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Presenter : Dr.Sanjeeva Rao
Moderator : Dr.Kishore.V.H
Prof&HOD,Dept of Radiology
NMCH. NELLORE
EMBRYOLOGY
( First appears late in the 4th week of embryonic life as a
nodule of endoderm at the apex of the foramen caecum
on the developing tounge
( This nodule descends through the neck at the end of a
slender thyroglossal duct, which breakdown by the end
of 5th week
( The thyroid continues its descent to reach its definitive
position by the 7th week
(Located in the anteroinferior part of neck
(infrahyod compartment) outlined by
muscle,trachea,esophagus,carotid arteries and
jugular veins.
(Extends from C-5 through T-1
(The thyroid gland is made up of two lobes
located along either side of the trachea and
connected across the midline by the Isthmus
(10-40% of normal patients have a small
pyramidal lobe arising superiorly from the
isthmus
(supplied by
R&L inferior thyroid artery,R&L superior thyroid artery
( .Drained by R & L superior, middle and inferior thyroid
veins

( Muscular landmarks
a. Sternocleidomastoid muscles lie laterally
b. Longus colli (prevertebral)muscles lie posteriorly
c. ³Strap´ muscles lie anteriorly
( In adults mean length is 40 to 60 mm and the mean
anteroposterior diameter is 13 to18 mm. thickness of
isthmus is 4 to 6 mm
 |ltrasound of normal thyroid

Normal appearing thyroid in transverse view. Thyroid is

homogeneous and slightly hyperechoic. The lobes are bordered anteriorly
by the strap muscles (SM), posteriorly by the Y
  YY Y
(LC), medially by the trachea, and laterally by the sternocleidomastoid
muscle (SCM), carotid artery and jugular vein. A portion of the esophagus
(ESO) protrudes behind the tracheal shadow against the medial border
of the left lobe
|ltrasound technique(High frequency
trancducers:7.5to15.0MHz)

(Patients are usually scanned in the supine position

with the neck mildly hyperextended by an pillow
(Both lobes are scanned individually in the
transverse and in the longitudinal plane
(Any specific abnormalities should be studied in
both planes by rotating the transducer 90 degrees
over the area
(If the lobe is longer than the transducer, a ³split
screen technique´ can be used to measure the
length of lobe
 Measurement of the
thyroid (or a nodule)
involves three
measurements: the
width, depth and
length
  !

( 

   

å 
  

  Y  Y 
  !
( 

 
  
 It is usually found when
ultrasound is being done
for some other cause,
such as evaluation of a
nodule in the contralateral
lobe
Hemiagenesis of the left lobe. |ltrasound done to evaluate
the palpable nodule (N) in the right lobe reveals the thyroid ends at
the isthmus (arrow). The strap muscles (SM) have filled in the space
where the left lobe would be. Physical examination of the left neck
was normal
  !
(s
 


 can occur anywhere

along the path of descent
most common at the
base of the tongue
µ 
 ¶
 Resulting from failed
bifurcation of two lobes

Failed bifurcation of the thyroid. This patient presented with an

apparent ³goiter´ located 1 cm above the larynx. |ltrasound
reveals a normal amount of thyroid tissue, and thyroid function
was normal
  !

( 

  
 Sometimes the entire
thyroglossal duct persists,
and protein material
secreted by the lining
epithelium may form a
thyroglossal duct cyst that
manifests itself clinically
as a midline mass in the
anterior aspect of the
neck above the isthmus. Fluid filled Thyroglossal duct cyst in the
 can form a sinus midline.
Muscle anomaly

Patient was thought to have a nodule in the right lobe by physical

examination. |ltrasound revealed enlargement of the strap muscle
in the right neck (arrow) causing asymmetry; no nodule is present
Thyroid pathologies
(NOD|LAR DESEASES:
Goiter/hyperplasia , Thyroid adenoma ,
Thyroid malignancy( Papillary ca,Follicular
ca, Anaplastic ca,Medullary ca,Thyroid
primary lymphoma)
( DIFF|SE DESEASES: Graves¶ disease,
acute suppurative thyroiditis,subacute(De
Quervain)thyroiditis ,Chronic autoimmune
thyroiditis,Silent thyroiditis,Riedels
thyroiditis
NODLAR DISEASES

(In thyroid nodular deseases sonography

has five major applications;
1)Detection of nodules
2)Deffrentiation of goiter/hyperplasia from other
thyroid nodular deseases
3)Preoperative determination of the extent of
known thyroid malignancy
4)Detection of residual,recurrence
5)Guidance of FNAC for nan palpable nodules
 Each thyroid nodule has to be studied :
å Echogenicity compared with normal
parenchyma
å Presence calcifiacations/cystic changes
å Pattern of margins
å Presence of echo-poor halo
å Amont and distribution of blood flow
v

 

(80% of nodular desease is due to hyperplasia
(When single or multiple hyperplastic nodules
lead to global enlargement of the gland the term
Goiter is used(either single or multinodular)
(Sonographically; most hyperplastic nodules are
Isoechoic with well defined margins

( Cystic changes are present in 60-70% of cases

(Typical comet tail artefacts seen with in nodules

(Macro calcifications are present in ³old´nodules
These Calcificatoins are typicallycurvilinear,
annular or dismorphic with posterior shadowing
(Doppler:
- usually less vascularised than normal
parenchyma
-Exception of rapidly growing hyperplastic
lesions in yong patients
Isoechoic with thin regular halo cystic with multiple comet-tail artefacts
and small internal cystic change
Adenoma
(Represents 5-10% of all nodular desease
(Common in females
(Various subtypes of Follicular adenoma
1.Fetal adenoma 2.Hurthle cell adenoma
3.Embryonal adenoma
(Sonography:
>commonly solid masses
>May be hypoechoic,isoechoic or hyperechoic
>Thick and smooth hypoechoic halo
 Doppler imaging:
>blood flow from perifery to the center of the nodule
called´ë



´ appearance

Thyroid adenoma shows peripheral

Vascularity with Spoke and wheel appearance
,blood flow towards the centre of the mass
 Thyroid malignancy
Papillary carcinoma
(Most common thyroid malignancy(60-70%)
(Common in females ,
(Slow growth and good prognosis
(Sonography: >Hypoechogenicity
>Intralesional punctate calcifications
>Hypervascularity
>Cerivical lymph node metastases which
contain punctate microcalcifications
Follicular carcinoma
(Accounts for 5-15% of thyroid cancers
(Associated with hyperplastic/adenomatous
thyroid nodules in 60-70% of cases
(Significant criteria: Capsular & vascular invasion
(Sonography:
å solid,homogenous,
å hyperechoic or isoechoic
å Thick irregular capsule,tortuous perinodular and
intranodular blood vessels«.signs of extra
capsular spread
Isoechogenicity,perilesional and
internal blood suply features of
V YYY  

 Anaplastic carcinoma
(Represents 5-10% of all thyroid carcinomas
(Mostly occurs in eldery
(Highly aggressive,invades adjucent structures
(Sonography:
å Diffusely hypoechoic with area of necrosis (78%)
å Dense amorphous calcifications (58%)
å Irregularities of the boundaries and the early
invasion of the thyroid capsule
å Infirtation if adjacent structures
Large anaplastic carcinoma with irregular margins,
posterior extracapsular growth and infiltration of
the laryngeal recurrent nerve(arrow)
 Medullary carcinoma
(Accounts only 5% of all thyroid carcinomas
(May be familial, assoc with MEN llA syndrome
(Multicentric and/or bilateral
(Prognosis worse than Follicular carcinomas
(Sonography :
(>similar to papillary carcinoma
(>Hypoechogencity,iregular margins ,
microcalcifications(calcified amyloid deposits)
(>Hypervascularity with irregular blood vessels
A large hypoechoic nodule with thick
halo and scatterd microcalcifications.
Pathological diagnosis confirms
Medullary carcinoma
 Thyroid primary lymphoma
( 4% of all thyroid malignancies
( Rare,Mostly of Non-Hodgkin¶s type
( Rapidly growing,may cause symptoms such as
dyspnea and dysphagia
( 70-80% cases arises from preexisting Chronic
thyroiditis
(Sonography:
>Hypoechoic,lobulated,nearly avascular mass
>Cystic necrosis&encasement of great vessels of
neck
>Adjacent thyroid parenchyma may heterogenous
due chronic thyroiditis
Metastases
( Metastases to thyroid are infrequent
( Spread by hematogenous or lymphatic route
( Commonly from Melanoma(39%)breast(21%)
&RCC(10%)
( Solitary well cecumscribed nodules&diffuse involvement

Renal cell carcinoma metastases shows a round hypoechoic nodule

(arrows) and an irregular-shaped hypoechoic nodule (arrowheads). 6

Color Doppler sonogram of the round nodule shows increased internal
vascularity.
V
 " # #
INTERNAL CONTENTS
Purely cystic High probability Rare
Cystic with thin septa High probability Rare

Comet tail artefact Intermediate probability Rare

ECHOGENICITY
Hyperechoic High Rare
Isoechoic Intermediate Low
Hypoechoic Intermediate Intermediate
HALO
Thin halo High Low
Thick incomplete halo Rare Intermediate
MARGIN
Well defined Intermediate Low
Poorly defined Low Intermediate
hhVh
Egg shell calcification High probability Rare
Coarse calcification Intermediate Rare
Microcalification Low HIGH
DOPPLER
Preipheral flow pattern Intermediate Low
Internal flow pattern Low Intermediate

Rare :<1%
Low :<15%
Intermediate: 16 to 84 %
High :>85%
Grading of colour doppler flow
mapping(Fukunari N, Nagahama M, Sugino K et al (2004)
Clinical evaluation of color Doppler imaging for the differential
diagnosis of thyroidfollicular lesions)

(Grade1 nodules had no flow detectable.

(Grade 2 nodules had only peripheral flow,
without intranodular flow.
(Grade 3 nodules had low velocity central
flow.
(Grade 4 nodules had highintensity central
flow.
Grade 1 Doppler flow. Grade 1 lesions
have no intranodular flow and no flow
to the periphery
 Grade 2 Doppler flow. Grade 2 lesions
have peripheral flow only, without
intranodular flow
 Grade 3 Doppler flow. Great 3 lesions
have low to moderate velocity central flow
 Grade 4 Doppler flow. Grade 4 lesions
have high-intensity central blood flow

 




(Diagnosis usually made on the basis of clinical &

lab findings

(On occasion by FNA

(Sonography is seldom indicated

DIFF|SE THYROID DESEASE
(Acute suppurative thyroiditis
(Rare inflammatory desease(bacterial infection)
(|sually affects children
(Sononography: useful to detect development of
the frank thyroid Abscess
(ill defined,hypoechoic,heterogenous mass with
internal debris with or with out septa & gas
(Adjacent inflamatory nodes are often present
Sub acute granulomatous thyroiditis
(De-Qearvain¶s)
(Spontaneous remitting inflamatory desease
probably caused by Viral infection
(Clinical findings : fever,enlargement of gland
and painful on palpation

(Sonography:
( May enlarged and hypoechoic with normal or
decreased vascularity
(Diffuse edema may present
This patient had a painful upper right lobe with
elevated sedimentation rate typical of deQuervain¶s
thyroiditis.Note the line of demarcation (arrow)
between the inflamed upper lobe and normal
appearing lower lobe
 Chronic autoimmune lymphocytic
thyroiditis(Hashimoto¶s thyroiditis
(Occures usually in yong or middle aged woman
(Painless,diffuse enlargemant of thyroid gland

(Sonography: >Diffuse coarse echopattern

>Hypoechoic Micronodules (+ve predictive value 90%)
>Fibrotic septations with pseudolobulated appearance
>Doppler imaging: ³Thyroid inferno´
 Hashimoto¶s lymphocytic thyroiditis. The echo pattern is
heterogeneous, hypoechoic micro nodules with interspersed
discrete white lines representing fibrosis .
Also called ³Swiss cheese´ appearence
Hashimoto¶s thyroiditis (hashitoxicosis) has intense
blood flow (thyroid inferno)
Grave¶s desease
(Common diffuse abnormality

(Biochemically charecterised by hyperfunction

(Diffusely hypoechoic in young patients (due to

extensive lymphocytic infiltration)

(Color doppler shows µThyroid inferno´

 Graves¶ disease has been described as the³thyroid
inferno,´ typically showing very intense blood flow
Riedel¶s struma
 Rarest type of inflammatory thyroid desease
 Also called Invasive fibrous thyroiditis
 Primarily affects women and tends to complete
destruction of the gland
 May assoc with mediastinal or retroperitoneal
fibrosis or sclerosing cholangitis
 Diffusely enlarged & inhomogenous echopattern
 The primary reason for sonography was to check for
extra thyroid extension with encasement of adjacent
vessels
Para thyroid glands
 Parathyroid glands
( These are two pairs(superior&inferior)
( Superior parathyroids develop from 4th pharyngeal poch
( Inferior parathyroids develop from 3rd pharyngeal pouch
( Measure 3-10 mm x 2-6 mm x 1-4 mm
( Lie between posteromedial thyroid lobes and carotid sheath
Close proximity to: a. Tracheoesophageal groove
b. longus colli muscles

( Supplied by inferior thyroidartery & from anastamosis of

sup&inf thyroid arteries
( h$| V % |!|
 The patient should be made to lie flat on a firm table
with one or two pillows placed under the shoulders to
enable full extension of the neck
 The structures of the neck should be carefully studied
in two or more axis at multiple levels of the neck
(Most common cause of primary hyperparathyroidism
>Adenoma,Hyperplasia,and carcinoma
(Secondary hyperparathyroidism usually a response
to chronic hypocalcemia in uraemic patients
Superior parathyroid adenoma seen in Inferior parathyroid adenoma seen in
longitudinal view longitudinal view.
 Double inferior parathyroid adenoma in
panoramic view
Parathyroid adenoma indenting the
posterior capsule of the thyroid gland.
(False positive Para thyroid adenoma:
Cervical lymph node
Prominent blood vessel
Esophagus
Longus colli muscle
Thyroid nodule
(False negative:
Miniamally enlarged adenomas
Multinodular thyroid goiters
Some ectopic adenomas
 Parathyroid hyperplasia

Large hypoechoic parathyroid hyperplasia capsulated parathyroid hyperplasias

on right side & small lesion on left side

> Para thyroid carcinoma with mild hypoechogenicity
&irregular margins
NECK LYMPH NODES
( Neck lymph nodes are classified into:
> Submental,Submandibular,Parotid,facial,Deep
Cervical,Spinal accessory,Transverse cervical,
retropharyngeal,occipital and matoid
( Topographic classification based on 7 ³levels´
> Level I incudes submental&submandibular
>Level II,III,IV deeep cervical ,nodes deep to SCM muscle and upper
spinal accessory chain
>Level v Transverse cervical chain
>Level VI Anterior cervical chain
>Level VII Nodes in superior mediastinum
 Once LN detected define whether benign or malignant
 Size,echogenic hilum,level of echogenicity,necrosis,
extracapsular spread,vascularity and calclfications
should be evaluated
( In inflammatory conditions: Diffuse,homogenous and
preserve their normal oval shape
( In malignancy: greater transverse diameter,rounded,
asymmetric morphology, thin echogenic hilum
( Cystic necrosis seen in TB nodes
 Doppler:
 Benign LN shows Hilar flow&central vacular pattern

 Malignant LN shows Aberrant vessels with course

entering from the nodal capsule

 Malignant LN have higher PI&RI than benign LN

Hyperplastic lymphnode of neck with
Central hilar blood suply
elongated shape,cenral hilum
 Rounded hypoechoic TB node with
macrocalcification and poor vascular supply
Typical metastatic adenopathy
:rounded,isoechoic,with both
perilesional&intralesional vascularity