Page iii

Practical Head & Neck Ultrasound

iEd\!~ed. by AmI. T .Ahmj!<lL

~BS (Bomh~y) lli.ID (Bomb<1lY) lIFRCR FHK:CR FHKAlVl[

Associate iP~mressor Oeplll1lnellliI of DJ!<lI!g:rLo.SJ1tic R1lI!dli'anogy ~d.llig:1m mBllgMg CmneSie Uwers,ilty ofH011Ig K.Orl!g· JP'm.oe of Will!es Ho.spl1ta] Sh@ltin

Hoog:Ko11g

Cmn<ill

r,..m. Be}] FReeR Conmanlt R&rnDEDgmS,1t Riitrno]ogy Dep<lli:imenlt MDms,1tOl!1. HO!spl1t~ Momsltofll. Swansea W.a1!es

UK.

Pageiv

.,~~~~. \...:'--~x::"-

(jn~lem~rn MedlrcaJJMern;]lj. Lilm£lted 137 E:1!l!srltan &oa:d

Lond.on.

NW'1.2AA.

Apm HOm.~y lu d~g for lliepmpoSJes ofr·eSJearrn or pm.ralte smdy, or 'criticism or review, ,i:iI:SpemI:Jit1h:dMdier ili;eUK Copyrig}\lt ][JieSJigns. ,~d jp:ll:itenrlts. Act 1988, iliItiispj[]bJffica1!ioF:lm1l!j' Flot.be w:epfochoedl" ssored, m 1tr~ed,many fOmJI or by any means, \vi!~0l!li1: tlJiepriorp erMscsiioo ill writillg .of 'ihe])ll]!bJ1isJl.ets.,. orm ilie ease ofmepmglfa:p11illc teproc:m:01t1on. omly m[jj)cootdmoe "viil:lh the :ite:l:l!HS of ~el&Oe1iroes ~sS:lIToo.by ilieOi!:ppi:opri<il:~elEtepmrnro1t1on :Rights. OrgrulliMim1l5 olliitside lOOe UK_ &qrnies oQ!Flc:~greplfornrc:1tiarn1J ontsmde ilie 1te:rnB8SJt1lL:itedl ]],eresJloIIil!dlbe :s:emt ~o lOOeplillib1llishers. at &e lOFldorn1J ;<iI!dJcheSlsprin1ted a'boC)i\.'le_

Thepl.!l!blli~efmHes Florept.es;oota1tiion, express Of .impJliedl, wi!ili.regardl to the :1IDCOlaI:<il:CY of the iiMofm:~l'tion. oon1tmoo. m t:lThiisboo:kud crumot acoept ;<my ]eglilr,es;porulmrlty orlli&biilllrlty for m1yerrors Of Om:lS810l'l!S: ilialma!}'bem1itde_

Page .... ·

,C OIU.te:nts,

CfuJaplbe:r 1

i'\n:a:lbomy:mdl 'fecfuMiqure RMEvam

3

4

6<

Chaplber2. S~ID)' H]1ll1d)s

lVJ1Jmdley

19

21

.21

.25

26

26

3.i

Chaplber3

The Th:vm:oid aad f:m:,;jJ:l:hvroiidis

, '~. ., ~

A TAhuja

37

37

39

43

46

48

49

50

511.

53

55

55

58

59

Cfu<i!p1ter 4- Lymph. Nodes R.UEvam

61

68

74

Cfu<i!p1tef :5

LmJl'psgd BmJl]J.8 m{i]e Bei!l:d.<md. Neck A .TAhuja

87

89

94

97

Wi

Cl1uap1ter6 The Lm:}'lWl: .E Loveday

W7

108

109

uo

Cl1uap1ter7

\Nllijl!E the SmgeOl!TIi Neem to Km:ow, :iiIl!J!d. \Vhy DWPat.t:on, K C Sil'l1est;er

lH

122

112

U7

Ch::ilplter S-

iF me- Needille Aspira1tiou Oil! GOlfe Biopsy? NJ A Cozens, L Berman

131

Chapter 9'

Cam1tiidlOimd Ve:l1eJbrali. U]tr@so~oy.apihy S No, C lYe,tri~eli

147

153

153

fu1:d!ex

167

C ontr.ibutors

Anjill, 'f ,MiuW<1ll!vmBS (Bom) ~, (Bom) meR iF~CR lIFHKANll

Associate jp\[O£essor.

Uepl1l:litm;e:rJt of Di!1iI!g:I]osilllc Rad!i!o:bgy aad Org[JfJJ kIlliaiging

CI1imese UMrie:!"Sil[y of HO!l1Jg Kong jp'rmoe of Wailles HO::1p1!-tlil

S~a1t:iillJJ, HOlThg Kong

Glm1ilJ,

Laereaee Berm[M1JJ, ilFRef' FRCR

CQmim~imt R~dID]ogiist lJ5c:mre:r/BO!l1JOf,ill)' CQmim~iIDt U~eFsjJ1t}, BeparfimetJt of R[lJ;rnomogy

AdJdJerilhrook!e'5 Haspi~ N""HS Tmst

HiJs Road

CWliJ!bridge

:i!v'irnad Jamesos Br,ildlliey i!v.m, HeH i1FRCR C(M'l!s.lllil~oot R~dliio;]ogiSt6U1idl Hooo~m:y SemOf G1!e!c<i!i] Ledtm:a

XjEt~lynepm1lNeJflt

Nortlh Bris.tol TmLS,TI

SOll!IJ1mead. HDS~

Wesf'bmy-oNJ,- Trym

Bmto]' UK,

Neill, Cozens. D~ JFRCR CQmim~Mt R~dID]ogiis1i

Berbywe Royall ~ruy 1\I11S TmsTI Derby, UK,

ID1.o00. M EvMIiS :ME, BCh, FRClR. Coo9lJilllt:mt RadID.ologiist

Ra;rno]ogy DepiM.'tmen[

Morris~on Hospi!1ta:]

,~1orr:is;ton" Swansea

W,omilles,iUK.,

S~e1lli11l S Y Ho 1vlOP'mI RDMS RVT S,em!Of ROl!rnograp:her

Depill.1tJiJLLe!I1J1i ofDiagIToSttl1c: Radli:obgy Mdl Organ ]magmg CI1imese Um.r;erSil[y of HO!l1Jg Kong

jp'rmoe of Wailles Hosp~1t1iI,

Sfllia1tiwJl!, Hong Kong

Clm1ilJ

Eric- l-ovedac"i..'

".{

CQmim~Mt R~dliid]ogiist

X R&yDepID'ttla.en1i SOlillillimea:d Hosp,ita] WeSJtbmy-on-T[}m Bris1to~ D"lC.

C Me1tI:ewdi.,]FRCR iFRCfl

jp[oThes:s,Of.Mldi. CfuJaM.mml

Uepli!l:l1tm:enI. of Dia:g:I]ostic Rad!i!o:Iogy ::mdGrgm. ]maging Cl1IiiI1eSle Uruv.ersiry of Hong KcOfig

"uoe of W<lilles: Hospi!1ta]

S~~, Boog ~ONJg

D1iIwd Willilli!;m]J. jp:1ID1tIDO:IJI. ro FDS FlRCS Consm'E;mtOrallandl Mdofa:cialJ 8m,goon Dep,litI1!m;ent ofOrali.iirn:.dI. Mdaf<il:ciid Sm-gel)' Mo~1ion Hosp~1ta:ll

Momls;1irul" SW<iIEI!SieiiIL

W;~es" i[JK

Kelt]] Cllli~des S~es1ter NillBS (I.'rnldl) BDS (I.'rnldl) FDS Res .~g)FRCS (Edi)

Coru,lllil~ootOr;8liI.H.dl F:[lJ;ci~ Smgleon

Uepii!l:l1tm:ent of Or§:]. ;omdi. Muofl1ciall Sm,gery MomsIon Ho.s:;pitail.

Moms;~on" Swaasea

\Vailles, UK.

Intrn duetien

'Ve h§!;Vle iliepffiiille,ge of wor11cingMdI. m,-mg dJrnrIDg <1I.1tiim:e oflimpreoedJentred. tedIDo]ogica:ll. aWruloes ill ,dlii<il!g:I1iostic medicine_ 'fills a;ow meMS ili:§t for .~ onedliiat.g:l'los1tl!cPHyMe:m we ~,jl!:'i,~~ot omy .}][ilveonemeiliod. of oo~gbll~mi:lliJJyme1hodls .i:ilLv.d);iMe 1!OllJ!S_ Wi5euSie of ilie YrulOlillS ltedIDo]ogies clictMes :!hat 1tfue most nOrnillJaWe,£eas,t fu!mTI!llfuill,most ei§iSJ!l~~<ilLvaiilla'b]eMdl1Ieast expe:l1i~e tred:miquxes :sli:omd.be e:1'I1Ipbyedimst

Wiili. ilie:m:Wa]. of CT ,. ~, ·l!lmltrMomdi.Md. fll.!illderu- merncme in merncO]] .. OO<ligIDg, ili new era. of dtiiiilg:l1iQsticudJenltmdllil1g of the he:ad.Md l1ec:k iIl:&S f]!oW'el:·ed

J!n 'lhesolFlI 1!l!s5lITeS of ilie .l1edk:,mlimY of 1the ,m~osticp~X)iJb.]ems iliiiltpreSJent lto 1the cllitmci<ilfl. canbemill1:<ligied \w1thm~aJJ ,efficiMCYl!l!sIDgrntri[fiOl!IDdL Sm-prisiinJg1~., despite 1thepiiooeeri:liJJg of neck.wtriiill50md by iBnmettol1.<iIf!I!di. Solibii1lilli, ii§[ ~iifge nIleher of neck. ex::m1il1[jlti!o~s are s:1tiill].hemgpffiDrmedl1!]!si!r:lg fll!l!clem mewcDe,. C'F :mJ!d ~_ OlJ!e nllight lwiilVie tI1ol!JigM iliillili flecklllilltriiISJol!l!n1dwowd ~e .m. ThJ:oSpllta1!s: m. whim. Gfill1dlpilrtiicllll1!arlY, NOO :a!·e li]Qtr.ea;CMy i<ilLvIDll<ifMe_. M&s, i1tS!eenJ!siliOlt IDOSit ,dilliici;rn;s wo1.!1!l!di.prefer to let 1tfucirpa1ti~ts. WmiliSie\i\eEiiIiI w,eeks for ThOOmldl. '!he:l1i. ll()t~et iOJ! S:atisf@ldorymsw'BI",raflher 'lhoo o!b1tm .. 1llJI.'lllillItr'Mol.!1fldi.s:c;m.q;lliick1o/ HOm. a.1lmo\v]edg~b]eproID'e8sio:l1!ali.1illd. h§:;V'e .iMli. aocma~e i;mSWefSiOOner_

There are severa] t'e;ll:ES on. D<iI!giElg of ilie Ewe<il!d amdi.neckI,llbnE lOOeSie :<iI:lfepredJom:an!tliy Cl' .<md ~ oriefllta:~ed_Ap.art H·om. dhaptrers m. SoIDbliaEi. MOl. llizz;jj:1t1to"s. boolk} iliere ~s: "\f.ery .1li1t1tl!ehdpfull ooor.ma:1tl!oo. ~o .en[i[b]e '!he f<il:dilloillogiist ill> i[jj[b1!]!sy general hospir1t;irll ~o ccme lin grips v.'lith.lIlilltriliSiOoodi. of ilie heiildli!l:l1d1 fleck_ Ths ~s1iIDfOl-m:1:ll.1a~e- Climte<ilP,mH.om ilie1iJ!slIJ!ali. \V,el!I.-UOWll. a:wOMlt<ilg,es oflllilittr<MiOl.!1fld in the fueadmd.l1:eck, it isre:m1ll."ka:lblIy11ocmate .Mdl e1ID5J!ef to .:app~y ~m CT ,and. NllU_

Tms. book ilierefOfe~s. ~o ::fiilliI. iliat g:1lp_. The Itext is. mWe:lli.d.ed.i§iS.~pr.iilc1tl!ca1l.grndJeand. bem.rn book; n is tobe :I1;oped ~<lI!ll i~ will. ·enDomi<ilgeMYOlle \wlttl1! fiI. reaso:l1!<l'ble .kI1owledJge ofl!l!lJtrasJol.!md tOp1cli:::. up '!he (appropriate ,!) li:l:'ansrnroefiMl:di. stmSic~g Iili:e neckclIecwe1ym'l:her 1tllli1ll1 siimp:1Y'ge] spreaemg'_ lt is m~end!ed Ito bdp 'lher·ea;d!er It.obe able lto ul:[ild1J<li.11illSiefuru]. Op6oo ill '90'% of theproMe:ms tl\i:ilt arise m da:iillyplf.ac1tioe_ The tel1lJ<~g l '0% \\i1!lI ~iitVie trobe ]e.m1It »omperSiOl1'a:] .~pmenoe <illdgreOl:lter m-de;p1illl re<lid!IDg_ By the jp'Oll[·edopmcip]e, E[ymg tro OOVle:Ji" ili1lt 10% wo1!1illd.pfi()ibablY qil!]l~dlrnp]e :l:fue~e of;ttbjs 'hoo~., so do l!1!ot expeot tlilllS book to lTh,iEve t11eusw.er to ev~g_

B esiidJes olililirlillil1g t,aritnes we :h1l:ve .;!ISioiil::voidedmytths-fLo.Sie;:meotroWil'Ji\l:clhi' 1tlliat.kleep teappe:aring m.ltex1tbooksa:l1:di. 'ex~a:fu!0ns but. wmoh one .ne"ilie;l: sees inmI. diiilliyprao1tioe_

TheboO:k oont~s ~e SiOrt of wOfmatiof:l. ili1il:1!: we '!Mis.}] we oolllilldJ. l]"ilIvie l],<lid whem.. we stmed.l;1leckSJc~g wOO years ago_ MlITcl!. of '!he i!rno:lD1a!tUon is §:;v:ml!;[Jbille m.li:l\i:e l!ilterau·e but is :S:C<il.tler·ed!_ Her,e the most uSJefiut]. wormafu!on_ ~sg"<il:th,er.ed to~et]weribypoopille who <iLOm~ySicafl;. the 'Th;1tJter -laud' h<il!S 1tfuerefo!l:e beoo. w,eeded. ont

jp~.BiDe fl;o.~e that &lis. boO:k is mtremlied. for '!hose Who wilill adill!dy sean. n depends on i1ll1 mil!e:r.aoWe appm<IDcJ]_ lt. is flot'meant :IDor Iili:e CjpR. (ooUlCih.potatro :l:"iil:wologJist) who slltsbiilc:k<lll!d. meES otlielfS :penorm the ·SJcamI. ia:l1d. tlloo. 'repoo:s:1!:he ~r" _ W.eSitronglYheThieVie 1i:hat IihlJs is flOlt the way ltoprilofu!oemk<ilOOlilllld. W eare also strong beThie\'iefsm 1t'I1e opmOOJ iliat (good~1!l!1kmol!md is llot'operatror d!epe11!d!enf', all ]eOliSl no more SiQ ilirulJ.'N.][R][, CT Of, {or iliatmatle:r, smge:ry mpa'lho]ogy _ The d11iim. iliatmMMOml:d is .operator dfllend!ent is mere1JYiil. feeble meofdJefenoefor CjpRs Who :arem1~g tor.olJl·up '!heir sIJeevesiill1l!d. ]eiID'l bow to do ilie jolbproper]y'r

lIF'or 1tfuyroiid nodl!l!l!e:s,. we CH now malbe i[jj[rnarg:l1oSJIs 'i.-vlhl\lwumol!rn:dl1tllli1l1! C1rnJ Ibemoref!ei~b]e &1iL1iJJ.me-flee:dllie[fiptralli~. c)1oDogy (lFNAC) md.rMmore 'l!]s.ernJi. tIlli<lll!.scin1il!graphy., whim. smpris.mg1~ ~S sti1il. mentiCWlOO. in tl]e texts as

Page Kii

Wi'lh. m:.ecik: ]ymphm:odles we C;]Il1I!. llliOW '~e thcirV.MGI]illiMi1ty, 'I1:ot Druly wi'l:lh CQi]o.low aI1!dpower il)oppillerbl!lJtmo wir[!]. 3D'i,~omemCm:I!a;]ys.B_ The detd. &~tt canbe seea m lo/mpfll1:odJesis sllillperim to ;<mdlmofe c1iru)c.~~ l!lJS!ffiJ!lI.1!han.thil:tt oh1tam:ed.'by ei!~e:1f Cl' Of~_

The cl1;ai:&c~eriS<iltioN!Md EocmIDS;l,iItioN! of sdvmy .g]Md rumoms: ~s simpDeMd easy WJi1i:hDnt ilie need. ~o mffiect oontrMJt or cruwiulilla~e ilie dl!l:c:ts_ Even '1:lhose m¥s:lteriom. Wp,s .1ll1dlbrumps t1hiil1t do El!oll.S!eeJilil. ~oJb.el!OFl!g to tile ,expededl orgi1ID5pevea] 1!hdr secrets tolililltr:,Molil!lil!dL

:m Nruwy cases oee is ;~b]e :Ito .rnmlbe ill coNIidioot db!~oSJ!s before lFN.AcC or hi81tO;]ogy,hl!]t ill tltoSie cases where :lhis~ rus. s1tiiml. mrncia:ltedl.1ll'l1kMomdrus. tlJre

" .. ~. ..;,1\._~ e _,1\." ~".;I';_. ,,1\.. .;I,~ ..1\...' . iIil . ..,.1!..;,·". "d1.;l1 jIIi' -N-A'" . _,11,,1\.··1\. "1\. . ~. . . Th" . ,1\. 11~ 1\.

:ttm<ilgt!l1l!g ~eQ:liIl!JJq;l.ITe Oll ,0101.Oe m. gJilliUILI~gllil!fe N!eewe to lis l!J'eSI mget_ Jr:""y<ll1t:rOOglllill' ,eU!. 1E' .. '. .' as N!ot O]]!lj 1!J'ai:l!J'iYfCI!J'l!lJ1t m[j[ccmatte __ I eose W][O .rurOW UOW

,mcW!: itt I!s 1togJilldle ;[j([llllieedilie .m1to[j([ "ltMge1tOOdier oo-eott -viruaJi oon1tiro]'!,'i,iill.uow wh¥ ltN,e b_d. ~PlfIO@!d11!s mjjJ;ocm-alte_ Ji1!l. 1tne8le &ys "bhd'biopsy "~edmiiql!rti'ml!J!stSiJ.llt[elYmeru:l.'b_d. ~o1tfu:e hene&i~s O!f .gmid!edbiop.sy'_

Lest ilierernJdJe:r COI!1!sidJer ~s book ~OO d!og1!Datic" we<1pp'fecia~e ilirnt ~ereru:;e ~5>1tiillI. ID:aJj:Of CONJltfovietsXes to sort O'llltr,MdJ.d)[fferent oenkes ~aI\'ie v,~g :sttr.engllihs <iLl1d. tllereioredillTerentappro[j[rnes t.omagl'lioSiful.c mallrnJg'eJiliIoo1t _~ isbest eXiemp,J!wedlby ;jhe dhap1ter de~g vri1th1h1:opsy ~eclmi.ql!J!es which voices 1tfue ,diillIeremll ;iilpPf0110hes th<il1t c1lliI.bel!J!sedi.m the l1e1ilidMd aeck.

Despite ~ts ml!1!lJtrip.DernuiliDfship 1Jhiisbook ~§lS a. $eeJ:ing of OOmIlIDof:l.p1!1mpoSJemdi ] wo1!1!lJd Jlile ~o iliIDl, '!,\:ri!1!:h oonsiidJerab]epriidJe,.iliiilll. 1tl1iis ~s. iliefeS'l!1!lJI: of ,iij; OOliIlWOO. origin fOlfse¥eralJ of :ihe:aJl!lJ1illors_ lRhodri. iEv,1llJ!5,~e lBrad!ljeyW1:d Eric Lovecillay hillLVie :d.pas8ed. WOl!JJgh. my depar1tm.ent m. tile Cmne&e UlWeJr,siiry of Hoog Kong at 1tfue 'lmOe of '~.irles HospiiltiiiJI_ ]t: was here ~alt they ]eiilTIlt ilie .imTh1!1tiirn:ll :sJk:illills1ll1:d h<ilLvebe;oo.<lb]e ~orlt.e ~eSie brndk: ~o ElI][ope 0: belllieve 'lhlltBri1tam is oOFl!sidered,. by some, EO be part ofEm:ope in. aperipher;1llI.sort ofwa~'!I) and. to deve]op 1tll:e:rnfmflllier_

Most of theial!]ilholf:S .h<ilLve triJil!J!ght at the Morris:lto!ll He1IDd::wd!. Neck Uilihiil!Slol!l!t1d Workshops_ As: ltN,e Momston eourse eyo~ed, itthocame d,em lIhEil:E lliere .I!s ;<iIllfe1il1l 'I1:eed.£OfillL co-ordloo<il~edl. ;[jIppro<il'rn. ~o the .heiil!d1illdl neck. 'Thills :ltex1tsillio1ffiilid .• :ruJI.1tfu!<ilt need, Tfue 5pec1tnlllll1l!Ji. of 1tOp'~.c:.:.S.dill8cllsSied.sho.mdp'foviid!e ~e fleoess:arybackgmmdfof ,~ones;trru::tri!:lg owt mhern:dru1:d. necl:1i!1!lJtrMOl!l!fHi

The Morrist,.on. OOl.!lfl:Sle has lJiOlt.SJO far not:. mcmdJed. <li. ,Sleccttron on. cmottiditmdi.\,'imehmJ!.uaillfu;,asolil!lil!dlI'Dlopp]er.; howeViel:, it was:re!l~ ~a1t thJ!s is ;1m! eSi:>enfulaJJ oompO!n1oott of neckm1tr,illiSiOIl!l!lld1lldi. F!<iIiS thereE:m:ebeefl.1ilidded_ The SiOrn'l!O]ogiiSt Dr :SiOmDgrapher w}llio deaJis, '!,'!,:riri:fu the fueadmd! n1:eck mIDllstlhe oOMpe1teFli1t. Fl!ot o~ mgreY-Sic<rl!em1trooom1d.l1}1!l!t oalow Il!oW1mdJ.pllills:ed. BoppFer as wellli. m 'lfte fleck. we b<il\!ie ilie oppo:l1iiID1Jty of1!J!mg every new :lteclmiique that the mW;lli<cJI!I!n1!d dJes;iigners 'cru:lgEv.el!lJ5!~

It isgratti}riJn'I!g to ]e1itm. th<illt the ElI][opeiim ASS10ci<ll1tfoo. nf Radllio]ogy h1ll5 nowrecognised :I1e1ilidMd llledk: oo<llgmg as .i1iI. sl!I!bspeciiil!1'tym. lts D"~. right, ;~ongsid!e SlITciI. dd!er womes as nem,ora'.rno]ogy 'Mdpa:edi!amcradio]ogy_

Ths 1bext is ilieresmt OKi:iI. tJeam. dfoll_'\.Ve iliae$oreS<lY ";jhm yOM;~O tlhe tJeam_ We wouilldp.M1t!olilll!ru-l~' llillliJe to ilim'jProf M; Jor giv-mg1!J!sboili. Ole oppo'l1l!miJ1ty 1bo deve1)op om .m~aest ill l1eOl!dMdI. neckM!lIltr,[tiomdL We aliso owe ,ElL large debt ofgraltiim:d!e 1bo om oolilletilguresllldl SEm of omresp eCIDrre hospi1t~5" l1I'ruE;e]ly:: The JP'Moe of W~e5 Hospi1t~, ShiilM,. Hoog Kco'l'lg; Momston. Hospi1t;m]i" SWMSe1ID.Md. Neiilili. Gel1ier<i!ll. H05pi1t~ lor ilieil:gel1iefoUS ~llpport,l!itot_ilust iIl1 the r"vriliIDgarJ!oJ ,e~g of ~ 1bextbl!JJtMOMrn 1ihe OlfEi<i!liJ,iLsirl1lg.mdJ.~g of ~eMrn-risJ~on.WlOtkskops_

On.<i!J. morepersMa!li. ]evd. wem1!J!s,t <i'C!uO'I.v]edge the dOSJe sllP'port. ;;md fuclp]:J.fOviided:Oy omf<m!1iilli:es_ jF"Of . .lUM'I.1tl];iS ~s"mpru1ticwm., his "WIDe Cl1uru. W;;ai Po, ms m01J1e:r and. ms ]iil1be failie:r. O!l1i iIUlooo.'spm. _iOio]c}\);. ynm\;w i Lynee, Ca:trm, lB e1tfl:u. ,<ill G\V}'EJ!' _

AN1L AND RHOnlEU

1-,

An,ato:DlY and. T1echnique

E~qlllpmemd a:u,d, l' eC]l:wque Anatom.y: Introdndlon U.krasJOililld An,a,tomy

P.age3

'Ov-;er 1ili:e :P<illSll ID.VO d!erndies,.r,apidi smd!es mlllllitr.§lSiol!m!cl (US) tecmo]Dgyimd mpa:rtiicm<ll ~e de\iiel!opment .of lTh1!.g]1J. f,esorurttiiO:l1! US h2lVie led ~o <lJ.greEiLlte:rro]e :Worll.lill"ItI::&5D1!l!I1d m. ti1:e<ll!Ssess.nJient of ilie 'exltraCfaru<irl!. fieildtmd neck. The wcrea:sed. :spafuJa:l!.resomltion. <iJ!crne\iied.1hy ~e ]a~est gooer.illtioo 'ofmil.rnm:esal1d kiilil1lsrnroe:rsa:ll!ows exoeE!eflt neiilill :frdd.meS!OimtiO>11J. '\Vl1en. one oo~d.ers, 1!h@t iliem~jiDrirjty of s,1tI:l.!JJc1tm"es and <ilISSiodartted. p.m:I1!o]ogy m tfue :!leek llUe om¥ bemeeJ!l. oneud fuie oooTIlne1tres bel!ow 1tl1:e ~. sm:£1IDoe,Mdl.gYefI. ilie S;1mperfor resoimtion that fuJigllli.resom!J!ltron US ean i!1~ it ~s nDtsm-prismg thrnt US ~s E'i(Ji;nmg mpDplflillmrtty .Im. tlle IilleIid ofhe<iLd.ru'I!d neck E<iI!gmg .. As it ~srd<il:mdymexpen~,e (m Radliomogy lteml1!5) ;ru<d ~ :rlea~ ,llIvd2lb£e.,. liIe1lJ!SJe of US- \V1iiIill lConwMe Ito mcre2ls.e.

One crilticism. of US ~s that ~t is "operator dependent'. WMe ~ere em he El!O argmnel1t ,.,,~ili iliat :s.1talte:l'llJ:ent, it is not 1:11. cri1ticism.1illIrnt~s m<1l:de of oilier iilnaging 1te~qll:es" wihicll.ill,e ,eq1'J!dri operaltor d.epeJ1:d~t W,eilooeplt tll[jjjt· c}'lto]ogy ~s: Ooperaltor dependent we .blOW Iillat slmrgery .~ operaltDr dependiel1t,SiD why is'operaltor depelllidelThf a. crilticism. iliat is OOOWlllrn:lll}, heOlJfdl w'llen US is .diis.'C1'J!Sis;edi? Most me.dlUcEe 1S operatoe dependent m O:I1eForm. or oilier.; the ml}1:h :!hat US ~s mor,e'qpera.1tor depell:denf th:m. olher tedniquess:fuolillilld he ]OJidi torest.lff one is ,enthJ!]SJi@!SlticMd wiiIilli:ng to ~eam,t11;e ]e~g cmve ill US is FlD .s.lteep'ef "!hillJj. ~a1tillllim<wgn5ticreSi~1iIl1I!oeE<iI!giilliug ~" OOmpl!]iltedl ~Dmogra;phy (eT), or i1ftly oilierbmncll. OhiiLd1!olDgy.

Thelk!ey lio IDl.wdersltiMllidmg OK ilie ned!::,1iI'5 ill d. oilier areas of iHIDQli:O]Ogy, is a.SlDmd.l\:now]edge IQf IDlJa~omry. The .illrnJ of 1tI\u1s rnaplter is~oprovi)dle ilim know]edge as at basis for ·1mdJe:rS.1tru1dliwlg1!1!lJ1trrlliomd of ~e neck.

A slt1i'lte-of':'~e-m l1ligh.r,esomnon USma.c.lillrne is .d!emab]e bot not ,esseE1tiiaJi .. A dediicalted.lulgh.reSto'mtron. USmilcrune .is. ,1iI' mmy:WDr mosft or ~Ds.e who work mbJ!]sy US depm.tm:en1ts; howe'ilie:J[, mo.strepult<1l.bEemml~ctio1Ji m<iLcMles m:ow hatV'e s.lillifficienll hlignre50mtllolFl! lllimd\ville,SiofuvmeiIDdJprdbes Ito ,allliDwadeq1lJ!1ll!e ,ex~llfllon IQf ~e l1:e1iLdud neck. A bear 7.5-101 Rv.l[Hzpm:be wiil:h. @H:!llaltweJlysmallll. ''fODtprint, ie. a s.m§J!l. ooo1t<1l:ct is;m:Ea\Oe area, is Oop_&]. IF:Iigher Y,eqllJ!oocyprOlbes:, i.'e. loIJI i!v.IiHz<lll:d .rni!b{);\ile, dow :SJaPeriorfJeStorufulo:IJI.for :SJaPemciaJi :snc'lh!liresibnu 1i:l];er'e is .iiI. tradJe-oif iI1J. ]liI:ck. of deplth. pene1tl:a1tloll1. Be ;iil.wru:e iliat a.prDbe OK ItOD Jillillgfu @»eq1ITency, i.e. 1.1Ci'-13 il'clHz, CialiJ. ,de&lliltdybe ODl!]I1IlterpfOrnxcm~e when. ]e~g~fDr ilie beg:ltrnter, IDlJ apprecia1tiion. OK [he o\iierd.a11211tornry is m1!])c:h more easill~ dhltUtedJ!]smg ~Dw>e:rl&etpIToocypmbes. There ~s a. r,o]e :£00£ .5 &1Hzprohes in. assessiag deep ]eslblW cSllWOO. ,1lI!5 ilioSJe m 1tl\Le deep Dobe of iliepm:01tl!d. CoEom:lIlJow;fthl!cili1tiies are now :sltru.dMd. 'on mJiOSJ[ .mlild~mes;, udl. wmIJeprefer,<1I:Me :lheyme nDt neoess~ esS!en~alI. ThehegI:Mer \viiIill.Md itt easier ~opid: out 1tlb:e ·v~c1!J!ll<iLrMaltomy of tfue ~ed:.1!]!smg ODb.!lIl:" nDW, bUIt ~ere ,."vi1IiIhe less: dependienoe osee :1famiim"ly ~th&e ana1tDmy :hasheen. <il:1tE~ed_ JP'owerlIl!ow ~p]iCi\l.fu!oosar,e desirable for assessieg ]]!owpafie:l"l!JiS, fDr '~3miIp]e ill ]ymp,fu. nodes <mdl :ili}'f()~d nDrnies. The begim:ermiilty be de1be:rred.from GaH}.ng out ;<iIlmopsym, tile .heiitd1il:l1dl neck .if 100]0« EagiiFJJg is regmID:'l¥1!J!sed. MMY head.mdl. l1:eck IDiIlIlo_s<ilf:ld.lJymph nodes fu,:~I!:'i!ie spedac1!l!l!ar oDlomlIJ!owlD'e1iImes:bl!1~ oorebiopsY1illld.fine-~eedille<1liS1piirationbiiopsy (JFNAB) C<ll1I.SJ1!:illill. be smelly carriedl o1tl!ItT

One eSSien1tl1al1. pieoe ,af e~menlt is. .i:1I. rugll q1!J!a:lIirlry, ad~stllb]e oodmo1b1ille taMe. ~t is irnzpocltMt iliat :fOf US ,and US .~.dled.pmoedim:es m 'ilie fleck, 1tfle ,e;:;~er.is ·oormforEaMe. Amo<1b:iille ~aMe that canbe ,e;msj[iy posi1ti:ooeds.o1!hrnt tfuepa:tien1i's l1:eok is ]evd \viltth.IDe USmooiwm: ;Md \VJ!~:!he Gperaltors sc~gr<mge ~s eSSJentnaJLMDst operaltors md ilie most ooWortaMepDcsiittioo to be, one m w~ch. ffuepafllffit's neck lis ]evel] Vlirl:h.1OOe~er"s thillgh or bees .. Wltel1i. ~g ouubiopsy ~edWg;lWes: the Dperaltor .l!iI!11!J!stbe pDsittruoned. SiD ~<ilt 1the mcft1tor c1iI:liI.be wewed oomfoftrn:b]y ~rlhol]tmooe s,ltr,etcimg or twiis1tIDg. A IDOl'I!l!ltor Dlil.<iIl IDMOel!IDvmJbEe .;mr]J. is ideorlL ThepiiLMen1i's ,neck. 'slli:ouilld he :51ilIfficien1t1y close SiD ilialtboth. t11:e .hMdl }1o]d!iing 1tI1epfOlbeud.1tI1e TI:<M<d [I1olc:lli!l'JJgilie needrue mmopsy .gml!.orr.e in ar,e!l!m!!edpo5litiofl, agUil \viiI:1lol!J!tmooeSJtretclMing Oor ti.v1500g. Thepmlbe, needile, moWl:O:I"Mdp1l:1!l)ml shomdbe in i<ill ugh! or a:CU"IDe nel!d ofv:iew r()iD: op~<irl!.posi"l:iomng. C060rt. of Dp e:raltormd.pafulent ,."viililll',ernmeprOoM.eJOOs \vfu:en fi",ee-hmd.1biopsies <H,epeiformedl.m1!d!er re§].-m:ne US iQonltml.WhlI!e :l:fuJjsiilppears to be ~o mOore oommOil1l. sense, most OK :fuepmMems enwm1teredi.by1i:fueauiliOf \vhen.1teiitd1ir!iJ!gfree-ffil!Md biDPSy ltec.laruq1!])es are De topDorposi1t:ioomg QfboiliraJrno~og;ustMdpa1tiient.

Thepilfuiwt .sl1:ouailidbeposirtiooed ,."villi ili.e .~.ed{. ,ex1t.endl.ed!,<iIlpillIDow hehmd. :!he .sl1:ouaili.ders and!. Fower neckliLfllowmg "lhepafulent to adopt at oonio!l1aMe

"" . ~1\. 11..·"".;;11 ,,1l- ~tL.. ~1\.. .;f", Th·1I.. .J=: .,./1' " • _;11.J1 11" ". " .. 1\. ......... 1\."": " - ~- ." . b11 " .. 1\..

]ToSl!1t!l:on.ma[ cru1l.iJe m<ll[l1i;1llllelli. fulllil.01LJ!5'i>!Ol!Jlit. me :smUj. Ilerem<1l:},!I.}e 'WI!illlGi!J!Itue.s m. ,d.i;uer,),pa1trents ""WILIW.tl1.I.lw.]tl!c fleLl'k.S 'OiI:"f,eSp1!l"attoryprOo' lel!llS;, liIiI. wes:e

P_e1'15 ilie 1tab]e .s.flolllilld. he adjiulS!1tecll1io 45 degrees and ,I§[pil!l!ow

Page.:!.

piliiaoedbd1:IDd. ilie sholtl!l!dJ.ers, ifp ossible, to 'el1J.i<l'bleSiome exltooston of &e neck. Thepa1tientt m<J!:Y bescanned m ;as.i1t1tIDgposiJltiOill wneoessary ,irlilio1!J!.@ assessment of!i:l\te ]ower I1JfJclk:.m2lybe oOm]J!I:"oDE!ed_

Thel!l!SJe Oflli geJI.Mook. ~s. somemnes reqm.ed, p<lrliclilillm-1}r .if one iSl1JofMes\s:ed ,."vi~ 1iI.prdbe ,."vi~i!lLsm:d. foo1tpril1t_ JiI1,ltegr;~ltedi. st.md-ofl'lJh1k:s are .no1t neoes;siiIrY _ :fu ornm "';a:l1Jgmillai' pnsiJltiol1is, SJIITch ,<1Ii5 '!he ,m::JJglJe of ilhe mMrnb]e ;;md sllpf<ilcl[jJJwo1!J!llar fos:si!IL ill ~1 fidliW&rniill1is, a.better image \viillI.be obtmed 1!lIsi:lg ;i!lLs:t1ill!d. ,rnfModL The <:Iil!]ilhoroodls ,§[ sf:lJ!d \9 CliJ:JJ).,ro1!J!l1idge1Jdrus:c (A~iaJ.j)ex geJJp[J)di,. iP:aJf~el' ]abom:ltories.,. USA) 1to be !i:l\tel1i1osts,a:Ells{@c1tOf}'_ iEt ~s washaMeilmidl1!l1sl!l!a1!lly ]<iI!S;ES for 4-6 weeks iin.a bl!iJlsy dep~ent Kone haliS <iI. hlIgh,fr,eq;l!iIIell!cypr,dbe ~'I:lh. ,<llsmalill.foo1tpnll'it, :lhe~pplli!ca1tiOlfl of iii. good cove:rmg of gel iS1!]s1!J!aJilly .s.llIIfficient for llieiil!SSJesSflloot of Ote mOSltSl1!]]JerliciiillJls1tll!l:cmres_

JEIigl\JJ n,e~U!ency (7_ 5-11() ~'Z),smiIlil fOOtprliilTh1tpfobe COI]Om- -El!ow .tm[J)girI;Ig

MiIDlliOelil!W:;IJb]e mm1bo;f

Mo:b1ille ad~sta'ble t.a:b]e

iPl1Iillow1!J!l1iderpa1tiffitis shomdlers

Gmmoctt is: v:it.~, for operaltor <m:d.pafuioot ,~e

Anatomy:

Inboduction

FigweU-

S:agitiaJ! section s.ho' .... -ing iliedivilsiions ·ofllie Illppefaef!odliigestirve tlrad_

P.age5

~ow~edge of ltlb:e ;iml1'1tomry of just 1hli.eemililJ!S!des.- :!he stenTI!odemdioffl<fuS,trncl, dlUg,&s,mcmdi. ()mo:fuyoiJd-rus ilie JilJey t01lilllldJerst<ID~g ilie m~gl!es of the :I1!eck_ The slten1odcidiomas.toid, wmch rnrI')!S -from. ~e m<ms.ltoiidi.proDess to lihe di<lliv-rdJeorn:d.s1ben1l1Jm,OOriides 1tl1:e neck. into two ~<ltI"ge manglJes;: <mlteno!l"<ll:ldi. 'P0s.ltmrn_

'li'I\.. ., " ", ",111 " .1\_ .;;II;' ":.;;11_.;;11 " '. '. , .:ill I :~£_ 1\.., "d' I ." Th '. ,_1\. ".~ . . "," &;, ..... 1\. ' . .;;11;'.';:.;;111 .;;III1\. . ,,1l,. ., '"11" _.t1'. 'f .;;I~.. " -,~

JL He ,mltenoill m<iffi&e.1!5 SlllLlUillVillUOUL mio :SJUlpnll- ,m.ll!.I!II!J!]J,E1I-u},or' . pomoil'ls_ .. 1 ne :s.npr"lLUYOlJU!. pomon l!SJlWI!.I~er U!]vI.ll!Btll ,ILlY !UJllie "ilfEite:l'1!Or' 'uooryj' 0/ 'rng<il!5IDC mlillSlwe

mlto Mle 51!l!1bmen1ta!li. ;<mdislllibmMd!bl!l!l!ar m1ll1Jg1!es_ The ilma:l1y,o&d.pm11iorll. is ,dlNiidled.1by ilie s;1mperrorbeJllr-r of :!:he omohy,o&d. musde m1io mllSlc1!J!liarmd, lG11[otrd mm1lg]es_ Theposlteriollfudily of dffigilSmc mrrrh thesilllpe;rlorborde:r of the ,cm:oillid. m<IDg]e_

Theposlterror m~gl!e. ~s de:llliilfC1illtBdby 1ihepas.lterrorbmder of sltenTI!.Dm<il!5ltrndi1lIDltmodYud, ilie<ilJ!1IDeri:O!f.border. of1trapeoos,postrerib!l:lly _ The apex ~5 :mom:led,by Mle OCcipll1t ...vUe 1ili:eb<ilt5e of tlteltriMgl!e is formed by 1tll:e d:mwcille_ The manglJe isfm::ilier 'sl!l!1brnvrdiedby ilie po&lterrorbelllY of ilie omoill1yord, mllSiGle, fo~g H. occipirlt;m:] mrulglJe ,SJLr]p,eriorl~ ;1ilI1d <]IL~:mpr<ld[itvicmlrr mrulglJefieriody_ Thed!Evl!smoEl. oK;!:he neckb}' the S1i!en'1DrniillSlOiid. OfienpOSle5 <iI. d~eJillIll[il. inmI. ilia1t a .. maslS deep Ito 1t'I1e Sl~enTI!omi!l:s.:1to&d is no!!: :Somctllym ilie afIlteriOf Of thepOiSoteriof mrulglJe" the pos.:1!eriofho!l"deJ! OK 's,1!enTDm~-

SterlllXllei!i:ll:Jmaskiidi -----+'I-!i\7+------4;lF;-!T'\: mU:$Cle

rngas~ric lII'lLlsdie

~~--<t1~

Omohyoid rIltlSdie

F~gIi1Ie 1.1-

Di .. ':is~o:l].o,fllie fled iIlto' 'tri~gJ!es' .. Theanrl:~of'mi1U'JJgfe ~s. (fiiv1jded!.mto W Sllibt:ile:ntai! (]}mbm:3lldi1!:m:1Jar, @ cat·\);fr:id! .and @ IfI:ll!ilsee1!lilarfuiiangles,_ Thepo,sftenolrtriangJie :lsdi'l1:ided! into';3,. riIDoocipita]. mal1Jgl!e andJm @ sil!:lprnclaVl!c1!1!llar."

Page 6

Theiilfficent 'Of C'f ,i:iI.li1dl l!vffiJ hfJiSmol!]lght:a:bol!l~<iI!,fe<llppfmal!,bYfarlJ)d]o~sts: of lOOeW1!1i~omy of tlhe 'e;ll:fur;jLCf,amaJJ:heiildi,1lI1d neck. Th.eml!lmttlp~W1!W: capilJb.iillifuies of 1\00 mpncl.!l!1lru: ,fuJ<I;;V1e e:I'l!:abled],iiiI, fM bene:!" apprecm1tiilll of ilie Oomp]ex'ilf):[il~omy of tlhillsmegloiI'l. The "spaces' OO:l1oept h<lliS beoo, her~d!ed as ilielbey to .fiIl beimerllillndler$t;m:dllll1lg of ilie ru'l!atoB'lI)' Mdi,pOl.ilid]ogy of tlle ~.eadM,di neck. Rrn:dlid]ogiis1ts, ID,pru1iolill!l!:ar Hrul1iS:berger,3"';§ b<ilVie deV'eJ)oped .a dernIruld,pr<lc1ticaill m~od, ofusmg 1tlb:e spaces Goooept to irula;]yseThtmd Hal nec;k,p<lIiliology (Figm-'es: 1.3, D.. 4). Ahov·e tllJe:l\iyoidi1bone lthe sprn:oes concept works: welil,md 1b1:ow]ed~e of ilieslI]])mfu!}'ord&p.iiloes aidsassessarest r"villi,ml.iltrasiOwd, ,hOWeVief 1fhe same is not De wfien,rn:sSJeSJs.mg ilie nr..mryoiidineck.

C<lrotid spooe

f't~ilryng~~1 ' ~uco!O:ill! 5IP~C(l

iu:iia], se;ctiion depicting ilie 9b-igEiive' sp3!c'es ,ofllie nook, i.e., p~a]Jha:ry"l1lgea] sp:aDe (n,di)., parotid! s.p,ace ('IJitMe), C3f,\CI,fu:di, s:p,aml" filas,ttcat@f' sp,a,ce (fuo'WTI),. and pha:tyngea:l! IfIll!illD@s:a1\sp\ac8;.

Mar;.,it.a:lor 5paD31

1~1ig !!)P~OII

-.40/-- Sutlo!n8nditJuiar· space

Ff~e 1..4--,

CO:l"Of!IJa]. seocti~m.sho,,,,;jng ilie.majio:l" spaces.,. No1i:e ilie Cfaniia1"caM.dla]. ehief!lJsionofiliepru-apharynge"a1i aad mas1li:c:atol!" sp,aces . N~Mle alse ili,e, cOfl:l:Il:lmcatimll be'P;vee~ ilie ,p,~aphaFYTlgeaJ!;rn;d s1!Itmandf'l:m1l~ spaees,

"W1lliere do ill start?' iis ,@f1ll1Lliillliarp]eOll whoo atltelNpoog1Llilltr@SJomdi. of ilhe beiilidal1:d. ~.eck. :lit ~S es~~1tiiaJI. ~o b<ilVie an. e~lyrep]ica:ted sysltemml:1tl!csfur.&'l:egy:IDol: '!:he ,e)!;ruilil~1!ation. of ~e ,ex1tl::ocraruia'l l1ead and. neck. 'I'hisdows key :~1!!I1J:c1tmes, Itolbe rdientmedMd. efl~lb]es .atS:&es.smel'1I of 1tlTI:e whoDe neck The .~ of thlis chapter .~5 1topresioo1! a.s.trmegy ilia1! mJ)ows 'iheSiolll!og:l:aphe:l" or md:i!o]oglst to qrucl\clly <M1!d ·sys1temil1tIca:lll.ly ,ex;~e 1tfu:e fleck.

Page']

Thebm:d.ers >of lOOes1!limnen1ta]. m1mglleme eMiThY demedi. (lm:JJ ·mtrmolllil1:di_ The El!.oor ~ :Formedl.by themy~ol1r-:r"oidml!1LSicl!e,.1lI1d. thea:pex of the mMg]eby the :sym;p~sis .men1tiis, the base .of. &.e m::mg]ebemgIDormoo. by 1he hryol1d bone_ Thei'm~erim:bel!l~ of ilie m§<il®mGmI!J!Slcl!e5r,epre~e:I"It t:he :smd!es of t:he miil1l!glle_ These cMI.be folillowed down. m trmsve:l:seSJectioo. !to Iili:e furyomd_ The o:l1!l.ly oootem:JJ1i's Oif llo~ene theslliI!1bmoo1taJJ ~h node gro1!IDp_

The geruOgl!osSiIiliS Md. geWofulJ'oid~llSdes form. ilieroot of the tonguJ!e_ T.ogetther wi1th. iliehyoglhsSil!lLs mlilisde they malbe .Mp the mrnej:olf extrimic ml!JlSJdes of :!he !toogru:e_ Them~l]oilhry.ol1dml!J!sde ~s.s}'Nic:m:ymol!l!s \VJ!ili.1heflJom: OfmCFIJJtfl, fo~g :<iI.ml!l!scw1lJfsllliilgbe1b.v'flie:l'l. the .mernaJJ :~ed of IDem<rndhlbwm- bomes_ lP'asteriodty iliemy£OIfuylOJid fuJas, OlJ.free ~ck. hmdJer :;md is 1!:hiooer<m~eriiml5t where it is attached. to ilie .m1terior m~dti!b]e .mor Ito ilie ori~s .of ~e gem<irll mlllsicles (gemogl!o8sI!illSMd.geNoThJ.rylOJid). TheMilteriorportrc:m . .of ltfue .my]ohry.ol1d 'C&I'I be dITfficm~ 1to de:IDl»Is1tl::a~e,mdJ mSiOme m1talThoes ir1! ~s deffiicient :iiill.rtteriorl~' _

The1lfirlgI!l!<I1l may CM. be e1liS.i!l1y pickedJ .1!l!p1illJs.mg ooIo_ illJ!ow itrnJ~g,mdi is a.lfe&m1}rreoogmSJedJ F<mdlrn,nk_ n~sjinillst mern<I1l. to ~e :I1YOgi'O-SISIiliS ml!illsde_ Di[erel1lfui~oobemreel'l.1the ·rntryIOi!b,yoidMd. furyoglo.S<slilismIiliSic1!es caffiI.heal1dfidi.bysl~g m 1ihe oOlfOllla:lJp~Me, whiille :~g 1i:lTI:epa1ti!el1IE !tomO'i1if: the ~ongL!lle from :side ltoSJidJe_ The mryillo;l\tryo~d~sf!eJl<il1t:ivd¥ .iimmo1b1ille wmlle ilie lThYOgDOS81]JS is idru1tIDled[ <lI!cltivelly OOOIT<lI!c1!::iing (see JF'lgm:el_61b, c)_Contractruoil1!. of 1t11:e fuyog1!O!ssl!Jls ml!J!sdediepresses the 1t000gJJ!e_ L:alter.a:ll. to tlte hyogJlossl!l!s, ~e s1!l!1bmMdulbmru: ;(]ud Glilbe iidienlliiied./,.partlolllillm'lly if ilt is dlilllaltedi. (see JFigm:e :t6d)_ Tai'e care .iI1!olt Ito oDl1fl:J!s;e ~e .ooclt 'Wiith. ilie .lllingJiillaJI. Vlei:rJJ Vimm silts ruolllg:s.iidie 1hepmm~. sl!l!bmaFl!cJlJI1bmiliam- diad; oo]om-fl!ow oo[jl~gl!]s:l!illaltlly lidmltiifies the veW:!_ TheSI!l!'lbmlimidlbiill;u dl!il:ot ~sS:Mdf",richedi. 'ioviil:lh. :!the :sil!l!bllillgEJ'al.g1iMdhenveen the byog]osSil!]S :Mdilill!)']ohY1oiidi mliliSides_ It llies jJ!st Silil]Jerior :Md ]atera] 'Ito the mgJrn<itl.mery.,.whid-!. canbe ~defl1!iIffiiedi mema] ~o the hyog]ossWlsml!J!sdle (iFig 1l._6b).

The s:J.!]ib_gJlJla:ll gl!mdl is~ rudJen1tIDed . .on. U,aJlJiS\iyerSie or :aOO;<1!!I.SiOOfuJOmlatS. :an. donga:lted .. lli!yper,echorc: :SJ1tI:l!J:crnr,e,. l!alte:r<I1l ~o fuyOgl!OSS71iliS. ]It is mnd!. ]i:ilrger than ~s. Fjem:JJera:l!l1y :<iiP:PfIBCl1il:1tedt :mlteriim1)r ilti:i!Wos;t ~olIT&es the symphysl1smen1llis .mdlpo.s~eri:o.t11y it :[]'bl9Jts ilie deep smforoe oj[ ttfie sllillbm<iOO&lhma:[ gl!udi_ The :S:l!J!bmmdubmm ooct oien.r,oowes <lI!. large aooesSioryooctrromilie i:iIIIltoom :part Oif lOOesll!blIDgJ!J!al!. g]):IDdl (Bru:1!1JJ()illffiiS ood)_ The SiIili1bIingJ!]&1!.g];;md ma~be ilomedi to the :slil!bman.dub1J!l!w:g]mdi. ~0lForm.i!iI .. ]mge,stigIe sll!blli11!gL!l!<fr-SJllillbmandllbw1lJf oomp]ex_.

Themy~Oi:l\t!ylordimlilisde ~s the lk!ey Ito diIDeren1tiiaoog \v}\];ether Olf not i1iI. ]es.iol1 ~s m the :Slil!bMgL!lI;rl ors;lilibmMrnbmJru-spa:ce_ Lesices deep ltomy]o!b,Y1CJrdl are Vlirfthi'rrJJ. ~e sl!libhgJl]allspa:.oe; ifm nes-rOl1 iis .sHperllicii:i!:ll.1to my]oh~oid)jt llies '!,\~. theSJl!J!bmmdublllillrn- spaee (see iF~gl!lfI:e 1_4)_ .Amnd thepos'lteriol[ border.of :!hemy]o-

(aj

~ b)

FigIlIl"e, 1 .s-

(a) CO·fO:llial! alldi (I) s,agiittali irllage,sofilie suDtneurta:i! Iregilon_ (1) An'l:e4IO;f belly of dligasmc muscle_ (2.) MyrOflj'oidi_ (3) Ge-:I1io·hyo~d!_ (4) Ge:ni:oglOSSl!lis .. (5)S.MbbgILl1al!.gl!an& (6) Mandrlb&e_ (7) Hj'oidi_

P'age S

~yoiidl. nllilill!scillelIfee OoomJil.!l!l1i!cation ~S :p ossi!:I)]ebehveoo 1ili:eposlterior sl!llbllmg'UJ'i!IllsPaJoeandl1ili:ea:dj1a!ooo1t :S1!J!1D:m;mdll!blllillarr and. iMeriofparaplila:rynge1rl. space (ilI!S .Wi a .: ~g t<mW<lIl- .iiIlfJet)ention cy.st of lthe :sl!]JbM~<illi. g]and 1!h<il.t ,ex1tel'l:ds:po.s~eriOl!]y .mto theooJb.ma:l1rnbl!l!l!<n spaoe .a:nd imerior~' irliL1to tlLe ]:l!<iI.l!;apl1:aI.}.rngem. space).

Thesl!])1bm<ilf:ldl1builliitfcm:c1t ex1toockanlterio:dylIfom ilie gl!MdI \c\:ri!tMr:i.1ili:e ,s,I!])Jb.m<mrnb1!I!l!ar ~5>p<il!oe mlto ilies.I!]):I)]im1~§,] sp<l!oe,s.we:l'vmgm:owdi ~e Keepos1terior border ofmy]oihyoid_.

The mibmmdillblillil101tl' glJHds,i~·s lliike a. saddille<fuSmdie 1ili:ediigMmc and my]o~!yoj)dm1!JJsdes 'i.vfuenwewed. m<lll 1!:r;mwefSieplme_ Themteriorheillllj'.of ilie d'lligiillSJmc m<l!y be seea 'elill:e£gimlg <HIlteriruIry _ Theanlteriol! belilly of ~e dliga&mc ~s:mme ffl1!J!StcuillM1mdi e~ieJf Itode&m:e&an.llie t,em:GIDol.!J!spomoo . .of '!he po.sltmof belilly \vrnch is ~d!e:llttmeditmmed[il1telly posterior 1!!o 1tl\tebodly .of the ,s,lIJ!bmmdillbwargl!1lI1d_ The Wel'l:doo. of ltheposlte:riiorbdThY crulhefoilllbweddo'l,';,fFl. ~ow;ardl5 ilie hyoid ~edlia1te]y

Figw:re 1.6-

(a) Transverse, ('b) co'IlJ<l:a1i, ('c) c@m<l:aJJo;bl1que, (clJ) t!ms.'\fe..s e mews. ·oIllie 5l!1fu.m~dI1m1Iar fegi:ollli_ (1) Supemicia] sl!1bman&:bllilat ~a:I1!dL (2,) Deep Sl!Iblmmdftm1ia. glandi .. (3) Mylohy,oild! .. (4) Hy@gillOSS11!J!S,_ (5) P,ostenor be:Uyofdigaswl;_ (ifi)&l!Ibmard"blliar dl!l!C1L (1) LillgI!l!aiI! veiN_ (8) K . .iI1!gI!l!al.artery._

(9) F8!cital!arte,ry'._ (10) Hyoid!.

Page. '9

fienof ltD iliesl!])bmOUlQl1blLlilliitr gEand it c<iIml:D1tus1!l!aliIyhe seen as It s:p:llits ilie .s.1ty]ohyoiidi. m1!l!SJcille<md 1ili:en enters l1tS las:ci:all ~cl. TIle s1!J!1Dmandl!!blllilla:rgli<mdl rilles .Wi iliep];me IOf Ithei§lfl~erio!ll ibel!l5f IOf dlig<lSmc, h~oemor'e IOf liillle anltmorbe1!ly .iIs idlentiied m.paJ!~girltltal!S!ectiom of theoobm~.dlI!bl!l!1!ill g]<MdJ liha:n. ~e pos1tmorbe1!lY wrndlJifl!l!l1js m i!I. more ,cr.wr;tlL,c;a1!l!d1rl o!l1ent[i[tioillJ, ie.:Illme V\e:rn:cdly. Morepos:1teriD:dy ilite mry]ohyo&d is viiSllb]e, i~Spos:teriOlfillreebci<lfd!er iIl:dlentmg llieSliJJOmMrnh1!1ill<rr ,glU:d

.An~erio'[ ltD 1i:l\te s,l!])1bmtlWdlI!h:JilliitllgIill1di is ,ijlsmaJill" :E[i[1WllIed WM~a:lf space, Lymp:h.l'I!Ddes eae.be id.entiied Wi ~r,eg:ion. 'FWQ Ooos,ti§lfltVel1!Dl!]S .~1iI:l1i&:!:i:<ilIks OllJil:llffie tlhe S:1'l!fu.mMdllib1!J!llm gli1ll1d;1MiIlteriDd}' ;iiIJ!ldi.S'lllperiDdy the mci<lll viem. can. be seea cDmsmg :Sl!:Ipemcid)l, <IDdlpOS~eriDdy ilite <m1terimd:WJjsiOOJ. of '!he re1trom<mdlubmal'v,em Cirulhe rdientmedL '][11,jjs joias r..virl:h. tlhe :E1IDci[i[lJ. ·\'icili!.1to dram. mltD ~e mte:ma1i.jllguIillru:V'em. Di!s~~1il:oement.of thisvOOOlLJ!SSinOmre ~s the key to dtiillIer,entr<lloog wlW.elther ,[ill moos: is ari~gfrorlilll ilie cSi1!J!1bmmd!b1!J!llm gl!1iIJill!d ;a11Ii1toonltlly or 1tl1ep;llotiidgllmdlpDs~erim:lY. The cS!upe:mci:llJ "Vlel1;OUS ,1iIfI!altOl!IlY of tlJre fleck, wM!e v;:;mia:b]e,]J!i:ovidies m1myr,e'Oogrns<itole ]mdmMks (Ji'igm:e [.7). The :SJeqJ~gIDDl!illS: OD_Sie of iliell11!cii[].me:ry !C.wJi.1De rdien1tillIiedi. v.:riil:h oobrn:ill!ow imaging as .irltpiiliSses deep ~D &e an1te:riiDrpmt:on . .of 1ihe~1!l!Jb.m1ilJild!ib~1lI" gllmdL .It emLte:rges Hom.helWd[ 1ihewdlt.1ll11teriD:rpOmrn1J. of &egE~dl topass 'I!]]J< ,&l!ld. Oyler the bDdy of mmdlible.

n. ~Ji D' '~.(iE".' ] 8) raJ':O,r.,i!U B.:eg,wn Iill'~gure .,;1

The parotrdSipaoe e}!Jtendlsfrom the e:de:rl'l!a]. al!])di~o:l}' meamssl!lperim:lly to. tltemg1!e ofilie m;mdll!b]e neriOlfl~'.Wl_. tlte glJandi fuiesilie:roe1trom<mdll!1Jdar y,eiin, (R1\l:nl}m1d1,,~stmediiiaJJ to it, 1tl1e e:deuJi<lll. camfuldi.m1ery (ECA). The ID\w iis .<ih~<m.dimaltk fDr the fa:cia:l! .. nerve wfuiffi. coersesjsst Iiller.dY. The lEL~ am. be taen ;[jllS.i1Ilm<itl:liIJerIDOf iliediiviisiofl. of 'IllepOl:l"otrd mlto :Sl!]]}e:rlici<1l!ll1Ml!d ,dJeep]Oibes.A1~e:m~eJ}y,M1. oo[jJJgirlThm)' lme m,[1l\w <lll)Dng tlreoocis of 1i:hef.am1!J!S ,of :Illemud!!1):]e wOl!]gh. Ehe 'pMotid aots ~oOOrid!e 1ihe~nperlicia]J <IIi1d dleep ]Oioes. The mm 'pMo1tidi met is rdeniliiiedi . as an. edlDge:ruic lliine wi!~ the :Sillperlicia:lJ ]obe. Them<iJiS;SI~erm1!J!Sicl.e .lliiesji1!J!s:t ,c:fuep ~o tI1e.ru"l1teriOf ;1IDSipec1t 'of thes.uperliiciaJJ llohe,<iU!llid.[i!ooess1ory]Dbes of 11I1epru-otrdaJ!,e idlffitmed. m ~ regioN!. The p11l:otrd met n:1I'1s~proxiima1teb' Gillie ngerhre<3!.diil. hel!ow 1ili:e zygpm<lltic1ITch, com:smg <M'I1te:ri!od1y Ow01!J!gh lOOebl!illoca1Jspaoebefme

Splenius rmllSCJiE:' \

Le~,ator s¢apli.ilae i'i1!lI1sc!!e-------k..JI#Hhw:

1-1'--------- S!UpernclalllIlmporal veinl

w----+i-- Ma:w:[II;ll1')! Vf!11i1

S~aJenlt,i$ ,!'fiMIIi.i$..-----r~Fftttr-t'-n7¥ all']I;! .~c:a~B nllJa p06~e~jm mllsclifr

Figwe 1.7'-·

'Sl![P erlk.i!m. vec:l1Ol!JJS ;1matoIl1Y ·ofllie neck.

(I:)

(b)

HgI!I:l:e 1.8:-·

(a) AN:i!a1! image of bo dy ofparotiid(., (I) ,axi)aJi. image ofplll1"ofriid.1tail!, (c)axi)al! image ·ofbulClCaJi. fegiion_ (1) St:J.perliciaJi. ]oibe piaIotiJdL (2) De'Eif' lobe p.arot:idL (3) Pa£I,'lt:id dllJ'ct .. (4) R.efu'otll~dib1!1l!aI vein_ (5) .E:x1emm.l!. caI·ofI1di ,a:ri:ery- _ (6) S1iemotlltastoidL (7) Massetes. (S) POSterii01 beIly digastric.

(9) Hllliocil1!at.O:l"._ (10) Mandr1:l]e_ (U) FaiciaJiarl:ery'. (ll) Mlllicos.a_

pXacmg tfuebllliocIDilfm ml!l!scle_ The 'IhiillJ1bllliocIDilfm ml!l!sdie 'e;x1toods1ll!11teriorlly aad jJ!!5Jt medi&lilly !to ilie <ID~erior mru:::gm of tfue masseter (iIF~gl!lfI:e L ge). As:J.lcif:lg ilie lXil1tl!ent to 'l)il0WCllillJI ilie cheek or ,doooh. the ~eet:b. :aidis its ildlm'ltIDica1tl!N1I_ ThebllliccrnJl. :spa:oe, 'wfuic'hllies nil~eralJ lto ilieblaocm.atormllliSicl!e, OOiflE~S; :lLhLI, iliefucia!ll :I1!eJ1Vie,. ~, al'ibe:ry ,ruld.pno1tl!d dllot.

[fpper CelWi:cal Reg,ion: (Flgu:re 1.9)

As. iliepmbep<il!5Sies. d!mw. :fr,om ilietd. ,of 'lbep1il:mtlid. gllmd. ;!he ,ope:raltOf. ~ ooMon1ted.by .<it~efiieilld ,ofvmJ;cmM ,s,ne1tm"es. Co]Oltlf.fl!ow ooi:ilgmg is. of greatassistanee m, 'lhis. area.

The Thvos1i:m:cmres topiclk: Oll1Iru:e '!he in"l!en1!i!!lI,~gdru: veil!:! (lTV), which, acts as '!he IMdmMk foo:n: the deep Oen.r1Ci:i:lJ .1~'fflp1\], !I1iode c11.ruru,.ilI1id thepos"l!eriru

'Ik",li1\'" _$: .;;II;, ", ,~,111 'iIi'I\., ,', "1J,.~1,1\". f~1\. .;;II; ." ,1['·' 11~ .' , ." ,," ,,,1\. " '"d'I, " L ~1\." , ..,' ':~._111, "

u.J.j" 'UJL rng[fuS,meml!llSiue_ .~ ]xepas,"I!e:I]or m:::.ili!j 00 IILJjXe 'lilillgas;ttrl!C fflllli5Cre ss <iI. I!!cey SHone ,m. s-epnaMg lLJj~eparo1t:l!·, ,'regl!on, ,1LIi'om. me ~e:r 'OffVl~ 'regl!O!I1!

iI1feri0r1~ _ Cl!i!rnca1tly, iliepos,1teflDrhel!lI}' of ilie dJigiilt5mcml!J!sclemm:'ks the ,dlWJisiion.be'hv'een, iliesl!ll1bmMdlllH!lilli:ilf womglJe :1lI1I1te1"liodly,.d, ftfle CallofuJd.wMg]e mmepos~eflody _ To ~dJ.e11LiliY i1t,a:l!i,gI]! [;fu;eprohe ]JrnSJtM~erior to 1ihe matSJ~ord 'Jlifoc:es:s:, cmecmg dO\VFI.~D\-V:ru:ds the fuy;ord Thepos1te:ITOf belli)' of dlig~mc wil. herdJentmed e:lne:rgil'lig deep tos"l!e:m:oma:sttoiid l1IJJl!J!sde to abut ~e ~a:illI, .of thepm:otid_ It is <l!.s,1ape:mciorl. soe:wemdl OOl!Jf..Sies at apP1fOxDa1te11y

Page II

FigI!Il:e L9-·

.'\;cia] i:tnage~ofthe I!lWe-! ceo!".riie..aJ:f.egi!oa. (1) PaI"o·tijdi. glIand!. (2) S'l!J!Omaadfbwar g1!and!~ (3) PosteriiO! belly digastric. (4) Inrftemal! j;l!.l!gr.rl!af veil1i. (S) Inrl:ema:l! carorftid!arl:ery'~

(6) .Exlle:mal! caJ!o,fidiart,ery-. No"!:e the 1lll1ion of the paIofidaadi s:urnlHINdfb'llJb" glland!s (nOfll'lal! '!i/:a:!liaat)..

45 degrees to, ilieplme of tlle nor1th-sol!J!tlJJ :ms, of 1thepMo1tiid. gEancl 1!llere1troIDm1:ow"bwM ~ffi1d1. its oomoo1tfo!l1! 1t'O 1tll:e ex1tenl!a1i.~gmilin .~. c<ll1J,.be seea ptlSsmg :supem.ci<i!!l. to it Ths is the ()~lm<lLjor V;iiliSJcwE:llisnct"me ilia1t issupe:mci1aJ!.1to tthe ·pos,1terio\£:beID.¥ of dlig"01Smc.

By ~g iliepfobe :sill:ig]'1il:1y illIDooo:r1}r ,,uO!l1!g the Me ·of tI1epos1terio!lf belilly ·of d)igiiliSmc ilie vessels deep "1\0 .itMe seea. Fml!'11l.pos1teriO!lf ~o1m1terior ,ilieyru:e '!he in1tema1i.~gm!l!M·~.m1temJa!li.ca:ro1ti!dme1).ffi1d1. exl1e:rn<llill. cMotrud.mery (lFigrurre L HJ).

511--1----- Inlgrnal -tiaro,ltl a1t~ry -il-T-fttI--t-----.lInglJaJ artery

q-1--1i:----f-----.IEXl!eirnal. CClIolid M~i'~

.Fli.gme 1.10-

'The keY!I"cliafioaslhips ,ofllie posierioifbe11yo,f.d!igasbic tlll!lscle ..

Wl1!ere does 1i:l1elilP'pe:r oBlVi.rnJ! r.eg:UotlJ. end aad ~e n:Midl oe:rvi:ca:ll,regio.flI, hegWI! The oBlVicaJl, r.e,g:Uot1J is dM!d!ed, m~ol!lipper .andlrJru!d,pomom, hy the fuyord bD:ne_ The criCDid cW[ilge dWiid!esadlfrom ]ower ]JomooK

The omo:fuyo1diml!J!SJde ~s. an lmpodoot ,Sil!lillgtcaJI ~<m~ru:lk:_ Thes.lilpeflO:l:bel!1y of omofuyoiidldliviidJes tlhe imfahyordpomcm oftfu:e IDLterior mugEe m~o. carotid!, :mdml!J!scmru- m<illgl!es whiill:s.t 1i:l1epo.s~erior ormeriDr heM!y dWiides 1iDepo.s.~erior m<illgl!e ,m~o oocip1i1tal1,~d, :S;I!l!bcill!fuviian_1tri~glles_ Mru'l!~r" mmDlililfS are trea!Dedi.

;tL '. "£Ii,. - .. -.. ..;tL '~1J,~,Il,. . .JII .J'~ ," Thl'. ._;tL '.JII,_l'I', ," -,", -, -, - ']1 .JL,._ l:~~,.e1\. .,-, ~~_~. _,1'~~~ ,"

[}y 1ti!wom £'eS!edmn \-V1!U!] ,<ill -S;ll]Jf,[jJJ~'Omi()!I~y{)ru, "1 "",yn nooe tiJSoSiBCiIDrOt1J_ _ "e omO!l~y{)fu ,ruSO mep,£'eSiel'lJts. ,mJj lImp03ii1f1taU!ILIl[ilfK m,lLI!le f<itll!l!Cru, fliell<l,u!Ji&SiBo1trOmJ_

The oOmo:fuyo1diooSJes. i:om llieM!Deriorp.olNOO of iliebo~ of :!he hyoidboil'1ebefore~g dblillql!J!eJ:y ~o CfOS8[i1f1tenOf. Ito. ilie OOml!I);O:ll c1lfo1tid :a:l1eryMd

.. 1l,. d'i " ' "- '.JIT: <I\. . ',_, .J~, ' . .JII· 1\.~_1\. ,',,' , ,,1\....,. - "..t\", t:, "_,11 11;:.,.", ',:1l,. .JI' .. 1l,. _,11 ':_,1'1 A' .. <I\.': " e., " " . _,1,1\,,, ,11~

'lLI!wef!l, ,'. eep toO .slte:mrnn<l!S~OOUL ,Jl~, ]]<l!S :at1I mt-e:l1TI11:erna~e ~OOuruJi W~!1ilia] passes l!EliI'O:llJ!&" ,i:lL1i!l!SJC_~i:J!I, :SJ!l!JJ]g at1t,a.c,]]eU ~Oltl!le ,u::IDw'tJJJe_, ,', t u:iliJspom1tl!1t ODCaSJ!ruJi:::wy' ()lve:rJilieS

'!he ][J\f but ~sl!J!s;lJld~ fomwdi Drnerniil!!De1Iy]<it~eralJ ~o It, \-vfuer'e ltm::IDY herJru!s1t:i&e!1J! for :!fu ]ympn l1ode_lit tflenflllilThs. obllliquxelly <!I!gm :1irCfOS.S. ilhe f;JJ;5'ci<i!:l! carpet 'Df the _eriorpoSJ~ffiolf m!1lI1!glJe to at1ta;rn, to iliepos.~ffiol!<niS:peot ofilie n~!Der;]JJ diilvide_

The ll::iey snc1ti!Jtr,es of 1iDemid oBlVi.rnl!,reg:Uot1Jru-e the OOlililil1!Jion, cm:01tiid, :mi[,e1Y ~CCA)1illd, ]N _ S~g neflody mi:lLKUSVie:I'Siep]ru1e del:,edsa!l!], :;wdJi<il!ooot l¥mpfu ~1!OdJe5 :Md :a:lilbws 1the omohyoid ~o he idJffiltMedl cfo5smgfr,om mediall, to Fa!Derall ever Thhe -DCA Thspomt ~5llS;llJj<rlly at tlre ,te\'ielJ of 1!he rnro~c:ill_ Cal.1i1Jil1ge, de:n:llmcaoog the dillvli's&OO!,beThveen,iliemid<md ]ow,e:rpDmOIJiS ofilie deep oe:l:'l.flc<Ill cfuaiil1L Wlhen,Sic~g H<ID5Ve:l:Sie]y,_ijy]st

(ail

F:igm-e IJ 1-

(a) Mal! and (I)) sa_g1rtltal! views. ,ofilie ricl] cewi!c-.a:l! HlgfOn; (C) :1lXliJal! view ,of the fOWel"Oe-Mcal! fe,g1011L (1) Ste-mo!lllastoidL (2) Omohyoid!. (3) 'Stemohyoiid!_ (f) mrl:e-mal! jugw1la!: VM_ (5) COfl1m.of:l! ca:!:olhid!;;mery' _ (6)&al!enus, antefiio£_ (7) Thy-r'oiJ& (&) S1i:emoilij,'1'O.fdL (9) Weri!orilij,'l!'ord! artery,_ (10) Oes,ophag'l!l!~'L

as \Vhffi ,ex:~g ~e d!eepViffiDl.!rnS sys,lbeJmi. of ilie ~eg~ repeatedThY oOlillpress ilie mr (~_e_bmIDoe M\Iepfoibe)_ Ths does nvo 'I1hln:JJgs: it ,~ id!en1tilles ilie ,oompr'esSJ!1i!e ][JVmd ''£x,es' 1i:heU"V m 1tle ,oerl1Iir,e or 'i:l\ieFl1fobeiIDld oobseq;l.!Tffit Iiielldl ofvie\v _ ~erl:!:he mJ!d. '<ll1di. ]or".v,e:r oervic[j(1J "!',egroffi Me scanned, "!he oescphsgns ill1ily:l)e rd!.ootmedime:druJ! "Ito "!he eCA Md, all 1tim;es it is :s1r1ti.!l!<ilcltedq:mlbe ]<ilclter[il!] to 1tlhe 1tI:,arne:aL ][t is mime oOlillmooilyseoo. 0111 1!'I1e ]e:ft_ ASk. the pa1tient to swdow ~o :pe:lT2l!Thi!t easy clarmmtion_

CmlOOlffe 1tOSCtm. im"e:riDdy ill the H':Mi]!!SVier,sepIiime,][]smg iliegreat vessels .<iI!S key .]ocdsmgs.:1tnJ!cmres, ~.ore<il:C'h. iliejWmotion or tlre Sl.!l!bcillil:W~.Md OCA ms.marks 1tflemot of1the neek; ilie origin. of 1tlhe sllilbclavlian ,mer;' caa.beseee by :M!gh;g '!:he 'pm:olbe Dericl[l~b~d ilie mediia]. hea;d. of ~e d<1lmde_

The .lbey sncmr,e .m.1t1IDe :r'C)OE or 1ifLe neck. is. the .ScmOO][]SiID"ltWOf w][]sde_ 11];iSll:lilIil.!l!sdefll!ll];s Derior1o/D:.om. "!he u,~sieplfooes:ses or tlJ:e oervi:au! .. spme, p&S;s:ilrrlg Jlos,1tooor to ilie ]N to dmp be!llmdl1themern&l!. diilwde 110 atlacl\u 110 iliem:stlfl!b_ S~g"!he llV' tr~S\!IersdYMd t:ll.eliI m"!he s:iiI!gJ!tla]pbne m.me neriorlt¥" iII iisposSJ:He to idJenili}r :Illesc<ID!en][]santmorw1!l!sdepos"lteriolf to ~e .mr~g Hom. 1.2o'dock "Ito 7 ,o'c]orn (00. iliepllruient"sright)_ 1bis E1Illsde llies betweea the ~S!eoo!l1dpm. or the Sl.!l!1bcmviillJi.mezyp'o.s~eriodyomd :!he s1!l!bd<ll:v1iom vcin,1ll1~eriorl¥_

H~vmgre<lirned. tfue d<Wide" oae now heaJdis florilir;,vardls @gam to assess iliepoSJterio[ mmg]Je region Begillmers ill netl!d .;md. l11ern1.!1ill1tr@SJmmdla:re ofierJJ mIl!l!1lbed, mtfueir ;<ilHe:J1I:Ipts atsssessisg tlJieposlberior ;ftri[jJpJJgl!eby 1tllmeffi[ll'gefEllmba or mlilO!S!cJ!es1if:tl<it mtiID1t1lyffi1ml the screen. Vl&ere does eae csW1tt

&em;ember ~at iliepos1t,eriOf momgJ!e iSiiI1'velf}'5l!]]J'erliici<il'l!r,egiio'E!. of :!he neck,hordered, m1lteriodyby ilie s"ltem:omas"ltoid. ;[M1;dp oS"lteriodyby ili;e tr,apezMs ml!l!sde_ Thef]oor ilS fm:medby m1!l!sdes~g oibJliqJ.!illeJly: llieSJe .are (:iom :;m"lterior ~opos"lterioi) lles.caJ!e:ne" ]evallior sJCapllillOl:e;mdj,J)~e:!Ws capitis f1:Ll!l!sdes_ CO\'\eflng iliem1!l!oo1llillnillloor .iiR .~ carpet or oervi!rnJI. f1ilSici<iL The col1!~~1ts .of ilhepos1terior kll[jJpJJgl!e wlliid1 .. lli!e .S7L!pefii~."lto tl\ue f&riaJ!. carpet aJlfeIDew: s;pm1rl ;[iJ:COeSSim:y :I1e:fVie (Xl[)" :spmali accessory lYmph node c1l!m,pre-.uary

Figm.e U2-

The ke,y're1iatrCllf:IJsl][ps, of the scalenus al1i1:ellOf tlllill!sde_

~.a)

P:age14

~ b)

Figm-eU3-

(a,_ iti) "~viewsof the pos.tenof fu1!<mglie fegion; (c)axi;al!. vtew of the Sl!l]J1:acJ!a'll'icmar .egi~HlI; (dJ) sagittal!. wewofilie 5111pfadavicma. legion. (1) Stemomast-oiidL (1) -SeaJ!et1lLl!s anl:e4io1~ (3) ScaJ!enm me,dil!JJs ... (4) ScaJ!en1ill!s postmof:. (5) IA,~!y.aitof· seapulae, (6) Trn.pez:t1ill!s .. 0) Fat. (8) .Brachial!. p]ems .. (9) S1!l1tJ.chvian.mety .. (10) Ap-ex [1!1lI1g.

fuf&C'hiialp]ex1iJ!s., dims:<iiJI .. s.c1}~)llliIl1l:l: :I1:efVie<mdEl:1lt More iMeriorltt ~e 1tranSViefS!e oe:rvic1rl.merymdl vem,rulslling ;from. ~e ~)'fooe:l'V1icaJ. ~ and IrV [Jf.es.pecwe]y, ·crmhelDol'l!l!1d! OCH]lfmg -pM-dd tto 1t11e dI<:Iwde.

As.Siessmeflt is 'e<iI!Syiif it isr<5l11lteJ1l'lbered. tfu,3l:1: iliepos.1!eriior m:amglle is ;[jJJEilllt -lEilll!ed.:Mpe:rliicia:1l s,Bcllilre. Thep'n~e be1tweoo.'lhe sl!]]}emcia1l.sl:.e:m:OOlliatS-1toiid.ru:td trapez:ms ID1iJ!SlciJJesMd[ the deeper IDl!J!sdes. of 1tl1eposteflm: m:H:Igllefl!oOll' is ~d~t:ffiedlMd ~SicamIDg iismd!er1tnen. ill ;§L trmSVieJfCSiep]Me Homm~1tord 1t:ip,_ i,e .. ste::m:omasto£d -origin!, ~ommdlllla:1bera:ll diil!viid.e. RemeJ1l]jbeJf ~;jL1t 1Ililie spm;a]iilooessory l!1e:IV-e (IDld 1Ililie <il!ooompu~g ]ymph node .d1!aiin)nI!IiIS HOm. a.pomt il!mv:til.ry he1tJ.veenl1!he ID&s:1toidJpmoessmd.<iIl!JIglle ofmmdllHe 1:0 &e Olilli~eJf tl'm:d. of &e d~[vide;mmt~g tfue[IJ\l:d1be m tllat he \viilllI. 1e:n1iSJW"<e ~at ~e 1te:rn1tmy of '!he spm::rl. accessory .cham is oOVier-edt. On. fu:ID1SVie:n'Sie scans, tlilie 1t:ips of 1tl1:e 1trID')!wers;e prooesses of 1tlh:everltdmae m<:l)' beseea <IDS ec:hoglemc Strn:CH<eS ,."viittllJJpos,1teriO!lf aool!]Jsru;c.sihadimvmg. no Flot M5J1tai,e tfu,eSie :E01" ca:lJcmied. qmph l1!odes ..

Page 1)

The tmeem<ill1rorlml!illsd!es to iiden"ttifjr'1rr.e the 1!rOiLpeziiu!s, omoF:iJy,o&d.;md[ ~s,lte:ll1!om~ltoid_ The &is.tall 1!r:<i!:pe:zms, is :~tt1ta:.d];ed.lto IDe F<iI!ltera1!. o~cl)e~ irts<ilfllterior :free lOOrder is ,etiilllyrecogrused The imeri.orbe1!lY ofomo1hY>o1id ~s.ID!Sl!l!~<ilppMen1t.cme ~o 11ts. ()lbl!iql!l!epll1lle_ J1!ills1t s.uperior ~o [he weriorbeli]y ofomohYio1id. me '!:he U<iImV,tlSJe o~ca:lJ mel)' :1ll1dl vei!l_

Movmgmerna1i1y, i~. ~s.po.SlSi1!b]e to id!en1!:W; the bra:maJi:plexuJs,3 '!;wlihrn1tr,1iIiSOl!mdJ (iFigm:e Ll.Je, d)_ Nolte tlJie sealeses [iIfIlteriorml!J!SJcillem the 1tI":1ill!S\iltlSiepIue, b~d. ~e ffii' _ Sc~g iliferiody,lIOl!l!l1!ded hJ'iPo-'eCho~c s.1in!I:cw,es '\Vl11lI.:beSieen. e:me:rgil1;g nom behind.1ihe falte:raillbordler of SiCaillffil!illS :<m1teno!l" <ll:ld.pass.il1g ffiwerdtY"j;mt ,superior ~o ThlIIDe 1i:Mrd.poottioo of :!:he sl!lJbd<iL:v-rID1 ,merry_. TheSiel!epreSlen~ !the ~s. of 100e br,a;cl!&aillpne;ms_

11£ulline (Figure 1.]4)

MOist ope:r<iL~ors.<ltI:'e oomIDortalbme r"viitl\!. iiIE!<lgmg of the llio/foiidL How,ever ,most fd. ~o e;ll;amitI1e 5ys.ltematic~ the u.cIi!!1:eSJncmres. of the ~eck_ ]f :<iI. oomprdl~ ex~altion of Ite l1!ed: ~s to be ;i:Ld1i:e'i;'led!, i~. ~s. iimpmtM1t to exaraiae ~e .Md!Ilmewommillldl!He ~o cs,~ernllJ!lIJL Theru:J::a1tomy of 1tl1e thyroid :;md ]ID'J~1il:I"e dea1J1t '\w'l:h. in! det&illl. m Chap~er.s 3Ml!d. 6, however :<iIl cOIDp~e of:ar,e§[S wmc'h 1tend.lto,he ~egDeded.by SiolThographers :Mdira:rnotogilsts are mgMght,edillm,e_

F~gme 1.14- The truidl1ne !l"egion_

The .]<ll}rml: .lis ,aI1I1illI1fi!i)ljjIJ,iil:i<rr snctrm,e lto_<ilge ~t:h uS,m:YI!J!t 100e opera1torsholllilldbe riMe ltoSJiSioe:r:Ems.{)mer,eoogm:s.ab]e];m~[l[h-l!heSle :<itlf,e the ,ep~gl!otltis

.JI "",,11'".. . . . 1),,;:_,1:.. .•... " ._,11 . " . Th' . .JII_ . b· .. 1)" &,_1 .J11 '.. 1)" ".JI...::t:::_.JI' ."_,111· .JII·· ...• '-.~ " . Th'

:[IDupre-epill&ottJ:c spa;oe, W~.lld] Me :SJeen.1ill1I. 'S:~g:J!n<ll!l. secaons. . 1 ee ooru~,. ' OI!J!.lJ1[1JJSleMUl ne, c •. ue llll!enl!l!l!i.t=U. m.inJ)<lLI ~.LlJ.P1rr.~tt<llfl. seeaoas. .1· ,Ie

,ma1bomry of the thym&dI.Md.pow,aIfuI}"foiidls tIS diseassed m C]ulp1ter 3 "

The rnooidJ 1rnr1tiillaJ!ge ~5 .at good ]M~IDJ[ m 1!he .m£diIlmJe;. il: 'ltends.~o lli:e jMs.t[iJ)bov,e [he .iistThmm of 1!he thyroidLEt ~s1ilJ.bro[jJ)dJ ,rnr1tiillaJ!gm;Ol!lJ5 Sinotrm:",e ID1di 'CiiJill].he id!m1tIDedin! :5:~g:it1t~SJec1tiiOOJ.:In oon1tr:1iliS;t'ltO theooer CWi:LgROl!J!S 1tradlte1llillMgs iliOl'l:me seea more iimeriorlly_ One :sholill!l!d. he <iLh]e to iiden1illft}r these ]MdmJ1rrks_

U11ttr~om:J:d. c<iIfI.belillSiedl.~o identiill)rtlJietra;C:he.a.::mdi. i~s CW1ilJgii!1oillsnngS,dmvmg US -gmded ~)l.!m!cmres of 1tll:e 1!raciJea tobe perl"ormed. to filtcilita1te perCUlIE;meOl.!l!S ua;dloos;~omy _ 9)11 The op1tiln;[].SJi~e 5ibe1t\v'eeN!. ThlIIDe mst;mdiS!oocmd 1tracJle;[]rmgs_ iP',ercll'iiill'1eol!lJstr.adTI:eos.1t,omy 'C<iJn.he h<lllZMdlol!lJS .m. :afI oedeasatous or obese aeck. UJ.lltraSiowd C~ iiden1illft}r the ltmdlte1ill IDlJd .~1ts 'ri:m!gs (Iiigme i_H) wUs.t .1lIillSiO id!m.g oilierpo1tel1l1til[i!i] 'i1mm,d\s 51ITch. :<iI!S :tiIl Fru:ge tfuyroiidiLstJhml!lJs orveaoas IDlomaJlies_

The s.furapmu:sdes form. ,a. ~.an~erio'l: cO\!ienng of [he .lilIi1i6e s1tn:J:c'ltw:es~d.lt is C!Ol1:;;i\emoo1t. :1:00 grollp 1tl1:eSiemmdes. toge1the:r.a!S 's,fur:apml!lJsdes"_ However :;ID IDme de1taiilled.bow]edge of 1tfu:e ruJ!<iI!~Dmy is.reqmedl '!;v:l1ennymg to idmili}r ~e exaet ]ocaru;on. ,of iliyroglJo,ssaJlcm:01t cycs;1ts.,.1lmlterior oen,';teal! d\J.1ilIDJ nodes" etc. (iFigm:e L 15).

Now that [her,ei:il:der ~Sr;;J1QiJ.1~;'1il:I" wii:h.aJ!. s.y:s.1telill<:Wc.<itpprollCJh. to ,ex~g 1the l'1eck,.r,ecogmfuJon of ,<iIlSieries of illmrlim:m:hsholllilldl:bepo.sslilbk.1tf 1thiisb~c :iiLpproa;cllli is 1!l!Siedmd modmed aooordlilng to 1tl\te needs of ilie ilweSJ1tIga1tioo, 1tfu:e begimlers&:ould be aJb.]e1tD <iLppro;:)l.d]I!l!lItr.(jJjsomdlSic~g of the :I1:edk: '\VF!:h ,1iI degree of comrdenoe_

P:age16

."- M"':loh~oid

StlilfnUI11l=~._

HgmeLl'i-

The' str.ap lJ1llJ!scles.ofilie' nerl;"

References

L ,~eriC3lfl. Joint eo~fiee on. Canees, AJCC CanclerStaging,ManuaJl:Amer.ican Joint Committee on Cancer; 51th. edliJl. New York: Lip.pmootl:lEt~I!Vim, 1'997.

4. H1!l.Jb;1bd R\¥" H<iIflIsberger HR. The pru:aph1ll}1'J!ge<il.'lSpizl'Oe: The~ey ttollDJoc~g the Sll]J1fDYoOldneck. Sem.i'J1 VltrnsQwu1 CT lW? 1990; H: 444~ 459'.

5. Harm:berger HR" Os:bOff.l .. AG. DimIeremtia.ll. dliag1fl:o!siis of 1Thea:dl ood. neck ]es.foosbmed, on. their space of origin .. 1: The ~npr,ruThyoidpm of 'I:lhe neck. Ann J,Rolen.tgeno.ll9'9:L; 157: 147-154.

6. Smol~er \VRK, Hru11ISiberger HR. niillIer<ellli1tii<i[]dlli<ilgn0S~5 of hei!Ldi. ~1Ml!(1 neck ~esi'0m. b<iliSiedl om. ilicil: :sp[ltoe of origm. 2:: The mM~yi()rudpomoil1ll of tNre neck .. Ann J Roe1'ltgenoI1991; ]S7: 155-1:59.

8. Ymg \V1', Chlillill. jp1', Me1!n~,.,.v·dli. C.ka1!o:my 'Of ilie nonn;}] br<il!d1illolll.p]exl!J!s;~ev;e;illled, by Siooogr.,jlphy ,~d 1tlhe "Ide of sonogf<itphlc gmdluoe ill ~M3tes.ili;esJi1m ofiliebracmalJpi]exl!JIs. AJR 1'998; ] 7] 1~6): 1631.-1636.

9 . .BBl:itrlruil1lJ. S, lEmshmfR Nore:r B. UTrIir'ilSiC)l1]ograp:E1£cMatom.r-f of1illte ,an1tooo1f.neoc li:mp.llications :£Olf 1i:Ir@cheas,1tomy. J Oml Maxi.llofac Surg 19.95; 53: 142{);'-1424-.

Hl .Mw1ill1imadl. IK,. jp:t;ttion DW, EVIDlS R..M" Marj:m E. jp'e:rCl!l!tanelOl!J!S diiliatatiornIDaiI. fu[.~dteos1!omry I(lPOT)md!.er11J!l.lttri!lli5ol!il!lllid. gllidiIDloe. Br J OmJMaxilZoj'ac Surg l'999.;. 3·7: 3()!9-3 t t .

Page 17

2-,

Sau.va,11' Glands

NO!flllal Ana,to!wy Sa.I!iJ'r:uy· 'Gbnd l' echnique

iCabrllii aDd Ac:nlle hrifl!:.uII1ll:dmy n~se3.se ,Cllrou.l!c InOanlmatory CO!udiit~ons 'fra1l1D.3

Sa.~iili'a:ry 'Gland 'rumours l\f~sicellllaneous,'Pamm:d' Les~foiUs

P:agel'9

Tills ch1ilp~er deSJrnbes 1ili:e ,normalJs.m:al1f gEanda:n,a~omy, higEmgh1ting ~e'uJJlIkaoolil!l1dfel1tm:es1illd, ~a:l1i,&n~ks.. jp'.a1ci!e11I pr'epm-a1tron, .and, ~,ec.fuJ&r.:p.ues are on'lillffi.ed, ~o ,iiIlViOid JJ1tfa1ils. m dilliilgn:oSJ!s.

The ,mEllxori1ty of casespresest ~o tlle cl£mci1ll1, Md, smJ.:oillogJist as :1iI, fEllci\a:ll, .of flock, ~"MdJ rurus. dliapter ol!JJtilli:!1es :1iI1 druEl!g:rJ!os.1tiic<iEppm1J:dli,~o'l:fuepr.ob]elJJL The .effire.cyofl.!l!l!trasomld ~sd)e5rnbed, 1toge'l11er \\"tfu its inu'erac1tXoo \vi!1tli:I, .ollier D:EI!gmg m.odill11iillies, m~sJ!aJ!ogra:phy, erilll:d,~. I

NOinna.1 Ana,iomy

The paro1ITdg]Md ~s1il1m~mpnedgl)ili1d ;for :~;iiIlpfornrc1IToo if:! 1themol!JJ1th., The g]<ilNd lliesm !the 'paro1tl!d space, wJill1d:! is1!he ,mo,s.t ]a1ter.@! :spiloem the :I1<i1!s.opl\i!~gei1!ll,are1ilL, It eX1!ffidls "i".om ilie 'ex1!e:lNa], .iihl.!l!d1!1tm:y CMa] s.'l!])Jerior1Y 1tD the~evlel1, .of tl\te ID:IglJe of 1them<illT~'b]e ,weriDd}'. The mas.1tica1tof, pilfap}]~ge~, :<md c;:u:otid, 'spiloesbrn:d.er ~epilfotids.paoe 011 its med!ia;], a~p'ect B'om,an1troor ~OP'QS1teriOf. Th,epos1teriorbel!1y of ilied!Jjg<lslIric ml!llsde &Wlides. 1tl\Le caroOtid, :&p<lLoe IOIID]J, ~epEllfo1tlidiSJp[jJ;.oe. It lis ItliThl!llS.OOpOOil:l1I lto oorurdapruho:]ogl1es ,msmgfrom these s.p<iloes, \vfuen ,ex~g ilie "pM.otiidl, lill'iiI!SS' .

• lymph nodes,

The f~cialJ ]])e:l:'ve creates iln~ciali,pI[iI;fle 1to wide the gDud m1to sllpe:dIiiciali.<iIIldi deep lobes .. AoGllltfa1te ]oc111lis.;aMDIJ: of tlre mifllSs is. wpm1toot i!:n d!~g :~mgic<iLl! ;<lIpproadil.baili. forad!eq[l!]i:iI1ter.'I!"r.ec'tiioo. and .. m. lihepr.,er.ervaEon of tlhe facia] nerve,

U1\tr.El!SJomd. is not yet ;~b]e to id!ffiltiy defii!:lii!~¥ tl1e f<il:~ nerve. Howeve»; .,.viJ1iliu lQ;e\VgOOeflil1!iOI1 eq;ulIipmtllt tlhills.maybeoome i1iI. r,eill)iL5!1tl!cp!r.ospect W:mJ .'I1!<iI!S aHmedi. m1ted[ vie'i.vS .of lihemam facial! lJ:en;'1e ~blill!t tms is. often mii.s,1t~en. fOf :5.&1}' ,cillcts.2,3

The facial! l1.efViefll!l']S ,an1teroO-imroor.~Y u:d dbiJru(jjlilleo1lyn-om ,the~1tyb:dTh(J.f.iii:lnel1f.SJ1.!pe:rioflly ~Ollgl] tlJ:eparo01tiidgliand.lift lliies.s.l!lpemci~tot11;e vaocm<trp;];me, 'lherefor.e tlre VEl!SJCWatl"pn1lle .~5limp0l1[jlli]t inJ.gmid1!ng the Sl0I10&OgUSlt toO theposli1ci!olJi of 1tl\Le {,lIdaJJ nerve.

R®tram<lndibuli<1r ".~ir] Faci'"il,flOl_i''l@

Miandible

ir'l~~rfi<l~ ~~roUd' a~tery Ir~tennal,ug,lJlar ~{ji,n

F~g1:lre 2.1-

Line ciIa.v"ingof,a itransve!se seocfr:ion ftlH01!J!gh the ]J!~I') .. fui:dJg1!al;l(Jt

Th.efivo ·mam.v.e$s.dls·1l!m! meCfuJ:] <IDol ])(ij[[aJ!]ellto th;e f~cia:'! .. nerve r.,virth tbie ,ex1te:ma] cm:01tid. m,erybcing 1tlhe moslt medlfia:] of &e 1tlill:ees;fur1!l:cues (1the retrommdlu1h,mm:V'eM. issMob.Vl1dled.m tllem'idlGJl!e)_ TheSieV'essds:ru-e ililli!s BPO\Hi:iIl1It Jru1:d!!ill:11:dbs for tllep]amH~: of lOOe fljJ;ci.<i!lI. nerve ~Mdlm dWiision. of the 's.illpe:mci~. ~<llil:d d!eep kibes._ 4 The ~clllillM :p;]<M1!erul'lsj1fom,S;~e:ro~P(\S;1too0t]y to &e imerior]<ilte:rallpo]e_

Ly.mph Nodes,.,

Th.e Jl@I>(}1tl1d :splilloe ocmt~c5mdrtlp]e !I1.0:rn1l!iicl! lYmph nodes: bo~. ~iliillrI.1tlbJepiarotiid. gl!ud '<nli1l1l >()lllrttsl!dJe. tl1e gillmdL TheSiedl!r~ s-ites :from.1!lle ~. 'e:xc1te:m!~. ,000urn1tory canal as welill as deep!E1IDci[1].s;pa!Ge:s_ The rn1tf:il:paIo1tilld fiodes Iille m<rilJ!]y ill :ltf:ueSJ1!]pem:ciall Ddbe but deep ]ohe nodes ma!y also be sees, They<ne idel1!tmed. ;asrol!J!l];dVov<1lil. hypo-echoic Ees.r011S, ge1!Ler,<fl]J.1y Iess :ihal1l!. 5mm. m ,dlUame1te:r ;1ll1dar,el!illswillly wel!ll delIm:ed i\.n. edhogemc hUs dBer,enfu!m,esH:ue .node from {)ii:llBl" pm:oltidm<llIS:Sies (iF'~gwte .2,_2)_

Fiigmre 2-1.-

Axiiaill.1!1lbas O'Wllcli. tlittage sho\v-il1g intrap,ai"oudJ nCr.·ciCe_N ete

(1) aenbaJ. eclTogeni.c hiillliliS (m"Owed!) ,and. (1) mandliNe (am'lweJd)_

ThemuiiiI!g]mcfuillan: dlllcEsdi:;m l:mO ~iiI.mam. s~g1Je dud wflich emerg,es :6:om 1tlhe ;1lnl1trow aspect of the g1!W1d1. EOfllll'li. oY,er flle cs.npemcicrl.1iIiSpec1t of the !Ill<lliS'Siet,erill!l!]Side_ The mm dmc~ is vlISJ!b]e a,S;@m.e ernog~c he r"vlt:fuilin &e S!llpemcia:].']O:be_At its ~1toom horder" 1tfu:e ,di1!JJc1t thm IDrn,smerndy 1tfu:olillgfu.1tfu:e b1ITocma1to[ ~o. efi~er ~edleek.mlfllOOS<li at' ilie ~eViel!. ,of :ihelilP..'per sBcoo.di.mo:Ia:L

uLTRASOilf!'lJ""D ANA1'Ol\II'V Of' 1'DE PAROTIn SiP AlCE

1 HOm0~eNieOl!Jls.., f1yperedliOi:c g1i;md

.2 S~5m!em1Ii"'S dm:ct- hrigh~.pardel!.,~ogemc Mes, momOl'e tlW[jjJ;]. 3mJ11!1.m {iamllie1te:L Noil'm~ lIDoltsBe:fIheY1ood :ltf:uep<itl!em:clt~'m;jJL

3 lI:!U1,JJgn<m~ .&motts - .~ort dilsc:rete hyperechoic ~.l!ines ~ ilie g]<mOl 'pa:r.el1.ci1ry.nl1!<1IL

4&e1!fom~ohi'.b1!1illm: ·Viei!rnl.-~g olbThjquJdy 1!:hrOlfllgfu. ~e gllMdl ~1IDS :@ wdilJ-dclm:ed hypoBcholic 1mihe_ LMdfmarkforE<lci<ilil.m:erve_

5Ex~erEl!;d cillotilldl. artery i5 deep aiI1.dlPill,dJd ~o tlWe "V1ei'!n_.

6 lPiO",S!~eriOi[ beilll}f of ,d\jg:asmc - demarca:~es CMOtirl. space b01!J!l1cll<ll"Ji'_

7 mU¥'MQ1tiidllYmp]ru nodeS:-fomdVov:ill!, < 5: :mI:ThI.m1llJ!1e1ter., ,ee]ruogeru:c hlms._ CoU]];rn1illy lliems';n:pemci[]]. bbeblill!t mjj!Y alsobeseea ill :ltf:ue deep~Dbe_

The or,a!! cawEy oon1tu.sMo .m<1lIDor 8.p@ces::· the Silil!JbiJ:IDgua>:3J1 spa:oeruJ!d. :!:he sl!J!bm1IDdliibm<rrs.p1IDoe_ The mlY,]ohyoidm1l!scle divides tl1e NOs.paoes;, 1illre 'Slllbmrmdrn'bmmspa!Ge lis ~OC1l1tBd. wer>()l]a~er~. ~o ltfle my~OIfurroiid mus-die wWl!st lillie ~bhgJll!~ 'sp&oe lilies sllIDperomecl!iial!1y _ The s';lll1bmMdi!bl!iillmgllood:ll!ii15 .Slnpedicia:'! ,[IDOl d)eep ~Oibesbl!JJtBiilgmg ~s; aot mtOfflil!aillIyJ[e~edl to ,Q:UI"e:r'em1ill!:a1tebe1t\veJemJJ. them as 1ill.e ,sm:giic~:] options Me mv.~lly fllli.esame :IDOl' ;iiIl'L)' :S:l!J!1bmmdlubll!lJ<wmMs_

Su..bmandibuJar space:

SubHnguaJ space,:

Supg.(icial ~:>,.~~~_+-

~ljbIT\aI1dl,bu i(l!F gland

Page 2,1

-i-------- HycoQllo85US

Oe.ep sut.rnandibll!B!r ~I<)rld ant! (IIUet

_1,_."._=~L!l1giJ~1 £!tti:it~' ::r:;;:'::~~ __ EJody Qf ~W{i~(lltXln~

FJig'lllIe 2.3-

li:nedIa",ing ,of:a COfl1JnalJ 5,ectiion tfuoug}1 llie sl!lh!11a:1l!d!r"ltm:l)a1 ghanclL The my1ohyoidJ. d!eFm:es the fJ)o@!dllie moulli. and!. dJemafcates the s,l!l1i:l!lland1bmaf' space .. The hyiO,glI~)Ss.ll:lJS, is llie l"ey f:m iid!entif}:rmg llie s;ufum;rn;dJ!1!m1Iar al!lct Theanterio·f beRy ·ofllie d!i!gastric dJe.:t11afc:ates ilie s.UDme.nta:l! space, Theall.rl:en:o,lLa,cia:l! vein "l:res posl:erinto llie s1ilbmandf1mJ!a!g1Jand! and

~5 l!l!s,~f:n ,dlI¥ec:l"mtiiating beffieecH Plaf01li:d! ~and! s,utnJ.andl!blliW-origind,a mass,

2 HiiIL'iJle "lhepa1ITent .sitt. orreclIDe ,."riI:Fru.1tlIllie neck. 'ex~emlJedL Thep1il.llilMt"s h.e1il.d sWlol1lilldl be ;lh[]med. oontr~61~er;]]y.forbes;t access. A. wat'er baili. of5tud-off m.ec:lliiJnm is flOtIill!SJ1!J!a111y rreoessmy exoeptll'orpacs1toperawe O[P'Qst -f<lrnolherapy :paIDients_ fu1tl<em:e11y sllperlici<l'll ]eSJJo:l'ls are sometim:esVJ!51!J!u&edlbett,er ,."vi~ irnL sitm,d-{)ir,me~_

ili""I..TRASOl)l'''j1)' ANAl'OMY OF 'I'IffiE SID.BJ\lIANUIBlil.AR.'& SUBI.:II\1IGliALS.PAC~S

1 Bomo~eneo1!J!s furypeJf.echo~eru!city sDiillrrrtotBep1llotid g1J<ill!dls._ Thes;l!])hmgJIilla.] glimdis deFl!il!olill!s,1tr~esilimiillru: ,edlo~emcity to 1tl\Le oilier s.m.v.-my g1J<li1!rn_

:2 Wharton.' S ooatt- ~s ~s seen w}\]ewJj ~t ~S<itlhlliOfill.Y diiIlMedi. (FligJ!l!lfe 2_ 4)lb19Jt ~t ma\¥ oOoc:a;sio1ll!d.¥heSJeen. m :llonJ1]jal] cases, The &ct e:od,endis HoOm. '!he .gll<md .l1lliruJs medJidiy ~o cmve ~<llOm1!d 1tl\t.e mynoJ~y'o~dm1!J!Sicle,,1iIP,p~g brJtBl"allIDo 1tl\te fuyogl!OSiS,lillJ5 m1uSJde_ It then. Ol:dv:moes merniirlil.¥ to iliep.apiilill~ ill> iliel.oof of 1!i1e mOlilftth_

3 The mtr<il!g1l<il:m:W!<ll" allots appeiilfliliS m. iliepamllildl, ie_ :slli.oo" d.efuedl fuWer,ed1oicllmes_

4 neruTh~eriofdivisXoo. of :!be 'fe1trommollllh1!]]m- 'v;cif!I is s;:mdWiid1ed. hmv,eoo ilie P0l8t,eri:Orpo]e oOf ~e ~lhmmdillblillill1itl: gl!<iI:fldlimidl1!he <HI'ltem-oO-weflorm<rrgm of"ilie p::n-01illdlg];md Thi'ts];mdmuarkma.rybe iilMpm1ant when. ~1t iis dUsp:lJ&Oed by ,<iii. lJarge m&S5,. _g;Wmg<llfm::l:l1e:r .iI1cllic<lI:ltiio!l1i. as IDO the origililll of :!he ~esiioo, ~-,e_ p1itlfo1tiid. Dr sl1llilbmtm:&buillar_

5 The s.l!l!buguJ'i5lll.glimdis<itl"e e~ 'wsl1!J!~edl s1!J!bmentd¥ deep to Ile liil:ry]o]wyord <mid. ]liIi~eral! 'Ito "lhegernofuyoldl1geru:oglJo,s;51!J!S_

P!lge22

Hgm:e2.4-

Tr.mS'!{et!:Hl image, (1) DilJateJd! sl!J!jb·mandJ:lhlli!8!fdl!l.c:1l (an'owedJ) SWerii"ing .al'(Jmldi (2) ]:i.o,ste.rijuibOHill.e1ofH1yrofu)'o~d! (arrllJ:wed)"

.~ ~t C1llI hed:iill]i;C!m~. toscam.1ihe enm-e deep Lbbe of tllliep&I!Ottid. 'beCaillJSie of the bo!l1ty <IDa~omy-&o,jta:1te Of <mglJe 1tl1epJf,q,he,. orneove fuepatielil!t's ~.eck ~o oib:ltrun. best access.

""'~'e-l_1:. J'-.'~ " (ifj''' ..,..jJ '11 '7) ~.w:urMtfl1.ln'S.lS '!-"" :lgD'reS _ ,'_'" "I

SJ].!lilbm1ll1mbmM emami. MemO>fe oQO'l1lllilllOIDI. tbamJ. p,Mo4id!. caJ)cu_ Thegrea:1!e:r .liIl"i:lLl1lBibe:r >(8{)%) of o~ami tIl!<l!1t occmm 1LI1:eSl.!l!hl1lllialill:.dhlblllillM .g]MdMe :mlt1111b'lI:lJ1!edl to "l!fue grea:l!ermllICOl.!ll5 COfI1t,e:nll of !!f:ueslWrnn<irn:&lblllill<rr s;m.§J,spiMo1tUd~a ~end)ili;]g 1tobe .mLore [iI!:lliueO'llill5_ '90i% ofsuibm1ll1dliblllillM ci!tl!cl!l!llii.Mer@d!iio-op<l!.q'1!Jie,. wher'ea.5 o~ UJI% of p<lIrotid. stones.a:rera:.mo-op<ilqlille_ The :I1illiilljion"fty Ofp&EWe:nIs preSlen1t 'With1il. SOlliEill}' calliCWID!S; however., mmtipllie calle •. liIfefol!m:d. m. 3'% ·,afpat:U~t·s_

High .. SlefI&iffiriry (94%1 s]}eciicitY < HJ QiID~)Md. :a,aOlillf:a.cy (:9:6:%) me d~e~ for iliLe de1tec1tii04l. of cillil!cll!Thi. by1llillfr.[ilCSiomdL iii S1ill:OOilll')OI!li[:<iI:cy em .omJiy' s1!!e:I1I!iIwom metfcl!lillolills ~ed1ll1:l!qIJ!e_ mtr.~~W1:.WJ1!m: lca1b!lilli.ar·e easier to de~ect lli<m. wcta] st,ooe.sibll:lJ1t,. as d!lis0MLs.Sledi.pr,eviousl}r, i~ is

Figme25-·

Traasvesse il:h1age .. (1) CalloulU5 dlemeastr:ate:d!. 'ilIi~ dlistaJ!. duct (rullJw), wirth pm~l:1a] sll!l!d!ge_ (2) My]ehyoi!d! (.armwed!)_

Page 23

FJJ_gl!lI:e 2, .. 6-

COl"Olllal! s e.cllon. (1) Stone d!emof:lsfu"a1ted. m dlis1tal!. dl!lct (anro,we,dJ). Nofie l!"effiaitliol+slhip. to (2) :antefi!o·l!"· beRydigas1tric :and!. (3)ecbogenic sl!lbm~ gland! (4) lny]o':hyo~dJaf:ldJ (5) genfO':hyo~d!.al!s,o' d~llonst:rated!.

M. iliep<ilil.o1tiidlg]and tlle mm.cm:ct is ,~jjd!entiied[ <iliSpndd ,echogenic .1lhnes.Thmctal! stones can he id!ooltilled. ifoner'enl:eJ1IlIhers !!hat 1tlli:e m.m.. dlill:ct lOonml!J:es~pmm[iltdry one illmger brei1l!d1illl.fudow 'lhe :z:yg,oma1ticncllmlliltiiIJ ~tp'ieriOes ilie:fulill:OclwwatO[ .mus.cle,.ud sl~gs:'holllilld Itne ·p]Me .iFu.1tliliilspiane.

Thep~e of the s.lIlihm<M:l!cilbwrn: ,c:mct ~gmorernffion!l.iI: ~o ]oca1te: tlte~ey to id!enili}rmg tlteproximDa1I.ooct ~s IDe hyoglJosJS1!l!S mlillsde. ScruJ!m. the G'OrOfl!1Ilip]ane ,afl:di ~dentiillY1ihe l1I1o/ro/hy<o~dml!]Slde1llJ:d. hyog£.ossl!iI!s m1uSJde more mern.!]r 'Ih.e PfO~<iI1lcmct ,."viillI.be sa:N!mvidled.beweem,. ilie hvo, ~ogetl1!er .... Vlitl\! 'lhe UgI!illaJI \iiem_ ldenltiify tllevcin. ,-"yittlJJ 100~Om:!Il]OW ~.e:Jl'I!. gen~yro1tiil:1te 1tlb:e Jlillohe wmJje~eBp,iiIlig 'lhe dl!Tct oeliltm!llm1t:iil. ,<ill tr~e:rSiepnru1e .5readed. \\'lith.lthecmct id!mtmied .. ]at,er:<i!ill. to ~yOgIOo.sSJlillS .. Thernst<l1l ~ct is nOoll!l!SiI!illalll., idJ.en1t6ed.m:hlless i~ isdtiillalbedL lit opens m1!o ilie ;f]JOoo,r of ilie mtD"IJ!I:n appmxillna1te11y one oe<!l1tiim:etre jh~d. ilie aRci1mwt oftlte :<ilflteriorbeJlil~' of di!,g~mc rnIllSJde to Mle mandible. A oOf'O:lIDill.SJcillI. ]oo~gffiuSJtpQst,eriOf. to llie<ilnteriof. 'helllly orrng:a!5kic ml!l!wle sflolilll!cl. rudenltiillYi:iI.11IY rns,t[]]. cirlG_, .S1!l!I1"o"lJ!l1l!decl.by 1tliIDefuyper,e&oiie lliiFJJgl!llaJIgllru1d_

FigIillIe 2 .. 7-·

CO!l')flal!.obl1'q_l!J:e image sllo'il<1ng (1) c..:ru:CWlillJS, (aMo,wed!) in Pl"O'Wlla'l dl![cll sancilliY·ilched!. betweea

(2) n:tyrohyojjdJ (=I')w) ;andJ (3) :hY(!Iglo'SS'l!:l!S (=I')w) l11mdes,"

iT· 11' . . d·l. d" . "_1/.·. 1L . __ ,1L •.. .' _"-. ':01L. .•..•.. .~111 . .;I!. .•• lll -"L.. . • .• _.,~"1 .i[;'.'_~~~ .::I!..... ..:;I:~. :1L

U!iltra!SiOl!ilil1' IDiiI.\y·· ·emo!l'l!SJtra~e .SJ!<1JiectiJiSJ!S;, .iJlllJlypoC!U.lll!orc ·PM'eJi1u.!~ym1ilL WliW. :prOlilllil!lll:efLt wtr<il!eafi!U!llI!!aI: UiliCES .l!51typrcaJi.· F r-illi~U!lIJ!d ,U!I!![il1t1iE:OO C1mi. ~LteSJeen,

I!l!su<iillly 'i.vhen. '!he dlITct c<icl!clililinJJsis;IDiso id!en1tilled.. a The oompllica1tiQlF]js of c<icl!c_, !I1!i[I!iIllie1y :si311ooel!eru1J.d abwess,ma!y~so be .rd.en1tlled. \viili.mtr,i!IiSlo1!l!l1d 9 DliJ:ct smc1tm"es arebes1trna_gnOosedi. ali: :SJia1Jography ..

Uliltra!SiOlllWd Cm:I. m.mmy wSElIDoes .~ ~e s_geOfi. d. :!he iim"Ofm<lL1tiol1l!.r,e;cJjlwr,eQl o1hvil<l.~g the need. for Sl!a1ographry . mtrag]<lWcmillill" orprom<I1!. dud .stones are deBl!1~ v,"li1if:u.'Illi<ilL1iIL oerWca!ll.<iI!P'proi!licfu (F'igJtl!l"e 2.8) whereasan in1tr'1iI!~or:<irlI<iI!P,pro:m;ch wiilll. beused .ifsto!I'Lesare .rd.en1tilloo.M the ,rns1tajJ slill!1hmandbl1hw<iIr or [p11l:01ttlJdcm:ct .DIrnctca1Jcltl!Thi. m1aryil),eremoVioo.ra'.rno]o,grcaJli.o/1iJ!mgb.d!ool1!S orb~ets,.1illd. Thiiliompsy is .a1Isobeing used. ie

Page 2-1

Figl11:re LS:-

Cb"lllnic: siiailladiel!l.iltisof(l) sl!JiDmaI!LdibWar ,g1.la:n:d! (!liI1!'I'Jwed!) v;;illi. (2) calbllim cllemolllisltmted!

in p1rOo:IDua.'l diMe'!: (aMOW)_

SlA.IJOLITmASIS

iPru:encli.!]'IDdldl!l:ct c<n1!cl.!l!lli.- sm-gery orr,[jJ)rliiolbgiicallllygmdied ba1ill.Qol]llh~e~. extr::[jJ)ctlon

iIJllIDctdiill[l['i';[l[tron- ,SJiaJlo:grapl\ly ~o iidenili)r sm;rliooct stoees ordJact smomr-e

Si~ed<ilsJis-sJl;]Jbglf<il:pJill,y if[ ohs.nc1tiv,ems.1brny AhSioeSJsJwectiOOi.-l!J!!rtr~SiOWd·- gmded~Sipiil:altion ,m])l!l!S

u1'tr<ilislolD!ll!c:li showshiill[l[1ber<iLl s~,my gliMdi 1e:mJ[j[fge:lil!lel1t \\itlJJ. ;<iIl Fl!omJ!a:lJ IBc:hogemci1ty_ Soml!etlrne:s "l:he~[mrn.,[j[f,e fuype:r,echonc 'ooe to fmry lmiiItr;&1tioo_ Ths mJ:1il!.}' be seen ill. ohesiltty, ailioohoThism, ,cl1iiahe1bes or m&emi!~_ F.a1t1tyillru1tl:atloo CialiJ. be seea ill l1:ormaJi . .wcIDill1ts; fu;~g<M1J, 'erne b~i§iS, <Ml!dl is oommorulySJeeJilli in No1i:fu. ~~·jL VariOl!l!s. rnetaryMdi.mefu]!hoThic dllisiOrde:rs. '<i1!5 '1"veilll. as ,dlnJJgs. CalTII. ciilJ!.]SJeparo1tild.emMge:lllent Aproment<il:ooess'IJof}' ]dbe of ~ep<ii:l:otrd mary be seen as ;[jJJ lilorm;a:] v:mill1t

The parotid. ~s ilie sallivarygn<rn:aimo.st o01flilimo~mIec1bed.:by <il!cl!J!1bes.~p_,1J.we ,s,jjaill<il:dJem1tis.; '!he lli1k!e]y Cal!J!Siesru:estone,.s.mo1tm:e Of d.e11tycka1tion_ The '01:ga:lill!SBI ilsIillJSil!l!aJ!b' s,taphyZO'CI:JiCCtM aur,eWl,bl!J!t Str,ep" pnewn/o':niae, E, coli: and HaemophiJU8 .i'1jluenzae h1iLVe;[]5o beea ~sd<iL1bedL 1'lillherclili!aSJis.m<il.!y cal!l!siegrulllillomatol!l!s irnliiil.:llllffii!il.1bory disease, as lill!i1IY 1!l!cJmTI!OIDI}'iDOiSJis,Syphi!s, b]Ol!SJ1boml}'l()os.is [jill;dllhiis.top]1IDSmos11s; howeeer, tNeSie conrntiDnsMe w:me_1 I

The1!l!cl!14!ti}r iirnlJ<Mlled.s.d\r,ary gIi<mdl sllows.e1lill[jJ)fgelllf:.:fL1t<md f1y,po-ecno:gemicitry onm'tra&Owd. SiC~g_ Thep[J£,oocJ1ymi1l. ffi<ily}]aVie [jJ) }\te1terogBneOl!l!s. pa:Hem. a1tltl1burlt<llble to iliepr,e5eFl!Oe ofmicro-iIowesSies o~ ID~Sied!. wet diill&Eafuiomr!e.1tel1fuio:l1! cysts, iProgressloo.1bo ,iID.a:'b.SJoessr,esl!l!l!tts m.a:n. iiIiI.-dcliined. h}]:Joe:chogemci1ty '\;~ilite gliiMllid,Siome1ililnes wiili nm.fmiid ooo1bent There mi'1iILybe furyper,e:chorc ibci. ,rn:m.e ~omiCfo1blill!b1billes of giil's "WiJ1!:fuID. the abSioesK iP'rio!" to 1ID.q;lIT.eE1!l!ctron, tlte1ihs.o.ess will. a'ppem- M~l illiI.-d.eJllilTI:ed hypo-edl0ic i:rJ,f])1ll:mIlla1to[), masK The ibright m1tl:,lIrgll<mrn1ill<llf dJruc1tsm-e deml~ sees msidi.e the ]eslbn,mmcaMg 1!f:uat '!he £esiloo. is illil d.efuJ.ed '1iIF1dperme~t,es. tl:JillOl!J!gh tliID.e gl!ru1J.d.r&ilher ilirlfl ,rnJ1]!smg dJmict disp]<iI'Oement .ijli5per 'ffiimom_ iP'<iIIDfu]pru:01ti.di. Of. neck :llOdes are often jlilleSiel11t<md itt ~s posSJ!1):]e '!hat ilieSJem<1l!yaJiSio lli(j)l!l:eI}r ;~dprornroe further ahSiOe5.cSieS_ UTllir<iliSlomdgWd!.edaIS:p.i:a~on a!illows appmp,ri<1lJ1be ;<lll!ltllbi)otlc ilierapy tobe inltrodlloed; ill It'he ease ,of1!1!rull!oowillar a:bSioesSies: irltmary aJ'\!irndl &e :Ileedi"Dr s_gery_

m, TRASOUN""D' APlPEAR..,~.NC1:S, IN 1\,OU"""1'I:. 1N:.FL411/Il\/IATION

Si<lffiOO.el1l!1!Us-h.51\B[ogeneol.!l!S, hypo- eehoie g]Md.,millc:mabscesses

l!ml!<iL:Iillma1ory m;a:s;s- hypo-echoiie, ~-.d!cliiI1!ed g1!an.cl. dJ.ixc1ts '!oViJ~ ]eSJ!Ol1.

AhSiOeSs.- n1rnklmd!,.giiliSmrcroJb,lill!lb!Jb:]es

VSSies" .. m.pa:dicwilf tlle .rnIr"l!&pisms, ;ru:e the .mo,stfr,equeflI canses oEsm:m:y g]<il:nd. sw,elil!ffig_. Vir,<i!!lI. iimoc~oo 61ill!Sl!l!aMYiiIL ,cllliW.cal! IW~gn:QSJlS, .flottreq~g ;MY ID:u<1l!gi[lg_ U1i1t!l:I§!SJomTI!d. slliowslllil"hl1ll<1l!tera!lJ or bi1l![l[1bet;a] .glImd! ern;rrge:m:ent, olen fuypo-ernDre iiITI! 1bex1tl!Jtl:e_ Ce:l:Vic1d. nodesare OruJ!][l];Ofil_ ViiI;:&1! im"oo1tiiom .m1ilLY

-"-- •. "_11[ .;II .'. .1\.::_.1l,....... ..' . .' . •• (jJ[i". .., f'I) 12 Th' '. ." .. ' . e ,,1l,. .,.,f .;II

canse a. 'C:!llilomCSll<fla!.o;.eruJlt:!s Vhu'C:!] CM. eanse re\cmr,entpruotl1t1!S "le· ~.gJ!l!I""e ",._'j'. _ I'., e mruI1I! .. reMOO. :J!!Dr'lill!e1i.l!J!H:iilLSiOlil!l1ll! seaa

PagelS

F~gI!lft!, 1 .. 9-

;\xi)aJ!sl1!-cuon ·ofthe pariilJtfdJ Sf:JJor\YiNgml!i1tipIe m11ltl!d!~cli fuY]Jo~ecl1o:ic areas, 'iYitfuina fue,'l:Bfogene01!lJs. pmenc:fuyma_.

No.te, (1) lliand1lJ.re,. (2.) leuolilLand1lJ.Jlli1Jar v,em (anowed!),. (3) erlemaJ!cafotfd.arlery (aMl1lwed!)_ Dijagno.s~s~ Juveniil!e crul1lruc: sdad!enit:is,"

FiigIllIe 2JOL-

.'\xiaJ! image ·of taiJ!ofp<3Iotfd!: (1) iI1LdJefine,d! abseess ";viili internal! dJeibris (aMowedi)_ AS(pil'attiiof!!!. yieJ!d!e,d! Pl!illS,_ DouMe ;anI'D'w-· (2)pmlleii!of be11~' d!igastric; ..

Sjogrenis s}'Nmome is a common alllJl:o-'~l!l!I1e oo~dlirn:iioo sleenamtost exdu!SJiv,e11y m women_ Thep§:liien1ts me1!llsIl!a1ll~1" Dliid!dille-agedl.ID"emailles \cv'nopreSien1t \.viJ.itt1lli-4-<.· ." re'\J1eS<lIl1I!dmDlI11th

~,J .J . -

~. :!he eru:lo/ :s.1t<il!ges :!he ;s.;nillW<iIf}' glludls Jllill![iI)' be @o:n:miicl! or :showdifu5Je rm[jJj[ge:rn;ellt r".wtfl fiorm;]]. eoooigemcitty_ The ~a~e iellmres me vTrurilly dli~g:Ilostl£;: i::I. l\J:e1terogefleo'll!s echo texmre \\"liili.mllill!Jittmp]efomd hwo-ernoi:c

Ffg'l!lIe 1.1 1-

Sj:og:reri's,d)is,ease ·of slLlpemciaJ:. pra:rotidL ROhllld!ed! fu)'po-eclIi!o~c: areas .... illi '!eliafIiive1y normal!. fuadgrl1llllilldpCllilTenc:hYlt1<l_

F~gure, 2.12-

SJibgrerls disease, AJ.riiaJJ section ,ofprafI'D,tidi ShOr\ving mlillilitlp]e l'I'Dllrn!dJedJ hypo~ecl:ioiirC <l!I!e..<asdiismoorl:edJ tmo~gnolilrfi: the glandL N.ote silnilla. ,agpeanmc:es: to s:liaJ!acliemtis,_ (Fiiguillre 2:9) .. MandlMe (:anrocwedJ)_

Thelf{)]e ofmmrasol!l!l'ldi run Sj:ogre1i1's di!SJe;we is avo-:fold!: (a) to ooil'lirm or excmdiesmID)! glimu:dJ WEVONe:IlleFLt; (by ®o ~Odlk:. for ~rmpihomi:ilt}()ius ,d]1ffige, as '!her.e ~s <mi. <il&socii:1l:fu!on of liymphom<iIL \Vlifh Sj:o'gnB1lJ!.'s sym:mome_

S~aJ!ogr'1lPhymacy :Sill>owpoocta.t.ep1]f'oorno/M;IDi opmmEon .cmdi. mEli'iIL\IMa1t1rnJJ.c:me to dffimgilliliiSled. ·ooot 'ep1'1:ihel:im]]]L Scm1!l!g:r.apfiy caabe 11dpillimill for mD.l1i1bomg ilierespooSJe to ilierapy _ Howe~eJ[., :lheSie .mod!<rlitiespro:babilly homV'e llitfe ,e)!j1tl"~ to OlEme:rm m~g the d'ill~g:rrOSJ!S_17

S:Mco&dlo.s1s l1Si:iI.rMe ,~ca] m.dIDg in tl1ie s:6ary .~dl (6%)'I)11]!1: ills fiiLst,o]Oglca:llliy present in 33% Olfpa1tien1ts r..virl:h. sMco&dlo.SJ!s_ It maypreSien1t as [iI. mp, l,wlOO. 'or 'Wi!iliOiI:JJ1t lIoCi!lll.p~_ li11ID1:,1iI!5ol!1illlidi is: nONi-specmc !hl!JJ1t m<ilL)' sJ1owdmSiel\!ypo-ernogemci1ty m a. norm<iiJ!. :sJmed. or ,e:lThlJmged gland, The sl.!l!bmruJ!dlillh1llilln gli1ll1l.d is ilieElliIlvomed.Sl!1be_ It is ~e11y ilii:1l:1t 1tl1:e ,g]Md ,-,..\:riMI.beEl:!cisoo. for a .. ms1to']ogtc.:§!li. dii:il,gno.slism1illess, as moome mstm:mes" lOOe rni:ilgNiosills has.e<il:d!y been ,estllhThishecllby o1ther me<ms,. ie_ omebiiop.sy_ Heerlimd~.'s SjIDdrmlle isan.l!l!I'll!llSl!lla.].form ofs1]f'C!oli.d!o:sls oons:isug ofweiitis,.pw:01ti!di.swdillirlllg and!fu:ci;IDi P.'iIlDiidf-ySllS_

RijJ)d:i!ot11eJf<il.pY of tl1e neck mi!l)' r,er.m~ in]ocailliis:edpiilll,orswe1!lmg ill ilie s~~ gllan.ck. 'Thills tLS more oommon. ill '!he Slill!1bm1mrnlhlllillMg1i<mdLFn. tl1ieiiLClIJte [p:l1J1lliS:e tlJie glliillQd is ,emmgediIDild. fuypo-ernoic: whem:,e1lI!S cm-onic dl1ffigeresllillts m<iIL SJ!l1I!aillI. iiLtr,o,prned~ hypo-echoic gll~d_

Tr::iL1!lm~. ~o1tfue :soilivruyg]andlsus'Jillidy .MvoNesiliep.m:d:iidJ g1!1lI1:d_ The ,clliimcdyepOHi!WI1tmTI!iiI.'ltwciilill.s1tl:"lm:cwes .W:!.1tillsSJim~tt:ioni!L:l"e ilie e:de:IJ1I!~. CMotid .

. artery.,. 1ili:e Iilci;[]. ne:I.'Ve and StooSJoo.'scm:ct CT ~sprob~bd~ ilie op1tiJmali. miit!aiI EiiLgmg mod1il:ThJ1ty, b1ilJt1ill!lJtraSiolilll1ldl. May hemp, IDO <3iSSieSS <lI. siii3l!ooele O!l"' :hll.e:lJ1l!;j[tOml'~_ Si~og:r<itphy m1ltybes1t u,;]Uge tlle S1teme.l'l':5 arud mjm}', .howe'V05rrutr.<il!WlillI1Id cili'I.de:l11Lomtr.&!te tr1lrn!S:ectioo. olfilie met (W~gmr,e 2-_ i3)a:I];d :lTIdpm. ilie assessmeaa of :ffiis1Milli:1l:e_

F~gM1'e 2.13-

Ax!ial! image sl1~""-rnrg fur,ll:I]se.cledi. ·d!ista:l! p'3:I"~fu!d! dud (a:rmwedJ)_ mj,my slL]sb;ne,d!;f®m~'WiNJ_g an as s.ami ""iilia bmke.n glJass .

Th.ep<iltioo1i's :s)'flIpt0rnJi51!J!SJl!]ldiy rdi!l.'lte ®01ID.pmp.~Jb:]e. mp orprun_ Up IDO }~)% of c:lliOO)ca1illy dill<IDg:I1!Oc5Jed smal1}'gl!Md~ses are fOlIDdiltobe dlrrne to ]esilloos 01!l~sj)d!e ilie sdv~ .g1l<rn:dby1!J!l!1tr<tiom1d. (F~gJ!lIfe 2_14)_ l!l The mcidenoe ofs:a1lEv.;ny gl!&nd ~om:.5l1s ~ess 1!h~ 3perUJiS .ll!ead ofpo,pMilla1tiolfll, .a1lI:fuOill!gh iliere are r>BC!og:l1l!SJedl geo'g,nilp]]illc v;mafuions. Sm;iJ:I)' gllmd. fu!mJ;oms.iitlf.emme 'ooml!iI11!lomlySieoo. ill 1tlh;e 'p[jJ:l"iofuidl; 85--'90% of ~eSle<tr,e beJ1l!ign_. The ,~ca::l. piiIl[:[il!ffietrer.s formug:Il!<illcy :arerapid!ly growmg £eMO:Fl!5, ~odlaJJ emiilllge:mel1l1t<iill:df&.ciId1! fle:f.Viep1llf.<id~si!s_ HOWeVief,becal.!l!sJeSJ\TI!1bmmdlibwH ID1lli1SieS JEl'iilLVieiill yea1te:r.propefilslrty forma.1lignrulcy (33%1~e sJOnO!no~st .sbomd haJ:V'e <:I. ]owe:r tmesho]d ofslQJspicioo. Jor ma!lliignoot mmoms WE. tltes\TI!1bmrul.rnlh1!1!llotr or .51!]JbmgJilliallSJpaoes_

The SJruL\o]DglSJ1ts&.nwd beware of <iI. ]ru::g,e 1tI!Jti!nom or one .msmgfrom. ilie deep nobe (llies'siliJ.<ID. HJ!% IQf cases). 19 It ~s not :<i!lIr,.V&Ys e1BY to <ilocm:atdy assess 'iheext:en1t of @te lesion. m :ihes:e rnclilllllSitrnThoes.,~d Cl' or MillU \villiI.bereq;uir,edJ... Oocasiml.id~r <iI. deep spaee mOliSs., (pi!L:I"apha:rynge<iJill,. CMofuid m ·mas.1ti.Ci:il.1tor space) mi:1l:y .wsp]aoe '0([ .irlIDV'i:iIdle ~epHo1tiidilllill!d!.s.iimlllill<il:1te .<iIlpilllio1tiidm&Ss '00. dilw.c<ii!l. 'e:}l;~;]Ufuioil1i_ The SiO~O~0giSi1t needs toassess wTht.e1tlh:e:r. lOOe hOl!lll1dm.es of 'lhem~s coo. he d.eM,ed O!l"' whether omo/ the "1tip, of ili:e iceberg' ~s 1) oog m<il,~edJ... Deep, b1he mas.S!es <11ppeotr medlii1il!].1to ili:e mudi!ble ;1ll1!dV:1ID.5Clllill~p~<me1illd. cuSJepred!omIDi:i1!11i:l¥ ]ll!te:r.'il1I.cm:ctdlffipffi~.C!emffit_ U11tr.aSOlillid.~s as effecwe as o1tl1.er modJdrruies ill~ero]e of mtmom ]ocma1tiOfl_liII

Page 27

SOl,li]sry

? COnSlB'.rvali'\o's

CTIMRllmr

" d13ep, rOlJ~' parotid

• ~lIe-Flt of i1ll~I!r8itlo!'l, larg;e!llmour'S

/

IlflilFa. glaML!Jar

/' \

Well d~~ined 51JliIary hg!ll!og~f1!)!,j'$

I'aca1 invasior;J associa.lad FflailignaJll node$

us. dE;3,gllOStic +J-o~her in,\!\g,s~igaJi(ffiS

Benign

.MiOIllgfi<lFlI

F~gI!lIe 1_14~ Ultl":as'®l!lI1Icd!.of's.ati'ii'alY gJ!<mdl mass,

The origiirJJ of iliem[l5s is oopol11IDt not oml}' ~. the: dliIfferen1!Jlrurn1l!gI'l!O!s1s ibl!JJt.m.o mgHIildIDg lOOe .s,m:grcallilpproach to ilhepi:iltiemt -& 1tr.,amplMotidi ,~proildru v..:ri~ ii.d!en1tiliic<lI1tl!oo. ,of 1ili:e faci<i!ill nenJie, O'r <iI. :peri-O'r<iiill or s1!J!b-'m<md~11}1!JilIM incision. fOf ,<m extr~ID:'01ti!d n1i<iliS5.

TheillilitraSiOl!l!l1!dI. dis:1tiil1c1tloll1! of benign. ;~aJmoilign'<mt ~esions is l!1lotpreciSJeb1!JJI sllsprcion.sholllilldi.be MOllsedl \cvhm 1tl1:e]esron is: iillI. dJ.clined. m bca.llliy IDv-;a;rnng, when iilt is: iF! 1tE1,e deep ~oibe"Md. when lleck. nodes MepreSioot ill1tr&SOllliIld is ;~b]e ®o ev<il1ll1il:1te ,<iIlhel'l!ig:ll ~es:ioo.m over 801% of C<iI'Sle5_ 21 Go.]o_ Dopp~elf mJ:1il!.y ;a:lISio~dJ .iIl. :!he assesssaeat ofmdgl1!1IDcy;. 1he £esion. 'iMiili. adisorg~Siedl oob!1il' lD'Opp,Der :p<iI;El:etn <iIillldl.lRI >0 _ 8, jp1 ).2- is more .e1Y to be mallignat jp'r,erno1tioifl. ofma:Th!gI1!i!Iilll!cy mary ,mI601ttl1es.m-giic~. :[j!ppm1lch, :<md tfue d1'lilg:l1!os.is: m[ilLy!I).e ,eMi<illced. '!),YMe-needille ,~mr.aMoo (iFNA)_ 21

llnkap:a:ro1ti!d. or extrap:a:ro1ti!dI? \Vel!l!. dclined or i1Iill. ddiil1ied? [,oca]. mv:1iliS~O:I'I?

S~e:mci:~lJ or deep ]cihe:? SiIilig]e olfm1!lilltt:ipl!e?

Comp]e1te bOlill1!diMies Qiffilm1tf~omd? Need, f.or otl1er tm'lli.gm,g!

Facitd. l!le:l:'V<e?

Nodes?

lP~eomOiFpbic Ade:I!l!Oilna

jp']eomorpfui:C ;Bl:doooma ~s iliemos:1t o011lllim:on of ltfu:epmo1tiid 1tI!JliilIlom:s ~6(}-80%)_ lH:iSJ~o]ogyre\,Iie1Ills <1IJ,rn~D[t~me of 'Bpiltfu:ellEorli <iI:I1Jd ml)'o-epilhel!iiaJI oehlls., l1enoe ws COnlmoo. n&me of "benign. moo truImom' _ Thepaltienlt is t)>picd~ more tlh:m 40 years ,o]dli!Iilll!d compi]1:liI1!s: of <11 slbwlly grmvMg mass_ :E1t ~s ruNe Oomm011. m women. ;;md.1is 1t~. ~es 'ffior,efi,eqlIToot ill !tl\Leparo1ti!d 1tllIDan ill !tl\Le s;l1JJ1bmiliilicl:JJbmEl:lf gllm1d_90% ofp[jjJ[o1ti!dpleOl1l1orpllic @denomffimSJem ~e . .s:lillperliici,IlJ robe :omda:re :ieqlillentilly~s;eSi$led adieElc][]!ateliy Jb.Ylmmttf@Siomd ;aillo~e_

lit is d~ed iliat in '1!lpto 25% ,ofp]eomorpl1ic aJdjenomm> smd.s.a1te!llite ioci. casbe deJ!ll1:0<l1l5Ma1ted.s.eparatewo!lOO tfue m<ill1mas:s_13 TIL:is: l1!m> me!lilleddeba1te 'mraiil. mlLJ!tttlooomc origil1 'Of tlhls ·c:fu,.e<iliSJe_

jp']eomorpfuillc ;Bl:d!oooma ~S1!J!Sl1!J!<1illy trea1ted by <iI. :SJUillpericiil1lpilllo1!idl rdhec1tmnybl!JJt :!here ~Siil.pfOpel!1'sity fOf[eCllIffe~1LOe_lin.some .iIls:tuoes: !this mary 000_ ,heca1!l!Sie tfue mlilffiticenmc flj[j!ue of ~e truImom 11m> flotbeen. identiiedl r..vith. the re~rn~ tlIDa1i: itt is: Mcompi]ete1yresect,ed_

Thelllilltr<ll!Siol!l!l1:dililppeID:<1Im1:oe is: that OEi:iI. ~(]".o-ernoic :Siolliid.m<illS~s whicJh; is:ml!l!l1:.dl 0'1:' ov.liiI.m1.dl wel!l!. delillnedl ",,,rIf:I.;<iIl rOib1!]]a~ed. orbQs"sda:lted. :smaoe_ 'I'ypiccll1y :!he]Jilloomorpmc <il!d!enOffi1il. is: £ess ilim.3 em. ilmI. dl1illle1ter, Jfuypo-,ed1:orc,homogelil:eo1!l!s" wdl.d.e&ted~d ,oEIDen, d:ispbys "1tN:o][]!gl1i,' tr,msmss,JiruJ!, (Figl.!l[es 2_ LS, 2_16)

Fiigl!11'El 2.15-

Tj"pilC;3] 'WoU!gh~ t:ranstJ;tis S10ft (a:lNJwedi) dI~lOmtr,atedJ m !l~1l!llticenm::c p].eomofpmiC adenomata 'iv-ltlJinJ llie]J!afo,liiidL

F~gt!ll'e 2.16--

,,'\x:iiatr i:magelLlJsmg 5 !'!.1Hz probe .sno!\",ing (1) smaJ:lpleomol@rnc;adienoma rn dleep ~obe (anowedi), Note (1) 11tandll)]~

(3) s1!lperli!ciaJ! ~o;be:piafot!iidL

'Thcis.sillo1!i!l!d. :I1d. Eeadl. ,to itbeirlg comlm~edl vtiJ1tI\I. at cys't- oob!lI1: Dopp]e:r may d!entolll!ska1!e mrraTIImom :Ill!ow., or FNA can oomirmih iI1iOOi~cystie fll1Tm"e_ 'fillie 'i1!hn:Ol!l!~" 1tr,~cSlioo is. :prob1iLb]y c~]]JsiedJhym arttemctt- .]]uyperernorep.;rr,ooehyrm><l!. SJltllff,oum:dliI1g <iI. :m<M~ed[iy hWo-,oohorc m1iliSs,_iUso, tlle .m1iliSs, e'ffed .of '!he ]e:SJio.n. ]ea:dlling ~D ,&wet d[Ls.p~jjj)OeJillentliU1d crowdifulg m'il.!)' .m*e 1ihe deep w<irl!i, of llie ]esion echQg~cally Jb.rigl\l~er _ M<illign~cy :shollilld. be ,oooSJid.ered '!;vhen EI1:e]esJloo rus:poor.1~ dem.ed. or ~ere isfr<IDk. ]oc;n]. mV:asJ!~)!NLLadk:: .of hOm0~enel!Eys&tol!l!l!d ~o be fe,gl;rrded as Sl!J.ISpici'OllS_ Thepl]eomorp:lMc ~denol!NiiI, ~s: gem:era:ltL¥regarded. as abemgrJ! ~e:siofi; some sl!J.Iggest tllliEil:1t i~ ]w;ms: :m<lilig;lllii:illlltpot!enI!l!11l:IJ1IJJt ~ js: oon1!oo'l])Ql!l!S:_

Large fu!lIIl!10mS c- ]; cmJ)[!l[,emo1fepm:l1!e ®o CystDC .or ]w<l:e:inouh[JJg!c d.egMe:E":ao!l1, r"v]riiclTh .mary 'C!illJise,:I["ed!!a;ced .hoiJ!illqg~city on.1lill1lr<fuS!o1lI!l]dL C!1IillOOC[il:fu)O:I!JIl!illaljt also occm: m b'lJg,s,1tandJil!JJg frntm:Orl!lf_

I'LEOlVIORlPHIC A:nENOl\lIA

Femaillepa:Eient > 40 yiMJfS HOlflTI!og~eOil!]S" .hrypo-echoiie Wel!l.-d!elIined,rol!lll1!dl ~o:h1!J.il!<iI.~edl '!ThOl!J.lghi Wm~s,ioEl!.

iPeripherali oaDaM :@OW [)Iopp]erp.rn:tlern Mmnloenmc

'Theool]om OO[.lp]erpmtte:ll!l of thepte011llo1]lihic adiel'lJDm1ilirus Vru]<[o]eh1!JJt 001ill1lmQl'lffiy sfuows, mctre;:asiedJperipEler,ailvesSleJis.,. m~ "\'reFJ:Orl!illS_24 Ths .P'<!IUe:m mJ!aly heseen\w:l:h mdgn~cy <illdso Cruilit!Jlot be;regm:dedl asdii<il1g:1l!OrsEic_ HoweViet: ill <. (lr_8&nd.lIf"]·< lJl1mvul!][' <iI. oemgn. ]esio!l1_;;ti

Wadb:iio' s Tumour (Ade:no1!y.wplloBla.}i.r

"Th:ismmol!lIlf :OC'OOil!l!l1ltS for '6-WtI}Q ofp,1l:[o1tidl mrn:Orb]I[S_ It typio~preSient5m tlillJe elld!er]ymale (> 5() years) as at mp m &ep.MolLiidl1taiil_ It iisrmdy :S1eenim 'l!fue 51!illb:l1fUlID'ldll!1)l1lill[il;[ g1!i!U'lJdL The 1t'uDOlll![ arises Mom hel:erotoprc s:~'g1!and fi1L5>SilITe m:p§:[o1tl!di. l~rmp}\]. nodes. .I[t fum i1llJi. rexoel!lJent. pro,gnos&s i1llJidl does :I1!ot'itelllidl ~oreom: ifreSioct}edL lndeed. many '\V.~'s 1h!m:i.oms' mayl!J!l'l!d!ergo s.l!l!£\!\dlil!mDe vtiJ~outresorl:. to s.mger-r.; FNA is llil1l!s .p1ll:tDclllill<Jtl~hclpfu]. ifsmgery iis lOo:l11tnlu:I1:.di!ca1ted. (lF~gm:e2_ t7)_ Lessthas 15'% <trebJW.ner&1l_

Onlillli!r~ow(tjjj) '¥~'.'s. tmllo •. rus typrcd'y wre!)!! aCll!l!IJilIoonlJed. :ID1:d.l!l!sl!J.I<il1il!y less tI1Jm 3 rem.m rnme1ter _ ltm<l!.Y s11iow .m1!em<ilJj. he$eroge:l1:eltY of siollidland cys1tl!e areas, 11ncl!eedl, .<iI. ksXon Iih[il:E ap]),ears wd]. defu1:ed.,W'lJd.sho.ws 3. ml!]JEiLSlept1~ed. cys'EDcardllt}ocmre may be d!i<il1grJ!oSied.as <lI. W~'.'s: 1tmno,lllt[ ~1tIl <:I. ~gh. degree ofs>pecmcitty _ 'I'Ws ;dMsirnll' :ap'p~Moe, howe\iief, lIsl!illl'l.l!l!SJilll11il_1J5 W,~;:s. 1ti.!mlom miiiy ,~so :iiIf.IpeMiiIfllitedloie rr,.\~ hOl!l!g]lli u<1IfI][csmsloo_ It is. of1too IIWs1t~en. 'wltra®o:ro!c<illy£or <iI.pllieomorpmc ;<ilid)ffiomaJ_ Cd]cIIil!][[]OW

F~gw;e2J}-

FNA of't}"Pi:c:aiI WailiIlhiiN's tumeur in taiJ!ofp,;ti"oifuidL Not,e (1) e;cbogenic needle tip, (2) :;,oridl/0'sti!c: rumom-" (3) pm~mo!be_J]y diJgas,tric_

M~e > 5()1 years

Hypo- or Meciloic, welil dcli'!!1Led '1lrrrOil!J!g}\Il' 1tr,ms,liIliiss.iofl MlilmtiiSJepta~ed. cys·ti:c mchirl1ed.e Biilla:1ter.al1

Ape:dtrui. ,of :s,Ulpe:mcii<ill illQbe

TfuiiS:1J.]!11OOl1lililOOOOi. 1t1i.l!IItom ;iilppeorrs: ei!!c.m~eliy m~e o]d).e:radJoilllt {> 50 years). It ~s; a. ;8Jollid :itmEom oompoSied of o:l1ooqles (llmge cells \-vihl'JJ grmm1rr 'easmoplUc c}1op]~) ;<mdJ is ioood ill iliepMotidL There are fiO ,speciicmtr;a:sJol.!l!l'ldi£eanes; ~t is ;smM map,pea:I'MOe Ito ilie oilierbe:ruign, ]esiotThS_

mherBe:niign Tumonrs,

These ]es.J!o:l'lsmSie ~. the g1!MdllJIarSp<10esfrom flOl!1!~parencltrymatollJls eille:l]j])ents_ They ilndl!l!de 1lipomffi1!5 ,Md Viill5cl1lillorr . fumlno_s_ The lmpomat 115 wdill d!elIEed. ;<mdlllliyperechotc_ 1:118, oompresSi.ib]e~<ID1re <mdl.bri.gfu1tstrer;rl1rsp<n,deJJ to the .skm. ,smaoe :<neuSlemJi rnagl'lOiSJ1tiic£ea1h!Jilles_ CTmdlJ1l.OO are dw;wgl1os1!lc ;<iI!S they diemonstralte ci1;nact,erisfu!cia1tt-f aMefll.!l!<lITIon mS~g:Fl!<1l1I_

HaemJ<IDgrornffi1!5 are mOlf,ew,eqjl!l!entllys;een. m ,dilldr'efiJ. or Yolil!l1!giil!.d1IJ!1ts_ They mary ;a]80 ibe oompresSJ!b]e<llfld m<ily~eijlJ.1billmiSh. ;sm.dlliscdomatl!ofIL TherymffilY c:}\]af:lge iinI size 'WiJili.po.s;1trn'e or orymg_ The~\tr,~l!liI1!cllshows an IrntOmD~ffieOl!J!S;]esi0n which iiSl!lLS.1!lldypOOrlly d!.efiinedL 27 V~1!J!llM~~oes OfiilSs,oCt&ltedi. ;<lIOO:Olfmiilly Farge vessels .lill!<ilLy oC"G~o:i1Jdyhereoogms.edLF oeal ,y;illJcmc;j!Mon (pl11JebQll~s) may be idi.entmJed. ill ~SiO'INe iiffiIs.t~oes_Cab!][ ]Oiopp]er irs gemer<llillymlludpmillas ilie m1te:I1M:lJ illlJow is ltYP!cd.1ysmggjs.hrmd 1i:hlIl!S it. isdliIliicmt ltD de:JLllomtr8lt!e ~S;l.!]oo. ~QW :f]!oW1i,ocloQtmes_ Co]om '!:mI. iinI.'mJaryhe observed l!]]J~r,eilleas:e m[preSJs,meaier 00ifnPreSJMOfI of the maSK

M~g:I1!amt 'f1l~ili&~ lti!Jmoms of ire sOJJ!iv,my .g]M& iil!oool.!l!l4ltf[m 1 7% of .~. epiili.el'riali1tJ.!mm;oms_ The cSmaillier S:~ID)'gitmffi h<il:Viegre1ll:lterma:Thi.g;I1!mtpaltem1tii<ll.t@ 'IDmOM in. the Silil!blli:l1gJ!ID<i!:lI. OfsubmMdllib1lJ!llm gli1ll"ld.beim!gmOli"ell&e1Y tobe mdgnMi :lba. <iI. mmomm iliepMotidi,

Ulifur1ili50l.!l!l1di.orli.o:l1!e m~yprernct mallignMc-ym 80'-89% ofC<lliSes_2R ThelllililtriiliSiolil!l1dfea1tmres .i~mes:ii!:!1illHIDor d motliiig:l'l!<mt ]esio~s :and it is not posSJ!b]e 4\0 ,d:iillIeren1tl![j[1tehem.v,ee~n tlle hll.s:to]ogfc;a]l1types_.

Mli])oo-ep~di.em:ojjd cmcil1!om@,[]:CQom1Is.for 5-1()1% ofalllls:dv.m:y gb.lIDd. mmoms, 1i:l1em[]]jiori1ty ariising:from. ilieparotidl. (80%)_ It oeeers at~y age and 'Ille:f>e is lJ!DS;~pped!omil:u1ID'0e_ ]t is "'e most OOl1llmOO. mdgnant rulliE:l)il1lill afdillillcltood

Most of ilieSJe 1ti!oooms are sJ!oWg:l:owmgmCli.preSJoot as Hm. or .hrud ~esiioo:s_ There is a marked. ~,oodency for ]ocaili. mv:~oo_ ]P'm. orltcllmgm ilie :E@ciaill :I1:efVie 1ten11tory ~s MrnC[]]~e of@maThigFl!ru11tpm:ofu!di tI!lmom_

Ml!IDoo-.epid!ermoxd. c:arcmomiil!. ;arJ!s.eswom. 'ooctali eplith~_ The m~rIDo:]ogllca!ll.gr<ildefd!a1tes Ito the ,dlmcal!. Jllctme: ;~ ]ow - grade ·fu!Jtlno_ mOlLY leeliMd ]oak illi!ke .[jJJ. bemgl1~esj)oliJj_ SiimiiillM.l~t, ]ow -gr.a:de £esJiomm1li}'1ltpp eru' we]] d.e:ilThed wW,s,1t ltflO!SJe of rngfuigr@diemepoodly defuedlru:J!dJ IDiil.cybe i:,~1y 1'ml!]k~e (lIF"i!gm'e 2-_18)_ ~t is diilTIftfclllliHodlliSJ~[j[lte iliehef!Liign .or

F~gw-elJ&-

IIJ.Lrliefined! lh!e~e!il'J<gel1le~1l:lJS ml~l!lf in 8l!I;perlI1ciial! to'De ofp;a!"o1tidJ (aM.orwed!) .. Ml!l:co-ef~d!emL~~d! c..a1'Cm~!l1a ..

;rn<rlig:ll!tIDt Fl!illIne of ,<iI. :sm~ loornpsllJillat!ed ]eSJ1oo1!l!~gl!l!11tr"i1isol!midlllH!~t ]ru:g;er !ti!l!lill0_S ~el1d ~o N!<iI!re <iIlmJ:m:e cOI!lll]J~ex ~e1terogooeous iIlli~en'l!<i!'l!. edlopliltltefi1_ 'I'hiis. irIiIomog<ene1r1ty [elects neercsis or h<il:e:Illortlh:age wli_ 1tlTe rutm:OM_ U]1t:r~oDd aliso de1bec1ts .~ floda:ll mel:'[iIiS,1t&S!es m 100e neck_ CoblJ!l. Bq,pp]er ~s mor'e lliTIkJeIry ~os.howpronol!W!oecl!V<lIiSiclllil!aris,._on_::1:9

AdffiO&d. cys.tic cru:cmDm1il .: arises.m-omperipherali.cm:ol:s. ill ilieparo1tJid.g]1lI"1d!; it @OOOmlts. -:IDor 3% of parol1tJid. hmlOMS '1IDd up to 17% oFslili!bmru1:rnblllill<itl. ~oms_ ]t tends to show .It!Hiillka1tiol1. (Ii~~gmre 1_19)Md .. ~s.pro:l'te toperiiFtemials.prreadi; even Slill1I'<iillperipher.lJill rntI1Iito •. s mV<iI!dlepromilll aerve ihrres_ Ullttr<iliSJolillIl1dsfuows '~ru:~eatmes. llo 1t'I1e ml!Too-eprdiem1!ord C[ll"rcEoma<md CT 1m: 1\00 l1I1!~y be ireq;mred. to assess DociilJI ~'1!r.1illlioo_. Adenrnd cys,trc carc.ill:ornatS are more commoo. m women. over 40 J'iears. ,Md :appearatS soJ::itru:y rOllmd mrn:oms. aooompwed. byp-am or :facial !I1ieJfVie m\iio~ent

~4ciim:i:c eel CarciIll'o:ma

1\!L4LIGNA"N1' 11J1\/lOUXs,

• m-deil1edV1!oc;dly .itl'i;'~e

• J!mlomog~eolil!s.Md.llypo-ernorc

• As,sociat!edi.magn<ilfll nodes

.~ Dlisl()rg:~Sied ooJ]oudJJow, ru >- 1~18, jp'] > 2'

F~gw-e2J9-

Arlief'l~caroin(!lmaofp;a!")j)tlclL Het.e.fergene~l!l!5, lh!Y¥")j)~ecboi:c mmow: 'ilt-iili iirre,gllllJar ma:rgins (ano,wed!)_ N~lle mgh.peak. systol!i:c veil!ocity \vi.1lli a mgn :resiis:i:ano,l spec.tr.alJ trace,

]\.IIella:sta.uc Tumour

Thepmo1tid gl!ancl oootm<s Jiympfu nodesbeeaase :of ~1ts embryoro,gicdy ]a1te el!lc:apc~lilili~0:1]_ These nodes dir.m.1tl!llie ]~1terall.fi:J)e;e :<m:d S'~ and.lex1ten'l!a] :mrn~oryme1iLms "-vmofu exp1J1iIIDis ,."v~y sq,1ill!iilIiI1I!ol.!l!s: C1llcil1!om1ill1illdmeJlm(}m~ of tIllie -~ in; tIllieSie :[jf;J[e<il!5mJiilyme1tatS1t1lL:SJ!se ~oil:hepamfuidglJ1iLill1:dl (lligm-e 2_2{j;)_. Theyne ofiens:een. as s.m<iiill. wdm-ddiined ]esroN!s ,Md!. oNilly ~eiiI- m1l!J!lJtt£plffidty :SlI1d!. grmv1th m<il!:y give1ill ,c:me to ilicir UliJ!e mdgn1iLn1t na1tJl][e_ ;rrr ~ere is nordev,001t ms,1tory of a.prilnm:y rumom ltoaille:l1:. the cl:imcim,. then. jF-NAloo.r'ebiopsYrnI![jI},proviidie ,§[ m.1to]ogi:call. ruag;l'1o.s.is_.

F:igl!1:H~ 2.20-

Ob:lli!ql!ille image sllo\ViI::Ig (l) d!illatedJ p:amfidi duc'l:

Gl:l!e ~o (1)obswcting tI!ltJ:lom (3) MmdibIe ~d! (~) mperlici!aJI. pa:rofr:id! gllmd! ~drenrfuifie,d_

Non-Dodgkiin':s Lym.p:l:lolill.a.

Non.- Bo.dgkiwl's l~'mpfuomiil.l!JIsl!J!dly mVio~es thep<itl:otid flod!esb:uJ!1t m;jj_yf,<it[dly~e rise 1toex1t!l:<ID'l!Odaill.diseMe ill llies~ gll<mdpnffid1ymaL Mrut1p]e nodes are oien al1Sio seen m:dlare3!S of ~e aeck. Sol:irJt<itl)' nodes mel!illl'll!J!S'l!]l<irll. for lh.lliil:lphoml1JJ_ L ympfuomf:llOns. aedesare ~pica:lily ·\'Ie!fj'bypo-eoho.ic Of ,;memorcad miily 'sfuow'ltMouglli tr<lll!smmS;s1'Olli_. TheY<lI!e ]:l[ge~d mmltlp]e_ 30 Co]omillbw DoppDersllow:s matkJedi ¥liIiSIom,ll:i1tty 'i,vi~. ~eS!e nodes,

The s.ono]ogi!s11 .11011 _eql!J!en'l:]ym..dls ltfutl:1t.1tl1:e origm of llieparo1tlid. IlIiJ!<l!SS ~5 \Vlm. 1them:j1:S'Sie1ter ml!J!SJcill.era1ili:er than m.1ihe paro.1tid.g]Olll:d_ A his~ofj' ofreoen1t. demta:'!. tream.erIt m1fuyimille:n1 one to. ~e rua;g:nQs&s of ;~mi9iSse1terml!J!:5dea:hSiOess:_ U1:tr<lSolLm!d.shows <11. w·clI.-dldirned.uec:hore ]esroo m ltfuernI!<iI!:SSie1ter,wiri:h. or '!,\';~Ollt :fr.<lI1l:.lrnd. colillec1tl!OO! (iF~grn:e 2_2 l). The ,rn~osis 'Of .&hs.:oess is a~ev'ed. by t1\te rns.tory ofp.am, d)ent~. sepsis orpl.!J!s:as.pWa1ted. at jF-Nk jF-NA createsthe 'QPlPo~ty~orrn~gI'J!o.s.is. 'm~l :~bSJoes:s. and. ~d!entmc1il1tiol1i. of the Olf§1IDiL5mJilli welill as dl&ru!~e m.rn.<ilge which. mary 'abVliafue dte need for S:1!J!l[~e:ry_

Otther iocrnJ! m<llIS'se1terml!J!S!cille Des.roos mdmJd!e 1tl!J!m:OM, wrndTIi ~s US;l!J!aIy .metatStaltrc_ .Breas.:t orbronchloill c1lIrcinoml1JJ IDl!d mell1IDomOlJ. Me !the mo.s1t COIJ!llilllO:l:l prilnmes_ lFramJk:bOl1!e dbwc1tirnTh. orperio51teaJireijJ)cIIT0l1!. IDacybedlli<:lyt05tictolf m<iilig:l1imcy_ Boilil eanbe d!e~eded. r..virl:h.mh.a£liolmid!,bl!l!1t f<il!rnogrl[itp::I1ry (lli<nme1~ .allli. ,rn1:l1opal!l1tomogtll,a:mj s:llllilJ furlS ;[][ .SJigniicMtro:]e_

The most OOIDI1110111.ItIiJiInOI ill :!hemMS!e1ter I!2IiIl!J!Sidie is the fu<:lel1l!l~giomi1l_ Thel!l!lltr:r&S!Olimdlteamres are ilio.Sie ofru1~yperipfuer&ll.hae:lllmgiiomac l\iyp 0.- edJ:o~c, ill-defuted .ood compr,esSJ!b]e, ,,-m.p:MeJb.ollillis_ V'es:S!e!lis iID:'e Siomet1mes 'Sieen.bl!l!t coEom ]]Jow ~s ofiemr m:eg:aoe becaase of Eow ]])ow velloooes._

U~altBlf<lllrnmiSs~elfml!J!S!dehype:l.1!l:ophy m:aybe e~ dWi1I1gFlOS,Bdl on'Urni'm[jlSjQ'l!l!li1dL The ml!J!sde .~ows .l1ioifma] echog-emcityhut thebe1!1y is: ~s..lgMlLilll1t1ly 1hfdberled oomp.amd.~o the Jloo.-symp'~omllllITc~de_ Ooc1lIsiioo:illy .l!ll<il!:SSie1ter .muscle Jhyperltrophym:ayhe b11Il2l~erall;: t:lhls m~es l1tilia:rder ~o ap])reciial1e :!he 'I:hi~emiwlgbl!l!tf}1e c.llmillc<ilill.present1iLillio:l1!shoulJd a1Jerl:~o1t1\te diijlg:l1ios..is_

Fi~2J.l-

(1) Masse'l:e1!l1lLliscleabsoess (ano.wed!)_ Not,e (2) masseter; (3)]J!31;efu!dL,andJ (4) manG:iMe_

P!lge32

• Hyp,ertr,r,J'pl\iy

• Ahs.oess

• TmIJ!0m:::prim~- h;rem]ljangiom~Sie00flcfuuy- breiil:S1!., btfo~ffiliillS, .m.ellMDnl:<iI.

Otiel"ll{;ass .Lesions

Cys1tllcm&SStes. ,of tbes;iliv'lll}'g1i1IDru 1]:l:etfare_:; I Themi@i:onty ooc. m tfu!epiilfo1tidglJoodJ « 5% .of. £esiOlili5)_CoTI!gemtal cysts ;;mls;e :from flllie mst Otf :Siecol'ldhIfMffiiaill.groov-e and are most c~o~ seea ill tlte n<mt The .other'l[!<itfe 001f1geniJt<iL1l. cy.S1t is the d.ennordl 'ComJlsoog .of kera~g: sqllliamOl!llS ,ep:ith~_ ul'fur<iliSloudsJ1oW5 mi. :mf:'eJlo1c wdill.-de:fi!l;ued. feslon_ AOqIDr,ed cysts mat)' he seen m .. .AJDSpaf:Dents Mdm""5!1tliY m c:hiilldir'e11 (bemgn lo/mphD-

'"t, _jl~_',~ .\ . el!I" .'.. .....' . '"t, .. .'" . ..;;1 .. _,~ _,.,1~: "2'3 'S' 11. , . II.. . ',,1l.._~~~~ ~,.,~ '. iDiT'!i r. .'" . . " .:lI

flplil!J!lcmai!. cyst's) as W .. 1 . as .ill. oOFliJ!lll!l'1e1tuoo. 'ipYlJI!J!] ltr.iil;llliIillJ~ :p;no1tl!t:ls: IDJ!Ui. Cifill.QllilwL""' . lOme .~11TI!i1pnO.-epl!lJjJlli=i:lI!I. ll!OtIJwes .m ill! " -.pOSl!we patl!ents mary uenloasuaie

:s.ollid !Mdt cycS'mlC 'C!ompo~emts.l[eSie:t!Il!b~g mmoms._34

.MllliClllisre~entio!l1i cysts r"vith. a.ooe ,~tl1e1al! J!mWg, ar,elfall,ebl!JltmOliyaris;e ,."vili]' pillliotid wet o:bsnctroo_ .MlllioooeTes on !!he IQtll.er hiJm1idw:e !I1iot illaJe 'cystS' and :lte:l'l:di.lto oeel.!][ in the :S1!illbegL!ll<rl,d<md (nMlI1!1!ll@J_

Refe:r·e:oces

1_ Tha;o Y, ZihiMil!g R.DirnJeren1tiia] dlii~g:Illios,js ofp<n"otid gl!and .miJiSs<es bygre'YSIC;;;rlefe<l1l.-tl!m:el1lilitr~owel!_ Hua His IK,o Td HsU!en Hsueh Pao 1'990; 2][: 'SU,_J9':5_

2_ Tevesi LM,.KdliilJl.E., L;mkm.KB., Haoofee '\\IN_ .l!vm. W1l!glllg o:f~e m1!r.mpru:otidl-fucl1ll1i. ~~: !I1iorm~:] ,ma~om.~r udlp['lfuorogy_ AJR 1987; ]48:: 99'5- l{lO~l

:1_ .MMd!ellibtl!: 8M" lEh,a;lim. lli',Dav-iis'lPC" Fry 8M" Jacobs ill" Bafrnm:M. rc. PMotid masSies:: 1v.lIR. 1tm1ll,gm,g_ Radiolo.'gy· V}o87; ],63: 411-414_ 4_ Lmg ~1lR N.l1cl<:en:ow WS_ mltmparo1tld. ;W1ia~omy of'iheE"i:l:ci!a.] ~.erV'e ill1IdrehlOmomdhlb1!l!l!<iIf¥W!_ .Br,J Surg 1988;. 75: .3 llG-.3ll_

~llRlIlihmel!lli.L" Spongat 1',. 'Cim:dliEl1!J!1i. iF, lPirtritillf,el!IJo F, .A:n.d1rettat M_ ~till!emCmT'el'Lts.igffio;]e'C1ta1tic Jli1ll:fo01ti:ru!S.: :ft]]e m]e .of Sloo.o:g[iilPlhy ;ud.s.ialiogr.apl\!y'm dm1llgl1iosisi§l1ldi.Jlbliliow -:llp_ Br.J Radil)lll9'8 7; ,610: 1211-1214_

HI illill!o .H,. Sdmeid.e:r 1', Nil1tsdle N~W.oYJtrz: IG" MMiiemJh<ilgen J" Elill C_ EX;IDr:1ll-oorprn:,e1rlshock w~re .lliilioIDpsy .ofa s6arySi~one_ .. Dtsch .Hed Hi;ochenschr 19'90.; H5~. 12-14_.

i2_No:za1bi.H,. H<mIiSl1WOlJA" Bara.H, KOM!O.4., Slllge1taA_ UJ:tr[i1isonogr<IpilMc~ea;De:s .ohe~ll!I]iefl~paro1ti1lJ1sm.cM:dih!qod_,P,ediatr.R.adio.ll994·; 24 (2): 9'·8-1{){)1.

14. CO~Ol!][S B, De Oerd\:. LS,. Fl[MCZ I." De Sdlle;ppBrA,. Ver:cmYsSie iHA., Ste~Ffens Wl_ Ulitrr.1iI!SiQfiograpfuy oftfue s~:ny .g]1illdls ill ili!e 'B;l:m1iltion of Sjoglien'.'s s~&IQme_ Compmsofl. ,."viJtl1i .&ii3J!ogap:fuy. J Be1gp Radiol i 99 1.; 74: 189'-1.9:2_

16_ Sf!Eme:!: E, 'Gr,m~e:r W, H:itz:elli<il:lLl1l1liLef J, L;iI1\cits A,.lPe1te:l:<iI. ]P',. jF'l[illll jp', 'Gri~z:mrum. N_ c.o]ol.!][ coded ~]ex :SJonogr.apfuy ofthejJ'itmtid gl!mdm S jiogf'en'.'s; s}'l1!mIQme ~Genn1ill)_ .Rqfo FO'r:tschr G,eb Rontgemtr N~ueJ'l.llildtwbV:erfahr 1994; ],60 1('4.): 29'4-19'8_

17'_ ~1ill!ll1il. E, lP'okomry G., R~r1tn M, Kiiss t Kovaes fA, Kcvses L_ ]Pmotid. g]orn:dw1tI:a80FlOglf1ilpihy;1l!S a.rn~oSJtiic f!oo] m~1M]i' Sj!ogrel'l':S s;'11dtlrome_ s-s Rhe'lJ;lJ1,at;oI199'6; 35 (l0l): 972-'977_

19'_ Da.-Xi. S" Hi1JJ. Xiong S_ Q~<mg Y_ The dwa;gI11""g,m:c vmrue ofllli1ltrr<l!50'l'lOg:t:l1PhYMl:ds~o'yaphy ill safu...arygllandl masses. DeRt:ommciJiqjac Radi;Oi{ [9'87; ],6:37-45_

11_ Bnmleto,a. IN, Mo.mDn .. ~_ UJ!tra:soudffi '~:y ~Md. ms;e1liSle_ on. JO.to'rninQ,.laryng.oI.1k:lat S.p,ec 1993; 5S (5): 184-189'_

26_ '\1;,.l'hyme ru\il[, lByrne N_ A COn:!paflSOfl. Ofool!Ihp'lIliEed. tomogr1ilpih~ 'Md.lil!lJu§!SoooOi m ilie1l!Ssessmen1t .ofpnotiid masSies_ Clin .Radiall'9'87.; 38: 33'9- 343_

2.7. Br<il!dilley M, S~ewm l. KilI1g W "Me1tn:ewdli. C_ ThemJe ofl!l!IiEI.<iIisoad. <mel! OOJ'c RIle :Sicm'1t:igraplily m 'ttlllie rn~gnO\SJis of ililes:a1lEvmy ,gllMd. h<ileJ1llli1il1JJ.grom<:l_ ]]r Orul.Mmci.ll,qfac Burg 1'991.; 2~91: 164-1.65_

Page 33

30 _ BmI];e'tioNJ. IN,, C<iI;If<llmel!lli1il E" Rom:: iIfI', F'Mm D ,~b 11_ Com:pmsolfl ofiuillfu:<iliSJo:r:tog:l:aprucMdllhillsto']ogtca1i.mdlIDgs for:mmooodlnillm- ~es.io:m; of &e s:<rllEv,m:y gEmdls_ EurJ.RadioI1985; 5: 29:5-296.

31_ Wmk Wll'_ Cys,ts~d congenir1t;[ll ~esioos; of iliepa:ro1tidg]MdL Otolaryngol Clin .No~th Am ll.'977;. ]01: 339'_

3.1.. Goddart D,iF'ranorns A, Nmm.e J, Ve:I]1IY].en C, COff>1l!J! IG, C]ap),}'l1i. iIfI', C][illl!S D_ Thepllmt:id. :g]andIlMCwmi!ilitty:fomd. ill cmJ!dlren.S<eJfoposimre for hlilm&1!il. immmodeidency ms_. Paediair .Radiolll.990.;, 2.0: 355-357_

33 _ Sllug;j1:1f JJ1vli, So:m.fM, JaeobsoeAl., Ry<1l!JJ JR, Be:mm:d f'J, Di.olk:mJru1J. SH_ MUI!l!1tioenm:cpm:01tid C},8tSMd. oervrcalJ EtdffiOp,iilt:ny m .~Sp~ents_ .14 fl.e\vl~feOQ~ed efl1ti!lly~ Cl'IDl!d. MDRmrumes:1ta1tro11!S_ Laryngoscope 1988;. 9'8:: 772-7"'15_

34_ Man::ltiNJoIi. C, iIfIlfe1toles,j F, Dell BONio V, Derd1i. LE, Meoea D_ CmMamonrn<ilLM_ Bemgn llymp:fuoepi~eillial.pM{}1tiid. ]esXons in HN-po.si~ep.a1tiieli]ts;: spec1tl:l!lm.offutdliiimigs at gr:&y-siC~earJjd dopp:]e:rs:ooography_ AJR 1995.; ],66:975-979'_

Page 15

3-·

The Tbyro,id a.ud. P'a.ra.thy.roids

Uftra;solilld Oil the Thyroid Anato:my of the Thyrord Exam:iin.auon

jp.ap:i!liJ!ary CaF,ciioom.a Anap~a,stiic Careiaoma ]\IIedU]I:.uy iCarciinmn.a. 1'00li:clllla:r Lesfon Ly.m.phoma

T.hyroid ]\!lefasb.sles Hm1ch~.e 'Celli. Tumours, l\IIlJhmodll~a:r T.hYlio.rd Thyroid 'Cysb Thymid:iitiis

lP'ost\opera.Dve Hyperlrophy Ullt\rasQund 01 the iP.a:rathyroids

iUkrasoilInd oftbe Thvroid

." .. ~

Th.e pa1tioot \~1th. a.1tl\iyr.o~dl nodlilille :pr·eSJen1tsOll oommoo. mc<i!.l!. dlill!~'<iI_ Cn.ci3Jl·ex;~<ilEi:on. ~smlab]eto rd!entfify the neflijlilll:e of 1!ill1e iI1ioame, ud Dijlglng mary be neoessill)'_ The .~. of BiiI!giwJlg \Virili. ruJ.¥IDocid1try is ~o dlli51tIDgWsfu .ilIlbM1igllHom. ;ZI.mualligl1!Mt ]es.ion_

The 1thyroiid iis11llil1iiql'l!e am:bng end!oc:ri:l1.eglJill'l!dis m ~1!sreJIam.rleq Sl!lpaiiiici;;rli. nocattiofl_ The nom:u<rltly homoge1J!eol!l!s texilll:e of iliegllalIDdl llj\s dead}' clclIDed. 'smroDd!itng .snotmes,.md. fthepro~ty of COflSJ~tWil!<iL~O~C ~liWd!nillbsl!Ich as ~e c1lf.o1tidlmery and!. ilie im1~en1<icl1. ~gm1l:[ veiml.mall:Je i!tiilfl. ~d!ea]. strn:c1tm:"e for evmaEi:on.by :high resom!J!l!ionmtrmoflograpllio/ _Miliol!l!gl\ImhiiliSollmdl is SJem1we m det!ecfu!oo. of iliyw.idi floci:Iilles, in mexperiioooed l]1m:dls .i~ bdrs :spedffiici1try.; tills: CUi. be ov.e:roomeby ilie lact iliat: it:~s e~ >combined. v;ri!thfue-needillern;spiration {lIFNAC) Cj1td]o:gy_ Ul!1tr.11iS!oliWJ:dI. oombifled. \vi~.lIFNAC is 'lher·elFme Mle iideaJI. n1tJlaill iiliJi'i,!\esfui§;];jj]oofm 1thyra~d iI1ioc:milles._

Ana.io:my of the 'fhy.roid

'T'1L~: . .• . .::II!.. . . .:1L 11_ .. . . _£.e1L ~1L ".::II'. rol'"' ''J' ~) JL];!]Js. Sleo1ti;rn:Ji, eascusses Il]~e i'1!ey .Matomy Oil mfe u]}'fOfu:regllOFl, ·~lIL·~gJ!lill,e ,21_.ll .•. _

The i1yroidgffiadi ooos.Fs1ts. of~gh1t[ll];d. ffieft ~dbes cosnected m &ewc:lilli!Fteby a. l1!tm:ow .ii5ti1mll]!5.. Theg]1M1d. isslmrolll!l1declby a.sbeatfu. dl~.ed ]fom tllwe :p.retrarn:ealJ ~ifuy,er IQf the deep ::EatSici<il!, wrnd~. aEti3:dhes: ilie gliruld.1to the rrachea. artd. the ~ary'fIX_ AbontHJ-.301% ofpa1!flefl1ts. hifu\'e <iI. :ttillrd .. ~o1he (iliep}'frumd![]]I kibe )arismgfrOlilll the ismm",projectl!liJ!gnpWMds .Md l'lJ!I'I~Wg a]ong ilie milldilli!l±e orsllig]'Fl:1y to the]eft, ru1terior~otl\t.e tl:iyroid cWiilge_

Hg:mre3J-·

Transvesse seetiion at llie ]ev·e!] GIf 06 sho'\'1"i:ng :re1!.ev.a:nt .anatmllY ·ofilie lli~-m~dL 1_ CeNical! 1~111ph f!to·d!e_ 2_ Inte.mru j,lillJgulliar ve":ln_ :3 _ VagIlills nef'!il"e_ 4._ Common ca:roticli.a:rI:ecry_ .:)_ Roc'l!1Ment hUyTl!gea] fleF!le_ f~_ Oe50phag:I!ilis,_ 7.. LongJLl!s. corti ..

. 8:, Sca1JenJ!ills .anll·e!io·:r:_ 9, Ol:tlGhyoidL 1(1. .s.temodcid.oma5to~cli_lL Stemohyoid!.

12_ :Ste:rnolliy.;oii& B. Trachea, 141,. Pfe,badlieali fascia .. H. Thyuld! gllaMd!. 16_ Ca!\'lfci!d! 5healli.

Page 38

Al'lt:;erw:r aM laiera!;

Posterior and lazeral:

Medi.al amlposi,erior,:

• Superior tiryr,()!id artery ;.ms,es:fiJ011IiI! t1le 'e%WenIDirl. cafo'ttidl ,merymdi. descends ~OW[llfds. the ipsiil![]Jte:r<I1J ~liyr{)~.d. ]ohe_ At 1ihe1!I]Jpef:poDe of thegll<moJ ~t ,rnviid!es: m1to '!he <mt,erim: '1ll1:d.poSowerirn- dM1~on'5_

• InJenior .thynoid artery ,; <ID!Sles <Mom.~e tfu}'l:'ooe:rvr:c3'll ~. ,<mdasiGe11:dls~OOJg 1the hack. of1tl1;e glJandl.o toreaeh itspGcS!1teriiol[sm:Eiil:oe_ ];t is dosdly rdl11tedl ilto ilhe 1f!eOMfoot ]<llJ"lJgeffilill fie:flii\e_

FigIllIe12:-

PosteriOl: ... ie,w oftfueoes1op,hagl!JJs: all!d. trachea sho'wing llie v:a5c1lil!a< .cliatiiol1!s ,of the thJ'!I':i~d] and!. ilie. foe:atio!l:l of ilie: p\a1'alli}'!!1li!d g])andis,_ 1., Pha<ymL 2_ Sll!lpeMOil' tnY10fdJ arlery._ J" Thy.oid! glianclL 4._ Sup,erio'l" p'a1'.ailiY1o~dL .5. .. IrIlferiof iliyf!1l~cl: arlery: .. 6, .. hne..-riOf pa:miliy'f!1lidL 7._ Oes,opoogILls .. R Trachea.

• Superior; 111icldle and .ii1!en:or thyr{)'tdl'lI21~'l8,: origwH:l1tei-om 1!11:epooiliyroidl VEllO,llillS nernrorlLL The 'sllillP.,er.i)ormd mid!dille vemsmaill !into :!he :ijp.oo<ilteraJi

Tj'l'!1 .' 1" '11- £1L :~£,.. £1L ".:lll" " , 'lL ' ", s: .. 1L ", £1L_ .. 1L ' "£1L ,,1L ;__£" d. 'f.:ll "L .. 1L "".:l[.:ll J!.!'I:, w~ •. eseas me llIJil.'IDOf 'myr>O~!di v~r>eoer\liesm[jl!l!tm.es .f:I.>OmlLl!l.e 1SiI!!W]~lillS, IlLIlen ;mas,tomOiSieS \':\'1iI!!l]W.e .liI~enO[ 1LI])'f:01uViem .. 1!iI.om. ,lLIle >opp Oi51r1teSl!.~.e ,<lI1!.Ii..II.

mIDiThs m~D thefu'llacWooepfuJirliC\i1eID_

Ly.mpha.tics,.,

I-}~p;ha'i:l!c; vessels :from.lthe tThiyro:ndlform .. <iI. :8l1J!bC[ilIpiSilllil!a:r nenvork ;ud.g:Nemeto ~ajtera!l :iIDdm:ernOiill.o colillecmg ~s_ These dl:m.m1to t:he :ant,mor ;<md miil:kr.:rl. dolin. of nodes ',<iclJoflg ~e Irll (deep oervruc<rl. ,dl;ID;n),,[Mdl1!Nepr,e1tJr;<il:d1ieBliliHilid.pm;maclllie[ll] @(}dies_

Fi~JJ-

Tf:lmSv·oMs,e, s,en~gI'am. ,ofilie left sid!.eofilie neck d!el1Hlit1Jstl'ating feJie!'l;o:ant ia:l1!at~my_ BoM.a:!Io.w-fl.acllea; c1!illI'!.fe,cill wmte ag'O'W

- OO11tfIlONJ Cornltl!d! arte~ (DCA); open c-mved!. wmlIeall:o'wO'es~p,:I]agI!l!s,; ·oIJ'en wmte .aflll)'WS,- slCaillenmial'lte-nol!; ll']adt

,aM·o,wllieadis - sbap ll1l!JJscles; smal!l!. Maek .aM·OrWs.-~mohy,~jjd!. muscle; huge brad;; anll)'w5-stem~cle.,jjd!~mas1t~~d!; iaste~risk -lli~Il)j)d!. gland!.

The 1tJhyroidJpar'el'J)cl:L}'lilla:ll. rec:hoesilll[.e~e,l!l!Wf;on:lll.iim!d!. h}~e![,eCJhoic; oompar,edi. ~o 1i:lhe adjilitoent ml!l!SJolJes_ The vessels v."~. the g]a:I1d!s aeebestseea ,a:jt "!he po]es_ The ed1og~ciliyrordJ ctjLj).SJlilille ~s dearllys;eoo. 'ruI.I!l!lItrr<1l!SJOl!JII1!dl <IDd. fuclps~QdBerenlti"l'lbe 1Jhym&dJ ]esroos "from El!.wa1thyro&dI1lllm<iJiS;Sles sl!l!rn<ilrs parathyroid ad)mom[fuS_

1 The right bbe 1tffidls. ~obe 'sJliig]1t]y ]i!t[ger iliru1.1iliue ]eflL

:2 The Rohes are ,oi,en not at :!he same ]eV\elIs m the .neck; ~ ,omomeds: !!he ~OGl1trOrnl. ofp<ilillalthymrd~esJ)oos_

3 ThebOliSJe of ilie]Oilbes m<ilr:y he~1te ]ow ill '!he neck, at ~e oen.rlico'lhoracic j\mtdlion,.md oonsider1lib]e hyper,ex1ten,SJioo.m!<ilybereq:M',edl ;forsonograpfuic ev,.a1tiloFiL

4- Thepyrlil:mlid!a]. Dobe is :rru:.eIy seeadee 'to lr1tsSlDd. an1ter,o@os.terior ,diiameter_ It m<ilLybeSJeel1li .. in.1tlIDe yo'Wg1b,ut iIt:l!illidergoesprog:ressNe atrophy mi§l:.Cfu!1~s_

5 There m~y be .[11[ 'ipcs1el!ilJdo-miiliSs'at 1the]owerpde of lil\ue thyroid! glImdL 'fhiis isepMa1tedipomrul of ilie glJMdl~c:s<ilLpar:m:hyroj)d. ]esiDn, 'p.ar:lti)0lili1lar1~l 01'1 1!r,jjU1IWe:l:SieSC1ilflS_ .A ~muglfuwdlIDa]SiCM. g;mdcl~ oooilliimJis ~1ts !thyroid origm r(Flig:m:,e

3 _ 4)_ Sl!l!ch. <iI!. mis1taibe ~s COl1I!1m.O:l1! m a.:I'omdedl fu.!}'Pe:Ii:m]Jimedl .g]<lll:dl.Ol!s in GriIDViesi rnSiea&e rOlf 1tbyroidlifuis_

6 The oesophiilgl!ills ~s i.d!en1t:iIITed &5 iiilr'buililJ's-rej"e' v;rllli .: <iI1!lI edl0gremc oelil!tr.e of air 1iWl!d. sorliiv<il!. ruld. i:iI. hWD-.ernorcrimJhecallS!e ofi~smiI!Jis.omOl_e_ It is COIJililnomy d.evli1il:ltedllto tl1:e~eftiim!dlsho1llilldl. not he mst~en. for .is!. m<il!S,s]esron_ .

7 Ther,eol!l!IToot ];nyngem :I1:e:l'Vie Cru1I. be seen rO:Fli.]illJJglllilillJdlin<il:JJ .S!C1Ml!S as iiillm, lilinear,. fuypoernoic .snctu]febe1tJ.veen ilie 1ll~oid.1m1ter1odyafl)d the Foog1!lls 00. ,po51t,eriorl~'_ ill1tmay ~we rechogemc redgesdl!ille to '!he c<il:psl!l!l)e 'of lihe 1th}~oiid1Mlidl 'lhe ]Ol1!gIll!S oolli. ml!J!Slde_

EX:.nniina.tiOi.n

MQSJ1t of 1lleM§tomy d!eSirnbed abo\'le canbe de:IEomtra1tecl. \\'irl:h hligh. resofum1!l!on tram!ClI1]!Oer:s._ However; m 'C@SJes of ,dleep-sealted.1t1tlmoms., :l:etras.1tern.mreuod<ilr:wcmon exlten5ii.oo.o.Omnom:s,. obesepatients ""VliEb s.l1i.ort. necks, ,olf:pa:trents who CilIiMot adeql!l!§~e1y nyperex1tel1d iliei seeks, one m~y [h,\lL'i;i'e 1toresort to iiiIi. ]owerresdilO!1tJion 1tIfiilN!soooer (5 llv.l[Hz, Wli1iliu.o:l' 'itviiliout .iilll stID1:d!-olif~e1)_ The .aim. if! 1i:lhe&e cases ~s to iidJenili}' '!he:rdevM1tpll1thO]ogj'iUl:d.lts.

" "--,~ -,~ • ".1l,z."

m<ilDj1olfMa1tmwCi:ltl.l"CJJa1tr.Ol1I3.l"l'S_.

fbf

F~grn:'e, 3.4-

Traasvessesenegsam (a) sfuo1W"iIlliga h)'po-eclIoiic llli~H!I!u1!e (bllack <ill"!D'WS), s.epmaftedifi".e:tn the lliYI"Oicli. by a brigfu.rft lli1"I1J~di !capsl!1J!e (wh:ite :<DI1)'ws)..llis may be n:uistakeN! fO:l" a pamlliy:rI1J~d!. Fiowe.'Vflr" ~Ol1!&rudlina1. scan (0) sfuows lliaft i'l: is a tOl1lgIWe,offuype.meprne,d! lliyrDldi ,gl!andi (1!arge bllackar:rows).

Thes.OJl1:o]ogffit5&:mrnl!d5Jtm ~Si~g m ~e 1tir:[j[ffi'ir~aS!epF1ille as tIleiitdljla:oel1t :[IDa1toaciIDJ.reli[lL1tlol'l!:Wps of 1tfue iliymiid Me deill"~'WSiI!]![llliiS!edl_ ·W'ben. eVilillllMg :If:t1J'r()~d flocIDilles :lheex~atrol'l! caabe dlivilded. m1!OID.VO :pms:

:2, ,1IDcffij:aooots.1tm:cm:.eS5lffic:h :<iI!S lliecru:otildi. mery., m~en1i<icl!. jiuJ,gJ!lillar. vem,. Des:opfuffil!gJ!illS, s1tl:ap ml!]s.des ,Md oe:rvrca].liympfu nodes; .'~1im1oo of "lheSie .snc1tm:'es ~sm;mdlaljoryal1dJ ]Orrn1US an. eSSief11tJla:lJpm. of the ev:ailil!ill<lrtilon. of an}' iliyroid l1iodm!e_

BeNore 1tlh:erni1lgELos1ti!c1!)!]traSiollffijdl. appe<n'MOes. of ¥moU!s. 1tlhyr.o~d lliodm!es are dUs.cU!s:s.ed!, one b<iliS ~obe f~[jlli 'ioVlitl\! tl1!efe&Fm:es. lliat c1illJ.be ev:;drni]l:1ted.:IJy mtr<§l!S.!(Jl!mdlli:l\tcirsiligMicMoe, ,ilIld 1t11emruscOlllioep1ticms (~) :!hat Cl.!m:el1I~' exist

l\ilulltiinodllbriit;y

It is ,giooer..dybeJlIDevooJ tllJi!l:t m:a:llijgnMcy ~smore OONammJi m a.SJOIJ:irE<1tIY :n:odmille;, :omd. ~atmlllllimodmillm1ry iisl!l!S'l!l!a1iq associated \viil:b. beru_gn. d!lise<il!Se_ However, m1tiroo(}l!J!I]jd[,."vl-l:h lhillghr,esomttion. karndiMoeJf:s com£s.rEOO~ dJe:m;01l!s.1tira~es ILIlElIlil!1!:ip]e ,dmru)c<1lli1~ occmt llJ!od!lli!es wmch.m:a.ryr~sdYfeass.lID',e 1tfue :SiOflO£OgU5it M~g:I'J!:a;[lt<IDd.ben:ign l'1o~es are ofie1'ljJ1feSient ~oge"!her imI.1i:fues<m1e .glimdl: appmxiilna~e1y 110'-2~[l1'o/U',4 ofpapillillilli}' caillcmomIJ<iIiS m:a.ry be murutioenmc_ ThJ.!jJs, "!he preS'oooe ofmll!lJtip:]e lliodm!es. v;i~ ffue th;!foiid does. flOE in.rnca~e'l)em~ry_

It is&l.lSJofueTh!e\'iedi ili1iL1t cy.Si~C nodmilles.1ll"e belf'liiglJL Howevea, De epil:helliialJ ili},'r,rndi cy.s1ts1itlferMe~1iIfI!d. :!he cys,1ti:c nodiuJilles seen onlliiTr1!rmol1l!l1!d imlVari~]y lliJrn.'ie :<iI.

P!lge41

Figme3.j-

[~ongimdillaJ! S!ON!O'gI",lll];1 cl!eJllON!S.tmting the c~}me,t tail slgrt (small! ,!!Mill'W:» in a colJ!oiid! no dll11!e_

Hgm:e3_6-

T.,am.vetse sonograms sl]o"ying mo types ofcakifkaliion.

as:l!ociate,dJ ..villi b~gn l1r:J1H~1]JlJasfiii:c; ne Gwes,_ Note (a)ilie almllliliar ,c:alicific:aion (Mackan:ows) in cne, and!. (ib) cl!ens.e shadie,.vlng ca1!ci:llcafu!o:l1l iI1I.anplli~ (wrnteanows)_ 'Op'ei1JJarf'OW .~clfm<ft:i:ffi!es llie ]i.o.s~t:rou.

of the barn.ea ,aI"ldi c1:1fVedi;an·l'l'w man.:s the OCA_

soThid compOJ!1e1!1t. Nodul!es r"w:l:h ~ru:§e ,cystic compol1!eflts '<iI!I1e 'USil!l!oilly ben1igl1 'I1odJuilles tllil1t.llli11LV1eliliiThd!e:rgone cystic deg'ffieramio~. Of ful1eIDOrr}l[];ge_lln, 1llJe

.oIL 'I . . ' • IL_·II~· "1'" ':l "'''I,,' f ~1lII. . . ' _,I'I IL ." ~ .:!II! ""lL _,111 ""lL . 'd' I .::IL·.ll

;,ilil!]mOr 5 ,ex:pOO.eJ1;oe, nowevee, ;;imJ;ost .. ",'~.J'--:3'~F;O 0 'pap!I!ili:m:y cru:cmOlffiJat5 asso J!][]L'Ii\ei:il. cy:stl1c compoo.ent,. mrnca1!mJg :l!:Il'<ilt not ,oll!! cyS1trC:l!:ll~!fO~ '.' llnU!l!.IlI!eS[ilIl:"e:

hemilign_

O:lThe hlJ,gOOy :speGill\icSJigl1 o:flb'em~1ty of[ll thymld. n.oc:IDille i!s 1i:Thte:preS!Mce of <:I!. oome1ttd. (J'lgJi1!f,e 3_5)_ In ~e <i!I!lIllioi'sexperi.ence ofo\'\eJ[ 500 eases the preSloooe: of ,i\li oo:me1t 1t1ll1l.slign mv:miiLb]y sligdiediiil.herngn ooWo1id .. iI1I:odWe;® 1th1!sgjgFl! W,<iI!S l1te'¥er loooomtered m <iIL!I:I1;rlll~iIDlIt Te:sioo_ Aspiratiol1'l!J!So]IDdy yielJds WSlC!OlillS millThge oo:]omecUlirndi.(coFl!sistoot wil:]]. oo:1illoiid!), ;gd mTh:\!',aria}):]Y,feqmes theus:e oHarger caThlbre lTheedll!es_

Edloge:nrd1y

lit. itslf'5poned' muEit 1i'I1e mcidooce ,mmdigl!il!Mc), is ,om¥ 4'% wl1.elJJ ;iiIl solliidJ. ili}'roi.di £esIoo .. ils bypeJf,eoool\c_ lIif [he les.ron. ir.s ~Q-,ecllliorc ilie .mci)dlm.ce ofm.mcy Mcre;aslBs Ito .2j6%, wlilll:.emailliglThID1J . .:yoeems.ill63%af.fuypo-.oclhoiic:mMSies_ .. ·Iin.dld.ypr<1ctioe.fuioweve:I: .. berugl.l! :I1i.omn;esi:il:l:e very cOl!1!2rnIon <1I!1:di. ;§L :S!olllritary hypoecll!Olc nodJuille is. s1t<11tis1ticaTh{mo1f,e 'Ilililelo/ to bebenlign_-4

Aperipfu:e:ra]J fuiilllo ofdeorea!8el@[ernogemci1ty is seoo. ;i:iIJfQ'1!m1li!. iso-l.lThWierecfuoic flodlmilles_ it is. caesed by le1i1her the ciilp81ilille of1!henodfuo!lle or oOllIl]J,r~ssed 'It:tlJ'fo~d ms:sme ud vess:ek4 A comp~e1te IbJruJoarOlllil'H]J :Itfle ~e:s.iion is 11

wes more !:OOe1Y~o mrncate a.benign. ]es,i)on ilian. a IDaJligFl'1IDt~esion_K ~e l1§1io ~s moo~llicl\e, @benign. ]es,i)ot],. is sltiilll. 4 mnes more lli1lbe1~ 1!h<M'l 1iI. midigfJj1IDt ~esion .. 7 HOWeVief" .ijI.l11l!l)o m&y alsobesees m. 15--30,0/0 or mDgm'ill:ciess,&-m1md!.lr1ts])r,eSJenoe~s lOOerefoill'e notpllLiliogflomomc .of beru~r1ty.

Thepres'ffioe of c~omcatioil1l in! tfuyr,oiidillJodJrnlJes. \v&;Pilleviioll!l!s1~{ oonsicdlered .~ S~g:Iil! ofbemgm1iy. CaJJc.mCi:lliiillli. is. dletededi bylillllitr<MIolThograpihy m :~bol!l~ 10% ;Qf d.1th~,oidllJ!od!Jmilles. 4 jpleripnerallrim. c<ID!cm:cafuion :mdllnge areas of OOMSJe .sl11l1!d!o\\~g c1il!um:caMon. are more :frequJien1t1y Sieen. mbeJ!Thign.~odiWes. (lFiglMe 3.6). Fmep1!ilil!J:c1t<iL1!e caJ!cmC900. ,c:me ~o c;rlcm:ed.ps~om<il. bornes. ~5 seen mpapillill<H)' CMCrnOm<il:S. (25-4QtuI;i,).11 S1!Iclll. caJicmcalITOFlJ:Ill<iL!y;mo beseen.is me1tastalliic nodes Hom.papiMla:ry caJfcilloiI]]JJ<iLL Sm<rll. ca1JcIDic foci m:ary be preSiffi1t m mec:marn<ith1' carcmom<il., ·bolli. \vruiliill ilie prn<n:y1tJlm1om aI1d.m~~tam:c IO~CI[] flodies.I1

CO!brn: ]lbw B!<1I!g:i:I1Igm<ilybe :§l dlllIDm.gprospect to tl1el!l!l1ilrnttill11ted. There is extoo~e Thi1ter@.me fegru-dffig ltrsl!J!se m tlre ili!lj'fordL The al!lJ1i:fu:or mrn iliat ilie ,dlismbl.!JJ1tiion.ofvess.elIs. vori1tWnJ<mdl. ru:,omd ilie l!lodhiJille,failie:r iliruJJ. me3l!5m:em:001ts: ofped: ve]oci1tfes, 'p1fovides 61ebes.t ,ome to 1OOedliaJgllos.iis. .

. 'T! .. .r·· .. jl·1\- . _£ £I '. . _.11 ._ . ..!.1L~~~,,1L ..:lL .• ,fl H . ~. ,,1L ,,1L". .' " . . . . . .. _1L~~ .,,1L ,,1L '~ 1L~:~1\,. . . .." " .....•. "!~1CI " .'l\-lk, .l.yp:e. .. , ,: comp!e1te aesence um :J!lCOW :SJ!g:l1if11. W]ILl!1illI] we :IlliOli.J!we. I. owever, m. Il][e <i!l!lJwors expmenoe, :Ile'l.ver .:Illliluwles. 'iNl!w. ILIIel1f ]l!l!&!' Siffi5.l!1tIv1J1ty w:ili!! mv.ma.IlJ·.J

demo~sfu:ate smd. vessels \Vim most :Ilo(fuilles.

'T! fl..'T'~ .. ..:lL..,~.!'II ",,1L .•.• ,11 ".]1 . . • .• ~ ....] . _,1L .". _1~! .. .. . c:I " .. 1l,. . ':OlL ." ~~: .... ~ ..:f. .•. ~ !'II

.1. ype. '.1.,: .mn.am.oU!w;,u .I!.I!OW \'il1!ILI] mw1!:np.e v.i:WClIJ!JlaI poes. 'GJJ]iiI:.o1trci:ll..l!Jy .1itff.Mgel.lli., \'il1!m. 'Dill \VlJl!:I!fO'lillitSlJ.&,I!J!J!i.Gl111Ett Perm:OUWaIIlfOW.

H:igfu ;resorn1tiioHsoI10grapny h~ d1;;mged [he W.1lLY m wmdJi [Ill}'iI"olidi :Ilocil:illliesMe ev.mlltedL.AJtl1ougThi none ofiliemk,a!SiOl!l!I1!d.FeamreslIhov:e is by i~S!e1if ilXilfflog:l1iOMomc for .md!gnmcy., Wl\L.enl!J!Sled. iml comow<iLtlon 1tl\Leyar,e Viel)'l!]51eMl! m dBere~1!1tiiaoog ,jjIL mailliignamt nom.&1bcemgn. noc:ID!lJe.

V·. __ • ,. .• .,rAld·· c<

~nl..T«Lt:w:n .q)' ' ... Jl'f1£ent .~.trll£tW'~S

ICommon Carotid Artery and Illitem.al Jllgubr Ve:iin

Thepresenee of a thwm1bm. \vil:ml'l.&e caJfotld ,mel}' .or iin"l!e:maJi .. ~gWJM v,em,.m <il:SSlociatlolJ!. WJi1th a ili:ymiid noc:fu!l!l!e" is :l\lJ. cfu:e to iliemdgl1!<ill"l: 'Il!~1tI!l!I:e .of iliie :IlocWJe. Tmno,_ tmomlbl!JJS,,>vflen.preS!oot,iis mor,e oo~omy sees m.:foJtlli)cwaI ca:r.ciinom~;mdW1!ap]<lllStlc carc.illom<lllS 1ih1ll'li. m. papill:ny cucitnOW<l!. ·o:f~e 'i:hYl"OiidL I I ,15

mVOWelillil:el!1t of tl1:e ,s,1!iI:ap .IDl!J!S1cl!es ~S1ll'li01tlID.er ,cme ~D tlJ:emailliignwantflaMl".eoftl1:e1tlID}.lfold.noc:mille . .11.1iis. lis seenas ]OSiS .of 1tl\Le I'l:OrmaJi.iMali.pb111es befiv,eoo 1tlIDe ili}'foii.di;:mds1trapmmdes. :md i1Iill-d.clill:edl olll1t1lirnes of lil1iemlllJocJ!e.

Extraili}1'I:.oiid spre1ldl Mdm:dli!!iJ!g mw.Oiwem:ent or the oeSiop;}\u<il!g:uJ!S, u@rneaJ.,strap INl!J!SdeSMdrecm-rent ]~gea] nerve, .lIS ydMotfu:er ,c:liJme to Ole m<iiligmmt flaRe of tlJ:e nocW!e.

JlJ1tI1ough llite m;jljffiority .of 1tl\iyr.oid cncIDom<il!s-pl"eSient as .aJ. ili}'foid no&:lille, 1 :5-3t(j,oiopresent 'iovi.iIi].iHImm,gedl p<iL]:p'~Me oe:rvi!c;rl.llymph node. l~ NodJid met1ili5tifies ooom' .mo.st OOlillmOr:hl1]' ~ilip3:piilll!my cru:-ci'illThomID> of the 1Jhyr.oi!.d!, :rangmg kom. 3{l-40% atpreS!el'I1tatrofl.I.'7, Ia,,19 Fo:Jtlli)cmaJf !thyroidl car,cm.om<il!5, m0r,efi:e~en"l:l.1y asscciated r"mi1tlID.QWSl1tiIDE ha:em:at.ogenol!J!smet1l!S;tues (mg,bOl'l:e),. gener.a:lruy ,exhJJbii1t :l\lJ. ]ower .iincidenoe of oervrcaJI.llymph;jld!em;opmhy (iiI:JJ."I:11:e raflge of 1!G-1. 5%). N The fficidmoe of ce:nvIcall merns1tiiliSes n.om weilll-dffi"e:r·en1ti<iL"I!ed CID"CmOID§lS ~s far llill,glli:.er mpatien"l:smder Ole ~g,e of 40;md iSSl~g tin cMchen, wl1:eremet<il!S,1ta!8lesare seee m 61J-90iD/o ,of CMe:S.1:I The nodes OQifN:MO~ micih;lediru:e iliepre1t:r:1ldleaJI :1ffid.paratradl:eaJi nodes <ffid. nodes ~D:I'J!g '!he iin1tem;:al!~guIillm: ·'i,I\eitu.

Meoomtic nodes ]fom.p~illl!m:y cMcm,om[jJJ.sllow cystic aecrosis ill 25% of QiliSesMdplimo1ta1te Ca1!.cmCi!iuIOO. mSOI%; they:m:e fuyperedlo1!creilllltiive ~.o IDl!J!sclem 801%.1;;'; Theappearance or tlte .me1t1il!5t<iLtlc node iis often very sm;y ~o 1thlllt .of liheprmmy mllll0m m ilie 'l:hyro:iid.

AJ"1\.· ",1". .. • . . .:lIt:;:. .. . .Ji."I~11 . ,'" , -~ _1\. __ ,II_::t:::.,·.. ,,1\.. ., . " ',1\.t . 1\. .' _,t,.. . ~11 "d" -,~

I!illfOll5":i, metas1tll1ti:c nones ,llEOilllJi, meuli1!J!J!iJill}' CmC1!lil!Om1ili ,tillISO~10W 'Ci:lJ!.Cl!I!ilica1llion ,lliIrey :Me l!I1iv,ma.,J~y ~illypo-eCHrnc r'OJ!aEEvie to ,[jI',,]~oent'mlll!s;ctes_

Now iliat llie s.<mo]ogiist is furniJorr ,."wth ,ev,m<Ymg ~e ~oiidli1tsa:dji1itoemt s;ttfl!l!CmeS :<md ilie!l:el!ev;;mI. S~gFl!S: ~at caabe.seea m ;[jI, iliymid flocWle"iiftlen1tlO!l1J! m1!l!s't he ~edi, ~omu,oomm:d's:prim<ilfj'mle- the de1toc1IToo, ofm;nThignMcy_ Thello]e of11ill1k,[lI!S!owd m de1teeJting 1tlh!Yf>oidma:Th!gnMcy l!S 1tl1ere£of'ediscl8!ssedi, :next

JP'ap:lllIIaf)! Car,ciioom.a

The~erm "oocl!l!l!f or 'ipapillillarynCfocmc.mrnnai,' iis1!l!SiediThor nes.rombe1tJ.veeFlJ, 4 :1llld. 7 '!Inm, m :sWe_ Haradl, et aP dtllil:oF:lsua:1tedJ, 1iliI<lt 35_6% of alllJ~opsrued pa1tlenhm FD1llldi. lliilii]ld ~slITd1J. <iI. mmom: m '!heir iliym~d andi, [}eCJommendied, ili,ilt 1llillimoms: 11ess iliili'l, :5 ,:mm, ,~o1!1illd.be comsiidJeredi, lTonna1L How>5'i,11e:1"., most ,alllJilioritiiesbeJlUeVie iliat the ma!Th1gN:olflt narutre o,fs,llrrn, tl!m!lomsshol1!1!l!dberecogmSJedbecaillse flodrrl ,andlc1Si1ta:n1t m.et<lliS1t1iliSies }\)<<iI!'i,lieheen, don'iIIMentedl,a1]Jb.ci1t !l:a:re1~' _,2~

lP:apjj~ c[il;J[cmom<iliS ciill!1J,be ]ocaIDed.1M1Ij"\v}\]a,e \vi~ '!he t:Ji:JJJ'm~cl Theyar,e:mm~ !I1!on-el'1c:apsmarJted. ol!parliidly e:l1;capsllllla1t,ed. H!lrioooms.,omdi.ma!':l sl1;ow C}'s,1t!c ch1m~e_

Uncle:!: iliewCfoSJoope,ps.aJiiIlmDmaJ.bornes ma.o/beseem. (4(}-5(11%)M lin ~d!rn1t!0n. '1)0' '!he ,rnariil:c1teriis1ITcp11piilillM)' !I1!§_e .oK ilie Wlimom _ jpiSam:IiIJ!omJ<lJ bodries. '<ITe :b:med.byR;jJ;Jfdedpapjjaea:tItr,j,jIcoog lcaJ!CDm!. WIDe'}\]; isd!epQs.i!~edlloo, llie .dlyIDg celills_ Thcirp.,eSieflOe m fhe 'i:fu'}'!o1idJ olfiitdji<il'Oen1t aodes is pl11'hogm:omomc ,of,&papiillll1ll'}' cMcinom1ili_

JP:apjffi]<ll)' ci:llfcm:oma oOO!iimONilly wv.adesf.eg;roll!iil:11 ]ympl1a1tl)cs; mhi!s ,;aooomts for ~e m1!l!l!1tlociil:11 fla.Re of'lhe 1rnI:IJ:om IDl:di. its spread. toregroll!all flodes_ lP:a:iho]ogfcaill.V\eflOl!l!S mv.~o1'l occnrs m 7% ofpllpillru:y c11lfolllom1iliS,mdi.;:map]1iliS1tiic c:}\]mge 'i,.vil:fuilin the 'iti!m1o_ is r'i1Iill:'e_ ~ Diis1tmt.metaiS:1t1iliSes ~omgomdbrnle ,are seea m 5-7% of cas:es,1b1!JJt Sl!1IllVW.aJi. ~s, S1tillill.pIa]O'l1!ge~ es.pecia:llliY "vi!1iliI. lf1il!dlJjo-'£o~e!tlfeiil.1tment 2!1ii E'v;en. iliepreSiBlThOe of '[itdjiaoent iI10dJillJ me1t&s1ta.S!es does flota:d'iiie:rSeIty .mee1 tllepa1ITel'1t'spmgnO!s,is_

• ]m:ge size (> '3 cm)

• lillll!a1le sex

Subtypes of papillary carcinoma:

D.iffuse, sclerosing type,; ;meds. cM.d!r'elJi. ,~d Y0llmga:dJa!1ts_ Tlll!mom:pe:rmea1t,es. ~e glJud. "viil:lh. nl!DierOlll!sps~.om<il!. hornes<iWd. ¥tiom<ililfud ]ymphill1tlc pem:teaill!oo_

Ulltrasolmd.1' eatlIres

2. MO!stI~t solllid (701%) However; 2()'~3QrtYo }][iJtVie .<iI. cystic OOmpOflffit liEu. cys,tilcpapillillary 1h!mrroms Wirl:il1J.Slep1t[iIJ wi~,. ~Gmmtyma!ybeSieOO. wi~ 1tfue :Siep1t[ilJ_ m hemgn. cys1tiicmocmilles the cSlepta :[iI;J[ellJ!SllJ!a1~1iliV1iliSiCW<rr _

~ n..._~. .. _,II_!e ".". . . . ". "2" '" {1,OL 11;1\.. ." '. ." ." . ... n ""'~h" 14 f Ail!" . _,II_;e:. • .. " 1\.!",c1\,jk, . _!e .l.'"' .'lIi11

T lrW'Ict&IDe c<iU!.=catuO:l1!.1JSp!I:,esootl!11 .' -,,_!trio, ~ul!lJ1t 1111 some senes aCGIS 1111 as mrulry .<iI!5:;io'\jI?O_ !'I']J!Cf.OcIil!J!L.l!I!fficaEl!Om ~s. ~l!l!5'!i!lJy spe=c .l!!orpaplli!J!ru:y mmOMS

;I\.. ' .. _,11.;1\.. . ". 3.511",( e1,l,.~ .1 ·"d·· ·.:ll . . .;;Ii. .. ,~ 1" ."_._,1~1,.... _._,II_::t::"· (jJ[i'''. 3·· 7).:l1 _.",1\..';1\."'. "_1\.. dl. ,"

I!Jm can. ;[lI]S!O lLIe .seel!l llI1i .. , -.' 10 OIL .""},:I:'>er]JlaiS,'I'1. <i!Uffiomafom, nouwes_ .. 1 ypt~y,plilll1c1tar1te 'Ci:lI:JiCl!J!ill.rnltuoo. \J.c·l!.gm:e ... _ . . uoes ~01t ,Cll.!!l!l!lLIltpo.sIDenOlf Milia· O\vm,g_ .

..,. '" 1\.-,11· ' .•. 1 r ·3",@,j")Il'-HI.L:. . ..1~,~ .ll .. d: ... . "'. '.. . .' ... ,,1 " . 'lilI.. . '. ".:ll . 'iill! dl_t'::... .:ll! ':'1\.". "",1111, .. 1~_ . (jJ[j"" 3 7\ .:! .B muO ~s.s>eeE!. ID. lL_)- \;.t 70,," .. l!:!.e~ffitll!J' .moompile1te <ID .... !l:epreSJoo1t1lllg enC<ilps:LilI!ua1t:J:oo_ 1 ne '!I:e:IJ;];aJlI1!l!l!ef 'He, II .: ·CWle.UL \Vl!t!J!]. ne,5ui.ru" OllJiILl!l!]I.eS 1"),,. ~,gl!]![e ...• _ -. ;_

F~@!lI"e 3)-·

Tsaasverse (a) a:I'l!d! rongirudlllJa]. (I)) s,onogrlUJ15 ·of:a papillary cafci:l1!oma (btad :ane,ws)_li: ~s. h)1}o~e>cl1!eicomd! s,ollidi, '>villi. p'1!lIlcta"l:eecl1egmi:c foci (wmie ,<me,ws)_ Ne,l·e, lliat ~"l:ap:pe'a1s we1lLcl!efIne,cl!. en t:l".a:115YefSe S'CanS (a),

out S:h0'W8 megullla1 ,ohl!tti:nes m. the ~ohglirudmJaJJ scan. (1))- Ope<:l1J .. anl],w ~cle-nrfrilI[es. the ]Josirtiofll ·oEthe Er.a.::lle.:.aandi. cm:vedi.an·"Ow marks the: OCA_

'7' C" II,. . .." • •.. .JI . ". 111),,,-21 .' , "~]llI'i~lde:l1s.1tl:c[jtu;ffi.opa1LJl·l·_ "

• cys1tiic aeerosis ill 15%; mSJorne eases iliepre.SJoooe m 1tI1e oerv1!caJJ ch~. ola tlliillck - w:dJed. cysltillc m<liSS .or ,at cys1tiic mlIDs..5 \-\iili. :[iI.Siolffid oomp.one11lt wb)d] de:l1iil:oo<8Jtrattes ¥i§l!Sicmm1ty on co]o]'!]!l:lB!ow .iim~gilThg (Iiigl!]!l:e. 3 _'9)maty be tfue ,~r cme ®o lOOepr'ffiffioe of <ID. oocmt cm:cmom[ilm tlLe 1th;yroidlMd.m[jl), be l!J!IIiiSit"OO :f.or <iIf.I, wededbr<iLll1ch!.tl!. CJ'cst 21

Fig'llll:e 3;8:-

l"oo:l1JgimdlnaJ! s,ono_gl"am 'ofa ty-rnp,h no die (b]aGk :<mo,ws) with. a pltl.:l1Jctatee.cl]ogem:c E001!l!5 typic.a]. ·of a metastatiic no.deEr"o!11 papillary c=.inoma ... Note itts density ~s slu:uiJla1' to' the tlll!illsde- ,llI11leriorl}, and. the no de iN.cl!en1ls llie muema]

jilLligulliar ve-in (an:owheadlsJ

Page 45

F~grn-e, 3.,9-

Traasverse !'Hlilu'Ig:mm of.a l'~e, cystic metas,tatic node (llarge whille an,I'!I'ws) ilTil'!lfn papilla!)' carcinoma willi a EOC,cl, so/rid! comp0:l1:e:n1l (Sllla'lJ!. wllltearrn,ws),. Ths cystic nod!.e, may be miis,takenEof .a bml'ldhiaJi ,cyst voiili. diebris,_ Hawever; tlo,te the i:I'Ite-ns,e vas:c,lilliI!ariliy 'Ni.iili!iN the s,olJid! OOfJ1POfiefiift" sl!:J!ggesfu:ng llie sooste! nailWre ofllie mass,

Ibl

F~.gme 1.10-

Transverse slon0g!ran:t ,ofap,apiillJary=cino.fl:Hl seen las, a s,onidi, :iJll-d!eFined heter,o'geneo1!J!s nodu1Je wi'l:hin llie fuyl!"o~dJ (white ,alIO'Ws), Note llieftUlffe,d!. rnaot!lc intl"ano,d111illar va!';,c1!1illarity wi'lhin fue nodl!ll!e 'on Do/]em- power DoppFer (iIJ)- Wfuii1te 'ope"n amJW ~d!enrW1.es, fue position ofllie tmdh!ea, bFaci;;a:IT/ow mms, llie CCA andl.llie bFack openan-,mv ilie IIV"

Bcweeer, oflemllJ!S!tbe <illli"vme of sl!iI1tmiIregrrullllillomarn 'i,vru'l:lE the thrym1idl boo which. m~ymilm'C: lt1!mom:reom-renoe_ TheSie are also jilllJ de&tedl, solIDd.mcll !I1ypoechoic wi!tll. echogooiiclloci. :slli;owmgpos1teriiorsh<ll!dJo'!;vmg_ The echogesic ioa. ~. ilieSie Fesro:lThsrn:rellJlslIJ!ahly ~arger and de11!SJef mtll, grea1ter aeoustic sih<ll!d!m.vmg (F~gm-,e 3 _ By _ ru'm1ll!SioDd-gWdJedIDllIDe~~eedil!e ,a5pii1:milOOJ cj1o]ogyr'etil:dill.1y ,dlfiffer'ef11tilaltes beThveem.11I1e t;.vo_

iP\redJommfllysoThid, ill-ddmedl hypo-,ernofc iP"mJ:ctil~e cakirc~oo

OlWlloltic v:ascmarpa:tlern. on oo]o,m:Jl]jow iil:nOl!~g A-Sis!Oci~1too. rnlilf<iLc1beris:1iic lIympThl!<ilidlenopa'i:by

Figw;eJ_ll-

l,oNJgimdi:nalJ s,~m:oglanlefan iJ1Ld!efuedl, fu}"Pe~ed]e1>C::" fuetel!",O',gene01!I5 fiod1!:1l:e (a). The mteN!s e v:asclliiarity m S1!Ic-h asmall ne'Gween ce]em ~m¥ef Dop;ple. (b) sl1lggested! llie sEsteo!N!aru:reoftfuiis nod1!Il!e,. a p1apillJaq car,cinema ..

F~gI!ll'e 1.12-

Transverse s,onoY·llm ·ofilie iliy.oiid! bed! In a p,at:ienll w -iili iliynid!edomy Eo:!' papillary' ear·cinema_ Note llie hj'p'e.echei:c nodllie (lJa.ge .:me,ws) witll. a smail!eccl:Logenie fecus (Sf.l'LaII.a!IllJ'Ws) m llie ili}'!eid! bed!_ A~p,ear;mces

.a.,eof:a pap1tlial)' earciaema feOCmT.efloe, ~!I"llJb:ab]y no,dlal .. CO!:npa.,e tlIiis, ¥tilli.F~gme, ],.13_ Open .aIT,OW ~de-:I1rillie5, llie :pesiilioa·ofllie tr:ae-he-a ,and!. !0l!1rVedJ :alIiO'W marks the CCA.

~ap]<iI!S;ltic cncIDomat repreSlMts 15---:2JrJlf)jJ3 of ,;dI 1tliThyrolid. c<IDoe:rsMdi. is. one .of tlh:emost ,aggressWe Jhe&.di.mdJ fleck cancess, ,.viJ~ S;l!l!~vw;m:].r:;jL1tes ofmontlh;s failie:r 1!h1ll1 years. Thes.e 1hinC'fl.!lillS miilyrepre.Sient ilie ml]]. s.:t<ilge ofde-d:iffe:rootil1il.1tion ofp¥,jlany or~olilliic1!iilliM c;ncino:!ll[il!5_. The rniilg:I'J.>osJ!s: iisl!]J5l!])dly ,dirnc[il] "Wiiili a.fap&d!I'y gr01jJi,:rmg ftryroid. lJ!odiuilll!.e, 'paltients i:e~e1lJtlIyJlfeSloooog wi1tl].preS:8me ,SJigns: md symptrnl15_ U11tr@SJoud.lh!clps to OOmtrm. ilie cJmc<irll.d!iiaJgnOis.i~ :;mdlgutlid!e lIFNA:C, whiid1i $]i]iS le:!l!oelenJt :Sief:l5li1bWi1tyfof 1tills. 1rILmlOM_

Therei:itre two types;:

Ff~e3.,13-

Transverse s,dnoy.arn ·ofllie llijf!oi!di bed! in a p,atien1i: ~-iili lliy-n'lfd!eclomy fill·j! papillary ca!!'cinmua .. Note the hYP''''H,eboic no.ame (illarge ,an\'l'w:;) "",illi ~argee.cl]ogeni:careas (smaIl! allows) in llie ili)"l!>li~i!d! bed!. This was a S,l!:lme,

y.lID1i1J!011la_ Compare 'Ihlis. 'i'.'liili. F~gI!11re IJ2. Opena:rm,w idle~1l:i:Ilies llie po,sifI1on ,ofllie tm,che.a ,a:l]Jd! cl!1IVed!,anmv 1lt!ID::5, lli.e DCA_

wrrere goirttre is ell!di.em:c" <rn;di.:rrepre:s:ent's IDl,llppm:elllt U<iIfIslom:J:<il1tlon of <iI. hemgm or now -gf<ildie ~es,j)oo_. ThepliEflel1!1ts. me us,l!lIdly dd!erlIyIDelill!irles., a.fuillstol'Y OK goiltfehcinJgpre5ent m 8{lfIDA._

.Anllp]<iU51tlc:. 'G1llcmomilli are seen aslarge .ma.&S!es ""vihll1il.pmpencsartyfor mtr,mruoo.iiIJ!llid. appeiIDrp<iltlllio:]ogic~ as ]ru:geJ[]esl1!y mmOl!l![S; ""vihll.m'"'eii1i5 of [hae:morrllli<ilgeMd.l1Iecrosis._ At 'lheperipfuery of tfue 1tiillmoms, '<liSsociiil1t1ed weltll-diffe:ren1tliiil1t1oo lliIill:om:s. m<l.-rybe f6l!l!1:1dl,;represenoog <Jdenomatolls g,o~tre, IDo1!liicmiH ]esions, 'Of HmiMe octl! Iti!JtlEOMS..2lli

F~gm:eH4-

Tranevers e (a) and!~]ong:imdinaJi. (0) S'ONiOyll1l1~ ofllie lli}'l!oid! showing ,lID d1J-cle;fined!, hY]Hl-echoic mass, (lJal"ge ,ag,ows) agaiasta baciYIil'Wld!. ·ofnodclarity (sma:1l. ,ag'IilWS)_ The iappea:r,ar:J.'Ces are ilios·e ·of,an. aNiap]as!tic carcinoma_ Open. ,an-,\'l,W fd!en~es.llie .p'o,sitfon o,f the. itroc.he~ :and!. 'Cl!l:[Yedi . .anew marks the. DCA_

Page 48

• :m-d!~edl.fulypo-ecfu()iic, ofi,en cys,jilc

• ilLmorp1]011illS c&l!cmC1}1tiOfl!

• Bild::groltl!l]ld fiOcmrnMit)'

• Ch&o1tic;~wnp~ne:m. ()rn'lI OO;]D_lIl!OW imJ~gmg

• Fr,e(}[]]!oot<HlijOl!QfmtV<il!SJCmillli mJ'i,,<!l!Siio!l1i

• FreCJjlIToot m.'sJOcia1tedl ]ympihadooopil1!:hy

MernillID)' cHcEom~. i5f,e:l!~e]yrlMe, If,epH:~~,SJenMgJ1m,t 5'% of;d :I:h!}~oi!d CMOe:rS_::lS The mtlMom arises Hom.1illIepM;lloJllii)cMiJi1l[ C-oe1!ls wmc:fuSiecre1!!e 'l:hyrocaill.ci~omm_ lin If}-2rJi% OfCifies. 1the:re is .iiI.lfiltni!l1y his.tory of tbymid.ltI!1rI:i!1oms Of evidenoe of hype:rca1)ca:emii~. or p:lh:aeocNomo Cyl:GilNiiI_ J[n. 510!iM. !I1iodW meti!I!SJt~es.[iEI'"e :Sieen. m. flreSlootiil:ill1oo"mdl15-25'% fuiil?;,lie dlm1tmt: met"[fiti][Ses. (1m'g,bom:e, bei)_ li'!"

The1tmmom is: OOl!J!1lDooJ.~ seea at Efu:e@1te .of mm:iml.!mJJ. C-oel!l. oD:I1!cootra1tioo"t]]e .rna1terall.11p;Pe£ two tfmdls of the .g]Md:2llli illt is. keql.!illoot:1y w,eliI,cil-ol.!ltlllS!rn1b,edl ilJl!J!t ill1ll1lyh;][[\,\'e ~mNeibo([d!ers._ The lMimom ,rnM,;iI)c1teri51tica:liliy con1t_amy]oiidl; Siome m&y ~~owmttr@E1m1o([<rll!il:ecr,,)cSJis. 'O([hae:rEo!llf@<lge_ It illaty also mv@cl!e]ympDcs:[M'];d~_ "1ln.1illIe J<IIIliilliaill fOrMS ttfiere m~ybe m1!1illtip.]erurr[jlJthymrdl~ fu!miOlill!lfS_

UlltrasOlmd.l'ea.mr'es

1 Solliidl bypo-ecl1oi:cnocIDille_

3 E<rnogemc~oci m 8'~9 [)I% ofmmoms,,~es;er,eproeSient hoth. denSle depos.J!ts. of1ll1illl}i]o~dlMdlats.SiocJ!<jl~ed.~oc<illl c<lillcmCijI;ttion_I1,'.2J The ca1!c.mmt:1oo. ~el1:cls ~o he deM!ef tlJJruJi. mpapiMJ<rry Gillli,cmo!ll1![iI[mdl.m[ili}' ~aWID:<mt POs.1tooo!lfs.illiad!owmg (Figw:e 3_15)_

[b~

Fiigw-e,:3 .15-

TtI"amve4"s.e, (a) .and! ton_gimd:i:naJ! (b) sonogramsGlfa lJ:ted1!l1lla!y car;c.in®ma (ill~e :an.oilNs)_No1te ilia1t itsapp'e31anee is sirru])8I; 110' ilie papillary car,ci:no:tJ:ta. in F~gI!illI"e 3..7 _ The ecl1o_genic f:ilJ,cj (S1:l1a1J!. an;ows) ,8I:e d!e!I1I~"et :and!.eiliLbii~: ]J o'S:teriOf snad!o,v;.ing c~mlp·,ared! to' the p'llillctatefoci ;in papilla:!)' eascinema. Open

alIO'W id!~r@es the pOl5ilftio!l1l o·filiettrarnea ,and! omved! ='O,w:utms, the OC4.

R '. . . . . .". _jL ••. 1~11·" ·f ~1L ~1l,.. 'd' Ii~.'~. ed .' ~._,11"··'. '111 . _,11 '1l,.!,,,,t;,lk, '. _X: .. Ii!: . . .

,lXil'1ffenC;e <liS: OOlilllllOO, 1[1. mellJl!J!Il!ary IC1lI['Cl!ITOmiiIL 0 I I!!Ile m}ff'Om" _ t-tll mcr'e1lli5B . 'S!e:I1!lIIillJ. 'lA::IlCl!~ornn. ~eViCJi .. 1lS ~1ill5"J!.o1 .51pBCl!l!Ji.c~O[ 1tlruI:I1iiOl!lill re01!mfell0e.

• s.o:Thi~, fu~o-ecl1!oic

• F OC[]]. or~SJe

• ED:hog~C foci. 'l.W~

• CfuJiil:olii£; vaSlcm<upaHem, Om! ,c'(li]om:low .im:~g

• AS:SJociortedi. clh1Ma.o1tefl&trc ~ylJcrph1ID.d!efl0paW:t\'f

Notoe.1the1.!'ls,e ofl1the ~e:rm "Folilli!cmm ]esioni when. deso()flbmgJolillromorrlt1!ooom:s.mt is .@otpo.sSl!lbrne b~ <iI.1ilI)' .ooagil11g mems oflFNll.:C or oore:biopsytto

.:l~ ~ ~"~~t., 1\.. .' ." , . ~ . , . .:iI' 1\.. ., .. .. ..' (£ ~n~ ... ,111 d1 ,.) Th . . .....,. .1l,.. , . " .:If 1l,.~: .. ] ,'--ink,£.

'!.J[Ls;W1.5~.' [)et\.'\i"BOO, aa WV,iilSNe C<iIf'C1!1101illiSi :iiIilO!UL .~ts lliJ'el1llJgn OO'l!liI1~erpm, '(lOJ!W!CL!.Ji!<U ,<iii ·el1:0m<il. ,I e lenm,e .s,peCB!elllLIJilI1.!'Ist oe ,exiilJiIlil!l]eUl ,~l!l!S~O Ogl!.CilJ!I:)l .!Lor

atpsmotlf1ll'l:di. Vt100Wru:' ~rn1J.\Ve{l]eJf,efore grol!:lp Ote:mllMd.er{l]e tefElll.lOililli!o~ ]es.iooS:l, ,Md. db notl!l!Sie ~e ~erm 'iadenomai'. Thus Otern::wg'l1!OSJis of::w iWdlllli:cmru: £esiion.1.!'Isl!]!aN~ ~llies: the .fleedl for smgica.ll .:e:IJ!lOV31i ..

lP'a.tholo:gy

The ~ll!lm.p[jl1!i,o]oWc[iJ)J] m1!efla for at fo:lillrcmar ctEDcinoma are mvi:il!S&oo. of the c[j[ps.l!lilJe, O[ mVi:il!S&oo.ItMOl!l!gh flle Git:psl!l!1!e of the hm1ol!l!lf,.1itl1l:d MV:~OO. of [Illie veitlllism 'orbeyol1d the ,capSJme. The ,cri~ffi<li fO>f vatScmotlfmvasi0FI ~pl~~ :8J01!.elIy to 1tfu:e VieIDS: in or heyom:cll1L11e cilpswe. Tmnom:'pmgs:m the~illmeSi; ~ '!he ~Ol!J![ ]w<il!Vie lThodli'lwgn:osru:csiiglliillIci:Jil!1oe.::Il

F o:llicmar ctEDcinoma Ol!ccom1lis-lFo[ 1-:5% of ;aJill.1i:h),'f,ord c1lI1oers.1.4 Hor"v,e¥e:!", miodme d.clici.ffiE me<lt!5 1these nEll!lInm::s: are mmepr'e\'.i[]ooE, 1:5-:301%.31 Men ~odin1:e is~d!d.Bd.1tO tlle dl&et,.papillm)' cmcmom<il mct,eaiJies: <MlI!d. follicmm: CMOMom~ dect'leaiJie.31: :E!l.moSJt ICMes: it de\!ie]ops Mom. aplf,e-e:lli,Mgi!ld!~OMiSJ.14

.2 Fm.l1ifcly~asiive: obviDllllS v.1ili5cm<u IDvi:il!Siioo. ater beyof'J!d. '!he ~eVle] of the ~o'm c<itps:uille2l~mdl. tiliJymi:d m\i'.~Dn. 5GJ;-8{)1% 'me1t1ili51t<iliSilsle14 aad :h<il!ViE: :at .high. mtalliUy[.iiLlte (501%).

Both. types: haJve a.propefJJSJityfOlf :l]1l.eJill1li<il.tOgffi01JiS :s:plfe~.dl ~o bone, liumJg,. 1b1[,~. ,1ll'l:d ])We:r., ~d.p&rujentsfre[jj[l!l!en'l1iypreslel'lt \viiI:h. ,rns:1tl1'11t metmtasies. NodlOlil! ilMe1t1iliSt<iliSJeS::it[elfeJi~e1iy ·m!I!.CIOom:oo.

Ulltrasolmd I'ea_res (Follicllb:r Lesion)

1 f!" .ell ' ~. *11., ~;..lll TuI". . .,,1l,. . . '. ' '.J!':. . d _1~ .!L lIr"lf,etli.Gl1ilWl1ian"'J ,SlOIJ[U •. l!J! .preSJoot"ILI!.e cysfu!c .poliroo. ns .:I!!Ii.eql!l!ffilL.liy .SWI!D.

<6 .0:1'1. Oo~ol!l!lfIOWD.iiilgIDg, iliem@j:ority (8n-~9GJIIDA.) ofbM1ig:l110llllicmM Desrons s;howp~ocimillMJblIoO{ill.fJ!ows.i!gn;;&. (type :1M; iF igm-e 3.17), wllereatS midig'l1!mt.f7oilllliic'l!lill<tl: ~es.imI!S fu<ilJv-;e a itype :m v§&Ommty in O\'ef 901% of eases.!"

F~~,3J6-

L~lili~rudl::mlill S o:l1!eg:l'a:tIl showing. a we1lLdefuled!, homo geneol!ilis"so.J:iid!, hypemct:Hli!c lliy:roid!. n\'lGJ!1!lje (llMe,ws), suggesting afolliclll1!a:rlesion..Noifue that it indieniIs the CCA (lln7Owhead!s) 'b'ui1! dbes no,t mrvade if.

Fiigw:elJJ-

CoDo1!ll' powef'Doppille! ·ofallo:mo gMeOl!J!S. ise echoiC:,. wedlHJ!eJinedi s,oJ!id ;I1o,ame 5ho¥>lin~])fedo:tJiinanlly perir:J:odlll1!ar vascu1!ariliy ... F~lJlo')Wing sm:g)1M)' lliiis was confumed! to be alfbn1.cmllal! adenolJiLa_

I'OLLJ:C1J.LAR. U-S.l0N

• Hyperechoic,. ho;mog~eol.!)js

• H<iclJoed

• C1il1JcIDca1tJ}omr israre

• Ghiil!ofu)c; v,&S!c!ulillnpllIfieul (lI'! oo]om:ll])ow ilrnagfu1!g m.·{Olllixcwn

As. swed!. emJli!er" i1t is l!lO,t :PQssrub]eby ~rg.a:gi;ng ®eolDqll])e" Of lFNA:C cytology, t:o·rns1!:i:l!:u~ eotr]y IDv,~e cMoi!l1om<iIL nom ir1tsbBfliign. ,c:ol.!l!l]llierpm1L JF'ollicl.!l!1!w: c1lJl"cinomi3:S are as5ociiil!Eedi \\:1tlh ]]yp,erp]1li5fuidad~omafol!JJs. 1tbyroi:dJ no ames m. ,6iO'~?O% of eases.l" MtlIE:WCa1t1IOOi of sl!JJ.ch. ,<iI!. noCfuille 'liWiI:]B ,Oll ml!li1ooodlliJill1il£ 1tl\i}'ford lL5 diiffio1!J!l:t ;;md1llill1!r~l!IDdmaybe1lma:ble 110 idlm1tEry &eSJe {oci of m&llUgIlli~cy_.

However". :iliern~os.B ,of:maJ!Ug:I1!ill1J:cy c<ID.ibes;ugge5~ed OliJi.mttrasol[Mdi .. if aI1IYliloc:hil!e is jilll} d.em:ued. aad .hypo-echoic '!,~. he1temgffieollills m~e;I]llia!l·echoes. 1(iIF~g:m:e .3 _18)_ Fmi:l1.er :SJigns sl!JJgges.m.g m<rllignrmlc}, .McMde: :a tllick m-egwillw: ICi:lp:swe;promSiernapti!c,uc\lilll:olillSperm.oCfuill<iII ,i:iWdJmk,omodW!w:veSisds; vMcmillar mv<il!SionMdi. extiI:@ cap:sl!l!l!ar spre@!dL

Lympboma ...

Lymphomatmac}f ru]SieprirrI!:IDiI}fHom ~e 1thyro1id or mv:oiwe ~e: thrymid SiOOO!lThdJarilly·as .p1ll1:. of ~ s.y~~e:lDJc llympfuol!N~_ lPmn1ll1' '1ID.d.SJeooodaw:y iin\'iO~e:meFl!t of ilhe 1ih}'m1\d by ]y'nilp}lliomSIL tL5 w:;<tre, ;i1LOCIOmThmg ]0([ ,oruy 1-]°10 of;<iill.Iih}'1",omdi. m1iiligl1!illlcy_ Not1l-HodgllrnTh.'s lIympl10ma iismo([e OOl!nl1!1rnl.iI1tuD. Bo~'s m5>eooe,mdl all ,::m1tooedienl.his1toryr of Ha,~D1to!'S tthy:rO~.d:i1tii5 is ,aillmQ(st ,<i!'1w,iilYs preSJe1'Lt 11,23 Itmec1t5 .elderly Wome!l1, oiel1!.pre5>ents as a.orapiidilly ,enillID'"gIDg !rn!MS, md mary e:demd. ol.!JltsidJe :!:he ltIlyrordg]md_

F~gI!ll'e 3c1$-

Lo~girudJ::rJ,al! 'sonogram ·o,fllie iliYl"'ojjd] showing a solf4. he1telTOgeN!e'Otllis, :pfediontMaI1t1y fu}'poc.ecli(llic flodUl!e, 'iViillil:lli-dJe.1i'iI'IedJed!ges (am')ws), suggestillgi1ts maIigl1!ant natw"'e_ 'This ptati!e-nrl: p1e,s,e-n1te,d!. v;.iili. hOfl~ I!I'Hltas,tas,es. and. the lliyl"\'l:id! nod1!!1le was conmmed! to, be a lfbn1tC!lIDaI! carcino~a_

1 The Itbymidl is o~rn1iliY flypoc--echoic_ However, l}'lJ!lPfu:omaJm<iiY somemes. .P'f'eSJent <llisJimpEe gll~d!JJilliH ,enilla£ge:m:ent ~rl:h flO ObWOlillS ,jbnonn.-tty m :!he thyroid eclJJopafieul (oosloc!iajed ch[H,ac1teris/1tiicrryl1i1p:h~d!~opafhy m[].y he:!he omy cfu:e)_

P!lge51

J'~gme 3..1 9-

Traasvesse sonogram sho'OVing a SiOJ:id\, h::l'1)o eclloic ~j'm:p,homa~o1!]s rilod1!1l!e (lIargec white ;;mows) in the th}'l"I'i~di.Noil:e the h:ypo-e-elloit, lJ!e'i:erogeneo1!J!Sp;arenchyma v;.-jjlli.lliin fiOflC),irilc s.fu'eaks, (smalJ!. white

an-I,'),ws) sU1,ggesti:l1Jg a badO::,&,I,')1!llldi ·o.fHashillloto's lli}"Hlidifr:is. Open ,alll,')W iid!en1Ii:fies: '!:he ]J'osifr:ionofili.e 1nrn!ch.eaand. ~1!ID1ed!aM\'l'W marl;;:;, ilie OCA.

3 iFocaJI1Ym'PhomOl.Iol!JlS: nodh!lilles n:JJaJy h<itVie a'pS!Bl!JId!ocys.ticiappear;ance \\"1iili.po.SteriO![eW}M05m!e:t1I c:&I1:dmay bel!Jfl!isE<:&oo for cystiic Eesiions: (thegm .Siettmgs.ilIlil'l!Sit be .mcr,eatSJed. ilto idlffi1tiill)' tihe :s<oIiidl nIDlrn:",e of ~e flocMl!e).

HglMe3..1O-

Longimdmia] s Ofl:o'gI"aIDofan emargedi lli:ytoid 'Willi a :hyp o~e-iGhoic:,. hete1!"iogem:e,o'1!]s ed1iop!a'l:tem of ~51e l)'mp:l1iomatol!:lis my.o]veJJ'llen'li.. A :;:imiI!w: ,appearunce may a:J!s 0' be SElf4JJrn me,tastatrc lli}'"10fdJ rn.'V'olye11:l'e~ri:.

6 Associated. ]1iIf_ge,illoliilliThdlfurypo-echorc, fuype:lV.<llisc1!I!llm ]ymp;hnodJes wblclJJ dJ.eJ1IiiI:of];SJtralliep'os1tmo[ 'eSmoement are o]!I!<itI",a.c~ffis~tic. TheSJe llliod!es: mal}' ,d\isp]a!oe ~em1]jffiOrVies5eJlshl!J!t[:ar,e1}r eaase 1t1womhos.lis.13

• Hypo-oedl!0lic

• .F oca:ll. o[·diIffi!illSte thymid .. ~cY]I,,~e:I][]!ent

• jp';Ste]!l!docysoc<qJp,e<itl:",mloe

• Heterogeneol!J!s ;ernop[ll1tl!:en:Ji

• Chrul[ges '{)<:fH~oto's thyro~di1tiis

• NOl1-'specmcV:i!IiS!cmmty ofl1cdowloWDSIlgiing

• As:StociOl.ted. ,dThOlfaderi&trc ~YDitphOl!.d!efl!opa:W:t\'f

Tbyroid I\iIeb.sta;s es

Me1tas.1t~e&~o:lhe thyro~dm:.e .meqlIToot, occm-ril:JJg ]atem :!he coerse.cf illLe diseese ruiLd. gMer<rlly as [fuefe&m1t of sp1f,ea.dl by a .. :ha:.e:matogooOrl!l!S (more

... lk,) 1l~ t. .•... . Yr. " .. '.::II .. " ... :' . .' .. '1.. .. ~I~ ... ' . • .'') l'7~'x C·· ... " .. ,_e' .•. ~. ~.~1L ... ~ .. ~~. 3·'9·1@,>,1\--.'')100,,(

'oommo,,,)', 'Olf ]ymp",~:a1t:rc lfOl!lilte. 11tsl!l1:cJ)tle:l1:0e, .m; Plll1t:!e:I'I!lts \Vl!I!.-I!~. a .. l!lJ!rO\YiI]. pmm1ilfj' ~5~-' . 70. ' olilLlil1'l1onsa~,es Uli ongm .. l!I1:ui!!J).U!e: 1m!.cJJ[ffiOm1ill .. ' . 70, rn.'e<J!5t "::'dt. 70"

[[,enid oelllJearcEomar. HJiDfo.

The]e@.o'l!'ls ase ofiel1l! :SiOThit<tl:y ;iiIl!J!d. we1ili. cirCl!DiSlC1fi!hed ,\<\"1i'l:h :<lLn.[lIPP e11fMDe~;f[ Ito that of ~eprimID:j' frnmllibm.lili The g1!amd .mI!<1Ilyihow'e\'eJf :sill1ow ~Sie mvoi~eme:l1t, wlIDol!l!t !the f.onIl!a:1!JJoo of :<Jlllitocmille ..

3 Non c~cEed ..

P:age52

F:igur:re 311-

Longi!rudlnal!~j,()l1og,lllltS' ofilie ili}~o:idi sho,v;..-ingtj,olldL, h~iPO~echofc farge mecftastati'C no d1!il!esi (whil:e iaMO'WS.) in the ]O'Wef :po]es,- Theedges may he well. di.efu:ted! (a)orles.s oOrJ:Unomy ill. d!.efu:ted! (0).

TIf'fROIH l\ilETASTASES

• Large.mdSJoTh)d :focall. wa,s.5

• HomogffieolWs.lYfurypo-edloiic m1ili8S

• Typiicdry we1!1l dJ.clilledl

• .DMIo!SJe EIDeI:'erog~ecfl!]s 'ernopa1tltern.

• NOFI-S>pecmc -Y,Mcm;rrp.a1tlte:m.00. cdom:loWBOligng

• fuvari~lb,]y i:;mssocia1ted. ,.,.milidlis's~a1ted. diis.5ID]Je

Hmihlle Ce.I!II Tumours,

Hmfie odl!sm-e deriJ,~edi Hom. :folli.cmar epi&ellrum_ They caabe :folllil1:dl m. ililL f11!E!ber of oO!Fl:dliltlom aad eanaot.be C!oosi:der,edi.specmc for any disease entity_ They are seen m.mrurEffioci1uilliiII :iliyromd,. d:lim:mc ili}rforrn1tiis, H~otO'.s ili}rfrnrn1tiiSMdi. ]o:l1!g-stmTI:~g :IlJypen:hyr,omrnsrnl_ Most Hl!I!I1:He oe1ll. ]esro:mlsEitlfe :molllliic][]]ar mp<ll1tlten'JJ,<md. :S2O lliLe cri1terii1l!. fordlHeren1!i&ooghenveooben:1i.gn.::md m.rn,gIl!<mtru:esirn1ill§:l. 1io !those for ::molllliicl!i!l!<M ~es.ions {ca.pslilli1!<ilf1illd. vascm6lIl"' m:\CllliSJio@)_ TheirwwatSiowd. <it;ppei1l"IDlDe.sm<ilY ,~SiO dosd~reSJe:IiIlIbille <ill folillbilll!ru:]es.iDElL

lPleviolills1~ oo~d!eredl. bemg:l1!" these mmoms do ,e:dIrub~t i~.pOltefl1tii~$01f"mJJaTh)gI1!1lI1!cy :1lI1:d.mJJiiilymetast.mSie to the mngsMd l~pfu llodes. (3~)i%)_ Theyru-e l!1floomrnon ~es.ronsMd.1bridge ilie gap lbenveoobffilign.:md mrulgll!<mt thyroiid nornilllles._

Thepa1tE:tdnogic:iitl. cnlteUliILforma1!Dg:I1!EJlilcy ,EiIl[,emet mor,efi:eql!l:oo~ m. Hm:1tlhille cd]. tL!B!oms as compm,edi1tolOOm nO:El.-Hm:1tlhille c!OllW!1terpalis_ ThlWS.,. where&5 omy 2-3% o;[SJolli1tiiilli}', enccilps1!1illat,ed ltJieoms, :showiiJjl'iif~e chuiiI!.clterisltlcs,. 3'0-4{}'% ofHllliI1Me oellli. Iesioossl'lliow S1!JJd!~eaDes_2liS

lP'afllofogy

Most Hliltrtl1ille oe!lll neopi]asmsare solli1tru:y m1IDSS IesIDif!ls tlhat4tow oompilete orp.ru.1Jjaill.encap.s~atiOOJ_ They mary rare1Ysd.ergo tl!m!lom ~ctfoo (pm:1ticIIillacrly .ait.er iFNA)_ Ther'e1ilJf'e ThVO .dj.e:mM~ep.1iIlth()i]ogik:m 1type:s,beniigrllmd.maillignIDant Lesioss grealter thill!. 4 'cmi:,eq1!l!entlY (8()1%) 'exNhit'midig:Fl!1mt cri~eri&

UJtra.sonnd I' eamres

Page')3

F~gIillI'el.TI-

Tsaasvesse s~mog;l".am sho'W-u.g:a we1J.Ld!efued!, predominanTIly hy-PSfecfuoic no dille with .. areaso,ffu:;l]Jo-erno ge.l!Lic.£ty .. v:itfufn (aM'OrW5) .. At :>m;gery fr.rns, 'Mas,jt'®·W1Id!·to, hea HliII"iliille oeIU ad!e;nonm.

N o~e irl:ssintiJlari1ty to ,aF'®llicruar ]esloH. White open awow marks ilie OCA ,and! fue blaiCl;:open ,aM"'"QW id!enti:fies. fue llV ..

5 eO~011lfl:~Oweaging .iSfiOfl-dlEaJgnlO,s.1tl!c @5 ilie appe1itlf3J!10es m'e~M to ,at fCJIllicmllll ]eruofl!, i_'e.ilie :Illiodul)em1illY:IDow mJItif,rulocIDillill! v.illiS0willari1ty, type TIl [p.[j[fiem_.

~ COl!2l1lil!J!lliomymeSJemMes '[iI. ibllliiicm;rr feS&o!l1i. OI1!.m1tr~oDd.

• 1vfuied m1i!efl1l!aill. ed1oge!Iicity '(lThyper.eC:hofcMd hy!po-edlo~c)

• fuoompEe1te h~o

'. NmlJ-spec.mcv:~omi\ll[pat1terl1l! on.lCo]o_f]JowD~gDg

H1iIlv-mg eoasidered tl1ema1lig:l1l1rntOOim:omsofllie~.l.foiid.wemlWstflow<il!dd:ress.!hemor.ecommon.hemgn.flodlliiilles_.Fn.duypra!ctioe.maJ@g:I1i<mttl:tr::r.To~d ]eSiiOE[jjfemOO(lW']1lo:n1J, wlle:relihS be:miiign 1tl\u}'lf,o~d flodJwl!e8ru:el!J!Jb.iiqm~Ol!J!8_ The ODmImones.t o011tdi1ITon enool!l!l1lteredm ~yrordllik,'iI!sol!illlllidpr.;]tcltioe~Si1ill mmti'!l1:odlml[j[f thyroidL

"MmModll1!ar grntr·e' is. <ill oOilEimon. ~,erml!l!S'ed.lto deS'cmibe mmliipllie ,uodiJwl!es ,.,.vi.i!:l1m 1tll:e 1thyrorud The term. "goltr,e' tmp,llies. .1lllI. ,el1illnged. gl!Mdl so Wh[j[ll does one ,CiiilllJ ,i3l flCH:m&] :sWed. !thyroid. ,C!on1t~gml!l!litlp]e l1!Q;cmI!es'? We ilie;cefor'e db flO1t ,OOiQomiilige tlWeuse of the ~emJ!.'mmtiFJ:odll1!;rrg'Qiltl:,e'bl!Ji1tprefer ~o ,C<1!.lrn tllese :glImm "a. :ml!l!1m.odlmlm- 1Jhyro&d!' _

It ~s M\te OOmlil!1.onest (8101%) PliItho]o,giiciicll. oonrn1tiio:l1J. of the !thyroid!: 2-B% of thep op1!1illa1ticon. ]w<il!:\'ie a ~cdYp1rlpa:b]e m<il!Ss_ 2il!i The pa1tiients.a£e fie~1illoo1t1o/ .ilSyrnp~omlilticiblillitmiilyp:ll,e5e:1111t ,-,.y£ili ,C!ompr'esme Syrnp1iOmIiS or '<iI.r.aprdlly ,el1illm:gmg m<il!Ss (the 'OO!l:l1:lll.ooes1t C<11!J!se of wfuiclJi is :I1:iileB:orrhiilge "'~~.1iIl flocWe)_.

Hyp'erpI~1tiic [flodmilles .<ne eomposed ofbror"Wi1 ~oi)d 1!iisslffe_ i1F"IDrOSl!S .ud c.:&l!cfica1tiioil1l! are flo~ed \viiliiilllL MCfosoopiicd~', oolilloid. bllEesaliIDeHl!am.g wi!i1 :IlO1]]l]Jall to lmyperp11illStic foci of flhyro£dl msue,ha.eJ1llliorrhaJg<e,. :flli1[osils ,illllld C~ciiiCll1ITOfl.ll[>e IDl.!m:d_ Avanllb]e<J!IMomt of ])'IDpllliocytic imilhafuJrulmay mobe

Then1tiia1tii!'l!g event ~s.pmlliIfe:ration iilThvo:mmg one or iiiI. grolap offolillides_ Theadlji<il!oent ;[ollliUdes1ITe qruesoe:l1lt V<il!SiCl.!l!l!ar oompress~oil1l (ooe 1tofollic1!Iillru: byperp:]asii[il) £e<l:rn to foc;all RSirna;~at, ne'Clfosl!s <ll1d liEilllJ11mmaTIory d\tI<iWlges_iPlrogressrml!. of tfu,eme1illSem.st £eiitdls 1\omaom,uodlillelDonTI!J!a1tiirul wifll.[ilsollidi :swoue bUll :sllbsleql.!IeJ'I1t1y dl1ll'l!ges sudi!.illi hiilelllDffhiil!ge, :Emrn:oSJ!s. 'Md ,~dffiic<il.1tl!OfI.1t~ep]aoe_2il!i As, 1ili:esle rn<iWlges .~e ooc~g, ilie glJ1llildlilfe:mrill1smd.er [hOm1on;[]. imm:em:oe_ The :fOlilli!cl!l!l!M1md v@SiodM ,dhistorITon. mltweres wi1th. ,rnsW1)l!lrfu)oli1l of rorndeMd.1tl\t~o1trop1ml,resl!lllimg m areas oHoC<J1j byperpill<il!SJ!;]t (wb:ch !Ir,emeNe ,exoes:s:1tlliyrowopm) '<iWld. areas .of ,aw.oph}' (rnre t,.o tI1J.l}.rm:01tlropm. defliciency)_

u.Urasmmd if eatnres

3 Cy.s.1mJc oOm!pooen1t m 6081o_ 'Thlisffli3lyrepilr,eSiffi1t hiilelil!1onl1:Ol!ge or rolillolid. "vi~ the l1!ocml!e_ H;]telil!1onl1:Ol!gemto ,<ill Hoc:mJ)e .is ~e OOl!llmoneS:I caJ1!l!S!e of1ill rap&cIy el1illiil1f:gil1g ~yro1id IDiillSS_.

FrgJ!l1e 3.13-

Transverse (:a):and! rongimwdin,a] (I)) 5,OnOg:ra:tl1S sl]o,w-mg typical! :appe<n,llnCesof'lllj'Pel]J£asfrid acl),eno11:1atm!JiS 1110 cl:lLl'l:es, (a:nro'ws). Note the cysfri:cJcoll!oi:d! spaces and! rnil:enr~g s.epta_ !Oipe'fJ: <!M)l)'W ~d!e11!t:i:fie5. iliepos;itionofthe, trac:heoa and!. c1!liI'\fe,di,a:II'ow lnal'k5. the, OCA_

7_ .on oolbm :f1!ow E<ilgIDg '!he nocfuilleseiilier ~ow :type l. or<il. type llpat'ltenl. (iFigme .3 _24).. If the flodl!Jil!e becoeaes toxic it millry d!emOFlis:Jtr.aJe m1tnmod!Juil!lll: v<iliSCl!l!llm1ty (!type ][JCljP1r1t1tf111)_ Debils (clots) wlt:bID. ]rua:e:Illorrlhagrc nmm!lJes me1ru:\{a!SlC'I]!lim:,iliue:sep1till. wi~ 1tfue .'Ilodl!lilles memo [jIM<1IiSiCmilltn_ Thepre~eJLloe .of V:lliSIcl!lillmry \wm1ihe debffiMd Siep1t<iIL :sl'tol!lilld.r.me 1ihepos&t"bii1ty tham. :!he tTocIDille .mary flottbe a. n~'Perp]rns1tic flociliJrn]e (]F~gI'l!I'e 3 _25). FN.4Cfor slIch.a :I1odlliJille ~s manda1tory_

F~gw;e 324-

Co]om p owe,. DOPP]ef sho'iY-irlig peri!intrmo udal" vas.c1!Il!anty wi'l:hin ·om :i5,o-ecl1o~c hJ-pe~]as~c noawe_

Mastpatl1oDoglistsuS!etlle 1berm. "hypeqJ~liI:Stic nocEuilles" to deSlrnlbetlle flodJuillesgolmd. m. aml!l!1lti.-nodl!lill<:u: lliyroiidL However ,somepa:tI1oFogist:s m<:lyuS!etll.e 1temJJ. ":a:die:noma.1tmJ!s nodiJuilles', wmcli\! can creste o01!lifusmo:lil_ .J!u1.adenoml!<l1tom:FJ;omrnJie ~ .<llirns,maotmdl separalbe e:l11!l!tyi-om. :~ follic1!I!llM ,<iIi.dlm01OO<iIL. ]F'O[ '50flO£OglS1ts (mdl.many p~ilh()!l~)giists) dliSltrmCruJon bmveen \-vfuefuer i!I. moCIDilie ~sm. adlffiom~1tous flodimille 0[ .<l!. fuo/Perp]<l:s1ttc :I1oame is <l!cadamc:" 1iill1eyrepreS!oot 'lhesallle 'bemgn lesion. iowdl m a .. mil:llilittJ1.-tloc:millar thyroid_

Wlliille soeee .illilitfu:ors:miiIJY s1t[jh1te 'I:lh:a1t dHerentia1tiofl. beThveeJ1l! &die1l0matol!l!S modm!es Mdt fuyperp]iiIl51ITc moc:mmes isposSllble 0:l11!l!TrI!r<1llS!omdJ,. tlJre:re is flopomt ill W,[llstil1!g mneood I~erID' m ltryIDg to dimerentia1te hem.veen. '!he two_ K1eep ~gs :sID:ip]em.di.use 1tl1e ~erm "hyperpbstic ~odtnillei \-vhene\!ierposSJib]e~r

PageS)

F:igm.:re 1.25-

:tongimdlitTIJaJ! sOil1oYa:l1l1S (a, b) ,olIa lliyuii!d! f:lod1i!1l!e w-illia cys;fri:c oomponeJ1l'l: ",,-illi intemaJ!. d!ebris and!:a ]!1Juma'l:e,d! :iso,ecil!1l1:C OOIllP!1lf:l:ert'l: an1teri!1lfty.·_ Co¥mllI p!1l'we~ D!1l:ppteJf (I) ded'Jl!1Jnsfuia1tes ~8f:ge vess,eJ]s 'Wirl:fu1n. fue S !1l1iid. eomp!1lnen'l:_ AI: smgety lli:is was, E01!IDJdi to' bea lIollic,maf CllIciIloma_

There '!,viI.31iJ.Vdrys be a.SJ!lld.g:fo1!1tp ofp.a1tlents, fu!owe\'iel:, where tl1!e pr,eSel1!oe ofma'Thigl1!ill1:cy fS :millssedL It lis d!.e1tec~ed. omymltersm:,gery or '!,,,,hm 1tl1:ep.a1tlent presents .sOOllie1t!me ~<iI.~er \,wrf! obviol!J!s ~ca:lJ and ~Slo:ll!ogr,a;plh,i)c~gI1IS OK mUgIl:1MJ!cy _ 1ms is 'iiIlreo~gprob]eJ1I'I! 1i:h&t Sl1tiilllcmmot he '()"\i\e:WOlillJe_. The ()nill}' re~s.m,iMl:oe ~s '!hat 1tfue .iincidJenoe of m<il.Thjg:ll!mcymStl!J!rn. a. ili}ffOlid is ex1ttrem~ low" om¥ 1-3%_11

• Ml1l!ttiple nocinill.es

~ ]F:reEJ}Il!ent]y iso-eescie, we1ll d.e&tedl

• So:l!id<mdl cystic .eJ!eE.en1i:s

• Come,!: 1tai!1l.srgl1i.

• Flbrid. caillc:rurnfion

• On. 'ooDom fllOW6<i1!giI1ig :!:hey ,exJhrubit :!type ]Md. ;!type II patlenJJ.

Tme epiiliLeJ:iia!ll. t:hymiid cysts are-rare. ~- Most cysltic ~yr.oid ]esro:ll!sare ooe to ~a:emori:h§!ge Of d!egenera1tfo:ll! r,...,,:ri!iliirr:! @ byperpm&s1trc flodlllille_ The1tl!l.ltt:riiliSollilllllid ,&ppe<ll"~\CJes of :!:heSte .h&Vie been. ,d:iStol!J!5:se&

T.l1y.minilfiis

H~oto's lifLyrolicllim is themo.Sit ,OO:lillilEOO of the cmiomc:: 1tlh;yrolicllitides}'7 ~t ~s .mOf'e oOlillililOO.on. im:I. womf.l'li. ~d. has .~.ped: incide1l.\CJebetween 4{)!a:I1:d. 60 years ,of .1IDge_ The dE1lligl'losilis is'l'iIIsl!J!&liI}'b.iiliSJedi. on.seJ[,o]ogy ~5 i~ is .[liJj :[il1!l!1to-Dmm1e ooodli1tioo_ H}poiliryr,01!.rnsm ispresent atpre,S!oo1t;[j[1tioo ord!e'ilielbps ]a1ter ill 5{)®A, ofc1IDSJes_1I

P!1ge56

There is <ID1I. asoociated.maea;s;edi.ris:k for ~e deVieliopmel'Jt of floo-Bodgkm's l~'l!:IilPhoilTI!1~_ 3!l~0tO:'S: O:!Yfoiidlj;tlis iITI!1ay he associated l.Vliili o1!fuer~ill!to~m:te O();llditii011lS_

Acute,:

·JF"oc<i!!ll. :I1:ndruilla!!: ~oi!CIliittiis;s.nTI!<J1Iilj., n}'po-ernrnc, 3JV:at5c1t!iliar nndmilies ,."wth iI.-dEfi1edl olIlilillines. Thes;e,repres;enta;reatS of]ymphoc}1tiic imiilltra,tr011l <mdl miil!)' he USit"oo.for a malSS ]esIDn (UCH)11.od!l!l!!!arp1lll:'euIJ-

·~.... .. to • .:ll~'· ..• ,.,1' .', ~ . ~ __ ,1'1 . '''1\. ..' .. . i .. 11[ . . .' 1L':~ .. to tI,.. ~ rill 1 .. .:ll[ Th ";~ . .:l[1 • .' __ .,11

' •. vmlliJ!Sie l!ill]yroltiliJilt;JJs;mrn1tl'pfe lliI!oumes \Wm. ,a I!Il!rCfO:l1:0UlI!I!Iar'pM1temJM¥(}]'I{l!EJJg I!illilie \V]tOEe :5':i:iLIJiUL ,I e::¥uu ~5 ;~CI!:I!J:1lf.

ChJ'o'n.ic,; eEi!1iargedl glland Vlliili fdb1!1illa~ed o1!lrltl!li:flemd. m1!J!]tip:]e illJI:-d.efmedl hypo-e-cfuoi'Care~ ~Siep.<natedby ecl10gemk :fiibrolJ!sseptiil!. IOF l.gJ!lllie 3.26). The gl!;mdl is hype:rva!S,e;m<!lIl" (maIDlyme:ci~bo"lJh. 'i.lIl'lhm ~epM'e:I1.ch}-!)1I'l!;jt IDJ!d.1thefIDrm.!l!S .Sleptiil. (F~gJ.!li[e 3.17). 14 The ,~peM-!mDeS<!lIl",e sl't!nilll<ll to tlThe'th}')foid, 1m"e:mo' :S!eenill> 'Gr<lli:'Wies."rnseaSie .. :il9 Thls ~ype:I'V'liI's.'Cl.!l!ll~m cMornc thyml1c1tiswhenl1ypo1thyml1rnsmdevdoPc5.rus dlJ!e EO' ~e hype:l1trophilc actlon,ofTSH. 'i!fi'ol!llO\vmg keament (WhelO tl:ieTSH ]ev.eJ]s reml1iJ!. ~o norma]) iliie n]liP,e:rv<ll!S0ltlillarity d.ecrea8es.3~

'T'IL. . . . "'" 1\. • "~.-.1~k, .' .. ~ . .':.1\.... _~_. '. e. .. d' ll .. 1\. ....1\. rij!" ._A ..' . . . ' .•. ' ... ... ~.1~L. .. '~_1'[.:;I!. '. Thl ". • f·' ,,1\.

.lL He .Piil1trffit C]f1ilf.a'C1tert!S1tr~'I]J'lIeS!en1!:s \VlJl!J!l neC±'l.p11m!.,.l!!ever ,m· . ~el!illl[j(fgys~10JJi!JIJ ,<1IL·W.er ,ru1l!ID]?per reS!]J1[.jjl1bory ff@C1t ftfeS5 or V1[,i:1J! U]S!e~e_ ' ,e regt0ifJJ '0 I me

iliym1id ilsp~ llD iliIre ,a'ollJJtreS!t1'l!ge flIDepll1tl.ffit -mary be :ili}'1fotoXJ!c, fo:lillowecll.byprogress fo atfuYiPolfI}'1foiidl. st&1tem 1-4-mof:L&s;, typiirn1illy, .ailer .SiD:: m:oothis ef onset ofp~,. iliepafuientl!e1tI!m1s to a . .el.!Jitl\i}'ro~d s1ta~e. 37.40

UlltrasolIll!IJ.l'ea.mr'es

Ff_gI!ml3.26--

TmI:lJsviMse (a) and! ]Of!tgJ!rudI:l>aill.(b) SOflO_gl"atllS ·c;filie ili~i'~!.'Ji!d!. sho'W-mg ~s e e.m~geme.£t, hyp,o-ernoie hete.!c®geneol!:lJS e.;e:lll!opatl:em. Viii,Th brigfurl:li'iIJ1oti-c s.'furws (wfu:ite, ,almcws)..

AppeaI,llli!C'es ;;u:eofHasmn'ollo,'s. lli:Y'!.'Jiidi1tis. (}pen ;ano'w iid!e.nrftifies llie posiit:iof!l!ofilie furarnea and !Ln"O,wlleadis. mati. the OCA..

]no ilhe subaciu« phas.e EI1e 'entif'e ~obe., Md ,eViel1i the coollifilll<ll1ter,aJi. ~obe., rusCiffioJsldyh;ypo-e:chok \wth ,emM.gement of1!he g1Jaml The _g]mdre111!]ai!nS[IJ'~ <mdotclij!<J:oe1Jt imJ!W'liI'l1Ia!!:ollij .n.odles are sltillil. seen.

PageS!

J'~gme 3.1:1-

Go]~m:l:" po'we:rDopplel! sho'wing mali'ked! v;asclli!ari1ty wiiliin llie iliy-.o~d!.i:n Hasmrnorto~s iliY1io:idl1ciis ..

F~gt!ll'e 328-

Traasvesse s~m:o·'y.am sno"",-mg a Sil1:1all!, lHJ,s.lI-Hashimotr®'s, a1I:mpmc hecte1ogefl~o'l!illS iliy-.e:id! gllandJ (aa,ows). Op~ .ano,,,", ~d!entifies. llie;p o,siinioilil ,ofilie t:!<J,cheaand!. <ill',O'wheadis mark '!he OCA.

" . ... . d_ '" '. _jL_,~ £: . "_'J:, '. ~1L ..it\. . 1L·f ,,1L ,,1L.' "ell 41

m. :some cases l!ill~eKe rus nouu!re JOlilllli1iL1tI!omr Of; mere m1ilY .De atropuy 0' u]e ILIlyrom·. _

TherGi]e af11liltr1iLsomdm ftllliesepa:1tleflES is :Ito ,1iISSJes:s Ute evom1tJ)on of ilie diiSle~e. JP!a1!lioo1tsl!illS1!l!dyreco\'ie:[ v.:rruili. medlica:]. fure~Da1tt ,-".Vlithill @X mOl'llilis, how,eV"e:r;ihe]JillOglIDo.SJ!S i!ll. worse ~ ~e .bjpo-,~oicf'egiom oonOOlITe !to .M.cre[tie. .1n.~e \cvhll!e tl:tepa:ue:I1It. ismeoeiving ue~ent

ACl.!]]l!e 'Sl.Ilppma1ttive ~oii.dri~,.~Oll],gh.fa!!e,.pOl:l1"illcll!l![ll[1J' meds cWI!meNL JEt lh<lliS @illcl1t -'smdJedi J)!fedO~MOe mal ~ :ieqW!ent]y iliSSiod:a1ted!. \wtl! <lli.fOim1fl ibfruThcliuiaJi. deft IDJ:omal!y. The ,eW.d. typ,iirnJillypreSie1l!IS ;[lm~dy ~iftb~~,:tbyrordl :sweJilli;n_g, feV'eK, mdl'pam oa . .swElilll!O\ymg. There.iis l!J!S!lill'§lffiY;<1I rnstO>l}' ,of :preVJJ.Dl!J!SS.Diirr ,ep:ioodJes.

F~g'I!ll"~,329-

T:r.aiIiIsr"'-el!S e S.~fl~g:r,am sho,\ .... ing an illl,.d!eofinecl!.,h)'p~'_e.;Glhrok: nodcle ill! ilie ilipo~cl!.. anteriorly (bFa:c.k am'lws). The .p:aEient pfesefl'l:edi willi fe'V·S!8l1!di. P"ai:!Th 'O'!l~ ilie iliy:r~idL Thedmgno sis ofiliy:roid11tis was oonfimled byFNAC. Wffite .amJW idffit:i:fies the po'sition ·~filie t!acl]ea :and! omve,d!anowHxarks. ilie OCA.

The .Im'ection. 'ill!SJl!l!oillybe~m ilieperithymidJal sol us..Sil!J!es .. The ili}'roid .g]MdJ itStelf is -r,elJ~e]yre8iis..tmt to .dec1!i!oo.bea,J!]!se iift has .iiIl trurn.ffiJhmill!s ca:ps..me, isvery vncWlii:!: ;1illdl c-onJt~s :iii. fuJlgh. l10dJIDe cont,entMd. 'e:!l!t~e .~l1:,mc:s: ..

BOlth. m1tfa.- ~ru1!d 'e::ll:1tI"<1I.t~1j'f{)l1dl abscesses are seen .. 1iIiS iillIJd.clmec:llhypo-edwoi:C, ~dero.gooeol!l!sm:a.ss \\~tlliJi. mt·e:I11![i[]. dl.e:l1n:i'ts ¥li1:h or \~Qilil!t .Siep1t1il. malg<lli5. Adffia:oentimillamJ1ll;illtmy mtodesarefireqw;ent]ypreSient

Jin. cases w:l1ere ~e fun{ecitioo mvo~~s ",my ilieperithyrc~dl.rnJI mS.l!l!es;, the fMci<l'llpl<mes be1IJ.veelilJ.the tlThyroidl.llI1!dI. tlle SimE tl!ss:lITes ru:emm1t~ed (iF.~gJililie ]. 3D) .. ~ffi '!he iliYfoild iss:eoofl!dim1ly ID'liiowedl.1ili!e :fMda] ::p]mesru:'e dbTh!'I!er~1ft1ted and. ;ttfle ,e:xt'ffis.i'On of ilie ~<lI'bSioeS:5 mto ~e ~Cl''fcord.!is. deat.]ySieen (F"i,gw-e 3.31).

The,lfo]e ofl!l!l]tr.1iIiSomd lis to oo~1ill.aJhsJQes:s,. mvolv.emJe:lJt .of ~e iliyroid1 gliMd (worny) ~;mdl therda:ru:on~ of ilie ~hSioes:s to ~e m1IDj:or !!leek V.eSSieJIS. 41 TheaJl:i'Sioess 'C3lflI. be <fuSptr:m:1ted. at the same t:iin1e,wd!er 1i1!lhiiLSOl!liliJidl.gmdlaoe. UllIDriiLSOWd [LS, ~SC! ·l!l!SiOO. ~omorl1l!1i)or the:

F~~,3..JO--

T ransveese s,bn~grnJ:]l ,sho'ill-iil1lg ,a small!, hetet1O~eneo~us ,!C,~ITe.cti:@n ,(all'l'lws) anterior t~, llie s,w,ap muscles, no,t mrvo4~g llie lliYfoidL Open ,aMOW id!enrEilfes llie ~osition ofllie fu',ac..hea., cmvedJ,am'J,w marks lli.e, CCA ,and! the omved!ope.n ,aff,@W lliellV_

jp'atrents w11o. TI!1l\'1-e had smgery oieJ];present ~[jI~e:r 'i,Ji,.:iH:!a,p1rlip~lbme 'l'Indlliille" m Ule ~1'£oid1re,~on_ ,1lIiI.moSJtp3rltiffilts 'i;.vho ]-u[ilcvemd!er_gooes,m:gerylDor'hemgn il:hyr,o~d noOOilles (hyperp]<1I!S,1I:Uc)" Elb:e eanse of tlte el1ilJ<iIr:ge:moot ~spr{jh§lJb.}-y arecm-r,oot flJ.ocmJ!e or ':I:e~cfu><ID]. nocmJie_, ,]n. S:lITc;fl, Ic~[ties:w1mr'~mTI!d lLS,USlemill. as it IcafJJ, 'e~a1te ilie n<iJ,ue of 1t!he ~odlJru1le_,

]no ilhose who. fuJ1ffi\'lem1:d!er_gonesm-g;ery for GfiffN1es;rnSie1llSie, nowever, the :¥l,~<'ih]e noditi:!!l!e m1fuyrepfJeS!ent hype:!il"o;p:hy oftheres.iidEJa:] 1thym:-oiid tlLs]sl!J:er,allie:r ilhu '[jJJ tI.1llie .n.odJrn]e_,

Qn,lill1tr.iff!5!ODCtf,egeJ1!er.&~g 1t1lli}~oi!d, gl!llllid,~er smger-rfof iGr<il'l!1es' dlnseas;e ~5 hypo-edhoic,r"vil:hmad.ed. OO!l1l!~mlil::5 ~dl[jJJ :I1J.e1terogefJ!.eo'l!l!5ed1iopa~em (iIF~gm:e 3 31)_lt is oemtI,ed.m Ile:regiioo of;j}j;e iliymidbeclood, .of1t,en slillpe:mciaJl ill ]ocaru;OO!, tfuUillspreslentinJg1liS. ,aJ,p~a]b:]e ili)1'£oiid.inodiE1ill.e'i _ On oQi]o«fl!ow

, .. '. . ,,1\. ' _,_.11[." ",,1\.::'" ,,11. n .;1!.._11 'I 1\. ,,1\..' ..;:II;.. .] .. _t." ... ..£,,1\. _,11

lm§gt!I1g lLI1.e:I">e .lSV1aseWM.1!1ty r"Wltlm]IWenOlllJia!J:e ; ~]owe\'iefl!J!:lelfe ~s: no 'U!J!SP <IDBm.oot OJ[ 'OJi~aJ01trC al"faFJ_gem;OOE Oil me vesSJC!.I!5.

F~g'I!1I'e,3.Jl-

Tra:l1!sv'e!se s,(':nogr,aJl1 sho,,\<mg a hete!@g,enelJOl!J!!< coJ:lecfnion (cmyedJ.open ,Olfmws) 'Ni'lfl an .mu:alliYI,@idJa]. IDO!Ii.pOnen<l: (llarge :alNJws.) ,Gfllie abeees s, Note llie podetofgas: "villiinr the collec.tion (sma1l!,am'J'ws.). Open ·affO'W id!en~es the po'sition .@flliet:ra.c1'1ea:andiomve,dJ,aff,I!)WH:tal'Ks, llie DCA,.

The prililJ!m:ylto~e of'ti!1!l!1tirmomd ill ;jj[CiWe of "ili}'ford. ~oclhrime ~.olillilJd. mw.a'Ys be tlillJe die1!eutiJoo of mi3!llignoocy _lllir,a;s:omd is .0 <iI11lJ. diecwe Itci£l!gem 1ilhe 'lN6I!I1I!<l!geJ1l1tl11t ofp~erit's. 'l;v1i1:h 1iI. iI:h!J'w1idi. fiodWe_ It idenlliilliies iliree clil~egorie8 ofp~erit's.::

:3 jp',jrl]e:l'L1ts Wh.o :mIi<il!}' eiiliaiffIVoirl,sm-gery 01' ~§Lve ilicir :Slmgel:ycieJial}'iel('iL ~grolilpprinm:rilly illcltlccIDes ~OiS!e. "vith 101llic1'lii<lll[ fesiom_ Theml!mlI!ilI!,glBlllefljlt of 'lhes;epiil:1tiemts. dep51l!d!s on. ~oca1l.prac;1tlioe_ 'ill"lm: m<il}' .McmdJe :S;1][gery.m. 1fI1e mst..mS!1tmoe 61:"§L ''r"v:~1t. ~d :see'pOiTh!cy_

P:age59

F~gt!1!I'elJ2-

Tfill1!Sverse s ~n~ gfll:lll sh~winga ;rmrnd!edl, hy"p~ ernoic, futyp ertrIDpfui>c lliyro~di. glImdJ (brad;;: an:o,ws) It'bfl!mving sm:geryrjfb~ Graves' dJis ease .. Cm:v,edi. :af!I",~W iidien@es. ilie ClCA ..

Uftra;solilld Oil {he lP':ara.{Ily.rord:s

'T'1L ,. .::I~ . ." £. '. . ' . e ,,1L .. _"1L .'.::11 "'~ . .::111_ ' ~. _._.~! ." ...£. ._'~] .'. .." 1L . . . . 1111,.. ".::I~_~ iIi'Il ,,1L ~ c.' .. _IlIL.. ,,1L dL. .."

,lL ne 'mianFJj, m.rnC[]]::uDn, .lILlor oo[WgtLng IOill lLJj;Iie par~ly.riOl!U .. 5J!M,l.Ej ss Jj,O-lA::illJs,~1t:ti,on. IUJL ~o:rd], esrolJ!S C~]1]jsnll!g, lliJyp·elp[l[aILJJJj}~IOl.lEilli_ r (l_morogrci:!nJJ}": ute lLE.Iill,lee m(Ml]

:<ile1tl!oIogiesare:Oldlal!Dl"CHilL, wl11Jd! is :~Ocs.ta:1\,V:[j[!J's .lliiIm1li!~edl ®O ats.lmlligl!e gJl<illl!dt fuyperpJlasia" wlhl&.mec1ts :a:1iI.iOm:gliMffi;.Mdi. carcmom<il!, \vmd!,llilIbe ad!e:l1l!om&" mVoiwes amy one gl!and .. .Ad.ooorni:il. ~s !the C<11!l!S'e ofp~m)' byperparalli!}'l:{)1dism. m. 8lQi%of cases, hWerp]~jjI. in illess ~<iIII20% ,and. carcinom<il. m. 1 % .. 43.

The mrnc~ill'Is fmpm.althymid. gagmg can.be Qoo1tl:overSJ1aJ! as is iliernoioe of _i:iIgirI1Ig modirDity .. The~. of1thl.sS'eotiioo. lis ~oE~ariseilie S01l!ol!Oglst v..:riJ1!f:u. thew1tl:.,iliSooodl,':I.])peEitfMOeS ofp<itfa~ordJ .~eSl!rn18mTI:d. 6le OO!l1illimOO!.mliis.t.es oae marymJoillbe rnmlrIg SiC~g ..

Ther'e is. dli15put.e ,a)hon1tllie f011lme1!J!S!e ofpill,e-operawe Wjjj;gmg ill '!he ]ocdsa1tJ1o'l1l ofpmafhyroiidl<il!del1ol!lliliS ... Fn.l!lloo}' ms.tlru-HOO5, ill <iI.patient l1lotpreviomJ:y oper[il~ed ollli.forp:na1th;ymiiddlffie:i:ilSle"p,re-opera1t:UJre mocaJi:isaltllon.1is nott camed. Ol!l~ .. 'Jruis dec.iisioo iisbi:il5ed Ol1'1heE'ac1t 'ih[j[t opera~e ~e, mOlflbilldi!tymdi mooaTh!ty m'e flot ~enoedl. byp'fe-,o,pe:ra~e EoC<drP5liItron ofpm:a:ili}'lfoidl adienom§!Sfru fl(j']Jerp:yiIili.¥foiid:iism .. 44,4j The sm:giicall.pmoecmre ill iliese ms1tl!Hrttlioos c~s.ts ofhiil!a~er1il.:1Jperirl:hyro~~ ,expIoratron, :p11tliowillarl¥ at ~e mooorpo]es. ,-,.vNi.er,ep1il.lfalliyrol1d ;1IDdmomas :M'e 'OOrJ:milJ!Oll .. m ,experioooedl :I];md!s :!he seceessrateis OVlef 901% .. 45--49lli1;.flld, cSlomereoommmd ili[j[t ~e ,rnuruy Docalillsa1!iioo,'req_ed is tl1!at of:<ll.~oodlpm.a:lhYfomds.mge\()f1 .. 45

BOWeVie:f, '5ome SiI!l!fgeoos .m<ilyreql!l!eSlI tbc~s:ation.p,reoper~eJ}y, ~lil!ggesoog iliacI fhllsmcm:oes: hoth. o,pe:ra~e 1timeMdlllieriisk ofope:r1il.iwe dama;ge ~o 1tl1e !lfeCllnentt Jl~ge;I] nerv,e <TI1d nmm11:l. 'pmailiyro£dIs: .. .so.)' 1 Thes.e s,mgecms ,."vii.perform .atri[j[~er;a] neck. ,exp]or:1l:!ITon if ~epr,e-qper<il:we iilDi:iIgirI1Ig lis. deiJill1ciiv,e" bntt ,."viillI OO'l1l\!ietl: to biill[j[~eri!l.]sm:gery iif 1tI\te oo1il.:gilI'l!gfIDdiilm,gs:;ue eqwociiLll Of Ji2I!l"IJi11tiIfodi aoooRl!l<iilitty.is: :s]}O\Vl1li ..

M.pments ,."vi!1th ;<ilLprewJ)1!l!s faillledl,expi]oill.ation, '~OOO1j");d1ru:yexpkir:a1IToo8fu<iltVie orny i!I. 7{)c-gOI%8\TOOeSslfa~e:, 5Q;ud 1tl1er,e i1s Th!tI:J!erns:p1IJJ~e ili1il.it ~oc.:ds:atii01l1i. :sllo,l1i!l!d he atte:mpt,edpriof to reopera1tlv,eparmhyrolidlectones orprio:r toa 'pmailiyroiidiedomy lin '~piii.tient who has lha;d. :~Pf'e\.q)01!l!5 iliyroidiec~omy .. B ·1in.ilieSle :si!m[j[1!iio!l'l;silie .g]md! is more lliilbe1y to fu em alii. edoprcposi!1ciioo ..

.ru~01!l!gh. tJile m<ilffiority of people }lli<iltve~bm: gl!<mdls- rn--opns att1\telllp,per mt.dI. loweepoles ,of the [I1rym~d glJandl- 25'% of m.dliviicma1!s: hiiJ!:\!\e more "lhu.iliiis !l'l;llII!J!iliber .. 54,:55 The sIDpeflorgliill'l!m,me .more oornt.m! mpoo~t&oFlJ;:illjOOJg ilie dors:<ii.JI.[fu5peot of the S;"l!illpOO:OlfpoEe of 1tl1e ]<il:E,er.<ii.JI iliyrord ]oibes, .netrr ~e 'feCmlf:001i: ]ru:y'ngelil.lJ fl.e:rve ... The neriorgli;mdis.;uemor'e varied. iIii;.pnsitiioo. :1iIill0Fl!_g·1ihed!or:s:aJi. ~peo1t of tl1!e iimerrofpO!]es: of tl1!e t:hym~d. glI;md .. However, 'iliey IDBlybe :s.omewtilEioe :1iI.w,ary Hom. ~e ]ow,erpdes of ~eiliyroiid!" at t:fue oervruoat:l1ora:cic ._iiuw:c1ti:.on. or eves m. t:fueSlillperiolf merna;stmlIm:l ..

bife.rior;

Atyp:lca] Sines of a. Parathyroid. Lesion

Uude8Ciencled,:gIurn ruong ~e OOlilililOOOOJ. CM01t1d. ID1t,el)' _ :5T,Sa They aI'es.MM m apperu::artc:e toeodes at ~s ~SJ!1t'e_ The m1t'.e:I11![i[]. v;a!5cmmtyiMl!dJ iFNA l!ID[jIY help 1bQ drus,w.gmLSil\I1tl\te nvo_

lntr:athyr.o.idal; m ilie IiWd!dil!e ~o]ower iliird. of the iliyrordi gllMd_ The m1tramn¥ford gll<mdls ;<It[e<i!:Th!gned! ill 1iill1e long MlIs: of iI1b:e EhtroidL They ~c 1i:hyr,oiid. :IlodJrn]es ;Md.ar'edficm~. to dJ![jIgIlose_

Retr'Qitrrlcheal.: ~eSieglJill'l!dis,are dflfficmt 1bo de1ted.hecillJ!Sie oOf ,a;oo1!J!s1ticsillii!l:d!owmgrurom ilie ka:rnea H ;jheym-e ];:mrge,ilieypro1t:l::L!J:de :1lLQliL\SS iliewclineru;td. am. ilien. he Vl!sml:!1!Sied_.

m. om ,experienoe i~ ~s ei!l:s.ieSi1tltoSi1talJlISi~g in. the 1tI:al1Is\'1ersepi]1IDe,hegiirn~g above the n.evcl. of ilie1!l!p:perporue of the tIlryroid ud.movmg dDWll!)"v,arm sc:rummg tmOIJ!.g]Th '!he iliyro~d to ilie]e\!leJJ of ~e di91wde_.Et ~Slillill!i:IDda1tO:l)' ;lt01!J!se <11. 7_ :5-10 ~l 1t:r;amc:m:oBr. Thepllmen1t llUes S7illpWLe \Vi!tfu ilie .neok :I1.~']:J'erex1tMdedl ;<i8fa:]se nega1t:EVie SlC~8 m§ty he ob1tmed. mp<1lTIents W1\I;D ,<It[e moorreot1¥pos~tiiorl11edl pm:1ti!cmru:lo/ m elJd.erl5'P<1lTImts \V1\l;D may helimJ:ab]e to i]yper,ex;temcllOOe neck_ jp'MaElllyml1d ,a:diooom<il!S are oflten. bC1iIted. ]ow ill ~e neck; byper,ex;tel'l!s.iolll! devaltes ilheSle me~om mto tlhe neck. \vner,eilieyar,e ,~ vis'lJialliSied mp<il:ltiemts \wth :short flecks." Of. l[)ijbeSiepaMen1ts v..'litfu, tlJick necks, ~t m<1lyhe l'l!e.'oes:s:my touse :[iIL ]ow1er -ffireql!ille:l1;cy 1tr1M'JjsrnroeJf (5 Nlliz) \wlihOl!. s1tand-oOllfgeJiblod::: to m.p.ro\!leviis'lJia1IDsOl!1tioil1!_

~ lP'<Hailiyroid ]es.XOfis are :sep[ilfatted[ffi:om. iliyroid 1tiis1s'oTe by ,[M1j, ernogeru:cpillomehe1tweeEl. the ltJ,;vo,f!epreSJelTh1t:l!!1g ili;e c~slllilie MOl!J!l1clJ the iliyrolidMd. paratl:!yr.olld_

• illrresp'ecttiv,,e of [he na1tm"'e of the ]es:roilil,[]!bnm:mail.gD[M1dls are ,",equxem1!1ti¥ hypo-,echolic oompared to 1t:!e 1t1h::trolidL 'Jl11ills £s me ~o themmofilil. hyperoeimillaritty of '!he Desruoos. 5,:5

• ]n 15-201% lili:ereare varia1ti'D:Il!S ill ilieapperu:;:moe oOf ilie nestol1!_ Some .g]ru1:dls m<il¥be iso-ecbcic ·ltD M\te !thyroid. g];;rn:d!,md.Siome mary oon1taiiin. ,obvious Icystic chMge, :Siep1tiiILMd. dehris (cm:e 1[;0 cysttc!ha:e:m;orr]];<iI!glc. degooer,[il:1!lloo)_

Coi]omEJ)Dw B!<iI!gIDg is f.01!J!mei§r '1IlIslecll ~o bcdsleMd ev'druatJel:il.para:tI1r::tmid Ee~on and ~odiil"erentJjatJe irltliom. oilier Eesioos sum. asa lo/mph. node_ The $oIIJmvmgpomt's sllmlilJdl he !I1!olted. 'Wiith.r,egru:dl toparatho/fo~d~esiiolll!s;:56

F~gw-elJ3-

Colom- fi'O'WeI" Doppillel:sho,.vmg inuapillIendlj1l1al!. vas,oillallty ';\li~ a ]J181'alliy~o~d! adern:oma(anl1l'ws).

P!lge61

F~gw'e 3.JJI!~

Traasvess e sonogram sfuoi!i'O-mg ,8: f(Ollilld, :s·onotl!!l:ceont pou:ailiy>loidi :adle41onta (curvedi. ;artOrws.), pOlsllerio.1io :!:he iliJ'lro~di (!l.LslCeorisk)_ .BlackopenarHrw~lll!enti:lT[esr

ili.e CCA and! white open alIOrW ilie 1J\I"._

Ff~335-

:Longimd1:naJ! s:olllogrnmslho'Olt-mgffi.oremargedi,. eval paraili~ojj::il gli~d!s (anll)rWS) pOrS:te.fto:1' to, ili.e ili~ijd!.(asterisli::)_

:5 S01])og:r:alJ~cpafie:ll1l. a1!o~e c[jM)otdffi"erentiiat!e 1]J. be:lili1!.gn :fi':om ,<11 .. m.mg:ll!ru1E ~esio~_ B~gIiI ~esi:OM:Mem:o:1b1lfe w11Jem. tlJJep:me:lTht swdows wfu:ereacSn:mThlgtil!Mt ]eslons miilLV be iooed! 43

:.:,I' " -

6 I~1iItIf~!I:hYlfold.p.1M:a'l:hyro1!dtEil:d!el!o:lTI1l!~ 'rOcom m 1-1.!lfo~ :!:hey h~'i,lie no :specific {eaDes.:, ,MelllS:l!JJdy fucypoeohoicruldt weilll. ~ed \¥ir!:h :21. 'flay .shmp edge hernreen. ~e &d!emom[jJ. iU!d lilThe :[]!dj:aooot t11.1}"f!o~dl.p1Il'enc'fu}m'il.}3 ud Sihow :pID'"rood1ym~. V<ilLSiC~rnrity ~~_

lP'a:r.a.flly.roid Dyperp,la.stiia.

lP'a:rathyr.old Car.cmom:3

TheilliliEl'asoli:lrl1dl appe<ilf.at!1oes.mp~yrrrnd. cm:cmoma me ,smar.1io ~oSJempEil:l[ailiyioroi. a:dl.~O!l1l1l!6!, lexoept tlThm ~ere may be demomtraMe ~o!l10f ;<lI:dijijJ!.oentstrn!otm:eSJpims IDImo1i::tillltyoo .swaJillo,"",gg_ Me1tEtitEties ~oEil:dj:<iI!.oent nodeSJ1II'e seen m. :2-1-18% of c<JlSes_59

[1:11

F~gI!lI"e 336-

Longifu!JJdlina]. s,onogram (a:) sllio'Wing ap;Ol1,alliy!l1Jiidi.acieno:tlJta (liOl1.ge ;;m,ow) willi a cystic COID]HJN!enlt (wuilJ!ano,\vs) be1Jo.w llie ]owe±pore, ,ofllie lli}{j!",oiidi (as1teN5k) .. Nolte ilie vas!Ol!11!arity 'iVithin the sioTildi. oom]) Of'lenri:on tOOTOID po,werUopp]e,r (1))-

EtllMO;] <lh]a1tllon of a.p::rrmhyrord ~.d!5nom~. iisperlbrmedm1:d.er~[jlSjol!l!li1dgWdMoe bypercll!"itap];eolil!5 mj:ec1tlloD_ ill1t lls.1IJ!SJe-cilmpa1m!mts withprim1M}' O!f seeondary .fuyperp<MailiY'foiid:Jism. who maty bepoOfs:W'gk:<l1I c::mcldal1es_ Tills: 1tec.hmiiq:l!le wmmst d.eSieNbed.by Soillbiia"ltii. et aloo md. ~s nmv a.oomIMruill)·

__£ _ji - .:lL.~ lilli. " • _jl!.. .::III _~,1L _. ..' .• .. __ . ..!.e1L. . . ,,1L.. . _~.111 '. d ~~ . .::111-' . ':"1L. . . _jl!C.. ") ")5. ." ..•.. _j~

pCl.10rmeULprOOt:lUII1!I.,e_ .. it rus. m.rnca"IJelil. 'UJjili.l!J m.p&1ti!en1ts W]I!lI!] ;!lot mOrel!:l!~i:iI]l NO 'G1:1!1arge . ,&,urn>,.neJJme:l: ,exoeeUl!]wg ~-~_ . 'G:mi l!IiI lOOliOOmllIm. rni:lm.e1ter_

&ocl.!ltITenoes folillo,."vmg~Mation. miilybe cilliillSied.bypro;llieraltion ofpa1"athyro~d.1Il!ssl!l:e ,.",,1ifu th.elIlbrotlc ,g]ill:ld!, or tlJ:e de'i,'ie]opment of;~ new :I1yperp]OliS!fu!c gbnd. (iI13{)I% .of cases). 56

The ,rno&oe of rnl1tii1lll. Haging 'mod<iiliry (w;i!IflIY) lin fl]llf::IjJ<aJrailiyroidliism. \viillI.a:lh.V:[ilIYs be glO"\iie:med.by .]ocaill.practlJoemldl eX'pe:rtriis.e_ llisSleo1t!on '~1iIiS deSiC.":l1!'bedi 'lheuS!emJl.mlttr'1iliSol!l!f:ldlFe~rltm'e5 tlJiathdp m.liden1tiillyillgpara:l:h}!foiid. :ad!enomll1ta.md. hypeqJ~a:s1ti!cgl!md!s_ WMe d1l!5CI!JJs.sron or ~e merits of o1tl1:er:IDoms of _1iI!gmg mp::rrmhyrord ,dh!SJ~e :nsbeY0:l1d11tl\i:escope .of ~ ~elL1t,. tlter,e rus .:1110 doubt 1illu<llt1ilillttr<liSiol!l!f:ldi. Cilllfue<iIL Cios,t-el'e;c~e .a1tl!a].me<ilm Dfoo[il!g1I1g_ lli1t.M\slO has ;auSiefull.r,o~e as m.JJ. a!djiltmctto oliker 1m1IDgi;ngme1i:1Thodls (e.g, SesEa,mjJ1J.i ~si01to,pe :s.mrnes) ;md. :in the 1trea1I:lm:.elThI (ie_ et:lID1MJ:cY] aMmon) .of oernm grolilp<S .of patients_

References

2_ K.i1!JJg.i\D., .AJ\l\wjliil. AT, Me1tre1J,vellii C_ The m]e ofmti:r,[il:SiOlJ!l1:d m. the diOl!glTI:o.s.iis.of <iI. ]ar:ge,f;apld1.fy grov,:rmg, iliyrord.lli<ilis:s. P,ostgrailMed J 1997; 73(816]): 412--414_

Page 63

7'. So]biilifIl1 L,. GriHIgrmrlJ.e A,. De lP:f<1tL et al jp"e;I:'cUl!tif:W.eoll]!s mjroctioo. ofpw:afl:Lymid!. ID!D01.!ltl:S ii:1Ifidhillltr'a!S!o1!l!lil:dgmdiam:.oe:n,eOl1l:lIl!el1tfrn:seool1l:di11l}' hy;perpm-.)woiirns.m_Radiio.logy 1'9.85.; ISiS: 607-610.

Hl Noydc A.!.\1,lF'~eh~cin DM,. Km!.-.Sicn JC.Di<ilgFlO\s1m1c imagmg of 1th.e ,1th)'"fJOOdg]Md lin F,~. SA, 'ed_ Thyroid disease,; Endocrinology, Surgery, NuClear .Medici.jq,e, amlRadiothempy., New Yo:dc Ra,vefl.lPres:s, .t990.;pp 79-116.

11. Y01iJ!Siem. OM, Sdffif A.M_ Th'{foiidi.mdJpH[])thYfoidL ll:!lC Srn:.IlI lP'M, Crum 00." eds .. Head ondNeck: Ima,g;i;ng, 3rd. edn. St Loms:: Mosby,. l:9:916;.@ 95.2-'9'75.

14. Solibi1J:fni. L,. LM:~ T, Bd<rr&fIi E, ~erill!.oe T, C)-,esp~ L. Th)'£oiidJ glJandL :me Solliru&fIi L,. Rizza:tlo G, ern .. Ul.trusmmcl of Superjic.iaISitruc.tu:r,es" 'Lol1:dJonc C1Thm:ohiilll Livmgstonf:, 1995 ;.pp 49~85 _

1:5. Comp{l!gliJo J. DiiSJe1IDS!es of 1ili!e 1ihymilldL :ITl1i: .Bi;nm.es L, ,ed.. Surgical.Pathdogy ,qfthe Headand Neck. New Ymk:. M[l[[oeJi Bekk!e:r,. 19'85 ;pp 143:5- 1486.

16 .. McQ!I:liOl1e SJ" Eis,cleDW _ Cerviclilill. ]ymp,fu. n.ode .metrast&S!es m w,eI-dMerel1lilllill~edl1thyroid c<J:r'cmoma. Pr.o,c,eedmg.:; 4th Intrer.rm.t.ionaJ COI}'ifenenoe, O'J:i Head and Neck Cancer; 1'996.; 967-'971.

18. Mi:iItZzm;e:I"ri. EL, YOm1!g JRL. lP:llpillilliil1)' lliyroid C11lfcmom[jj[ <1IL ~.em1I. yejj[[ fol!lbw l!lpf'epO!rt. of [he inLpijijd of tlllie:r.apym 5: 76!1:'l\Mill~ts . .Am J 1I.ted 1981..; 7'0: .:51.1-518.

19'. C[llCaID.gmMI.·, Zampi .0,. ~illA et d, lP:<$p1!lIDru:y ICMcmomac oill"ilie ~o1idl: a. cwcopa"lbo~ogic: ,s.mdy of241 cases Moe<i1tedl ali ilie U~erSi.iry of F]olf'enoe, lIti1y. Cancer 1985; 56: 8.0:5-828.

21. iFr.dentlJiOlJle:r M, S elITifuJ. RV, C~gW A ,et al, Lym]Jfu l1!odeme1t~1ti[S;es. :fr.ompapi!ary,.:follliiiclllillru:- :i:fu!1poidi. CHICmOm1ill m YOl!illlilgpmiieFIJts.. Am JSUYg 19901; 1:6i(Ji: 341-343 ..

22 .. Ah1!lijiil. AT, Chow L, Cfurck W ei aI, Me<t"<m5tanc o~c<itl. Flod\esmp.apllmy C,ncinOM<iIL of tltelthyroid OO.a:Sioll!l!];dl.-mdi histo]ogiciil. oorr,d]I<ifu!oo_ Clin Radiol1995;, 50: 219-231.

24. Ha:lrlldll m, Flf,ami!<iIL KO" Wa&~ v. OOQlllifrI:p.apil.ary Ca:rcim:OIDEil of tlhie ilij"foo~dl: <1IL ~Offl])§!] mdiil1!g m ]F'fimtd .11 S.Y:S1iel1iMXC antops.y smdt;t. Cancer 1985; 56: 531-538 ..

15. lP'a1trndsky AS, Kdlli.er m" Mm>Sii.el!d. CM_ Solll!t<H}' vert.e1hr,;a]. oolimilThnm:e1tMms~s:fr{)m occmt sderosm,g c[llcmom1ID. of the iliyroid .g1lmdL .J Cli . .,.. .Pathol 1.9'70; 53: 59'6-601.

2!6. LiVo]s.i! VA. lP!a1iho]ogy of 1!h}'m!d dlmeillLSie. :lin ]F',a1!k. SA,. ed .. Thyroid disease: .Endo:crino.logy, Surgery, Nuclear lltedic.ine and Radl;otheriaRj'. LippmmEE- lft:jj[ven,lPMiW.ddpllli:i1:l!, 19:5H:; pp 6:5-HM ..

27 .. lill1iJ!jillA, Ng CF" King W" Metre'i;.ve1li. C. Solll!trn:yeYSIne N:och!ll met<1StOl!Slis. i-om. ooolllilll: :papi.l~ CMcIDomOl!. of "!he ~1'folid~cJ.lciiI1!g a. mmcmotli cyst ,[jJJ potenfu!<rl.p1itEaJlI. cs« RadioI1998;53: 61-63.

29. K1iI!1tl!liIl!oolFll Roe 'IF, lsaaes H" WeitzIDllim JJ. Md@s.ta1!ic mernEillmy Cm:cinO<ffiiil. ill }lomg cfuillJdlren. 'i>VJjtl\! mll!oo,s<3lli.l1!eID:om.!i:! synmome. Pediatrics 19182; 1.0: 263-267_

2Hl Nooo!l1! lA,. Froonie BA,Fmre1!lJ RE, \¥e)1Js SAM1!1ilitip]e le!I1!obcrine IJ!eopbsliiil.1'ype ][Eb: 1!f:te .rnI!C!istaggrles~e :J!mm afm.e:dJ!jJary CIUcmO"m<ll .. Surg Clin North Am 1.979.;.59': 1(}9'--118.

31. lmgW, Choriu H" H'I!l!I];dies:@l1gem1l. H. lRisk. fa'c1!msm :l!o:lllircl'l!1!m lthymid cm:CMOiJill!@S ... Alfe1tfospecwe folill.ow l!lps1tJ:]d~' oO\ile:rmg;i:lll 14 yea:!" 'poood '!,Vlith emp]w~s O!I':Imorpho:MogiC<iLll._d!iiIJ!gs .. Am J $urgPathoJ 19'86; ]0: 246-255.

33 .. Mscomb e Al!.vlI, Wright DH.lP'rimm.y malligl1ill11!l~homiilof1tl1:.e ~oi!d- ~. IDIllOl!1f ·ofmIITCOs.<ilLOliSSiOci&"I!ed ]ymphoid tis:slll!e: review of'se\'ie111Iy-.M cases. Histopathology 198:5;. 91: 81-87.

3'9. [..[jJ;g;d!0lJ:R,. Carsso G" Bema! l,Nov.Mijij V, Gdriiail1lil.F. Bd1:o-Co:]ollJill nopp]er lin 1the 5'm~ OK ~ypo1!hyrorrn5l1l'l! m1ild!l!lil:~·5. Radl~ol ll[ed' (m illtalliian) 1993.;. ,8:6: 281-283 _

42. Ah1!lijOlJ AT, ~ ]F, ~oe'blITd: DJe,t al. The:roi].e ofm1trmomdandl oeso!pllli1l!~ogr1illphlJ' 'm Ule ma!1i1l!.~eHl;el1it ofiil!C:l!l!tesupp,m.1ilwe 1i:fu}'fOrrnrltlLs m clJiilldl"en 1iIlSs.ocia1ied. r"vi1!1h oCi11lg.ffi1itaill.p)morm.·-:IDOss:a .. siI1I!us. Clin Radio11998; 5,3: 2cG9-21 L

Page 64

43 _ Moreill:J.!jj. JiF_ fm~iliyroiidgfumdls_ k lBruIilite1tolNJ. ill" edl_ U1trmonogruphy of the Neck: B edirru: Sprmger -Vedill!g, [987;pp 51-63_

44- Car]son. GL, J'mnd!mli JR, Cb}1on B et al: Th~ ~()1tope ,g,cm1tl!graphymdl1ill1tr[fu5Mography.: oompru:aw1e ,smrnes ofb::aillisaIDiiol'l!.1tedDi.q;lIJ:es m h}'Perp<ilfailiyro~dtism_. BrJ Surg 1990.;,77(3): 327-329_

47_ Edis AI, S~ee~ PJ', Beahes OB et a1 Resslts of reoper,mwon:folf nyperp.ar.at:hyro&dlisrn, ,,,ith, evamawoo.Oifpr,eopeJfawe ]oca1lis~ttiion smrnes_ Surg.ery 19'78;84: 384-39t_.

50_ JRm,scll CF,. L_:d ID., ]F"ergIill!son. VitR_ SCru1.-,cm,ec1ted1rill1teJf,all eervical 'exp,Emattiionfo[p1Mailiryro~dl &d!enOID<iIC .[ij[ Fegiimna1te .approach_ ~o'r{d J Surg 199D; 14«3): 406--4(),9_

52_ Atrltie IN_ Locmmwon::pmoeCffim'es fOlfpiitra:lf:tryro1idldii&ea.s>e_ Proceeding« 4th International ColJ'fier,e:nce ,Q'n Head ,& Neck Cancer; Va:] illV,. 19:9:6: 4015-411_

53 _ V<mI. Hee:rden.1A, James E..M,. KMSdlli.fR. et al; SlLl!lldlpart.~,aiSOflOg:l';ii1phym 'primmynyperparmnyroimsm_ :Jini1tl!iIl!. lexpeflffiOe_ Ann Su:rg [~981; ]95: 774~77~}_

54_ L~o]sii V_ Ji:rr Sten1he:i:g SS, edL The Thyroid ancLParathyro.id.: D.iagnostic Surgica1.Pathology, 2l1!di eoo_. New York: R[ll\iiel1!,. 1994.;pp 52-3-560_

:5:5 _l~o]SJi. V _ f"iZI!fl1olliDgy of1hepowllili}"foiid glI;mds_ .bJc Bernes L" ecl Surgical PathoJ:ogy of the Head and Neck: Ne\v York: Mm:oe]. D~.er, 1985 ;pp 1487-1563_

56_ Jlrng.alZZO]OlL C, Bergamo Al AN:d1r,eis l So]b~llttii L ]P:ru:ailiyro&dgllMdIs_ h SOi]Jb.ii~1t1! L, Riizzafio H, eds. Ultrasound of Superficial Ssructures. LOINJd!0fl[ Chm:cl1iillI.l~-mgslh)1l!e, 19:95;pp 87-1.l4_

.5 8 _ F~~er BL, Doppm<m JL, Sl1!~'\v~e:r m et aJ. Um;d!eSioend!ed.pru:<lfl:hYlfOidi adeFlomIJ<l!: '<ill.iimpoFlt~TIt eltiiomogy for -faiil!edl ,operaltiirnlsfol:]Jrimary ihyperpm;afulThymiidlism_. World J Surg 1990; ]4: 342-348_

59'_ Yoesem OM, Sdleff}l.__M_ Thyroid! mdpMa!l:lhyro£dLhSom.fM. C~ 01), eds. Head m1d.Neck Imaging, 3rd. ,eoo_ 511: Lom: Mo~Jb.y, 1996;pp 952---'.~n5_

6(1 Sot1bi!a1tii. L, GJ!<HIgrmdieA De f'lf<l! L et al. f'fjfCmMlBm'[l!S mffioc1IToo. of eili,lillo] ,of -pm:a1!h~o~d. rumomsmderrnkaoolimd gmdiMoe: tre<illinlffiI fO[ seccndary hype:rpar:~iliyroidJJs.m_Radio.logy 1.'985; 155: 607-6 H1

61_ Kar.s,1tm]:l, S,' T:r8s:1hO].l Holl:m.OO, :G]oo1!hog A, Begeoos L_ ill'1tr1il!SiOllDd .gmdJ.edl cfueJlJilii,oi\lJlpID'ailftrym:o1idJedOThlY mpllmen1ts \Vlith fuyp erpnai:h}'f,ordJism .[jJJ fH:ospeomr.es;mQy_ BrJRndiol 1989; ,62: HB 7-1 042-_

Page 65

4-

Lymplb Nodes

Ana.io:my

Ulltrasound Anatom.y iCbs:silfica.oon Syste:m.s ,c.r.me:r.ia. of Nla]ilgna:l!I!cy

:E!J. '!he flOf.m,il.][ildJrn1t fleck ili.er'e m<il!y be .~ 1t0 300 ltimplIu flod!es:,f<ilil1~g ill siille :mom 3 'l!JiliIM. Ito 3 Cill_. It lS ~1ID.llill1:d!.erf>1ta.1telNoolt 1to,s:iilty ili1il.t ilie ~Miil.1tOmy ~1IDd its V,m01!1LS associated datSsmc.orn>,gr.ompmgs, sl!libgroIDpmgs IDld,mmefeoent]y, ]ev',"els, ~s: oomp]ex_ Thef&rno]ogtSil. wlllio decides ~o ignrn:e 6IDe slillib:!:l!eltlies ElILd ,oomp]exirftles .of 1tI\Le 1}rmphaltics .of 1the heiil:dli!md! iI1.eck.fegIDn.\viillI~.orhea1)o!l'1e_ Y,e!t, if one \viLsihes~o ,ex;~e the he[ildi. and .fleck "region,. cae CIDIDot ig:rrof,e !the 1iyuIpha1tiic system, Man~'p3llito:logtes in.1!he beiil.diMl:d. !I'1eckfegionpreseril1t as a.p1lEp~b]e ]ymph node, Mos1t oe:rv-tcirl.1}rm])h aodes are VIli~ 1-2 cmJ. of '!:he ~sl:m.s.m:fa.oe,Md lthe Sl.!lprnmfeS!om.ltioo ofm1tr<tiomdl now:a1illow.s. thel1l1!oq:Jiho~0gYMdl. Hood. ]])ow e'h::rrao1teristi.cs of ]ympfu. FlJodles ~o he clear~ deTh:ted_. 11ts.r'eoom1tloo is S'ulperim to <m}mg ilia1t oompu1ted[1tomogJf"ilphy (CT) 01" m[jJjgl1el:iic~eSiOfl1IDOeilln1llJgmg (Thrnu) can cllm",entliY .offer_

Anato:my

I-ympillu flod!esru:;es:.m1il, oval orr,e.nimm.bodiiies" Itypiic<iilily 0_1-1-_5 'C-m ~.o:l'lg, l~.mg ill the oomSJe of1\ympihijlltic vessels. There iSllJ!s.mrlruy ~<iI.5m!a:llI. iiI1id!.en1ta.1!lioil1l. on. oae side, the ~~.ol!J!gh. wlhidw.b]ooclJ. vessels enter arJ!d ]elil!:veaJill:dI.rrom wfuid! ilie e:IJer'e1ll t-r'lOOphanc .&0. e:lller,ges {iIF~gl!lfI:e 4--0- Mlll!l}ttlp~e afferen1t i}'WIph<ilfu!C:~5d:r,m. mlto the Ol!JJt,er ,oelJJill~ codex of the node; 1}mph. ~.eE. ,enlters '<iI. ];:]jbyrmfh. of l~p]wafu)c d1JlMmeJis: 'i;VJ!~ 1tl1e l'1od!e_.

M1iIc:I'oplli:<ilges !IDe 1!heSie: 'rnrumells or are ,entoog]edl wl!trnn 11I1e: :fibries cross.mg ilieM_. Lymph ~s~pos;edl ~o ilieSiephiil!gocyttiic oelills ,1lI1!dl~SiO to nfle1ilc1tilvJi1!lies of Band. T -l~'lOOp:l1ocyites a.dlfu:.eri:lTIig to the e!I'1dotfu:elliiSJ_. Thes.e'l,o;ess;e]s :form. ~[]L dense .sllliibcaps.m[llf 'pEe1>:l!J!s wmc:b gtiidydlr~s mto lOOe sllJ!bcaps.m[llf .s.mlll!S (JFigumre 4_1)_ F"rom.1tl1e slillibcllpsm<iL:l" :smlll!s. mn!lIitlp]eradi<il1l om:fu!ca1l. :smlll!sles ]ead ~oilie medJ.!ill<il,.. oo~eSioillg as: .]ugermed1uilll!ary sll!1l!l!SJes. Themernrllli~~l!J!SieS or ]ymph1il.1tic oordls:hlil!:Vieiilpa:r:m!lillel! .1iI:Ilf.iIDJigemen1t at tlhe med!Jillill]liI!: as they oonverge ~o form the ill1ilfge efIDa,entViessd ]e<livil1!g !the aode.

Thev.a;scuilil1ooe .of ilie ]ymph flodeu-rors it:sp:hys.iOi]ogica:ll~Jt:EW1ty_ mk,1m;odla.l!. vessels are spMcSJe vri1!:Ellin ~e meciilillb_ li1I1I. ~e cortex, meries.fOITlil dense arcades of .merio]esi!mdi. c<iip1!1llililriesm. ~l!:m:te:J[o.l!l!silll!<il:S.lt(}mo.s,mg ~.oops,. ,evIEnmdYlre1t_l1ing to l1I1!ll!1lip]ehr1rn!~g vessels ~i!mdJ Vlt::im_ Capiilillaries[jJ;[e pa;rtlcl!l!ll[Mllypro_en1t1Mfomd ~e {iYlllli:cles of tlhe cortex, \vfu'ille ¥enl!J~b Me {Ol!1!f:l:d! m ]arge l1mmhers im1 M\te paraoortici]('] zones."proviidlillg ~;m Mtpo:l1lffi1tSJilte .of lo/mpfu.oc]'1trc l'Illiigra1tioo_

F~glllr:e 4._1- E_J'lllph N:oa!eana1tomy_

Wl1efl . .iii. FlodJe1.!m!.dlerg;oes. .M1tl!gmc .stimIIill<il:1tlloo, li1:fe~c:ts. v..:rirtf:u ~iill. Wtcre~s;em si?lemdl Vill!SiCiuillooty_ The .iI1!il!1ii11iher ~~dme of g~~ centres ~~. ;tthe -IDo1!l1des mcre11Sie as ]ympnQcymes1H1Jd ma:.cropn[jjgespmlliera1te_ The lThmne:J[olll!sp]<iI!mJ!~. oelil.ls milite medJmlIDElLl!illi.d!.ergod!imIere~lItiiat:i"o:l1J_ Tills ~s miirmr,ed.by mi. mcteas;e m V<iI!Sc1!l!l!mity \\:i~. ~e node, [he de:l'lis.i!ty of ilie capillm:ybedis m ~e Olil!~er cortex yea"i:1y m.cremg_ I

Omll11llderSJ1talldlrng of ire .hl!l!moo. ]ymph!afi:ic sy.stem. owes ili ,great deal] ~o &olLillJ.'-1ete"s Orul,gma1i work.~: The ]y'lllillphattic sys1te:IJiI O~5ts oflil!: .SieITeS ofv.~ed vessels Vlitll.l)rm:pfu. nodes d~smrlmlted[ a1!oog ilie 'comSJe ,of vessels, FIow~s: oon1troll!ed1 by votllv1es" lThowe\'ie:f ilieillJow Giill.bef!BJieJrSJed[ by 1ti!lmDM or .wec1tDoo_. Jifl. ,"!he ne1IDdMd aeek, "lllJow 1teJ1!rn. to ~he ill :<iI. C1iIlll!d1:aJ!. rnr,ec1!licm.E>owmoo d"llterllie right l}rmp1lli3l.tic molt .or llie"lhOlfacic 'c:mcrJ! on. ilie ]e:ft (Iiigm-,e 4_1)_ Shl!J!:l1JM,g cam. oocm when .. <iIll~'l1I'Ipfl node ooo1t~s <iI. me'taiSt~s" ejJ1J:];];er to ipsia1!e:raJI aedes o!fpoS:SiJ!bl~ ~o .tit fiodem tlte oookrua1te:J[alJ iI'leck_

Page 68

:ll---t---~~~J :~-- ...... =~~~~

FigI!lre 4 .. 2-·

N\I,'M!Jvre"H1'S. ongincal! schematiC" re]J!res,~.:nrftatr"''Il1J ·ofllie ty1llp:hat:i:~ rnai!llJs. ofllie neoci_ 1_ o.ccipilaJ! n.o@les._ 2_ Mastoid! no des:_ 3._ P:ar·otrdi no des,

4 .. Spi:l1;a1!aooess.ol}'t)'lnpllafu::e: ,cham. 5._ Tsaasvesae c·er;;-"ical! ty~npha'lic ,chain .. 6_ } .. n1i:en:o:r ~il!li.g'lilla:r r~lmp:hafu.:C chain. 7, InlIemal!jl!.]gm]ar tymphafu'c clIain_ :S;_ Sldfu.rJ:taocillary l1!O des._ 9_ SldOmel1!tal! no dies .. 1(t Facial! ne d!e_

:ogy, lilt is> ~pmlant ~a.!t ~elf:@dlro]og:USJts,mgeo1NJ. IDlclpby.sici&l!Ji 3p~ "!he samelangeage. :llit is eSSJenlliJaJi. to uSie a. OOrtill1lm!O:ll dalSsEcm1oo. sy;S.~e:m IDl:d!. wOo JhaJ\lie ,i3l bow]edge of 1tIite v.mol!l!s~e:rms;. for cill<illD!CllEOrnl. a glessary of :!he lte:m1iS<mdl<i!!1~BIl1!aWe lterms1!l)S!ed imiI. d!esclllbmg l¥mph llodes rus~emJJ ill TaMe 4_1_

Ulrasolllid An:.domy

W'her'e does :!he begillma ,SEm:t whelilli nymg ~o 'ev:afu!a~e the lymph nodes of the l1I:.eclk:? A~illeH.;]Jfo(fu:C..l!b]e system ~smeq_,edfof ,~g the aeck, Ths SJecifiOOi. '!;villil. desrnbes,lITrn '[jJJ. syste:lil1l!;fOf eacharea ex<IDilitecl. llie'iwHj[~omy Oif Ole tympi\! aodes \WllI.he rn"s.clIJsSJed imlde1t&ill!_

As1tmcb"d. ex~a1!ioo. OOrrs.l!SJ1ts ofiil series of'sw,eeps'by lillIeplfo1be (fll!lIl1lJJberred 1:-1'0, Figm-e 43),.Sl1t~g m lihe SL!Jibm.enta:JJfegioo ~d. e:dem:lM1JJg over one side of :!he nedc_ If:!he sys~eJiliI ~slfoilillow,e:d '00. :!he otl\ter side of :!he ned, :!he m~iOori1ty of 1t11:e oetvtca] llympl1l. node Ii.er.ritories r"viillI. n&\'iebeefll. 00V\"ef.ed

Submen;ta1Reg.wu ,(Figure 4.4)

Thepmhe is !heM. transv,erselly _ EdleniliJ ~etwo llIDeads of ~elll1l"l!eflolfbelilly of ~e~gatSJmc .'I'I:IWlsdes as ~ey come off'iliieb<il!d. of iliiesj-'lffi]J,l\iy.sis .mootls of :lTIemMdi!b]e_ Thelll!oolf Oof the s.lIlibmen~. mMgl!e ~s 'ihemy]a,nn,roiid m1!l!Slde". Sweep :lTIepriQhe dmvn to ~e

J1!J!g1!ll:o,dl!gasm~ no,d!e Deep cer.-""ical! ehai:l:il

Alternidiill'il te:nI15!ldJils,cript~mlll

'Sentine.ll i(h!ghest) nod!e .ofinlIemal!jl:l!gmar cllail:!

Deep cenrical! mai!llJ t}'TIlpll no,die j,l!.]S,t mperim: itoomoh}'oiCil (wher.e: fi: C1!"o·s.ses. jilill.;gmilla:r ve"IDJ)

'Sf.gn,aL' node.

Lo,wes,t no die, ·of d!ee,p cenl"iic.;a1! mam

Suprnda'l'icwlll:" mai:l:il

MOist medJiaJi. no·d!e ·ofn-ansv·ers.e ,Ce:rv1!C:a:Jj rnarn- ,C!llI1J be involved. in carcinoma ofilie 'stoma'ell

PosteriClif maN!gille cl1:ai,n DOl!"S;al! o~""i;ca1!. cllain

IncllLl:d!es pretaryngeal!, pret:raci1eali ;and!. paratlra..:::heaJ! nodes DelplWan node-important in calD:inollla ·ofllie ]arym;:_ Rec1!lI"I"ei1t ~ary'ngea1! no·dies.

:tateral! no,dies ;are no des ,ofRm!.JN:iere

P:age69

F~gI!1Ie 4 . .3-·

Cem\c;a]. 1!1:1Jftl.a5i~H!mdi.exa1lmafu:®n_

FigI!Il:e 4 ... 4-· S,lilibme;nriaJi .e§ion.

iI1y{)idl hooe,.]oolliiing .s;uperliici<]]. to 1tlIDemy]cihyadru~dheThvleoo ilie dillg<lliS;ltrlC ffll!l!soEes_ Nodes me ooEl'l!m!~ seen anltmolflo/belJm:d iliem1mcillJ:]e ill'ihe midlilille bet.v,eell! 1tl1e m~Mmc m1.!J!sdJJe fnse:r.:tri'OnK More im'eri.or~,. aodes m~y·beseen. on, or~s;t medlJ!a:]. ~o, ilie diigm.mc ml!ills.cles_ TheSie !I1iodJes .a:I'e {)O~(}mJirlIy <il!5ymrnemc11:l mdlffi1tllb1ll!troo 'i,\i1th. <iI. dJlJ!5I1ter Gf~od!e$Sieen. on one side orily _ Rru-dy, uodesareseen &s,~er'edlnear iliehyordlboil1e m.~e woom ;aspec~ .of the sJilli1hmm1taJllfegUoo_ The lilll!lil!Ilbe:r of lliod)es :fbmrd m 1tl1e slillibmffi1ta:lJ[He~. vmes Hom one to eight NormdiY"m .. om. aCfu!1~ iliere aeebetween one .<ll1:d.~ee nodes. S1!])1bmen1tilll nodes. 1tem:Ld. to ~<l!ve ;1ll1!. ,e!llip1ticaJi. orsJtigfut1o/lfOl.!l!I1;dedshape_

These scdesreceise ]ymph HnID ~e chi!nJ" £:ips, clleeks;, -ffi!oor ofmol.!1t11J ood oolterim ltor[lgJlJ!.e_ They m mm. m<Mn mto ~e ~s1!])bmm&h:llil!1ilJ[ nodes <ilI1d :!hoo. ~e mpper deep oe:rvica:]. clll!m_

Theprdbe is now 5'\.Vl!IDg Moum:d EO one side of ~epafuient wi~.t1\tepa:1tienfs. head ~ed. ~o tl1;e '0pposite side_ Thekley lio assessiag tllesubmMcib1!1illar fegtofl.is 1tl\i.e cSl1!])1h1!nMcl:JJbm::rrglJand itStelIf S~gpiIDfdd ~o ~ep]1ille of ilhe bodly of 1tlhe NruIDdtJ!Jb:]e <lI:I1!d ill1!glIDg ilhepmbe crillJjjidiy, ~es,1!])bllllandtJ!lbmiimf gli1rn.d is idien1l:iIffiiedl posterior to ilie an1teriofbel!ly of 1tl1ed!i~a&mc m1.!J!&c1Je_ The POStteriofD:eeborde:r of lil\temy]ohY1ordl ml.!J!sde eaabeseea ilwdJenoog ~e <ilI1teflruaspect of ~eg]mdL Nodes Me deSJrnbedl m. lfda1tion. ~o ilie~l!JibmW1:dllb!l!l!arg]i1li1d Use '!he sl!l!bman&bill!llw:gl)and as ,<lI:llleIDer'eJi1cepnmt :i1li1d[ICOllIiIEOOt on Whether the flod!e~S1m1terior, sl!]perior, mpDs1tmor Ito ilie gllmu:d_ The:reiIDfel!]S1ill'<rlllybmv1eJe:I1i. iliI"eemd.sh aodes (.a\'ief.<illge fom) m &e sl1libmmdll!buillID'" regfon_ .45 elsewhere ill '!he neck" ilieirme vmes m m\'ie:r.Slepropomon 1to M\te nlil!l'l!])he:r of:l1!odes[preSJoot_

SmaIill. nodes me oOl1stantt:y ,Sleen.aELltenor to tI1:eS1.!J!lbmilllwbllillm-g]ill1dhe1tweoo. the wanwb]e .omd. tlle dtligill!£mc DlIl.!J!so]e on.1llill1tr,asowd_ S'l:ilperiodly.,n.odles .1n1e also d~eded.ill!~g 1!l\te fadirlmery _ Nodes ma~aillSi0 bepreSJemtposlteriO!lf ~o ~esilJ!1hman.rnbl1lillaJ[glJi!mdL Rare1Iy., nod!esMSlry])[e d!eep ~o ~eposteriolf .aspect of ilie gl!M&

The Sl!illlbmilllwbllillm-glimdm1:dergoes. early encap,smlil:1tion ,~g its embryomc deveJ)o])moot" ilierd'olf'e 1tflemajlOmy ofsl.!J!hm;mdWb1!llil!ar nodes. ase ltrne lex1tf.~gE1llllidJuill1ll: nodes. V'ery oc~oodly1ill Sl!J!bC1lpSWM ~!Mph !I1!ode mOl!}' be present, :A1~Ol.!J!gh 'lheSieslillil)caps1.!J!lJar nodesare m m~ai!e oOil'l1tad 'i,wili. the pare!l1icl1t!}'W<1Il iliey me .not 1t:Ilire mtr.21gli<ll!1cmilla:r sodes. The vm1t.'m1IDjonty ofsl!illbmmldli!blllillar rJiod!es llre o1ll!tside Mle Stlill!bmmd!!b1ll!D1lI"glimdl (as disMct:,"om tlJ:e pam1tid region, w~ch. wil1lI.be mStcl.!J!SiSJed, ]~lte:lf)_.

f1:e!t~mandibular vt:.n

Superio(lr

F~g1:ll"e 4.j's'l!J!Omar:JJdftm:lJa.'fegion,

The sl!l!bmMdliibm<ll' flodesm,m 'lheomterior fud"IlI s1tniI:cm,es .Mdt s.kin. as w,e!llI as &e :loor Dfmm~1thID1:dlomterior oral Ci'l!wty_ TIteypredommMl1t1Ym,~ m~o ~e deep !OervXciIll. c]}wrlilL

Um.e ~e sl!l!llim<mdlJllJ1iI!l!m gJiMld 'lhep1[J!'otiidl.glIMdudJer:goes enc~slilillat:ion. ~a~e ill i~semhryomG d!eViel!o:pment Lympl\!. flodes are 1i:l1I!JJS iI1:colliPora~ed.boili deep to ilie cijJ]psme (slllibc1lp,s,~<ilI:')arJ!d. "WlrttlbJrll tfuJepar,em;rn¥J!il1l!i:1I .of ilieg1!11I1:d ilts.df (;pr,ooom<mj[]y wiltlhm. t:neslillpe:mciilll ]abe) ,~g lts eJIIJ!lJfj'o:~ogUciIll dev,eJjopme:nt lP:notiidl ~od!es.mary 1tfuereforebeplfeSientt sli1pe:mci<rl 110 lillue :glJ::md {~_e_ extr.apru:ot:idlSl!li1bcaps;1!JilI;n- {ex1tJragl)mdillJ!]n) 01[ Lymg deep '!,vi~. ilie par,em;dto/lli<Jl of 1tl1:eg1!md (mtr.'1IDglI<rn:ditlffiar).

TheparDtiid.lf'egroo.wJ!]stbesc1lll:l1:ed.botlh.tr..ancsver.sdly <md 'CiOlfOl1!tli!Iy_ Wirth. tlIDeparo1tid. glJarJ!d <iI:S :!he 'poiimt oflfefa'e11oe" care ml!JJstbe 1t~e1li. to ex:~e the .areatbeThVi(le:l'Jj ~epos,~eriQ![pm:-01ti.d1IDd.1tl\te ear. M.1tl1LJjsfegiiO!l1! iliesnpe:mciallplll"otiid orpre-Emricm;n- m:odes:;n-efowd (e:l!!1tirapm:otiid nodes). Th:ee or {om s.md nodles (particmlll'lo/ m the ~O ,CaI1! bellomd .<m~e:rfOf to ~e tr.@gJ.!l!s,_ Slilib&sci<icll. l1!odes ru:el!JJs,1IDd)rfomd .at 1tl.vosii~eS::<ID~erior to the tr..agJ!ills (pre,l]Imcmiitl! node)::mc)]pOis1toorn1y '!,\i~ ~e tail. of lOOe gllaml Therr'ear'e '1!J!SI!]i~, one or ;t.vo s.rihcapsm;n-plf,e-<il!mOm<ll' mod!esa:I];di[p'osSJ!lb.]y up 110 ;trM'ee or rom :SJm!hcaps.mon .ma.-a,-rc1!1!llar .FUodles m :!he 1taiil. of ilitep<llotidl_ They Me ornEJmodly idlen1tfied ~[fu.mk,~ml!l1;d) jin, CMmelTh_ 'ffue deep FUodles" ~_e_ mtr.ag]~CWl[ll nodes" lliie ~tlB. ~e sll!1pemcia:1J]dhe <md m ,"!he -fu8cii<il. betweea s1IDperliicia] and. deep ]obes_ A crusta ofnod!es mary he present lleart11;e e:dem~. ca:ro1tidl im'efj'iiI:I!llid. '!,vhere ~elfe1!follill![IDdli!1J'mar ·~.~ei'l!ves 1beparo1tiid. to 310m tlJie eX~en'l!a!I.jiu~arvem_

Slliblascial_ IllirfL-$iunCuldt

Figure, 4._6- Pa:r·~fI:icl! 1egion.

The area :primariillydlr.amedhy 1tl1:epMotiid. fUodies ~S !the skin. of ;!he Ilbrehe&dl" ~empolf.1llI.regiio~s,ID1:d.extenl!a1I. <:ll!lJdi1tory coma1l_ m addritiion ~:h dr~sliom ~e iElI:]s1ta.oE'hl!a:I1I. h!he" 1bl!illocailml!J:cosa,.pos.~eriO!f cheekamld ". gJll!Iilli imItopm:ofu!d. nodes_ Tfu:ese .iI1!odes .m.ltmn. dr~. m1to tfue d!eep oervic:;rl,c:h~_

'J? "~. D "(iJij''' .01 7\ I' a:C,M.f .neg,UJ'H Il~ 1!gnre "1 •. - Ji

H 1tl1:eproilJ.e is illoViedlanteriordly Rom iliem1tmm aspect of 1!:fues.lilpe:rlici<iiill ibbe .of 'lhep1[J!'o1!idl, .<lilloil1l!g a.lJIDe .dlria\w. '1)0 ilie comer of fire mOl!l!I:h, one v,:rjj. he ill "!hehIXCtciIll.regron_ Hfi1Lci<lill.lill:od!es alfeplf,eSJen1t ~eysllomilldlbe fOlmdi m tOOor,egron_ ]F'aciiIll ~odes :!tend to be V'efJ'SDltd. :!lodes 'lm:d ar,elfMelJy ,em;ool.!l!ll~~edl ill l!ill1i[[iilisiQil!l!ml They are :sl!JJbcl!lJtiID'l!eOillS1IDd. g'en5lf,dylli:e;illlOflg thep]ID'Ie of 1tIllie -fiildirl.1itI1e1)' 'MdI. V'ell_ There;n-e ~vom~ groups;: IDe .itl:ieriormdru:ygr.olfl]) ,<rn:d. ~ei\}lIToci:ni:il:tor 01"' hl!J!ccaJl. gro~_. The im"enor mda:ry Diodes. me fomd clo~g 1tll:ean1tefl!Ofhorde:r .of iI1\te m<iliSJse1te:r_ The most merior ~od!e of ~s, grol!lp mlihy .lh:e on.1the .fierio!fbolfdie:r of 1the madllb]e; !i:l\tepatimt ,em. oi'e1li feel!. E11ms ~odie if i~ ~s.. ,enilllil:l:ged .. as .~t ~s. :lfOliI!edl Q\i\elf !i:l\te booym;mdh1lJ]e_ Thehl!illoca:] iI1iod!es; Thie m 1."fu:e fatp.iil:diID~eriO[ ~o 1t'I1e m<iliSS!eitermmide <md s,l!IDpemciiirll ~o ilite b"l];cc.m<il!1torml!JJS!de_

~i1r'lIHim !ll;l;(ILlary_ Mass!JiElr

,

-

_ Buccal

F~glillIe4._7- F.acia:l! :l"egi~a_

Deep Cerv,ical Cho.iin 1(J'~gm:e4 .. :8) ..

The d!eep oe:l"vic~. orjiHglllilllll" cllim. of llympn iI1iod)es:f~ iliemiiIiFIllymphiiltic :!horol!illglE"liI:I:e .of 1fu:e fledk:_.~t ii:s ;OlJ. ve:litl!c~.t:ymphiiltiicesc<iclli'l!toif '~~el1ldilFlgfroml "!he feve:lJ of ~e dJi§Mmc .~l!illsde to 1i:l1elfoo1t of1the nedc

Ompllyoid

o

LIII!iII .. - - _,,". _ ....

o

uv eGA

Figw:re 4.;8~ DBelJ' ce!'\<"1calcl'1.illn_

The key lloOl!5S'esmg '!he deep oervl!ci][]. o~m ~s 4\0 .S'CaNJ. :!he ~:Ililtenlliali.~gmill:n·~ (11V). U1ll1!$VieISJe1}r ]fOOJi.l!he Fe\'icl. of tIllie ~a,illj. of ~e paro<1wd ~o its]im1,ctiDn ",viitl\u the sll.!J!hdlaWH\lie.i£:JJ_ J1.UI!s"t ;§iSmSic~g Itl\te deep veias of the ]eg, 00mp:resSlloo.lis ilMpOrEaflt .JlJ:ways "bolilililoe' t]weprobe <lilloog Itl\te IT'V _ Thiiis. does wee tl1mg~: .it .~ows ~d!enttEca1tiOlilli of 1tI1e If V, itmU11t~s E1\te IJ\! .m 1the oentr,e 'of the :p:robe" and. it enrsm'~s ilia1t Y{)'l!l! db not l1IilllS's ;a tlUollillibOiSJed lfV (iii. :I1!ot 'l!l!I1oomm:o:l1!. .s;hl~e whel1l. ex4!el'Imre metM1tatic ]ymphadmop<iLthy ispreSJent)_ Nodes d. bere[])dlill.Y ~dent:m:edl.[])djiaoeElt to [he 1JV" Jlmdo~rull1ly @l"fIDligedi ;ru:oml!cll il:sim1tem:~1llte:r~.~oct

The deep oen1!c:alJ colli:oilll ~sdli:v:id!edl.w1to1.!1ip,per, ~d!dllieaJi1dl.]owerSiections by the .h10~d. booe<im!dl crioo~d. c<IDtiill<1l!ge, aJithough.tJill;e ~a~est .AJOC3 (199'7) dMsmca1!frn:l.I!J!Sies the cricothyroid memJbranre,1ll1!d flottl\te cricoid cM:tt:iill1IDge, as the~e\lid :£or dfiv1!dli!11Jg·the deep eervical 'Ql;u:! mto mid ;<md ]o\.ve:rfeg:Urn1lS_ Nodes in 1tlllie ·llPpeil:firu1: of the dleep oe:rvi!ctrlI. cham. ;a:hm t1itepos.1te:l:io(l: beltly .of t1ite dig asIDe l!ll1lil'J!sde Q8'~gm:e 4_9)_ The ]argest node ~s the most Slmperim:- the

" ~",11. dj" "(.JD .. ) dl 9i'1I,.~:' A·. .'... ..:J1_11 ... d.. 1~_ f ~11,. ..:JI~:. ". . .... ~11,.. . ,,11,. . d...liT"11 ....".. -1~k, 11,. ~... ' ~~: . 11..!:_11_.. '11! 11,. -,~Jil!l!.s"'"'O: gasmc '." .. " ~.oe_ 1 ~.lJjS ss Of~OO. onenr1tat,e~. ,ruong Ii:!]e J!I!He 0' lliI:rell!l!.~~mc :l"aJi.l:reE mru1J! lliI:re .L 'Ii, oC'C1il!51'OO;mWJ ]]<iltVIDg ,<ill S~5'l!J!J!J!C.m'l1t .1i'Uilll!l'l as lilt. ues .[J\1l!LK

hel1md. iliepos1teriof belllly of iliedigasmc_ l1t canbe dillfficmt ~D diillJe:renlliia1tebe1tv1eoo. tile JD node amid iliepos1terior bellly .of ilie .digasmc_liden1tiicaltiion. of :!he dli!g<ih5mc:. lffillillsd!e is dOiffile q(ID!i1te eatSJ1l.~bYMgOOg 1tl1repmbe obllicp.!rnel.ly<itCfOSS "!he td . .of 1ihepru:otiid, idJeFlJtiill}.rmg iliepos1terio!lf belily as i1tfl!llil1ls ()iblliqllilleiy nom deep to llite s1te:l]1rnJl!as1to&d down 1to :!he hyad

.4no1!:lhe:r key muso]e 1t'D rdooti}r is the omol\lyoiclmuSide_ ~ eosaes do\VII. off the Dll1tem:1J 'prn1iim:1! !Qf lOOe bodY of 1tlllie :ITh}"oid to noSis; lOOe oommolFl!. cm:otid ;m,elY l1:.e.m" lrltsmiid.pomt W11:en.bwllry, 1iheomobyo~d. e1ill. ,~y bemiis.1ta1l::!eUThOf<ilt lo/mph. m:Dde ;[iI:S .11t cros.sesM:Oill.medU<%lI.1to Fa!teJfll:lJ ;iiIill1t!erio:r :Ito the OOniLl!llOOi ci!I:[otid1ll1e!)' _

HgI!II"e 4 ... 9-·

.18 e:ni!gnj,l!lJgmWed:i!gasfuic no die, (1) Idndie:rl:yul!g pos1teno! belly of djjg.astric ml!lJscle_ Nolte, paIotidJ Sl!Ip~orly (1)_

Rom..];a,e2 deSJcnbecl ID.vosdhgrOlffi'PS .of lIylOOph lilOOOS. liiIJj~gnp tile deep o~c<itll. ,rnm <lI!. ~a~e:ra]J illildM.M1teflo:rrnam_ The Da1te:r,<i!l!.grOlrnp forms .<11! gi!l:[]ru:J;d of nodes ;;rrooodl1tl1re ]a1terllllbo:rd!e:r ofilie Inl_ As .l1t ex1tffidiswerio,rl"ilie ]a~e:ra:lI cl1!1MI. S\vmgs medil<dy befulld. ilie Inl_ The1illilIentJ!:I:grOl.!lp ;iiIill:e exte:I1!S~em nImJlbef 5uperi0r1~, oocupymg the "s:pa:Deberur,eoo. :!he rng,iillSmc lWl!l!SJde ,s:uperio:r1~ ;W1;d 1}rmgm,ec1tlry1lfl1tenof ~o 1i:lli:e lJV _ Ther'e may be up to .~ :I1!od!.es 3lrnpeflOftym the .1l!duilltt; howBl,iier,. in ,cMd!n:,el'I!,·1flP ~o ~~ nodes m<1l!ybe preSienrt MOII",e lm;'erim:~ tlIDe!M]J:r<ilt-.oEl10hyord :I1IodeTh:es m theMdlpoflioo_Thstdy" nodes .clli[,ec1i:1)' ;<iL1iJ.rtterior 1tD the llV arerase.

]fone eonsiders 1i:lli:eright deep oerWcal1 dliu.,. nodesare ltyp1ical!1~ IIb_d.be1t\veen.1i:lli:e ~.en. ,O:'dock ,1lli1:d1two ,O:'dockpo&itiio:l1!S (Figw:,e 4_10). ]jfl'[jJi5sJim1g lim"eflDJdIy,. Flodlesrota:t,e]a1te:ri31lly,slO illcrey ;ru:e fomd ill ~etU1e ,oidockm~g ~om ,O:idod:posiru:on_ Ex:~g ilie ]eft Fleck, lillie nodla] dls1tlJ1Jl!lrttioo. rep:res:oots @mm.o:r iimage_ Note ilia1t :!he nodes 1}.mgmernaJi.1to :!he ommmOll. ciiIill:01tid.me:ry are flOE deep cervical . .or ji1!]~M cham. ill origm;iliey me parawadtea.JI ,cham nodes_

The deep oerv-rcm nodes.~eQeNe ]y'11lilph yom.ltl\tepm-orttid, te1tlr:ophru:yngea:lJ .md. sll.!J!fu.mM.dblbmm- nodes. lim'mrn:]y they enThp1ty .mto the lJV ors.1!l!bcl![jkwu\i\eID,. O[dlr~. d~:ec~ .m1to 1tI1e tl\ro:raciccMct on 1he Deft 01'

F~gm:e 4.1.0-

MaThi_gnan1i: Eefit rid!. Gm;ilc~ ~~d!es, ali the tBn dcl~.ck ,aI1Id!. fr\¥~ ~'clecl;: pos~ti~f:I!S,_I.fV, m1tema] j,l!ligW:a:I" vein; Cl\, ca:l"o,tidia:rteoryr.

As: i~s ~1iI:m:emnpTh!es,1tlIDe~h node rnm.:IDollliow.s: the spina:lJ aeeessery (XI) nerve. Htom'iierel: deSioohed. one ,orposSJ!1bJCt h,vOp<il!tf,d.eJll.fOWS, of :I1iodies; :;wma~ymg ilie 's.pm:<rl.<ilOOeSfiOfj' ne:l:\'iem hils origi!ml<IlldJ!s.SieCiITOns_. ][n order to eoves ~e OO_:Sie of ilie :;wcoesSiOfj' c~m 0~e needs ~or,em.eJ1llliber 1tlh:e ]anrnnarks .of ilie XI nerve. .lit e:I'I2le:r'~e5 kom. '!he ~.bmeWiil iliejiillJgwillarfolfalllefl_ It iliefl. 'p<1iSSlespos-weri!odly deep Ito the 'po.s~eriDrbeIDiy Olfthe diga;s;mc :<md. ~s;-wernoclJeiidDm1li5~o~dmllSid!es to rniI'li. mto1tfuepos~eriim: kW:Igl!ebefolf,e dlnppmg bel1IDd. tlle :<iUTh~eriOfbord:erof.1trtitpezm5_ A lMtem&'i,VNn.olilil the .m<il!S~oid Hp ~Q &e a:.cromlio'l1!n~pr'eSioots !the oom:se of.e spm1ill!1IDcoessmy nerve. '][l;e oper<il~Qlf 'sholillilld SiC1ll1J.1tr:<mwerse1Y nOrnl ~e mi\l!S.~oiid!. a1)ong dteplfedioted. Be of :!:he .spilwal<W.C!Dessmy aerve. Rem.elil1lber 1tfuat the Xl[ ne!\~,e ~s ;at .s.uperliicial.s,1tIl:illctm-,eSJi1ttt:i:l1lg oa the fascial carpet Olf 1tlTI:epo5~eriO'l" ml~glle_ ['ooll!: for the p][MJje beThveeFl.tllie ~s.~e:rn:om<il:S;t\oid~d tl\temderlymgs.caJ!tl1;e aI1!d ]evawO[ :Sicapma:emllSicilles as nodes wiili1I be i!d.en1tEed.m trns.s.~e:mcil&llp][MJje,. i.e. \¥i~ 1- 2 em. Olf t&e ·~.~oe_ One Ctlll1!safdy ~g:l1!Qre tlle :s;ltllITCmreS deep ~o tlhe scalese muscles. billeriOllJy, pick Orl!lilt tl:teiID!'lwertor border of trape:z:ffirJ!s; ~s eWec~~ iffiarks tlte .]m1ctloo Oif ~epo.Siwf:lri.o,r IDill'IglJe ,rn~ IDllcll1tl1e W.afIWelfSie o~c;aJl ch1lin_

Trlllpo:lim:

C ).

o C...__.. _::J 00

:SpleniUS ci:lpilUS

il{lv3:tor scapetao

PQ~lilliriQr Middle 5cOliliinil

F~gIilliI"e4._11- Po,sten:o:r Uflangt.e_

The point where ~e c5~e:m:omi!l&~aJ!d ml!l!Side ffi'ielfllfestlliepcl:S.~eriiorhellly of &e .mga;smc matks. the ]m1:ctioo of !the :spm1il'll. accessory <Mlldl t11:e deep oe:f'i.<i)ca]i. daicnJs_ O:l1;e crumot dEl'ererl!1!:D1il~ebem.v,een ·the two :a.t thispomt

The Sipma.:1J aeeessory rn.m.dlr.aim .oocipiritaJi :Md.m1ili8toidl aedes, pme1ta.] S)rntp,]a:~era] ~.eck Hd.shollliM!ct ]ymP~1iltics_Et ilia'll. dllf:~5primady m1!o ilie trUs,ver'Sie oennca.ll chm_.

Onoe tile 110:00000. i!s reaehed, tfueprOibe IC1\l::I1i.1be 1h!lfI:nedJ tMOlugh :9:C)P m1to ,[il5<i1gl1tttaJlp]ruJie_ ]hf oae kJ.eeps 1thebo.1t1tom. Olfthe 'plfolbe .a]iglled Oli1!. ilie d<ilLviclem:td sweeps .merna:lilly ~owm-dlsilie 5We:IDa.lI.lThokh, one 'i;viillIIhe sc~g ;alJrn'l!g tllep]alTI!e .of tfue k.i§If:Is;\ii"eIs,e eervieal vessels, ~-,e_ thep]<iIill1:e .of ilie !traf!lSVIelf~Sie cervieal (S:~I<ilcl[jJJ:vic1llilln) ]ymph node chaiin_ M.pracfu)oe ltb!s meoms 5C;~g 'i"vi!1tlh. MIle werior~ect 'of ilhe prohe on (or iin. most cases jiu~1t above) llie dtilvlde,. ~oa1l::i!!lg to lidi.e:l'LtiillY ilies.l.!l!bda:wOl:Fl.vesSJeJi5mm,emerna.1illy _ \~e~f.I :trhe]JfOlbe reaehes "!:he 5te:mDml!1ili8toidl.~e jilll!gmillo- sll.!J!hdacw1iIfIjmlctioil1Jishol!l!lJdbe iden1tiied_. Ths.pomt l!Datks. the jil!mctioo of ilie 1tr:MWelfSJe lQer.viicaill. !clIDaiia mdl the deep eervical d:uilmL The mostmeornali. node of ilie 1tr<MJiwerSJe lQer.viicaill. >dIDaiia is .OOVi'l1! .

• <IDS 'froisiiei's. iI1Iodie as he was iliem:::>t ~opomt Ol!l1t. t'Illia.t iliis. node m<ilLy1become ml'ii!aded. in GMc.inom<ilL .of [he 51toma:ch_

The 1tr.am\'ier::>e o~cru. cbaiFJJ.reocives ]y'»1ph Yom.1tlTI:es.pilla.1l aceessory cfu~, deep oerW~. cfum, upper MwmOf ches.t wd.a:ndlltlTI:e . .sk:iirI. ,ci!the :an1te:r,o]a:l!er:aJilm:edk:_.

PageT],

F:igure 4..12.-

T •. aasverse cetVicaJ! cl1ta:in_

Now tDe ite pmhe back. to' ite IiIMldllii:lllie ~iM!I:d.p,iick. Ol!l~ fue furyoiidhooe_ Tms is thiest:nliingpomt for ex~g the .;m1tmo!f o~e~. sodes. Sc~g kiYISViel}Siel\y ]fO!lllJl. tlb!ehy'o~fl, sweep' neriody lto id!em:iy the 1tlhyrold!.cartiil!1IDge of lillie ]m}'":I1JX, .cri.coiid!, kad'l!e<ll, flII}rro~d. ~S~llSiil1id. then kiil!mw. ;<lIg~befci1:e ~t dlis;ii!p;p'e~s. mto !the merniillS!Mlilim.-lIheiID'l~erim: oe:l:V1ie&llreg:uOl!1 \viillI.tlJ:e:Il fuaJ\!iebeen oovered

lP'relarynge:d Nodes

C(Jmln~}n C~rg~iQ !!t1£i,r~

F~gw-e 4 . .13- .Mtefl®f CW;<lCa] flo-des,_

lP'retthYF1oid Nodes

'ThepiJfe1trillidleaJ! nodes; ;1nes,~e:mcial!. nodesfo:lillo">;vmg 1!:he 'OOl!lfSJe of &eilll'l!eriDr~guJillMVicin~ m1toonr to 1t1\teb:arne<il!,bel!oW" [!IDe 1i:hyrorci They &<ilID. '!he :l:hYliOtd. ~<md§lld. Irfmpihfrom ilieml.!J!s;des: .~d :s.kW:I. of ltfue :m1tmor neck. They dram. in1to 1the ili01f<Wcic met on.liI1e ~eft<md .mto liI1e ~owest deep oerviea!l. iI1:ode Ol:l!IppeK 1i:lao:l:@cic node 0:111. tlteriight..

The ]Ji1]f.<ill!:.Olcheaill nodes me ~Q Mm\'ll .<J;S tlliielfecm-rel'lt ]liI:I'}'nge;l[]E:ooles as fuel' ~ccomp,~' tlliiemcm-rentr ]liI:I'}'nge:<II~f.1Ve_ The majlorlty offues.e [I!OCi!es ;[ITe~Ol!mdl b1ter<icll.1to the tr.:m:rne<ll. m '!he 1tI:;acEleo-oeSiQ]J~ai?ieail. groove_ .lilr m tlte 1t:I'adThe§l Md. oeSOpl111gtill1S CruJi. OI'ernote diffiic~es m ;ilSJsessin:g these Trymph ;I'l!od)es_

F~gJ!lI"e 4 . .14-

~llfg.ed! (10 fll1m) pafatrarne.aJ: iI1!ode (mowfuead!s)" :p'0st·erieno the th)'<®id!.(am'l'wed~, lnWllckil1!g a' .pllfalliY'1:ordJ adel1!oma_Thagn~H;~s;: S·llfCl(\l·rcil!os~s ..

Page 7-1

W'boo '!:ills :standMd. 'El!:~lltron on.boili. sides of~e neck.liThruobeen. 'penOO!Eed, lOOe l!lI1IHajiority of'lhe ]ymph. flode f!B:I'ri~ories of the neck. will!IlThaVieheen. 'oov,er,edl_ The 1}fl1I1ph node lteniltories~atID"'e nDt oOViered.1by tmss1tiimdru:d. ,ex;lllImHiL1tiioo. ~ID"'e ~ow .momdJed. for oompIBltem:es5.

TheSie nodes caanotbe ,iiI!SSieSiSied.hyllllli~a!sol!m(:JL Th.eyare often. W:1i\iiONed m l1iiil!Sophia::ryngea1! :;md. orop]]~gea].prilD1ll:)'·ffilnCJim:s_ ms nodla!llam:ea~ol!i!l!d ;~va!}'.s. he .cfuJdecl[ m. ili.en'e<iI.sC3lmI!edl w:l1:en.l1eprim;ny mmo,m ~<iIiS,SiesSied. hy lli.OO or CT.,. 1tl1.erehydo'i;vmg .<ill thorough. ;iaiSLSies:sment There me two grol.!:lpS of nodes: "lhemernilll. grolIIDp lymg nen iliea.dlIliwTe m ilierekopl}]~ge.ii!!ll :sp[iJ)oe, .1ll1!d.1!:fue ]a1teriii:] l1iodes or .l1!odies of lRomere wfuilldl Thiejiust blter<rl. to "!he Dong-lillS ooli. ml!l!scle_ Themedlii<rl.l!lodles are .~ot~ormdo/ seea whereruo the aodes of RoliWliere are wdl. seea on 1\00, 'p.m1i!.clilillady m Yollmger 'patients_

At ilie Viefj' <itpex of "!hepO!sterior 1trimglle, s:a:ml\viiclledl beThv,eeJillJ the s.:lte:mOm1J<ilislto&d Md.1!rapeoosmliillSides ~;md the oocipi!taJl'hooe S;llperiorl)·" iliere ex:istsa. ·smd. cmster of nodes. They :arel.!l!Sil!l!a1illy i'invoruwed. m a.ciil!l1tl\tood. hlOJt ffiOlLyhepres;ent m cMdihood_ They ,drain dMicl1y mto [he sp,maJi aeeessory cllliaicl!l. <rnda:re ~cw~ to idJenEi}r 'Wiiili.1!1!lk,lihSiO'DidL

Asmd. cmslter of nodes exiists~st be1mJ:d. "!he ear, mor-e 11illlimaOills in "!he ,cl1iilld) ~<Mli. m Iili:e acmlt. The.SJemolln.1i:fu:e ,':L111ridellldl. eX~e:rl1!;jJj ~al!Trn1tory me<l:MLS_ Lj'mph.1i:l\ten. mruncs mlto ilie. .iEierimparotid. fiod!esaN:dl'IDpper deep oe:rvICEll nodes_ ~. ~<11. oo-operamre cW!d thes.e nodes are te<ldllily .rdentmed.hl!l!E: m ;the ,1ID.cIDillI: "!hey .h~'i,lie1[]Jsmr1mymvom~,ed_ 'Vi'lh."!he Iex!Oep1ti01!Jl 'of me][iJ)flO<miil.1tl1ey ,!ID:,e!l:<Hdly :SJig:OOliC1illt milie .ro!ID~_

,Given. ~eplfe.cSJffiDe efso 'n:uany ]ymph. nodes mtlJie "norma:lJ.' neck, ROW many 1}'lfIlPh.l!1odies sllliolillilldl1ihe operator expeo1t lto see on. ex~g '!he neck v.:riltlh mk,;a;sorl.!l!l1d? There ~ID"e 300 .1lym;ph.l1iodes iin.1ihe lleck (i,e_. 1.5'0 on. e.ither :side)_. Atypi.call.f.<il:d:rca:l!l1edk: dJissleotrOl'Ji. ':s.lli.olillilld yidd. 30 nodes on. card;!]!]! pl1ilio;]ogical1 ex~a:1tioiJ!]l_. So, how IDomy 1JyD:Ipl\! l!lodes~olillilld one expeot ~oSJee 'it\'llilirnh~1ill5()l[]Jfldl? Themswer is, "It depoods bow billIl:d you boJ.ld'i_ ;!if YOl.!l! use .1lI.lillgh "i"e~fficypmbe;md. :sp'end.l1oms: ex~gd. ilie~'m:P:b fiode territories y.ou 'itWl!lfutdmmtip]e nodes ill ~~.a:reru>_. Bnttr'e:mJ5m!ber !that: _.dliI'l!g hemg;l1! imlooent nodes ismor'e ,dllifficl!l!l!t "lhH det,ecoog mdgnant lYmph nodes. iP'ailio]ogica] lYmPh nodes \ViJill ]e1W Ol!Jit at you. 1000oeYOl!l!. llliarve m3l!5~er'edl ilie ~b~c lllllikaiSimmd. examitniU:Ol'lL Do llotbe worried if YCJi1[]J amno1t lide:nlillftY mmtlple Niodes 1iIiI.d. ~errirttoriies". 'foe SPffit Iooing i"OfSJ!lla:lill. mSJigl1rnc.m1t nodes is me 'iov~[iJ!S~ed!_ Ol!loe Y01[]J l1!a\/iem;a;sta,ed t1;1;eb~ 1tectmillque,,<ill st.imrnnd ,e,}l;~i1J.tiOfl. of 1tlhe ~eck slliomd 1t.e .no .more tltilll. i.'G-15I11ilIDlOJtes. The glfe[jL~er tlte experiesre ~ru1:d the h1iglliJer the :freq[l!llfficy ofpmhe'I]JS!ed, the grea:lter ilie flllDbet of]y'lill1lpllli nodes iliat \villill.he detected. Nodes ~omwe:lli5 we beceese o]dJer_. I·Y1iIlpll.nod!es:are fMmore l'lil1!lILer,Ql!l!sm"!he yomgermrnvirllrnil1!; 'ioVhen.Sic~gar. 'inormaJ!' teffiaJger's l!1ec.lk: one woU]d. expect ~o dietec1t BJ-2t)1 nodes wirft'l] ease,

J1!JJst when we were gettmg ~ogrips rwiiili. "lhepille"lhori:ill .of mllnesmd :Syc~~erns for ilie lymph nodes of the l1:ec.k, "!he AmeriC<lI1I. Joi!Ilt e~~ee on Caacee (AJOC) infu"ornxGed[ llie']e\'icl ~e:mJiinaDogy' _ 3 The COllOept of "]evdi' is drweNi.by lliernct that ili:e e)!cltent ~<IDd level of oervica;]. node m\/iOi~e:n1t ~spmb1I1brlly 'lhemoSJt~rn1antp .. ognostic :Eador :IDorp:ments 'itviJ"I:1iJI.<1I. sql!l!ruJJ:O:l.!]!S, oeJruplfiiI1!ll!<M}'_.Node]ewJ~s. .iSJ. m.gMlys.ii.~c:a1!Jtp .. .ernc1tor. of s~a1I_ St,.e!llli,4 m ~<1ILrewB.v of 105 8piil1tiien1ts \Vli1i:h. Sql!l!1M1IlliOl.!l!S oel!l. ciITd'tl1om<ill of 1tl1ehe<il!d udl nedk:,.sJlliow,edl tN:<iI!t ~e 5- y'e:m:~ii!:ll.raltefO!rpa1tiioot5 ",viil:h nodes ,[jilt ~eViel! ]j (sllillbm[jJ)l1idlJ11hw:ar) W,iiI!S 34%, wfuiil!e ill was ornly 4% forl!itod!esalt £e¥e'll. W (lower oe:l:Vlirnl!)_

It is; iimpm1iimt ili:<lt we ~iSJS!lfa:rnoEo.giLSits ,em;broaoe '!he concept .of '~e\'le]js" _ Smgeom base ilieir 1tI'ea!tmen1tpn~ OFl!. tlle ]e\'lel! of t:;.rmpllli. node mON1emooE, iIf ,a.J!]}'_ Th.e AJOC ~Sime:llle ~aWs to :sDplliIfy the ~[jLS;Siessment of1!:fue ~ed::, <'lilli. ~a:im wrncJlltmaIDJly ac.meves_ The levelsscheme :I1:<iIiS; ,eViO'Iviedfrol1lll S01!IITh'S fll.!l!lEeriC :I1oda.ll dEEs.m;caltilO1NJ. sY.SJ1!e:III,,5bl!l!t ile:reare some ~ponant dlHe:re:l1oe~_ iFi.gJ!l![e 4_15 is ]argdy SielIf-e)Cpill;matory,b"IJ.~ there are a.Iewpomts worili JilligMigh1!imllg:

PagelS

F~gm-e 4Ll)-

The, J\mencan J'~mt C~1111J1ijtl:ee~n Caacer (JVeG) ~e'!{eJl! classifk:ati!~f!I_

.2 Le\!1eJJ V {lliepQcs,1terior mruJig1le) iLS~ersl!J!bcfu,-j)d!ed!.m1toIDpper.,.Dd)dJ!e1ilfl!d. ]ower me\!1elJs oorrespolID.d:i!'l!g ~o 1!:Th1ep]mes 1iha1t. dMide ll, illmdl N (~_e_ byoid :;mdl a]ooili}'foidimemior,Me)_.

5: Nodes of ilieID]J.'per spilIDalIiiliooessory dl!.illI. ma(jl be .m.d!!I:dlOOI. ill the .Te\!\e:JJ D1Wld. illiil::l"ei3iS,m :iilididi1tiicm. ~o ~e deep oe:rvi!c;]!Ji. chm_ (i .&e:Il!le:mher ID<il:1t s1!rnperior~ ilie E;pm,[il]~c_'oeSSJQiryMd. deep oerv1!ca1J chams merge; diIDerefil1tlia1t1co:l1J. heThveen.1illte two in tlteliliPper ~eck ~s amdemic_

The UIfOC-1'NM daissmcll1IToo'ire:rnams a.]<ilfge1IyM:llOrnlcali. daiSsECll1ITOO_. Care is need.ed"lThoweVier, when.'l]Jsmg some of ilie 1tenns. eJillJployed m deSJrn)lbmg' tl1e t}rmph. node gronpmgs, e_ g. dors.all. ceevieal (SJ1!]p'e:mci~. oervrca10 r,elDen:tng to Ute spm~.<il:ooess.'Qry c:ham. aedes.

M;my oilier cl;n:s:smrntEo,nSJohel'lill!es 1exfl51tllbn1i, whliL1tev,er S},Stf1I1. ns used, it ~IimpOdM1t. &attsm-geoo. @I1dllf.adlrO:]D~St USie 1tlTI:esruiI1Je 1te:l1ililrul1iO]ogy_ Usil1lg <ill :gr,apfuiic ibrma1t or :stomd<ilfdtiSJed worksheet fmrecorrnngllymph aodes jjsf!eOOl!il1ill1t~ded_ iRJecOi)j",diliI1g iliepoSi.i1ITQII"I! and .. nl!D!her I()f fiDdles om a.S:E<mdiflldi ,rn[jljgr,a:IJ!JJ 'Of ~e fieck. ea;s,i[~ OO:l1i\!1eys the WOlfmOl.TIO:I1i tJiJ:esmgeon.reqmes ,Md eases oompa:l;liSiO:l1i. ,oo.£ollliow -'llP'SJmrnes". Th.es1tMdlard. ex~mi:O:I1i. d!eSJrnlhBdl ;~O\WS, ~em1trillicolil!lil!d mc:lli!l:JJgs ~obe u,ial!l.sJia1bedi ,~y m1bor,eadill.iy j!d!ent:iia:lb]elterri1borie5~olJj" the,s;mgeorI!_. The s.m:geoo. Of ,cmoo£ogi5!t 'rn1!Ji ,e~~ ua1!lsJiille 1iha1t mIDorma1tlioil!l m1to ;;g[ ~eve] d~siicatioo!. sys1beJiil'JJ_.

RaJdiio]ogish sllolililld 'I1otbeoome 1booboggedl. do\\'1;l. 'i,vi~ d~smca1tiO:l1r sys1bems_ Use a sys1be:I1lJi llirnt ,rnlillowsfor ,qmaMdeJffi.iciemtam'lo1ta:1tlirul. of nodes de1bec:1ted_

Th.ere is no d!olllibt ~<ilrJtmi[[M01!l!ITId~s ;iillS!eI1!slWE ,ex;~iil:1tiion (OJ[ oervrclilili 1!ympJhadJe1lop.atthy_ 9--14 Lympllli nodes are e~ de1boc1ted loooe ili:e o'PeJl"a~m: is ,experiioooedl m 1illtemk@Slomdi. Maltomy .of I:te ;I1!eck_

The pmfu!]eJiliI. '!:hell]. ames of uyil1lJg to d!ecidle w'l1efth,a '!he ]ymph. node d!e1bec:1bed .1s:b~gI'l! >Of ma1li,g'I1!i]lliJJI:. Do c:rll'lteri;g[ exffitfm .rnEfer,entE~gbet.veen.beruign :<md.m<rlig:l1!ruilt 1}'mphiitd!5:I1:0P.~YMcllIfslO,;ne 1tfuey vddt Sl!Id~. rn1bmOl!. do exmstbnt wWe some are exoeJefil1t ill diIDerf1"11tiirnEO!l1!, o1ihersmepoo[_ COlIMmorniyMSJed. cri1!!OO§l are:

1-· Size

>

F~gm:e 4 . .116-

l}"ll1¥'fu N:~,de sitze as an m.d::ic:at~! ,ofmatignanq'~

The]m-gler filellymph iI1!ode dlel!edecl1tlIegrea1ber file lliilbelliil1iood. ofm<1l1!Jjgll!Mcy;fuowever iI1!odes ofillP.' to 3-4 em. m ]engili.a:Ile 'Oie1iJJ.l0md. iin. florm~ mOOridrnaffis,p2tl.1i1C'I!lillru:r~1 dhiilldr,en_ Size ~ofle is Ehe:re~m:eiillpoor or1i1b®O:I1J for ,dtrnIerenm!a:1tIDgbe1t\veoo. beJ!1l!gI1! .&ndnlJdg-

Page 76

:I1!iiIm1!E io/mp:h nodes. 1IfQli metimelll1lel1lE is t~en" lliLefljiDJsE as m. ern lE is :!he aru<ill!. OrErIDl!SVie£,s.ern1mJ:e'Ee:I" tlJiat :htiliS Mleber.E. oondation \Vlit:h. [he IDcr,~g. .clilloodl ofme1t§lS,ta1tic: rnseatSJe. The SIe]OO1tiruJ!, ofsitlle ,i51i5 a. c:il1!erioo fall" dilltiJere:l1!1tia~ghem.veerl!hoo§lad miMlig:l1!<ilflt nodes .mlillsthe based on. oomjJillOliJms.e. A :S1!Nd!e:r Erornsm<lll JJimne1ter mcreOliSlesSienS£t:iviry, blmt witth. ;aslilfh,SJeql]!ent decrease mspecmcity :~Gill de1tec1IToo ofm:e1t:Mtamc ,rnSif:SSie. VMI d!eJ!lI iBrel!o:1. ,et apo ,ma:1ysed .[ilr<mge of mimmaill. mcii<icl!. 'rnamet,ers in ilieNO nern ;and, fCJmldi. tlha1t a. -IDigm:-,e of 7 iI1!llm.lDol[ slillibmrmrnlblilillarandSll!l!llimenta]. nodes.,Md 8 m:m.~o.r .;n:llli oilier flodes,ga\lie am. oVierd.aocm:,a:cy of7()iDlo. llIills igm:e is lowler ;!:hm 1tl\te wms:IDrii<rl dEa:l!llete:l"sgiven mp<itp ers d!eSJrnlbmg ilie1!l!SJe of Cl' iGill stagiDg lYmPh :i1;odemet&lt<wes (ie .. H) 'l!J!1ill. ,;md 11l!J!1ill).ls .A:i1. ;[ji)d:vtmtage ofmk'iliSiGm1!d Ov-;e[ Cl' ~s that ;;jI[ trMllsWa]. dii<ilmellet" is a.ltI:lITe ;<%cia:]. Of 1trIIDSViet"s:e rname1te:r, ie. tilt is: trilkJen. at90iC' to ilie]ooglfurn8iil:u<Il! mciis of the .node. hi. the case of sllil]hmMd'wbuill1lli nodes" wrn.rn. a:re orien1ta1ted. m EIlfdaweliy fuomOl1l1ta] [pi]me, diiiiLme1t,ers ,on CT<itre dOSier to 'I) emg ]ongiimJdliinJi'a:].mem.m:euLffi1t:s &1ill. nema:li. or transverse diruilllie"lte:rs.

Jin1t,ere:sM.g]y, Vrul! den Eh:eJ!.oe]. et aP 'sta!~e '!hat 1i:lb:e tkemo.]d. :{Of81iJ!S])llcion ~s lffi1!J:rn. ]ower illp::aments wlThere1)rmplh ~od!eme1t1ls;1tMes ,a:re S1iJ!Spoottoo. (~.e. p.mB1'l1!:s ,."viili<illppe- {}rposHre<il:1t:ment mOWlJJprmary), <md a ~a:] .maE dillamet!er m 4 ·lilliIJLI. i51iJ!Sledfor the selleotJoo. 'of nodes :£or :fu1e-need]e<illSpiooon cylt()]ogy (lFN..4:C).

mmltmSlOlIIDd 1i:lb:ell.lJse o:f.sm;<rlIJe:r.IDci:ali. rnameters fOf s1iJ!spiicion of me1tasta!1ITc llymphadenopailiy :fun ilioSie 'lTI!SiBd. ill otker .1mOllgIDg mo.d1l1liUiesresm1ts ma.hl!gner :SJoosiwittybut ~1ilh. ;11L oonespon8iil:uglly ~ow'e:r.speciici1ty. '1'lh::is: now spBcmci1ty caabe ffilpwvedby 1!1!lk:[JiSJowd.-gmded FNAC. Ther'e tS .no. dOlilfbt ilials&ze ;<llJooe ~sapoor cri1t,erioo,bu1tmalJ dWal!]LeI!er's 1llefueJ:pfuill <mdl'can.beuS!ed .. m. OOill1!jjmTho1IToil'lJ \\cri6. o1tl1er cri~eriii:il. for dill"erenillimoo .. AD ID:cre<iliSJem .. size on. :Siffiaill 'e%~a.1ti:O:l1! is ,;jh good. :SJign ofmaThign1ilN!cy wl1!en.Siearcll,iililglIm me1ta51ta1ti'C dise:JIiS:e.

2-,

F~gm-e4..n-

Lymph n~de shape, as an indicat~.f~f1llLatignancy ..

The sil1:11pe of ~e l)rmpffil node ~s a.ffil"betler mrncatrn: ofbemglThi1iy or maillig:l1!Mcy t:ll!::m its size .. Berngl1. nodes tend. ~o be ,eJjong.a1ted.md. msilIDDfm in shape (F~gm,e 4 .. 18) wber'eiillSmailligll'afltt modeslttm:d. ~o hiiltv,ea:.gre1l1te:r [!;iills;l,~,erS!e rn<Ime1ter,~.'e.;jI[liiI!iLoill,emmd.ed.siI1:<itpe. 00 w<iIi5irst lhiiI1,1ted. at by 8mru ,et al; 16 wnos1t<lledl ~a1t m.e1t§lS,tmc nodes 'show iii. moremmded. comtfigm:a1tioo iliH.lill!OO-metlS;E1lmC l1iod!es. SO]Jb1la:1tll et aJl", :mstd!.es,rnbed ilie1lJ!S!e ma ]oog"lto shon ,msra1tto (LJSrafu!o) in the dJism.o1ttom1.be1tween.bmg:n. {VS > 23)Hdi.m<il'ThiglTI1,rut lliodes (JUS <:: 2.,~]i). Thill'S was ornEirmed.by l'OMOSI!]and hiLsoO:lille[jjjgJill!es, ra wflome1ll!Sm'ed. ilie short to ]oogms (SII..)fa1tioM oen.riicaJ!.llymph nodes ofp1l1tiien1ts. \VlJ1tlillJ Oes.opflargeELli cill1!oer~doo:mp<il:l'ed llNS wl1th. ~epe:l"oootagre cm1!Oe:l" oo~tent O~. OOCfo-3ill1Ja1lysis. J\:rI. Sfl-m1tio grea"lter ilian.'~15 mrnc.;a1tes a.·fOmd :lWode, \vm,eteasan. Sill t<lL1ITo ofEess. ilim.0.5 ilwrnc..:a"ltesm. ovRlll,msibirn'l ::s&:aped. miode. The ;i:iI:'i,i\er.age can:oer oon1tenE iin. ~e meta:sEol.1ITc ]ymph. nooos wirtth . .iiIEI. SII. fiil:1tiomder 1~}5 was 26%,. Icompm:,ed!. ~o 59'% W. fiodles. wfler,e&e S/L ri9.1ITo wasgreater iliru:!. {15 .. TFI1!l!S, 1!hemmeromd!ed 1tlm.e node, ilie mmellillbe1y i~.lis to hm'bommemstrlL1ITc dlise@Sie. The:re ~s one e:mep1ITon"lto ttlhillsrme: sl!l!bm:;md!l!bmru:Md. s1i1!1bmen1taJJ nodes b[jIJ:'i,i\e a. more ovciJd :<mdro1!1:l1d.ed 01!lrt:1im.e ~m oilier oe:l"\l-rc1l1i. nodes, I~ and. care ~ere£ore needs ~obe1iJ!sed wheflliillsmg :sill11i1.pe<i1i5 ,a cri"lterioo. "1.viittlbJ.node:sm lthe .SU!bm~t<Il! ,md. slllJ!hmadliibmru-r,e,gtoos.

A ·U::ihe:rs;m:ci¥14 :h~ :sho\vn. ili1l11 .1iIfI. [ilCCltl!l";[jjjCY of 80% w§.iS,[iI).c:me\lioom,1ID. NopopmaEillI ofp@1ITenEs \vir!:h. ;iiIlPrmum:y mmol!l!l" 'C9'2% :SieFl!slWi!1ty, 63'% spedlfi)city)by1iJ!s:mg a.ratia of more :lhal1i. O. 5:5 for ilie ~dtmoo:DmJ1I tf.ID1SVef:Sie dirum:e1ter, i.e. a.romdled oID1iline as ~e

F:igJillIe 4, .18~ :B:erignlfulsif:~nn shape,d!.t:;,"mph node '>Villi. '0~tra:lJecl]~'genic M1lJis,"

Page n

J-.

Edl;ogen;ic .Hilla

o

>

®

F~gme!IU9-

Ecli.oge,ru:c hitl!J!s' as a. !C1i<l:erionoftJ:lail!ignallcy_

A l1:ormorl.berngn. i~ph.l1:odJe is .i!Il'li. d~pticorl. s1Ili1:JJctrm!e 'i<vir!:h. <iIiI1I. Qtl!l!~er h!ypo~,ed1:ojjc orniex.<IDd.<iI oenk1rl bright eclLog~c: Whlis (llii~igme 4·_20)_. A oenfu:.~. ,ecnogemc me or wrus w@sir,SJtn~p m1edi. m 198:5;11i 1tll:e ecfuogemc soodh!lIIfe W1iIiS 1tll:Olill!gl1t ~oreplfeSJentfa.ll ,.,.viiI:mnJ 1tll:e node. S1!])b_SJe(J}!J!ent al!JJ1!horslfe~[jjlfdedi1tll:e urnng of .~ss,1trI!rc1tl'lIlf,e asa :SJign. ofherngm1ty_ 21)~ Rl!l!bdtel!. ,et a,[B were iliemst to oOffle]la~e tlThe .S011iograp]YcmdJ 11Us~on0gica:ll.mdlings_ They dem:onska~ed. "Ih<ilt ilie loootr<Ili edtogemc. wrns ~5cme ~o iliep[iIl[,;djeJj mT<iIrI!gemoot 'of 1tlh:e oen1tl:i:i!'lI.llymphi11tic s&!:!lll!SieS_ 1mspru:dd .iiIJili<rnge:ment serves as aseries of speomru: fef]jeo~ors wfurucl:!, when :a1lignedpardeJJ :l!o iliel!l!l]1tI:<iIiS.·omTI!di.beam"reSimts ill MI. echogemchilli1o!s_ TImsan ernoge:mc lliims .1si§[releotro!l1 OfflO:I:M1rlarcl1ilitectl!l!l!e l.W~ <iI.lo/mph nodle.; ]Eh!l!ba:1~eliTh!.MdI.l1ills boiJille<il1gJITeS ~erefolf,e oonooO!edl1tl1;,jliit. ;ihewdli:l1!g of ,i§[ oenltira:JJ 15CinO§eID;C .be .is ,aJ.v:::ilid Icritterio11l. ofbemgrnrlty_.

Fiigm:e42Q-

Beni!gn ~}'1JIF'n flo,d!e willi ])rnl'lEenr!: ech.oEjeru:c Ml!J!s, oontrnl!lOiJlills'Wiili. S'I!lIFIlll!J!fld:ing Ea!_

Wlillille the edlogemc Whois is .m1I 'exael!J!ent .~gIlli of bern~1t;" i~ is flou,woo]proaf Wl1el11.at flodieW1dJergoes m&lliig:n<lllt u<im!SJFo:l:mati.oa, ilier,e v,crilI!I!be a.pomt w11.el1I. ,oru:y maIDd d:iis.n!]pl1tibn of.ilie Oef1tr,a].m:dill~edl!l![e h<i1:5 oocmI,edi,.Mdi.renmru1us oftfue oentrorl. mms ma\y bepresoot mat node 'i;vi~ met<l!51ta.1!ic depOslK Tms has heenfu11~gh1ted.by Evans ,et ai,24 who d!.eJlli;ools;1t:ralted :i§[ oootra!li edlogeru:c MiIoJs. m bemgn,]ymphomartol!J!s (FigJ!il'l'e 4_21J Wbero1!I!l!onsruTI!di. me1t<iliSta1tlc 'Sql!ill<ilm01!]JS oeJill. c1l[cmom~. nodes_

F~gw:e 4.1:l-

Ecllogeru::~ llirM!S m.a tI'~l!md!edj.n~i'P·o-emoi:~ n@d!e_Dliagn.osi:s:: lympnm'Ita_

V[lliSis:a1llio ,et afl:ll1!aJv.e :furth:erMa]ySioo. the fuiiIIills., <iIiS\sess.iil:lgboltllli.1tl1e wiid'tth. of ilie mms.and.1!f:ue oomcail. "vidll:h of the node. They ooodl!J!d!e tlJ:at .<iI! narrowed ~s m.&S'sociation. ,.,.vuiili eccenaic oortic<iJJ!. \vid~g:sll:olllilld.aJ!Siohe r,eg:M.dedi.1iIiSsl!l~iciol!]s ofmdgn<mcy (lFigJ:iltl",e 422)_ ThlillJS .<lI.1broad Iecll:ogemc :I1iiWs ~s .1li. good ,SJigFI ofbem~rttyihlillj!: mot ,ru:JJ.abSJofuJ1te one_flill.<ii:hSJent ~s OI:<iI!~. WIDs \wrili. HS!oci1l!1ted eooelil1tflc oom.rnill. wi!d~gsh01!1!lJd.befJegMded.as:<iI.1!Ji Mcl1iica~or ofmaThig:ll<IDcy _

Page 78

FigIiH"e 4. ")2-

Pos.terior triru1Jg1!e no d!e:_Eooenrt:llic comie~. lJJypewiophy m .association willi .. a tl:31!owed! hilllJJs._

4-' . E'chtJ>gen.icity

>0

F~gw;e 4.2.3-

ECllo,.§e11Ii:cifty as a c:rit~onofl1taligpat'])cy._

E:11!llli1!eton.andl NmmMd_l1'0 D-st d!esG:l1)b edl.llie~S!e fuy'po-ec.l10~emci1ry of lYmP1];omatolills flodies,pilrticnillon:lly Floo-Bodgkm's ·~homi1lL.. J!f .~. flodenratS a. Imdllllike apperu-,lmoe, ~_e_ liswmbm2l!1y .hYp'o~echok 'Wli1tl1! ;;]JCQ1!l!S;itl1c emlliMOe:!1ilifll1l1! (pSJell!docy;s;ID!clilp'pe;n<IDoe; ]F"~gm-e 4_24)., tl\ten'l1hejje~es are ~s:llJ!gges<we olI ]ymphom<il!_ Oiliers~§;v,e a]SiQ deSiG:l1"hed[ ~s:lle[ilE'e_1:J lBn:m!e1tonmdl Norm1ll1!cfJ15 sl!lIggeSit ilil[il1t the a:ppeari1ill)oes ase ooe to ~emmmll!lJ oehillmty .of:!:he node seea on .. ThuiSJtoEogrc;i], ,ex;~WO:l1i_

JIJllwii<ill ei aP.;~ showed. t}lli[i!Jt9()i% of iI1.od!es lrJi\lioweEllilm! lTho[Jj-HodlgllcilTI!'sl~1iI!l]:ihomiill (1'-.ItillL) m 1OOeMSiOOeS showeEll d1s1t;II '~ruJ:oem:e[JJt, o01ffi]JiiMedJ Ito ,amy 11% mflodes mwoo.ed by meoot<iltlle sq;I!J!3mOl1J!S oelilJ cm!cmom[jJJ (cys1tiic seerosis miil!y aC'C{),!m'lt[or iliisfil1dllil1,g)_D:i:st;gJj. ,e>ID[iIlloemen1t. is iliere£m:e ,1£ S~gnMC:M1t ~d !C!~~ent·dlimIer'el'1ti[jJJ~grea_eiJhehv'eOO! N"HL, <md!. meEa!5Ea1ti:c aodes, Md:mt~\C mtodes ~eE:d.· ~o .11ii1l¥e 'iiI. heterogffiemills a:ppe<ilf,WlDe:: tI1ed!egree of o¥erailll fuypo- ,Or ~}lPer.ecl1!.ogernui!ty does l1Jo1i: o(m:eJia'l!e \viilt:l.1!fte CMCJef OON!1toot

Fiigw-e 4 . .24-

.Lowefceru'C:aill no,de, (anrowhead!s)" d!ee~ to sten::lOmastd~d! (an.owed)_ Dliag_nosis: .lyfllphol'lla_ High gain s.e.'ftfu:JJgs. need.ed to' d!eJJlonstrn.te:intemaJ!. ec:lhioes,_ Note, inrl:effi!aJ! jiuglliar vein (UV) .

.5-. Necl'tQsis..

F:igure 4.25-

N eUllM:lis . as a rnteriion ·of matigll'Olli:cy_

mll ;apatlient \vitlTh <iI .. h1O\vm:'I. primary ftllliepresffioe of necrosis m. a. node lis .aJs1tl:ong ~gn of m&Thig;l1::mcy_ NeQ'io~SmJi!lJy mmiIIDest i1tselif<3!5a! 1tI1ill!e cystic area QF'~gm:e 4_2j6) 'iovl-lhffi.1tllie .nodle (cystic necro.sJls)., mpl."e:s;ent.[j5 IDJ!. ;ill'e;jt ofhwer,ecflogemicity \\;,itIB<iI.node (oo<il~<il:1i:ioo neerosis). COi:1lgmat::ron. ~ecrosis~s llJ!Sll'<iilliy ayperernorc m.fel!1iLtWOf:l.Ito ~e om1tex,1bl!l~ is aot ~yp!c.My.<il's ec&:oigeft'C as 1t:Iiesl!liffo'l!illI1d!i!nJg:fi:il.1t ;1iIJ!llid rus aot oQilll!m1!lli01!lLS v,;~tfu i~ 1(]F'~gw:e 4_]f7)- The oentr,<iclj l\JiiIDs is more ernogel'lic 6lli<il!11J. 001l!gmill1l!M..0fJJ. necrosisand ~s CmI!Mll!OilillS \\:ri'lf:! ~e ;sl!]ffom1dlingf:it Co1l!glliJ!1l!M.OfJJ. 'necrosis typ£c<1lily oceers m mciM1i;[lUSeSEromi k,eramllLmgs:qllJ!ilLlilII01!lcS cell ci:ucfiowi1IL.. ][t m<il!}' eo-exist \virtth.i:lleas of Cj'SiEC aeeeosis .iiElli tl\te SUI1!e aode; iheSJe '1bendJ ~o .h<ill¥e[jJJ'_geogfapmc" ·d)isW1b'l!JlItlO!l1 ."m~. the node" predb~m:ltlY oen1trr:aJ!_ The ,llppear,1ll1Ge:sme rns.1tin.cHfom ilie oentr,[l]. ec:f:to,gemcmliuJ!smd:s];uo1!illl!d .. ~ot cllIllJ!S!e1:WiliYrn<il,g:I<osJti!CprOMe:II1L A~;[jI1tiio~ ofilieSte .Measl!llt1l:d!er~~Iillrur&:sioliJ!llLd

F~gI!l:re 4 . .16-

Cys.tilCne,c.!e's~sm an .rn.rtmpiar~fu!d! ne die_ Noil:e in'egullID[ fu!ctening (aII'ewedJ)ef'C<lp.slLll:e .Diiagl1lo,::;i::;~ S'qtJ!Wl10l!]S. oell c:al!"Cir:toma Hletastas~s,"

H@ll'e 4_::;n-

Nas,opha1)'l1Jge:aJ! ca1fC.inema metta!sM!s,es rnpo,s1te<rio!" t:riru::IgJ:e,_ 'Note, hyp,ere.ci1JoilC ooaglli.lafionn~os~s, (an:Oowhead!s) m. conj,Wlction ,...11:1;1 areas ,OfCYS,tilC N:ec:r,\'l'SlS (aM,e,w)._

NeO(liSois is olen. rd!mtWed.ln. mbert'l!l~bus .flocl!es:, hesee C,iliUrfu)OO. needste ,he. 'e:!l!.erciSied. whenllIlismg :l:ihJJs cri~roon_ TlliherclllilloliJlsnod!es~.Md.~!O he dwmped! tQge1tlill!er \'vil:h.m.<iI!S:Si@aJ<l'I!edi .m&ll1mlil!edl Sl!lIffOl!l!ll!~gM~e:rS1!Jj1tffim_19 Necrosis ~s OommOfl. ad 1tlllie sodes m,ilJY appe<ilCl" :&~! m~g:I]!1IDt Thepo.s~eri!or mi[ffiJJ.g]e ID1:d s'lllprad1ID:vfcl!lill<ilCl"regiioos are OOrrnnl:.OO smes :fOor mo erc1.!:1iliolls cI1odJes_Wl1!ooever cy.stic necrosis ~s d!elteo1tedl m a. node, mbercl1li1!os&sshDl1li1!di. :mvays be ,~d!eJ['ed.in iliedlHeren1timm1JJgI1l!QcsJ!s_ Aspi!l:'<ll~es .sll1mlilid. beseet ·bDili. for c}1o~ogymdl. lor 'mUa;ob~o]ogiica:ll c1lill11tm,e_.

6-' .

EX.:tJ'ifiCapsular S-prefliJ

HglMe 4.1:8-

JEru::ac.aps1!:Illar sp!!',ead!.as a criterion .ofIJiIoafiignancy_

b1!r.a'ClilpSlillillm spre<il!d canbe detrectedbyl.!l!1'trMDWd_ ItIDlpJ:iesacgr,atV1epmg:l'l!os.iisfor iliepill:1IT.ffilL Theooc:l'i:l1lig of,extr1IDcapSil!l!l!m: cSlprei!l:d:reoooes ilie 2 -year .~~a!I.ratie :fOill Ehep.aIDientby 5: 0%_ JQ

Th.e .florm;jJ! liympb. iI1iod!e fu:<illS :at smootllli .mill~_m .maThig:nID'lIlJiU k<ill'lsformiil1ITon 1the .cI1od!e .hiillS :at ;r.ol!m.d:.ed. ol!lrlilline but t,.end!s~o mH1!tm .ilIl shmp bordier ¥liili.:!he 'smfomdritmlg :IDlls:ScJITes_WTirtl!. ;iiI!m.<ll'l!ci:mI!g m~gnr1IDcy, 1illie ~omlI1lll.millpsmoo'l:Jiru outXme ~s ]O!SJt (Figl!il[e 4_2:9) :ru<d e1l!M:,1l:c1iIpSJlllillar spreoosllliol!lilldibe :mspeo~ed_ .A .sp~c'l!l!!la:1tedl. margin or lmt:.dl.ersllmllld!. ;mv1fuysbe: cd.oo. ,extr&e:ap~Jrnllar

F~gI!ll'e .:!29-

Elt"tracaps1lilJar sp1e.:adL Co.agmJafIio!l1l necre's~s p1es en1!: whic:lh!.has. e-",1endiedi llil'l'mgh llie capsi!!il!e (an.owhead!s).

Note sharp D01d!e-Imamtaiflled! ~aEe,:I'a:u;}' (anlil,WS)_ :Exttacaps1!1l!ar spl'eacli cemirn:le,d! at Sill'gef~,"._

5lpfe.roL mV&£fOn .of<IDdij:aoetl!tml.!]5lcle" :1oilivalliY~tmd Md!. VeID. korn me1tim!S1ta1!!C nodles hiil!\'ie hBe1Ji. identmed. (lFigm:e 430);. are mrnm1!ors .of adiv<moed 'e2Lttm!c<iLps>lil!ll§fspre~d

F~gme ~.J,o.Inva:'lion.ofw'lie.Ml!alijugWaJr vein (IfV') by metastatic ~ql!llatllOl!:l!S, eclJ! ,c~orna nodes._

'7-' . ColoUFFlow

:Figme 4..'31- Co'IOlirrfl!ow (yasm!l)~ ¥1latlem). as a C~fl!t,eriOiIJJ ,ofma1Jj~qr.

The ttnpe:ruci&]. mJ~ue .of oerviica]. ]yRph N!odes Ee1llidls lESielIf t01ID5s;es;~.~1t ,."vi1i1l ftliigh. teSldmltlruu. oobJffitt' Bopp]er <lI:Il!dlpowerJl)!opp]e:i!' na:gmg_ M<iln)' oentres31~ 3:;;hi:ll,,~e a1tl!eJLI1ptedi. 1toCMierenttilMe ibehv,©oorbemign <md.moog:l1ru!1t lilodesllillsmg 00i]0_ :low ckM,aiC1ter51ITcs_ R&dy :5Jmcilll1es.31,32 demolli1i:ra1ted.lowm ilie .~. ,Or oemre .oheacwe l}'mph nodes._ OEhersJI.5 :s,~ow,ed. iliuat bemgn. nodes ;;rrel:ilk!e1~r' ~o ~<iII\'ie <ill Oef:L1tr;[] v:li!iSlCl!l!lJarpa1tl!enJi. wbereiiliS 11ill.Mrn:e d@s.orgmsedi. periphe!~ v<il!Siolilillar p0l.1tI!en1i.iLsseen. in malligiliut nodes_ H:is·tapatl1:Oi]og;il~. 'smclies.37,3"Rsil\tow hllliiil!E 1tThte mamr. weries ~dl-v,ei!n 'eF:Iter lihe node at the ~i!midJ 3p~eadl inbud!l!es Oflru1eflesiiIfLd.v~mes lthra1t oOllIlfSlem dgmllient wiilf:l ilie ]o:ng ,m of the ~;,mp,hflod!e_. The ooill1ex. of ~e .]y;mp,fu. node .is !£edi by c-<lpl1lillmes .msmgfirom.1i1IDes;el\Millru: and mernillmJ'\!iesSielis {lIF~gme 4_ I).

TS!c'h~er et apE. ha::\!ie M::Ither reffiined.fl!ow cl'Jiar.aou,eristiics" st0l.1tilI1!g, ~a:t a.ifD.~gn node has a.M<ll\!iessd. lmd!/'or .;jI. ]oogDmdlmiiul¥essd_ lBr,mci1:es :fi:om.1!:h:Jis ]ooglmc:l:m11ilves'Slcl.m;aybe demom1i:r<1t1tedLM~gI'l'iM1ItflodJes lillJiiiy :slli1:ow :!:he folllowmg d1!ooges.::

·jocaJ absence. of peifus.ion

~.eliJi. :ifues!e rn1tefla:. wereused, TSirn~5:I" ,et ol sfuowedl.at :94%pOslme pr,ed!iic:we ~eformaillig:lTh<mcy wfum .i!i:liI. ro_colo_low !criteria:. werel)reSJoo1t b1!l!t ,~ <iI.67% posawe 'pred!c1tive '~e jIf,Dl1iliY one crit,erion W<iIiS .preSffiE_ The ~o;ss of:lhe 'ecltogemc EWu!sMaJ <lI.roll!l'l!deci Ol!lrith;e were fOl!m!d ~o c.orn:~]jate welil. ,."w'l:fu tI1:eiDlop:piller Critf1la: fo:rmagnMcy, !!he foSos .of nom:mil.iitl.d11!1t©owemin-omg 1the ,~]:nl0li]i]1I!iiIffi. v.lficm<rr 'iitl.chi1bedI!1II"em the magl1![iillJ[ flOck (FigL!il!l"e 432)_

Reeens de\!iel!opments. mcmde 1II1tel.!]5le. ofedilio-o(mrr;M;E @gef:LES. w'mdlr dow tmpr>c}V1ed. d!dim1e&fu)o'l1! . .ofMoodflbwd[iLs;mibufu)ol'lL Mori1iz d af$! C']m a.HJCJI% ~ocm-acym dli!liIerem!1m1aoog bmveen.be:l'Llign l[llTd. magN:[iillJt ]ymp(h<ild!em:oP<il:iliy~g1llIk.i:1I!soll1Il'l:dl OOrlU::.1I!st medliaiL ~o1!f:termteres'l:ing ,devdopment is ltheuS!e of 3D 'ViO~e1triC laSSJes:s.niI!oo'it of b]oodlJ])owp0l.1tI!eDIsm nymph flOdeS._.4!l ']['IDs r"viI :proba!b]yfu:ci1liiftate :!he de1tocru:on ofallmormall v<il!Sicma1trn:e (espedoillilly cs,l!l!ocapslillil!<iII vessels) iin.lymp:Elli. aodes, A1b:l1orm<l!ll. ~ortLo!o,s.J;ty of m1i:r<'lm.oda]. vessels is: .Olil!so dem;ol1skill~ed. wiith. ~s ~eclmJjqI!J:e <mdWI1Y

F~.gm'e 432-

Aseas ·offoc:a:l! ~ab::;.e.fice 'o.fperl1!J!si!ofli (ane.whead!5) and!. S'l!lik:.apsllilar vess eJ!5, (an-,e,ws)on ~JQ]®mfl!o·w ilJlLagmg_

Page si

prove :lto,bemotherlill!sclirrn] .Siigl1i for the dclection. ofmugniIDcy (iIF"~gm,e 4_JJ)_ &e:IJ!1emiber ltllli<iltpa1tfue:ms ofb]oodllow rns1!fl!blllrtiioo.1iI§'e ofmnre vam.e thSlf!l lowmrnoes_ 0l'10e co]o_low gmSiebgs Me set oonectliy, ~e asSiessm~1t of cdom fl!ow 1takes .Flomore liIlan 1t'he ;tOlITcn. of a.b1!ll1titOOJmclt1tep0sltrol1iimlg of a. om:S!oLlF·k~wpatle:rn.<iI's:S!ess.mentsTh1:ouilidi. a:d!d NJO more ilim.a;.fe\'!,\' secoads ~o tlle ex;~a1tioil1l, of arpill1tic1!Iillarr .fl!odie" J}ro'l,~id.ed. tlle':preS!ef .:Ili!1i5 ibeoo enltered!. oorrec:[]y_

Iigllil:re4J3-

3D Y'OfUl1:temC smdy.No,te tlle 1tommsiry ,ofilie in1t:r,lmO dial! yes 5eJ!S (an:or\,vs:)_

8- Number

F~gI!11e 4.34-

Nl1illIltOe.f· ,of ncil·d:e,:; as a orite.non. 'ofmatign:al1!cy_

Thepresence of a. Cilil!llSilter of ~od!es in a dr~g;[~giOFl! IOm. :<ilJprirru1il!}' hlIMOl!][ wolllilld. beregardedbysolnei1l!l!l!ilio:ns <1I!S <:I. ,SJ1g1i1 ofmailliglLl!iiIllcy_~,Hl If liher1e<illie wee m·morebordierme fiodles m. apru11Qmillru:regioo ~ffi.iliey '~ollililld. be vier;,vedl Vliili.$liJispiciOfll_ Vm. den lBrekel et aPSl1t<ll1te: ~<ilt tbeSle rJ!odess:flmnilid .haL\lie

. . ., . .

,<ilLml,1fJ,mm,aJ] ,mcia].mi:ll1lllie1ter 'of~otmor'e !th[HJJ. 2, 'IIll!]jJJ. ]es.s~P11!JJ t1te rl1r'eslllio,]dl~l!1m .1ill@!l.iIlleai5me:Ill.el'1tfoill lth;TIfeg~011! (7 liEm. for SI!l!OmaJilidlbwM iilIfid

su1bmffittaJL. 8 l!lllilliJJ.fo(f :sllJ!bdliigi!li5mc mlodes)_

There is no d01J!Dt ~[1I,t thepres.em:c;e ofcms1ters of e~ocall m:odJes: ill :[jJJ.p~c:l!IillMregiiooaf ilie~eck C<YJJ be fn1terpretedi .• as a sl.!l!$piciol!J!S: 'S~g:I1l" llliowever the 'fi:ndlirlIDg ,ofmmItlp']e '.smalil! .. !liLodesm <1tr,egtoo of tlh;e .!I1eck. ,is fiotml!DOlililimOl1J, ]R'omrrer,e2 st;]:tes 1IDm.m .a:1ill. areas Qftthe I!]jeck t1te n1!mJJber of sodes fowd r.,villill. be mV'e:l:SJe]ypr'QPomrnThaJI to 1!hei': size. .It lis. mlot ·lill!IlCommOilll. ~o :ind .sAN:6r :SJe\'ie:l'l.smd. 'I1!odles m 1!he s:l'])1i}m<IDdl!"bmillregrol1,Mol1tl1iisoodlfm1!g :aJJooe :SJfuoMilJdl. mJOrtt 1betil. c[1I,J!jJS!elDbr OOl'1ce:m_

9-· . Calc,i/'u:f11ion

Figm~4J5-

Calicifica60n as, a crite4ion.ofmal1ignancy._

lP'timc~e areas ofca:l!cmc~olJ!. {ma();cakmcailli!oo) m. <iIl]}'mp;:h. fiodle .sholililldJ .. iwmedlia:ltdy aIe;rt llierel!m()i]ogUSJt ~o llieposSJilhiillirfty Qf<ill meta!Sm~sfi:om. a ,pa,p&lllimy ,rnt[ciI'l!Dm'i§ll of ~e iliyro1id (lfigm:e 436llBrigfut echogemcill!eoks canbe m1ldie oint mmet~t[jl1tiic mlo.des:41 i:ompiilpiill!my cm:ciirnlmn<ilJ. of 1!fue: ilij'f!o~dl_ A diligetl!1t search oftlte Ithyroiidl for the primary .s:holililld.be ca:r:ried!.ont whooever Sl!l!&. aSJigll isseee, ]F-NAC of ~e ~h node

FrugIillfe 4~36- "'C;t;Oca1icillca1l:i!on (~whe.ad!s) in a rOWe,f a~cal! :I1!o·d!e_ The 51lelllOlJlastoi!d!~s ,Wl[·o,wed.

Thagno sis.:metastati'c papillary c;lf.cinoma_

Page 8:2

1 ,. C ,. ,. .-1' ),1'_1:

, uterpre,ting., 'nten;a; ~Ji,~l:liaUgn:ang'

Howsiholllilldi, weuse tl\tese"Vrulolillls.propoS!edi criwe:!.i[]j? No :smglle ,ori~erioo ills; ahSJomtd¥ s:pecmc $orberuigruty ,orm!allig:l1:Mcy,bl!JJt :shape, ;<ilbSiel1LOe afWhws., ireglllillm:- Of :s>picllJilated Ol!JJtl:mie, ooagmilla1t:iio~, Dr cystic aeeresis ;mddi1isorgalll!liSied :p;eripi1aal1 oo]om: ]]!ow pa~eJi11,a:rea:l!IJ cStl:Oflig SJigns ofmaThiglThMcy _ These ,SJigns ,sinolllilld.belill!Sied ,iiI:J;, s,WliIJillia1tron- if ,<11 node dliispFiilLYs ,s;e\'ier,a;] of ~eSie ,dlliijiliaderisfuics 1ih.elf'e is <ilL hli,gh,probahiil!ifty ofml!ililigll!ilIl!Cy_ 41: ,]Lymphomi:il,snowd, ;ru\va!]'s,be 'lhOlilllght of m ~e diifferen1tlt;rl, d~~.;g:IToSJ!s ifmudedl dlillTIl.liJJs,ellyfu}']Jo-eclU:oiic f]odeslil:lie detected.

Thebeal!JJty Ofl!lilltrMOl!l!l1!d is [he ease \vith, wmchlilllllErMol!l!l1!di-,gmded iFNA can beperl"om1edL Use llie cnt!erl)a, ~o ;se!lied ~e node lDol[Otipn:aoo:l1L Sm~eom !ffl<ilcY not be ,itmpr,esS!ed,'I)y ,illJj,mk<ilL&olilil'Ldlfepol'lt sl!J!gges1tIDg maJJiignOlllcy."blill!t 1ihey ""vii sirl:mpand I:rube l1!ofu!oe wlill:el'l! tlJieaoc.ompmymg smpporting <C)~o]ogy feport ,;nrives;l~ lI1i, om IDSl1!l!mtiOil'l, ilie 'Simg,eo:l1Js 'use iliemlr@Siowdrepoflud CJ1al!o:gYMdiings iimI, oom1bil'l!afu!mli when Si1tijJjgIDg the neck. If 'lhem1!:r;fiOlilil1!d feport,S;1!J!ggests malliglThmcybl!JJt the mAC ishefMiglTh, ~e !leek is :s1tiillll.l'egrn:d!ed. asposJiwe for :malligmlfi1cYill1d tre<l.D:e.1'J.tpill<ilml!ed.<il:OOOH_~_ i\::s m tlte illallagemw1t oflbl'e~t cances :!he cyl:o]ogyomdl!l!liftr<lllS!ol!W!d:fu1:d!lingsa:re .;I1!o1t viewed iiI:J;, isoFaEillI.blill!t m. oomhiinla1tiio!l1i_ U1fu;<iIiS!()l!liI1d]. m. oomJb.i!1!ation \\:rirl:l\i, lIFNA:C ~s now om: acoepted melhod fOl"stagmg the ned:: mp.i11tiiwts wruilisql!Jliilmol!l!S oe1ru card:l1!o:lJillJ[jJJ_. Ill!. Om:hMdJs Sel'LslmnJry ilsn~%,spec.Ecil:y 83%, and. ilie pO!~1tiveprernc:It;i~,e v,me ~s 86:%£0,1' lthe del:,ec1tiioo . .of mel:Oti1ta1tiic nodes H.olM S:~l!J!<m101!J!S oeltll cmcillrnnOlL 43

HowdoeswkaiSJom1id m. combilluoo. ",o1lth.lIFNAC oOllilpare "villi 1the otl1er .B:iilgmg mod1lllii1tie.s ?m. the amy ]&ge series44 1!h;jJ:1: ~<iIiS oompared. ;<rl] modOiilifuie.s - iI1!1lINilie1iYl!l!lJltriilt5ol!llilild (US), US-:gmdled iFNAC (USg lIFNA:C), NOOall:d. CT ·-l!l!l.Itt:r,iiIt50llillliJ:d ill> oom)JlJ,iiI1ia1tilloFl. Vlirl:h. iFNACp:fOVied ~ohe the most @ocIa1te 1tec1LnJjq;I'Te_Aoomacies .of 86'% (US), l()O% {USg lIFNAC1, 89% ,~CT)Md.8 8'% ,(JVllU) were ob1ta:med_. F<iI:I" more .sJi~c.ml!t, ~Qwevf.:r, ~s. :the aromacym necks wha,e !ITO nodes wer,ep.~~lMe (NOnecks)_ 1ms ~s t1\te gr.o1!IDp ,afp1!l1tl!.ents m wlli:om 1tl1e diel:ecEEOOJ oflylOOpb l!Thode mel:<iliSi1t@Sies .hilli5 .1iI. gre<il'lter m:rp<ld om mM~~enlLent_Aocm:~cy m1he NOgrollp m VIDJi den. HrekeF's sruczy W;OB 68'% (US)., 86% (lIJSg iFNAC), <661% (Cn ud. 75% (Nl[RJ[)_

]t is m '!:he assessesest of ~s: NO grolap tl\i:1l1if,~dlrO~o.g1i8ts: cru1.mat,e tlIDeg:re&~est .impact The fllimber ofp&1iioots who;rremder - 01" o\lier -,tl:eated \viillI. he ,~Sihed. if we caprovid!e !:he 51!1II:geo.n v,cri~ IDl!. arom:rue 'ltedm.ii~e EOf evam~g !:he neek.

The1}rmp,:ha1tl!cs of :!he fled:: .Sil1:olillil!d. flo]ONlgerpmw<1l. dOl:mlltm:gpm:spect fm M\ter<!l!dlio:]o.giis.t U1ha:soli:lil1d. rus flOW an eXioelillootrn<iligl1!osltic toot provided;ijJj :s~]emeiliodliicm. sy.s1teflil. is foJlliowed_ U smg tfue fllilllill . .:ange of cri1teri<il .. ;avda:b]e" dBe:renl:lialllionbetweel'l!.l'ea'C;~eMd momg:l1l!afIl: ~ymphadJem:opa1thy lis FlJOW poS:&lJ"b]e. lI1I OO:mbIDllEE.OO. v;rihl\!. ]F-NAC,mrltl'aSJomdl is. .<lIn. aoom:rue 'ltedmii~e Em ev:am1ll!::i!l1ig !:he neck,

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L Benn:m fiG, LYOMei: D, lIFmgetitlm1i R, Tl!J!ttJie RN_&egiooalbbod:low to the llympiThu fliode ~g :the lmmwe f,esp0'lThSie_ .. '4ymphO',logy l'~l7'6;. :9': lm.- 104_

.6 _ Byers ID.\1, W,eher]RS, .Mrnews T, McGillill D, KMe R,. WoW f_ lIFfeq;lIXency and. iliempel!J!mc .ilmplliC<1L1iiioms of .slcip mel:Oti1tlilSies'm ~e f1l!eckffi:ol1l1! SqL!illilIJilO1!J!S oelill ClttciiniOm~, of ilie .ora:li, t.o:I1!.g1!J!e_ Head ,& Neck: J<ID. :97: 14~t9_

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12 _ B.iWa~e.:ribm:g die JOllig RI" &O:l1!ge:ll iRJ, laflil:efl5 J8, Hrioom M" Ve:l,,"voe:rd COA,. Knegtt iP'_ ,Metastatk ~.eck, dliS!~e: .p[il]pa:1!J)on vsl!l!1!trooom1!d, ,~~atl!:l!oo_,An:h Oto.laryn;gol.Head,Ne.ckSurg 1989,~ 115: 689'-619'0_

l3 _ Evans IDVlI, Hodder S, f~anon DW, SiiJiv.es1ter KG_ l::JillThph flOdJ~ meEaiSEa5eS mpati'~1ts ,\"1,~'I:h, SqJ!l!<m1.QiUS .oe]], c§;![cm:om§[1lJtiill~1ty or us ;ru1;d US -,gmood_e l'leedlle <il!spira:tiion cy1tobgy_ Radiology 1'9'96; 2011: 4 U- (.A;bsw<iI!ct)_

14_ l';~~iiIl S, SO:l1e: S" Nomm:iiIlN, Tomiy1ll1Ji1ll N, K.obarf'~ T, 'N~<m1l!llli,OlJH_ NCMJ!p~MeD}'lOO:Pfu ~odes offl:te ,neck: assessaieae 'i,vru"ili US ::M!];d US gmd!edlllline needille~pir;;rt:Uoo,biiopsy_ J Cli:n Ul:truso,wul1997; 25: 283-29~~t

17,_ SOil!lJ.iaD, L "lIlizzatto oG" Be1illoID E et oL H:i.gfu-'resJOIDmI!iOFJi :slolITogr-¥ihy of oervmcaill. ]yflWPliiI mJiod!esm ]:];eadMdl ned::: CillToers.: Gri~eri;§rfOl[ dliIfferentm'liM, of rfli\l:Cw,e versU!sm~gJill!,jllilt nodes. ,lWdiology 1.9'88,;, 1,6i.9(iPr)~ ll3 (Abs,tr.ad)_.

18 _ TO:OO05l!J! N" Ol1odllll S" ISJo:l1!o K_ U1trooo![IJograpmc 'e'iri'm&Eron ofoerWca1i,1YmP:h node meEiiIi51tooes m ,eSiopillli<iligooJ! cmoer 'i,Vl!1t1\! speci<llilfd"er,enoeto the rrel!ationls:lNpbefivre~:lheshortto ]oo.~ .~ill:atiO (St1.)~d. fuIlliec~C!er oontrent J cu« Wtn:1S0u.oo 19'89.; I7: HH,-W6_

19r_ Ymg M, .4i1uji1il .4., Broo&!: F, iBrown. B, Me1tre'i,v,eTh] C. SOl1iograpruc appem-anoes ;<mdl rchmli'lI:lJruJon.af nbmID,d rOervrc:~. By-mph. nodesm C~eS!e poplililJa1ttoo_J f.llt:raso'und Mred 1996~ 15: 431--436_

2(lr_ MilIfrn;]]. 'G,. Oyenr R Ver.Sic:haJ.lm~l!en. I, Gelllin 1, .BijlertAI." S1!es.StelTh5 Re_ Sooog:lfaplli£cappern:oooes of:lil:orm;m!ll¥mPh nodes. J Ultrmo'lmil1l.leil1985.; 4: 4- [_ 7-41.9_.

21_ S,lJJfiO:l1llRT." Re<il!rling ~C, Cfum;ho1liea.1LJ! JW, James:lli\lJ[" Gral'Jt CS" .Hay ill _ llJl!tr,iiliSioudi ~d!ed1 biopsy oaf :Iliec:k miiil!Sses ffipaSlt ope:r;a.~e mmlilgem;.ent rof'pi$1tl!em1t5 wirlb :l:hj'1io~d Cillltoe:l:_lWdi,o.logy 1.r988; 1168:: 769'-771 .. _

2,e,) jFl' r'. Bra·· .;;I1_·1~~~ ·6·· N"" iC' jFl" . " . "if if . ",t\,~:E;' F'· . . fI" Tdl ~.. ". . ._t':: . .:;II;. . ".. .. -~I "11:~t: dlil" C' .;;II;: ",",,_ ,Jrrerm, .,'. ,[llUOJ!J!.l:l] .,. . l!SiI!. ~" Jrle:Jf1tl11l JL", lL1!mg."'.]I[', ,E&ss,on. Jr _ ,Il·· ,ffiI!illJ!J!C<EII.Dl!1:e erOgfdHC3l U!J!. <it[reaJ. tpereoo_ge:l1J<1Il oentr,<lI:Ie !;lie:!. l!I!.Il!I01li· _ j.::l eg:l'lo 'll!I!.

mMo<ll!di.eJ1l];opol:'titit berng:i1!olL .RadioTUed (Torino) 1:98-;.; 14: 535-538_

13 _ Rl!l!b<11t,elilli. L." frro~o E, SallJmJMO R Bolii:o]et;tto f'., C1lIl:dliiru1lii. F" JP'iierp<il!o]o C, SOflOg;r.a.p~ 'Of :owooonna:llllympfunooes m",_o: oo:rrd&1tl!on.ofSJooograprnc 111101. mstro]ogicaillfudlit!'l!gs_.AJR t9'90; IS15: :t24l-1244_

24 _ E¥mslR1VlI, .1UJil'lJj<il .. A" MeweweJ:ii C. The Jlffiem. echogeJ!Thic ~5m oe:r\."J!caJI. tymplhc<il!.d)f;1;1:Qpa1ihy -<ili.sign 'Or befLiiglllity or mAgnaiThcy? C[fn Radio:l t9~n.; 47: 261-264_.

25'_ V[iI[S;s;IDillof', Wre:rn;ecke K,Ro05 N"jp'elte:rs fK Merel1l'~oo rofhemgnffirom.magFl'rul[ sllrnperlicim 15<11!iIpifuJ<il:O:mop.aThfuy: &erole offutig]lfes.om,oo. US:_ RadioZogy 1992;, 183: 215-22{)i_

27. ill:smu. JlF~j:iiiE, Sl!mliI.ci R Slhm0'~[jI. K., Kai'io-viiIlSJe N,J:\maJgiiillS:3l TUt1trriillS01i1£c dlni:llgllliOsB o[o1[a::1J i1ll1d.1!iLecK. m"wg:l1l!1lIl!fl¥mPEtOMiiIl,!1yJZetin o/the, .'lo,kyQ Medical and .Dental Uni:l'Iersity 1992;, 3:.91: 63--6:9_.

28 _ .AiLuj!::iI.A, Ying- M,.Ymg \\IT, Ewms: R.M, King W, Metrewelli C_ The use of Siooo,graphy ill dfifferen'Eiamg oeEYic[1l:lJ i~homafo.l!l!S: fJ!odes:frol"n cervical .metil51t;;IDc:t~lh nodes. cs» .Rad~0'119·9'6; :51: 1 86r-1.9U_.

29_ l~j\ll]ii<l.A" Yrng M, Ev<ll'l!s iR1\ffi, :KiiNrg \Jl, Metr.ewe1li. C_ The ;ilpp]tcaDoFli ofmtr,[jliSioliJ!l1lcl0ri~erii<1llf;ormdglllimcy rn (lliJe:rel'l!1!ii$1ti!I1!g mbe:rcwoiJB!s cesvical mmtls. Ifom me1ta.s1tatic N!Mophru'}'n,geall oarci:n:omaL Clin .RndioI1995; 50: 3911-.395_

31_ 'fmmgton BS" &e<iJ:dii!:lg OC, Gh[iljfbonelil]]J 1VI_ CoblIlf [)lopp:]er US in the l1iedc dJrnJerrel'l!_mg l1ieopEatSl1ITc yom ;IlliOOi-neop]1ili5tJc ]}'lMp;had!enop~y_ R,adi;oZogy 1991; 181(1'): 177 (Ahstr.:a:d)_

32 _ Ol'meSJO!fge l K,oemg, H, Sd1iillI S, Woillf KJ _ Cobrn- coded ,cmpDexSJo:l1!ography ofpa1tl1:o:1ogiicaEly enllillgedJ i¥mP:h. nodes_ Radioi,ogy 199, L; IS:JrCiP'j: 17 7 (Abs1tmot)_

33 _ TSJcl]1illlIJ!llil)e:r .A, Ott G, Sc:hiM1[ 1', Seel!b<il:rn-rGo,ebeJJ B, ScliJJw~grer K, Hi1!:l!m. D _ L~pfuJa:d~opa'l:lhy:fierenttii~onaf1bemgnffiro!IiIiJJ maillJig:l1l!;mt d!1,SJe1ili5ecO'lomDoppllie:r US aSSJessmenl ofilltr<il.1!1od!alJ illl!gXo.an,cJ1Jj~ectm:e_.Radiol[)'gy 1'998,; 20:8:: 117-12-3_

34 _ GiOYaJgl]:orio F, G.illIEZiO R, Avi:Elto A_ ]E,llmwo1Ji. o,f-V.iiIlSJcmmp.1lfie:ms of oep,.-lrnlJ ~ph. EIiod.e.s ,rilthpower D1oPlpille:rSiooogra;pnl}'_. ,J Clin VltralSotlJ:ld 19'9'1.; 25: 71_:76_

35_ Ch;mg DB, Yr1LJ!<IDA, Yu. CI, bm. KT, K:ll!O' BS, Yang fC_ DifDeren'Eia1tiioo oafbeliliignmdi maThi"gN!<il1\Jt oerWciirlJ. "h fllodes Vli1tll. >Glob:}!!' Doppler ,S<OlilOglf1IDp]],Y_ AJR 1994.; J.62: :965~9\6R

36 _ Loo.aoilll M, Moretti. M" Am:JiI).otlt<ill hi, Bassi A!VI[" OJ! iCImrulliJo M,. Hmci~ollii C_DBeren'lla1IToFl! of beillgl!]j .Md!.m<i!ill:J!gIl!ili1!t :S:lQiperli)cia] llympl\J:ad!e1itopruful)':' v:ame ormgllreSiolliLwtiioo.powerDopp]er US_.Rad~o.logy 1996; 201(iPr)~ 125 (J\:bSitriil!N)_.

39'_ .Moritz JO',. Ludil;wg .AlG, Kiil'clol1f L, VoW:uciffl. 'f, OeSJ1tmiMm. J\¥ _ Contr.;Ol!S.t r~mooo. co]om Dopp]er1ill1'1t1f@Siorl!l!l1dJ m 1!fue ev;aJi1LJ!a1ti:on. ofremmged omlirnll ~ymp:h. nodes in lite@!d lad. l1ieck. NmOllltrS_ Radf,oZogy 19.98.; 20.9: 3 Ul.

4~1 Me1tlf,eweTii. C, . ..AJ1l!J!j:iiIl A_ \¥.orrkmpmgress: 3D rc:oIom: :pow,e:r ~gio, does irl:hrili\f\e <iI. potem11ti!;dyuSle:full.wtem .~rmphr[jJ)d!erJ:Qp1l11by? Et.tr,J [litruso'wu} 1998;S;~1k Sl'6-1.7 (Abs.tract)_

4-1_AiLuj!<ilA, CJwow L, Mok CO, KiiI1ig W, Me1tlfe~vreilii. C. Mrerta:s1t&1tlc cervical lymph nodes m.p<itpiJary c<llcmomOl!. of the ~j'1fo1idJ;JillI1'ttr:,iiIlSom1!d;mdl rus;1tO:£,Ocgirn'l COfid!WO:l1!" ClinRadiol 1995; SU(JP'); 391-395_

42_ Eeaas IDVlI"AJ\iuji<ili.A" Rful)'s WiiiaJiFlls: S" WaldrOH. C" VruiJI HatsSle1~ 'CA., KiiI1g W,MG~re L_ Ul!w.iiIlSJowd IMd1!l1l1tr.&5'(lrmQi.gJIEidiediillMe .FIeedille ;1lliSiprr.UOFJi ill oa:v:ic<1l:ll. ~l\J:~.dJeElOp1}tlhy_ Br J.Radio.l i '991.; ;6,4~)::m (Albstr;ac1t)_

43 _ Hoddier' SC, E"r;am; K1vK"]I[l:i§:t:!tooDW,, Siilives~er Ke_. frrm,peoltWe smdy of the 'use ofilll1k<n!Simmd (m. com!bin&tXO:I1. ,."vitlThFme Needllie ASip1raHruJi Cyldogy) ill the. s.tjjjjgmg of Neck Lymph Nodesm (h;]] S~ilI1IiliOllS Celli! ,Qrrdnoma. British Journal of Oral and jliaxillofacial Surgery r(1np!\es:s)_

44- _ Van den B:lieb:l!. ~, Cas1!eillijim. lA, S~elJH'V,. r(j,()i]dlIiFI!g RJlr, Meyer CNl.." Snow HE. Mod!e:rn:J! IDTh<iliglng ~edm,jiql!illes: <IDdm1l1:<ilSiOrlmdgrni.d!ed. as;piir.a.1!ion cy:td]ogyiIDorr ~e assessmeet of fleck node metastiillSes;: a.proSipocweoomparmwe smdy _ EurAr:ch Ot:olaryngoI1993; 250: 11-17_

Page K5

:5-.

Lumps, and. Jlum.ps Inthe Head and. Neck

1\lbs;s es iim. the Sl[bmem.td R.e;giom. l\II,3.s.s,es. iim. HIe Su:bm.a:D!di!blll~a:F Region J\!Ias,s es iin tile Parotid Reglon

J\!bs,s,es. along tJle ,Camud Artery and Io'tema1. Jngn~ar Ve:iin. l\Iia,s,s,es irnt.he Posterior Triang~e

l\/[is,ceUaneons. N ecll:: l\/las,s.es;

PageS]

Most ~ex1tbooks dJiSJollills;sd. ]esiioos of 1he fleck in! te:l'ms of ili:eiill illlreqHeflcy ,bl.!l!t 1tlhills rn~lte:[ taibes3l dliilie:llel!'lt OOl!][SJe ill dieSlCfllbmg ]eslnns acoordliil1JJg ~o tlTeiJr :SJ!1te 1(JIF~g:me :;: _l}.As d!eSirnbed. ill OThuap1te:r 1, .s,OF1ogr~;hy of the neckshomd.he c&miedl ont syslte:matic~,s.tOl:l.i:ffig ill ilieS!l!J!bmen1tallreg:ron. ;<mal &ew:JJ ;pmoeedi!rJJg to the dliIfferentregio:llliS of ilie l1:ernm seql.!l!oo1tii::rl ord!er_ ThiiSPfotoOO] is Wponiilflt because ~t ,ensmes ~1ilt ;;dI. the neokreg;Uoos are slC1illfied. :rnetic1!lffiolillsliymd. ilie chMoe ofmI!1issmg a. ~esio:l1! is ~SiedLMsiO" as most l~siio:l1!s in! 1the neckare 'SJ!1te 'specEc, ilici:rprede1te:mi!Med. tloca1tion. m 1!1ue neck,. IQomlhiilled ,V1ilLh.lill1b:<iliSJol!Jil1d!.tlll:dJ lc:1iirncm.fuldlillgs,prowdes a cfu:e 1t0 1thedi!ag:noo,SJ!s_.

We \viiIl!. ili:e:refore start wihl1. fes&oos m ilie :sl.!l!bme:n1JJ1t;<irl!.1itIfeiillandprooeoo ~o dlmmss ]esiicmsm 1the othe:r.pms of ilie l1:ern, Joilll!mvmg 1theSlc~g fOn_e sl!J!gges1ted. e[1f'liter _

J\ibs;ses, iin the Sl[bme:nll:d :R.e;gion.,

Met[jllS;1t~tic nodes at 1t1hillssiittem:e oo'l1tlm!omJI}'D:om caacers of tlTe trn1!gu;re,ru11terior or,aJj C1fuW1ty ,Ioof of ilie mOlill!I:h, llipMd ,1lI'Iltmm gIDgW:aJ_ HOWeVieJf, one IDl!J!St :I101te ilia:1tm areas \vne:re :I1JMop;haryngea]. carcmomrnt (NJPC) is 'endeJ!:lil:1!c,me1tMtlltic 111:0005 m '!he sl.!l!bmel!'l1t~. ,[It[e§LID§Lybe the orn¥ ,ome as to the pr'eS1e:l1!oe ofili:eprimiilf}'_ The slillilbmm1ta][,egroom[i[rymo he 1tl1e ruhl~SJ!~e ohocl!l!fflel1oem NJPep.:n[el11ts. \V}]01\uac'i,iiebeel1J)reV£DnsJ.~ ltIr'ea1tedi 'i;wth r~d&o1ili:e:Jf.apy _2

Su1bmenlal regllorl lymph flodl1ls 'Ral1lLlla

Congenit!lll c,,~ti() !Ieslo:ns: da~mlJ;ld, epidE!t!ii'lOid

ri':amtld rl!gh;1I1!

lLa®lorui Im';ollling .he parolld gn;lnd {$~e Cll:ap1e~ 2)

Ib,;!s~o!l<s oiJ!tsida ~he ,~i!ilnd; _

.. First bf:JJruch;I~1 ele~te:yst .' F'rifj"a:u,riGlIlar ~inus

.. H<i~man9iom"

.. M<I$(;ater rn~scle liIypertrophli

Carotidl spaDe

Lymph tlQdfli!l, Paraganglioma N~m'Q ~11~ .. ~h tl.!m(Nj~

Ilmemlll jlJgllJlslf'oroi n iituDnlOOl;;if;,

SUlcliliellrld·lltu.i!I!lr rl!gicn

Le5!OnS in~O!ving the sl:Jbm;JJndi!}1Jlar gl<1l'id t$~~Ch~p!l\!r :1i}

lssiuns {)U1Sid~ thE! SllbmOilfidibl.!lOif gland: .~ Lympn nedea

• Ail>$eess, telllJli~is t Lipl:lm<l

'. Congfilli~al qyslic I~~ion$: -S!01cond branCh'IElI ~8'1't C't'sl

-L~mpharnfllot1fil<l5

~lhyrcigl{];r,sal duet Cij!1i1

PO:Merllar triSl!ii!g)~e

L~iITlph noo!},.\'; L~mph"fl!giol1!1i;;ll,~~s;tiCi h~'£I'rom!l! l"aJ~m<l_l'lgl~I"ia

lipoma

NelVe sl'tealt~lllmOlJlr Third IiJr~nChil1l cl~ft cygt

MillioCelianeOU9

Thymiclparathyroid C'l.'S,1 Bow~1 loops and .mE!$!9fi~ery lllryrngoolllle

Figwe5J-· CotJ1fnonmas sesin the neci::_

Page 88

1 Simple mrmla. Thslis the .lTIilOeSJ~ CO!l1ILl1llliOFlJFO!lNl! 'iilfl:cl.imr.ariabllymv'O:~e.s 'ihesl!J!bMlgll'[i[] g]1iIftd_. It[e:l:M:~ m.ilhe--Elbor em !!he mOlBJ"tth .. i1hoV'e !!he ]e~d of tl\te my]onycidL It iis .<llOe cYe5>1t, 'i,Wlli .. <ID epiilieiorl!. fuling_.

Ulltrasou:od Appe:uances

A sfm,pi]e 'fIDlJma ~s ernm<lLct!eris,tic<rll.o/aiJmiill!oomar, wee1ru.~d!cliined. cys1ti:c ~esioFlJm ilhe s;['I!bmen1b<lll~ sllJ!bllingJ!]a:lI'~pace (Iiigm;e 5_2) ;E1t m1iBJY oonttamme m~e:m<icll eec'hoeS,ElI]!~y de1b:ris_

FigIllIe 52-'

Traasvess e" s ~n~gmlJl ·of,a ~y:;frfc oolillecirion. (auoews) ~eskiiC'ii:edi.ilo· thes1!lb11ngI!l!al! sp<a'Ce_ ne ,appearances are llio·s:e .~f.a rnnThll1a .. These .are Iypi.6ill!y otImidlli.U€l

I:t1IJ position" but llllay ec.1tendi fir!:,oe the ll1idtine-:..

F~gillIe, 5..3-·

T •. ;ms.verse s,onog)l"atll.ofllie 51!lbmomd11t1l!i:1iar s}JI1l!De sho.v.ring a hete!'Oge1'l:eol!JJs !Collection (1!a:r:ge .aMlll'WS)_ N~te ijts !"e'lati:onsfuip te the 8:lillilJ.matulliifuwar g]aI1id! (oFe.n .<ID1il'W5) and!. ~t:s. ·exi:e,nsion 1nt~ fue s'I!J!bbgl!llal! spa:ce (smaill.an<Jw5)_ The, .appearnnces are typ.ic:a]. ofa.di"'!iFingf.an1!tla ..

1 .Epidermoid ,or ,epidermal cyst. Ihiis is iliedermordmoSi1t OOm1!il;lomy fo:wd ill the .lTI:ead ood FlJedc It iis sl!l!I'f!C)mtdiedl by ,afID·mlillls cE1!psl1lilielll1!d .l1:<l!Su. eep1jilielliia] llim1Ig_ ]1t does fJio1t GOEL~ .: sm. appefJ!d!<ilgies:_

Ullt\ra.sou:nd.. Appea:ra:lIJces.

Am'!!. ,epidermoid is 'HSl!J!aliliy welll. defiooecla:1!"lhol!J!gfu. cYS<ECC, it ,e:dwbits<:l!.pSJel!illob-£oJ:rdJtl!pperu;1ll1oe ruJililillt:r&SJ0l.!mdl '\wth.I!llI1&EOUlJi. m1be:m:m11 eehoes (iIF~gJlille :5 _ 4)_ m

. "., " , .

oongernt~. cysts. Elms appear<IDoe. is tlto1!]gllt ~obe. cooSiedlby oel!fuillar .m<ilteri:~11 Wtlltrnn tl\te cy;s1L3'

F~gu;:e 5. .. 4-

Tr.ms¥erse s.t"lnt"l.gratl1.sl]o.\ving a pse~d!.o~s,01id! appearance ·a·fan epid!em;to!id! cyst (Macl: an-o,ws).

Iij·o1i:e lli.e houmge.nreooillJs m1Dem>aJJ .aI!.cl1itetC1h!1re, s;lLlJgges.t:ing a s,oIicli. oons~s1tet:lcy .. HeWfNef the ]Jo.s:'l:ea:of<e!mJiaHCef.Ile,nt il;! a Ciltille "IDo, llie cystic l1!allire·Mili.e fesfan (irrIOrws:).

De:rrmoilldls futilL~e med .. ilIID1tefil!<rl. ernoes: becaese ,ei :lheiE'iilit contel1t (JF'iglMe :5.5) <IDOl m,iIJY,show :lhepres;ffioe of oSSJeo,-dentiitli :s:oocwes wi~,. seen .. as fjcl1;ogemc foci 'iNiiili. doosesh<il!d!o'i,vmg_

Flgm:re 55-·

Transverse s enogrIDJl ·aria lrud!lllle" s;lffDmen1taJ! cy.s.tI!c; mass "villi fuJet.emgene,olmJs inil:.en1ia:J! ~l1oe·si (ano,¥.;:.)_ The Fo·cation .and! lLIiItras,o'Wldi appearances. suggest ,a dJenno·idl.

Thew]e of11liltr.1lIsomd as Ute iru;m)a]. itlwes!fu!g.&llioo of cl1o~oe m ;ev.IDIm.r<:l:Mg tlllie sl!Jib:lllMd'illbuillm: gl!tmd its wei!l. est1l!bTh!sJh:ed ~a The SOflOmOglls;tt mMsttbe .irlerl: ~o lihe EEad ~[ilt1ilLpedum;o1liJla1t,ed.m1fuS.s:arismg :i'om.lihe apex. of thes,upemci&l. ~Oibe IQf ~ep.::uo'dglimdma¥ ,encmach on the sliJ!1bmam:rnlH!lillotr space rulld.be wst*en, fm <iIlsmJ!1bmudrub1!I!llm m~s_ Tl1he £esion. ~s flollf,eoogrnSJed a!5p1llfo~d imI.oogfu !by ·bo1iill. :lhec:illimd<iLlil. <llllid the ·SiOm:Omogis.t <iIlsmJ!1bmiil1Il!rnb1!I!llm11p'],~H·01il!d!l \viillI.bemOl!de ~o ;thispru:otid lesmOlTh., resmm.g lin. poors;m-gic~ cOO!llrO;] of ilie :f&cialJ nerve. 9

Most mdlMJdJrn<icl!s: 1h![iJ)¥e demoflSitr~iiliMeflo.dJesm ~es;lill!1bm1ilLl1!dlJj1bl!l!l!<itf area. MijJilli~1!<iillJtt flodJes ,iilill 'I:lhJjs5i~e are 00lillmrn1l1Y~ ~1]om[iJ)III,.ll. iand metiZliS1ta:1tl!c lWod!es. from JC<J1!];oers of tlliie :ltoogJ:ille, M1llimo>[ orm. C1iILvruEy, ]]Jom ofiliemollttllil!,. 'lip Did. ;[lfilliertO!fgil1!g:ivaL l!m oITen1taJis,. ,emargedm1!!l:.api<Hottidi1!il:ml!es iaJill:d.1!iI:odesm 1ili1e :s;l!J!1bmmdl!!bll!lJm-r'egtOll!, ~. or. \vilholili1t :S~;ill)'gll[jJ;l1d.mMSies, ~S:hDMilld. ;[]]j5:I:iII lillte SI01'lOFOgiSI ~o the pOS'SJ!biillit}, ofKimm:1iIL';G diSie<fuSie_12

hli.llhe .M:l1tIibrD~c ,era!,1i:11:e mcid!efioe of oe:rvtca:ll<i1!bSioess iornd oe!llfu1littis is~O\v _ It is oommo!l1l~r seen imJpoSitoper~epa;illjen1ts,dI:rn!gl!l!SierS ,Md ~mThoo011l1pIDwSied.p<l1tief:lJts_ AbSioes.'s ud.oel!lmilliJ1t!Ls. lin the s:1!l!1hmadl!!bw<M<li:I',e<][ IQrigm:alte :Kom S:ll]J'ftlil:l[ative§!dmopatlThy, s;~ru:y gliMd. i1mElc'lWoo, d!oo1t<rl .1il:h50eSS mm,iIWHJl!1)l!l!l!<itf osllieomydli1tlls, or;Eo]JJowmgrarn.o&er1il!p)' ~o ilieMe[iIL

iIi"!'" '. '.". . '.. . .' "..... .;i_·l~:_"11... 11.. .' d ." . .. _:111· -':~ " . .~- dl..;;i':"' ··"d ~,. '. 1~ • .. of' 11..

Jrflor ®OMp1!If<llEuOO. OJ[ smg~ lt ss lIm]JortMt ~O 'IlliOmle1illie ime il1llJ1SiOeSS ,M . ~hru1iOl.1tOml!.ctli!. fCJJotEl!OnS_ l!:EI. :§!rnilt:i!m:I., one eM. r .. OOI!l!J._r oompm:C<ilEuooS '. I i~l 1iIJlJ.SiCie:SS

Sl!l!cli. as ,tilL VIOOOl!l!S ilirrombosiis er <C<itlfo~d ~oJ]y,e:Illent The

Page 9~}

Figu:re, 5 .. 6.-·

Tlrlms.veJ!'se S,~l1;~grat11.ofllie submaadibl!i:tar r'eglion sho,willga o~'bb]es.tone :l'etlcu1!atedJ .ap:I=te.arance_ The appe.afal'loe.s. are typilca]. I'lfce1I1ll1Jjfr:is" c~tJ:lIDomy pos.t mdIollier.apy_

,,:t\n ribsoess~sSiee:l1li as <ill il.-deffinedl.neglllillM ,oo:lillec1tiion \vil:lfuJ iliiJck. wallo illThdi..m!itenTh[]]. debris (iFigIllire 5_7). ~tlill1l:iaJybemMillocw<ilJf orm1!1ill1tiillocill1iM,. \.w1:h oedj.eJi]Jj<l!. ofadjl<il:oentsoft DlS!5l.!J:eS_ Th.ere is ]O.SiS olfthe fliltS>d~.p]_esEiU1:d tllepreSieflOe of adj<ll!000t iml!i!illIDl!l1tOry ~od!es_ The ·rinI. of tlleoihs.oess mill!;Y demoostrl1~e fu}']J~c1!I!l!mty on. w]o,.low _iiIlgmg_

Thed:Berenti[]]. rn;wgflosiis l!]lIiUl!St :<dl,vays .mcm.dlea neerctic maillDglThElilliJ.l1: node wirth. ~er<ldJd!ed. gecll1oil1!_ SlITdJi.lwod!esaillSiO' fuacve ~ck,negH!liM wdls r"..vi'lfu m~e:m.iOl!lI. debris;[llllid m,jJJ}'s1];o\.v a~ ofv2I!sc.m11ri1ty_ j1frm:e-neeclllie~ir<il!1tiion (FN.4C) 'i,viMI.d1iswgllis.hbetwBel1! the ~WO_

l~o!lil1lJEiIiS :1[[ebemrg:l'l 'ffictlipsmillac~ed ]es.iio~ wfuilldJi<il:1"e ~1CaillIY S'J!]lbCll!lJ1i:MeoU]!s6r :SllJibmlffOo.sa1i ill ]OCiiltroo_ They ~elllidl fio dlli~m<l!oe .r:iiI!1tIler iliiiillJ. imhliEr:[ll1te1ildij[jJ;oeril: sttnITo1tJ!ltl':es_ AhcJI::lJI l3% of ailllI.EipOrINars ocem iin.1tfle be:a:d,;IDdi nedk:_ m fer:lllalJes 1theYMeltyp,iic~ ]ocatedl :§!di]!11000t ~o tlJ:e dar vide,. where<IDS m men flllieyru:e m(}C.a1ted in l!hepO!s~eriof mruliglJe_ Imiilk.aMg ]ipom<IDS <it[IE!fiiU",em .e .!Ilea:dru<dl neck jIfIolillo'i,\iI1g 5imgefj!the. ~eOl!l!li]f'ffiC!e[[a.~'e r<smgh (:5QI%}proh;]llb]y oiu:e to ~croSJC!Opiic .iIlifilliEr.&jjj)o:l1!. of adj~oentSirn1t.1ti:S:S1IITes_. Themecllliff'ffioer.a1tef.ormltr..atlmgllipomEiliS .rus even llii.glliJer- 62-_5%_13

F~gIi1iI',ejJ-

Traasverse sonog:l'a:m showing.an ilI-lllleffu:edl" :fu!e'i:.em g.~ejolillJs col!ledi!~n( ~p e,n :aM'O'ws.) .omteno!f ~o' ilie OO!I'Jl1:l10n IC<l:FOfuidJ .: anBD' (small! an,o·w)omdi. the il1.r~ema]j:lillJglliJar v·ein (1!arge: aMffi',v)_ The:" :ap;pe.ar.a:n'Oe!;i are ili~,s e ,of:m abscess,

Ulltrasolmd Appea:r3:D!CeS

. ,. 11~~ .~... •. II!:- .' .• ",1\, ·~11 . ,,1L_._.~ . . . d'I'lL

,~ COFEit[i!illlj]. l!liI]ear ec]~ogem:c m~es @1t flJ§:I:.t :1illiIyes to IlKl!ell.l!LiltratS!()1lliIiI!· .ue<llm

Page 91

FigI!1Ie .5.:8:-

T.,;m~.vers,e S'~f!l:Og'a:rJl ~f:a we11Ldefin.eGill.111ass (lIorrge mr,o'ws) 'Willi.lIn.ear sb:eaks piarm:ueJ.ll~' the .skin smil!ce (sm;rl] ,anows)_ The ap]J'e:a!anees ;a.e ilil'l'5,e ora lip ema,

Of ,&1iI!. ilie br['1mcm<Il!. deft:m:om~es, 95'% MSie Hom ~erenmlmts: of ~es:ooondJ 1h1f<mcm1rl. app<llalffis_ The most GOl1IiliIIIJiOnEOmJi. of trns ]es:iioo isa ,cy,sti!c m~s -wifuO'ut <il!. sMUS: Dr DS:~ 1iI:1t ~e .&IJig]e 'of&e 'mmdlli]b:]e_ 9 Seoood. BCCs@jf,e mm'e COlwu01iJi.m ,oMd['eJ1J ;1mdl yOlilll1lg adhillillts:_ !:l)5" 9'7'% afBOC lllilli!IJig.s. contam ]lymphoid tiissm:e ~ei~e:1' ~odMillar O1r dillffirnSie) wl1ic:fu CiYI. fuype:lJlt:l:Q]J~ry d:m:lll1!g ;<m. iliniecltroilll;. Bees therefore oien. 'preSielilt Joilll!owmg ;~IDipper respia1tory WilliC1! mecfu!rn:JJ_ Uii The site of ~e BOC rus: em)"b1}'()~ogJicallly dcli:fiedm tlThepo\stmorSJl!li1bmmdli!lblil!l.iM!l:egllO!l1! at :!he ill'J!g]e of '!he mmdt!lb~e_ Typicallly ,<ill. second Bee rus: moc~1ted. :slIIDpe:IDoia'lto;!he aOm:lilloo CID'"oflldl mery (eCA) ;&Il:d m1De1ll<ill.jMgmm:¥em ,tJrl)"POSitteriO[ lto fulThe cSilill!1bmal1idID"bl!illll[M g]and ;~d ,ill!ol1!g;!hem.edlii~.@J]];dl u1tenormargID, of!llJe s~e:mode:J!dJom~tood ffluSJcille, c.'Ogmorrly near :!he IeVie] of !llJe<IDglle of 1iIwemudlIilbTe_ A :sJepol1!(llHCC .mi:illj' 'Oc!C~oflal!l.~r be associsted '!,m a.sil1iUiS mnlstnilla: :lhiil:I opens mIn tl1:e ~rn1!siJl1iIII:]OSs:1JJ_ The furad deSioenm ;1rl)Ol'l!g, ~ean1terio1: bonl!e:r of ilhe cSit'ernodcid!OO!lI!1liS!~oidl.m][lsde~d may open. on ilto ilhe .skiiI1!. smiaoe1l1lj'\vllere .~OI1!g 1tlhiispmfu_

UniJ1fect;edbn:mchial ~t8, M~$t of ~ebr<IDd1iirn:ll. cysts ·.djemQl!1];s1tr.a1te ~e ~typiic[1l]. appe<il'l:"aIloes of~ C)'SiE m 1iha1t ~eyare w,elill dclIDed! IDldMerno~c wi!tl'ID no m~em11il. debris ;:mds&.DWPOSlf.1JJQ! ,oo!h<ilFl.Ce:llloo1t (]F'~gJ!l!li,e :5 _9) _l"T"m Hmv,~er., :SIOMe cysiltsm;jlY ,exill'ili1t .. ~. :PSlelilld!o-wTh1dl<itppenmDe. ,.vith.worn1l mt'e1ll<ii!l 'e!='Thioes (JFigJlltlfe 5._H:l')_ Ths ~S J):[()ih1Ib]y dilille ~o tflep®eSie1lliOe of vmaMe q[UillOlflnties ofm1!l!cllI!s, cl1:oilles.1tero] cryst&1is, debris, ]ympl1ocytes.[UJ)d. epJ!tlJJ~ oel!ms ",~.{I1e CySit 5:.)8;

Flgw:e),9-

L~f!l:yrud1:ll!aJ:. S'~!I1l'lgr,ll:I'l1 OIaI1Ilill!I1:infe,c:1i:ed!., :p:I"ed!~ll"Ii:I1!al1.rl:J!y ,ali1ecfu~f.c m.llI1c:liMiaJi. cy.s:!: 'iYiilli 1l:llm!. w,aIl!~i,""iThpos,te:li~.eiIDanoement F,atl!tift .in~emaJ]. diebris ,andLaf!l:tenof il"eye~fbe!atton .a;rt·e$ae1l al'e s,ee.n .... iilii:n llie cyst, No,te ~ts li'E!]atlonsrnp to lli.e ie;;lJ!"o,fu!di artel)~ (blacl:::.an.o,w).

F~gId1'e 5JO-

Tsansveese :'l®n~'gm"l ,~fa blrmcJl!l\a].cys:!: sho,v;.ing ,a. ps f:!llilld!e-sioilJjdl. appearnnce (iIJ]adan~ws), .a:11.r1:e!i!~. flo' ilie ~fujd!. ~!C.ati~n (wl1lte ,anID'ws)" 0':111 cOIl1:P:I"f,s,si~n :'l'i'it~g-'e>c:hoe5; wdli be, se'.en '",,-jri:lhin the ,c:yst_

Infected braJ'vchia{ :cysts, TheS'e 'Cys1tsn'el.!]Jslill!~ ill. d!dmed. i1ll1d li:hl.ck wa1ll!ed!; 1ii1:ey oonta.. iin~en1!a1J debrismd. :s>ep1ta. (lFigJ!iltlf,e :5.11). 'n:eapipenuoes are seeondasy to ;['epe&t,edi wedron . .of lh;i!l:enilOffhiilge. The Slo:l1!oiogist m1!J!st be [j[I\.VMe OK !!he fad 1illi!at c:ys1mlcme1tal£1t§!S!es ]fom '<1I!.p<lIpil[M}' carcWtO:lll<1l!.m:ay fuoi1t'iiie<1l! '~ru::appeM'Moe.19 A d!e:ltdoo. ,exammaru:on OK t1\te 1i:hyr.ordM.dl iFNA of:!he c~rstic ~es]oo must iliterefore beperl"ornaed..

F:igI!I:re 5.H-

T:I"a:I1I1SVel"S e S01U'I grana 'OE an inlfec'ted. ru.ru:lcma:Ji ,cyst ·\vith. tb!ck w.alJ!s (open a:I":I""Ow) and! mrrrem,a:1! cleJJ.risi. Note llie position (]Ifllie cyst in dose P!I";ooointity ~o the. carotid. artery" (arrID'w).

In "!he ease .of brMd1iia1i cysts, :!he oPeEa~or .millstbe<ilware !!hart fueymilLY hJ&\'ie c:rr:mallpru:,a:p~<iIfj"N!g;e<iLll (bmveef:l carollid.ma}'a:I1!dI. b~er,~. phOli}"N!g;eirlw,d) ,ex~ens.iol'ls 'i,vmc!hmary no1t ,o&,va,ysbe deprc1tedl .onlllillltriiliSiol.!11!1:d . .A. CT .or ~. scm. ~s theH~fore ir:t~c[lI1ted. m cases where the ex:lten1t 0'£ 1t1h:e illes]on CalIDo1t be rudlffi~edby1illillltr_olil!l'ldl.

Lymp.hatiic l\ii3.l'ol'.mamons

Lympiha,trc maili:IDor:matiO:l1!SMe oongeniltallrn:1bnormaThi1ties thataris.e ... vhen.d!.e\'ielbpmg lYmP~atics ;fflill to est§lJb.lID~. oomm~rntion 'i,,,-rim de\'iel!ofJmg ·Viems.1,ll1,:;n They eanbe dillviid.ed rn1to 'Ihr'ee types;:

Thegr,e;a1test ~)'mphll1tic devdopme1'l!U: oecars eiIf]y m. dJiil!difu:ood,. ilie w<1I!ffioriry of the.se ]esiol'llspr,ese1'l!1t: m.pllfuie1'l!uslmdier ThVO y'eafS orage. Sollitilry' cySJ1tic fuygrom<il5milLY beseen m )'ooog1ld1!J!]tsm "!he sllJb.momdlr1JmMregiooMd ~epos1te;rior mugl!e.Et rusbeill1e'\!ied iliart ilieS!eMelJ!s,millypost-u<lIllmllTIcrailia 'lhoo cOl1lgeniJ1t1lill. m OIl.gill.16

Luge cystic bygromas d'e ilie 'ftypemOist OOlJilLmiooilly seea; the :r'eJilJ.lamdier of 1!he ·WStOlJ!SslOn 'i:herd"Ol:,elDoclJ!Sles on. tl].e d_cirl.rudeshl.1Iiom omd.lll11kaoomH:m. '<lLppearru:J.oes, of cystic hygmm1il. 50-6;QiIDlopreSlefi1tiiltbm,ruloilier 3()i%]J1fes,ffioogby 2 years .of age. 1:); ~. 'ruJJ. B1ll'I1t "!hey are OOl!2lJilEOWy bC1l1ted. m tfue posterior .triaRgJ.:ernnd. the oe:I.'YTooilhoiJ[aJctc jm1:o1tioo, 'i,vhereas madl:I!l.~s th.eym:e seea m ilie ~s;lillhmen1tiilill~ :sl!l!hm<mdh!Jb."I:lill<1lIl"' and. parotid spaoe. TheypreSten1t IcilliimcillJ.~' .&Sp~ess oompres;s'l!lb:le ·fflai5SesMdi,whe.l1!. slilifficiellfl:i¥ ~Mge, 1t:rr:[ll~611te. iFolillo,,"vmg ll:ll.e:lJ1lion:l1:age, howe\iler, "!hey 'CilllJbeoomerigidl Sl!l:dJdl.em!ly iincrearngm~e1tD oompress, &dii~oent stnmorures aI1!d C<il1!J!Siepm <mdf1lci<illl.pM.rdiySJiS.liIS

Thepmm:y ro:]e of&agmg ~s ~o demo:lls.tra1te 1t1h:eMa1toDc ex1tefil1t of 1t1h:e ~ygromOlJbefore ~s;l!l!I:"gery. Tills is eaJsf.er sl§iid. than dO<ll!e,<iIiS, cys1tiic Jhygrom1IDSru:e trusspmiJa:lI (m:vommgmore 1thu . .ol'l:eanalto~c<icl!. space) IDJ:d!. im.mll![lIlte 1illi!eJiJilIS!e!]viesbe~v'een. ~e .major nel.!][O¥iiliSiomm:snotrm:'es .m. ~e .fleck. iPncdar .afioo1tion lOO1!J!sll bepiilic]i to "!he ilIDerior exteetas llOI%m1mj' exltend. .mlto :!he merniil!S:1t1~lfllillIJjjJL 12 A1i1hougDmU<ili5ol!IDdl C1ID. mne ilie IDiiffiE<illI. m<il!gI1os.l!s of cys1ti\c [hygr.oIDa" CT .or ~. w~gmg is aeeessary to map ~e :milllJ ed.ent of I<itI'ge ]es.iio:lls.

UninJect,ed lesion» are seen as ~mw1tipJe, oompr,esSlJo]e cysts ofv:a:rymg sizes wrirl:h. ~. wiIl!lsa:m:di. m1te:l'\'l~gseptlih (Figm:,es .5 .12, 5. U) wrnch ~'tr<llu'e behv1e.en <mdarol!IDd neMOivmc1!J!lions1t:rn:crures. ,,4J~DUgfu 1tfuey IID1iI:y be Dru:gem.me "!hey do. aot causeasass effeo1t orrnspboeFlill:eFI1t of.iiI:.dj,aoent :sooorures. lliw rnc1t,<iI!dljlaoenll ml!]sdes .md\'iessds C<l1!J!&e OO.d!E1ThtaMOO!S on. tl1e h~gromBl.

F~gme5J2-

Traasvease SOfiO'gI"alJ1 of:a cystic hygromasho'''v-il1!_g millruiple cysti:c sp;aoes =.01 s,ep,ta.,N-orte irl:s:~erat:iol1ls:hip to, the COfi1lTIon C.!llD,fu:d!, art,e.q (~'Ill'W)_

:m inJe,ct:ed ,or J-taemtNrhagic ltls.iom the cy.SJt w~ :Me megmm, ,oo~11iaID mte:rn.laJj, debris" me ,moomp'lfeSS1!1)]e :1IDd~c a. soTh)dI. ]esroo_ They ID1'§cYPlfodJrnoe :<iI! miil!5s.weGt<m,d[ com]J!lfes.s ilie tr@dleiili, C<ll1lJ!smg r,espw:<iI:l:ory ,dliSJ1tr'ess_ 23

A 1thyro_g1,o.ssa11 ,rnrot cyst isa ODl1Igeflita]MQm~r,e]<iL1!ed !to. ltfue tliJ.I}'fogl!oss.aiI,rnrot,Et lis thought ~orepreS;eliI1tSie_g:l11l!e,f11t5 of 1!he ,dbm:ct ilia!: fd ~ofJegl'es.smdl. 'cooiSie~en"l:1~' ,cliHer'enttnOl1te mlto 'epiilhelJii<i!!ll-illIDoo 'Cystcs".di4 de\'iel!()pmg <myv;;rher,e ,<l1Jong the course of :ihecMc1tr'enm<ll:l1it ZS: The :Illt:l!ji()n1ty memel!altoo, ~D tThLe hyo~d. ~hooe_ ,A1bol!l!1t :25-65'% oocm ~, ilie m,m}~ord neck, 15-501% OOOM[iJ!1: tl1e~e\!ie1J of ilie hyoid. :;md 2{)f.-2 :S%[l!fe S1IDp1fMlyoidJ lin ]()Q;luIOO, ,encroa.cM:l!g1!:lp00J '!be sl!J!bment.aJJregrofi_. mes ooomrmg above tlJ:e iliyroid. cru:1!iillarge arel!J!Sil!llid.Iyrnii!~e wlmiereas,tliOcS!eat :!he .~e\!ieJI. of;jhe ClitI1iibgem:,e oEfwcline_

lP'a:ltiie1lli1ts.1IJ!S!l!illd~pres;el1I1t ,-,.vi"l:FruiSJ.pUlillessmdtlim:e lill!liIi5s<il:l1!d 1t11:ere is: ofue:JillJ .1iI. hiLsltoq ofpr'e'i..fl!Ol!J!5 fficisiioo.<lil'dl dr,m<Jtge at &e mlte_ A1bOllJJI: 50% p1reSien1t lbefo1r,e 'lhe<iL_ge of 1()! ye.a[s,~eSiecoo:d YOlap ofp..Dienl:spreSienEirl1!g m yomg[1tdmilllhDDdL

TDCsar,e dJ![iI.gn:O:Sied[ Mrn1!1Iy§!l1dJ tllew]e of ooargilThg is 1\0, oomfil:m tlle ,di'!mcal. dlJi<Jig:llos.J!S:<mdl.pmVlid!epr15ope:rawe lmo!llm!atlloD.regardliil1lg thepreSiel'liOe of.[jJJ 'SioThidi. !c()mponen1t w~.1the cyst Ulir<llS!O"l!l!lld .. is idiea1!]y :S!m~edi. ItDp1rovid!e 1tlhJis ilicrfoffl1!<iLTIon :<1I,lJJdl ill mDst cases no o'lher mu~g: ~s necessery.

Theltypruc;]]l1illil1tl':asowd :ii!ppeM.11I10e of<JiIDC [l]asbeeI'JJ. deSirnbedi. as -!hat ,elM. mecl1:oiic,.we1ill.-dl'clltmSirnbedi. cy.st ,.,.m"ili. WtO!lfle:<illSiedl .ougfu 'lirMSOSis&OO_2S,lil5,27fu. om ,~perioooe, h()wev'e!If, 00 .is l;Tot 1tl\te ease. We .:h~ve f01lJ!fldi:mom-pal:IDen1Is:2s

F~_g'I!lI"e.!;U3-

Transverse 5ionO'_grnmJ ,ora cysfu.;c fuY'y'l'lma (mas.s" tafgearf'Ows) sho''iYi:I1I!g a cystic res~o:l1J willise.pta (smaJruanl'l'ws) rn close p!l'lxim:iry te the SoMli)l:I1UU'l!dl:bWaf g1Jafidi (Std) ,and! ,Fi,afl'l,tid! glJand!, (p ARl- At thiis, s~te" tj.'1l1phllngi:l'llJ1as inad1!1l:"l:s ase said! tl'l' he p ostn:mrnJaafu!c in ,origm.

F~.gm'e .:I_14~

RAJngirudlnatr .sonogr.am. ofan l!illinf:e;clled!, lnf:rnhyoidi lliy!I1l'gl!Os saJ!. dillel: cyst_ Note M-Ie aNBcholc ll,Iameofllie -cyst and! post'mo!" el1I!himce.moent_ The hyoid! ~5 lcl!en1li:l!ed!. as ~_

FigIill"e 5.15-

LOl11glmdlOOaJ! .. sionogmrn ·of:an irn"ededJ lliy'fo gl!ossa:l! dlillC1!: cyst \villi inte~a:l! deMSiand!. s,epta_ The hyocid! '~sid!e4]Jfti;ijejd by a:I1I a:m1)w ..

Figm:e5_16---

L(lngimdliDaJ! sonogfIDItM'an i:nIf1~Y'ojjcl! llijFl!OgJ!OS:s:aJ! dl!lc'it cyst (OlM:OiWS) sho,wing a pse,1!]!do-'soTh:d! .ap¥,ear,anoe_ Note lliat ~1l is just bel!o,w llie ]ev·eJ ·ofllie hyoid! oO!l1l!e (H),

T 11!.... .::III _,11_ 'd' ~,,1L. . . f·' " 11~,_j1. ,,', ',,1L~~ ,,1L ,'" -j~ " .::11 ,0 '. 'f' ,,1'- ",,1L _11!_1111~~~~ 'f' ID" C' _,~,,1L ",1,\" 1'-

Ull!ll,@i5'O'm1i1dl aiso ,r I,' efil!]J!l;esmep:resoooe 011. liiI1IY ool!r.lll,oompoooo1!. v.A!1LI1ill1illJ, ,l!:Ile cys1f; mtlll!!!gIl!<iI1It 'll:eg,meraltl!.OFJJ, Or I I!lI!fE: rep1!l!lI!fl:)J!lJi:1IJ! ml!l!Ul5 Or I a • I I ,', " 'i:1IJ!mOlill!.&1' rare, ]~&S

heoo '[reponed '1S,3~ UJ!waiSoDd,-gmd!ed, me-m:eedille .a1tiion GJ1()1]ogy IQFNA!C) is ;ttflerdor,er,eClOlmm,ooded. ,irr:JJ.<IDY ease ofa solliJd. oOlililPOIl1efit VIi~, :0lJ. mG.

,h j!.1L ";1,\,, _._,1' .:<I .::II "~..:£::- ,,1L ' _.1111 • , ". _HL • "f,,1L'" .::III f ID"C S" ....... _11_ ~1i:!]0'1J!yJi.lwn~o_1lI. coes not rU6l1Iwy' we k:[iI!ct m ,<1IiIlcmes, It is ~ott 'rnrltrci:1IJ! :[J'Bc411I]SJe,l'I][lespeo1tl!ve Or I' ILIff: slfl!e, SJ1Zie ,1rniu, ap])ear.,1rn:oe Or I' ,aL ,I I " " a .' ':i!SI!llWlII"L

pmoedim:e iis 'feco!ll1lilill:endJed 31 ms ent1illl1Jsf.,es:ectlJon of ilie cys1t .md. any relill~g tr:act, t\o,ge:1!.hier ,"wlli excwoo. rOf ilie _ddille tilimd. of the hY'o~di boae. boompnetereSJedroD, i:l1!:vmabllyreS'wEs ,m, :recJm[lel1oe_

Lesioas ,m,tlte.pru:otndi.r,egi1oo Dim, be ,~dled, mto iliOise mo:k,.-mg~epID"otndl g]1Mill!d ,ud .os:e .;111 are ,~tr@gillimduJliID' _ The m]e 'of1lliltlr~1illIl!d ill ,evam~g '!he :pru:01llidi g]~dl~5 welill. dJoCl!mTI!e1'Ii1ted9:}2)3 ~d[ .~<l!S beel!'l .: cllESiC'IJ!5Sied. m. C:ITh~]JI1te:[ 2_.

Mab5Sie1te:r mlll!scle nyper1tropho/m;arybeMillllll1terru.m1b1illa1t,er,:J:lL The a.e1tioEng)' is ohscm,e,bn1tmostp;jJ:1tlients F:!iilLve hiitlb~maJl dooc:h.mg orgriflc::fu1Jg ha:bi~ of ~e ii<1IW, especidly .~g sleep. The hli.g1lest mci.dlenoe ism the ;s..eoood.imdi ~d. deoades of1li7e<mdl1tl1ere is. flO Siexil1fedliillee1t1OFli_

Treawffit, if iI1dlliOi'il~edl oonsiists of mMSie1tericresee1t10rliJj.Mdi. te.cmooo:l1i. of <1IiSSiocia1ted.1bony hyperos.:1tos:iis_ However, moo]! s.:l.!][.~.eonsilfe neSJiEru>1t.lto !lfeool!illmend smgery fm :lDisbemillgn oondli1t1on, pru:1Iowillarlly <115 ther'e lis .i:lIiJJ.Msocii:il1ted.risk of :Narial n.efVie~<ilge <m:d oOF:lsidJer@1b]epo5i1topenllti\N'~morlb&dlllty_ The .lb10\Wl!. ;a;c1t1o~s ofbo1h!I!llii!1l!l!1OO 1toXliil1.~pear Ito oEme:rpoltentiodbelleID1t Ito patien1ts tlla1treqmre 1trea1tl2l1l:en1t<md. mSl0me oenwes 1tl1iis is 110W ilieprimill}':IDorm. of fu:"eawel1It Folil!o\cviilThg mJec1tioil1! ofbDmillinllBl 1toxil:!, it~s notpOSSJilb:£e for '!he pa1t1ent Ito ,dencll1tl1:e 1tee1i1l .: ~rnre to mo1tio<l'l!a!ll dene:rvaltion of iI1\te j<1llw; it is ]JO!s1tIll!l!a.1ted t11:<ilt truperiod offomed m&emlli1ty .5 s~ci.ent ltoibren.lOOe ha:biJ1t of doodW:!glgrn.ditmig_ 34

U1!tr.<iIiSOood h[jliSi:iI.[oEe 1top]a!},mpaltients. wil1Th. i!vlliffi as .11t C1M'li. ele~1!a1te ()1tl1er caases ·cf focali sWlelilliinllig aad e'V.~<1I!1!e1iU!iLdl oompMemlll!sclesUie_ The 1toxm. Ci1I!!I be mjreoted.mdJermlruri:iliSomd. oontrol UlIruri:iliSomd. is .a1ISOIll!SieMll. mmoni~oril1g the ~e .of the mWSlde ;m1er fu:"ea1tlll;tent

Ams,t BOC .mSies ]i0mi.~nmmaJJ 'enilibryogenesiis .of the mstbr,<mdThia1l. appm.acmsMdI. aoool.!m1ts:IDor 8'% of .a1ill. bruchla1l d!eft.a1b!l1ormaillirlies_ I~m<il.i}' be associated 'W1ili.bon~ !rn<mges m lMeform of~ tract tmOl!l!gh 1tlTe ,ex1ternalJ alll!dirtt01)~ C1llial!. ;<ilf:l.d 1tempor.alJbolTe_ 35 These cysts oeem mMdilfooodi iliepMoltlJd. glkmdl, 'e:ll:1teffla]. illll!dlit,.o:!), C<iIliJ!a].1ll1~ tI1:e angle 'of lifLemaJildJIlbk The t::r"])iicalJpDeflt wii'lh. ;<1I!.msE BOe .5 a willdd!IJe-,agedJ. woman. wi1tJh. a.hiis1tory oflilll!l!1~~e pru:otid <il'bSioeSSies l!l!IM.eSipOlThsWe ~o ;,ilillJItl!1)·roMcsMd.ch;mage_ Theremia1Y be1iliS'SiOci<1l!~ed. otmdl!OeOlL. The SOl1t0]o~Si1tmaty be 1tl1e mSi1tperSio:l1i 1toSiuggest. ilie ,rni:ilgn.oSJis_

Ulltraso'IInd Featnres

~A1rlhough the1!l!1Th1:.i:3iSiOllliI1!diappear<IDoesa!lfe ~ar ~O ilioSie ,cf;at .Sieoond. BOC,m om lexperienoe ilie mOiSt. OO!lll1lmO:lll is :atpSlelll!db-'SiOJrdl. ~pear.;moe vni1th. 'l!l!I1i'Oml. m1terniitll. ed1oes.Ml!dpoSi~eriior 'eMMOeJ1l]je1'Jt (]F~gm:e 5 _17). Wec1ted. cysts \\:rith ne1te:rogMOO1!l!S m1tern<I1i. echoes. are fieq;liren1t1~m:ist~en. for flle more

W---"1L~~" . . . .' -.-.~ lk,' _.11

CiOliDllM,OO :i:lE.ILIiJ!lj]~. s ~O;~Iill,=, 'P~CWaIlIJf ,m, '[Iillj]jm.es_

F~gm;e .5.1 7-

Tlra:t11s.vefse s.~n~g:ram .sl]~.\'YIDg =ecll!~.,geru!c cyst (alYl'J.ws) cl~'se1y fellated! t~, '!he pimla_ The]~ca1ii~nand! appeaJf3.!l1cea:re Sol!J!ggestive~jf a fi:rst iornncl'llia] clefl: eyst.

jp'[,e;-,a,Ecmru: .s.iI:!l!l!Sles are 1!hemoSi1t 'OO!l1!llilllOO. looogeEl!l!1!,a] aooa,rmd1tym 1tl\te. lThrodmd Reck_ They~esD.~fromilhe iefltl::iilpmen1t of ec1tod).e:n:ma]. epirtlTheirJm m ~e mst 1brrmcm<Ili.<MciI. ei£emen1ts .of I:te lex~en1!otI. en_31:5 They db no1t mvo]v;e])mmches of 1tll:efaci<lli nerve. WWe mos,tlfe:llil~.[fu5ymp~o:mll1tic, 1.lJ.sm<i!illlmority :beoome imec~edrmd. tlJills ~mal}' canse cm:omc:.driSicihMge, repea1tedlllbsiCJe:s:s forma1tio:FI <md].Sic::anmg_ Sonogra:plhy ca:m_de1teoipire-;aOOem<itfsmllSieS[iU'Jjdl their blru1I!cl1&!1gpatlen:J!,p!l!ovidimg the sm:geol1l wili1th.v:~:aMepfe-Oper<iL1ti)v,e lmOm1!i:iI1illoo_

IHba;solilld F eamres

F~gm:e ).1$-

Lon_girudli:l1Ja]. sonogram in llie P!I"e--alllriclli!aI:!f'e.:gion showilIDg (a) a non..:hlrill1~gsml!ili~ (ano,ws). (]b) Note llie ~assiociated!. 0oille-ctiion (l!a!I"geamlws) ~and! gas 'i'ili'iliir:! (smallano,ws) ..

• The:l"!e~:s i:iI.ps;eu:dio-.glim.c:millm- OOOllPOOefll<il5:Sioci<iL1ted. ,..,vi!1fih tJiIDesmm." dime "Ito ;<iI!OOlilimlllillaEon of siecre1tio:l1.cS {tigm'e :5 . 18b). Ol!1Wtr&romd irl: is ]ir,eql!llel1lElIy welill de&ed. ;<md.gl!Db1!J!lj1rr,s!ho\viilJJg~ofilJJ. m1te:malJ echoes.

• Ullftr,asomd <iLocm<il:Edy identWe.s therdaltiiooships of ~esml!l!s lto 1IDeal11terim: crux. 'Olf 1!he hem,.tlhegroo\~ebrov,een.lOOe heh.Md. ti1etragl!l!s, ,<iIli1d!the :SJUlpe:mcii~.:l1 1tempOlf.aJi me:!}'.

They are 001111mOn. ill 1!he ~ ,illllid tillle lex1tl",~1tie5butm.commo:11 ill 1!he ThteijlJdl :[ll];d. neckil"egioo (1itppil"Oma1be11y 15'% of n1ilOOill:i:iI.lLIgUDm<ili5).::; 7.)g Theliil1!<iItS'Sie1ter IDl.!l!s.cle is 1tfue mo.S:[ oommoo. :si!1te (36%), ioJ!l!owedby flfapeziws ml.!l!Side {24%),s:1be:l1Thomi:li5toild. OO%),.perim:1b1~~ lIDl.!l!s.cles (lO!%) <mdl 1!empOfUS. mm.de (8,%).J":B,;39 Vi:li5c1.!Iillr;rr maJifo:ITl!l!lltfo1i:lS macy h§lVie ]<lrge (C~Ve:rn:Ol.!l!S) sprn:oes;, capilllliary.eJ)em;enE:s, l~phmwc dements or oom1b1ination:s .of~es;e.1:I,411

Thelf{y]e of ~~g is. ~o rden1tfiftY 1tfue. 'e:ll:iiL.ct<lll!mOmc rocalIioo. aI1d.1tfue 'ex1bent of tillle DIlBs.hefore therapy. Lasge .naernJ:angUOlill!<illS M§ly:ibe ~ans.-s;]J!ljl,tiiIl!. The ,rniilig:IIDos&s ~S )lfea:diidiy IDa:a:e bylill!l.lttr<fiolill!ll!dl :pru::ttiic1!J!lJru:-l}r wThi:e.IJJ ilie preSJel10e oftillpfuiliebo]ir!1illJ isdeJ!llomtrated, hlillt i\tOO best de;pl!c1ts ~e exaet <ll1!1iI:1tom:c ]oClltiOil1!. ,Md. ,ex'itent .of ilie lesion.

F~gm-e 5J9--

Transverse S®<loganl olfa haejfJ];anrgioDla., s}\]o,v;,ing a fu}']}o~ecllo.iic mass, (an:®,ws) willi ml!1.lJfI:ipFe vascalar spa<:,es 'iYi~ (aMowbead!s) .. On .• eal-tilll1~' s!C<l:Ill1i!I1Jg one will of.'l:easee s>]ow fJ)ow v;-i~ ilies.e' spaces, CoEo'm· Dopp]eo! may aJ!so de1tloas:mr;alle stllJrgysht'Jbw..

f'agelJH

• iP.billebo~ areseea WI ~abollt20!% of eases (iFigl!lI[,e 5_10)_ However, ()'Mreoent ,expmelil!oeshows th1Mt. Gille c<lElrd)5l1!~ tuepreSiel'lOe 'Of@LpMeho:fu!fhm ;~aS!t 6(]i% .of cases w];}m ,~ ,car,emillSle<nrn. is m~dJe_

Figuml52i1}-

L~H1:glirn~aJ: s,o!l1og'm:tn ·of .ahaetJlOlngioma, slh!o~-illg.a :hYf ..:J .. e>e:lliorc mas s (o.pe~ ,aM:OiWS) ""'ith vasiCdar spaces (all"owlh!e-ads)_. The pres1efi'Ce ,ofa!pful'eootiili (all"OIWS) cionlU!n::; iliediiagnosls,_

. jp',[ll"<iI!_g<mgllUomas, .'0 .DOwn. as :gloffil!ills mm:om:s, ru:iiSienom nem:i9J! erest oels r,.w"l:1fumi the Vi essel wd_ .AJiJmJ.o.st d. "ihepiM:<iI!gi1lflglliorn<1l!5m ~e .~e<J!.d md Eleck regroa ooom.:

U1iItr<l!SOWl:d. can omy ey;a!m<De !the cawfu1dlbod~~~om:,~dls:o 1i:her'Bs.1t of thlJs: dliSJolJ!s.sJ!oo. ",vi! focas o~it CBT:spr,esent ,liIiSplillills.&1iiille,p~eS'sm<il!5SiBS in [he <1ill.®eriot: mi§flglJe ji][]s1tbeJ!or",,,,, tlJJe ID1IgDe of iliem~dllib]e_ They are :s1ligfuillly .more I(!ommon ill, women, iliam. men"Md.mi\ltybe 1b1lliallier~ . .ot: ;atSsoa!ated \wili. 'Oilier l\teiID.dI. ;Uid) neokpa:r~angJ:iorn:1ID5_ ].n :pOl.tfents v.."ri'l!h&f~~ rus.~ory OfpiY.1IDgMglli!omOJ.is[I1;epre"llirlIenoeratie ofslil!rn. mmtipEe EmnOlms. is 25_33'%_43-45 The ~ey ilto ilhe ~d!oottMC<lI.tiO!Eli of[jJJ CBT is i1s ]OG<iI,1tl!.on :<il1t. tfue cMo1lli@ljb.ifur0<tttrDFl!, s,troo.dillil!l!g 1tlbJebbcallOFJi ,<rn."@[ &p]1iI~g :lhe'ii'iess;eJjs_.

iHllbasou:od I'ea_res

• Co:£om 1fr])owwaJg1llg· de:rn:cM1iS1tI:"m,esflJ!e enc@SJeJ1I;]!ent !(]fthebmcaoa. by IDInOmpru::ltXclllmru:']y wel!ll. 1(iF ~gm-e 5 _2 IJ It .also .shows the VMCmlliarity 'i,vil:rnlJ! the :mmom (nilEigll1!gwOl!E1 hY]}Gl'v>!I!OOMillm- ~o bY]) BIV.Mcmru-)_

~m ilielbhc1iIE.oEl ~s seea 'i,\:1~ the MIooOW:, the.dlJi1lligl'los.iis can.be !Ill1ldie 'iowrili coillfdel!1oe_ lliII. slo-meiilwSJ1t<ll'loes" how,el.'\ef:[, llie lOO<irnS diis.p]a:oes 'Mdl5p]~'S '!he

F~gI!ll"e 51.11.-

T • .ans."le.1se s.o!l1og:nl1l1 ,of.a. 50riiil! tl!J:t:rilloli:f(l!arge .a!I'O'WS.) e!I1>c,..asi!I1g fLhe bi:l'.'m"cati!on ·ofllie qommon caI!"·otidi. :<ID:e.ry' (small:a!I'ows) .. The tocatlOl1l! ·I'lfilie ve5,se']s. "",itllin the

fumom~s charadeas.fu!c ofa car,ofr:id! ltm,dy hEln01!rr_