 Hello and a big thank you to all for watching the first edition of masterclass ultrasound quiz. Thank you for your valuable feedback. These are indeed difficult times, please do take care. In this next edition, we concentrate on pediatric ultrasound. Hello and welcome to this edition of masterclass ultrasound quiz, the theme for this quiz being pediatric ultrasound. So let's quiz, case number one. A young boy with right scrotal swelling presenting for ultrasound, ultrasound obviously reveals scrotal hydrocele but then in the sagittal section you can see that there is fluid in the right inguinal region as well. Of course there is fluid in the hemiscrotum and that there is fluid in the inguinal region as well. So we are dealing with, so irrespective of the specific diagnosis that you give, what we are dealing here is basically a type of a communicating hydrocele, right. A communicating hydrocele is due to the failure of the processes vaginalis to close completely and when we state this, it is obvious that we are going to deal with a spectrum of clinical presentations and therefore a spectrum of ultrasound findings. For example, in an insisted hydrocele of the cord, fluid does not communicate with the peritoneum above or with the tunica vaginalis below and this is a very common presentation which presents as a inguinal lump or as an inguinal swelling and in that spectrum of finding we would call it an insisted hydrocele of the cord. A slightly different spectrum or a slightly different presentation would be a funicular hydrocele. Now, in a funicular hydrocele, this is obviously a type of communicating hydrocele where the fluid collection communicates with the peritoneum above at the internal inguinal ring but does not communicate with the tunica vaginalis. So there is no scrotal component but rather there is more of an inguinal component which however does communicate with the peritoneum above and therefore is reducible unlike an insisted hydrocele of the cord. Now, sometimes you can see debris or echoes within the fluid. Mind you, this can often be a normal thing simply because of the long-standing nature of the fluid collection and does not necessarily mean that you are dealing with an emergency or an infection or something like that. And obviously if the process is patent, can a hernia be far behind? So sometimes there might also be an associated inguinal hernia. Now, differentiation of a funicular hydrocele from a simple scrotal hydrocele is essential since management is obviously different. Case number 2. A 14-year-old boy had presented to me with an abnormal LFT to perform an alert of sound of the abdomen to basically look at the liver. Now, while he did have very specific features which would suggest an hepatitis such as, you know, Hepatomegaly thickening of wall of the gallbladder, what was a surprising finding was this mass which as you can see is anterior and just medial to the left kidney. The mass is about 9 by 8 cm in size, extremely inhomogeneous and you can see multiple hyperacoic foci within consistent with calcifications. So 14-year-old boy with an incidental detection of a mass related to the left kidney but separate from it as you can see here, growing needily practically encasing the renal vessel and extending anterior to the aorta. So what could this be? The thought process here is that the first thing is that when you get a pediatric case with a mass related to the kidney, that is you start thinking in terms of a neuroblastoma that is the kind of association, neuroblastoma is the most common solid extracranial malignant tumor in children and in fact forms about 8 to 10% of all pediatric malignancies. It is common in the 1 to 5 years age group. Neuroblastomers arise either in the adrenal medulla or anywhere along the sympathetic anglion chain and the average size is about 8 cm representation which our mass seem to fit rather well. In older children, other neural crest tumors such as ganglionuroblastoma and ganglionuroma are more common and these are more common in the first and the second decades of life. These also present as solid masses, homogeneous or heterogeneous with or without areas of calcification and fiochromocytoma is another differential diagnosis that we must keep in mind. In this particular case, it turned out to be a ganglionuroma and that seemed to fit rather well with the fact that it was an older child, a 14 year old boy who had presented incidentally with that mass. Case number 3, a small girl who presented with dysuria and symptoms suggesting increased urinary frequency, what you call the lower urinary tract symptoms, maybe there was a little fever and this was the ultrasound appearance. There was no hematuria. So what could this be? Cystitis as we generally define as when the bladder wall shows a diffuse thickening which is more than 3 mm. But rarely, cystitis produces focal wall thickening or a polypoid mass as was in this case, which can be thought of as an inflammatory pseudotumor. So this was a slightly atypical presentation of cystitis, what one could call an inflammatory pseudotumor. Now, while this particular case wasn't a cystitisistica, which is an inflammatory process localized to the trigon and urethral orifices, it is a broad based irregular isoechoic or hyperechoic soft tissue mass, which could mimic a rhabdomyosarcoma and that is another type of a focal cystitis, case number 4. I don't need to describe this. This is a spotter. Here's a neonate and this is the liver and you can see something. So do you already have the diagnosis? In case you don't, here's a clue. There's the pylorus. There's the distended stomach, which is fluid filled, yes. And now coming back to our original slide with the measurements in this case. You can see that the pylorus has an overall measurement of about 1.5 centimeters and a muscle thickness of almost 5 millimeters or 0.5 centimeters. In the longitudinal section, you can see that the pylorus is elongated just over 17 millimeters. And you can see the red arrow pointing out to a small prolapse of the pyloric annulmucosa into the stomach. This is called the antronipple sign and you can see the black arrow pointing out to some hypoechoic or fluid clefts within the pyloric channel. So do you have the answer now? Right? Hypotrophic pyloric stenosis. The first picture shows us the olive shaped mass in the epigastrium. It's about two to six weeks of life. Non-belius projectile vomiting is how the neonate resins. And as we showed in our slides, thickened pyloric muscle greater than equal to 3 millimeters and elongated pyloric channel greater than equal to 17 millimeters. The antronipple sign, which we showed in the trade arrow, prolapse of pyloric channel mucosa into the gastric antrum. And the double track sign due to hypoechoic stripes of fluid within the crevices of the mucosa. Sometimes the thickened pyloric muscle reveals increased flow on Doppler. And if you ask a question as to post-Ramsted procedure, how long would this thickening persist, then the muscle may appear abnormally thick for three months post-surgery as well. So that does not necessarily mean that there is failure of the surgery. Case number five, a four-year-old girl presented with this left inguinal lump. Now this child was absolutely asymptomatic. It was her mother who was agitated. She was very sure that just the day prior when she bathed the child, everything was absolutely normal. And the child was playful, went around to the playground, played for some time, came back and it was in the evening that she noticed that the child had a lump in the left inguinal region. The child was asymptomatic. These are the ultrasound features. You can see that there is an anicoic cyst in the left inguinal region. In this slide you can see the relationship to the urinary bladder. So what are we dealing with? If you had stated that this was a hydrosil or a cyst of the canal of nuke, you would be absolutely correct. This is again like in the first case of the young boy due to a failure of the complete obliteration of the canal of nuke, which is the patent peritoneal pouch in a girl. This is the patent peritoneal pouch extending anterior to the round ligament and into the labia majora. And hence it is indeed another patent process for Janalis. And due to this patency you can either get an incister hydrosil as you see in this case or even a hernia. Because if there is a patent process, then the ovary or even the fallopian tube may herniate into this canal. Here is another case. This one was on the right side, the right inguinal region. You can see in this section its relationship to the right iliac vessels. It is medial to the iliac vessels. And in this particular case you can see the herniation of ovary into the patent processes. Case number six, an eight-year-old boy complaining of vomiting and severe pain in the abdomen presenting with a lump. This is the transverse section of the lump. I'm sure most of you must already have had the diagnosis by now. Yet another view of the lump. So what were we dealing with? Intersecretion. That's right. Intersecretion is common in children more than three months and that's because it's most frequently related to enlarged lymphoid tissue post-infection. Since prior to three months of life, immunity is passive, it's logical that it's going to be common after the age of three months. Now when the diameter is more than 2.5 of the lump that is, and the length of the lump is more than 5 centimeters, then an iliocolic type of an intersecretion is more likely than an ilio-ilial and it is this differentiation that is very important. Another feature is that there is an ecogenic fat core in all cases of iliocolic whereas ilio-ilial show little or no fat and therefore the fat core to outer wall thickness index if that's greater than one then this is supposed to be a hundred percent sensitive and specific for an iliocolic type of intersecretion. Here's another example. This child again presented with severe pain and vomiting and I saw this insisted fluid collection in the left abdomen. It did not have that typical findings of intersecretion in this section but on transverse section it indeed turns out to have very characteristic features suggesting an intersecretion. So what was this fluid? This fluid was basically a sign of this intersecretion gone bad and that thick segment of intestine that you saw within the fluid collection was the segment of bowel inside which had become gangrenous. So case number seven, a young girl presenting with lower urinary tract symptoms and a palpable lump. So what is this? This is a gainous spotter. Here's the lump, right? If you called it either as a hydrocholpus or a hematocolpus you would be correct because this can either be encountered in the neonatal period or at the time of menarche. The presentation could be as a palpable mass or very rarely as an interlabial mass in units due to aversion of the obstructing membrane or septum. Patients could present with cyclical pain. Noting the relationship of the cystic mass to the urinary bladder it is very easy to imagine that urinary retention could be a very common presentation. Generally trans abdominal ultrasound suffices for the diagnosis but a transpirinal scan can measure the distance between the perineum and the caudal margin of the cyst. Next case, these are ultrasound images showing us the right and the left hip of a young child. You can see the right hip and the left hip. These are images of the same patient of the right and the left hips. I am sure that most of you already have the diagnosis. Here is another patient again images of the right hip and the left hip. So what are we dealing with? Detection of fluid in the anterior recess of the hip joint. Let us not come to the specific diagnosis, right? What did those ultrasound images reveal? Detection of fluid in the anterior recess of the hip joint. The ultrasound is highly sensitive and as little as 1 ml of fluid can be detected. Now the specific diagnosis or the causes can vary. You can have a transient synovitis in which case the fluid is more likely to be anechoic as it was in our cases. In osteomyelitis, perthase and slipped capital epithesis and fractures in arthritis the fluid is more likely to have ecogenic debris within the collection. These in as we do in all musculoskeletal cases compare the two sides and what is important is that you use an anterior oblique plane. Now the anterior recess has a capsule which parallels the neck. The normal capsule has a thickness of about 2 to 5 mm and the difference between the two sides is less than 2 mm implying thereby that if the capsule is thickened beyond 5 mm or if the difference between the two sides is greater than 2 mm then you should consider that it is an abnormal appearance. So the normal appearance of the capsule would be that of a concave capsule parallel to the neck. If it is convex then that is abnormal. Now to come to that positioning of the transducer, now I told you that the normal plane is slightly oblique to the shaft of the femur. So rather than keeping the transducer placed like this, this is how you could place it in which case you would get a very perfect section of the anterior recess of the hip joint. Case number 9, a neonate, we are looking at the cranium and we are looking at the coronal planes. You can see some numbers 3 or 4. So generally the way to do a cranial ultrasound through the fontanel is to obtain coronal and sagittal and parasagittal and steep parasagittal sections, right? Now you could, depending on the kind of protocol that you use, you could have about 6 coronal sections or 8 coronal sections. What is important is that in the coronal section labeled 3, you can see the third ventricle and you can see that there are ecogenic masses in the floor of the lateral ventricle, right? Which are bilateral. Parasagittal sections revealed there are ecogenic masses which you can see extending from the coroid plexus anteriorly. Now there was a clue. What are we dealing with? Obviously germinal matrix hemorrhage or caudothalamic hemorrhage which occurs in the stress sensitive, highly vascular germinal matrix in the caudothalamic groove. Now why was that subtle emphasis on the anterior extension of the coroid plexus? That is because the normal coroid plexus does not extend anterior to the caudothalamic groove and we will come to that in the next slide. Now since the germinal matrix matures by 34 weeks, this hemorrhage is rare after 34 weeks. So it is basically more common in pre-matures. Most occur in the first week of life and there are four grades that occur into papill and in grade four you can see extension into the brain tissue. Let's run across some slides here. Now this is that explanation. The thinner arrow roughly points to the position of the caudothalamic groove. The normal coroid plexus never extends anterior to it. So when you see something that looks like a coroid plexus anteriorly that is anterior to the caudothalamic groove in this given clinical setting it is almost surely hemorrhage in the germinal matrix. Now depending on the age of the bleed you can have different appearances. An older bleed would have this kind of a cystic appearance and bleed into the ventricle would sometimes appear as you can see here as an apparent enlargement or a dense appearing coroid plexus. On this side you can see that there is ventricular megalae along with her apparently enlarged coroid plexus telling us that there is an intraventricular hemorrhage as well with an associated ventricular enlargement and this would be what grade? Grade three type of hemorrhage. And in this slide you can see intra-parenchymal bleed obviously a grade four hemorrhage. Case number ten this sixteen year old boy presented with undescended testis. He had gynecomastia and was basically sent to locate the testis. You can see that the scrotum on the right side is empty. You can see the cord here and you could easily identify the undescended testis on the right side. This was the empty scrotum so to speak and in the inguinal region the undescended testis was easily identified. On the left side the scrotum was again empty accuracy anything there just some thick skin or you know soft tissues there but to my surprise when I moved the robe syphilad to try to locate the left undescended testis this is what I saw a very well defined uterus as you could see the endometrium there the endometrium measuring about nine millimeters the left ovary with its follicles was very nicely identified the right ovary could not be identified in the right adnexa. So what are we dealing with a right testis like structure with a rudimentary scrotum on the right side and a very well defined left ovary in the pelvis a uterus in the pelvis and the endometrium in the pelvis. So the differential diagnosis was basically between a true hermaphroditism which is an extremely rare case and mixed gonadal disgenesis this turned out to be a true hermaphrodite a very rare case as I said in true hermaphroditism you have unequivocal ovarian tissue as we saw on the left side and testicular elements and this is regardless of the cariotype in mixed gonadal disgenesis you would have a differentiated gonad on one side but a streak gonad on the other side now all these things are important to assign a gender to this individual so that a decision for early gonadectomy could be taken and hence a biopsy is very essential apart from cariotype in these cases. Thank you very much.