 Hello everybody. This is generally an interactive quiz that I take within a hall or within a lecture theater which I have modified so that it can now be shared with you on this kind of a forum. So let's go get on with it right away. So case number one, 28 year old gentleman came with symptoms of left sided scrotal pain and was referred for an ultrasound. Ultrasound reveals an absolutely normal right testers. On the left, however, you see a very well defined, well-marginated hypoechoic lesion measures about 1.5 by 1.2 centimeters. The right chord of this patient is obviously enlarged. The right epididymis appears enlarged. The left was normal. So what are we dealing with? Okay, do you have the answer? If you have called it as tuberculosis epididymis or architis, you would be absolutely correct. The thought process being, presence of epididymal enlargement in addition to a testicular lesion suggests infection rather than neoplasm. There were negative tumor markers, absence of fever, leukocytosis and tenderness rules out an acute inflammatory process. There was a failure to respond to conventional antibiotics and this patient responded to AKT. A few weeks later, this is the picture. It has slightly reduced as you can see it on the left side. The left testers reveals a smaller sized lesion. You can see some healing at the margins where it has almost become isoechoic with the remainder of the testers and the right chord which initially was enlarged has now become practically normal in size as has the right epididymis. Case two. This elderly gentleman has a history of vitrectomy and an IOL implantation in the past referred for diminished vision and these are the findings. This is spot diagnosis. You see multiple tiny ecogenic foresight dispersed throughout the vitreous. I think you see it much better here. So what are we dealing with? Your clue is history of vitrectomy in the past. It's just not the IOL but remember the history of vitrectomy in the past. So in this post vitrectomy post trial patient that appearance was because of emulsification of a residual silicone oil. Silicone oil is used for tamponade and if there is remnant silicone oil then emulsification of that gives rise to those bubbles that you saw on ultrasound. Case number three. This is a hypothetical story of a young man, inspired of course by WhatsApp. There's an interesting aside to this actually on WhatsApp a few years back a colleague from the Middle East shared this WhatsApp story about a young man who as a prank used his partner's urine pregnancy test kit and did his own urinary pregnancy test and to his surprise it was positive. He shared it on the social media saying hey guys you know I'm pregnant and that sort of a thing and of course there were a lot of you know thumbs ups and oh wow's and things like that until one particular response left him cold. I'm not going to show you any image right now. The answer is to be supplied by you without my showing any image purely on the basis of this hypothetical story. Coincidentally on the very day that my colleague shared the story the day prior I had a case which fit this particular story so well. So what was the response that left this young man cold yes and that response was a young man you need to get a scrotal examination done to roll out a tumor. That's right on the right side my patient had this focal large predominantly solid inhomogeneous mass the left being normal. You can see the mass better in this longitudinal section color Doppler pictures. This patient on workup had raised serum beta Hcg raised AFP so markers were abnormal on surgery it turned out to be testicular teratocastinoma embryonal castinoma with choreocastinoma elements and that is why you're you know hypothetically speaking the positive UPT case number four an elderly gentleman referred for an ultrasound of the scrotum for vague pain vague swelling that's the right side that's the left on the right side you see this thin wall cystic areas you see them much better in these images there's a large one there that that's the largest one about 1.1 by 0.8 centimeters you can see multiple tiny cysts there as well and so we are dealing with yes cystic transformation of retestus or tubular ectasia a benign condition often in men more than 55 years generally asymptomatic often bilateral but as we saw in our case unilateral the pathognomonic as the location and presence of epididymal cyst and waltzes and the elongated shape of those groups of cysts which replaces the media stynum case number five this lady had symptoms of tingling numbness in her right fingers and pain in the palm basically that's the picture of the right median nerve the median nerve is the longitudinal structure which is more superficial the thicker structure deeper is a tendon as you can see in the picture initially the nerve is widened and the narrowed and widened again and I think this description itself gives you some kind of a clue this is an image a longitudinal section practically at the wrist joint level in the right carpal tunnel you can see that the synovium is thickened and there is increased flow within the synovium using the same setting on the left side there is practically no synovial flow that is there is no evidence of hyperemia on the asymptomatic left side the median nerve on the affected side as you can see reveals increased flow within you can detect actually flow within the median nerve on the asymptomatic side and in the adjacent synovium of course you can see the hyperemia the affected side median nerve reveals a cross section which is 0.10 centimeters squared whereas on the asymptomatic side it is 0.06 centimeters squared again telling you that the right median nerve was enlarged so what are we dealing with yeah this was very simple carpal tunnel syndrome due to compression of median nerve within the carpal tunnel the ultrasound classic triad is Palmer bowing of flexorate inoculum more than two millimeters beyond a line connecting the pisiform and the scaphoid as we saw in our earlier pictures distal flattening of the nerve that is distal to the flexorate inoculum and proximal to the flexorate inoculum there is enlargement as we saw in those longitudinal images case number six I think a description of these slides and the legend itself will give you a clue to those who are aware of these terms this patient had a classic condition which will actually be your diagnosis so just let's run through the slides first this is the asymptomatic side right middle digit these are transfers in longitudinal images at the level of the metacarpal angel joint and you can see that there's a structure which is called the A1 pulley which on this side that is the right in the longitudinal images measures just 0.04 centimeters on the other side on the left side the A1 pull in these longitudinal sections you can see it as a black band there is much thicker measuring about 0.12 centimeters that is 1.2 millimeters you can also see increased flow within that black ring on the left side which is not seen on the contralateral right side so what are we dealing with it's a classic condition a trigger finger trigger finger is a stenosing tino sinovitis at level of A1 pulley annulus trap surrounding the flexor tendon at the level of the mcp joint there are further pulleys distally that is like a 2 a 3 a 4 pulleys but we shouldn't talk about them at this point of time and this results in locking of the digit in the flexed position leading to the descriptive term trigger finger high frequency ultrasound allows visualization of the A1 pulley flexor tendon complex thickness of the A1 pulley more than 1 millimeters now remember that this thickness can be a uniform that is global or it could even be nodular and it this nodularity may actually cause something like an appearance of a notch between the pulley and the underlying flexor tendon hypervascularization of the A1 pulley on par Doppler is seen in the majority of the patients as we saw in our case and the obviously you can also pick up the tendinosis or the tino sinovitis of the flexor tendon which we also picked up on the color Doppler case number seven this is a simple case these are images at the posterior aspect of the elbow joint dorsal aspect bone muscle and there's some fluid collection with a lot of soft tissue thickening so fluid soft tissue thickening the bone interface what are we dealing with see that fluid much better than up this is the dorsal aspect of the elbow joint simple olycranon bursitis fluid collection within the olycranon bursa with or without synovial proliferation with or without hyperemia and with or without loose bodies within and associated triceps tendonitis case number eight a lady middle-aged presenting with enlargement of the left parotid region ultrasound reveals an absolutely normal and homogeneous right parotid and there's a lobulated hypoechoic mass in the left parotid you can see the very sharply defined lobulated hypoechoic mass and you can see some thin septae also within in this particular case so you're dealing with even I first called it as a pleomorphic adenoma but on surgery it turned out to be an intra parotid lipoma and that is why my subtle emphasis on that thin septae which even I overlooked it's very rare less than 0.5 percent of all parotid tumors but in hindsight if you go to the images you will realize that it yes it does look like a lipoma rather than a pleomorphic adenoma case number nine a teenage presenting with left cheek enlargement and you see a hypoechoic area what is it here's your clue masseter cystic circus well rounded well defined cystic mass with an echogenic skull X with them the adjacent tissue may or may not reveal inflammatory changes depending on leakage of fluid it is caused by infection of the larval form cystic circus cellulase of the pope aperm teenia sodium it's rare in almost all literature is from India another case this time in the right pectoralis muscle but an absolutely typical or a pathognomonic ultrasound appearance case number 10 a slightly older slide from my collection showing transverse section showing both the testes and you see multiple echogenic calcific foci within both the testes the patient as you can see had come for that scrotal enlargement you can see the marked wall thickening and of course incidentally I picked up these multiple tiny calcific foci within the testes so we are dealing with testicular microlethiasis it is rare 0.6 percent of testicular sonos that is on all testicular ultrasounds classic testicular microlethiasis is defined when you see at least five microlets that is at least five of those specular echoes on at least one image many centers recommend annual ultrasound in view of its presence and 50 percent of men with germ cell tumor but since it's very common in patients without cancer this direct relationship is not actually proven thank you for watching if you'd like to send me a feedback please mail me at villain at irad.guru and if you are interested in the field of artificial intelligence as applied to radiology please do visit my website www.irad.guru thank you