoglemc Strn:CH<eS ,."viittllJJpos,1teriO!lf aool!]Jsru;c.sihadimvmg. no Flot M5J1tai,e tfu,eSie :E01" ca:lJcmied. qmph l1!odes ..
Page 1)
The tmeem<ill1rorlml!illsd!es to iiden"ttifjr'1rr.e the 1!rOiLpeziiu!s, omoF:iJy,o&d.;md[ ~s,lte:ll1!om~ltoid_ The &is.tall 1!r:<i!:pe:zms, is :~tt1ta:.d];ed.lto IDe F<iI!ltera1!. o~cl)e~ irts<ilfllterior :free lOOrder is ,etiilllyrecogrused The imeri.orbe1!lY ofomo1hY>o1id ~s.ID!Sl!l!~<ilppMen1t.cme ~o 11ts. ()lbl!iql!l!epll1lle_ J1!ills1t s.uperior ~o [he weriorbeli]y ofomohYio1id. me '!:he U<iImV,tlSJe o~ca:lJ mel)' :1ll1dl vei!l_
Movmgmerna1i1y, i~. ~s.po.SlSi1!b]e to id!en1!:W; the bra:maJi:plexuJs,3 '!;wlihrn1tr,1iIiSOl!mdJ (iFigm:e Ll.Je, d)_ Nolte tlJie sealeses [iIfIlteriorml!J!SJcillem the 1tI":1ill!S\iltlSiepIue, b~d. ~e ffii' _ Sc~g iliferiody,lIOl!l!l1!ded hJ'iPo-'eCho~c s.1in!I:cw,es '\Vl11lI.:beSieen. e:me:rgil1;g nom behind.1ihe falte:raillbordler of SiCaillffil!illS :<m1teno!l" <ll:ld.pass.il1g ffiwerdtY"j;mt ,superior ~o ThlIIDe 1i:Mrd.poottioo of :!:he sl!lJbd<iL:v-rID1 ,merry_. TheSiel!epreSlen~ !the ~s. of 100e br,a;cl!&aillpne;ms_
11£ulline (Figure 1.]4)
MOist ope:r<iL~ors.<ltI:'e oomIDortalbme r"viitl\!. iiIE!<lgmg of the llio/foiidL How,ever ,most fd. ~o e;ll;amitI1e 5ys.ltematic~ the u.cIi!!1:eSJncmres. of the ~eck_ ]f :<iI. oomprdl~ ex~altion of Ite l1!ed: ~s to be ;i:Ld1i:e'i;'led!, i~. ~s. iimpmtM1t to exaraiae ~e .Md!Ilmewommillldl!He ~o cs,~ernllJ!lIJL Theru:J::a1tomy of 1tl1e thyroid :;md ]ID'J~1il:I"e dea1J1t '\w'l:h. in! det&illl. m Chap~er.s 3Ml!d. 6, however :<iIl cOIDp~e of:ar,e§[S wmc'h 1tend.lto,he ~egDeded.by SiolThographers :Mdira:rnotogilsts are mgMght,edillm,e_
F~gme 1.14- The truidl1ne !l"egion_
The .]<ll}rml: .lis ,aI1I1illI1fi!i)ljjIJ,iil:i<rr snctrm,e lto_<ilge ~t:h uS,m:YI!J!t 100e opera1torsholllilldbe riMe ltoSJiSioe:r:Ems.{)mer,eoogm:s.ab]e];m~[l[h-l!heSle :<itlf,e the ,ep~gl!otltis
:[IDupre-epill&ottJ:c spa;oe, W~.lld] Me :SJeen.1ill1I. 'S:~g:J!n<ll!l. secaons. . 1 ee ooru~,. ' OI!J!.lJ1[1JJSleMUl ne, c •. ue llll!enl!l!l!i.t=U. m.inJ)<lLI ~.LlJ.P1rr.~tt<llfl. seeaoas. .1· ,Ie
,ma1bomry of the thym&dI.Md.pow,aIfuI}"foiidls tIS diseassed m C]ulp1ter 3 "
The rnooidJ 1rnr1tiillaJ!ge ~5 .at good ]M~IDJ[ m 1!he .m£diIlmJe;. il: 'ltends.~o lli:e jMs.t[iJ)bov,e [he .iistThmm of 1!he thyroidLEt ~s1ilJ.bro[jJ)dJ ,rnr1tiillaJ!gm;Ol!lJ5 Sinotrm:",e ID1di 'CiiJill].he id!m1tIDedin! :5:~g:it1t~SJec1tiiOOJ.:In oon1tr:1iliS;t'ltO theooer CWi:LgROl!J!S 1tradlte1llillMgs iliOl'l:me seea more iimeriorlly_ One :sholill!l!d. he <iLh]e to iiden1illft}r these ]MdmJ1rrks_
U11ttr~om:J:d. c<iIfI.belillSiedl.~o identiill)rtlJietra;C:he.a.::mdi. i~s CW1ilJgii!1oillsnngS,dmvmg US -gmded ~)l.!m!cmres of 1tll:e 1!raciJea tobe perl"ormed. to filtcilita1te perCUlIE;meOl.!l!S ua;dloos;~omy _ 9)11 The op1tiln;[].SJi~e 5ibe1t\v'eeN!. ThlIIDe mst;mdiS!oocmd 1tracJle;[]rmgs_ iP',ercll'iiill'1eol!lJstr.adTI:eos.1t,omy 'C<iJn.he h<lllZMdlol!lJS .m. :afI oedeasatous or obese aeck. UJ.lltraSiowd C~ iiden1illft}r the ltmdlte1ill IDlJd .~1ts 'ri:m!gs (Iiigme i_H) wUs.t .1lIillSiO id!m.g oilierpo1tel1l1til[i!i] 'i1mm,d\s 51ITch. :<iI!S :tiIl Fru:ge tfuyroiidiLstJhml!lJs orveaoas IDlomaJlies_
The s.furapmu:sdes form. ,a. ~.an~erio'l: cO\!ienng of [he .lilIi1i6e s1tn:J:c'ltw:es~d.lt is C!Ol1:;;i\emoo1t. :1:00 grollp 1tl1:eSiemmdes. toge1the:r.a!S 's,fur:apml!lJsdes"_ However :;ID IDme de1taiilled.bow]edge of 1tfu:e ruJ!<iI!~Dmy is.reqmedl '!;v:l1ennymg to idmili}r ~e exaet ]ocaru;on. ,of iliyroglJo,ssaJlcm:01t cycs;1ts.,.1lmlterior oen,';teal! d\J.1ilIDJ nodes" etc. (iFigm:e L 15).
Now that [her,ei:il:der ~Sr;;J1QiJ.1~;'1il:I" wii:h.aJ!. s.y:s.1telill<:Wc.<itpprollCJh. to ,ex~g 1the l'1eck,.r,ecogmfuJon of ,<iIlSieries of illmrlim:m:hsholllilldl:bepo.sslilbk.1tf 1thiisb~c :iiLpproa;cllli is 1!l!Siedmd modmed aooordlilng to 1tl\te needs of ilie ilweSJ1tIga1tioo, 1tfu:e begimlers&:ould be aJb.]e1tD <iLppro;:)l.d]I!l!lItr.(jJjsomdlSic~g of the :I1:edk: '\VF!:h ,1iI degree of comrdenoe_
P:age16
."- M"':loh~oid
StlilfnUI11l=~._
HgmeLl'i-
The' str.ap lJ1llJ!scles.ofilie' nerl;"
References
L ,~eriC3lfl. Joint eo~fiee on. Canees, AJCC CanclerStaging,ManuaJl:Amer.ican Joint Committee on Cancer; 51th. edliJl. New York: Lip.pmootl:lEt~I!Vim, 1'997.
4. H1!l.Jb;1bd R\¥" H<iIflIsberger HR. The pru:aph1ll}1'J!ge<il.'lSpizl'Oe: The~ey ttollDJoc~g the Sll]J1fDYoOldneck. Sem.i'J1 VltrnsQwu1 CT lW? 1990; H: 444~ 459'.
5. Harm:berger HR" Os:bOff.l .. AG. DimIeremtia.ll. dliag1fl:o!siis of 1Thea:dl ood. neck ]es.foosbmed, on. their space of origin .. 1: The ~npr,ruThyoidpm of 'I:lhe neck. Ann J,Rolen.tgeno.ll9'9:L; 157: 147-154.
6. Smol~er \VRK, Hru11ISiberger HR. niillIer<ellli1tii<i[]dlli<ilgn0S~5 of hei!Ldi. ~1Ml!(1 neck ~esi'0m. b<iliSiedl om. ilicil: :sp[ltoe of origm. 2:: The mM~yi()rudpomoil1ll of tNre neck .. Ann J Roe1'ltgenoI1991; ]S7: 155-1:59.
Tills ch1ilp~er deSJrnbes 1ili:e ,normalJs.m:al1f gEanda:n,a~omy, higEmgh1ting ~e'uJJlIkaoolil!l1dfel1tm:es1illd, ~a:l1i,&n~ks.. jp'.a1ci!e11I pr'epm-a1tron, .and, ~,ec.fuJ&r.:p.ues are on'lillffi.ed, ~o ,iiIlViOid JJ1tfa1ils. m dilliilgn:oSJ!s.
The ,mEllxori1ty of casespresest ~o tlle cl£mci1ll1, Md, smJ.:oillogJist as :1iI, fEllci\a:ll, .of flock, ~"MdJ rurus. dliapter ol!JJtilli:!1es :1iI1 druEl!g:rJ!os.1tiic<iEppm1J:dli,~o'l:fuepr.ob]elJJL The .effire.cyofl.!l!l!trasomld ~sd)e5rnbed, 1toge'l11er \\"tfu its inu'erac1tXoo \vi!1tli:I, .ollier D:EI!gmg m.odill11iillies, m~sJ!aJ!ogra:phy, erilll:d,~. I
NOinna.1 Ana,iomy
The paro1ITdg]Md ~s1il1m~mpnedgl)ili1d ;for :~;iiIlpfornrc1IToo if:! 1themol!JJ1th., The g]<ilNd lliesm !the 'paro1tl!d space, wJill1d:! is1!he ,mo,s.t ]a1ter.@! :spiloem the :I1<i1!s.opl\i!~gei1!ll,are1ilL, It eX1!ffidls "i".om ilie 'ex1!e:lNa], .iihl.!l!d1!1tm:y CMa] s.'l!])Jerior1Y 1tD the~evlel1, .of tl\te ID:IglJe of 1them<illT~'b]e ,weriDd}'. The mas.1tica1tof, pilfap}]~ge~, :<md c;:u:otid, 'spiloesbrn:d.er ~epilfotids.paoe 011 its med!ia;], a~p'ect B'om,an1troor ~OP'QS1teriOf. Th,epos1teriorbel!1y of ilied!Jjg<lslIric ml!llsde &Wlides. 1tl\Le caroOtid, :&p<lLoe IOIID]J, ~epEllfo1tlidiSJp[jJ;.oe. It lis ItliThl!llS.OOpOOil:l1I lto oorurdapruho:]ogl1es ,msmgfrom these s.p<iloes, \vfuen ,ex~g ilie "pM.otiidl, lill'iiI!SS' .
• lymph nodes,
The f~cialJ ]])e:l:'ve creates iln~ciali,pI[iI;fle 1to wide the gDud m1to sllpe:dIiiciali.<iIIldi deep lobes .. AoGllltfa1te ]oc111lis.;aMDIJ: of tlre mifllSs is. wpm1toot i!:n d!~g :~mgic<iLl! ;<lIpproadil.baili. forad!eq[l!]i:iI1ter.'I!"r.ec'tiioo. and .. m. lihepr.,er.ervaEon of tlhe facia] nerve,
U1\tr.El!SJomd. is not yet ;~b]e to id!ffiltiy defii!:lii!~¥ tl1e f<il:~ nerve. Howeve»; .,.viJ1iliu lQ;e\VgOOeflil1!iOI1 eq;ulIipmtllt tlhills.maybeoome i1iI. r,eill)iL5!1tl!cp!r.ospect W:mJ .'I1!<iI!S aHmedi. m1ted[ vie'i.vS .of lihemam facial! lJ:en;'1e ~blill!t tms is. often mii.s,1t~en. fOf :5.&1}' ,cillcts.2,3
The facial! l1.efViefll!l']S ,an1teroO-imroor.~Y u:d dbiJru(jjlilleo1lyn-om ,the~1tyb:dTh(J.f.iii:lnel1f.SJ1.!pe:rioflly ~Ollgl] tlJ:eparo01tiidgliand.lift lliies.s.l!lpemci~tot11;e vaocm<trp;];me, 'lherefor.e tlre VEl!SJCWatl"pn1lle .~5limp0l1[jlli]t inJ.gmid1!ng the Sl0I10&OgUSlt toO theposli1ci!olJi of 1tl\Le {,lIdaJJ nerve.
:2 Wharton.' S ooatt- ~s ~s seen w}\]ewJj ~t ~S<itlhlliOfill.Y diiIlMedi. (FligJ!l!lfe 2_ 4)lb19Jt ~t ma\¥ oOoc:a;sio1ll!d.¥heSJeen. m :llonJ1]jal] cases, The &ct e:od,endis HoOm. '!he .gll<md .l1lliruJs medJidiy ~o cmve ~<llOm1!d 1tl\t.e mynoJ~y'o~dm1!J!Sicle,,1iIP,p~g brJtBl"allIDo 1tl\te fuyogl!OSiS,lillJ5 m1uSJde_ It then. Ol:dv:moes merniirlil.¥ to iliep.apiilill~ ill> iliel.oof of 1!i1e mOlilftth_
3 The mtr<il!g1l<il:m:W!<ll" allots appeiilfliliS m. iliepamllildl, ie_ :slli.oo" d.efuedl fuWer,ed1oicllmes_
4 neruTh~eriofdivisXoo. of :!be 'fe1trommollllh1!]]m- 'v;cif!I is s;:mdWiid1ed. hmv,eoo ilie P0l8t,eri:Orpo]e oOf ~e ~lhmmdillblillill1itl: gl!<iI:fldlimidl1!he <HI'ltem-oO-weflorm<rrgm of"ilie p::n-01illdlg];md Thi'ts];mdmuarkma.rybe iilMpm1ant when. ~1t iis dUsp:lJ&Oed by ,<iii. lJarge m&S5,. _g;Wmg<llfm::l:l1e:r .iI1cllic<lI:ltiio!l1i. as IDO the origililll of :!he ~esiioo, ~-,e_ p1itlfo1tiid. Dr sl1llilbmtm:&buillar_
5 The s.l!l!buguJ'i5lll.glimdis<itl"e e~ 'wsl1!J!~edl s1!J!bmentd¥ deep to Ile liil:ry]o]wyord <mid. ]liIi~eral! 'Ito "lhegernofuyoldl1geru:oglJo,s;51!J!S_
.~ ~t C1llI hed:iill]i;C!m~. toscam.1ihe enm-e deep Lbbe of tllliep&I!Ottid. 'beCaillJSie of the bo!l1ty <IDa~omy-&o,jta:1te Of <mglJe 1tl1epJf,q,he,. orneove fuepatielil!t's ~.eck ~o oib:ltrun. best access.
SJ].!lilbm1ll1mbmM emami. MemO>fe oQO'l1lllilllOIDI. tbamJ. p,Mo4id!. caJ)cu_ Thegrea:1!e:r .liIl"i:lLl1lBibe:r >(8{)%) of o~ami tIl!<l!1t occmm 1LI1:eSl.!l!hl1lllialill:.dhlblllillM .g]MdMe :mlt1111b'lI:lJ1!edl to "l!fue grea:l!ermllICOl.!ll5 COfI1t,e:nll of !!f:ueslWrnn<irn:&lblllill<rr s;m.§J,spiMo1tUd~a ~end)ili;]g 1tobe .mLore [iI!:lliueO'llill5_ '90i% ofsuibm1ll1dliblllillM ci!tl!cl!l!llii.Mer@d!iio-op<l!.q'1!Jie,. wher'ea.5 o~ UJI% of p<lIrotid. stones.a:rera:.mo-op<ilqlille_ The :I1illiilljion"fty Ofp&EWe:nIs preSlen1t 'With1il. SOlliEill}' calliCWID!S; however., mmtipllie calle •. liIfefol!m:d. m. 3'% ·,afpat:U~t·s_
High .. SlefI&iffiriry (94%1 s]}eciicitY < HJ QiID~)Md. :a,aOlillf:a.cy (:9:6:%) me d~e~ for iliLe de1tec1tii04l. of cillil!cll!Thi. by1llillfr.[ilCSiomdL iii S1ill:OOilll')OI!li[:<iI:cy em .omJiy' s1!!e:I1I!iIwom metfcl!lillolills ~ed1ll1:l!qIJ!e_ mtr.~~W1:.WJ1!m: lca1b!lilli.ar·e easier to de~ect lli<m. wcta] st,ooe.sibll:lJ1t,. as d!lis0MLs.Sledi.pr,eviousl}r, i~ is
u1'tr<ilislolD!ll!c:li showshiill[l[1ber<iLl s~,my gliMdi 1e:mJ[j[fge:lil!lel1t \\itlJJ. ;<iIl Fl!omJ!a:lJ IBc:hogemci1ty_ Soml!etlrne:s "l:he~[mrn.,[j[f,e fuype:r,echonc 'ooe to fmry lmiiItr;&1tioo_ Ths mJ:1il!.}' be seen ill. ohesiltty, ailioohoThism, ,cl1iiahe1bes or m&emi!~_ F.a1t1tyillru1tl:atloo CialiJ. be seea ill l1:ormaJi . .wcIDill1ts; fu;~g<M1J, 'erne b~i§iS, <Ml!dl is oommorulySJeeJilli in No1i:fu. ~~·jL VariOl!l!s. rnetaryMdi.mefu]!hoThic dllisiOrde:rs. '<i1!5 '1"veilll. as ,dlnJJgs. CalTII. ciilJ!.]SJeparo1tild.emMge:lllent Aproment<il:ooess'IJof}' ]dbe of ~ep<ii:l:otrd mary be seen as ;[jJJ lilorm;a:] v:mill1t
The parotid. ~s ilie sallivarygn<rn:aimo.st o01flilimo~mIec1bed.:by <il!cl!J!1bes.~p_,1J.we ,s,jjaill<il:dJem1tis.; '!he lli1k!e]y Cal!J!Siesru:estone,.s.mo1tm:e Of d.e11tycka1tion_ The '01:ga:lill!SBI ilsIillJSil!l!aJ!b' s,taphyZO'CI:JiCCtM aur,eWl,bl!J!t Str,ep" pnewn/o':niae, E, coli: and HaemophiJU8 .i'1jluenzae h1iLVe;[]5o beea ~sd<iL1bedL 1'lillherclili!aSJis.m<il.!y cal!l!siegrulllillomatol!l!s irnliiil.:llllffii!il.1bory disease, as lill!i1IY 1!l!cJmTI!OIDI}'iDOiSJis,Syphi!s, b]Ol!SJ1boml}'l()os.is [jill;dllhiis.top]1IDSmos11s; howeeer, tNeSie conrntiDnsMe w:me_1 I
The1!l!cl!14!ti}r iirnlJ<Mlled.s.d\r,ary gIi<mdl sllows.e1lill[jJ)fgelllf:.:fL1t<md f1y,po-ecno:gemicitry onm'tra&Owd. SiC~g_ Thep[J£,oocJ1ymi1l. ffi<ily}]aVie [jJ) }\te1terogBneOl!l!s. pa:Hem. a1tltl1burlt<llble to iliepr,e5eFl!Oe ofmicro-iIowesSies o~ ID~Sied!. wet diill&Eafuiomr!e.1tel1fuio:l1! cysts, iProgressloo.1bo ,iID.a:'b.SJoessr,esl!l!l!tts m.a:n. iiIiI.-dcliined. h}]:Joe:chogemci1ty '\;~ilite gliiMllid,Siome1ililnes wiili nm.fmiid ooo1bent There mi'1iILybe furyper,e:chorc ibci. ,rn:m.e ~omiCfo1blill!b1billes of giil's "WiJ1!:fuID. the abSioesK iP'rio!" to 1ID.q;lIT.eE1!l!ctron, tlte1ihs.o.ess will. a'ppem- M~l illiI.-d.eJllilTI:ed hypo-edl0ic i:rJ,f])1ll:mIlla1to[), masK The ibright m1tl:,lIrgll<mrn1ill<llf dJruc1tsm-e deml~ sees msidi.e the ]eslbn,mmcaMg 1!f:uat '!he £esiloo. is illil d.efuJ.ed '1iIF1dperme~t,es. tl:JillOl!J!gh tliID.e gl!ru1J.d.r&ilher ilirlfl ,rnJ1]!smg dJmict disp]<iI'Oement .ijli5per 'ffiimom_ iP'<iIIDfu]pru:01ti.di. Of. neck :llOdes are often jlilleSiel11t<md itt ~s posSJ!1):]e '!hat ilieSJem<1l!yaJiSio lli(j)l!l:eI}r ;~dprornroe further ahSiOe5.cSieS_ UTllir<iliSlomdgWd!.edaIS:p.i:a~on a!illows appmp,ri<1lJ1be ;<lll!ltllbi)otlc ilierapy tobe inltrodlloed; ill It'he ease ,of1!1!rull!oowillar a:bSioesSies: irltmary aJ'\!irndl &e :Ileedi"Dr s_gery_
m, TRASOUN""D' APlPEAR..,~.NC1:S, IN 1\,OU"""1'I:. 1N:.FL411/Il\/IATION
Sjogrenis s}'Nmome is a common alllJl:o-'~l!l!I1e oo~dlirn:iioo sleenamtost exdu!SJiv,e11y m women_ Thep§:liien1ts me1!llsIl!a1ll~1" Dliid!dille-agedl.ID"emailles \cv'nopreSien1t \.viJ.itt1lli-4-<.· ." re'\J1eS<lIl1I!dmDlI11th
~,J .J . -
~. :!he eru:lo/ :s.1t<il!ges :!he ;s.;nillW<iIf}' glludls Jllill![iI)' be @o:n:miicl! or :showdifu5Je rm[jJj[ge:rn;ellt r".wtfl fiorm;]]. eoooigemcitty_ The ~a~e iellmres me vTrurilly dli~g:Ilostl£;: i::I. l\J:e1terogefleo'll!s echo texmre \\"liili.mllill!Jittmp]efomd hwo-ernoi:c
Ffg'l!lIe 1.1 1-
Sj:og:reri's,d)is,ease ·of slLlpemciaJ:. pra:rotidL ROhllld!ed! fu)'po-eclIi!o~c: areas .... illi '!eliafIiive1y normal!. fuadgrl1llllilldpCllilTenc:hYlt1<l_
Thelf{)]e ofmmrasol!l!l'ldi run Sj:ogre1i1's di!SJe;we is avo-:fold!: (a) to ooil'lirm or excmdiesmID)! glimu:dJ WEVONe:IlleFLt; (by ®o ~Odlk:. for ~rmpihomi:ilt}()ius ,d]1ffige, as '!her.e ~s <mi. <il&socii:1l:fu!on of liymphom<iIL \Vlifh Sj:o'gnB1lJ!.'s sym:mome_
S~aJ!ogr'1lPhymacy :Sill>owpoocta.t.ep1]f'oorno/M;IDi opmmEon .cmdi. mEli'iIL\IMa1t1rnJJ.c:me to dffimgilliliiSled. ·ooot 'ep1'1:ihel:im]]]L Scm1!l!g:r.apfiy caabe 11dpillimill for mD.l1i1bomg ilierespooSJe to ilierapy _ Howe~eJ[., :lheSie .mod!<rlitiespro:babilly homV'e llitfe ,e)!j1tl"~ to OlEme:rm m~g the d'ill~g:rrOSJ!S_17
S:Mco&dlo.s1s l1Si:iI.rMe ,~ca] m.dIDg in tl1ie s:6ary .~dl (6%)'I)11]!1: ills fiiLst,o]Oglca:llliy present in 33% Olfpa1tien1ts r..virl:h. sMco&dlo.SJ!s_ It maypreSien1t as [iI. mp, l,wlOO. 'or 'Wi!iliOiI:JJ1t lIoCi!lll.p~_ li11ID1:,1iI!5ol!1illlidi is: nONi-specmc !hl!JJ1t m<ilL)' sJ1owdmSiel\!ypo-ernogemci1ty m a. norm<iiJ!. :sJmed. or ,e:lThlJmged gland, The sl.!l!bmruJ!dlillh1llilln gli1ll1l.d is ilieElliIlvomed.Sl!1be_ It is ~e11y ilii:1l:1t 1tl1:e ,g]Md ,-,..\:riMI.beEl:!cisoo. for a .. ms1to']ogtc.:§!li. dii:il,gno.slism1illess, as moome mstm:mes" lOOe rni:ilgNiosills has.e<il:d!y been ,estllhThishecllby o1ther me<ms,. ie_ omebiiop.sy_ Heerlimd~.'s SjIDdrmlle isan.l!l!I'll!llSl!lla.].form ofs1]f'C!oli.d!o:sls oons:isug ofweiitis,.pw:01ti!di.swdillirlllg and!fu:ci;IDi P.'iIlDiidf-ySllS_
Ax!ial! image sl1~""-rnrg fur,ll:I]se.cledi. ·d!ista:l! p'3:I"~fu!d! dud (a:rmwedJ)_ mj,my slL]sb;ne,d!;f®m~'WiNJ_g an as s.ami ""iilia bmke.n glJass .
Th.ep<iltioo1i's :s)'flIpt0rnJi51!J!SJl!]ldiy rdi!l.'lte ®01ID.pmp.~Jb:]e. mp orprun_ Up IDO }~)% of c:lliOO)ca1illy dill<IDg:I1!Oc5Jed smal1}'gl!Md~ses are fOlIDdiltobe dlrrne to ]esilloos 01!l~sj)d!e ilie sdv~ .g1l<rn:dby1!J!l!1tr<tiom1d. (F~gJ!lIfe 2_14)_ l!l The mcidenoe ofs:a1lEv.;ny gl!&nd ~om:.5l1s ~ess 1!h~ 3perUJiS .ll!ead ofpo,pMilla1tiolfll, .a1lI:fuOill!gh iliere are r>BC!og:l1l!SJedl geo'g,nilp]]illc v;mafuions. Sm;iJ:I)' gllmd. fu!mJ;oms.iitlf.emme 'ooml!iI11!lomlySieoo. ill 1tlh;e 'p[jJ:l"iofuidl; 85--'90% of ~eSle<tr,e beJ1l!ign_. The ,~ca::l. piiIl[:[il!ffietrer.s formug:Il!<illcy :arerapid!ly growmg £eMO:Fl!5, ~odlaJJ emiilllge:mel1l1t<iill:df&.ciId1! fle:f.Viep1llf.<id~si!s_ HOWeVief,becal.!l!sJeSJ\TI!1bmmdlibwH ID1lli1SieS JEl'iilLVieiill yea1te:r.propefilslrty forma.1lignrulcy (33%1~e sJOnO!no~st .sbomd haJ:V'e <:I. ]owe:r tmesho]d ofslQJspicioo. Jor ma!lliignoot mmoms WE. tltes\TI!1bmrul.rnlh1!1!llotr or .51!]JbmgJilliallSJpaoes_
The SJruL\o]DglSJ1ts&.nwd beware of <iI. ]ru::g,e 1tI!Jti!nom or one .msmgfrom. ilie deep nobe (llies'siliJ.<ID. HJ!% IQf cases). 19 It ~s not :<i!lIr,.V&Ys e1BY to <ilocm:atdy assess 'iheext:en1t of @te lesion. m :ihes:e rnclilllllSitrnThoes.,~d Cl' or MillU \villiI.bereq;uir,edJ... Oocasiml.id~r <iI. deep spaee mOliSs., (pi!L:I"apha:rynge<iJill,. CMofuid m ·mas.1ti.Ci:il.1tor space) mi:1l:y .wsp]aoe '0([ .irlIDV'i:iIdle ~epHo1tiidilllill!d!.s.iimlllill<il:1te .<iIlpilllio1tiidm&Ss '00. dilw.c<ii!l. 'e:}l;~;]Ufuioil1i_ The SiO~O~0giSi1t needs toassess wTht.e1tlh:e:r. lOOe hOl!lll1dm.es of 'lhem~s coo. he d.eM,ed O!l"' whether omo/ the "1tip, of ili:e iceberg' ~s 1) oog m<il,~edJ... Deep, b1he mas.S!es <11ppeotr medlii1il!].1to ili:e mudi!ble ;1ll1!dV:1ID.5Clllill~p~<me1illd. cuSJepred!omIDi:i1!11i:l¥ ]ll!te:r.'il1I.cm:ctdlffipffi~.C!emffit_ U11tr.aSOlillid.~s as effecwe as o1tl1.er modJdrruies ill~ero]e of mtmom ]ocma1tiOfl_liII
TfuiiS:1J.]!11OOl1lililOOOOi. 1t1i.l!IItom ;iilppeorrs: ei!!c.m~eliy m~e o]d).e:radJoilllt {> 50 years). It ~s; a. ;8Jollid :itmEom oompoSied of o:l1ooqles (llmge cells \-vihl'JJ grmm1rr 'easmoplUc c}1op]~) ;<mdJ is ioood ill iliepMotidL There are fiO ,speciicmtr;a:sJol.!l!l'ldi£eanes; ~t is ;smM map,pea:I'MOe Ito ilie oilierbe:ruign, ]esiotThS_
mherBe:niign Tumonrs,
These ]es.J!o:l'lsmSie ~. the g1!MdllJIarSp<10esfrom flOl!1!~parencltrymatollJls eille:l]j])ents_ They ilndl!l!de 1lipomffi1!5 ,Md Viill5cl1lillorr . fumlno_s_ The lmpomat 115 wdill d!elIEed. ;<mdlllliyperechotc_ 1:118, oompresSi.ib]e~<ID1re <mdl.bri.gfu1tstrer;rl1rsp<n,deJJ to the .skm. ,smaoe :<neuSlemJi rnagl'lOiSJ1tiic£ea1h!Jilles_ CTmdlJ1l.OO are dw;wgl1os1!lc ;<iI!S they diemonstralte ci1;nact,erisfu!cia1tt-f aMefll.!l!<lITIon mS~g:Fl!<1l1I_
HaemJ<IDgrornffi1!5 are mOlf,ew,eqjl!l!entllys;een. m ,dilldr'efiJ. or Yolil!l1!giil!.d1IJ!1ts_ They mary ;a]80 ibe oompresSJ!b]e<llfld m<ily~eijlJ.1billmiSh. ;sm.dlliscdomatl!ofIL TherymffilY c:}\]af:lge iinI size 'WiJili.po.s;1trn'e or orymg_ The~\tr,~l!liI1!cllshows an IrntOmD~ffieOl!J!S;]esi0n which iiSl!lLS.1!lldypOOrlly d!.efiinedL 27 V~1!J!llM~~oes OfiilSs,oCt<edi. ;<lIOO:Olfmiilly Farge vessels .lill!<ilLy oC"G~o:i1Jdyhereoogms.edLF oeal ,y;illJcmc;j!Mon (pl11JebQll~s) may be idi.entmJed. ill ~SiO'INe iiffiIs.t~oes_Cab!][ ]Oiopp]er irs gemer<llillymlludpmillas ilie m1te:I1M:lJ illlJow is ltYP!cd.1ysmggjs.hrmd 1i:hlIl!S it. isdliIliicmt ltD de:JLllomtr8lt!e ~S;l.!]oo. ~QW :f]!oW1i,ocloQtmes_ Co]om '!:mI. iinI.'mJaryhe observed l!]]J~r,eilleas:e m[preSJs,meaier 00ifnPreSJMOfI of the maSK
M~g:I1!amt 'f1l~ili&~ lti!Jmoms of ire sOJJ!iv,my .g]M& iil!oool.!l!l4ltf[m 1 7% of .~. epiili.el'riali1tJ.!mm;oms_ The cSmaillier S:~ID)'gitmffi h<il:Viegre1ll:lterma:Thi.g;I1!mtpaltem1tii<ll.t@ 'IDmOM in. the Silil!blli:l1gJ!ID<i!:lI. OfsubmMdllib1lJ!llm gli1ll"ld.beim!gmOli"ell&e1Y tobe mdgnMi :lba. <iI. mmomm iliepMotidi,
Ulifur1ili50l.!l!l1di.orli.o:l1!e m~yprernct mallignMc-ym 80'-89% ofC<lliSes_2R ThelllililtriiliSiolil!l1dfea1tmres .i~mes:ii!:!1illHIDor d motliiig:l'l!<mt ]esio~s :and it is not posSJ!b]e 4\0 ,d:iillIeren1tl![j[1tehem.v,ee~n tlle hll.s:to]ogfc;a]l1types_.
Mli])oo-ep~di.em:ojjd cmcil1!om@,[]:CQom1Is.for 5-1()1% ofalllls:dv.m:y gb.lIDd. mmoms, 1i:l1em[]]jiori1ty ariising:from. ilieparotidl. (80%)_ It oeeers at~y age and 'Ille:f>e is lJ!DS;~pped!omil:u1ID'0e_ ]t is "'e most OOl1llmOO. mdgnant rulliE:l)il1lill afdillillcltood
Most of ilieSJe 1ti!oooms are sJ!oWg:l:owmgmCli.preSJoot as Hm. or .hrud ~esiioo:s_ There is a marked. ~,oodency for ]ocaili. mv:~oo_ ]P'm. orltcllmgm ilie :E@ciaill :I1:efVie 1ten11tory ~s MrnC[]]~e of@maThigFl!ru11tpm:ofu!di tI!lmom_
Ml!IDoo-.epid!ermoxd. c:arcmomiil!. ;arJ!s.eswom. 'ooctali eplith~_ The m~rIDo:]ogllca!ll.gr<ildefd!a1tes Ito the ,dlmcal!. Jllctme: ;~ ]ow - grade ·fu!Jtlno_ mOlLY leeliMd ]oak illi!ke .[jJJ. bemgl1~esj)oliJj_ SiimiiillM.l~t, ]ow -gr.a:de £esJiomm1li}'1ltpp eru' we]] d.e:ilThed wW,s,1t ltflO!SJe of rngfuigr@diemepoodly defuedlru:J!dJ IDiil.cybe i:,~1y 1'ml!]k~e (lIF"i!gm'e 2-_18)_ ~t is diilTIftfclllliHodlliSJ~[j[lte iliehef!Liign .or
Non.- Bo.dgkiwl's l~'mpfuomiil.l!JIsl!J!dly mVio~es thep<itl:otid flod!esb:uJ!1t m;jj_yf,<it[dly~e rise 1toex1t!l:<ID'l!Odaill.diseMe ill llies~ gll<mdpnffid1ymaL Mrut1p]e nodes are oien al1Sio seen m:dlare3!S of ~e aeck. Sol:irJt<itl)' nodes mel!illl'll!J!S'l!]l<irll. for lh.lliil:lphoml1JJ_ L ympfuomf:llOns. aedesare ~pica:lily ·\'Ie!fj'bypo-eoho.ic Of ,;memorcad miily 'sfuow'ltMouglli tr<lll!smmS;s1'Olli_. TheY<lI!e ]:l[ge~d mmltlp]e_ 30 Co]omillbw DoppDersllow:s matkJedi ¥liIiSIom,ll:i1tty 'i,vi~. ~eS!e nodes,
The s.ono]ogi!s11 .11011 _eql!J!en'l:]ym..dls ltfutl:1t.1tl1:e origm of llieparo1tlid. IlIiJ!<l!SS ~5 \Vlm. 1them:j1:S'Sie1ter ml!J!SJcill.era1ili:er than m.1ihe paro.1tid.g]Olll:d_ A his~ofj' ofreoen1t. demta:'!. tream.erIt m1fuyimille:n1 one to. ~e rua;g:nQs&s of ;~mi9iSse1terml!J!:5dea:hSiOess:_ U1:tr<lSolLm!d.shows <11. w·clI.-dldirned.uec:hore ]esroo m ltfuernI!<iI!:SSie1ter,wiri:h. or '!,\';~Ollt :fr.<lI1l:.lrnd. colillec1tl!OO! (iF~grn:e 2_2 l). The ,rn~osis 'Of .&hs.:oess is a~ev'ed. by t1\te rns.tory ofp.am, d)ent~. sepsis orpl.!J!s:as.pWa1ted. at jF-Nk jF-NA createsthe 'QPlPo~ty~orrn~gI'J!o.s.is. 'm~l :~bSJoes:s. and. ~d!entmc1il1tiol1i. of the Olf§1IDiL5mJilli welill as dl&ru!~e m.rn.<ilge which. mary 'abVliafue dte need for S:1!J!l[~e:ry_
Cys1tllcm&SStes. ,of tbes;iliv'lll}'g1i1IDru 1]:l:etfare_:; I Themi@i:onty ooc. m tfu!epiilfo1tidglJoodJ « 5% .of. £esiOlili5)_CoTI!gemtal cysts ;;mls;e :from flllie mst Otf :Siecol'ldhIfMffiiaill.groov-e and are most c~o~ seea ill tlte n<mt The .other'l[!<itfe 001f1geniJt<iL1l. cy.S1t is the d.ennordl 'ComJlsoog .of kera~g: sqllliamOl!llS ,ep:ith~_ ul'fur<iliSloudsJ1oW5 mi. :mf:'eJlo1c wdill.-de:fi!l;ued. feslon_ AOqIDr,ed cysts mat)' he seen m .. .AJDSpaf:Dents Mdm""5!1tliY m c:hiilldir'e11 (bemgn lo/mphD-
11_ Bnmleto,a. IN, Mo.mDn .. ~_ UJ!tra:soudffi '~:y ~Md. ms;e1liSle_ on. JO.to'rninQ,.laryng.oI.1k:lat S.p,ec 1993; 5S (5): 184-189'_
26_ '\1;,.l'hyme ru\il[, lByrne N_ A COn:!paflSOfl. Ofool!Ihp'lIliEed. tomogr1ilpih~ 'Md.lil!lJu§!SoooOi m ilie1l!Ssessmen1t .ofpnotiid masSies_ Clin .Radiall'9'87.; 38: 33'9- 343_
2.7. Br<il!dilley M, S~ewm l. KilI1g W "Me1tn:ewdli. C_ ThemJe ofl!l!IiEI.<iIisoad. <mel! OOJ'c RIle :Sicm'1t:igraplily m 'ttlllie rn~gnO\SJis of ililes:a1lEvmy ,gllMd. h<ileJ1llli1il1JJ.grom<:l_ ]]r Orul.Mmci.ll,qfac Burg 1'991.; 2~91: 164-1.65_
lP'ost\opera.Dve Hyperlrophy Ullt\rasQund 01 the iP.a:rathyroids
iUkrasoilInd oftbe Thvroid
." .. ~
Th.e pa1tioot \~1th. a.1tl\iyr.o~dl nodlilille :pr·eSJen1tsOll oommoo. mc<i!.l!. dlill!~'<iI_ Cn.ci3Jl·ex;~<ilEi:on. ~smlab]eto rd!entfify the neflijlilll:e of 1!ill1e iI1ioame, ud Dijlglng mary be neoessill)'_ The .~. of BiiI!giwJlg \Virili. ruJ.¥IDocid1try is ~o dlli51tIDgWsfu .ilIlbM1igllHom. ;ZI.mualligl1!Mt ]es.ion_
The 1thyroiid iis11llil1iiql'l!e am:bng end!oc:ri:l1.eglJill'l!dis m ~1!sreJIam.rleq Sl!lpaiiiici;;rli. nocattiofl_ The nom:u<rltly homoge1J!eol!l!s texilll:e of iliegllalIDdl llj\s dead}' clclIDed. 'smroDd!itng .snotmes,.md. fthepro~ty of COflSJ~tWil!<iL~O~C ~liWd!nillbsl!Ich as ~e c1lf.o1tidlmery and!. ilie im1~en1<icl1. ~gm1l:[ veiml.mall:Je i!tiilfl. ~d!ea]. strn:c1tm:"e for evmaEi:on.by :high resom!J!l!ionmtrmoflograpllio/ _Miliol!l!gl\ImhiiliSollmdl is SJem1we m det!ecfu!oo. of iliyw.idi floci:Iilles, in mexperiioooed l]1m:dls .i~ bdrs :spedffiici1try.; tills: CUi. be ov.e:roomeby ilie lact iliat: it:~s e~ >combined. v;ri!thfue-needillern;spiration {lIFNAC) Cj1td]o:gy_ Ul!1tr.11iS!oliWJ:dI. oombifled. \vi~.lIFNAC is 'lher·elFme Mle iideaJI. n1tJlaill iiliJi'i,!\esfui§;];jj]oofm 1thyra~d iI1ioc:milles._
The 1tJhyroidJpar'el'J)cl:L}'lilla:ll. rec:hoesilll[.e~e,l!l!Wf;on:lll.iim!d!. h}~e![,eCJhoic; oompar,edi. ~o 1i:lhe adjilitoent ml!l!SJolJes_ The vessels v."~. the g]a:I1d!s aeebestseea ,a:jt "!he po]es_ The ed1og~ciliyrordJ ctjLj).SJlilille ~s dearllys;eoo. 'ruI.I!l!lItrr<1l!SJOl!JII1!dl <IDd. fuclps~QdBerenlti"l'lbe 1Jhym&dJ ]esroos "from El!.wa1thyro&dI1lllm<iJiS;Sles sl!l!rn<ilrs parathyroid ad)mom[fuS_
1 The right bbe 1tffidls. ~obe 'sJliig]1t]y ]i!t[ger iliru1.1iliue ]eflL
:2 The Rohes are ,oi,en not at :!he same ]eV\elIs m the .neck; ~ ,omomeds: !!he ~OGl1trOrnl. ofp<ilillalthymrd~esJ)oos_
3 ThebOliSJe of ilie]Oilbes m<ilr:y he~1te ]ow ill '!he neck, at ~e oen.rlico'lhoracic j\mtdlion,.md oonsider1lib]e hyper,ex1ten,SJioo.m!<ilybereq:M',edl ;forsonograpfuic ev,.a1tiloFiL
4- Thepyrlil:mlid!a]. Dobe is :rru:.eIy seeadee 'to lr1tsSlDd. an1ter,o@os.terior ,diiameter_ It m<ilLybeSJeel1li .. in.1tlIDe yo'Wg1b,ut iIt:l!illidergoesprog:ressNe atrophy mi§l:.Cfu!1~s_
5 There m~y be .[11[ 'ipcs1el!ilJdo-miiliSs'at 1the]owerpde of lil\ue thyroid! glImdL 'fhiis isepMa1tedipomrul of ilie glJMdl~c:s<ilLpar:m:hyroj)d. ]esiDn, 'p.ar:lti)0lili1lar1~l 01'1 1!r,jjU1IWe:l:SieSC1ilflS_ .A ~muglfuwdlIDa]SiCM. g;mdcl~ oooilliimJis ~1ts !thyroid origm r(Flig:m:,e
3 _ 4)_ Sl!l!ch. <iI!. mis1taibe ~s COl1I!1m.O:l1! m a.:I'omdedl fu.!}'Pe:Ii:m]Jimedl .g]<lll:dl.Ol!s in GriIDViesi rnSiea&e rOlf 1tbyroidlifuis_
6 The oesophiilgl!ills ~s i.d!en1t:iIITed &5 iiilr'buililJ's-rej"e' v;rllli .: <iI1!lI edl0gremc oelil!tr.e of air 1iWl!d. sorliiv<il!. ruld. i:iI. hWD-.ernorcrimJhecallS!e ofi~smiI!Jis.omOl_e_ It is COIJililnomy d.evli1il:ltedllto tl1:e~eftiim!dlsho1llilldl. not he mst~en. for .is!. m<il!S,s]esron_ .
7 Ther,eol!l!IToot ];nyngem :I1:e:l'Vie Cru1I. be seen rO:Fli.]illJJglllilillJdlin<il:JJ .S!C1Ml!S as iiillm, lilinear,. fuypoernoic .snctu]febe1tJ.veen ilie 1ll~oid.1m1ter1odyafl)d the Foog1!lls 00. ,po51t,eriorl~'_ ill1tmay ~we rechogemc redgesdl!ille to '!he c<il:psl!l!l)e 'of lihe 1th}~oiid1Mlidl 'lhe ]Ol1!gIll!S oolli. ml!J!Slde_
EX:.nniina.tiOi.n
MQSJ1t of 1lleM§tomy d!eSirnbed abo\'le canbe de:IEomtra1tecl. \\'irl:h hligh. resofum1!l!on tram!ClI1]!Oer:s._ However; m 'C@SJes of ,dleep-sealted.1t1tlmoms., :l:etras.1tern.mreuod<ilr:wcmon exlten5ii.oo.o.Omnom:s,. obesepatients ""VliEb s.l1i.ort. necks, ,olf:pa:trents who CilIiMot adeql!l!§~e1y nyperex1tel1d iliei seeks, one m~y [h,\lL'i;i'e 1toresort to iiiIi. ]owerresdilO!1tJion 1tIfiilN!soooer (5 llv.l[Hz, Wli1iliu.o:l' 'itviiliout .iilll stID1:d!-olif~e1)_ The .aim. if! 1i:lhe&e cases ~s to iidJenili}' '!he:rdevM1tpll1thO]ogj'iUl:d.lts.
" "--,~ -,~ • ".1l,z."
m<ilDj1olfMa1tmwCi:ltl.l"CJJa1tr.Ol1I3.l"l'S_.
fbf
F~grn:'e, 3.4-
Traasvessesenegsam (a) sfuo1W"iIlliga h)'po-eclIoiic llli~H!I!u1!e (bllack <ill"!D'WS), s.epmaftedifi".e:tn the lliYI"Oicli. by a brigfu.rft lli1"I1J~di !capsl!1J!e (wh:ite :<DI1)'ws)..llis may be n:uistakeN! fO:l" a pamlliy:rI1J~d!. Fiowe.'Vflr" ~Ol1!&rudlina1. scan (0) sfuows lliaft i'l: is a tOl1lgIWe,offuype.meprne,d! lliyrDldi ,gl!andi (1!arge bllackar:rows).
Thes.OJl1:o]ogffit5&:mrnl!d5Jtm ~Si~g m ~e 1tir:[j[ffi'ir~aS!epF1ille as tIleiitdljla:oel1t :[IDa1toaciIDJ.reli[lL1tlol'l!:Wps of 1tfue iliymiid Me deill"~'WSiI!]![llliiS!edl_ ·W'ben. eVilillllMg :If:t1J'r()~d flocIDilles :lheex~atrol'l! caabe dlivilded. m1!OID.VO :pms:
:2, ,1IDcffij:aooots.1tm:cm:.eS5lffic:h :<iI!S lliecru:otildi. mery., m~en1i<icl!. jiuJ,gJ!lillar. vem,. Des:opfuffil!gJ!illS, s1tl:ap ml!]s.des ,Md oe:rvrca].liympfu nodes; .'~1im1oo of "lheSie .snc1tm:'es ~sm;mdlaljoryal1dJ ]Orrn1US an. eSSief11tJla:lJpm. of the ev:ailil!ill<lrtilon. of an}' iliyroid l1iodm!e_
BeNore 1tlh:erni1lgELos1ti!c1!)!]traSiollffijdl. appe<n'MOes. of ¥moU!s. 1tlhyr.o~d lliodm!es are dUs.cU!s:s.ed!, one b<iliS ~obe f~[jlli 'ioVlitl\! tl1!efe&Fm:es. lliat c1illJ.be ev:;drni]l:1ted.:IJy mtr<§l!S.!(Jl!mdlli:l\tcirsiligMicMoe, ,ilIld 1t11emruscOlllioep1ticms (~) :!hat Cl.!m:el1I~' exist
l\ilulltiinodllbriit;y
It is ,giooer..dybeJlIDevooJ tllJi!l:t m:a:llijgnMcy ~smore OONammJi m a.SJOIJ:irE<1tIY :n:odmille;, :omd. ~atmlllllimodmillm1ry iisl!l!S'l!l!a1iq associated \viil:b. beru_gn. d!lise<il!Se_ However, m1tiroo(}l!J!I]jd[,."vl-l:h lhillghr,esomttion. karndiMoeJf:s com£s.rEOO~ dJe:m;01l!s.1tira~es ILIlElIlil!1!:ip]e ,dmru)c<1lli1~ occmt llJ!od!lli!es wmch.m:a.ryr~sdYfeass.lID',e 1tfue :SiOflO£OgU5it M~g:I'J!:a;[lt<IDd.ben:ign l'1o~es are ofie1'ljJ1feSient ~oge"!her imI.1i:fues<m1e .glimdl: appmxiilna~e1y 110'-2~[l1'o/U',4 ofpapillillilli}' caillcmomIJ<iIiS m:a.ry be murutioenmc_ ThJ.!jJs, "!he preS'oooe ofmll!lJtip:]e lliodm!es. v;i~ ffue th;!foiid does. flOE in.rnca~e'l)em~ry_
It is&l.lSJofueTh!e\'iedi ili1iL1t cy.Si~C nodmilles.1ll"e belf'liiglJL Howevea, De epil:helliialJ ili},'r,rndi cy.s1ts1itlferMe~1iIfI!d. :!he cys,1ti:c nodiuJilles seen onlliiTr1!rmol1l!l1!d imlVari~]y lliJrn.'ie :<iI.
P!lge41
Figme3.j-
[~ongimdillaJ! S!ON!O'gI",lll];1 cl!eJllON!S.tmting the c~}me,t tail slgrt (small! ,!!Mill'W:» in a colJ!oiid! no dll11!e_
Hgm:e3_6-
T.,am.vetse sonograms sl]o"ying mo types ofcakifkaliion.
lit. itslf'5poned' muEit 1i'I1e mcidooce ,mmdigl!il!Mc), is ,om¥ 4'% wl1.elJJ ;iiIl solliidJ. ili}'roi.di £esIoo .. ils bypeJf,eoool\c_ lIif [he les.ron. ir.s ~Q-,ecllliorc ilie .mci)dlm.ce ofm.mcy Mcre;aslBs Ito .2j6%, wlilll:.emailliglThID1J . .:yoeems.ill63%af.fuypo-.oclhoiic:mMSies_ .. ·Iin.dld.ypr<1ctioe.fuioweve:I: .. berugl.l! :I1i.omn;esi:il:l:e very cOl!1!2rnIon <1I!1:di. ;§L :S!olllritary hypoecll!Olc nodJuille is. s1t<11tis1ticaTh{mo1f,e 'Ilililelo/ to bebenlign_-4
Aperipfu:e:ra]J fuiilllo ofdeorea!8el@[ernogemci1ty is seoo. ;i:iIJfQ'1!m1li!. iso-l.lThWierecfuoic flodlmilles_ it is. caesed by le1i1her the ciilp81ilille of1!henodfuo!lle or oOllIl]J,r~ssed 'It:tlJ'fo~d ms:sme ud vess:ek4 A comp~e1te IbJruJoarOlllil'H]J :Itfle ~e:s.iion is 11
wes more !:OOe1Y~o mrncate a.benign. ]es,i)on ilian. a IDaJligFl'1IDt~esion_K ~e l1§1io ~s moo~llicl\e, @benign. ]es,i)ot],. is sltiilll. 4 mnes more lli1lbe1~ 1!h<M'l 1iI. midigfJj1IDt ~esion .. 7 HOWeVief" .ijI.l11l!l)o m&y alsobesees m. 15--30,0/0 or mDgm'ill:ciess,&-m1md!.lr1ts])r,eSJenoe~s lOOerefoill'e notpllLiliogflomomc .of beru~r1ty.
Thepres'ffioe of c~omcatioil1l in! tfuyr,oiidillJodJrnlJes. \v&;Pilleviioll!l!s1~{ oonsicdlered .~ S~g:Iil! ofbemgm1iy. CaJJc.mCi:lliiillli. is. dletededi bylillllitr<MIolThograpihy m :~bol!l~ 10% ;Qf d.1th~,oidllJ!od!Jmilles. 4 jpleripnerallrim. c<ID!cm:cafuion :mdllnge areas of OOMSJe .sl11l1!d!o\\~g c1il!um:caMon. are more :frequJien1t1y Sieen. mbeJ!Thign.~odiWes. (lFiglMe 3.6). Fmep1!ilil!J:c1t<iL1!e caJ!cmC900. ,c:me ~o c;rlcm:ed.ps~om<il. bornes. ~5 seen mpapillill<H)' CMCrnOm<il:S. (25-4QtuI;i,).11 S1!Iclll. caJicmcalITOFlJ:Ill<iL!y;mo beseen.is me1tastalliic nodes Hom.papiMla:ry caJfcilloiI]]JJ<iLL Sm<rll. ca1JcIDic foci m:ary be preSiffi1t m mec:marn<ith1' carcmom<il., ·bolli. \vruiliill ilie prn<n:y1tJlm1om aI1d.m~~tam:c IO~CI[] flodies.I1
CO!brn: ]lbw B!<1I!g:i:I1Igm<ilybe :§l dlllIDm.gprospect to tl1el!l!l1ilrnttill11ted. There is extoo~e Thi1ter@.me fegru-dffig ltrsl!J!se m tlre ili!lj'fordL The al!lJ1i:fu:or mrn iliat ilie ,dlismbl.!JJ1tiion.ofvess.elIs. vori1tWnJ<mdl. ru:,omd ilie l!lodhiJille,failie:r iliruJJ. me3l!5m:em:001ts: ofped: ve]oci1tfes, 'p1fovides 61ebes.t ,ome to 1OOedliaJgllos.iis. .
H:igfu ;resorn1tiioHsoI10grapny h~ d1;;mged [he W.1lLY m wmdJi [Ill}'iI"olidi :Ilocil:illliesMe ev.mlltedL.AJtl1ougThi none ofiliemk,a!SiOl!l!I1!d.FeamreslIhov:e is by i~S!e1if ilXilfflog:l1iOMomc for .md!gnmcy., Wl\L.enl!J!Sled. iml comow<iLtlon 1tl\Leyar,e Viel)'l!]51eMl! m dBere~1!1tiiaoog ,jjIL mailliignamt nom.&1bcemgn. noc:ID!lJe.
V·. __ • ,. .• .,rAld·· c<
~nl..T«Lt:w:n .q)' ' ... Jl'f1£ent .~.trll£tW'~S
ICommon Carotid Artery and Illitem.al Jllgubr Ve:iin
Thepresenee of a thwm1bm. \vil:ml'l.&e caJfotld ,mel}' .or iin"l!e:maJi .. ~gWJM v,em,.m <il:SSlociatlolJ!. WJi1th a ili:ymiid noc:fu!l!l!e" is :l\lJ. cfu:e to iliemdgl1!<ill"l: 'Il!~1tI!l!I:e .of iliie :IlocWJe. Tmno,_ tmomlbl!JJS,,>vflen.preS!oot,iis mor,e oo~omy sees m.:foJtlli)cwaI ca:r.ciinom~;mdW1!ap]<lllStlc carc.illom<lllS 1ih1ll'li. m. papill:ny cucitnOW<l!. ·o:f~e 'i:hYl"OiidL I I ,15
Extraili}1'I:.oiid spre1ldl Mdm:dli!!iJ!g mw.Oiwem:ent or the oeSiop;}\u<il!g:uJ!S, u@rneaJ.,strap INl!J!SdeSMdrecm-rent ]~gea] nerve, .lIS ydMotfu:er ,c:liJme to Ole m<iiligmmt flaRe of tlJ:e nocW!e.
JlJ1tI1ough llite m;jljffiority .of 1tl\iyr.oid cncIDom<il!s-pl"eSient as .aJ. ili}'foid no&:lille, 1 :5-3t(j,oiopresent 'iovi.iIi].iHImm,gedl p<iL]:p'~Me oe:rvi!c;rl.llymph node. l~ NodJid met1ili5tifies ooom' .mo.st OOlillmOr:hl1]' ~ilip3:piilll!my cru:-ci'illThomID> of the 1Jhyr.oi!.d!, :rangmg kom. 3{l-40% atpreS!el'I1tatrofl.I.'7, Ia,,19 Fo:Jtlli)cmaJf !thyroidl car,cm.om<il!5, m0r,efi:e~en"l:l.1y asscciated r"mi1tlID.QWSl1tiIDE ha:em:at.ogenol!J!smet1l!S;tues (mg,bOl'l:e),. gener.a:lruy ,exhJJbii1t :l\lJ. ]ower .iincidenoe of oervrcaJI.llymph;jld!em;opmhy (iiI:JJ."I:11:e raflge of 1!G-1. 5%). N The fficidmoe of ce:nvIcall merns1tiiliSes n.om weilll-dffi"e:r·en1ti<iL"I!ed CID"CmOID§lS ~s far llill,glli:.er mpatien"l:smder Ole ~g,e of 40;md iSSl~g tin cMchen, wl1:eremet<il!S,1ta!8lesare seee m 61J-90iD/o ,of CMe:S.1:I The nodes OQifN:MO~ micih;lediru:e iliepre1t:r:1ldleaJI :1ffid.paratradl:eaJi nodes <ffid. nodes ~D:I'J!g '!he iin1tem;:al!~guIillm: ·'i,I\eitu.
Meoomtic nodes ]fom.p~illl!m:y cMcm,om[jJJ.sllow cystic aecrosis ill 25% of QiliSesMdplimo1ta1te Ca1!.cmCi!iuIOO. mSOI%; they:m:e fuyperedlo1!creilllltiive ~.o IDl!J!sclem 801%.1;;'; Theappearance or tlte .me1t1il!5t<iLtlc node iis often very sm;y ~o 1thlllt .of liheprmmy mllll0m m ilie 'l:hyro:iid.
out S:h0'W8 megullla1 ,ohl!tti:nes m. the ~ohglirudmJaJJ scan. (1))- Ope<:l1J .. anl],w ~cle-nrfrilI[es. the ]Josirtiofll ·oEthe Er.a.::lle.:.aandi. cm:vedi.an·"Ow marks the: OCA_
• cys1tiic aeerosis ill 15%; mSJorne eases iliepre.SJoooe m 1tI1e oerv1!caJJ ch~. ola tlliillck - w:dJed. cysltillc m<liSS .or ,at cys1tiic mlIDs..5 \-\iili. :[iI.Siolffid oomp.one11lt wb)d] de:l1iil:oo<8Jtrattes ¥i§l!Sicmm1ty on co]o]'!]!l:lB!ow .iim~gilThg (Iiigl!]!l:e. 3 _'9)maty be tfue ,~r cme ®o lOOepr'ffiffioe of <ID. oocmt cm:cmom[ilm tlLe 1th;yroidlMd.m[jl), be l!J!IIiiSit"OO :f.or <iIf.I, wededbr<iLll1ch!.tl!. CJ'cst 21
Fig'llll:e 3;8:-
l"oo:l1JgimdlnaJ! s,ono_gl"am 'ofa ty-rnp,h no die (b]aGk :<mo,ws) with. a pltl.:l1Jctatee.cl]ogem:c E001!l!5 typic.a]. ·of a metastatiic no.deEr"o!11 papillary c=.inoma ... Note itts density ~s slu:uiJla1' to' the tlll!illsde- ,llI11leriorl}, and. the no de iN.cl!en1ls llie muema]
jilLligulliar ve-in (an:owheadlsJ
Page 45
F~grn-e, 3.,9-
Traasverse !'Hlilu'Ig:mm of.a l'~e, cystic metas,tatic node (llarge whille an,I'!I'ws) ilTil'!lfn papilla!)' carcinoma willi a EOC,cl, so/rid! comp0:l1:e:n1l (Sllla'lJ!. wllltearrn,ws),. Ths cystic nod!.e, may be miis,takenEof .a bml'ldhiaJi ,cyst voiili. diebris,_ Hawever; tlo,te the i:I'Ite-ns,e vas:c,lilliI!ariliy 'Ni.iili!iN the s,olJid! OOfJ1POfiefiift" sl!:J!ggesfu:ng llie sooste! nailWre ofllie mass,
Ibl
F~.gme 1.10-
Transverse slon0g!ran:t ,ofap,apiillJary=cino.fl:Hl seen las, a s,onidi, :iJll-d!eFined heter,o'geneo1!J!s nodu1Je wi'l:hin llie fuyl!"o~dJ (white ,alIO'Ws), Note llieftUlffe,d!. rnaot!lc intl"ano,d111illar va!';,c1!1illarity wi'lhin fue nodl!ll!e 'on Do/]em- power DoppFer (iIJ)- Wfuii1te 'ope"n amJW ~d!enrW1.es, fue position ofllie tmdh!ea, bFaci;;a:IT/ow mms, llie CCA andl.llie bFack openan-,mv ilie IIV"
Bcweeer, oflemllJ!S!tbe <illli"vme of sl!iI1tmiIregrrullllillomarn 'i,vru'l:lE the thrym1idl boo which. m~ymilm'C: lt1!mom:reom-renoe_ TheSie are also jilllJ de&tedl, solIDd.mcll !I1ypoechoic wi!tll. echogooiiclloci. :slli;owmgpos1teriiorsh<ll!dJo'!;vmg_ The echogesic ioa. ~. ilieSie Fesro:lThsrn:rellJlslIJ!ahly ~arger and de11!SJef mtll, grea1ter aeoustic sih<ll!d!m.vmg (F~gm-,e 3 _ By _ ru'm1ll!SioDd-gWdJedIDllIDe~~eedil!e ,a5pii1:milOOJ cj1o]ogyr'etil:dill.1y ,dlfiffer'ef11tilaltes beThveem.11I1e t;.vo_
OlWlloltic v:ascmarpa:tlern. on oo]o,m:Jl]jow iil:nOl!~g A-Sis!Oci~1too. rnlilf<iLc1beris:1iic lIympThl!<ilidlenopa'i:by
Figw;eJ_ll-
l,oNJgimdi:nalJ s,~m:oglanlefan iJ1Ld!efuedl, fu}"Pe~ed]e1>C::" fuetel!",O',gene01!I5 fiod1!:1l:e (a). The mteN!s e v:asclliiarity m S1!Ic-h asmall ne'Gween ce]em ~m¥ef Dop;ple. (b) sl1lggested! llie sEsteo!N!aru:reoftfuiis nod1!Il!e,. a p1apillJaq car,cinema ..
F~gI!ll'e 1.12-
Transverse s,onoY·llm ·ofilie iliy.oiid! bed! In a p,at:ienll w -iili iliynid!edomy Eo:!' papillary' ear·cinema_ Note llie hj'p'e.echei:c nodllie (lJa.ge .:me,ws) witll. a smail!eccl:Logenie fecus (Sf.l'LaII.a!IllJ'Ws) m llie ili}'!eid! bed!_ A~p,ear;mces
.a.,eof:a pap1tlial)' earciaema feOCmT.efloe, ~!I"llJb:ab]y no,dlal .. CO!:npa.,e tlIiis, ¥tilli.F~gme, ],.13_ Open .aIT,OW ~de-:I1rillie5, llie :pesiilioa·ofllie tr:ae-he-a ,and!. !0l!1rVedJ :alIiO'W marks the CCA.
~ap]<iI!S;ltic cncIDomat repreSlMts 15---:2JrJlf)jJ3 of ,;dI 1tliThyrolid. c<IDoe:rsMdi. is. one .of tlh:emost ,aggressWe Jhe&.di.mdJ fleck cancess, ,.viJ~ S;l!l!~vw;m:].r:;jL1tes ofmontlh;s failie:r 1!h1ll1 years. Thes.e 1hinC'fl.!lillS miilyrepre.Sient ilie ml]]. s.:t<ilge ofde-d:iffe:rootil1il.1tion ofp¥,jlany or~olilliic1!iilliM c;ncino:!ll[il!5_. The rniilg:I'J.>osJ!s: iisl!]J5l!])dly ,dirnc[il] "Wiiili a.fap&d!I'y gr01jJi,:rmg ftryroid. lJ!odiuilll!.e, 'paltients i:e~e1lJtlIyJlfeSloooog wi1tl].preS:8me ,SJigns: md symptrnl15_ U11tr@SJoud.lh!clps to OOmtrm. ilie cJmc<irll.d!iiaJgnOis.i~ :;mdlgutlid!e lIFNA:C, whiid1i $]i]iS le:!l!oelenJt :Sief:l5li1bWi1tyfof 1tills. 1rILmlOM_
Therei:itre two types;:
Ff~e3.,13-
Transverse s,dnoy.arn ·ofllie llijf!oi!di bed! in a p,atien1i: ~-iili lliy-n'lfd!eclomy fill·j! papillary ca!!'cinmua .. Note the hYP''''H,eboic no.ame (illarge ,an\'l'w:;) "",illi ~argee.cl]ogeni:careas (smaIl! allows) in llie ili)"l!>li~i!d! bed!. This was a S,l!:lme,
wrrere goirttre is ell!di.em:c" <rn;di.:rrepre:s:ent's IDl,llppm:elllt U<iIfIslom:J:<il1tlon of <iI. hemgm or now -gf<ildie ~es,j)oo_. ThepliEflel1!1ts. me us,l!lIdly dd!erlIyIDelill!irles., a.fuillstol'Y OK goiltfehcinJgpre5ent m 8{lfIDA._
.Anllp]<iU51tlc:. 'G1llcmomilli are seen aslarge .ma.&S!es ""vihll1il.pmpencsartyfor mtr,mruoo.iiIJ!llid. appeiIDrp<iltlllio:]ogic~ as ]ru:geJ[]esl1!y mmOl!l![S; ""vihll.m'"'eii1i5 of [hae:morrllli<ilgeMd.l1Iecrosis._ At 'lheperipfuery of tfue 1tiillmoms, '<liSsociiil1t1ed weltll-diffe:ren1tliiil1t1oo lliIill:om:s. m<l.-rybe f6l!l!1:1dl,;represenoog <Jdenomatolls g,o~tre, IDo1!liicmiH ]esions, 'Of HmiMe octl! Iti!JtlEOMS..2lli
MernillID)' cHcEom~. i5f,e:l!~e]yrlMe, If,epH:~~,SJenMgJ1m,t 5'% of;d :I:h!}~oi!d CMOe:rS_::lS The mtlMom arises Hom.1illIepM;lloJllii)cMiJi1l[ C-oe1!ls wmc:fuSiecre1!!e 'l:hyrocaill.ci~omm_ lin If}-2rJi% OfCifies. 1the:re is .iiI.lfiltni!l1y his.tory of tbymid.ltI!1rI:i!1oms Of evidenoe of hype:rca1)ca:emii~. or p:lh:aeocNomo Cyl:GilNiiI_ J[n. 510!iM. !I1iodW meti!I!SJt~es.[iEI'"e :Sieen. m. flreSlootiil:ill1oo"mdl15-25'% fuiil?;,lie dlm1tmt: met"[fiti][Ses. (1m'g,bom:e, bei)_ li'!"
The1tmmom is: OOl!J!1lDooJ.~ seea at Efu:e@1te .of mm:iml.!mJJ. C-oel!l. oD:I1!cootra1tioo"t]]e .rna1terall.11p;Pe£ two tfmdls of the .g]Md:2llli illt is. keql.!illoot:1y w,eliI,cil-ol.!ltlllS!rn1b,edl ilJl!J!t ill1ll1lyh;][[\,\'e ~mNeibo([d!ers._ The lMimom ,rnM,;iI)c1teri51tica:liliy con1t_amy]oiidl; Siome m&y ~~owmttr@E1m1o([<rll!il:ecr,,)cSJis. 'O([hae:rEo!llf@<lge_ It illaty also mv@cl!e]ympDcs:[M'];d~_ "1ln.1illIe J<IIIliilliaill fOrMS ttfiere m~ybe m1!1illtip.]erurr[jlJthymrdl~ fu!miOlill!lfS_
UlltrasOlmd.l'ea.mr'es
1 Solliidl bypo-ecl1oi:cnocIDille_
3 E<rnogemc~oci m 8'~9 [)I% ofmmoms,,~es;er,eproeSient hoth. denSle depos.J!ts. of1ll1illl}i]o~dlMdlats.SiocJ!<jl~ed.~oc<illl c<lillcmCijI;ttion_I1,'.2J The ca1!c.mmt:1oo. ~el1:cls ~o he deM!ef tlJJruJi. mpapiMJ<rry Gillli,cmo!ll1![iI[mdl.m[ili}' ~aWID:<mt POs.1tooo!lfs.illiad!owmg (Figw:e 3_15)_
[b~
Fiigw-e,:3 .15-
TtI"amve4"s.e, (a) .and! ton_gimd:i:naJ! (b) sonogramsGlfa lJ:ted1!l1lla!y car;c.in®ma (ill~e :an.oilNs)_No1te ilia1t itsapp'e31anee is sirru])8I; 110' ilie papillary car,ci:no:tJ:ta. in F~gI!illI"e 3..7 _ The ecl1o_genic f:ilJ,cj (S1:l1a1J!. an;ows) ,8I:e d!e!I1I~"et :and!.eiliLbii~: ]J o'S:teriOf snad!o,v;.ing c~mlp·,ared! to' the p'llillctatefoci ;in papilla:!)' eascinema. Open
alIO'W id!~r@es the pOl5ilftio!l1l o·filiettrarnea ,and! omved! ='O,w:utms, the OC4.
atpsmotlf1ll'l:di. Vt100Wru:' ~rn1J.\Ve{l]eJf,efore grol!:lp Ote:mllMd.er{l]e tefElll.lOililli!o~ ]es.iooS:l, ,Md. db notl!l!Sie ~e ~erm 'iadenomai'. Thus Otern::wg'l1!OSJis of::w iWdlllli:cmru: £esiion.1.!'Isl!]!aN~ ~llies: the .fleedl for smgica.ll .:e:IJ!lOV31i ..
lP'a.tholo:gy
The ~ll!lm.p[jl1!i,o]oWc[iJ)J] m1!efla for at fo:lillrcmar ctEDcinoma are mvi:il!S&oo. of the c[j[ps.l!lilJe, O[ mVi:il!S&oo.ItMOl!l!gh flle Git:psl!l!1!e of the hm1ol!l!lf,.1itl1l:d MV:~OO. of [Illie veitlllism 'orbeyol1d the ,capSJme. The ,cri~ffi<li fO>f vatScmotlfmvasi0FI ~pl~~ :8J01!.elIy to 1tfu:e VieIDS: in or heyom:cll1L11e cilpswe. Tmnom:'pmgs:m the~illmeSi; ~ '!he ~Ol!J![ ]w<il!Vie lThodli'lwgn:osru:csiiglliillIci:Jil!1oe.::Il
F o:llicmar ctEDcinoma Ol!ccom1lis-lFo[ 1-:5% of ;aJill.1i:h),'f,ord c1lI1oers.1.4 Hor"v,e¥e:!", miodme d.clici.ffiE me<lt!5 1these nEll!lInm::s: are mmepr'e\'.i[]ooE, 1:5-:301%.31 Men ~odin1:e is~d!d.Bd.1tO tlle dl&et,.papillm)' cmcmom<il mct,eaiJies: <MlI!d. follicmm: CMOMom~ dect'leaiJie.31: :E!l.moSJt ICMes: it de\!ie]ops Mom. aplf,e-e:lli,Mgi!ld!~OMiSJ.14
<6 .0:1'1. Oo~ol!l!lfIOWD.iiilgIDg, iliem@j:ority (8n-~9GJIIDA.) ofbM1ig:l110llllicmM Desrons s;howp~ocimillMJblIoO{ill.fJ!ows.i!gn;;&. (type :1M; iF igm-e 3.17), wllereatS midig'l1!mt.f7oilllliic'l!lill<tl: ~es.imI!S fu<ilJv-;e a itype :m v§&Ommty in O\'ef 901% of eases.!"
F~~,3J6-
L~lili~rudl::mlill S o:l1!eg:l'a:tIl showing. a we1lLdefuled!, homo geneol!ilis"so.J:iid!, hypemct:Hli!c lliy:roid!. n\'lGJ!1!lje (llMe,ws), suggesting afolliclll1!a:rlesion..Noifue that it indieniIs the CCA (lln7Owhead!s) 'b'ui1! dbes no,t mrvade if.
Fiigw:elJJ-
CoDo1!ll' powef'Doppille! ·ofallo:mo gMeOl!J!S. ise echoiC:,. wedlHJ!eJinedi s,oJ!id ;I1o,ame 5ho¥>lin~])fedo:tJiinanlly perir:J:odlll1!ar vascu1!ariliy ... F~lJlo')Wing sm:g)1M)' lliiis was confumed! to be alfbn1.cmllal! adenolJiLa_
Lymphomatmac}f ru]SieprirrI!:IDiI}fHom ~e 1thyro1id or mv:oiwe ~e: thrymid SiOOO!lThdJarilly·as .p1ll1:. of ~ s.y~~e:lDJc llympfuol!N~_ lPmn1ll1' '1ID.d.SJeooodaw:y iin\'iO~e:meFl!t of ilhe 1ih}'m1\d by ]y'nilp}lliomSIL tL5 w:;<tre, ;i1LOCIOmThmg ]0([ ,oruy 1-]°10 of;<iill.Iih}'1",omdi. m1iiligl1!illlcy_ Not1l-HodgllrnTh.'s lIympl10ma iismo([e OOl!nl1!1rnl.iI1tuD. Bo~'s m5>eooe,mdl all ,::m1tooedienl.his1toryr of Ha,~D1to!'S tthy:rO~.d:i1tii5 is ,aillmQ(st ,<i!'1w,iilYs preSJe1'Lt 11,23 Itmec1t5 .elderly Wome!l1, oiel1!.pre5>ents as a.orapiidilly ,enillID'"gIDg !rn!MS, md mary e:demd. ol.!JltsidJe :!:he ltIlyrordg]md_
F~gI!ll'e 3c1$-
Lo~girudJ::rJ,al! 'sonogram ·o,fllie iliYl"'ojjd] showing a solf4. he1telTOgeN!e'Otllis, :pfediontMaI1t1y fu}'poc.ecli(llic flodUl!e, 'iViillil:lli-dJe.1i'iI'IedJed!ges (am')ws), suggestillgi1ts maIigl1!ant natw"'e_ 'This ptati!e-nrl: p1e,s,e-n1te,d!. v;.iili. hOfl~ I!I'Hltas,tas,es. and. the lliyl"\'l:id! nod1!!1le was conmmed! to, be a lfbn1tC!lIDaI! carcino~a_
1 The Itbymidl is o~rn1iliY flypoc--echoic_ However, l}'lJ!lPfu:omaJm<iiY somemes. .P'f'eSJent <llisJimpEe gll~d!JJilliH ,enilla£ge:m:ent ~rl:h flO ObWOlillS ,jbnonn.-tty m :!he thyroid eclJJopafieul (oosloc!iajed ch[H,ac1teris/1tiicrryl1i1p:h~d!~opafhy m[].y he:!he omy cfu:e)_
P!lge51
J'~gme 3..1 9-
Traasvesse sonogram sho'OVing a SiOJ:id\, h::l'1)o eclloic ~j'm:p,homa~o1!]s rilod1!1l!e (lIargec white ;;mows) in the th}'l"I'i~di.Noil:e the h:ypo-e-elloit, lJ!e'i:erogeneo1!J!Sp;arenchyma v;.-jjlli.lliin fiOflC),irilc s.fu'eaks, (smalJ!. white
an-I,'),ws) sU1,ggesti:l1Jg a badO::,&,I,')1!llldi ·o.fHashillloto's lli}"Hlidifr:is. Open ,alll,')W iid!en1Ii:fies: '!:he ]J'osifr:ionofili.e 1nrn!ch.eaand. ~1!ID1ed!aM\'l'W marl;;:;, ilie OCA.
3 iFocaJI1Ym'PhomOl.Iol!JlS: nodh!lilles n:JJaJy h<itVie a'pS!Bl!JId!ocys.ticiappear;ance \\"1iili.po.SteriO![eW}M05m!e:t1I c:&I1:dmay bel!Jfl!isE<:&oo for cystiic Eesiions: (thegm .Siettmgs.ilIlil'l!Sit be .mcr,eatSJed. ilto idlffi1tiill)' tihe :s<oIiidl nIDlrn:",e of ~e flocMl!e).
HglMe3..1O-
Longimdmia] s Ofl:o'gI"aIDofan emargedi lli:ytoid 'Willi a :hyp o~e-iGhoic:,. hete1!"iogem:e,o'1!]s ed1iop!a'l:tem of ~51e l)'mp:l1iomatol!:lis my.o]veJJ'llen'li.. A :;:imiI!w: ,appearunce may a:J!s 0' be SElf4JJrn me,tastatrc lli}'"10fdJ rn.'V'olye11:l'e~ri:.
Me1tas.1t~e&~o:lhe thyro~dm:.e .meqlIToot, occm-ril:JJg ]atem :!he coerse.cf illLe diseese ruiLd. gMer<rlly as [fuefe&m1t of sp1f,ea.dl by a .. :ha:.e:matogooOrl!l!S (more
The]e@.o'l!'ls ase ofiel1l! :SiOThit<tl:y ;iiIl!J!d. we1ili. cirCl!DiSlC1fi!hed ,\<\"1i'l:h :<lLn.[lIPP e11fMDe~;f[ Ito that of ~eprimID:j' frnmllibm.lili The g1!amd .mI!<1Ilyihow'e\'eJf :sill1ow ~Sie mvoi~eme:l1t, wlIDol!l!t !the f.onIl!a:1!JJoo of :<Jlllitocmille ..
3 Non c~cEed ..
P:age52
F:igur:re 311-
Longi!rudlnal!~j,()l1og,lllltS' ofilie ili}~o:idi sho,v;..-ingtj,olldL, h~iPO~echofc farge mecftastati'C no d1!il!esi (whil:e iaMO'WS.) in the ]O'Wef :po]es,- Theedges may he well. di.efu:ted! (a)orles.s oOrJ:Unomy ill. d!.efu:ted! (0).
Hmfie odl!sm-e deriJ,~edi Hom. :folli.cmar epi&ellrum_ They caabe :folllil1:dl m. ililL f11!E!ber of oO!Fl:dliltlom aad eanaot.be C!oosi:der,edi.specmc for any disease entity_ They are seen m.mrurEffioci1uilliiII :iliyromd,. d:lim:mc ili}rforrn1tiis, H~otO'.s ili}rfrnrn1tiiSMdi. ]o:l1!g-stmTI:~g :IlJypen:hyr,omrnsrnl_ Most Hl!I!I1:He oe1ll. ]esro:mlsEitlfe :molllliic][]]ar mp<ll1tlten'JJ,<md. :S2O lliLe cri1terii1l!. fordlHeren1!i&ooghenveooben:1i.gn.::md m.rn,gIl!<mtru:esirn1ill§:l. 1io !those for ::molllliicl!i!l!<M ~es.ions {ca.pslilli1!<ilf1illd. vascm6lIl"' m:\CllliSJio@)_ TheirwwatSiowd. <it;ppei1l"IDlDe.sm<ilY ,~SiO dosd~reSJe:IiIlIbille <ill folillbilll!ru:]es.iDElL
lPleviolills1~ oo~d!eredl. bemg:l1!" these mmoms do ,e:dIrub~t i~.pOltefl1tii~$01f"mJJaTh)gI1!1lI1!cy :1lI1:d.mJJiiilymetast.mSie to the mngsMd l~pfu llodes. (3~)i%)_ Theyru-e l!1floomrnon ~es.ronsMd.1bridge ilie gap lbenveoobffilign.:md mrulgll!<mt thyroiid nornilllles._
"MmModll1!ar grntr·e' is. <ill oOilEimon. ~,erml!l!S'ed.lto deS'cmibe mmliipllie ,uodiJwl!es ,.,.vi.i!:l1m 1tll:e 1thyrorud The term. "goltr,e' tmp,llies. .1lllI. ,el1illnged. gl!Mdl so Wh[j[ll does one ,CiiilllJ ,i3l flCH:m&] :sWed. !thyroid. ,C!on1t~gml!l!litlp]e l1!Q;cmI!es'? We ilie;cefor'e db flO1t ,OOiQomiilige tlWeuse of the ~emJ!.'mmtiFJ:odll1!;rrg'Qiltl:,e'bl!Ji1tprefer ~o ,C<1!.lrn tllese :glImm "a. :ml!l!1m.odlmlm- 1Jhyro&d!' _
It ~s M\te OOmlil!1.onest (8101%) PliItho]o,giiciicll. oonrn1tiio:l1J. of the !thyroid!: 2-B% of thep op1!1illa1ticon. ]w<il!:\'ie a ~cdYp1rlpa:b]e m<il!Ss_ 2il!i The pa1tiients.a£e fie~1illoo1t1o/ .ilSyrnp~omlilticiblillitmiilyp:ll,e5e:1111t ,-,.y£ili ,C!ompr'esme Syrnp1iOmIiS or '<iI.r.aprdlly ,el1illm:gmg m<il!Ss (the 'OO!l:l1:lll.ooes1t C<11!J!se of wfuiclJi is :I1:iileB:orrhiilge "'~~.1iIl flocWe)_.
Hyp'erpI~1tiic [flodmilles .<ne eomposed ofbror"Wi1 ~oi)d 1!iisslffe_ i1F"IDrOSl!S .ud c.:&l!cfica1tiioil1l! are flo~ed \viiliiilllL MCfosoopiicd~', oolilloid. bllEesaliIDeHl!am.g wi!i1 :IlO1]]l]Jall to lmyperp11illStic foci of flhyro£dl msue,ha.eJ1llliorrhaJg<e,. :flli1[osils ,illllld C~ciiiCll1ITOfl.ll[>e IDl.!m:d_ Avanllb]e<J!IMomt of ])'IDpllliocytic imilhafuJrulmay mobe
Then1tiia1tii!'l!g event ~s.pmlliIfe:ration iilThvo:mmg one or iiiI. grolap offolillides_ Theadlji<il!oent ;[ollliUdes1ITe qruesoe:l1lt V<il!SiCl.!l!l!ar oompress~oil1l (ooe 1tofollic1!Iillru: byperp:]asii[il) £e<l:rn to foc;all RSirna;~at, ne'Clfosl!s <ll1d liEilllJ11mmaTIory d\tI<iWlges_iPlrogressrml!. of tfu,eme1illSem.st £eiitdls 1\omaom,uodlillelDonTI!J!a1tiirul wifll.[ilsollidi :swoue bUll :sllbsleql.!IeJ'I1t1y dl1ll'l!ges sudi!.illi hiilelllDffhiil!ge, :Emrn:oSJ!s. 'Md ,~dffiic<il.1tl!OfI.1t~ep]aoe_2il!i As, 1ili:esle rn<iWlges .~e ooc~g, ilie glJ1llildlilfe:mrill1smd.er [hOm1on;[]. imm:em:oe_ The :fOlilli!cl!l!l!M1md v@SiodM ,dhistorITon. mltweres wi1th. ,rnsW1)l!lrfu)oli1l of rorndeMd.1tl\t~o1trop1ml,resl!lllimg m areas oHoC<J1j byperpill<il!SJ!;]t (wb:ch !Ir,emeNe ,exoes:s:1tlliyrowopm) '<iWld. areas .of ,aw.oph}' (rnre t,.o tI1J.l}.rm:01tlropm. defliciency)_
u.Urasmmd if eatnres
3 Cy.s.1mJc oOm!pooen1t m 6081o_ 'Thlisffli3lyrepilr,eSiffi1t hiilelil!1onl1:Ol!ge or rolillolid. "vi~ the l1!ocml!e_ H;]telil!1onl1:Ol!gemto ,<ill Hoc:mJ)e .is ~e OOl!llmoneS:I caJ1!l!S!e of1ill rap&cIy el1illiil1f:gil1g ~yro1id IDiillSS_.
:tongimdlitTIJaJ! sOil1oYa:l1l1S (a, b) ,olIa lliyuii!d! f:lod1i!1l!e w-illia cys;fri:c oomponeJ1l'l: ",,-illi intemaJ!. d!ebris and!:a ]!1Juma'l:e,d! :iso,ecil!1l1:C OOIllP!1lf:l:ert'l: an1teri!1lfty.·_ Co¥mllI p!1l'we~ D!1l:ppteJf (I) ded'Jl!1Jnsfuia1tes ~8f:ge vess,eJ]s 'Wirl:fu1n. fue S !1l1iid. eomp!1lnen'l:_ AI: smgety lli:is was, E01!IDJdi to' bea lIollic,maf CllIciIloma_
There '!,viI.31iJ.Vdrys be a.SJ!lld.g:fo1!1tp ofp.a1tlents, fu!owe\'iel:, where tl1!e pr,eSel1!oe ofma'Thigl1!ill1:cy fS :millssedL It lis d!.e1tec~ed. omymltersm:,gery or '!,,,,hm 1tl1:ep.a1tlent presents .sOOllie1t!me ~<iI.~er \,wrf! obviol!J!s ~ca:lJ and ~Slo:ll!ogr,a;plh,i)c~gI1IS OK mUgIl:1MJ!cy _ 1ms is 'iiIlreo~gprob]eJ1I'I! 1i:h&t Sl1tiilllcmmot he '()"\i\e:WOlillJe_. The ()nill}' re~s.m,iMl:oe ~s '!hat 1tfue .iincidJenoe of m<il.Thjg:ll!mcymStl!J!rn. a. ili}ffOlid is ex1ttrem~ low" om¥ 1-3%_11
• Ml1l!ttiple nocinill.es
~ ]F:reEJ}Il!ent]y iso-eescie, we1ll d.e&tedl
• So:l!id<mdl cystic .eJ!eE.en1i:s
• Come,!: 1tai!1l.srgl1i.
• Flbrid. caillc:rurnfion
• On. 'ooDom fllOW6<i1!giI1ig :!:hey ,exJhrubit :!type ]Md. ;!type II patlenJJ.
Tme epiiliLeJ:iia!ll. t:hymiid cysts are-rare. ~- Most cysltic ~yr.oid ]esro:ll!sare ooe to ~a:emori:h§!ge Of d!egenera1tfo:ll! r,...,,:ri!iliirr:! @ byperpm&s1trc flodlllille_ The1tl!l.ltt:riiliSollilllllid ,&ppe<ll"~\CJes of :!:heSte .h&Vie been. ,d:iStol!J!5:se&
T.l1y.minilfiis
H~oto's lifLyrolicllim is themo.Sit ,OO:lillilEOO of the cmiomc:: 1tlh;yrolicllitides}'7 ~t ~s .mOf'e oOlillililOO.on. im:I. womf.l'li. ~d. has .~.ped: incide1l.\CJebetween 4{)!a:I1:d. 60 years ,of .1IDge_ The dE1lligl'losilis is'l'iIIsl!J!&liI}'b.iiliSJedi. on.seJ[,o]ogy ~5 i~ is .[liJj :[il1!l!1to-Dmm1e ooodli1tioo_ H}poiliryr,01!.rnsm ispresent atpre,S!oo1t;[j[1tioo ord!e'ilielbps ]a1ter ill 5{)®A, ofc1IDSJes_1I
P!1ge56
There is <ID1I. asoociated.maea;s;edi.ris:k for ~e deVieliopmel'Jt of floo-Bodgkm's l~'l!:IilPhoilTI!1~_ 3!l~0tO:'S: O:!Yfoiidlj;tlis iITI!1ay he associated l.Vliili o1!fuer~ill!to~m:te O();llditii011lS_
Acute,:
·JF"oc<i!!ll. :I1:ndruilla!!: ~oi!CIliittiis;s.nTI!<J1Iilj., n}'po-ernrnc, 3JV:at5c1t!iliar nndmilies ,."wth iI.-dEfi1edl olIlilillines. Thes;e,repres;enta;reatS of]ymphoc}1tiic imiilltra,tr011l <mdl miil!)' he USit"oo.for a malSS ]esIDn (UCH)11.od!l!l!!!arp1lll:'euIJ-
M.pments ,."vi!1th ;<ilLprewJ)1!l!s faillledl,expi]oill.ation, '~OOO1j");d1ru:yexpkir:a1IToo8fu<iltVie orny i!I. 7{)c-gOI%8\TOOeSslfa~e:, 5Q;ud 1tl1er,e i1s Th!tI:J!erns:p1IJJ~e ili1il.it ~oc.:ds:atii01l1i. :sllo,l1i!l!d he atte:mpt,edpriof to reopera1tlv,eparmhyrolidlectones orprio:r toa 'pmailiyroiidiedomy lin '~piii.tient who has lha;d. :~Pf'e\.q)01!l!5 iliyroidiec~omy .. B ·1in.ilieSle :si!m[j[1!iio!l'l;silie .g]md! is more lliilbe1y to fu em alii. edoprcposi!1ciioo ..
.ru~01!l!gh. tJile m<ilffiority of people }lli<iltve~bm: gl!<mdls- rn--opns att1\telllp,per mt.dI. loweepoles ,of the [I1rym~d glJandl- 25'% of m.dliviicma1!s: hiiJ!:\!\e more "lhu.iliiis !l'l;llII!J!iliber .. 54,:55 The sIDpeflorgliill'l!m,me .more oornt.m! mpoo~t&oFlJ;:illjOOJg ilie dors:<ii.JI.[fu5peot of the S;"l!illpOO:OlfpoEe of 1tl1e ]<il:E,er.<ii.JI iliyrord ]oibes, .netrr ~e 'feCmlf:001i: ]ru:y'ngelil.lJ fl.e:rve ... The neriorgli;mdis.;uemor'e varied. iIii;.pnsitiioo. :1iIill0Fl!_g·1ihed!or:s:aJi. ~peo1t of tl1!e iimerrofpO!]es: of tl1!e t:hym~d. glI;md .. However, 'iliey IDBlybe :s.omewtilEioe :1iI.w,ary Hom. ~e ]ow,erpdes of ~eiliyroiid!" at t:fue oervruoat:l1ora:cic ._iiuw:c1ti:.on. or eves m. t:fueSlillperiolf merna;stmlIm:l ..
bife.rior;
Atyp:lca] Sines of a. Parathyroid. Lesion
Uude8Ciencled,:gIurn ruong ~e OOlilililOOOOJ. CM01t1d. ID1t,el)' _ :5T,Sa They aI'es.MM m apperu::artc:e toeodes at ~s ~SJ!1t'e_ The m1t'.e:I11![i[]. v;a!5cmmtyiMl!dJ iFNA l!ID[jIY help 1bQ drus,w.gmLSil\I1tl\te nvo_
lntr:athyr.o.idal; m ilie IiWd!dil!e ~o]ower iliird. of the iliyrordi gllMd_ The m1tramn¥ford gll<mdls ;<It[e<i!:Th!gned! ill 1iill1e long MlIs: of iI1b:e EhtroidL They ~c 1i:hyr,oiid. :IlodJrn]es ;Md.ar'edficm~. to dJ![jIgIlose_
Retr'Qitrrlcheal.: ~eSieglJill'l!dis,are dflfficmt 1bo de1ted.hecillJ!Sie oOf ,a;oo1!J!s1ticsillii!l:d!owmgrurom ilie ka:rnea H ;jheym-e ];:mrge,ilieypro1t:l::L!J:de :1lLQliL\SS iliewclineru;td. am. ilien. he Vl!sml:!1!Sied_.
m. om ,experienoe i~ ~s ei!l:s.ieSi1tltoSi1talJlISi~g in. the 1tI:al1Is\'1ersepi]1IDe,hegiirn~g above the n.evcl. of ilie1!l!p:perporue of the tIlryroid ud.movmg dDWll!)"v,arm sc:rummg tmOIJ!.g]Th '!he iliyro~d to ilie]e\!leJJ of ~e di91wde_.Et ~Slillill!i:IDda1tO:l)' ;lt01!J!se <11. 7_ :5-10 ~l 1t:r;amc:m:oBr. Thepllmen1t llUes S7illpWLe \Vi!tfu ilie .neok :I1.~']:J'erex1tMdedl ;<i8fa:]se nega1t:EVie SlC~8 m§ty he ob1tmed. mp<1lTIents W1\I;D ,<It[e moorreot1¥pos~tiiorl11edl pm:1ti!cmru:lo/ m elJd.erl5'P<1lTImts \V1\l;D may helimJ:ab]e to i]yper,ex;temcllOOe neck_ jp'MaElllyml1d ,a:diooom<il!S are oflten. bC1iIted. ]ow ill ~e neck; byper,ex;tel'l!s.iolll! devaltes ilheSle me~om mto tlhe neck. \vner,eilieyar,e ,~ vis'lJialliSied mp<il:ltiemts \wth :short flecks." Of. l[)ijbeSiepaMen1ts v..'litfu, tlJick necks, ~t m<1lyhe l'l!e.'oes:s:my touse :[iIL ]ow1er -ffireql!ille:l1;cy 1tr1M'JjsrnroeJf (5 Nlliz) \wlihOl!. s1tand-oOllfgeJiblod::: to m.p.ro\!leviis'lJia1IDsOl!1tioil1!_
~ lP'<Hailiyroid ]es.XOfis are :sep[ilfatted[ffi:om. iliyroid 1tiis1s'oTe by ,[M1j, ernogeru:cpillomehe1tweeEl. the ltJ,;vo,f!epreSJelTh1t:l!!1g ili;e c~slllilie MOl!J!l1clJ the iliyrolidMd. paratl:!yr.olld_
• illrresp'ecttiv,,e of [he na1tm"'e of the ]es:roilil,[]!bnm:mail.gD[M1dls are ,",equxem1!1ti¥ hypo-,echolic oompared to 1t:!e 1t1h::trolidL 'Jl11ills £s me ~o themmofilil. hyperoeimillaritty of '!he Desruoos. 5,:5
TheilliliEl'asoli:lrl1dl appe<ilf.at!1oes.mp~yrrrnd. cm:cmoma me ,smar.1io ~oSJempEil:l[ailiyioroi. a:dl.~O!l1l1l!6!, lexoept tlThm ~ere may be demomtraMe ~o!l10f ;<lI:dijijJ!.oentstrn!otm:eSJpims IDImo1i::tillltyoo .swaJillo,"",gg_ Me1tEtitEties ~oEil:dj:<iI!.oent nodeSJ1II'e seen m. :2-1-18% of c<JlSes_59
&ocl.!ltITenoes folillo,."vmg~Mation. miilybe cilliillSied.bypro;llieraltion ofpa1"athyro~d.1Il!ssl!l:e ,.",,1ifu th.elIlbrotlc ,g]ill:ld!, or tlJ:e de'i,'ie]opment of;~ new :I1yperp]OliS!fu!c gbnd. (iI13{)I% .of cases). 56
The ,rno&oe of rnl1tii1lll. Haging 'mod<iiliry (w;i!IflIY) lin fl]llf::IjJ<aJrailiyroidliism. \viillI.a:lh.V:[ilIYs be glO"\iie:med.by .]ocaill.practlJoemldl eX'pe:rtriis.e_ llisSleo1t!on '~1iIiS deSiC.":l1!'bedi 'lheuS!emJl.mlttr'1iliSol!l!f:ldlFe~rltm'e5 tlJiathdp m.liden1tiillyillgpara:l:h}!foiid. :ad!enomll1ta.md. hypeqJ~a:s1ti!cgl!md!s_ WMe d1l!5CI!JJs.sron or ~e merits of o1tl1:er:IDoms of _1iI!gmg mp::rrmhyrord ,dh!SJ~e :nsbeY0:l1d11tl\i:escope .of ~ ~elL1t,. tlter,e rus .:1110 doubt 1illu<llt1ilillttr<liSiol!l!f:ldi. Cilllfue<iIL Cios,t-el'e;c~e .a1tl!a].me<ilm Dfoo[il!g1I1g_ lli1t.M\slO has ;auSiefull.r,o~e as m.JJ. a!djiltmctto oliker 1m1IDgi;ngme1i:1Thodls (e.g, SesEa,mjJ1J.i ~si01to,pe :s.mrnes) ;md. :in the 1trea1I:lm:.elThI (ie_ et:lID1MJ:cY] aMmon) .of oernm grolilp<S .of patients_
References
2_ K.i1!JJg.i\D., .AJ\l\wjliil. AT, Me1tre1J,vellii C_ The m]e ofmti:r,[il:SiOlJ!l1:d m. the diOl!glTI:o.s.iis.of <iI. ]ar:ge,f;apld1.fy grov,:rmg, iliyrord.lli<ilis:s. P,ostgrailMed J 1997; 73(816]): 412--414_
Page 63
7'. So]biilifIl1 L,. GriHIgrmrlJ.e A,. De lP:f<1tL et al jp"e;I:'cUl!tif:W.eoll]!s mjroctioo. ofpw:afl:Lymid!. ID!D01.!ltl:S ii:1Ifidhillltr'a!S!o1!l!lil:dgmdiam:.oe:n,eOl1l:lIl!el1tfrn:seool1l:di11l}' hy;perpm-.)woiirns.m_Radiio.logy 1'9.85.; ISiS: 607-610.
Hl Noydc A.!.\1,lF'~eh~cin DM,. Km!.-.Sicn JC.Di<ilgFlO\s1m1c imagmg of 1th.e ,1th)'"fJOOdg]Md lin F,~. SA, 'ed_ Thyroid disease,; Endocrinology, Surgery, NuClear .Medici.jq,e, amlRadiothempy., New Yo:dc Ra,vefl.lPres:s, .t990.;pp 79-116.
11. Y01iJ!Siem. OM, Sdffif A.M_ Th'{foiidi.mdJpH[])thYfoidL ll:!lC Srn:.IlI lP'M, Crum 00." eds .. Head ondNeck: Ima,g;i;ng, 3rd. edn. St Loms:: Mosby,. l:9:916;.@ 95.2-'9'75.
14. Solibi1J:fni. L,. LM:~ T, Bd<rr&fIi E, ~erill!.oe T, C)-,esp~ L. Th)'£oiidJ glJandL :me Solliru&fIi L,. Rizza:tlo G, ern .. Ul.trusmmcl of Superjic.iaISitruc.tu:r,es" 'Lol1:dJonc C1Thm:ohiilll Livmgstonf:, 1995 ;.pp 49~85 _
1:5. Comp{l!gliJo J. DiiSJe1IDS!es of 1ili!e 1ihymilldL :ITl1i: .Bi;nm.es L, ,ed.. Surgical.Pathdogy ,qfthe Headand Neck. New Ymk:. M[l[[oeJi Bekk!e:r,. 19'85 ;pp 143:5- 1486.
16 .. McQ!I:liOl1e SJ" Eis,cleDW _ Cerviclilill. ]ymp,fu. n.ode .metrast&S!es m w,eI-dMerel1lilllill~edl1thyroid c<J:r'cmoma. Pr.o,c,eedmg.:; 4th Intrer.rm.t.ionaJ COI}'ifenenoe, O'J:i Head and Neck Cancer; 1'996.; 967-'971.
18. Mi:iItZzm;e:I"ri. EL, YOm1!g JRL. lP:llpillilliil1)' lliyroid C11lfcmom[jj[ <1IL ~.em1I. yejj[[ fol!lbw l!lpf'epO!rt. of [he inLpijijd of tlllie:r.apym 5: 76!1:'l\Mill~ts . .Am J 1I.ted 1981..; 7'0: .:51.1-518.
19'. C[llCaID.gmMI.·, Zampi .0,. ~illA et d, lP:<$p1!lIDru:y ICMcmomac oill"ilie ~o1idl: a. cwcopa"lbo~ogic: ,s.mdy of241 cases Moe<i1tedl ali ilie U~erSi.iry of F]olf'enoe, lIti1y. Cancer 1985; 56: 8.0:5-828.
21. iFr.dentlJiOlJle:r M, S elITifuJ. RV, C~gW A ,et al, Lym]Jfu l1!odeme1t~1ti[S;es. :fr.ompapi!ary,.:follliiiclllillru:- :i:fu!1poidi. CHICmOm1ill m YOl!illlilgpmiieFIJts.. Am JSUYg 19901; 1:6i(Ji: 341-343 ..
22 .. Ah1!lijiil. AT, Chow L, Cfurck W ei aI, Me<t"<m5tanc o~c<itl. Flod\esmp.apllmy C,ncinOM<iIL of tltelthyroid OO.a:Sioll!l!];dl.-mdi histo]ogiciil. oorr,d]I<ifu!oo_ Clin Radiol1995;, 50: 219-231.
24. Ha:lrlldll m, Flf,ami!<iIL KO" Wa&~ v. OOQlllifrI:p.apil.ary Ca:rcim:OIDEil of tlhie ilij"foo~dl: <1IL ~Offl])§!] mdiil1!g m ]F'fimtd .11 S.Y:S1iel1iMXC antops.y smdt;t. Cancer 1985; 56: 531-538 ..
52_ Atrltie IN_ Locmmwon::pmoeCffim'es fOlfpiitra:lf:tryro1idldii&ea.s>e_ Proceeding« 4th International ColJ'fier,e:nce ,Q'n Head ,& Neck Cancer; Va:] illV,. 19:9:6: 4015-411_
53 _ V<mI. Hee:rden.1A, James E..M,. KMSdlli.fR. et al; SlLl!lldlpart.~,aiSOflOg:l';ii1phym 'primmynyperparmnyroimsm_ :Jini1tl!iIl!. lexpeflffiOe_ Ann Su:rg [~981; ]95: 774~77~}_
54_ L~o]sii V_ Ji:rr Sten1he:i:g SS, edL The Thyroid ancLParathyro.id.: D.iagnostic Surgica1.Pathology, 2l1!di eoo_. New York: R[ll\iiel1!,. 1994.;pp 52-3-560_
:5:5 _l~o]SJi. V _ f"iZI!fl1olliDgy of1hepowllili}"foiid glI;mds_ .bJc Bernes L" ecl Surgical PathoJ:ogy of the Head and Neck: Ne\v York: Mm:oe]. D~.er, 1985 ;pp 1487-1563_
56_ Jlrng.alZZO]OlL C, Bergamo Al AN:d1r,eis l So]b~llttii L ]P:ru:ailiyro&dgllMdIs_ h SOi]Jb.ii~1t1! L, Riizzafio H, eds. Ultrasound of Superficial Ssructures. LOINJd!0fl[ Chm:cl1iillI.l~-mgslh)1l!e, 19:95;pp 87-1.l4_
.5 8 _ F~~er BL, Doppm<m JL, Sl1!~'\v~e:r m et aJ. Um;d!eSioend!ed.pru:<lfl:hYlfOidi adeFlomIJ<l!: '<ill.iimpoFlt~TIt eltiiomogy for -faiil!edl ,operaltiirnlsfol:]Jrimary ihyperpm;afulThymiidlism_. World J Surg 1990; ]4: 342-348_
59'_ Yoesem OM, Sdleff}l.__M_ Thyroid! mdpMa!l:lhyro£dLhSom.fM. C~ 01), eds. Head m1d.Neck Imaging, 3rd. ,eoo_ 511: Lom: Mo~Jb.y, 1996;pp 952---'.~n5_
6(1 Sot1bi!a1tii. L, GJ!<HIgrmdieA De f'lf<l! L et al. f'fjfCmMlBm'[l!S mffioc1IToo. of eili,lillo] ,of -pm:a1!h~o~d. rumomsmderrnkaoolimd gmdiMoe: tre<illinlffiI fO[ seccndary hype:rpar:~iliyroidJJs.m_Radio.logy 1.'985; 155: 607-6 H1
:ogy, lilt is> ~pmlant ~a.!t ~elf:@dlro]og:USJts,mgeo1NJ. IDlclpby.sici&l!Ji 3p~ "!he samelangeage. :llit is eSSJenlliJaJi. to uSie a. OOrtill1lm!O:ll dalSsEcm1oo. sy;S.~e:m IDl:d!. wOo JhaJ\lie ,i3l bow]edge of 1tIite v.mol!l!s~e:rms;. for cill<illD!CllEOrnl. a glessary of :!he lte:m1iS<mdl<i!!1~BIl1!aWe lterms1!l)S!ed imiI. d!esclllbmg l¥mph llodes rus~emJJ ill TaMe 4_1_
Ulrasolllid An:.domy
W'her'e does :!he begillma ,SEm:t whelilli nymg ~o 'ev:afu!a~e the lymph nodes of the l1I:.eclk:? A~illeH.;]Jfo(fu:C..l!b]e system ~smeq_,edfof ,~g the aeck, Ths SJecifiOOi. '!;villil. desrnbes,lITrn '[jJJ. syste:lil1l!;fOf eacharea ex<IDilitecl. llie'iwHj[~omy Oif Ole tympi\! aodes \WllI.he rn"s.clIJsSJed imlde1t&ill!_
As1tmcb"d. ex~a1!ioo. OOrrs.l!SJ1ts ofiil series of'sw,eeps'by lillIeplfo1be (fll!lIl1lJJberred 1:-1'0, Figm-e 43),.Sl1t~g m lihe SL!Jibm.enta:JJfegioo ~d. e:dem:lM1JJg over one side of :!he nedc_ If:!he sys~eJiliI ~slfoilillow,e:d '00. :!he otl\ter side of :!he ned, :!he m~iOori1ty of 1t11:e oetvtca] llympl1l. node Ii.er.ritories r"viillI. n&\'iebeefll. 00V\"ef.ed
Submen;ta1Reg.wu ,(Figure 4.4)
Thepmhe is !heM. transv,erselly _ EdleniliJ ~etwo llIDeads of ~elll1l"l!eflolfbelilly of ~e~gatSJmc .'I'I:IWlsdes as ~ey come off'iliieb<il!d. of iliiesj-'lffi]J,l\iy.sis .mootls of :lTIemMdi!b]e_ Thelll!oolf Oof the s.lIlibmen~. mMgl!e ~s 'ihemy]a,nn,roiid m1!l!Slde". Sweep :lTIepriQhe dmvn to ~e
J1!J!g1!ll:o,dl!gasm~ no,d!e Deep cer.-""ical! ehai:l:il
iI1y{)idl hooe,.]oolliiing .s;uperliici<]]. to 1tlIDemy]cihyadru~dheThvleoo ilie dillg<lliS;ltrlC ffll!l!soEes_ Nodes me ooEl'l!m!~ seen anltmolflo/belJm:d iliem1mcillJ:]e ill'ihe midlilille bet.v,eell! 1tl1e m~Mmc m1.!J!sdJJe fnse:r.:tri'OnK More im'eri.or~,. aodes m~y·beseen. on, or~s;t medlJ!a:]. ~o, ilie diigm.mc ml!ills.cles_ TheSie !I1iodJes .a:I'e {)O~(}mJirlIy <il!5ymrnemc11:l mdlffi1tllb1ll!troo 'i,\i1th. <iI. dJlJ!5I1ter Gf~od!e$Sieen. on one side orily _ Rru-dy, uodesareseen &s,~er'edlnear iliehyordlboil1e m.~e woom ;aspec~ .of the sJilli1hmm1taJllfegUoo_ The lilll!lil!Ilbe:r of lliod)es :fbmrd m 1tl1e slillibmffi1ta:lJ[He~. vmes Hom one to eight NormdiY"m .. om. aCfu!1~ iliere aeebetween one .<ll1:d.~ee nodes. S1!])1bmen1tilll nodes. 1tem:Ld. to ~<l!ve ;1ll1!. ,e!llip1ticaJi. orsJtigfut1o/lfOl.!l!I1;dedshape_
These scdesreceise ]ymph HnID ~e chi!nJ" £:ips, clleeks;, -ffi!oor ofmol.!1t11J ood oolterim ltor[lgJlJ!.e_ They m mm. m<Mn mto ~e ~s1!])bmm&h:llil!1ilJ[ nodes <ilI1d :!hoo. ~e mpper deep oe:rvica:]. clll!m_
Theprdbe is now 5'\.Vl!IDg Moum:d EO one side of ~epafuient wi~.t1\tepa:1tienfs. head ~ed. ~o tl1;e '0pposite side_ Thekley lio assessiag tllesubmMcib1!1illar fegtofl.is 1tl\i.e cSl1!])1h1!nMcl:JJbm::rrglJand itStelIf S~gpiIDfdd ~o ~ep]1ille of ilhe bodly of 1tlhe NruIDdtJ!Jb:]e <lI:I1!d ill1!glIDg ilhepmbe crillJjjidiy, ~es,1!])bllllandtJ!lbmiimf gli1rn.d is idien1l:iIffiiedl posterior to ilie an1teriofbel!ly of 1tl1ed!i~a&mc m1.!J!&c1Je_ The POStteriofD:eeborde:r of lil\temy]ohY1ordl ml.!J!sde eaabeseea ilwdJenoog ~e <ilI1teflruaspect of ~eg]mdL Nodes Me deSJrnbedl m. lfda1tion. ~o ilie~l!JibmW1:dllb!l!l!arg]i1li1d Use '!he sl!l!bman&bill!llw:gl)and as ,<lI:llleIDer'eJi1cepnmt :i1li1d[ICOllIiIEOOt on Whether the flod!e~S1m1terior, sl!]perior, mpDs1tmor Ito ilie gllmu:d_ The:reiIDfel!]S1ill'<rlllybmv1eJe:I1i. iliI"eemd.sh aodes (.a\'ief.<illge fom) m &e sl1libmmdll!buillID'" regfon_ .45 elsewhere ill '!he neck" ilieirme vmes m m\'ie:r.Slepropomon 1to M\te nlil!l'l!])he:r of:l1!odes[preSJoot_
SmaIill. nodes me oOl1stantt:y ,Sleen.aELltenor to tI1:eS1.!J!lbmilllwbllillm-g]ill1dhe1tweoo. the wanwb]e .omd. tlle dtligill!£mc DlIl.!J!so]e on.1llill1tr,asowd_ S'l:ilperiodly.,n.odles .1n1e also d~eded.ill!~g 1!l\te fadirlmery _ Nodes ma~aillSi0 bepreSJemtposlteriO!lf ~o ~esilJ!1hman.rnbl1lillaJ[glJi!mdL Rare1Iy., nod!esMSlry])[e d!eep ~o ~eposteriolf .aspect of ilie gl!M&
The Sl!illlbmilllwbllillm-glimdm1:dergoes. early encap,smlil:1tion ,~g its embryomc deveJ)o])moot" ilierd'olf'e 1tflemajlOmy ofsl.!J!hm;mdWb1!llil!ar nodes. ase ltrne lex1tf.~gE1llllidJuill1ll: nodes. V'ery oc~oodly1ill Sl!J!bC1lpSWM ~!Mph !I1!ode mOl!}' be present, :A1~Ol.!J!gh 'lheSieslillil)caps1.!J!lJar nodesare m m~ai!e oOil'l1tad 'i,wili. the pare!l1icl1t!}'W<1Il iliey me .not 1t:Ilire mtr.21gli<ll!1cmilla:r sodes. The vm1t.'m1IDjonty ofsl!illbmmldli!blllillar rJiod!es llre o1ll!tside Mle Stlill!bmmd!!b1ll!D1lI"glimdl (as disMct:,"om tlJ:e pam1tid region, w~ch. wil1lI.be mStcl.!J!SiSJed, ]~lte:lf)_.
f1:e!t~mandibular vt:.n
Superio(lr
F~g1:ll"e 4.j's'l!J!Omar:JJdftm:lJa.'fegion,
The sl!l!bmMdliibm<ll' flodesm,m 'lheomterior fud"IlI s1tniI:cm,es .Mdt s.kin. as w,e!llI as &e :loor Dfmm~1thID1:dlomterior oral Ci'l!wty_ TIteypredommMl1t1Ym,~ m~o ~e deep !OervXciIll. c]}wrlilL
TheparDtiid.lf'egroo.wJ!]stbesc1lll:l1:ed.botlh.tr..ancsver.sdly <md 'CiOlfOl1!tli!Iy_ Wirth. tlIDeparo1tid. glJarJ!d <iI:S :!he 'poiimt oflfefa'e11oe" care ml!JJstbe 1t~e1li. to ex:~e the .areatbeThVi(le:l'Jj ~epos,~eriQ![pm:-01ti.d1IDd.1tl\te ear. M.1tl1LJjsfegiiO!l1! iliesnpe:mciallplll"otiid orpre-Emricm;n- m:odes:;n-efowd (e:l!!1tirapm:otiid nodes). Th:ee or {om s.md nodles (particmlll'lo/ m the ~O ,CaI1! bellomd .<m~e:rfOf to ~e tr.@gJ.!l!s,_ Slilib&sci<icll. l1!odes ru:el!JJs,1IDd)rfomd .at 1tl.vosii~eS::<ID~erior to the tr..agJ!ills (pre,l]Imcmiitl! node)::mc)]pOis1toorn1y '!,\i~ ~e tail. of lOOe gllaml Therr'ear'e '1!J!SI!]i~, one or ;t.vo s.rihcapsm;n-plf,e-<il!mOm<ll' mod!esa:I];di[p'osSJ!lb.]y up 110 ;trM'ee or rom :SJm!hcaps.mon .ma.-a,-rc1!1!llar .FUodles m :!he 1taiil. of ilitep<llotidl_ They Me ornEJmodly idlen1tfied ~[fu.mk,~ml!l1;d) jin, CMmelTh_ 'ffue deep FUodles" ~_e_ mtr.ag]~CWl[ll nodes" lliie ~tlB. ~e sll!1pemcia:1J]dhe <md m ,"!he -fu8cii<il. betweea s1IDperliicia] and. deep ]obes_ A crusta ofnod!es mary he present lleart11;e e:dem~. ca:ro1tidl im'efj'iiI:I!llid. '!,vhere ~elfe1!follill![IDdli!1J'mar ·~.~ei'l!ves 1beparo1tiid. to 310m tlJie eX~en'l!a!I.jiu~arvem_
Slliblascial_ IllirfL-$iunCuldt
Figure, 4._6- Pa:r·~fI:icl! 1egion.
The area :primariillydlr.amedhy 1tl1:epMotiid. fUodies ~S !the skin. of ;!he Ilbrehe&dl" ~empolf.1llI.regiio~s,ID1:d.extenl!a1I. <:ll!lJdi1tory coma1l_ m addritiion ~:h dr~sliom ~e iElI:]s1ta.oE'hl!a:I1I. h!he" 1bl!illocailml!J:cosa,.pos.~eriO!f cheekamld ". gJll!Iilli imItopm:ofu!d. nodes_ Tfu:ese .iI1!odes .m.ltmn. dr~. m1to tfue d!eep oervic:;rl,c:h~_
'J? "~. D "(iJij''' .01 7\ I' a:C,M.f .neg,UJ'H Il~ 1!gnre "1 •. - Ji
H 1tl1:eproilJ.e is illoViedlanteriordly Rom iliem1tmm aspect of 1!:fues.lilpe:rlici<iiill ibbe .of 'lhep1[J!'o1!idl, .<lilloil1l!g a.lJIDe .dlria\w. '1)0 ilie comer of fire mOl!l!I:h, one v,:rjj. he ill "!hehIXCtciIll.regron_ Hfi1Lci<lill.lill:od!es alfeplf,eSJen1t ~eysllomilldlbe fOlmdi m tOOor,egron_ ]F'aciiIll ~odes :!tend to be V'efJ'SDltd. :!lodes 'lm:d ar,elfMelJy ,em;ool.!l!ll~~edl ill l!ill1i[[iilisiQil!l!ml They are :sl!JJbcl!lJtiID'l!eOillS1IDd. g'en5lf,dylli:e;illlOflg thep]ID'Ie of 1tIllie -fiildirl.1itI1e1)' 'MdI. V'ell_ There;n-e ~vom~ groups;: IDe .itl:ieriormdru:ygr.olfl]) ,<rn:d. ~ei\}lIToci:ni:il:tor 01"' hl!J!ccaJl. gro~_. The im"enor mda:ry Diodes. me fomd clo~g 1tll:ean1tefl!Ofhorde:r .of iI1\te m<iliSJse1te:r_ The most merior ~od!e of ~s, grol!lp mlihy .lh:e on.1the .fierio!fbolfdie:r of 1the madllb]e; !i:l\tepatimt ,em. oi'e1li feel!. E11ms ~odie if i~ ~s.. ,enilllil:l:ged .. as .~t ~s. :lfOliI!edl Q\i\elf !i:l\te booym;mdh1lJ]e_ Thehl!illoca:] iI1iod!es; Thie m 1."fu:e fatp.iil:diID~eriO[ ~o 1t'I1e m<iliSS!eitermmide <md s,l!IDpemciiirll ~o ilite b"l];cc.m<il!1torml!JJS!de_
~i1r'lIHim !ll;l;(ILlary_ Mass!JiElr
,
-
_ Buccal
F~glillIe4._7- F.acia:l! :l"egi~a_
Deep Cerv,ical Cho.iin 1(J'~gm:e4 .. :8) ..
The d!eep oe:l"vic~. orjiHglllilllll" cllim. of llympn iI1iod)es:f~ iliemiiIiFIllymphiiltic :!horol!illglE"liI:I:e .of 1fu:e fledk:_.~t ii:s ;OlJ. ve:litl!c~.t:ymphiiltiicesc<iclli'l!toif '~~el1ldilFlgfroml "!he feve:lJ of ~e dJi§Mmc .~l!illsde to 1i:l1elfoo1t of1the nedc
Ompllyoid
o
LIII!iII .. - - _,,". _ ....
o
uv eGA
Figw:re 4.;8~ DBelJ' ce!'\<"1calcl'1.illn_
The key lloOl!5S'esmg '!he deep oervl!ci][]. o~m ~s 4\0 .S'CaNJ. :!he ~:Ililtenlliali.~gmill:n·~ (11V). U1ll1!$VieISJe1}r ]fOOJi.l!he Fe\'icl. of tIllie ~a,illj. of ~e paro<1wd ~o its]im1,ctiDn ",viitl\u the sll.!J!hdlaWH\lie.i£:JJ_ J1.UI!s"t ;§iSmSic~g Itl\te deep veias of the ]eg, 00mp:resSlloo.lis ilMpOrEaflt .JlJ:ways "bolilililoe' t]weprobe <lilloog Itl\te IT'V _ Thiiis. does wee tl1mg~: .it .~ows ~d!enttEca1tiOlilli of 1tI1e If V, itmU11t~s E1\te IJ\! .m 1the oentr,e 'of the :p:robe" and. it enrsm'~s ilia1t Y{)'l!l! db not l1IilllS's ;a tlUollillibOiSJed lfV (iii. :I1!ot 'l!l!I1oomm:o:l1!. .s;hl~e whel1l. ex4!el'Imre metM1tatic ]ymphadmop<iLthy ispreSJent)_ Nodes d. bere[])dlill.Y ~dent:m:edl.[])djiaoeElt to [he 1JV" Jlmdo~rull1ly @l"fIDligedi ;ru:oml!cll il:sim1tem:~1llte:r~.~oct
The deep oen1!c:alJ colli:oilll ~sdli:v:id!edl.w1to1.!1ip,per, ~d!dllieaJi1dl.]owerSiections by the .h10~d. booe<im!dl crioo~d. c<IDtiill<1l!ge, aJithough.tJill;e ~a~est .AJOC3 (199'7) dMsmca1!frn:l.I!J!Sies the cricothyroid memJbranre,1ll1!d flottl\te cricoid cM:tt:iill1IDge, as the~e\lid :£or dfiv1!dli!11Jg·the deep eervical 'Ql;u:! mto mid ;<md ]o\.ve:rfeg:Urn1lS_ Nodes in 1tlllie ·llPpeil:firu1: of the dleep oe:rvi!ctrlI. cham. ;a:hm t1itepos.1te:l:io(l: beltly .of t1ite dig asIDe l!ll1lil'J!sde Q8'~gm:e 4_9)_ The ]argest node ~s the most Slmperim:- the
The deep oerv-rcm nodes.~eQeNe ]y'11lilph yom.ltl\tepm-orttid, te1tlr:ophru:yngea:lJ .md. sll.!J!fu.mM.dblbmm- nodes. lim'mrn:]y they enThp1ty .mto the lJV ors.1!l!bcl![jkwu\i\eID,. O[dlr~. d~:ec~ .m1to 1tI1e tl\ro:raciccMct on 1he Deft 01'
F~gm:e 4.1.0-
MaThi_gnan1i: Eefit rid!. Gm;ilc~ ~~d!es, ali the tBn dcl~.ck ,aI1Id!. fr\¥~ ~'clecl;: pos~ti~f:I!S,_I.fV, m1tema] j,l!ligW:a:I" vein; Cl\, ca:l"o,tidia:rteoryr.
As: i~s ~1iI:m:emnpTh!es,1tlIDe~h node rnm.:IDollliow.s: the spina:lJ aeeessery (XI) nerve. Htom'iierel: deSioohed. one ,orposSJ!1bJCt h,vOp<il!tf,d.eJll.fOWS, of :I1iodies; :;wma~ymg ilie 's.pm:<rl.<ilOOeSfiOfj' ne:l:\'iem hils origi!ml<IlldJ!s.SieCiITOns_. ][n order to eoves ~e OO_:Sie of ilie :;wcoesSiOfj' c~m 0~e needs ~or,em.eJ1llliber 1tlh:e ]anrnnarks .of ilie XI nerve. .lit e:I'I2le:r'~e5 kom. '!he ~.bmeWiil iliejiillJgwillarfolfalllefl_ It iliefl. 'p<1iSSlespos-weri!odly deep Ito the 'po.s~eriDrbeIDiy Olfthe diga;s;mc :<md. ~s;-wernoclJeiidDm1li5~o~dmllSid!es to rniI'li. mto1tfuepos~eriim: kW:Igl!ebefolf,e dlnppmg bel1IDd. tlle :<iUTh~eriOfbord:erof.1trtitpezm5_ A lMtem&'i,VNn.olilil the .m<il!S~oid Hp ~Q &e a:.cromlio'l1!n~pr'eSioots !the oom:se of.e spm1ill!1IDcoessmy nerve. '][l;e oper<il~Qlf 'sholillilld SiC1ll1J.1tr:<mwerse1Y nOrnl ~e mi\l!S.~oiid!. a1)ong dteplfedioted. Be of :!:he .spilwal<W.C!Dessmy aerve. Rem.elil1lber 1tfuat the Xl[ ne!\~,e ~s ;at .s.uperliicial.s,1tIl:illctm-,eSJi1ttt:i:l1lg oa the fascial carpet Olf 1tlTI:epo5~eriO'l" ml~glle_ ['ooll!: for the p][MJje beThveeFl.tllie ~s.~e:rn:om<il:S;t\oid~d tl\temderlymgs.caJ!tl1;e aI1!d ]evawO[ :Sicapma:emllSicilles as nodes wiili1I be i!d.en1tEed.m trns.s.~e:mcil&llp][MJje,. i.e. \¥i~ 1- 2 em. Olf t&e ·~.~oe_ One Ctlll1!safdy ~g:l1!Qre tlle :s;ltllITCmreS deep ~o tlhe scalese muscles. billeriOllJy, pick Orl!lilt tl:teiID!'lwertor border of trape:z:ffirJ!s; ~s eWec~~ iffiarks tlte .]m1ctloo Oif ~epo.Siwf:lri.o,r IDill'IglJe ,rn~ IDllcll1tl1e W.afIWelfSie o~c;aJl ch1lin_
Trlllpo:lim:
C ).
o C...__.. _::J 00
:SpleniUS ci:lpilUS
il{lv3:tor scapetao
PQ~lilliriQr Middle 5cOliliinil
F~gIilliI"e4._11- Po,sten:o:r Uflangt.e_
The point where ~e c5~e:m:omi!l&~aJ!d ml!l!Side ffi'ielfllfestlliepcl:S.~eriiorhellly of &e .mga;smc matks. the ]m1:ctioo of !the :spm1il'll. accessory <Mlldl t11:e deep oe:f'i.<i)ca]i. daicnJs_ O:l1;e crumot dEl'ererl!1!:D1il~ebem.v,een ·the two :a.t thispomt
Onoe tile 110:00000. i!s reaehed, tfueprOibe IC1\l::I1i.1be 1h!lfI:nedJ tMOlugh :9:C)P m1to ,[il5<i1gl1tttaJlp]ruJie_ ]hf oae kJ.eeps 1thebo.1t1tom. Olfthe 'plfolbe .a]iglled Oli1!. ilie d<ilLviclem:td sweeps .merna:lilly ~owm-dlsilie 5We:IDa.lI.lThokh, one 'i;viillIIhe sc~g ;alJrn'l!g tllep]alTI!e .of tfue k.i§If:Is;\ii"eIs,e eervieal vessels, ~-,e_ thep]<iIill1:e .of ilie !traf!lSVIelf~Sie cervieal (S:~I<ilcl[jJJ:vic1llilln) ]ymph node chaiin_ M.pracfu)oe ltb!s meoms 5C;~g 'i"vi!1tlh. MIle werior~ect 'of ilhe prohe on (or iin. most cases jiu~1t above) llie dtilvlde,. ~oa1l::i!!lg to lidi.e:l'LtiillY ilies.l.!l!bda:wOl:Fl.vesSJeJi5mm,emerna.1illy _ \~e~f.I :trhe]JfOlbe reaehes "!:he 5te:mDml!1ili8toidl.~e jilll!gmillo- sll.!J!hdacw1iIfIjmlctioil1Jishol!l!lJdbe iden1tiied_. Ths.pomt l!Datks. the jil!mctioo of ilie 1tr:MWelfSJe lQer.viicaill. !clIDaiia mdl the deep eervical d:uilmL The mostmeornali. node of ilie 1tr<MJiwerSJe lQer.viicaill. >dIDaiia is .OOVi'l1! .
• <IDS 'froisiiei's. iI1Iodie as he was iliem:::>t ~opomt Ol!l1t. t'Illia.t iliis. node m<ilLy1become ml'ii!aded. in GMc.inom<ilL .of [he 51toma:ch_
The 1tr.am\'ier::>e o~cru. cbaiFJJ.reocives ]y'»1ph Yom.1tlTI:es.pilla.1l aceessory cfu~, deep oerW~. cfum, upper MwmOf ches.t wd.a:ndlltlTI:e . .sk:iirI. ,ci!the :an1te:r,o]a:l!er:aJilm:edk:_.
PageT],
F:igure 4..12.-
T •. aasverse cetVicaJ! cl1ta:in_
Now tDe ite pmhe back. to' ite IiIMldllii:lllie ~iM!I:d.p,iick. Ol!l~ fue furyoiidhooe_ Tms is thiest:nliingpomt for ex~g the .;m1tmo!f o~e~. sodes. Sc~g kiYISViel}Siel\y ]fO!lllJl. tlb!ehy'o~fl, sweep' neriody lto id!em:iy the 1tlhyrold!.cartiil!1IDge of lillie ]m}'":I1JX, .cri.coiid!, kad'l!e<ll, flII}rro~d. ~S~llSiil1id. then kiil!mw. ;<lIg~befci1:e ~t dlis;ii!p;p'e~s. mto !the merniillS!Mlilim.-lIheiID'l~erim: oe:l:V1ie&llreg:uOl!1 \viillI.tlJ:e:Il fuaJ\!iebeen oovered
lP'relarynge:d Nodes
C(Jmln~}n C~rg~iQ !!t1£i,r~
F~gw-e 4 . .13- .Mtefl®f CW;<lCa] flo-des,_
lP'retthYF1oid Nodes
'ThepiJfe1trillidleaJ! nodes; ;1nes,~e:mcial!. nodesfo:lillo">;vmg 1!:he 'OOl!lfSJe of &eilll'l!eriDr~guJillMVicin~ m1toonr to 1t1\teb:arne<il!,bel!oW" [!IDe 1i:hyrorci They &<ilID. '!he :l:hYliOtd. ~<md§lld. Irfmpihfrom ilieml.!J!s;des: .~d :s.kW:I. of ltfue :m1tmor neck. They dram. in1to 1the ili01f<Wcic met on.liI1e ~eft<md .mto liI1e ~owest deep oerviea!l. iI1:ode Ol:l!IppeK 1i:lao:l:@cic node 0:111. tlteriight..
The ]Ji1]f.<ill!:.Olcheaill nodes me ~Q Mm\'ll .<J;S tlliielfecm-rel'lt ]liI:I'}'nge;l[]E:ooles as fuel' ~ccomp,~' tlliiemcm-rentr ]liI:I'}'nge:<II~f.1Ve_ The majlorlty offues.e [I!OCi!es ;[ITe~Ol!mdl b1ter<icll.1to the tr.:m:rne<ll. m '!he 1tI:;acEleo-oeSiQ]J~ai?ieail. groove_ .lilr m tlte 1t:I'adThe§l Md. oeSOpl111gtill1S CruJi. OI'ernote diffiic~es m ;ilSJsessin:g these Trymph ;I'l!od)es_
F~gJ!lI"e 4 . .14-
~llfg.ed! (10 fll1m) pafatrarne.aJ: iI1!ode (mowfuead!s)" :p'0st·erieno the th)'<®id!.(am'l'wed~, lnWllckil1!g a' .pllfalliY'1:ordJ adel1!oma_Thagn~H;~s;: S·llfCl(\l·rcil!os~s ..
Page 7-1
W'boo '!:ills :standMd. 'El!:~lltron on.boili. sides of~e neck.liThruobeen. 'penOO!Eed, lOOe l!lI1IHajiority of'lhe ]ymph. flode f!B:I'ri~ories of the neck. will!IlThaVieheen. 'oov,er,edl_ The 1}fl1I1ph node lteniltories~atID"'e nDt oOViered.1by tmss1tiimdru:d. ,ex;lllImHiL1tiioo. ~ID"'e ~ow .momdJed. for oompIBltem:es5.
TheSie nodes caanotbe ,iiI!SSieSiSied.hyllllli~a!sol!m(:JL Th.eyare often. W:1i\iiONed m l1iiil!Sophia::ryngea1! :;md. orop]]~gea].prilD1ll:)'·ffilnCJim:s_ ms nodla!llam:ea~ol!i!l!d ;~va!}'.s. he .cfuJdecl[ m. ili.en'e<iI.sC3lmI!edl w:l1:en.l1eprim;ny mmo,m ~<iIiS,SiesSied. hy lli.OO or CT.,. 1tl1.erehydo'i;vmg .<ill thorough. ;iaiSLSies:sment There me two grol.!:lpS of nodes: "lhemernilll. grolIIDp lymg nen iliea.dlIliwTe m ilierekopl}]~ge.ii!!ll :sp[iJ)oe, .1ll1!d.1!:fue ]a1teriii:] l1iodes or .l1!odies of lRomere wfuilldl Thiejiust blter<rl. to "!he Dong-lillS ooli. ml!l!scle_ Themedlii<rl.l!lodles are .~ot~ormdo/ seea whereruo the aodes of RoliWliere are wdl. seea on 1\00, 'p.m1i!.clilillady m Yollmger 'patients_
At ilie Viefj' <itpex of "!hepO!sterior 1trimglle, s:a:ml\viiclledl beThv,eeJillJ the s.:lte:mOm1J<ilislto&d Md.1!rapeoosmliillSides ~;md the oocipi!taJl'hooe S;llperiorl)·" iliere ex:istsa. ·smd. cmster of nodes. They :arel.!l!Sil!l!a1illy i'invoruwed. m a.ciil!l1tl\tood. hlOJt ffiOlLyhepres;ent m cMdihood_ They ,drain dMicl1y mto [he sp,maJi aeeessory cllliaicl!l. <rnda:re ~cw~ to idJenEi}r 'Wiiili.1!1!lk,lihSiO'DidL
Asmd. cmslter of nodes exiists~st be1mJ:d. "!he ear, mor-e 11illlimaOills in "!he ,cl1iilld) ~<Mli. m Iili:e acmlt. The.SJemolln.1i:fu:e ,':L111ridellldl. eX~e:rl1!;jJj ~al!Trn1tory me<l:MLS_ Lj'mph.1i:l\ten. mruncs mlto ilie. .iEierimparotid. fiod!esaN:dl'IDpper deep oe:rvICEll nodes_ ~. ~<11. oo-operamre cW!d thes.e nodes are te<ldllily .rdentmed.hl!l!E: m ;the ,1ID.cIDillI: "!hey .h~'i,lie1[]Jsmr1mymvom~,ed_ 'Vi'lh."!he Iex!Oep1ti01!Jl 'of me][iJ)flO<miil.1tl1ey ,!ID:,e!l:<Hdly :SJig:OOliC1illt milie .ro!ID~_
,Given. ~eplfe.cSJffiDe efso 'n:uany ]ymph. nodes mtlJie "norma:lJ.' neck, ROW many 1}'lfIlPh.l!1odies sllliolillilldl1ihe operator expeo1t lto see on. ex~g '!he neck v.:riltlh mk,;a;sorl.!l!l1d? There ~ID"e 300 .1lym;ph.l1iodes iin.1ihe lleck (i,e_. 1.5'0 on. e.ither :side)_. Atypi.call.f.<il:d:rca:l!l1edk: dJissleotrOl'Ji. ':s.lli.olillilld yidd. 30 nodes on. card;!]!]! pl1ilio;]ogical1 ex~a:1tioiJ!]l_. So, how IDomy 1JyD:Ipl\! l!lodes~olillilld one expeot ~oSJee 'it\'llilirnh~1ill5()l[]Jfldl? Themswer is, "It depoods bow billIl:d you boJ.ld'i_ ;!if YOl.!l! use .1lI.lillgh "i"e~fficypmbe;md. :sp'end.l1oms: ex~gd. ilie~'m:P:b fiode territories y.ou 'itWl!lfutdmmtip]e nodes ill ~~.a:reru>_. Bnttr'e:mJ5m!ber !that: _.dliI'l!g hemg;l1! imlooent nodes ismor'e ,dllifficl!l!l!t "lhH det,ecoog mdgnant lYmph nodes. iP'ailio]ogica] lYmPh nodes \ViJill ]e1W Ol!Jit at you. 1000oeYOl!l!. llliarve m3l!5~er'edl ilie ~b~c lllllikaiSimmd. examitniU:Ol'lL Do llotbe worried if YCJi1[]J amno1t lide:nlillftY mmtlple Niodes 1iIiI.d. ~errirttoriies". 'foe SPffit Iooing i"OfSJ!lla:lill. mSJigl1rnc.m1t nodes is me 'iov~[iJ!S~ed!_ Ol!loe Y01[]J l1!a\/iem;a;sta,ed t1;1;eb~ 1tectmillque,,<ill st.imrnnd ,e,}l;~i1J.tiOfl. of 1tlhe ~eck slliomd 1t.e .no .more tltilll. i.'G-15I11ilIDlOJtes. The glfe[jL~er tlte experiesre ~ru1:d the h1iglliJer the :freq[l!llfficy ofpmhe'I]JS!ed, the grea:lter ilie flllDbet of]y'lill1lpllli nodes iliat \villill.he detected. Nodes ~omwe:lli5 we beceese o]dJer_. I·Y1iIlpll.nod!es:are fMmore l'lil1!lILer,Ql!l!sm"!he yomgermrnvirllrnil1!; 'ioVhen.Sic~gar. 'inormaJ!' teffiaJger's l!1ec.lk: one woU]d. expect ~o dietec1t BJ-2t)1 nodes wirft'l] ease,
J1!JJst when we were gettmg ~ogrips rwiiili. "lhepille"lhori:ill .of mllnesmd :Syc~~erns for ilie lymph nodes of the l1:ec.k, "!he AmeriC<lI1I. Joi!Ilt e~~ee on Caacee (AJOC) infu"ornxGed[ llie']e\'icl ~e:mJiinaDogy' _ 3 The COllOept of "]evdi' is drweNi.by lliernct that ili:e e)!cltent ~<IDd level of oervica;]. node m\/iOi~e:n1t ~spmb1I1brlly 'lhemoSJt~rn1antp .. ognostic :Eador :IDorp:ments 'itviJ"I:1iJI.<1I. sql!l!ruJJ:O:l.!]!S, oeJruplfiiI1!ll!<M}'_.Node]ewJ~s. .iSJ. m.gMlys.ii.~c:a1!Jtp .. .ernc1tor. of s~a1I_ St,.e!llli,4 m ~<1ILrewB.v of 105 8piil1tiien1ts \Vli1i:h. Sql!l!1M1IlliOl.!l!S oel!l. ciITd'tl1om<ill of 1tl1ehe<il!d udl nedk:,.sJlliow,edl tN:<iI!t ~e 5- y'e:m:~ii!:ll.raltefO!rpa1tiioot5 ",viil:h nodes ,[jilt ~eViel! ]j (sllillbm[jJ)l1idlJ11hw:ar) W,iiI!S 34%, wfuiil!e ill was ornly 4% forl!itod!esalt £e¥e'll. W (lower oe:l:Vlirnl!)_
It is; iimpm1iimt ili:<lt we ~iSJS!lfa:rnoEo.giLSits ,em;broaoe '!he concept .of '~e\'le]js" _ Smgeom base ilieir 1tI'ea!tmen1tpn~ OFl!. tlle ]e\'lel! of t:;.rmpllli. node mON1emooE, iIf ,a.J!]}'_ Th.e AJOC ~Sime:llle ~aWs to :sDplliIfy the ~[jLS;Siessment of1!:fue ~ed::, <'lilli. ~a:im wrncJlltmaIDJly ac.meves_ The levelsscheme :I1:<iIiS; ,eViO'Iviedfrol1lll S01!IITh'S fll.!l!lEeriC :I1oda.ll dEEs.m;caltilO1NJ. sY.SJ1!e:III,,5bl!l!t ile:reare some ~ponant dlHe:re:l1oe~_ iFi.gJ!l![e 4_15 is ]argdy SielIf-e)Cpill;matory,b"IJ.~ there are a.Iewpomts worili JilligMigh1!imllg:
.2 Le\!1eJJ V {lliepQcs,1terior mruJig1le) iLS~ersl!J!bcfu,-j)d!ed!.m1toIDpper.,.Dd)dJ!e1ilfl!d. ]ower me\!1elJs oorrespolID.d:i!'l!g ~o 1!:Th1ep]mes 1iha1t. dMide ll, illmdl N (~_e_ byoid :;mdl a]ooili}'foidimemior,Me)_.
5: Nodes of ilieID]J.'per spilIDalIiiliooessory dl!.illI. ma(jl be .m.d!!I:dlOOI. ill the .Te\!\e:JJ D1Wld. illiil::l"ei3iS,m :iilididi1tiicm. ~o ~e deep oe:rvi!c;]!Ji. chm_ (i .&e:Il!le:mher ID<il:1t s1!rnperior~ ilie E;pm,[il]~c_'oeSSJQiryMd. deep oerv1!ca1J chams merge; diIDerefil1tlia1t1co:l1J. heThveen.1illte two in tlteliliPper ~eck ~s amdemic_
The UIfOC-1'NM daissmcll1IToo'ire:rnams a.]<ilfge1IyM:llOrnlcali. daiSsECll1ITOO_. Care is need.ed"lThoweVier, when.'l]Jsmg some of ilie 1tenns. eJillJployed m deSJrn)lbmg' tl1e t}rmph. node gronpmgs, e_ g. dors.all. ceevieal (SJ1!]p'e:mci~. oervrca10 r,elDen:tng to Ute spm~.<il:ooess.'Qry c:ham. aedes.
RaJdiio]ogish sllolililld 'I1otbeoome 1booboggedl. do\\'1;l. 'i,vi~ d~smca1tiO:l1r sys1bems_ Use a sys1be:I1lJi llirnt ,rnlillowsfor ,qmaMdeJffi.iciemtam'lo1ta:1tlirul. of nodes de1bec:1ted_
Th.ere is no d!olllibt ~<ilrJtmi[[M01!l!ITId~s ;iillS!eI1!slWE ,ex;~iil:1tiion (OJ[ oervrclilili 1!ympJhadJe1lop.atthy_ 9--14 Lympllli nodes are e~ de1boc1ted loooe ili:e o'PeJl"a~m: is ,experiioooedl m 1illtemk@Slomdi. Maltomy .of I:te ;I1!eck_
The pmfu!]eJiliI. '!:hell]. ames of uyil1lJg to d!ecidle w'l1efth,a '!he ]ymph. node d!e1bec:1bed .1s:b~gI'l! >Of ma1li,g'I1!i]lliJJI:. Do c:rll'lteri;g[ exffitfm .rnEfer,entE~gbet.veen.beruign :<md.m<rlig:l1!ruilt 1}'mphiitd!5:I1:0P.~YMcllIfslO,;ne 1tfuey vddt Sl!Id~. rn1bmOl!. do exmstbnt wWe some are exoeJefil1t ill diIDerf1"11tiirnEO!l1!, o1ihersmepoo[_ COlIMmorniyMSJed. cri1!!OO§l are:
1-· Size
>
F~gm:e 4 . .116-
l}"ll1¥'fu N:~,de sitze as an m.d::ic:at~! ,ofmatignanq'~
The]m-gler filellymph iI1!ode dlel!edecl1tlIegrea1ber file lliilbelliil1iood. ofm<1l1!Jjgll!Mcy;fuowever iI1!odes ofillP.' to 3-4 em. m ]engili.a:Ile 'Oie1iJJ.l0md. iin. florm~ mOOridrnaffis,p2tl.1i1C'I!lillru:r~1 dhiilldr,en_ Size ~ofle is Ehe:re~m:eiillpoor or1i1b®O:I1J for ,dtrnIerenm!a:1tIDgbe1t\veoo. beJ!1l!gI1! .&ndnlJdg-
Page 76
:I1!iiIm1!E io/mp:h nodes. 1IfQli metimelll1lel1lE is t~en" lliLefljiDJsE as m. ern lE is :!he aru<ill!. OrErIDl!SVie£,s.ern1mJ:e'Ee:I" tlJiat :htiliS Mleber.E. oondation \Vlit:h. [he IDcr,~g. .clilloodl ofme1t§lS,ta1tic: rnseatSJe. The SIe]OO1tiruJ!, ofsitlle ,i51i5 a. c:il1!erioo fall" dilltiJere:l1!1tia~ghem.veerl!hoo§lad miMlig:l1!<ilflt nodes .mlillsthe based on. oomjJillOliJms.e. A :S1!Nd!e:r Erornsm<lll JJimne1ter mcreOliSlesSienS£t:iviry, blmt witth. ;aslilfh,SJeql]!ent decrease mspecmcity :~Gill de1tec1IToo ofm:e1t:Mtamc ,rnSif:SSie. VMI d!eJ!lI iBrel!o:1. ,et apo ,ma:1ysed .[ilr<mge of mimmaill. mcii<icl!. 'rnamet,ers in ilieNO nern ;and, fCJmldi. tlha1t a. -IDigm:-,e of 7 iI1!llm.lDol[ slillibmrmrnlblilillarandSll!l!llimenta]. nodes.,Md 8 m:m.~o.r .;n:llli oilier flodes,ga\lie am. oVierd.aocm:,a:cy of7()iDlo. llIills igm:e is lowler ;!:hm 1tl\te wms:IDrii<rl dEa:l!llete:l"sgiven mp<itp ers d!eSJrnlbmg ilie1!l!SJe of Cl' iGill stagiDg lYmPh :i1;odemet<<wes (ie .. H) 'l!J!1ill. ,;md 11l!J!1ill).ls .A:i1. ;[ji)d:vtmtage ofmk'iliSiGm1!d Ov-;e[ Cl' ~s that ;;jI[ trMllsWa]. dii<ilmellet" is a.ltI:lITe ;<%cia:]. Of 1trIIDSViet"s:e rname1te:r, ie. tilt is: trilkJen. at90iC' to ilie]ooglfurn8iil:u<Il! mciis of the .node. hi. the case of sllil]hmMd'wbuill1lli nodes" wrn.rn. a:re orien1ta1ted. m EIlfdaweliy fuomOl1l1ta] [pi]me, diiiiLme1t,ers ,on CT<itre dOSier to 'I) emg ]ongiimJdliinJi'a:].mem.m:euLffi1t:s &1ill. nema:li. or transverse diruilllie"lte:rs.
Jin1t,ere:sM.g]y, Vrul! den Eh:eJ!.oe]. et aP 'sta!~e '!hat 1i:lb:e tkemo.]d. :{Of81iJ!S])llcion ~s lffi1!J:rn. ]ower illp::aments wlThere1)rmplh ~od!eme1t1ls;1tMes ,a:re S1iJ!Spoottoo. (~.e. p.mB1'l1!:s ,."viili<illppe- {}rposHre<il:1t:ment mOWlJJprmary), <md a ~a:] .maE dillamet!er m 4 ·lilliIJLI. i51iJ!Sledfor the selleotJoo. 'of nodes :£or :fu1e-need]e<illSpiooon cylt()]ogy (lFN..4:C).
mmltmSlOlIIDd 1i:lb:ell.lJse o:f.sm;<rlIJe:r.IDci:ali. rnameters fOf s1iJ!spiicion of me1tasta!1ITc llymphadenopailiy :fun ilioSie 'lTI!SiBd. ill otker .1mOllgIDg mo.d1l1liUiesresm1ts ma.hl!gner :SJoosiwittybut ~1ilh. ;11L oonespon8iil:uglly ~ow'e:r.speciici1ty. '1'lh::is: now spBcmci1ty caabe ffilpwvedby 1!1!lk:[JiSJowd.-gmded FNAC. Ther'e tS .no. dOlilfbt ilials&ze ;<llJooe ~sapoor cri1t,erioo,bu1tmalJ dWal!]LeI!er's 1llefueJ:pfuill <mdl'can.beuS!ed .. m. OOill1!jjmTho1IToil'lJ \\cri6. o1tl1er cri~eriii:il. for dill"erenillimoo .. AD ID:cre<iliSJem .. size on. :Siffiaill 'e%~a.1ti:O:l1! is ,;jh good. :SJign ofmaThign1ilN!cy wl1!en.Siearcll,iililglIm me1ta51ta1ti'C dise:JIiS:e.
2-,
F~gm-e4..n-
Lymph n~de shape, as an indicat~.f~f1llLatignancy ..
The sil1:11pe of ~e l)rmpffil node ~s a.ffil"betler mrncatrn: ofbemglThi1iy or maillig:l1!Mcy t:ll!::m its size .. Berngl1. nodes tend. ~o be ,eJjong.a1ted.md. msilIDDfm in shape (F~gm,e 4 .. 18) wber'eiillSmailligll'afltt modeslttm:d. ~o hiiltv,ea:.gre1l1te:r [!;iills;l,~,erS!e rn<Ime1ter,~.'e.;jI[liiI!iLoill,emmd.ed.siI1:<itpe. 00 w<iIi5irst lhiiI1,1ted. at by 8mru ,et al; 16 wnos1t<lledl ~a1t m.e1t§lS,tmc nodes 'show iii. moremmded. comtfigm:a1tioo iliH.lill!OO-metlS;E1lmC l1iod!es. SO]Jb1la:1tll et aJl", :mstd!.es,rnbed ilie1lJ!S!e ma ]oog"lto shon ,msra1tto (LJSrafu!o) in the dJism.o1ttom1.be1tween.bmg:n. {VS > 23)Hdi.m<il'ThiglTI1,rut lliodes (JUS <:: 2.,~]i). Thill'S was ornEirmed.by l'OMOSI!]and hiLsoO:lille[jjjgJill!es, ra wflome1ll!Sm'ed. ilie short to ]oogms (SII..)fa1tioM oen.riicaJ!.llymph nodes ofp1l1tiien1ts. \VlJ1tlillJ Oes.opflargeELli cill1!oer~doo:mp<il:l'ed llNS wl1th. ~epe:l"oootagre cm1!Oe:l" oo~tent O~. OOCfo-3ill1Ja1lysis. J\:rI. Sfl-m1tio grea"lter ilian.'~15 mrnc.;a1tes a.·fOmd :lWode, \vm,eteasan. Sill t<lL1ITo ofEess. ilim.0.5 ilwrnc..:a"ltesm. ovRlll,msibirn'l ::s&:aped. miode. The ;i:iI:'i,i\er.age can:oer oon1tenE iin. ~e meta:sEol.1ITc ]ymph. nooos wirtth . .iiIEI. SII. fiil:1tiomder 1~}5 was 26%,. Icompm:,ed!. ~o 59'% W. fiodles. wfler,e&e S/L ri9.1ITo wasgreater iliru:!. {15 .. TFI1!l!S, 1!hemmeromd!ed 1tlm.e node, ilie mmellillbe1y i~.lis to hm'bommemstrlL1ITc dlise@Sie. The:re ~s one e:mep1ITon"lto ttlhillsrme: sl!l!bm:;md!l!bmru:Md. s1i1!1bmen1taJJ nodes b[jIJ:'i,i\e a. more ovciJd :<mdro1!1:l1d.ed 01!lrt:1im.e ~m oilier oe:l"\l-rc1l1i. nodes, I~ and. care ~ere£ore needs ~obe1iJ!sed wheflliillsmg :sill11i1.pe<i1i5 ,a cri"lterioo. "1.viittlbJ.node:sm lthe .SU!bm~t<Il! ,md. slllJ!hmadliibmru-r,e,gtoos.
A ·U::ihe:rs;m:ci¥14 :h~ :sho\vn. ili1l11 .1iIfI. [ilCCltl!l";[jjjCY of 80% w§.iS,[iI).c:me\lioom,1ID. NopopmaEillI ofp@1ITenEs \vir!:h. ;iiIlPrmum:y mmol!l!l" 'C9'2% :SieFl!slWi!1ty, 63'% spedlfi)city)by1iJ!s:mg a.ratia of more :lhal1i. O. 5:5 for ilie ~dtmoo:DmJ1I tf.ID1SVef:Sie dirum:e1ter, i.e. a.romdled oID1iline as ~e
prove :lto,bemotherlill!sclirrn] .Siigl1i for the dclection. ofmugniIDcy (iIF"~gm,e 4_JJ)_ &e:IJ!1emiber ltllli<iltpa1tfue:ms ofb]oodllow rns1!fl!blllrtiioo.1iI§'e ofmnre vam.e thSlf!l lowmrnoes_ 0l'10e co]o_low gmSiebgs Me set oonectliy, ~e asSiessm~1t of cdom fl!ow 1takes .Flomore liIlan 1t'he ;tOlITcn. of a.b1!ll1titOOJmclt1tep0sltrol1iimlg of a. om:S!oLlF·k~wpatle:rn.<iI's:S!ess.mentsTh1:ouilidi. a:d!d NJO more ilim.a;.fe\'!,\' secoads ~o tlle ex;~a1tioil1l, of arpill1tic1!Iillarr .fl!odie" J}ro'l,~id.ed. tlle':preS!ef .:Ili!1i5 ibeoo enltered!. oorrec:[]y_
Nl1illIltOe.f· ,of ncil·d:e,:; as a orite.non. 'ofmatign:al1!cy_
Thepresence of a. Cilil!llSilter of ~od!es in a dr~g;[~giOFl! IOm. :<ilJprirru1il!}' hlIMOl!][ wolllilld. beregardedbysolnei1l!l!l!ilio:ns <1I!S <:I. ,SJ1g1i1 ofmailliglLl!iiIllcy_~,Hl If liher1e<illie wee m·morebordierme fiodles m. apru11Qmillru:regioo ~ffi.iliey '~ollililld. be vier;,vedl Vliili.$liJispiciOfll_ Vm. den lBrekel et aPSl1t<ll1te: ~<ilt tbeSle rJ!odess:flmnilid .haL\lie
There is no d01J!Dt ~[1I,t thepres.em:c;e ofcms1ters of e~ocall m:odJes: ill :[jJJ.p~c:l!IillMregiiooaf ilie~eck C<YJJ be fn1terpretedi .• as a sl.!l!$piciol!J!S: 'S~g:I1l" llliowever the 'fi:ndlirlIDg ,ofmmItlp']e '.smalil! .. !liLodesm <1tr,egtoo of tlh;e .!I1eck. ,is fiotml!DOlililimOl1J, ]R'omrrer,e2 st;]:tes 1IDm.m .a:1ill. areas Qftthe I!]jeck t1te n1!mJJber of sodes fowd r.,villill. be mV'e:l:SJe]ypr'QPomrnThaJI to 1!hei': size. .It lis. mlot ·lill!IlCommOilll. ~o :ind .sAN:6r :SJe\'ie:l'l.smd. 'I1!odles m 1!he s:l'])1i}m<IDdl!"bmillregrol1,Mol1tl1iisoodlfm1!g :aJJooe :SJfuoMilJdl. mJOrtt 1betil. c[1I,J!jJS!elDbr OOl'1ce:m_
9-· . Calc,i/'u:f11ion
Figm~4J5-
Calicifica60n as, a crite4ion.ofmal1ignancy._
lP'timc~e areas ofca:l!cmc~olJ!. {ma();cakmcailli!oo) m. <iIl]}'mp;:h. fiodle .sholililldJ .. iwmedlia:ltdy aIe;rt llierel!m()i]ogUSJt ~o llieposSJilhiillirfty Qf<ill meta!Sm~sfi:om. a ,pa,p&lllimy ,rnt[ciI'l!Dm'i§ll of ~e iliyro1id (lfigm:e 436llBrigfut echogemcill!eoks canbe m1ldie oint mmet~t[jl1tiic mlo.des:41 i:ompiilpiill!my cm:ciirnlmn<ilJ. of 1!fue: ilij'f!o~dl_ A diligetl!1t search oftlte Ithyroiidl for the primary .s:holililld.be ca:r:ried!.ont whooever Sl!l!&. aSJigll isseee, ]F-NAC of ~e ~h node
FrugIillfe 4~36- "'C;t;Oca1icillca1l:i!on (~whe.ad!s) in a rOWe,f a~cal! :I1!o·d!e_ The 51lelllOlJlastoi!d!~s ,Wl[·o,wed.
Thagno sis.:metastati'c papillary c;lf.cinoma_
Page 8:2
1 ,. C ,. ,. .-1' ),1'_1:
, uterpre,ting., 'nten;a; ~Ji,~l:liaUgn:ang'
Howsiholllilldi, weuse tl\tese"Vrulolillls.propoS!edi criwe:!.i[]j? No :smglle ,ori~erioo ills; ahSJomtd¥ s:pecmc $orberuigruty ,orm!allig:l1:Mcy,bl!JJt :shape, ;<ilbSiel1LOe afWhws., ireglllillm:- Of :s>picllJilated Ol!JJtl:mie, ooagmilla1t:iio~, Dr cystic aeeresis ;mddi1isorgalll!liSied :p;eripi1aal1 oo]om: ]]!ow pa~eJi11,a:rea:l!IJ cStl:Oflig SJigns ofmaThiglThMcy _ These ,SJigns ,sinolllilld.belill!Sied ,iiI:J;, s,WliIJillia1tron- if ,<11 node dliispFiilLYs ,s;e\'ier,a;] of ~eSie ,dlliijiliaderisfuics 1ih.elf'e is <ilL hli,gh,probahiil!ifty ofml!ililigll!ilIl!Cy_ 41: ,]Lymphomi:il,snowd, ;ru\va!]'s,be 'lhOlilllght of m ~e diifferen1tlt;rl, d~~.;g:IToSJ!s ifmudedl dlillTIl.liJJs,ellyfu}']Jo-eclU:oiic f]odeslil:lie detected.
Thebeal!JJty Ofl!lilltrMOl!l!l1!d is [he ease \vith, wmchlilllllErMol!l!l1!di-,gmded iFNA can beperl"om1edL Use llie cnt!erl)a, ~o ;se!lied ~e node lDol[Otipn:aoo:l1L Sm~eom !ffl<ilcY not be ,itmpr,esS!ed,'I)y ,illJj,mk<ilL&olilil'Ldlfepol'lt sl!J!gges1tIDg maJJiignOlllcy."blill!t 1ihey ""vii sirl:mpand I:rube l1!ofu!oe wlill:el'l! tlJieaoc.ompmymg smpporting <C)~o]ogy feport ,;nrives;l~ lI1i, om IDSl1!l!mtiOil'l, ilie 'Simg,eo:l1Js 'use iliemlr@Siowdrepoflud CJ1al!o:gYMdiings iimI, oom1bil'l!afu!mli when Si1tijJjgIDg the neck. If 'lhem1!:r;fiOlilil1!d feport,S;1!J!ggests malliglThmcybl!JJt the mAC ishefMiglTh, ~e !leek is :s1tiillll.l'egrn:d!ed. asposJiwe for :malligmlfi1cYill1d tre<l.D:e.1'J.tpill<ilml!ed.<il:OOOH_~_ i\::s m tlte illallagemw1t oflbl'e~t cances :!he cyl:o]ogyomdl!l!liftr<lllS!ol!W!d:fu1:d!lingsa:re .;I1!o1t viewed iiI:J;, isoFaEillI.blill!t m. oomhiinla1tiio!l1i_ U1fu;<iIiS!()l!liI1d]. m. oomJb.i!1!ation \\:rirl:l\i, lIFNA:C ~s now om: acoepted melhod fOl"stagmg the ned:: mp.i11tiiwts wruilisql!Jliilmol!l!S oe1ru card:l1!o:lJillJ[jJJ_. Ill!. Om:hMdJs Sel'LslmnJry ilsn~%,spec.Ecil:y 83%, and. ilie pO!~1tiveprernc:It;i~,e v,me ~s 86:%£0,1' lthe del:,ec1tiioo . .of mel:Oti1ta1tiic nodes H.olM S:~l!J!<m101!J!S oeltll cmcillrnnOlL 43
HowdoeswkaiSJom1id m. combilluoo. ",o1lth.lIFNAC oOllilpare "villi 1the otl1er .B:iilgmg mod1lllii1tie.s ?m. the amy ]&ge series44 1!h;jJ:1: ~<iIiS oompared. ;<rl] modOiilifuie.s - iI1!1lINilie1iYl!l!lJltriilt5ol!llilild (US), US-:gmdled iFNAC (USg lIFNA:C), NOOall:d. CT ·-l!l!l.Itt:r,iiIt50llillliJ:d ill> oom)JlJ,iiI1ia1tilloFl. Vlirl:h. iFNACp:fOVied ~ohe the most @ocIa1te 1tec1LnJjq;I'Te_Aoomacies .of 86'% (US), l()O% {USg lIFNAC1, 89% ,~CT)Md.8 8'% ,(JVllU) were ob1ta:med_. F<iI:I" more .sJi~c.ml!t, ~Qwevf.:r, ~s. :the aromacym necks wha,e !ITO nodes wer,ep.~~lMe (NOnecks)_ 1ms ~s t1\te gr.o1!IDp ,afp1!l1tl!.ents m wlli:om 1tl1e diel:ecEEOOJ oflylOOpb l!Thode mel:<iliSi1t@Sies .hilli5 .1iI. gre<il'lter m:rp<ld om mM~~enlLent_Aocm:~cy m1he NOgrollp m VIDJi den. HrekeF's sruczy W;OB 68'% (US)., 86% (lIJSg iFNAC), <661% (Cn ud. 75% (Nl[RJ[)_
]t is m '!:he assessesest of ~s: NO grolap tl\i:1l1if,~dlrO~o.g1i8ts: cru1.mat,e tlIDeg:re&~est .impact The fllimber ofp&1iioots who;rremder - 01" o\lier -,tl:eated \viillI. he ,~Sihed. if we caprovid!e !:he 51!1II:geo.n v,cri~ IDl!. arom:rue 'ltedm.ii~e EOf evam~g !:he neek.
The1}rmp,:ha1tl!cs of :!he fled:: .Sil1:olillil!d. flo]ONlgerpmw<1l. dOl:mlltm:gpm:spect fm M\ter<!l!dlio:]o.giis.t U1ha:soli:lil1d. rus flOW an eXioelillootrn<iligl1!osltic toot provided;ijJj :s~]emeiliodliicm. sy.s1teflil. is foJlliowed_ U smg tfue fllilllill . .:ange of cri1teri<il .. ;avda:b]e" dBe:renl:lialllionbetweel'l!.l'ea'C;~eMd momg:l1l!afIl: ~ymphadJem:opa1thy lis FlJOW poS:&lJ"b]e. lI1I OO:mbIDllEE.OO. v;rihl\!. ]F-NAC,mrltl'aSJomdl is. .<lIn. aoom:rue 'ltedmii~e Em ev:am1ll!::i!l1ig !:he neck,
References
L Benn:m fiG, LYOMei: D, lIFmgetitlm1i R, Tl!J!ttJie RN_&egiooalbbod:low to the llympiThu fliode ~g :the lmmwe f,esp0'lThSie_ .. '4ymphO',logy l'~l7'6;. :9': lm.- 104_
14_ l';~~iiIl S, SO:l1e: S" Nomm:iiIlN, Tomiy1ll1Ji1ll N, K.obarf'~ T, 'N~<m1l!llli,OlJH_ NCMJ!p~MeD}'lOO:Pfu ~odes offl:te ,neck: assessaieae 'i,vru"ili US ::M!];d US gmd!edlllline needille~pir;;rt:Uoo,biiopsy_ J Cli:n Ul:truso,wul1997; 25: 283-29~~t
17,_ SOil!lJ.iaD, L "lIlizzatto oG" Be1illoID E et oL H:i.gfu-'resJOIDmI!iOFJi :slolITogr-¥ihy of oervmcaill. ]yflWPliiI mJiod!esm ]:];eadMdl ned::: CillToers.: Gri~eri;§rfOl[ dliIfferentm'liM, of rfli\l:Cw,e versU!sm~gJill!,jllilt nodes. ,lWdiology 1.9'88,;, 1,6i.9(iPr)~ ll3 (Abs,tr.ad)_.
1\lbs;s es iim. the Sl[bmem.td R.e;giom. l\II,3.s.s,es. iim. HIe Su:bm.a:D!di!blll~a:F Region J\!Ias,s es iin tile Parotid Reglon
J\!bs,s,es. along tJle ,Camud Artery and Io'tema1. Jngn~ar Ve:iin. l\Iia,s,s,es irnt.he Posterior Triang~e
l\/[is,ceUaneons. N ecll:: l\/las,s.es;
PageS]
Most ~ex1tbooks dJiSJollills;sd. ]esiioos of 1he fleck in! te:l'ms of ili:eiill illlreqHeflcy ,bl.!l!t 1tlhills rn~lte:[ taibes3l dliilie:llel!'lt OOl!][SJe ill dieSlCfllbmg ]eslnns acoordliil1JJg ~o tlTeiJr :SJ!1te 1(JIF~g:me :;: _l}.As d!eSirnbed. ill OThuap1te:r 1, .s,OF1ogr~;hy of the neckshomd.he c&miedl ont syslte:matic~,s.tOl:l.i:ffig ill ilieS!l!J!bmen1tallreg:ron. ;<mal &ew:JJ ;pmoeedi!rJJg to the dliIfferentregio:llliS of ilie l1:ernm seql.!l!oo1tii::rl ord!er_ ThiiSPfotoOO] is Wponiilflt because ~t ,ensmes ~1ilt ;;dI. the neokreg;Uoos are slC1illfied. :rnetic1!lffiolillsliymd. ilie chMoe ofmI!1issmg a. ~esio:l1! is ~SiedLMsiO" as most l~siio:l1!s in! 1the neckare 'SJ!1te 'specEc, ilici:rprede1te:mi!Med. tloca1tion. m 1!1ue neck,. IQomlhiilled ,V1ilLh.lill1b:<iliSJol!Jil1d!.tlll:dJ lc:1iirncm.fuldlillgs,prowdes a cfu:e 1t0 1thedi!ag:noo,SJ!s_.
We \viiIl!. ili:e:refore start wihl1. fes&oos m ilie :sl.!l!bme:n1JJ1t;<irl!.1itIfeiillandprooeoo ~o dlmmss ]esiicmsm 1the othe:r.pms of ilie l1:ern, Joilll!mvmg 1theSlc~g fOn_e sl!J!gges1ted. e[1f'liter _
J\ibs;ses, iin the Sl[bme:nll:d :R.e;gion.,
Met[jllS;1t~tic nodes at 1t1hillssiittem:e oo'l1tlm!omJI}'D:om caacers of tlTe trn1!gu;re,ru11terior or,aJj C1fuW1ty ,Ioof of ilie mOlill!I:h, llipMd ,1lI'Iltmm gIDgW:aJ_ HOWeVieJf, one IDl!J!St :I101te ilia:1tm areas \vne:re :I1JMop;haryngea]. carcmomrnt (NJPC) is 'endeJ!:lil:1!c,me1tMtlltic 111:0005 m '!he sl.!l!bmel!'l1t~. ,[It[e§LID§Lybe the orn¥ ,ome as to the pr'eS1e:l1!oe ofili:eprimiilf}'_ The slillilbmm1ta][,egroom[i[rymo he 1tl1e ruhl~SJ!~e ohocl!l!fflel1oem NJPep.:n[el11ts. \V}]01\uac'i,iiebeel1J)reV£DnsJ.~ ltIr'ea1tedi 'i;wth r~d&o1ili:e:Jf.apy _2
Infected braJ'vchia{ :cysts, TheS'e 'Cys1tsn'el.!]Jslill!~ ill. d!dmed. i1ll1d li:hl.ck wa1ll!ed!; 1ii1:ey oonta.. iin~en1!a1J debrismd. :s>ep1ta. (lFigJ!iltlf,e :5.11). 'n:eapipenuoes are seeondasy to ;['epe&t,edi wedron . .of lh;i!l:enilOffhiilge. The Slo:l1!oiogist m1!J!st be [j[I\.VMe OK !!he fad 1illi!at c:ys1mlcme1tal£1t§!S!es ]fom '<1I!.p<lIpil[M}' carcWtO:lll<1l!.m:ay fuoi1t'iiie<1l! '~ru::appeM'Moe.19 A d!e:ltdoo. ,exammaru:on OK t1\te 1i:hyr.ordM.dl iFNA of:!he c~rstic ~es]oo must iliterefore beperl"ornaed..
F:igI!I:re 5.H-
T:I"a:I1I1SVel"S e S01U'I grana 'OE an inlfec'ted. ru.ru:lcma:Ji ,cyst ·\vith. tb!ck w.alJ!s (open a:I":I""Ow) and! mrrrem,a:1! cleJJ.risi. Note llie position (]Ifllie cyst in dose P!I";ooointity ~o the. carotid. artery" (arrID'w).
In "!he ease .of brMd1iia1i cysts, :!he oPeEa~or .millstbe<ilware !!hart fueymilLY hJ&\'ie c:rr:mallpru:,a:p~<iIfj"N!g;e<iLll (bmveef:l carollid.ma}'a:I1!dI. b~er,~. phOli}"N!g;eirlw,d) ,ex~ens.iol'ls 'i,vmc!hmary no1t ,o&,va,ysbe deprc1tedl .onlllillltriiliSiol.!11!1:d . .A. CT .or ~. scm. ~s theH~fore ir:t~c[lI1ted. m cases where the ex:lten1t 0'£ 1t1h:e illes]on CalIDo1t be rudlffi~edby1illillltr_olil!l'ldl.
Lymp.hatiic l\ii3.l'ol'.mamons
Lympiha,trc maili:IDor:matiO:l1!SMe oongeniltallrn:1bnormaThi1ties thataris.e ... vhen.d!.e\'ielbpmg lYmP~atics ;fflill to est§lJb.lID~. oomm~rntion 'i,,,-rim de\'iel!ofJmg ·Viems.1,ll1,:;n They eanbe dillviid.ed rn1to 'Ihr'ee types;:
Thegr,e;a1test ~)'mphll1tic devdopme1'l!U: oecars eiIf]y m. dJiil!difu:ood,. ilie w<1I!ffioriry of the.se ]esiol'llspr,ese1'l!1t: m.pllfuie1'l!uslmdier ThVO y'eafS orage. Sollitilry' cySJ1tic fuygrom<il5milLY beseen m )'ooog1ld1!J!]tsm "!he sllJb.momdlr1JmMregiooMd ~epos1te;rior mugl!e.Et rusbeill1e'\!ied iliart ilieS!eMelJ!s,millypost-u<lIllmllTIcrailia 'lhoo cOl1lgeniJ1t1lill. m OIl.gill.16
Luge cystic bygromas d'e ilie 'ftypemOist OOlJilLmiooilly seea; the :r'eJilJ.lamdier of 1!he ·WStOlJ!SslOn 'i:herd"Ol:,elDoclJ!Sles on. tl].e d_cirl.rudeshl.1Iiom omd.lll11kaoomH:m. '<lLppearru:J.oes, of cystic hygmm1il. 50-6;QiIDlopreSlefi1tiiltbm,ruloilier 3()i%]J1fes,ffioogby 2 years .of age. 1:); ~. 'ruJJ. B1ll'I1t "!hey are OOl!2lJilEOWy bC1l1ted. m tfue posterior .triaRgJ.:ernnd. the oe:I.'YTooilhoiJ[aJctc jm1:o1tioo, 'i,vhereas madl:I!l.~s th.eym:e seea m ilie ~s;lillhmen1tiilill~ :sl!l!hm<mdh!Jb."I:lill<1lIl"' and. parotid spaoe. TheypreSten1t IcilliimcillJ.~' .&Sp~ess oompres;s'l!lb:le ·fflai5SesMdi,whe.l1!. slilifficiellfl:i¥ ~Mge, 1t:rr:[ll~611te. iFolillo,,"vmg ll:ll.e:lJ1lion:l1:age, howe\iler, "!hey 'CilllJbeoomerigidl Sl!l:dJdl.em!ly iincrearngm~e1tD oompress, &dii~oent stnmorures aI1!d C<il1!J!Siepm <mdf1lci<illl.pM.rdiySJiS.liIS
Thepmm:y ro:]e of&agmg ~s ~o demo:lls.tra1te 1t1h:eMa1toDc ex1tefil1t of 1t1h:e ~ygromOlJbefore ~s;l!l!I:"gery. Tills is eaJsf.er sl§iid. than dO<ll!e,<iIiS, cys1tiic Jhygrom1IDSru:e trusspmiJa:lI (m:vommgmore 1thu . .ol'l:eanalto~c<icl!. space) IDJ:d!. im.mll![lIlte 1illi!eJiJilIS!e!]viesbe~v'een. ~e .major nel.!][O¥iiliSiomm:snotrm:'es .m. ~e .fleck. iPncdar .afioo1tion lOO1!J!sll bepiilic]i to "!he ilIDerior exteetas llOI%m1mj' exltend. .mlto :!he merniil!S:1t1~lfllillIJjjJL 12 A1i1hougDmU<ili5ol!IDdl C1ID. mne ilie IDiiffiE<illI. m<il!gI1os.l!s of cys1ti\c [hygr.oIDa" CT .or ~. w~gmg is aeeessary to map ~e :milllJ ed.ent of I<itI'ge ]es.iio:lls.
UninJect,ed lesion» are seen as ~mw1tipJe, oompr,esSlJo]e cysts ofv:a:rymg sizes wrirl:h. ~. wiIl!lsa:m:di. m1te:l'\'l~gseptlih (Figm:,es .5 .12, 5. U) wrnch ~'tr<llu'e behv1e.en <mdarol!IDd neMOivmc1!J!lions1t:rn:crures. ,,4J~DUgfu 1tfuey IID1iI:y be Dru:gem.me "!hey do. aot causeasass effeo1t orrnspboeFlill:eFI1t of.iiI:.dj,aoent :sooorures. lliw rnc1t,<iI!dljlaoenll ml!]sdes .md\'iessds C<l1!J!&e OO.d!E1ThtaMOO!S on. tl1e h~gromBl.
F~gme5J2-
Traasvease SOfiO'gI"alJ1 of:a cystic hygromasho'''v-il1!_g millruiple cysti:c sp;aoes =.01 s,ep,ta.,N-orte irl:s:~erat:iol1ls:hip to, the COfi1lTIon C.!llD,fu:d!, art,e.q (~'Ill'W)_
:m inJe,ct:ed ,or J-taemtNrhagic ltls.iom the cy.SJt w~ :Me megmm, ,oo~11iaID mte:rn.laJj, debris" me ,moomp'lfeSS1!1)]e :1IDd~c a. soTh)dI. ]esroo_ They ID1'§cYPlfodJrnoe :<iI! miil!5s.weGt<m,d[ com]J!lfes.s ilie tr@dleiili, C<ll1lJ!smg r,espw:<iI:l:ory ,dliSJ1tr'ess_ 23
A 1thyro_g1,o.ssa11 ,rnrot cyst isa ODl1Igeflita]MQm~r,e]<iL1!ed !to. ltfue tliJ.I}'fogl!oss.aiI,rnrot,Et lis thought ~orepreS;eliI1tSie_g:l11l!e,f11t5 of 1!he ,dbm:ct ilia!: fd ~ofJegl'es.smdl. 'cooiSie~en"l:1~' ,cliHer'enttnOl1te mlto 'epiilhelJii<i!!ll-illIDoo 'Cystcs".di4 de\'iel!()pmg <myv;;rher,e ,<l1Jong the course of :ihecMc1tr'enm<ll:l1it ZS: The :Illt:l!ji()n1ty memel!altoo, ~D tThLe hyo~d. ~hooe_ ,A1bol!l!1t :25-65'% oocm ~, ilie m,m}~ord neck, 15-501% OOOM[iJ!1: tl1e~e\!ie1J of ilie hyoid. :;md 2{)f.-2 :S%[l!fe S1IDp1fMlyoidJ lin ]()Q;luIOO, ,encroa.cM:l!g1!:lp00J '!be sl!J!bment.aJJregrofi_. mes ooomrmg above tlJ:e iliyroid. cru:1!iillarge arel!J!Sil!llid.Iyrnii!~e wlmiereas,tliOcS!eat :!he .~e\!ieJI. of;jhe ClitI1iibgem:,e oEfwcline_
lP'a:ltiie1lli1ts.1IJ!S!l!illd~pres;el1I1t ,-,.vi"l:FruiSJ.pUlillessmdtlim:e lill!liIi5s<il:l1!d 1t11:ere is: ofue:JillJ .1iI. hiLsltoq ofpr'e'i..fl!Ol!J!5 fficisiioo.<lil'dl dr,m<Jtge at &e mlte_ A1bOllJJI: 50% p1reSien1t lbefo1r,e 'lhe<iL_ge of 1()! ye.a[s,~eSiecoo:d YOlap ofp..Dienl:spreSienEirl1!g m yomg[1tdmilllhDDdL
TDCsar,e dJ![iI.gn:O:Sied[ Mrn1!1Iy§!l1dJ tllew]e of ooargilThg is 1\0, oomfil:m tlle ,di'!mcal. dlJi<Jig:llos.J!S:<mdl.pmVlid!epr15ope:rawe lmo!llm!atlloD.regardliil1lg thepreSiel'liOe of.[jJJ 'SioThidi. !c()mponen1t w~.1the cyst Ulir<llS!O"l!l!lld .. is idiea1!]y :S!m~edi. ItDp1rovid!e 1tlhJis ilicrfoffl1!<iLTIon :<1I,lJJdl ill mDst cases no o'lher mu~g: ~s necessery.
Theltypruc;]]l1illil1tl':asowd :ii!ppeM.11I10e of<JiIDC [l]asbeeI'JJ. deSirnbedi. as -!hat ,elM. mecl1:oiic,.we1ill.-dl'clltmSirnbedi. cy.st ,.,.m"ili. WtO!lfle:<illSiedl .ougfu 'lirMSOSis&OO_2S,lil5,27fu. om ,~perioooe, h()wev'e!If, 00 .is l;Tot 1tl\te ease. We .:h~ve f01lJ!fldi:mom-pal:IDen1Is:2s
F~_g'I!lI"e.!;U3-
Transverse 5ionO'_grnmJ ,ora cysfu.;c fuY'y'l'lma (mas.s" tafgearf'Ows) sho''iYi:I1I!g a cystic res~o:l1J willise.pta (smaJruanl'l'ws) rn close p!l'lxim:iry te the SoMli)l:I1UU'l!dl:bWaf g1Jafidi (Std) ,and! ,Fi,afl'l,tid! glJand!, (p ARl- At thiis, s~te" tj.'1l1phllngi:l'llJ1as inad1!1l:"l:s ase said! tl'l' he p ostn:mrnJaafu!c in ,origm.
F~.gm'e .:I_14~
RAJngirudlnatr .sonogr.am. ofan l!illinf:e;clled!, lnf:rnhyoidi lliy!I1l'gl!Os saJ!. dillel: cyst_ Note M-Ie aNBcholc ll,Iameofllie -cyst and! post'mo!" el1I!himce.moent_ The hyoid! ~5 lcl!en1li:l!ed!. as ~_
FigIill"e 5.15-
LOl11glmdlOOaJ! .. sionogmrn ·of:an irn"ededJ lliy'fo gl!ossa:l! dlillC1!: cyst \villi inte~a:l! deMSiand!. s,epta_ The hyocid! '~sid!e4]Jfti;ijejd by a:I1I a:m1)w ..
Figm:e5_16---
L(lngimdliDaJ! sonogfIDItM'an i:nIf1~Y'ojjcl! llijFl!OgJ!OS:s:aJ! dl!lc'it cyst (OlM:OiWS) sho,wing a pse,1!]!do-'soTh:d! .ap¥,ear,anoe_ Note lliat ~1l is just bel!o,w llie ]ev·eJ ·ofllie hyoid! oO!l1l!e (H),
Ull!ll,@i5'O'm1i1dl aiso ,r I,' efil!]J!l;esmep:resoooe 011. liiI1IY ool!r.lll,oompoooo1!. v.A!1LI1ill1illJ, ,l!:Ile cys1f; mtlll!!!gIl!<iI1It 'll:eg,meraltl!.OFJJ, Or I I!lI!fE: rep1!l!lI!fl:)J!lJi:1IJ! ml!l!Ul5 Or I a • I I ,', " 'i:1IJ!mOlill!.&1' rare, ]~&S
,h j!.1L ";1,\,, _._,1' .:<I .::II "~..:£::- ,,1L ' _.1111 • , ". _HL • "f,,1L'" .::III f ID"C S" ....... _11_ ~1i:!]0'1J!yJi.lwn~o_1lI. coes not rU6l1Iwy' we k:[iI!ct m ,<1IiIlcmes, It is ~ott 'rnrltrci:1IJ! :[J'Bc411I]SJe,l'I][lespeo1tl!ve Or I' ILIff: slfl!e, SJ1Zie ,1rniu, ap])ear.,1rn:oe Or I' ,aL ,I I " " a .' ':i!SI!llWlII"L
pmoedim:e iis 'feco!ll1lilill:endJed 31 ms ent1illl1Jsf.,es:ectlJon of ilie cys1t .md. any relill~g tr:act, t\o,ge:1!.hier ,"wlli excwoo. rOf ilie _ddille tilimd. of the hY'o~di boae. boompnetereSJedroD, i:l1!:vmabllyreS'wEs ,m, :recJm[lel1oe_
Lesioas ,m,tlte.pru:otndi.r,egi1oo Dim, be ,~dled, mto iliOise mo:k,.-mg~epID"otndl g]1Mill!d ,ud .os:e .;111 are ,~tr@gillimduJliID' _ The m]e 'of1lliltlr~1illIl!d ill ,evam~g '!he :pru:01llidi g]~dl~5 welill. dJoCl!mTI!e1'Ii1ted9:}2)3 ~d[ .~<l!S beel!'l .: cllESiC'IJ!5Sied. m. C:ITh~]JI1te:[ 2_.
Mab5Sie1te:r mlll!scle nyper1tropho/m;arybeMillllll1terru.m1b1illa1t,er,:J:lL The a.e1tioEng)' is ohscm,e,bn1tmostp;jJ:1tlients F:!iilLve hiitlb~maJl dooc:h.mg orgriflc::fu1Jg ha:bi~ of ~e ii<1IW, especidly .~g sleep. The hli.g1lest mci.dlenoe ism the ;s..eoood.imdi ~d. deoades of1li7e<mdl1tl1ere is. flO Siexil1fedliillee1t1OFli_
Treawffit, if iI1dlliOi'il~edl oonsiists of mMSie1tericresee1t10rliJj.Mdi. te.cmooo:l1i. of <1IiSSiocia1ted.1bony hyperos.:1tos:iis_ However, moo]! s.:l.!][.~.eonsilfe neSJiEru>1t.lto !lfeool!illmend smgery fm :lDisbemillgn oondli1t1on, pru:1Iowillarlly <115 ther'e lis .i:lIiJJ.Msocii:il1ted.risk of :Narial n.efVie~<ilge <m:d oOF:lsidJer@1b]epo5i1topenllti\N'~morlb&dlllty_ The .lb10\Wl!. ;a;c1t1o~s ofbo1h!I!llii!1l!l!1OO 1toXliil1.~pear Ito oEme:rpoltentiodbelleID1t Ito patien1ts tlla1treqmre 1trea1tl2l1l:en1t<md. mSl0me oenwes 1tl1iis is 110W ilieprimill}':IDorm. of fu:"eawel1It Folil!o\cviilThg mJec1tioil1! ofbDmillinllBl 1toxil:!, it~s notpOSSJilb:£e for '!he pa1t1ent Ito ,dencll1tl1:e 1tee1i1l .: ~rnre to mo1tio<l'l!a!ll dene:rvaltion of iI1\te j<1llw; it is ]JO!s1tIll!l!a.1ted t11:<ilt truperiod offomed m&emlli1ty .5 s~ci.ent ltoibren.lOOe ha:biJ1t of doodW:!glgrn.ditmig_ 34
U1!tr.<iIiSOood h[jliSi:iI.[oEe 1top]a!},mpaltients. wil1Th. i!vlliffi as .11t C1M'li. ele~1!a1te ()1tl1er caases ·cf focali sWlelilliinllig aad e'V.~<1I!1!e1iU!iLdl oompMemlll!sclesUie_ The 1toxm. Ci1I!!I be mjreoted.mdJermlruri:iliSomd. oontrol UlIruri:iliSomd. is .a1ISOIll!SieMll. mmoni~oril1g the ~e .of the mWSlde ;m1er fu:"ea1tlll;tent
Ams,t BOC .mSies ]i0mi.~nmmaJJ 'enilibryogenesiis .of the mstbr,<mdThia1l. appm.acmsMdI. aoool.!m1ts:IDor 8'% of .a1ill. bruchla1l d!eft.a1b!l1ormaillirlies_ I~m<il.i}' be associated 'W1ili.bon~ !rn<mges m lMeform of~ tract tmOl!l!gh 1tlTe ,ex1ternalJ alll!dirtt01)~ C1llial!. ;<ilf:l.d 1tempor.alJbolTe_ 35 These cysts oeem mMdilfooodi iliepMoltlJd. glkmdl, 'e:ll:1teffla]. illll!dlit,.o:!), C<iIliJ!a].1ll1~ tI1:e angle 'of lifLemaJildJIlbk The t::r"])iicalJpDeflt wii'lh. ;<1I!.msE BOe .5 a willdd!IJe-,agedJ. woman. wi1tJh. a.hiis1tory oflilll!l!1~~e pru:otid <il'bSioeSSies l!l!IM.eSipOlThsWe ~o ;,ilillJItl!1)·roMcsMd.ch;mage_ Theremia1Y be1iliS'SiOci<1l!~ed. otmdl!OeOlL. The SOl1t0]o~Si1tmaty be 1tl1e mSi1tperSio:l1i 1toSiuggest. ilie ,rni:ilgn.oSJis_
Ulltraso'IInd Featnres
~A1rlhough the1!l!1Th1:.i:3iSiOllliI1!diappear<IDoesa!lfe ~ar ~O ilioSie ,cf;at .Sieoond. BOC,m om lexperienoe ilie mOiSt. OO!lll1lmO:lll is :atpSlelll!db-'SiOJrdl. ~pear.;moe vni1th. 'l!l!I1i'Oml. m1terniitll. ed1oes.Ml!dpoSi~eriior 'eMMOeJ1l]je1'Jt (]F~gm:e 5 _17). Wec1ted. cysts \\:rith ne1te:rogMOO1!l!S m1tern<I1i. echoes. are fieq;liren1t1~m:ist~en. for flle more
W---"1L~~" . . . .' -.-.~ lk,' _.11
CiOliDllM,OO :i:lE.ILIiJ!lj]~. s ~O;~Iill,=, 'P~CWaIlIJf ,m, '[Iillj]jm.es_