DIFFUSE

THYRIOD GLAND DISEASE

IMAGING

Dr Ahmed Esawy

Dr. Ahmed Eisawy

MBBS M.Sc MD

Dr Ahmed Esawy

Scheme demonstrating how thyroid lobes should be measured in the longitudinal and transverse axis

Dr Ahmed Esawy

A lower frequency transducer can be used to provide a better scope image (convex transducer) in patients with GD when presenting large goiters. The image shows the transverse axis of the thyroid (a), longitudinal axis of the right lobe (b) and longitudinal axis of the left lobe (c).

Dr Ahmed Esawy

Normal gland has an echogenicity characteristic in ultrasound, easily distinguishable from adjacent muscular structures. Notice in figure (a) greater ecogenicity in thyroid (straight arrow) relative to the neck muscles (curved arrow) and,in figure (b) bigger or equal to the submandibular glands.

Dr Ahmed Esawy

State of thyroid blood perfusion Perfusion of the thyroid increases on several occasions:

increased cardiac output (a stressed patient),

in gravidity,

during an active autoimmune inflammation active Graves disease or Hashimotos thyroiditis ((in active Graves disease thyroid inferno).

hyperfunctioning nodules

untreated primary hypothyroidism because of TSH stimulation.

decreased perfusion in breakdown of the thyroid tissue as is the case of

postpartum thyroiditis,

De Quervain thyroiditis

amiodarone-induced thyrotoxicosis type 2.

Dr Ahmed Esawy

PSV normal up to 25 cm/sec

PSV at thyrotoxicosis more than 100 cm/sec

PSV at hypothyroidism 50-60 cm/sec

Dr Ahmed Esawy

DIFFUSE GIOTRE the whole thyroid appearing to be enlarged Size

hyperthyroidism Graves disease Suppurative thyroiditis Drug-induced thyroiditis Riedel s thyroiditis Iodine deficiency Organification defect pregnant ,menopause thyroiditis Silent thyroiditis

hypothyroidism Hshimoto s thyroiditis Iodine deficiency Radiation exposure Sub acute thyroiditis post partum thyroiditis

Dr Ahmed Esawy

Sonographic Findings of Diffuse

Thyroid Disease

Gland enlargement Normal volume

19.6 +/-4.7 ml for men, 17.5 +/-4.2 ml for women, scaling with BMI Isthmus over 5 mm Variants: normal size and small gland

Altered parenchymal echotexture and/or echogenicity Increased vascularity Most marked in Graves Lymphadenopathy usually minimal and in the central compartment

Dr Ahmed Esawy

Enlarged Thyroid with Normal Echogenicity and Echotexture

Normal variation-Height, BMI, Gender, Race, Age Mild iodine deficiency Medical conditions: pregnancy, renal disease Subclinical autoimmune thyroid disease Check serum TSH

Dr Ahmed Esawy

ULTRASOUND IN DIFFUSE HYPERTHYRIODISM

THYROTOXICOSIS

Dr Ahmed Esawy

INCREASE THYRIOD HORMONE

Thyrotoxicosis refers to the manifestation of excessive quantities of circulating thyroid hormone

Hyperthyroidism refers only to the subset of thyrotoxic diseases caused by the overproduction of the thyroid hormone by the gland itself.

Dr Ahmed Esawy

differential diagnoses for thyrotoxicosis Graves disease: Subacute thyroiditis: Silent thyroiditis: painless thyroiditis, which may be seen in postpartum women (postpartum thyroiditis); a self-limited course; and low radioiodine uptake. Multinodular toxic goiter: Toxic adenoma: Factitious thyrotoxicosis: Special features include no goiter, a low thyroglobulin level, and low radioiodine uptake. Iatrogenic thyrotoxicosis: thyroid hormone intake.Iodide-induced thyrotoxicosis: iodine-containing contrast agents or drugs such as amiodarone. Thyrotropin-secreting pituitary adenoma: Beta-human choriogonadotropininduced thyrotoxicosis:.

Dr Ahmed Esawy

Graves Disease

= DIFFUSE TOXIC GOITER = autoimmune disorder with thyroid-stimulating antibodies (LATS) producing hyperplasia + hypertrophy of thyroid gland

Dr Ahmed Esawy

Marked increase in gland size; less commonly normal or minimally enlarged Echotexture may be normal or diffusely hypoechoic Decreased echogenicity,Heterogeneous echotexture spotty parenchymal echo pattern Smooth or lobular surface ,rounded contour increased vascularity with (turbulent flow with arterial-venous shunts) (thyroid inferno) Prominent extra-thyroidal vessels Peak systolic velocity of 40 cm/sec or higher has 96% sensitivity and 95% specificity for GD Marked thyroid arteries velocity increase

ULTRASOUND CRITERIA Graves Disease

Dr Ahmed Esawy

The parenchymal hypoechogenicity is due to decrease in colloid content and increased cellularity resulting in reduction of colloidcell interface, and/or hypervascularity. persistence of parenchymal hypoechogenicity after cessation of medical therapy is associated with relapse of hyperthyroidism

Dr Ahmed Esawy

Graves Disease

Causes Autoimmune

hyperthyroidism

Sonographic Findings Diffuse enlargement

Hypoechoic without

palpable nodules

Markedly increased

vascularity (thyroid

inferno)

Dr Ahmed Esawy

Ultrasound scanner must be adjusted to gland for correct evaluation following specific thyroid protocol. Special attention to the velocity scale that must always be equal or less than 50 cm/s, to thyroid arteries systolic peak velocity measurement

Dr Ahmed Esawy

Transverse (a) and longitudinal (b) power Doppler ultrasound shows the markedly increased parenchymal vascularity in Graves disease giving the appearance of thyroid inferno

Dr Ahmed Esawy

Graves disease is an autoimmune thyroid disease and is the most common cause of thyrotoxicosis (up to 85%). Ultrasound thyroid gland is often enlarged and can be hyperechoic heterogeneous thyroid echotexture relative absence of nodularity in uncomplicated cases hypervascular; may demonstrate a "thyroid inferno" pattern on colour Doppler

Dr Ahmed Esawy

https://radiopaedia.org/articles/autoimmune-thyroid-diseasehttps://radiopaedia.org/articles/thyrotoxicosishttps://radiopaedia.org/articles/thyroid-inferno

Graves disease

Diffusely enlarged, hypoechoic, increased vascularity (thyroid inferno) Dr Ahmed Esawy

Graves disease

PSV HIGH

Dr Ahmed Esawy

Graves Disease

Ultrasound of the thyroid showing an intense vascularity on color Doppler that is consistent with an inferno.

Dr Ahmed Esawy

Ultrasound of the thyroid showing an intense vascularity on color Doppler that is consistent with an inferno.

Dr Ahmed Esawy

Enlarged gland Decreased echogenicity Heterogeneous echotexture

Graves

Normal Dr Ahmed Esawy

Graves Disease

Marked increase in gland size; less commonly normal or minimally enlarged Echotexture may be normal or diffusely hypoechoic Smooth or lobular surface contour

Dr Ahmed Esawy

Diffuse increased vascularity : thyroid inferno Prominent extra-thyroidal vessels Peak systolic velocity of 40 cm/sec or higher has 96% sensitivity and 95% specificity for GD

Graves Disease

Dr Ahmed Esawy

Graves with Occult PTC

Dr Ahmed Esawy

Graves with patchy regions:Lymphocytic infiltrate on FNA

Dr Ahmed Esawy

CT scan shows thyroid gland to have diffusely decreased attenuation

Contrast-enhanced CT scan shows enlarged right thyroid lobe with decreased attenuation (arrow).

Dr Ahmed Esawy

62-year-old woman with goitrogenic enlargement of the thyroid gland. Contrast-enhanced CT images (ac) show goitrogenic enlargement, parenchymal heterogeneity, and calcification of the thyroid gland. The thyroid gland extended to the mediastinum (a) with unilateral retropharyngeal elongation at the level of the left piriform sinus (c, arrows).

Dr Ahmed Esawy

a, b. A 51-year-old woman with goitrogenic enlargement of the thyroid gland and progressive dyspnea, wheezing, and stridor. Unenhanced CT images (a, b) show prominent goitrogenic enlargement and parenchymal heterogeneity of the thyroid gland and mild stenosis of the larynx (a). Bilateral retropharyngeal extension of the thyroid gland was caused by narrowing of the oropharynx at the level of the mandible (b, arrows).

Dr Ahmed Esawy

Dr Ahmed Esawy

Tracheal Compression

Dr Ahmed Esawy

Thyroid scintigraphy in Graves disease shows the thyroid gland is usually enlarged

Dr Ahmed Esawy

palpable cold nodule in a patient with Graves disease has a high likelihood of malignancy (4%)

mnemonic: CATCH LAMP

Colloid cyst

Adenoma (most common)

Thyroiditis

Carcinoma

Hematoma

Lymphoma, Lymph node

Abscess

Metastasis (kidney, breast)

Parathyroid

Probability of a cold nodule to represent thyroid cancer:

Dr Ahmed Esawy

Graves Disease

24/M

(+) thyrotoxic symptoms

131I thyroid scan & uptake Diffuse thyromegaly

Elevated RAI uptake values

Dr Ahmed Esawy

Diffuse Toxic Goiter

30/F

Palpitations, excessive sweating, irritability, anterior neck enlargement

99mTcO4 thyroid scan

Diffuse thyromegaly

Scintigraphic evidence of increased gland uptake function

38 sec acquisition time

Reduced background tracer activity

Dr Ahmed Esawy

Graves disease

Dr Ahmed Esawy

Thyroid scintigraphy of the Graves disease patient showed enlarged both lobes of the thyroid with diffuse increase uptake. R: Right; Tc99m: Technetium TC 99M pyrophosphate.

Dr Ahmed Esawy

Diffuse thyroiditis

Dr Ahmed Esawy

A number of inflammatory conditions can affect the thyroid gland, which are commonly described as thyroiditis : 1-acute thyroiditis

acute suppurative thyroiditis (AST) 2-autoimmune thyroiditis

subacute lymphocytic thyroiditis: silent thyroiditis or painless subacute thyroiditis

postpartum thyroiditis: is a subtype of silent thyroiditis Riedel thyroiditis Hashimoto thyroiditis: chronic lymphocytic thyroiditis Graves disease

3-subacute thyroiditis granulomatous: de Quervain thyroiditis: subacute granulomatous thyroiditis lymphocytic: subacute lymphocytic thyroiditis: silent thyroiditis or painless subacute thyroiditis

postpartum thyroiditis: is a subtype of silent thyroiditis Dr Ahmed Esawy

https://radiopaedia.org/articles/thyroid-glandhttps://radiopaedia.org/articles/missing?article[title]=acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=acute-suppurative-thyroiditis-asthttps://radiopaedia.org/articles/missing?article[title]=acute-suppurative-thyroiditis-asthttps://radiopaedia.org/articles/autoimmune-thyroiditishttps://radiopaedia.org/articles/autoimmune-thyroiditishttps://radiopaedia.org/articles/autoimmune-thyroiditishttps://radiopaedia.org/articles/autoimmune-thyroiditishttps://radiopaedia.org/articles/autoimmune-thyroiditishttps://radiopaedia.org/articles/subacute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/subacute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/subacute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/subacute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/post-partum-thyroiditishttps://radiopaedia.org/articles/riedel-thyroiditishttps://radiopaedia.org/articles/hashimoto-thyroiditishttps://radiopaedia.org/articles/graves-diseasehttps://radiopaedia.org/articles/missing?article[title]=sub-acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-thyroiditishttps://radiopaedia.org/articles/de-quervain-thyroiditishttps://radiopaedia.org/articles/subacute-granulomatous-thyroiditishttps://radiopaedia.org/articles/subacute-granulomatous-thyroiditishttps://radiopaedia.org/articles/subacute-granulomatous-thyroiditishttps://radiopaedia.org/articles/subacute-granulomatous-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/post-partum-thyroiditis

Thyroiditis is the most common group of inflammatory disorders affecting the thyroid gland and is encountered very often in clinical practice. Thyroiditis can be painful or painless . The suggested classification of thyroiditis is acute, sub acute and chronic.

Dr Ahmed Esawy

Thyroiditis

Hypothyroidism Hashimoto Subacute de Quervain thyroiditis

hyperthyroidism as GRAVE disease Post partum Suppurative thyoiditis

euthyroid

Dr Ahmed Esawy

https://radiopaedia.org/articles/de-quervain-thyroiditishttps://radiopaedia.org/articles/de-quervain-thyroiditishttps://radiopaedia.org/articles/de-quervain-thyroiditishttps://radiopaedia.org/articles/de-quervain-thyroiditis

Thyroiditis

Acute thyroiditis usually has a bacterial etiology and can be very painful

The chronic lymphocytic type of thyroiditis is Hashimotos and it is known to have an autoimmune basis

Subacute thyroiditis usually presents with a transient hyperthyroidism followed by hypothyroidism

The lymphocytic kind, which is silent thyroiditis [has an unknown pathogenesis or is autoimmune]

the granulomatous kind, which is painful [and typically has a viral etiology]. de Quervain thyroiditis Dr Ahmed Esawy

https://radiopaedia.org/articles/de-quervain-thyroiditis

A diffuse or multifocal decrease in echogenicity demonstrated on ultrasound is the hallmark of many types of thyroiditis. This decrease in echogenicity may be due to

A-increase in the intrathyroidal blood flow B-increased cellularity of the thyroid follicles C-decreased colloid production and or lymphocytic infiltration.

On color and power Doppler studies, increased blood flow is noted throughout the gland. This constellation of findings of reduced echogenicity of the gland with an increased vascularity is highly suggestive of a diffuse thyroiditis. In addition, the gland is often heterogeneous.

Dr Ahmed Esawy

Return of the normal thyroid echogenicity and blood flow is noted on resolution of the disease. However heterogeneity may persist if the chronic thyroiditis ensues [fibrosis may set in within the gland, resulting in a coarsened echotexture . Radioactive iodine uptake testing can aid in identifying the various etiologies of hyperthyroidism and also help in patient selection for I-131 treatment.

Dr Ahmed Esawy

Peak systolic velocities of the inferior thyroid arteries were significantly higher in patients with Graves disease than in patients with thyroiditis

differentiation of Graves' disease and thyroiditis in thyrotoxicosis

The thyrotoxicosis clinical manifestations in thyroiditis and mild or initial GD can be difficult to differentiate

Dr Ahmed Esawy

Comparative table of sonographic findings in the normal thyroid gland, in thyroiditis and in Graves disease.

Dr Ahmed Esawy

A 25 year old femae presents with a one week history of a tender midline swelling of the neck. She also had complaints of palpitations and fine tremors of the hand. Laboratory features revealed increased levels of T3 and T4 and decreased TSH level

Differential DiagnosisDiffuse thyroiditis

Diffuse thyroiditis

subacute viral thyroiditis

Dr Ahmed Esawy

Gray scale ultrasound, color Doppler, Doppler spectral analysis in patients with Graves disease. A: Gray scale ultrasound of the right lobe of the thyroid gland in patients with Graves disease shows enlarged gland with smooth contour and heterogeneous echotexture; B: Color Doppler of the same patient shows diffuse increase vascularity of the thyroid gland; C: Doppler spectral analysis of the right inferior thyroid artery of the same patients show elevated peak systolic velocity (V1 = 89.8 cm/s) and elevated end diastolic velocity (V2 = 44.9 cm/s)

Dr Ahmed Esawy

Qualitative (gland visual vascularization impression) and quantitative (thyroid arteries peak systolic velocity) assessment of thyroid gland. Diffuse increase of the parenchyma vascularization, known as thyroid inferno, in color Doppler (a) and power Doppler (b), before GD treatment or effective therapy

Measurement of right inferior thyroid artery peak systolic velocity in spectral analysis (c), demonstrating the increased speed in patients with GD not treated or not responsive to treatment.

Dr Ahmed Esawy

Changes to the characteristic features of normal gland, in GD are seen to B mode sonographic. Diffuse heterogeneity and hypoechogenicity, with dense fibrotic beams permeating in the longitudinal axis of the right lobe (a), longitudinal axis of the left lobe (b) and transverse axis of the thyroid (c).

Dr Ahmed Esawy

Color Doppler demonstrating a diffuse increase of the parenchyma vascularization, known as thyroid inferno.

Dr Ahmed Esawy

Thyroid arteries systolic peak velocity measurement is done 1 mm sample volume adjustment, in vessel centre, the insonation angle shoud be 0 - 60 and correction angle adjusted parallel to the vessel wall. Dr Ahmed Esawy

Systolic peak velocity above 100 cm/s in the inferior thyroid artery, can be reached for patients with Graves disease not treated or not responsive to treatment

Dr Ahmed Esawy

Multinodular Goiter

Dr Ahmed Esawy

Multinodular goitre (MNG) enlarged thyroid gland (i.e. goitre) due to multiple nodules which may have normal, decreased or increased (toxic nodule /TMNG) function. most commonly clinically euthyroid but may be hyperthyroid or borderline

Dr Ahmed Esawy

https://radiopaedia.org/articles/thyroid-glandhttps://radiopaedia.org/articles/goitre

sonographic appearance of MNG Well marginated,diffuse enlargement of the thyroid gland with a heterogeneous, nodular appearance . The presence of calcification, fibrosis, cystic change and haemorrhage contribute to the heterogeneous appearance.

Dr Ahmed Esawy

Transverse grey scale ultrasound shows the typical appearance of multinodular goitre as a wellmarginated, diffuse enlargement of the thyroid gland with a heterogeneous, nodular appearance (arrows).

Dr Ahmed Esawy

Transverse grey scale ultrasound shows the spongiform appearance (arrows) of aggregation of multiple microcystic components in >50% of the nodule volume that is highly specific for benign hyperplastic nodule

Dr Ahmed Esawy

Longitudinal grey scale ultrasound shows a predominantly cystic nodule. The solid component (curved arrow) within the cystic component * is due to blood clot, and invariably avascular on Doppler

Dr Ahmed Esawy

Transverse grey scale ultrasound shows the tiny, nonshadowing echogenic foci with comet-tail artifacts (arrows) that are highly suggestive of colloid content. Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Micronodular pattern does not equalmulitnodular goiter

Dr Ahmed Esawy

Dr Ahmed Esawy

Multinodular Goiter

Dr Ahmed Esawy

MNG

Dr Ahmed Esawy

Multinodular Goiter

Dr Ahmed Esawy

Multinodular Goiter

Dr Ahmed Esawy

Multinodular Goiter

Dr Ahmed Esawy

Multinodular Goiter

Dr Ahmed Esawy

Multinodular Goiter

Dr Ahmed Esawy

Multinodular Goiter

Dr Ahmed Esawy

non-enhanced CT showing coarse calficifactions in a multinodular goiter, representing degenerative regressive calcifications

Dr Ahmed Esawy

contrast enhanced CT showing mostly eggshell-like calficied hypodense nodules in a multinodular goiter.

Dr Ahmed Esawy

A, Axial T2-weighted image shows large mass located in right thyroid lobe (arrow) with strong heterogeneous hyperintensity.

B, Apparent diffusion coefficient (ADC) map shows high ADC value (2.20 103 mm2/s) in lesion (arrow)

71-year-old woman with adenomatous goiter.

Dr Ahmed Esawy

Unenhanced axial CT scan shows diffuse decrease in the attenuation of the thyroid gland (black arrow), which is isoattenuated to the muscle. White arrow indicates the sternocleidomastoid muscle.

Contrast-enhanced axial CT scan shows slight enlargement of the left thyroid lobe. Decreased attenuation can be seen in the posterior portion of the left thyroid lobe (curved arrow), and slightly decreased attenuation can be seen anteriorly in the right thyroid lobe (straight arrow).

Dr Ahmed Esawy

Sub sternal mediastinal extension Tracheal compression

Dr Ahmed Esawy

Trachea, stenosis. Chest radiograph shows an intrathoracic goiter with tracheal compression and deviation (arrows).

Dr Ahmed Esawy

Trachea, stenosis. Axial CT scan in a patient with an intrathoracic multinodular goiter (MNG), which is compressing the trachea.

Dr Ahmed Esawy

Trachea, stenosis. Axial CT scan in a patient with a multinodular goiter (MNG) compressing the cervical trachea.

Dr Ahmed Esawy

Trachea, stenosis. CT scan shows an intrathoracic goiter compressing the trachea.

Dr Ahmed Esawy

Multinodular goiter. Axial contrast-enhanced CT scan demonstrates multiple low-attenuating nodules in an enlarged gland.

Goiter. Axial contrast-enhanced CT scan demonstrates tracheal stenosis due to external compression.

Dr Ahmed Esawy

Goiter. Enhanced CT reveals an enhancing heterogeneous soft-tissue mass (arrows) that originated in the thyroid gland and descended through the thoracic inlet deviating the trachea (asterisk) to the right.

Dr Ahmed Esawy

Other causes of thyrotoxicosis

Dr Ahmed Esawy

Interferon related Thyroiditis:Serum TSH 12mU/L

Dr Ahmed Esawy

More commonly patients develop hypothyroidism due to iodine content The minority develop thyrotoxicosis Type 1 is an iodine load-induced hyperthyroidism which occurs in abnormal glands (MNG or Graves); increased vascularity Type 2 is a destructive thyroiditis; normal gland; normal or decreased vascularity; low/absent upatke on RAIU

Amiodarone-Induced Thyrotoxicosis (AIT)

Dr Ahmed Esawy

74 yo man on Amiodarone for several years now with hyperthyroidism

Dr Ahmed Esawy

amiodarone

TUS image in a 69-year-old patient who developed hypothyroidism after treatment by amiodarone.

Dr Ahmed Esawy

Amiodarone Thyroiditis

Dr Ahmed Esawy

Rarely acute suppurative thyroiditis cause thyrotoxicosis

Dr Ahmed Esawy

Infection commonly starts in the perithyroid soft tissues Abscesses, both intra- and extrathyroid in locations, (appear as ill-defined, hypoechoic heterogeneous lesions with internal debris. Internal septa or gas may be present) Adjacent inflammatory/reactive nodes are usually seen guiding needle aspiration of the abscess

Dr Ahmed Esawy

Transverse grey scale ultrasound in acute suppurative thyroiditis shows a focal abscess in the left lobe of thyroid in the form of an ill-defined hypoechoic lesion (arrow) with adjacent inflammatory thickening. The common carotid aretries (arrowheads) and the left internal jugular vein (curved arrow) are intact.

Dr Ahmed Esawy

Axial contrast enhanced CT of the focal thyroid abscess as an ill-defined poorly enhancing hypodense lesion (arrow). The common carotid arteries (curved arrows) and internal jugular veins (arrowheads) are intact and patent

Dr Ahmed Esawy

barium swallow study show delineates the left pyriform fossa sinus (arrows) associated with a fourth branchial cleft anomaly.

Dr Ahmed Esawy

Computed tomography scan showed a large, multiseptated, low attenuated mass in the right thyroid lobe and enlarged lymph node in the right neck level IV, V, and VI areas.

Ultrasonography of the neck revealed a right thyroid mass of about 4.52.54.6 cm with heterogeneously increased internal echogenicity

Acute Suppurative Thyroiditis

Dr Ahmed Esawy

2-year-old boy with acute suppurative thyroiditis. Contrast-enhanced CT shows a fluid collection (arrows) with internal gas (arrowhead) involving left lobe of thyroid gland (open arrows) and adjacent soft tissue.

Dr Ahmed Esawy

Dr Ahmed Esawy

Riedels thyroiditis

is a chronic sclerosing replacement of the gland that is exceedingly rare. The process extends to adjacent structures

Synonyms include ligneous thyroiditis and invasive fibrous or chronic sclerosing thyroiditis. This condition is characterized by overgrowth of connective tissue which often extends into neighboring structures.

Dr Ahmed Esawy

Thyroid Ultrasound in hypothyroidism

Dr Ahmed Esawy

HYPOTHYRIODISM

CONGENITAL Dysgenesis ectopic thyriod (Sublingual thyroid) Agenesis Hypoplasia Hemiagenesis

ACQUIRED

primary(thyroid failure) Secondary (Central) pituitary TSH deficit hypothalamic deficiency Peripheral resistance to the thyroid hormones

Dr Ahmed Esawy

CONGENITAL HYPOTHYRIODISM

Transient: P/o maternal antibodies due to a thyrotropin receptor blocking antibody; maternal ingestion of antithyroid medication or iodine overload caused by exposure to iodine containing antiseptics.

Permanent: 80 % of them are caused by: Aplasia, hypoplasia, hemiplasia or ectopy 15- 20% results from dyshormonogenesis.

Dr Ahmed Esawy

HYPOTHYRIODISM

PRIMARY(thyroid failure) 1-Hashimotos thyroiditis A/ with goiter B /thyroid atrophy end-stage autoimmune thyroid disease, following either Hashimotos thyroiditis or Graves disease 2. Subacute thyroiditis 3. Thyroidectomy or therapy for hyperthyroidism (drugs, 131I amiodarone) 4. Excessive iodide intake 5. Other causes A/ Iodide deficiency B/ Goitrogens C/ Inborn errors of thyroid hormone synthesis 6-Amyliodosis infiltration

Secondary (Central) pituitary TSH deficit hypothalamic deficiency (pituitary adenoma, pituitary ablative therapy, or pituitary destruction Hypothalamic destruction )

Peripheral resistance to the thyroid hormones Dr Ahmed Esawy

HYPOTHYRIODISM

Goitrus

Non-Goitrus

Iodine deficiency (diffuse goitre which often becomes nodular . The perfusion is normal. Enlargement of the thyroid gland is an adaptive process in low iodine intake)

Dr Ahmed Esawy

State of thyroid blood perfusion Perfusion of the thyroid increases on several occasions:

increased cardiac output (a stressed patient),

in gravidity,

during an active autoimmune inflammation active Graves disease or Hashimotos thyroiditis ((in active Graves disease thyroid inferno).

hyperfunctioning nodules

untreated primary hypothyroidism because of TSH stimulation.

decreased perfusion in breakdown of the thyroid tissue as is the case of

postpartum thyroiditis,

De Quervain thyroiditis

amiodarone-induced thyrotoxicosis type 2.

Dr Ahmed Esawy

PSV normal up to 25 cm/sec

PSV at thyrotoxicosis more than 100 cm/sec

PSV at hypothyroidism 50-60 cm/sec

Dr Ahmed Esawy

Congenital hypothyroidism

Dr Ahmed Esawy

Reference Standard for Thyroid Size (cm) by Age

Dr Ahmed Esawy

Congenital hypothyroidism: Ultrasound

Dr Ahmed Esawy

Congenital hypothyroidism: Scintigraphy

Dr Ahmed Esawy

Congenital hypothyroidism: Dyshormonogenesis

Dr Ahmed Esawy

10-day-old girl with sublingual thyroid gland..

Dr Ahmed Esawy

Ultrasound: Less sensitive in detecting ectopic thyroid (although has high specificity) NM thyroid scintigraphy : Tc 99m pertechnetate or I -123

Dr Ahmed Esawy

14-day-old girl with thyroid agenesis.

Dr Ahmed Esawy

7-day-old boy with thyroid hemiagenesis.

Dr Ahmed Esawy

20-day-old girl with hemiagenesis and sublingual thyroid.

Dr Ahmed Esawy

9-day-old boy with thyroid gland in normal location. Dr Ahmed Esawy

Parents can be counseled on either the certainty of lifetime therapy (for dysplastic thyroid) or the possibility of later discontinuing therapy (for eutopic thyroid, because CH may be transient in these children). If the dysplastic thyroid gland is absent or ectopic (usually a small sublingual gland), parents can be told that the infant will need lifetime thyroid therapy. If the thyroid gland is present in the normal position (eutopic) and the condition is transient (as shown by controlled withdrawal of thyroid in older children),lifelong treatment may not be needed.

Congenital hypothyroidism: How does imaging help?

Dr Ahmed Esawy

Chronic Lymphocytic (Hashimotos) Thyroiditis

Dr Ahmed Esawy

Hashimotos thyroiditis

Destructive autoimmune disorder which leads to chronic inflammation of gland

Enlargment not necessarly symmetric

Young Middle aged female

Dr Ahmed Esawy

classical sonographic appearance diffuse, moderately enlarged, hypoechoic gland obulated contours heterogeneous echo pattern fine, echogenic fibrotic streaks within. The vascularity varies with the stage and type of involvement

Dr Ahmed Esawy

Hashimotos thyroiditis Three stages

-Acute : enlarged in size

decreased vascularity

or hypervascularity in Hashimoto thyroiditis is never as marked

as in Graves disease, and the flow velocities are within

normal limits

discrete nodules occur in nearly equal frequency against a

background normal thyroid parenchyma

Those nodules with background Hashimoto thyroiditis tend to be solitary, solid, non-calcified, hyperechoic and haloed, while those nodules without background of Hashimoto thyroiditis

Ill-defined, patchy hypoechoic areas (~26 mm) separated by

echogenic fibrous septa may be seen Representing lymphocyte infiltration and echogenic rims due to fibrous septa

Dr Ahmed Esawy

Transverse grey scale ultrasound shows diffuse hypoechoic goitre (arrows) with ill-defined patchy hypoechoic areas separated by echogenic fibrous septa (curved arrow) in acute diffuse Hashimoto thyroiditis.

Dr Ahmed Esawy

chronic Hashimoto thyroiditis enlarged, hypoechoic, micronodular gland with lobulated contours. Diffuse, hypoechoic parenchymal echoes giving the appearance of ghost-like thyroid atrophic/end stage, Hashimoto thyroiditis small, hypoechoic gland with heterogeneous echo pattern, and usually hypovascular on Doppler

Dr Ahmed Esawy

Hashimotos Clinical Signs

Most common form of thyroiditis

Autoimmune chronic inflammation

Diffuse enlargement

possibly asymmetric

Painless

may develop mild pain over time

Eventual hypothyroidism

Young middle aged females

Sonographic Findings:

Increased Vascularity with Color Doppler

Texture is course and homogenous with

multiple ill-defined hypoechoic areas

separated by thick fibrous strands

Over time, the gland becomes fibrotic, ill-

defined, and heterogeneous

Dr Ahmed Esawy

Gland size enlarged, normal or small Parenchymal hypoechogenicity Diffuse or patchy regions May precede antibody positivity (15% pts) Fibrosis common Vascularity Variable, correlates with immune response Lymphadenopathy Common in the central compartment

Sonographic Appearance of Chronic Lymphocytic Thyroiditis (Hashimoto thyroiditis)

Dr Ahmed Esawy

Hashimotos thyroiditis

Sonographic features :

diffusle enlarged and coarse parenchyma

heterogenous texture

Multiple hypoechioc nodules in both lobes

Dr Ahmed Esawy

Hashimotos thyroiditis

Dr Ahmed Esawy

Hashimotos thyroiditis (late stage)

Heterogeneous and coarse parenchyma Multiple small hypoechoic nodules surrounded by an echogenic rim of fibrosis Vascularity : Variable; increased early in the disease and decreased later in the disease course

Dr Ahmed Esawy

diffusely coarse echotexture with innumerable tiny hypoechoic nodules that may become confluent, interspersed with echogenic fibrous bands. Vascularity may be increased, decreased, or normal, and FNA is usually not necessary for diagnosis.

painless enlarged thyroid usually in a hypothyroid state .few in hyperthyriod state

Hashimotos thyroiditis

Dr Ahmed Esawy

Chronic lymphocytic (Hashimoto) thyroiditis in a 53-year-old woman with a swollen thyroid. (a) Longitudinal duplex US image shows diffusely heterogeneous thyroid parenchyma with abnormal diffusely increased vascular flow.

Dr Ahmed Esawy

TUS image of the right thyroid lobe in a patient with Hashimotos thyroiditis with a large goitre.

Dr Ahmed Esawy

Nodular Hashimotos thyroiditis

Homogeneously echogenic nodule with a hypoechoic rim: white knight

Dr Ahmed Esawy

Typical TUS image of Hashimotos thyroiditis (TSH 17 mIU/l, highly positive thyroid autoantibodies). Note the inhomogenous and hypoechogenic thyroid texture.

Dr Ahmed Esawy

Preclinical stage: Scintigraphy may show increased uptake

Difficult to distinguish Hashitoxicosis from

Graves disease by US or scintigraphy.

Dr Ahmed Esawy

Hashimotos thyroiditis is often asymmetric Can be a solitary focal lesion Accounts for up to 10% of focal lesions May still require FNA

Focal Hashimotos thyroiditis

Dr Ahmed Esawy

Focal Thyroiditis

Hashimotos thyroiditis is often asymmetric Can be a solitary focal lesion Accounts for up to 10% of focal lesions May still require FNA

Dr Ahmed Esawy

Focal chronic autoimmune thyroiditis represented by a hypoechoic, partially defined nodule (A) demonstrating hypervascularization at amplitude color Doppler (B).

Dr Ahmed Esawy

Hashimotos Thyroiditis

Hashimotos Thyroiditis normal

Dr Ahmed Esawy

Multiple hypoechoic, ill-defined nodules 1-6mm in size Geographic hypoechoic areas Linear white lines representing fibrosis Interrupted capsule Variable vascularity

Hashimotos Thyroiditis

Dr Ahmed Esawy

Hashimotos Thyroiditis

Dr Ahmed Esawy

Are these nodules

Dr Ahmed Esawy

these are not nodules Cleft sign

Dr Ahmed Esawy

Patchy thyroiditis vs. nodules

Dr Ahmed Esawy

Over time the gland tends to become more hypoechoic and enlarged Palpable surface nodularity Pseudonodular sonographic appearance End-stage may be a small and irregular gland

Hashimotos Thyroiditis

Dr Ahmed Esawy

Hashimotos Thyroiditis

Dr Ahmed Esawy

PTC in Hashimotos

Dr Ahmed Esawy

Typical PTC features overlap with HT features Hyopechogenicity, solid consistency, irregular or infiltrating margins Key finding is pattern of calcifications Clustered microcalcifications or dystrophic calcifications Asymmetrical lobar involvement

Appearance of PTC in HT glands

Dr Ahmed Esawy

Infiltrating PTC in CLT (Hashimotos)

Microcalcifications throughout the right lobe without a focal mass

Dr Ahmed Esawy

59-year-old woman (a false-negative). A and B, Transverse and longitudinal sonographic images of the thyroid show fine isoechogenicity, a normal range for the AP diameter, and the presence of a smooth margin. Pathology results showed a papillary thyroid carcinoma in the left lobe and chronic lymphocytic thyroiditis after thyroid surgery.

Dr Ahmed Esawy

DTD of the thyroid in a 33-year-old woman. Transverse and longitudinal sonographic images of the thyroid show mild hypoechogenicity, coarse echogenicity, mildly increased vascularity, and the presence of a microlobulated margin. Pathology results showed HT and a papillary thyroid carcinoma in the left lobe after thyroid surgery.

Dr Ahmed Esawy

Hashimotos with Unilateral Lateral Cervical Lymphadenopathy

Dr Ahmed Esawy

increased incidence of thyroid malignancy in Hashimoto thyroiditis. A strong association is identified between thyroid non-Hodgkin lymphoma and antecedent Hashimoto thyroiditis.

Dr Ahmed Esawy

Hashitoxicosis

Dr Ahmed Esawy

Graves disease / Hashimotos thyroiditis

Thyroid inferno Graves disease: 4 hour uptake of 40% Dr Ahmed Esawy

Thyroid parenchyma echogenicity follows: grade 1 normal, echogenicity similar to the one of the prethyroid musculature; grade 2 hypoechoic in relation to the submandibular gland and hyperechoic in relation to the prethyroid musculature; grade 3 iso- or hypoechoic in relation to the prethyroid musculature grade 4 thyroid gland with increased volume and diffuse and marked parenchyma hypoechogenicity

Value of thyroid echogenicity in the diagnosis of chronic autoimmune thyroiditis

Dr Ahmed Esawy

Longitudinal view of left thyroid lobe. Bmode US demonstrates micronodular texture and hypoechoic aspect of the thyroid parenchyma. The echogenicity level of the thyroid gland is lower than that of the adjacent musculature.

Transversal view of left and right thyroid lobes. B-mode US demonstrates typical aspect of thyroid parenchyma echogenicity. The echogenicity level of the thyroid gland is higher than that of the adjacent musculature.

chronic autoimmune thyroiditis

Dr Ahmed Esawy

Longitudinal views of thyroid lobe. Mode-B US demonstrates a diffusely heterogeneous texture of the thyroid parenchyma with no nodule (A). Amplitude color Doppler demonstrates a diffusely increased vascularization of the gland (B).

chronic autoimmune thyroiditis

Dr Ahmed Esawy

Longitudinal views of thyroid lobe. Mode-B US demonstrates a diffusely heterogeneous texture of the thyroid parenchyma intermingled with areas of lower echogenicity (pseudonodules), where true nodules are not characterized (A). Amplitude color Doppler demonstrates increased vascularization of the thyroid gland; and nodules are not delimited (B).

chronic autoimmune thyroiditis

Dr Ahmed Esawy

Longitudinal views of thyroid lobe. Mode-B US demonstrates a diffusely heterogeneous texture of the thyroid parenchyma intermingled with areas of lower echogenicity where true nodules are not characterized (A). Amplitude color Doppler demonstrates increased vascularization of the thyroid gland (B).

chronic autoimmune thyroiditis

Dr Ahmed Esawy

B-mode US demonstrates chronic autoimmune thyroiditis with goiter: hypoechogenic and heterogeneous thyroid gland increase in volume (A,B,C). Presence of hyperechogenic pattern of fibrosis (A,B) and lobulated margins (C).

chronic autoimmune thyroiditis

Dr Ahmed Esawy

Atrophic presentation of chronic autoimmune thyroiditis with heterogeneous and hypoechogenic thyroid gland presenting with decrease in volume

chronic autoimmune thyroiditis

Dr Ahmed Esawy

At left, computed histogram in a longitudinal view of the thyroid parenchyma, and at left, in a transverse view of the sternocleidomastoid muscle (1),prethyroid musculature (2) and subcutaneous fat tissue (3). One can observe that the mean value of the thyroid parenchyma echogenicity is lower than that of the adjacent muscles, configuring the hypoechogenic pattern of chronic autoimmune thyroiditis

chronic autoimmune thyroiditis

Dr Ahmed Esawy

At left, computed histogram in a transverse view of the left thyroid lobe, and at right, in a transverse view of the sternocleidomastoid muscle (1),prethyroid muscle (2) and subcutaneous fat tissue (3). One can observe that the mean value of the thyroid parenchyma echogenicity is lower than that of the adjacent muscles, configuring the hypoechogenic pattern of chronic autoimmune thyroiditis.

chronic autoimmune thyroiditis

Dr Ahmed Esawy

At left, computed histogram in a transverse view of the left thyroid lobe, and at right, in a transverse view of the sternocleidomastoid muscle (1),prethyroid muscle (2) and subcutaneous fat tissue (3). One can observe that the mean value of the thyroid parenchyma ( ROI 1 at left) echogenicity is higher than that of the prethyroid and sternocleidomastoid muscles (ROI 1 and 2 at right), configuring the normal echogenicity pattern of the thyroid.

chronic autoimmune thyroiditis

Dr Ahmed Esawy

Subacute Thyroiditis

Subacute granulomatous thyroiditis (nonsuppurative thyroiditis, subacute thyroiditis, or de Quervain thyroiditis)

Dr Ahmed Esawy

A number of inflammatory conditions can affect the thyroid gland, which are commonly described as thyroiditis : subacute thyroiditis

granulomatous: de Quervain thyroiditis: subacute granulomatous thyroiditis Lymphocytic (autoimmune ) : subacute lymphocytic thyroiditis: silent thyroiditis or painless subacute thyroiditis

postpartum thyroiditis: is a subtype of silent thyroiditis

Dr Ahmed Esawy

https://radiopaedia.org/articles/thyroid-glandhttps://radiopaedia.org/articles/autoimmune-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-thyroiditishttps://radiopaedia.org/articles/de-quervain-thyroiditishttps://radiopaedia.org/articles/subacute-granulomatous-thyroiditishttps://radiopaedia.org/articles/subacute-granulomatous-thyroiditishttps://radiopaedia.org/articles/subacute-granulomatous-thyroiditishttps://radiopaedia.org/articles/subacute-granulomatous-thyroiditishttps://radiopaedia.org/articles/autoimmune-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/missing?article[title]=sub-acute-lymphocytic-thyroiditishttps://radiopaedia.org/articles/post-partum-thyroiditis

Subacute Thyroiditis

Subacute thyroiditis usually presents with a transient hyperthyroidism followed by hypothyroidism

The lymphocytic kind, which is silent thyroiditis [has an unknown pathogenesis or is autoimmune]

the granulomatous kind, which is painful [and typically has a viral etiology]. de Quervain thyroiditis

Dr Ahmed Esawy

https://radiopaedia.org/articles/de-quervain-thyroiditishttps://radiopaedia.org/articles/de-quervain-thyroiditis

Subacute granulomatous (De Querveins)thyroiditis Clinical Signs

Usually viral

Diffuse enlargement

Tenderness / mild to severe pain

Transient hyperthyroidism

Gradual or fairly abrupt onset

Dr Ahmed Esawy

Subacute (De Querveins) thyroiditis

The inflammation do not involve entire gland but infiltrates gland in non-homogenous pattern

Sonographic feature (hypoechoic and hyper vascular areas)

Dr Ahmed Esawy

acute phase 1-focal,ill-defined, hypoechoic nodular area in the subcapsular region 2-normal or heterogeneous, hypoechoic adjacent thyroid parenchyma. 3-nodular area is avascular or hypovascular on Doppler ultrasound 4-Tenderness of the thyroid is elicited by transducer pressure 5-Inflammatory nodes are often seen in the central compartment or the lower internal jugular chain.

Dr Ahmed Esawy

Transverse power Doppler ultrasound shows a focal, ill-defined, avascular, hypoechoic nodular area in the subcapsular region (arrow) in the acute phase of de Quervain thyroiditis

Dr Ahmed Esawy

subacute phase

1-progression of glandular enlargement to involve the whole lobe or even the entire gland 2-Hypovascular 3-diffuse patchy or confluent, ill-defined hypoechoic echo pattern. 4-residual tenderness on transducer pressure. 5-Adjacent inflammatory nodes may still be seen

Dr Ahmed Esawy

Subacute Thyroiditis-DeQuervains

0.16 to 0.36% of thyroid disease Usually a viral infection Usually an adult female with thyroid tenderness, systemic systems May have thyrotoxicosis or be euthyroid Hypoechoic patchy or nodular areas that resolve Variable vascularity Maybe highly vascular and simulate Graves Disease

Dr Ahmed Esawy

Longitudinal grey scale ultrasound shows that in the subacute phase of de Quervain thyroiditis there is progression to involve almost the entire lobe (arrows).

Dr Ahmed Esawy

recovery atrophic phase return to normal appearance Occasionally glandular atrophy residual nodule may be seen

Dr Ahmed Esawy

Subacute Thyroiditis

43 yo female patient with a swollen and painful thyroid

One year later

Dr Ahmed Esawy

Subacute Thyroiditis

30/M

Hyperthyroid symptoms

131I thyroid scan

Thyroid not visualized

Only background radioactivity

Dr Ahmed Esawy

Iodine-131 radionuclide scan shows virtually no uptake of radioactive iodine by the thyroid gland.

Dr Ahmed Esawy

TUS image of subacute thyroiditis in the hyperthyroid phase (FT3: 10.7 pmol/l, FT4: 33.1 pmol/l, TSH: 0.039 mIU/l, antibodies negative). Note the low perfusion as shown by the Doppler imaging (right).

Dr Ahmed Esawy

thyroidectomy

Absent thyroid gland in a patient after total thyroidectomy due to papillary thyroid carcinoma. Note fibrous tissue without residual thyroid parenchyma in the thyroid beds.

Dr Ahmed Esawy

Atrophic Thyroiditis

Autoimmune thyroid disease Small and atrophic gland Maybe hypoechoic or normal echogenicity Normal of low uptake on I-123 scan Dr Ahmed Esawy

atrophic thyroiditis

TUS of atrophic thyroiditis (a patient with mild hypothyroidism: TSH 9.43 mIU/l, highly positive anti-TPO antibodies).

Dr Ahmed Esawy

Post partum

TUS of the left thyroid lobe of patient with PPT which occurred two months after delivery . Four months after delivery, the patient developed hypothyroidism

Dr Ahmed Esawy

euthyroid thyriod Enlarged thyroid

No functional disturbance

Dr Ahmed Esawy

euthyroid woman

TUS image in a young euthyroid woman with negative antithyroid antibodies

Dr Ahmed Esawy

TUS of a diffuse goitre in a euthyroid patient

Dr Ahmed Esawy

Normal TUS image of left thyroid lobe (euthyroid patient with negative thyroid autoantibodies). Note the low perfusion on the Doppler imaging (right).

Dr Ahmed Esawy

amyloidosis

TUS image of thyroid amyloidosis confirmed by cytology

Dr Ahmed Esawy

Langerhans cell histiocytosis

in the thyroid may manifest as goitre and precede subsequent multisystem involvement

Diffuse or nodular hypoechoic goitre with heterogeneity heterogeneous thyroid enlargement with anterior prominent projections FNAC confirming the diagnosis.

Dr Ahmed Esawy

multifocal, ill-defined,heterogeneous hypoechoic lesions involving both lobes of the Thyroid solitary well-defined, heterogeneous, predominantly anechoic lesion with internal echoes and irregular margins/walls

Thyroid tuberculosis

Dr Ahmed Esawy

Malignant diffuse thyroid disease

Dr Ahmed Esawy

Accounts for 0.8% to 5.3% of PTC Patients present with a diffuse goiter Mostly are euthyroid (hypothyroid or hyperthyroid) Most frequently in young females Mistaken for thyroiditis Lymph node and lung metastases are common Similar cure rates c/w classic PTC

Diffuse Sclerosing Variant of Papillary Thyroid Cancer

Dr Ahmed Esawy

Scattered Calcifications

Psammoma Bodies

Diffuse Sclerosing Variant of Papillary Thyroid Cancer Dr Ahmed Esawy

anaplastic carcinoma

rapidly growing, large (usually >5 cm), painful thyroid-area mass symptoms from local invasion/compression to the upper aerodigestive tract, such as dyspnoea, dysphagia and hoarseness

Dr Ahmed Esawy

Ill defined hypoechoic tumour diffusely infiltrating the entire lobe or gland Necrotic areas and dense amorphous calcifications are common Background of nodular goitre is seen in 47%. Extracapsular spread to invade the adjacent structures is seen in a third of the patients Nodal or distant metastases are present in 80% of patients The metastatic nodes are hypoechoic and show cystic necrosis in 50% of cases Doppler ultrasound shows multiple, small, chaotic intratumoral vascularity necrotic tumours may be avascular or hypovascular due to vascular infiltration/occlusion Abnormal vascularity is also seen within the metastatic nodes tumour thrombus in the infiltrated vessels.

Sonographic features

Dr Ahmed Esawy

Transverse grey scale ultrasound shows an anaplastic carcinoma of thyroid as an ill-defined hypoechoic tumour diffusely infiltrating the entire gland (arrows). Note the dense amorphous calcifications (curved arrows).

Dr Ahmed Esawy

Transverse grey s cale ultrasound of shows an enlarged, roundish, hypoechoic nodal metastasis (arrows) with cystic necrosis (curved arrow) from the anaplastic carcinoma.

Dr Ahmed Esawy

Thyroid metastases

haematogenous spread, such as malignant melanoma (39% of cases), renal (10% of cases), breast (21% of cases)54 and lung carcinomas. Pancreatic and gastrointestinal malignancies

Dr Ahmed Esawy

Sonographic findings

ill-defined, heterogeneous hypoechoic lesions May be relatively circumscribed, iso- or hypo-echoic, and show cystic/necrotic components. They are often multiple, unilateral or bilateral. The absence of microcalcification is useful to distinguish from primary papillary carcinoma of thyroid Ultrasound guided fine needle aspiration was shown to provide diagnostic

Dr Ahmed Esawy

Longitudinal power Doppler ultrasound shows a thyroid metastasis as an ill-defined, heterogeneous hypoechoic lesion (arrows). Note the scanty vasculrity. Patients with thyroid metastases often have extensive metastatic disease in the rest of the body and thus a poor prognosis.

the primary bronchogenic carcinoma in the medial aspect of the lower lobe of the right lung) *).

Dr Ahmed Esawy

Chronic lymphocytic leukaemia /small lymphocytic lymphoma

Dr Ahmed Esawy

CLL/SLL 2 to 5% of all thyroid malignancies Nodular pattern Homogeneously hypoechoic with lobulated but well defined border; enhanced though transmission Diffuse disease- asymmetric enlargement, heterogeneous,hypoechoic goitre Mixed pattern . hypoechoic,enlarged neck nodes with loss of normal architecture and abnormal increased vasculature on Doppler

Dr Ahmed Esawy

Transverse grey scale ultrasound shows a heterogeneous, hypoechoic goitre of the right lobe of thyroid (arrows). Adjacent abnornal right jugular chain lymph node with loss of normal architecture (curved arrow) is present. Biopsy revealed leukaemia.

Dr Ahmed Esawy

Transverse grey scale ultrasound shows a diffuse goitre with heterogeneous, hypoechoic echo pattern (arrows). An enlarged pre-tracheal node with loss of normal architecture is present (curved arrow). Biopsy revealed lymphoma.

Dr Ahmed Esawy

Transverse power Doppler ultrasound shows an ill-defined,heterogeneous hypoechoic lesion (arrows) involving most of the right lobe of thyroid. Increased vascularity, mainly peripheral, is demonstrated. Biopsy showed thyroid lymphoma

Dr Ahmed Esawy

Longitudinal power Doppler ultrasound shows an enlarged, elliptical, hypoechoic lymph node (arrows) with loss of normal architecture and abnormal increased peripheral vascularity

Dr Ahmed Esawy

Thyroid Lymphoma

Small and atrophic right lobe

Enlarged and hypoechoic left lobe

Dr Ahmed Esawy

Enlarged left lobe Hypoechoic, lobulated lesion Good through transmission

Thyroid Lymphoma

Dr Ahmed Esawy

May have patchy irregular areas that are pseudo-nodules Tend to be small (under 15 mm), hyperechoic and non-calcified Larger lesions or those with irregular margins raise concern for a neoplasm Focal calcifications and asymmetric calcifications should be considered suspect for papillary carcinoma

Dilemma: Nodules in patients with Diffuse Thyroid Disease

Dr Ahmed Esawy

Sonogram of the left lobe of the thyroid gland in the transverse plane showing a rounded lobe of a goiter. L=enlarged lobe, I= widened isthmus, T=trachea, C=carotid artery ( note the enhanced echoes deep to the fluid-filled blood vessel), J=jugular vein, S=Sternocleidomastoid muscle, m=strap muscles,E=esophagus.

Dr Ahmed Esawy

Quantitative analysis of echogenicity for patients with

thyroid nodules

Dr Ahmed Esawy

The coordinates of three defined regions, the nodule, thyroid parenchyma, and strap muscle regions

Dr Ahmed Esawy

gray values inside the selected regions of the nodule = nodule gray values inside the thyriod = thyroid gray values inside the muscle = muscle

nodule can be classified as hypoechogenicity when nodule is smaller than thyroid marked hypoechogenicity when nodule is smaller than muscle

differences between nodule and muscle and between nodule and thyroid were recorded to represent the adjusted EI of the nodule and were denoted as EIN-M and EIN-T

Dr Ahmed Esawy

Autonomic references was calculated using the software

Dr Ahmed Esawy

where GRij is the gray value of the pixel (i, j), and L is the average of the non-zero gray values of all pixels in the anterior region

The average gray value of the outside reference (ref) was then calculated as follows

Finally, the automatic EI was obtained by

Dr Ahmed Esawy

Analysis of EIs of Benign and Malignant Thyroid Nodules

Dr Ahmed Esawy

echogenicity index (EIN-M and automatic EI (EI(N-R)/R) values for lesions

Dr Ahmed Esawy