substernal extension

[Samuel Katumba]

Hullo Stephen Bird,
How do i determine that a thyroid nodule extends substernally on ultrasound? Thank you

[Stephen Bird]

Hi Samuel,
I use a really simple method,

The thyroid gland sits relatively low in the neck and only the larger nodules or goiter type glands will have retrosternal extension.

As you scan down the right or left lobes of the gland in an axial plane, eventually your transducer will reach the medial head of the clavicle and you will generate an acoustic shadow from the bony structure.
If you have not cleared the lower pole of the respective lobe then you have retrosternal extension. If you are scanning down the midline, following the isthmus part of the gland inferiorly you will arrive at the supra sternal notch and then the manubrium of the sternum will be your bony landmark. Apply the same principle here.

The exact amount of retrosternal extension may be difficult or impossible to estimate with ultrasound and cross sectional imaging such as a CT scan can easily provide this information if required.

Happy scanning,

Steve

[Samuel Katumba]

Simple method indeed. I have have understood, waiting to try it out.
Thank you Steve.
Happy scanning

[Samuel Katumba]

First, my sympathy about the fires in Australia.
Internal echoes:
Some textbooks describe a certain cyst as “showing internal echoes”, the internal echoes are described as low-level internal echoes, medium-level internal echoes or high-level internal echoes.
what criteria is used for this description?, What is the Sonographic/clinical significance of this description

[Stephen Bird]

Hi Samuel,

I think this is subjective,

I would say a cyst is anechoic (no internal echoes at all),
Low level echoes I would classify as some faint echoes within the cyst seen when you turn the gain up higher.
Medium level echoes I would classify as about half the echogenicity of the thyroid gland tissue.
High level echoes I would classify as similar or greater echogenicity to the normal thyroid tissue

BUT,

I don’t think this matters much in terms of diagnostic outcomes,

Echoes in a cystic structure are less important than if there is vascularity within the echoes in a cyst.
If there are some echoes within a cyst and they are evenly distributed this is likely due to some haemorrhage within the cyst. Blood in a cyst may also form angular lines as the clot retracts similar to anhaemorhagic ovarian cyst. In fact it is worth looking at the IOTA classification for ovarian masses as the same logic can be applied.
Once you see Doppler signal inside the echoes within a cyst this changes everything. You are now not dealing with a cyst that has had some bleed within it but in fact you have a solid tissue element within a cyst and this makes it a more suspicious lesion that may require a biopsy. The determination to biopsy or not can be made using the TiRADS system.

TiRADS does not use vascularity as a criteria, however if there is vascularity within the cyst this indicates it is not a simple cyst and in fact is a cystic / solid mixed lesion and if the solid component has only faint echoes that will be classified as very hypo echoic solid element and this will score high on the TiRADS system making the lesion likely requiring a FNA.

Steve

[Stephen Bird]

I will be recording a webinar on thyroid ultrasound soon and this will explore the TiRads system in more detail.

I have already recorded a salivary gland webinar and this will be loaded into the shop soon.

Steve.

[Samuel Katumba]

Thank you Steve for this extensive explanation

[Samuel Katumba]

Hi Steve
When I scan the male inguinal canal/spermatic cord, I employ a “coughing maneuver”. when there is a sizeable hernia, it is easy to diagnose. I have noticed certain structures that respond (by moving somehow)even when there is no “obvious hernia” what do you think these structures/contents could be?

Again, which resources, e.g text books have you used and have helpful content on 3D/4D & contrast enhanced ultrasound imaging?

[Stephen Bird]

Hi Samuel,

Lovely to hear from you again,

Increasing the intra-abdominal pressure is essential for identification and assessment of inguinal and femoral hernias. There are many methods people use to produce a valsalva effect. Many like yourself ask the patient to cough and this works well but it is not my favourite. The problem I have with a cough is that it can be too “violent” and short. I ask the patient to put their thumb on their lips and pretend they are blowing ups balloon. I can then ask them to blow harder or softer and ask them to keep blowing and then to stop when I choose. This gives me great control with a pressure graded valsalva that is long enough to observe the hernia movement.
In normal patients without a hernia there is a variety of structures that can move slightly within the canal. Many people have a tongue of pre-peritoneal (extraperitoneal) fat in the canal. This moves with valsalva but the deep ring does not distend and no pain is caused. They can also have a cord lipoma which is an island of fat within the canal that can not be reduced from the canal and there is no posterior wall defect nor fat coming through the deep ring.
There is also the pampiniform plexus drainage veins which dilate with valsalva.

As for 3D/4D and contrast articles I have only limited experience.
In Australia in the private system ultrasound contrastt is not used as it is not financially supported by our Medicare government funding.
A sonographer and friend in New Zealand Martin Necas is the guru of contrast and I will ask him for some references for you.
3D and 4D we do perform mainly for gynaecology and foetal abnormalities like club foot, craniofacial, limb and spine deformities.

Let me know what you are interested in and I will forward you some material.

We don’t find 3D / 4D useful in other areas and in the MSK arena it is a fancy toy but never really changes the diagnosis or the way we think about the case.

My measure of useful technology is to ask the question ” If I use the new technology does it change the diagnosis or provide extra insight that will change my worksheet or the patient management” The challenge for 3D / 4D , contrast, elastography etc is to pass this test and then I think it has proven benefit.

All of these technologies have found some niche uses where this is the case but many applications are simply restating what we know.

Let me know what applications you have in mind and I will continue this discussion,

Steve

[Samuel Katumba]

Yes!
My puzzles on inguinal canal have been settled. Most likely, in many of my cases, the extra peritoneal fat in the canal was confusing me.
Again, your way of creating a Valsava effect is undoubtedly superior, i should try it out.

About 3D/4D, I urgently need gynecology and obs material e.g on mullerian duct anomaly assessment, IUCD localization, fetal cranial-facial anomaly assessment etc.
Contrast enhanced ultrasound is something i wish to know more about.

Thanks

[Stephen Bird]

Hi Samuel,

I will email you some articles on Mullarian duct anomalies.
I have a nice ultrasound gynaecologist lecture which I will record for the website which also deals;s with this topic.

I will also record my hernia lecture as many people have asked for it.

I will contact Martin Necas and see if he can help you with contrast material.

Have a great weekend Samuel,

Steve

[Samuel Katumba]

I really need someone to walk me through 3D/4D applications in gyn & obs.
Eagerly waiting
Thanks Steve

[Samuel Katumba]

Hi Steve,
The lymph nodes in the superficial inguinal nodal chains sometimes appear “elongated”/enlarged but maintain a normal sonographic appearance/echopattern. I at times get this appearance incidentally in patients with no much complaints. Is there any special cause for this appearance of superficial inguinal nodes?

Thanks,
Samuel K.

[Stephen Bird]

These are normal inguinal lymph nodes,
nodes in the axilla and groin can be very large and elongated in normal individuals.
Measure the node in the short axis rather than the long axis and look at the node morphology.
If it is long and has a normal fatty hilum without a thickened cortex I am happy it is normal.
If it malignant it will become rounded rather than elongated and will loose the normal fatty hilum architecture.

Steve.

[Samuel Katumba]

Okay, I juts thought there could be something unique with the nodes.
Also, I have tried out the “blowing ups balloon” way to produce a Valsalva effect. It works well, I shot two birds with the technique- assessed inguinal canal for hernia, and scrotal varices.

Thank you Steve.
Samuel

[Stephen Bird]

I love it !

Anything that valsalva is required for you can use this technique.

Steve

[Samuel Katumba]

Hullo Steve.
Recently, I had a case of complicated para-umbilical herniorrhaphy with anterior abdominal wall abscess, i had issues assessing the mesh. Any tips?

The informative articles on 3D & Uterine anomalies that you availed are so helpful.

Thank you so much
Samuel

[Stephen Bird]

Hi Samuel,

I am glad the articles were useful,

With mesh patients I don’t have any particular advice,

If the abdominal wall has been repaired using mesh I use the same technique and thought processes as scanning a native abdominal wall.

So I look for the gap between the rectus abdomens muscles (linea alba) for divarication or hernia. If there is a hernia it means the mesh has failed to prevent it.

I do look at the mesh as you can usually see it and I check around the edges of the mesh for hernia recurrence.

Also check for collections in the post operative phase, they can be serums, haematomas or infections (abscess)

Steve

[Samuel Katumba]

Hullo Steve,
Which site does a baker’s cyst develop? Green circle? or Black circle? See image attached
Thank You

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[Stephen Bird]

Hi Samuel,

I am not sure they arise from either of those locations exactly.

Anatomically they are in the medial aspect of the popliteal fossa in a bursa located between the medial head of gastrocnemius and the semimembranosis distal tendon which inserts onto the posterior tibia.

I have attached a typical appearance for you.

This is one I scanned the other day. It is interesting as it contains a loose body as well as synovial proliferation from synovitis.

Steve.

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[Stephen Bird]

More images

Steve

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[Stephen Bird]

And more examples,

Also Samuel,

I am extending my discounted subscription rate to all of your colleagues in Africa,

Some have contacted me already,

I will allocate them a discount coupon code if they email me to make the website even cheaper and enjoyed by more ultrasound lovers in Africa,

Thanks for your support mate,

Steve.

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[Stephen Bird]

A few more.

Steve

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[Samuel Katumba]

Hello,
You have helped me understand the origin of a Bakers. Thank you for the multiple examples.
Also, Steve, thank you for help you are yet to extend to our colleagues here in Africa.
Samuel

[Stephen Bird]

You are the best Samuel,

I am really keen to help my friends in Africa,

Keep the great questions coming,

Steve

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