 Hello, everyone and welcome to this session on pediatric radiology case-based review My name is Anjum Bandarkar and I am a pediatric radiologist at the Mid-Atlantic Permanente Medical Group in Virginia And what I'd like to do in this session is to review some critical findings particularly seen with ultrasound in the setting of pediatric emergencies. I have no relevant disclosures. I will be using a case-based approach to describe sonographic features of some common pediatric emergency conditions and I will also discuss practical tips and tricks to recognize pitfalls and mimics. We know that other imaging like plane radiographs and cross-sectional imaging may be required as an adjunct, but ultrasound remains the first go-to modality when it comes to evaluating children and it is often sufficient to make an accurate diagnosis. Our first case is a four-week-old baby boy came in with emesis after every feed. These are grayscale images of the pylorus in the longitudinal and transverse plane depicting an abnormally thickened pylorus on real-time exam. The gastric anteroom was distended with fluid and contents and the pyloric channel was nicely visualized. However, no contents were able to pass across the pyloric channel thereby establishing a diagnosis of hypertrophic pyloric stenosis. Infantile hypertrophic pyloric stenosis is a common condition affecting young infants in which the antropyloric portion of the stomach becomes abnormally thickened and there is an obstruction to gastric emptying. This is a pretty thickened pylorus as we see. It is not present at birth, but mechanical obstruction typically develops in the first two to 12 weeks of life and the treatment is surgical pyloromiaudomy. The infant presents with a recent onset of forceful non-bilius emesis, typically projectile vomiting. Dehydration and weight loss are often present and hypochloremic metabolic alkalosis is the characteristic biochemical abnormality because emesis of gastric contents leads to depletion of sodium, potassium, and hydrochloric acid. This is a normal pylorus in three different newborns. They're all normal and these pretty images have been produced using this amazing high-frequency linear transducer. On real-time exam, this is what a normal pylorus looks like. So let's go slow. This is the gastric antrum and the contents are passing through the channel emptying into the duodenum. Let's look at the sonographic anatomy of a normal pylorus. Being a part of the GI tract, the pylorus demonstrates the classic gut signature composed of five layers. Starting from the innermost, this is the lumen and antrum, the innermost to outermost. The first layer is the echogenic mucosa. Next is a thin hypoechoic muscle layer that's the muscularis mucosa. Then comes the dense echogenic submucosa. Next is the muscularis externa and finally the cirrhosa, which may be imperceptible. An abnormal pylorus also demonstrates the same five layers except that the muscularis externa is markedly thickened. The criteria that we use to call a pylorus abnormal are wall thickness, muscle thickness greater than 3mm and pyloric channel length greater than 15mm. Now let's take a look at some pitfalls in the diagnosis of pyloric stenosis. This is an infant who had a scan performed where the pyloric muscle was measured at 3.2mm thickness and called equivocal. However the images weren't as impressive and therefore a repeat scan was performed and at this time the muscle thickness was measured at 1.5mm thickness correctly and the channel length was 9mm long and it was called normal. So what is different between these two images? This exam was performed with a linear 9 transducer, a 9 MHz probe and this was performed with a higher frequency linear 615 MHz probe. The images were produced in a transverse plane and here they were in a longitudinal plane which allows for the layers to be seen more clearly. On this image the entire muscle thickness was measured including the submucosa whereas here only the outermost muscle thickness was measured excluding the submucosa. Another pitfall is when the stomach is over distended the pylorus can flip posteriorly and it may be hard to find like in this example it is going vertically down whereas here it's completely flipped on itself backwards and it looks like this and that's just a transverse image. A third pitfall is the GE junction. Remember they are situated very close to each other in the upper abdomen and in this example the GE junction is in longitudinal plane and transverse plane but since we knew that there is an enteric tube going through it it was easy to tell. It is not uncommon that if a sonographer is new they might mistake the GE junction for the pylorus. This is an example of both the GE junction and pylorus in the same picture in the same infant so you see how close they are located. But remember the GE junction will be closer to the base of the heart you can see the heart beating oftentimes and the pylorus will be a little farther away close to the stomach entrum. Look for the landmarks. This is an example of a child who came in with a distended abdomen. On his x-ray there was massive gastric distension and the stomach looked like it was modeled bubbly in appearance and it was concerning for nematosis. There was also linear branching lucencies over the liver suggestive of portal venous gas. He was having emesis and therefore received an ultrasound which showed pyloric stenosis. He was positive and also there was these there were these echogenic foci of air in the gastric wall suggesting nematosis. So this is only to create an awareness that pyloric stenosis is a benign cause of gastric nematosis and portal venous gas and often it resolves after pyloromyotomy. So if you look at these sequence of events what happens exactly is because of the stenosis there is a mechanical gastric outlet obstruction which leads to increased intraluminal pressure in the stomach that eventually forces the gas through the intact gastric mucosa into the venules and they then drain into the veins eventually draining into the portal venous gas. That's how the gas gets through the venules into the portal venous system. Finally our take home points recognize that the muscularis external is the outermost hypoechoic muscle layer that should be measured for pyloric stenosis and that the submucosa should be excluded otherwise you will end up over measuring the muscle thickness. Using a linear high frequency transducer is best to optimize visualization of the layers of the pyloric wall and finally when the pylorus is normal and there is a strong history of emissives remember to evaluate the midline mesentery vessels to look for a whirlpool sign which may indicate malrotation or volvulus such as in this case this was a two-year-old baby who had abdominal pain and you can almost see the mesentery vessels and the bowels whirling going in a whirlpool on this image this child did end up getting an upper GI exam that demonstrated malrotation. Our next case is a three-year-old boy with two weeks of abdominal pain and fever his ultrasound was performed the appendix was not definitively identified however they did describe what looked like a fluid field distended area behind the bladder in the retrovesical region right here and he was admitted based on his clinical findings but his condition didn't improve overnight so the next morning he received a CT scan and on the CT scan you can clearly see a thick wall rim enhancing fluid collection in the pelvis that corresponds to what we had initially thought to be a distended rectum this was a pelvic abscess and this echogenic focus here was the appendical lith so this turned out to be a perforated appendicitis with a pelvic abscess. Now here is a more classic inflamed acute appendicitis with a dilated debris filled appendix and a classic target sign on transverse images with increased ecogeneity of the surrounding mesentery suggestive of mesentric edema on real-time exam you could also see some free fluid in the pelvis with edema of the bowel loops and that is the inflamed appendix up here this is another example of an acute appendicitis with shaggy thick walled appendix with surrounding mesentric edema and this is what it looks like on real-time exam this is a normal appendix with gut signature and the diameter is measured from outer to outer wall it is typically less than six millimeter often it is air filled and you can find it draped around the iliac vessels this is another normal appendix and another normal appendix this is a sine sweep showing a normal appendix in the right lower quadrant here it comes and sometimes you may see just a transverse section of it but notice how the surrounding fascial planes are clean there is no mesentric edema or fluid and the appendix is normal in size compared to what we just saw this is a completely opposite picture this is a 12-year-old girl who came in with seven days of fever and abdominal pain and the bowel is already thickened there is significant mesentric edema you can see the inflamed appendix and she had a six centimeter abscess this was a perforated appendicitis when you have the appendical lint the shadowing appendical lint can be really helpful in getting your attention to the surrounding inflamed appendix in this in this example this child had a small appendical lid but it was enough to catch our attention and clinch the diagnosis of appendicitis so for our take home points know how to find the normal appendix measure the diameter correctly from outer to outer wall an appendical lid can be a great clue to appendicitis and look for other supporting signs like mesentric edema free fluid bowel while thickening and fluid collections in the pelvis a categorical approach to appendicitis may be used to help guide the management after an ultrasound so for example if it is a category one it means it is seen and normal so the child may go home if it's a category four it means the appendix was seen and abnormal so needs further definitive management if it's a category two it means the appendix was not visualized but there are no supporting signs to suggest appendicitis and then the category three is the important one where you don't see the appendix but there are certain supporting signs that tell us that this child may need additional cross-sectional imaging in the form of a CT scan or if the kid is older above five years then maybe an MRI to look for appendicitis moving on our next case is a six-month-old boy with bilious emesis his abdomen radiograph was read as mild stool retention and because of his history of bilious emesis he received an upper GI exam which was normal there is no mal rotation he was admitted overnight for observation and had a red current jelly stool and that's when an abdomen ultrasound was obtained that demonstrated a classic iliocholic interception this is the concentric bowel sign or donut sign and the pseudo kidney sign in longitudinal plane he was sent for an air enema reduction now while doing the air enema you could see the iliocholic interception in the transverse colon outlined by air and during the reduction this was pushed down now it's in the ascending colon and finally completely reduced with air in the small bowel looking back this was the iliocholic interception on the plane radiograph and this is the meniscus sign where you have an intra-luminal mass surrounded by a column of air that's stomach and that's transverse colon so our take home points don't let bilious emesis trick you into going for an upper GI because any cause that anything that causes distal bowel obstruction can present with bilious emesis and recognize the meniscus sign of interception on plane abdomen radiograph this is another two-year-old boy who came in with three days of frequent non bilious emesis and on the x-rays there was just paucity of bowel gas in the lower abdomen but his ultrasound was classic for the crescent and donut sign that's the fatty crescent and the pseudo kidney sign with some free intra-peditoneal fluid he also had an air enema reduction and it was successfully reduced but it recurred times three over a span of 12 days he had three recurrences finally he was taken to the OR and his pathology showed a hammer tomato's polyboy lesion of the ilium which was the lead point for the interception here is a nine month old boy with three days of abdominal pain and lethargy and increasing distention his abdomen radiograph on presentation showed small bowel obstruction he did have an iliocolic interception that was pretty low in the pelvis with free fluid and trapped fluid between the layers of the interception he went on to get an air enema reduction to see if we could even move this interception further up and it we were able to push it back to the level of the mid-transverse colon but it did not reduce any further and the child proceeded to surgery he had a laparotomy with manual reduction of the iliocolic interception that had reached the sigmoid colon and no lead point was identified so this was an atypical interception because of his unusually low position at presentation this is a two-year-old boy who presented with intermittent abdominal pain and bloody diarrhea on his exam there was a three centimeter polypoid mass in the mid abdomen adjacent to an interception and this is the longitudinal image showing the mass and the adjacent interception on sinus sweeps it looked like the mass and the interception were closely connected with each other there we go he went on to get an air enema reduction for the iliocolic interception and it was successful there was air in the small bowel at the end of the procedure suggesting that the iliocolic interception had reduced however you could still see the intraluminal mass he went on to get a follow-up ultrasound that showed the polypoid mass in the colon and this time the vascular stalk was better seen because the interception had reduced by now this was a colocolic interception secondary to a polyp and it turned out to be a juvenile polyp in the hepatic flexure now for some mimics of interception this is a child who came in with abdominal pain and had this concentric interception in the right lower quadrant but the diameter was only two centimeters and this was an ilio-ilial or small bowel interception it reduced spontaneously and these are often known to be transient the differentiating point from iliocolic interception is the outer to outer diameter in an iliocolic interception is typically three centimeters or greater whereas in a small bowel interception it's smaller than two centimeter another mimic is an eight-month-old boy who came in with urinary retention and constipation he was already diagnosed as having interception at an outside facility and he was transferred for reduction on his repeat ultrasound at our institute we saw a pelvic mass with some bladder wall thickening and it was fairly low this is the lumbosacral spine and this did not look like a classic interception so because of the suspicion of mass he received a CT scan that did demonstrate a solid pelvic mass this was a catheter fully catheter introduced to decompress the bladder urinary bladder and the mass was confirmed on a follow-up MRI the next day this turned out to be a pelvic raptomyosarcoma so as far as interception is concerned some learning points typical interception occurs between six to 36 months of age it is idiopathic which means there's no lead point it is iliocolic classically in right lower quadrant and the classic clinical triad of symptoms which includes the colloquy pain current jolly stool and palpable abdominal mass may be seen atypical interception presents at extremes of ages it is longer in duration very often recurrent and fluoroscopic reduction often fails on imaging atypical interception is typically distal in location way beyond the splenic flexure free intrapediginial fluid and trapped fluid in the layers of the interception are often seen it may present with small bowel obstruction and there is often a lead point causing the interception so our take home points know the differences between the typical and atypical presentations as well as the clinical features to make an accurate diagnosis and ultrasound is extremely sensitive to confirm the presence location and the type of interception iliocolic versus illio illio our next case is a 22 month old girl with crampy abdominal pain and vomiting she had a classic concentric bowel mass suggesting iliocolic interception in the right mid abdomen on her ultrasound exam there was some trapped fluid in the layers of the interception and also some free fluid that is not well shown here she had a positive interception at 14 months of age that had reduced spontaneously in her past history she went on to receive an air and a mud reduction and the interception was partially reducible to the level of the iliococcal valve but since it didn't progress we decided to use contrast positive contrast in the hope that it would push it further across but it stayed and the filling defect persisted so this was a failed fluoroscopic reduction and she proceeded to surgery on her surgery they found an iliocolic interception secondary to a meckles diverticulum now we did not find the meckles prospectively but this is a known presentation of meckles a meckles can act as a lead point and present with bowel interception i just wanted you to be aware of this and look carefully for a meckles as a potential lead point the next time you see an interception this is a companion case where we had a 10 month old boy coming with a bloody bowel movements and his ultrasound exam was impressive he had a tubular blind ending fluid field structure in the right mid abdomen it had gut signature and there were thick indiregular walls some free fluid in the peritoneum and the best part was he had a normal appendix that was seen separately in the right lower abdomen this is a transverse sine sweep from top to bottom in the right mid abdomen showing the tubular thick wall structure which we thought was the meckles diverticulum so some bowel loops free fluid this is the meckles and the liver next to it so because our suspicion was so high he went on to get a meckles scan and you see the increased radio tracer uptake focus in the mid abdomen this was a positive meckles scan so this was classic for meckles diverticulitis he got laparoscopic surgery the next day and did very well these are two different children with similar presentations and similar findings they showed up a couple days apart so we kind of learned from the first case and used our knowledge to apply for the other this two-year-old boy had come in with intermittent abdominal pain for a month and emesis and he had had three prior negative ultrasound exams on our scan we saw a tubular cystic focus in the left lower quadrant he did not have any supporting signs of appendicitis in the right lower abdomen and this cystic structure caught our eye because even though it looked similar to the adjacent fluid filled bowel loops it kind of stayed where it was it didn't move and it did not peristals like the remaining bowel loops so in this sine sweep you can see the cystic structure in focus and the surrounding bowel loops kind of peristalsing around so our suspicion was high for meckles because his right lower quadrant was negative and he went on to get a meckles scan and it was positive this is the increased radio tracer uptake in the left lower abdomen he got surgery the next day and did well this three-year-old girl had a similar presentation with intermittent abdominal pain for two weeks and it was only by luck by chance that we came upon this thick wall tubular cystic area in the lower abdomen there was some hyperemia in its wall and it also did not show peristalsis it kind of stayed put between the surrounding bowel loops and that kind of led to a suspicion for meckles she was also positive for meckles diverticulum on surgery so our take home points for meckles it is the most common congenital anomaly of the GI tract and often presents early in childhood clinical presentations include rectal bleeding, interseception, small bowel obstruction and diverticulitis and we've seen a couple of classic and not so classic presentations on imaging and finally tech 99 pro-technotate scintigraphy is a highly accurate tool that diagnoses and inflamed meckles diverticulum now let's move on to another critical topic a 16-year-old boy came in with acute right groin pain and vomiting on his ultrasound exam there was fairly symmetric appearance of the right and the left testes in terms of the size ecotexture and preserved flow on both sides but he did have what looked like a hypoechoic soft tissue mass that was separate from his testis and epididymis this is the head body and tail of the right epididymis and it looked like loosely bunched up spermatic cord structures on color Doppler exam there was no hyperemia but there was also like a roundish configuration to the cord structures on real-time sinus sweeps you could almost see the actual twisting of the spermatic cord adjacent to the testis so testis that's the twisting of the cord and some reactive hydrocele he was diagnosed with acute right testicular torsion with preserved flow and went on to get bilaropexy and the testis was salvageable a companion case this is a 13-year-old boy with acute left testicular pain on his buddy shot image you can see symmetric vascularity and ecotexture of both testes this was a right and the left side looked fairly symmetric and he also had what looked like redundant loops of spermatic cord in the superolateral aspect of his testis on the sinus sweep you could see the actual twisting of the spermatic cord in the right groin and he too was diagnosed with acute testicular torsion with preserved vascularity now in retrospect these are the loops of the redundant spermatic cord in the left side that were seen on the buddy shot image this is another companion case where a 14-year-old boy who woke up with acute left-sided pain came in and got an exam that showed symmetric texture and size and vascularity in both testis but he too had what looked like a whirlpool sign of the left spermatic cord that was twisting in the groin on the sinus sweep you could see the left cord with a twist and some reactive hydrocele and this was also acute torsion with preserved flow so the take-home point here is the presence of testicular flow should not deter you from calling this as an acute torsion this is a 17-year-old boy who came in with acute right testicular pain and he had had similar episodes in the past that had resolved spontaneously his exam was remarkable for asymmetry his right testis did look globular and enlarged and edematous compared to the left side there was more slender there was incidental microlithiasis on color doubler exam there was symmetric vascularity except that there was a little bit of reactive hydrocele on the right side on sinus weeps you could see redundant loops of spermatic cord in the right scrotum there it is and on the longitudinal images that's the right cord that just looked like it was loosely bunched up so we knew we were dealing with a bell clapper anomaly now while we're scanning he said his pain had suddenly improved and that he felt much better it was gone so we looked again with color and there was indeed increased vascularity in the edematous right testis which means we were dealing with a spontaneous detorsion he did go home that day and got surgery about 10 days later he had a bilateral orcupaxi and a good outcome so this was intermittent testicular torsion with preserved flow this is a 15-year-old boy who was unfortunately not as lucky he did come in with five days of pain and there was virtually no vascularity in the left testis there was a little bit of reactive hydrocele and you could see the twisting of the left cord on the sinus sweep you could see the left spermatic cord torsion that's the cord twisting and that's the edematous left testis there we go this is another 16-year-old boy who came in with one week of right groin pain and he had virtually no flow with in fact very heterogeneous looking right testis that almost looked like it was already beginning to necrosis there was some peripheral pudendal flow but unfortunately neither of these were salvageable let's take a minute to understand the bell clapper anomaly so normally the epididymis the green structure extends along the full length of the testis from the superior to the inferior pole and the tunica is anchored to the epididymis however in a bell clapper anomaly there is an abnormally high attachment of the tunica to the spermatic cord such that the entire testis epididymis and the spermatic cord is encircled by this tunica and this complex is then left to rotate freely on its own access and lead to intravaginal torsion this posterior attachment is missing and that's the cause for the intravaginal torsion to summarize testicular torsion is a urologic emergency that unfortunately is missed more often than we'd like and that is why i'd like each one of you to perfect your sonographic search pattern for testicular torsion we know that time is testis one of the questions coming to mind is is there a time beyond which we can safely presume that the testis is dead and we don't need to rush to accommodate emergent imaging and management the answer is no we know that the rates of salvage are higher the sooner the presentation and intervention after the onset of pain but let us not forget that salvage depends not only on the degree of testicular torsion or the length of time of torsion but also on how tightly the cord is twisted so a testis might become non-viable as early as four hours after a 720 degrees twist or it might remain viable for several days even weeks if the torsion is incomplete these are the sonographic features that are highly concerning for testicular torsion globular enlargement heterogeneous echotexture altered or horizontal lie a spermatic cord whirlpool sign if you're lucky you could see the actual twisting but more often you'll just see this redundant loosely bunched up spermatic cord or what we call an enlarged epidermal cord complex without hyperemia a differential condition to keep in the back of your mind is testicular appendage torsion when you will see an enlarged evascular nodular area in the superior aspect of the testis these are two different patients and they both were diagnosed with testicular appendage torsion the good thing is it is a self-limiting condition and can be managed conservatively in several retrospective reviews of pediatric patients who presented to the ER with acute scrotal pain the incidence of appendage torsion ranged from 46 to 71 percent and represented the most common cause of scrotal pain in pre-puberal children another differential to consider in acute scrotum is epidermitis or chytis this is a six-year-old boy who came in with acute right groin pain and right scrotal swelling you can see obvious increased edema and thickening of the right scrotal wall compared to the left side right testis and epidermis are enlarged the epidermis was traced in its entire extent from the head body tail and it was thickened and very hyperemic and importantly the cord was completely straight and could be followed through the canal there was no torsion so this was acute epidermitis or chytis so here are take-home points presence of intratesticular flow does not exclude torsion presence of redundant spomatic cord within the scrotum is highly suspicious for torsion and look for that enlarged epidermal cord complex because that will tell you that where the torsion knot is it is more frequently identified compared to the classic whirlpool sign a student analysis of the cord is key in preventing over diagnosis of epidermitis and salvage can be virtually unpredictable depending on how tightly or loosely the cord is twisted so surgery should not be delayed once the diagnosis of torsion is established even if the time to presentation exceeds the six to ten hour window our next case is a 16 year old girl with one day of pelvic pain on her ultrasound exam the left ovary was seen enlarged there was a hemorrhagic cyst and you could see some spaced out follicles in the periphery of the ovary it was sitting in the midline on top of the bladder which was odd but there was flow present and compared to the normal right side that ovary just looked way too big the volumes were in fact like 12 times that of the right side so combining all these features the midline location the enlargement presence of hemorrhagic cysts based out follicles and increased volumes 12 times that of the normal side led to the diagnosis of acute left ovarian torsion secondary to the hemorrhagic cyst she did go to the or and get detorsed successfully and her pain improved this is another young lady with acute pelvic pain for two days she was sexually active and her TV exam showed an enlarged edematous right ovary compared to the left side on synes sweeps you can see the right ovary is way edematous and enlarged which spaced out follicles and the transverse synes sweep demonstrated the asymmetry between the right and the left side again that's the midline urus and the right ovary here is enlarged compared to the normal left side she was diagnosed with acute right ovarian torsion and get and got surgery appropriately with detorsion and salvage this is a 16 year old who presented with acute right lower quadrant pain and nausea she had a simple cystic area adjacent to the right ovary and the entire right ovary and the cyst looked like they were sitting on top of the bladder in the midline the left ovary was normal and in comparison to the left the right looked a little enlarged and edematous this is a sagittal image showing the bladder the cyst and the ovary and the synes sweep in the midline transverse plane shows the enlarged ovary the adjacent cyst sitting on top of the bladder so superior to inferior ovary cyst and bladder she was diagnosed as acute righted nexial torsion times two at the infundibular pelvic ligament and it was secondary to an eight centimeter cyst in the mesosalpings she was taken to the OR and the cyst was resected and the ovary was detourced had a good outcome this is a 17 year old girl who came in with acute right lower abdominal pain and nausea she already got a CT scan first to rule out acute appendicitis it was negative the appendix was normal but that's where they picked up the adnexal mass so she got an ultrasound and the left ovary was normal the right ovary was seen in part and whatever was seen looked normal but there was this adjacent right adnexal cystic mass with what looked like one dominant simple cyst and additional smaller cystic areas and those smaller cystic areas looked like they had these tiny folds on the inside so that kind of led to the suspicion that they're likely tubal in origin on real time exam the right adnexal mass was seen to be comprised of the dominant cystic component as well as these tiny cystic areas and on probe pressure it looked like the ovary was separable from the mass so I'm applying probe pressure the adnexal mass moved away from the right ovary so we call this a tubal torsion and she went to the OR and the right fallopian tube was tors times two with a five centimeter paratubal cyst this next patient was an adult woman not a pediatric case but I'm showing it because she had a classic finding that I'd like to share she came in with acute pelvic pain and she had had a history of ovarian cysts in the past she had multiple fibroids and you could see a part of the ovary that was labeled as right ovary and there was a what looked like a dermoid cyst in the right adnexa but the other ovary was not seen on ultrasound and because of her pain she went on to get a pelvic MRI and on the MR you could see the dermoid the ovarian fibroids the bladder and what looked like a normal right ovary so if the right ovary was normal that means all of this was arising from the left ovary and no wonder we didn't see one on ultrasound these are sagittal images of her pelvis and we're going from right to left and back and you're seeing the fibroids the dermoid and the right ovary so one more time we're going from right to left so we start that's the right ovary the dermoid and then what looks like the ovarian twisted pedicle of the left and keep going coming back to the right side so this was the twisted ovarian pedicle of the left ovary and this was the MRI whirlpool sign she had a diagnosed specific acute left ovarian torsion secondary to the six centimeter dermoid cyst and she was treated appropriately in a timely fashion so let's summarize torsion may involve the ovary or fallopian tube or both it could be complete or incomplete and intermittent torsion is common it affects young girls and young women of reproductive age group in children the predisposing factors could be a congenital a long urovarian ligament excessive laxity and extrinsic causes like functional cysts or teratomas and the fact that they have a small uterus allows more space for the adnexa to twist on its axis it is important to have a high index of suspicion especially with a normal appearing ovary and an adjacent adnexal cyst on the ipsilateral painful side the literature tells us that only about 30% will have an accurate preoperative diagnosis of adnexal torsion so how can we improve on that here are some pearls gray scale findings are critical do not rush to put on color we know that presence of ovarian flow does not rule out torsion because 60% of the times the ovary may have a dual arterial blood supply think torsion when you see asymmetric enlargement of one ovary compared to the other size does matter the median volume of a torsed ovary has been reported to range between three to ten times of the contralateral side midline or super vesicle location of the ovary or adnexal cyst should be a red alert that something is out of place there may be an associated hemorrhagic cyst in the ovary or a dermoid or adjacent tubular cystic area suggesting fallopian tube dilation and these could all be lead points there may be free fluid which could be reactive to the ongoing torsion or hemorrhagic fluid and if you're really lucky you could actually see the twisting pedicle sign or the whirlpool sign our next case is a two month old baby girl who came in with a left groin bulge on exam she had a left inguinal hernia this is the fascial defect at the left internal inguinal ring and the hernia sac was noted to contain some fluid momentum what looked like in normal ovary and the uterus you can recognize the uterus from the endometrial stripe let's look at a transfer sinus sweep of the left inguinal hernia from superior to inferior fluid momentum uterus ovary and ovary so it looks like everything was in the sac uterus ovary number one and ovary number two it looks like both ovaries were in the sac this child did get a definitive hernia repair at three months of age interestingly she was a 29 week preemie and one of twins and both of these are known predisposing factors for inguinal hernia these are some companion cases this is a three month old boy who came in with a right side of scrotal swelling and refusing feeds and you can see that there was an inguinal hernia containing air filled bowel loops the testis was fine this seven year old boy had a left inguinal bulge that was intermittent and you could see like squishy ecogenic soft tissue popping in and out of the inguinal canal into the scrotal sac this was omen to hernia and this was just another four month old with a left groin swelling and a normal appearing ovary in the hernia and this is just a cool case showing the appendix entering the hernia sac it was a normal appendix with some fluid and momentum and this is an example of an amiant hernia containing the normal appendix sort take home points inguinal hernia is the most common cause of groin bulge in children in female infants the hernia sac often contains reproductive organs the dynamic nature of ultrasound can help assess reducibility of the hernia and it plays a critical role in preoperative evaluation of children with groin swelling our next case is a 14 year old boy with seven days of sore throat and odynophagia he got an ultrasound of his neck and the ultrasound shows a normal submendibular gland this is the right tonsil and it looks like it's enlarged and there is a focal irregularly marginated hypoechoic fluid collection along the posterior lateral aspect of the tonsil it was confirmed to be a peritonsular abscess seen on the CT scan and on bedside drainage four ccs of pus was obtained so this was a right peritonsular abscess peritonsular infections are common in children and adolescents but due to the similar clinical presentation differentiation of peritonsular abscess from peritonsular cellulitis or uncomplicated tonsillitis can be very challenging based on clinical exam alone and this distinction is critical because the management of these entities is different traditionally contrast enhanced CT scan has been used to diagnose peritonsular abscess however it is far from ideal due to the radiation exposure and that is why there has been increasing utilization of ultrasound as the primary imaging modality to evaluate neck infections this is an example of normal tonsil ultrasound the right and the left side this is performed using a transcutaneous approach in the submendibular region the transducer is placed beneath the jaw over the skin and on the right side you see a normal submendibular gland and the tonsil that looks like a hypoechoic ovoid soft tissue area with subtly lobulated margins anastroided appearance and specks of air in the medial aspect that is air in the fairings similarly the left submendibular gland and a normal left tonsil are visualized these are images depicting the technique of performing tonsil ultrasound this is a midline submental approach showing both tonsils side by side this is a submendibular approach transverse view and a submendibular longitudinal approach this is an example of a five-year-old child with normal tonsils this is a midline approach and the left submendibular approach showing the normal left submendibular gland normal left tonsil and part of the tongue medially on a sine sweep you can see the left submendibular gland and the tonsil beneath it and this is an example of a midline view demonstrating both tonsils and these are examples of pathologies you may encounter while performing tonsil ultrasound in this case the tonsil is moderately enlarged relative to the size of the submendibular gland however the echo texture is reserved with its striations there are no fluid collections so this is uncomplicated tonsillitis in a case of peritonsular cellulitis the tonsil is typically enlarged and heterogeneous in appearance with patchy hypo and hyperechoic areas and some surrounding edema and this is a peritonsular abscess where you see a marginated fluid collection along the posterior lateral aspect of the tonsil this is the right submendibular gland the right tonsil abscess and part of the tongue so in summary tonsil ultrasound is an ideal diagnostic tool for evaluation of tonsils in children for all of these wonderful reasons it reliably differentiates peritonsular abscess from other tonsillar infections like uncomplicated tonsillitis and it plays a critical role in identifying those patients who will not need surgical intervention thank you very much for your time and attention