 Hello everyone and welcome to Indian Radiologist. My name is Dr Sanjeev Mani and in today's tutorial we are going to be speaking on ultrasound of the neck. This is a basic tutorial in which we will be displaying the anatomy of the neck as we scan the patient and also I will be speaking on common conditions that we expect to see in the neck as well as a few uncommon ones. So this video is about examination of the neck by ultrasound and we usually get difference because of thyroid lesion which may be seen by the clinician or because of enlarged lymph nodes. These are the more common indications that we come across while scanning the neck. So while scanning the ultrasound of the thyroid how we start is by placing the probe in a transverse fashion across the neck at the base of the neck. We usually start by seeing the thyroid gland in the transverse plane as we can see here but it's a good idea to start a little below that. So we would like to start here from the supra sternal notch. In fact you can see the inominate artery right here and from here you gently move up until you locate the thyroid gland. Now it's again good to move to a virtual convex or trapezoidal plane like this. So what happens is that you get a greater view of the thyroid gland. So we can see both lobes here. This is the right lobe that is the isthmus or the bridge of the thyroid gland and here is the left lobe or the left hemothyroid. So we continue to scan this patient by gently rocking the transducer to and fro going down. This is the inferior poles right here moving up to the mid-region and then the superior aspect of the right hemothyroid here. Once we are done here we turn the probe 90 degrees and make it a longitudinal plane. So again we can see the thyroid gland right here. This is the superior aspect. This is the inferior aspect. These are the strapped muscles here of which lie anterior or superficial to the thyroid gland. Note the ecopattern of the strapped muscles. They are much much lower than that of the thyroid gland that is seen here. So we finished seeing the right side. We look for change in ecopattern. We look for any nodules or mass lesions. Come back, transverse, move across to the left side and start reviewing the left hemothyroid. Again go down mid-region, superior pole. We are convinced that there is nothing here. Again turn make it longitudinal and have a look at the thyroid gland again in the longitudinal plane. Once we finish seeing the thyroid gland we move to the adjacent structures. So as I move here gently to the right you can see two structures which are ecopore. So we know these are vessels. This happens to be the common carotid artery. This is the internal jugular vein. Structures above here are the sternocleidomastoid muscle. We look for nodes adjacent to the internal jugular vein right here. As we move upwards we continue in the path of the common carotid until we see is bifurcation. You can see it here bifurcation into the internal and the external carotid arteries. Go back down, look at the carotid bulb, go up again and that happens to be the bifurcation. We do this on both sides. Still above that in the same plane as you reach the angle of the mandible you can see another structure right here. It's oval, it's a little bright. The ecopattern is almost like that of the thyroid gland and this happens to be the submandibular gland. And you have to again look at the gland architecture as well as look for focal nodules or an enlargement of this salivary gland. We also move in the pre-auricular space and look at the carotid gland. So this is how we see the carotid gland. It's a thin structure. We can only see the superficial part of the gland, not the deportion. And you see the gland right here with a small intra-carotid node which is pretty commonly seen in the carotid gland. So this is how we do the basic scanning of the thyroid gland as well as the next structures. Now let's talk a bit about the lymph nodes. These lymph nodes are pretty commonly seen and we see them more commonly at level 1b as well as level 2. So when we start seeing lymph nodes you usually see them as a hypoechoic structure. It is seen usually on both sides pretty commonly seen in fact. So how can we differentiate normal from abnormal? And there are certain criteria which I have pretty much established which tell us how to evaluate the cervical nodes. So we evaluate them for size, morphology, ecogenicity, as well as color flow. So while assessing the lymph node for size, we assess it in the short axis. So we take the maximum measurement in the short axis and this measurement should usually not be more than 8 millimeters. But size is not the only criteria to evaluate cervical nodes as certain nodes can also be elongated and can be as much as 2 centimeters long. So we also look at other factors. We look at the morphology of the node. Now the node as you can see here is a classic cervical lymph node. This has to be oval and usually not round. We look at the ecogenicity. It should be uniformly hypoechoic and it has a central bright hyaline. On that central bright hyaline if you put on color you will see hyaline central flow. We can see a small little artery here as well as the vein exiting out. So this node has all characteristics of a normal lymph node. Now let's try to see how abnormal nodes look like. So that is the submandibular gland right here and just next to it we can see this much larger node. Yes, it does have a central hyaline as you can see here. But the lymph node is far, far hypoechoic. You can see another adjacent node there but this is the one that we are looking at. This lymph node was tender for the patient and the patient also had fever. When we put on color you can see a slightly increased vascularity in the node. Now let's compare this vascularity that we see in this node which is an infected node versus a regular hyaline node. So we can see on the left of our screens an inflamed node with reduced echoes as well as increased vascularity. Whereas on the right side like I showed you earlier this is a regular lymph node with normal hyalovascularity. Now here's a look at another lymph node. So this lymph node shows linear striations. There is loss of the normal hyalur architecture. You can see a small lobulation at the superior aspect of the node. So this is an abnormal node and when we diagnose abnormal node or disease node it is best to undergo a guided sampling. Now in sampling a true cut biopsy is usually preferred over an FNAC and I have this nice pictures sent by Dr. Vishal Kumar in which we see a nice simple video of lymph node biopsy being done. Besides lymph nodes the other abnormal lesions that we see are thyroid lesions. So in the thyroid line usually we see two types of conditions. Commonly one would be a focal nodule, would could be either hypoechoic or isoechoic or hyperechoic. And the other pattern that we should look for in a thyroid gland is whether the standard normal eco pattern of the thyroid gland is preserved or not. Now if you take a look at this picture this is something which we see very commonly day in and day out. You are seeing a very well defined cystic lesion and it has got a very smooth margin. There is no calcification. This is a classic typical colloid nodule that we see. Now if you need to know more about thyroid nodules and the tyrites classification and how to grade them. We have a great video by Dr. Alka Singhal on our channel. Sometimes however if the lesion is large and indeterminate it's best to conduct an FNAC and get a conclusive diagnosis. The other pattern that we see is a change in the thyroid eco pattern. So let's have a look at this case. This is a 55 year old male with fever and neck pain. And as soon as you start scanning you see that the thyroid gland has lost its normal bright eco that we see. In fact if you compare the eco pattern of the strapped muscles to this thyroid gland the thyroid eco is almost as low at the strapped muscles. This pattern is seen uniformly across the thyroid gland. The thyroid gland is showing a slightly pseudo nodular pattern but no focal nodule is actually noted. We can also see slightly enlarged lymph nodes adjacent to the thyroid gland. These are central nodes which lie within or inner to the internal jugular vein. And when we see this picture of a heterogeneous eco or low level eco within the thyroid gland with adjacent nodes the diagnosis is usually thyroiditis. Now there are several causes that can cause thyroiditis but the more common ones are the autoimmune ones. In this the common of the two is Hashimoto's thyroiditis that usually presents as hypothyroidism and the other is Graus disease that usually presents as hyperthyroidism. On ultrasound it is difficult to differentiate between these two and serological markers are required for a definite diagnosis. Perotid lesions are usually another topic altogether but like we said we see the submandible gland and the perotid gland and we are more likely to see lesions within the perotid gland than the submandible gland. Another rule of thumb is that usually perotid lesions are more often than not benign almost 80% of them whereas if you see a lesion in the submandible gland usually 80% would end up being malignant. So lesions in the submandible gland you would need to image further with a CT or an MR. Now let's have a look at this particular perotid gland case. As soon as we put the probe here you may think that this looks like a cyst because you're getting almost an acoustic enhancement seen posterior to the lesion but as you change the TGC settings you can actually see that it is nothing but an intraperotid inflamed lymph node. Of course you can see the normal hyalovascularity and the hyalurarchitecture still maintain. Interperotid nodes are pretty common in the perotid gland and can also get inflamed and give rise to pain. Now here's another interesting case not uncommonly seen. Now this is a two weeks old neonate but undergone a forceps delivery and has presented with tauticalis. Now when we see this picture of course we can see here the thyroid gland and on the left side as we start scanning we can see a focal area of heterogenicity within the sternocleidoid muscle. This muscle is bulky and is showing altered and reduced echoes. We come to the right side just to compare and you can see the flat normal smooth sternocleromastoid very well seen. You see the thickness and you compare it with the left side so let's go back to the left side and you can you can see a very thick muscle and you know that this is a bulky and large sternocleromastoid. No mass seen within it forceps delivery. The diagnosis here is pretty simple. This is fibromatosis coli or sternocleromastoid tumor. Now here's the last case this is a 40-year-old female who is on ocps and had a twisting injury of the neck. She suddenly presented with a lump a few days after that injury a video consultation was done with the ENT specialist and he asked for an ultrasound. So when this patient came for ultrasound and we do a normal standard screening where we move adjacent to the thyroid gland as you can see on the screen and we see this lesion. Now you can see that this lesion is lying anterior to the right common carotid artery and it has got altered echoes but if you keep tracing it back and forth you will realize that this is actually nothing but a thombus within the internal jugular vein. You can see here going superior right up and come back down again past the thyroid gland. The internal jugular vein joins the right subclavian so we can see it here joining the subclavian and the thombus is actually almost projecting into the right brachiocephalic vein right here. So this is an uncommon condition but the idea of showing this case also is that you can expect lesions almost anywhere in the neck. They needn't be just in the thyroid gland or needn't be just in large lymph nodes and doing a thardust survey and analysis of all the structures that lie in the neck will help in reaching a complete and correct diagnosis. Thank you for your patient hearing.