Infrahyoid Neck

https://www.youtube.com/watch?v=Dn7-jsMxk18

[00:04] hi welcome back my name is Nick Koontz
[00:06] hi welcome back my name is Nick Koontz and I'm a neuro radiologist and head and
[00:08] and I'm a neuro radiologist and head and neck imager at Indiana University School
[00:09] neck imager at Indiana University School of Medicine and I'm back with another
[00:11] of Medicine and I'm back with another full-length radiology lecture that I've
[00:14] full-length radiology lecture that I've recorded and just like the others the
[00:16] recorded and just like the others the the purpose of these is just to have
[00:18] the purpose of these is just to have some educational content that we can
[00:20] some educational content that we can share with the trainees the residents
[00:22] share with the trainees the residents the fellows the medical students right
[00:25] the fellows the medical students right now is we have trainees that are
[00:26] now is we have trainees that are potentially in quarantine or or being
[00:28] potentially in quarantine or or being furloughed as we're sort of adjusting to
[00:31] furloughed as we're sort of adjusting to the new reality of what's going on with
[00:33] the new reality of what's going on with this escalating kovat crisis so just
[00:36] this escalating kovat crisis so just wanting to do my part put some some
[00:38] wanting to do my part put some some educational content out there to share
[00:40] educational content out there to share freely among people who are interested
[00:42] freely among people who are interested in it hope everybody's doing well
[00:44] in it hope everybody's doing well staying healthy staying sane the this
[00:48] staying healthy staying sane the this topic for today's talk is going to focus
[00:50] topic for today's talk is going to focus on the infrahyoid neck and it's sort of
[00:53] on the infrahyoid neck and it's sort of gonna be a differential diagnosis based
[00:54] gonna be a differential diagnosis based lecture so we'll run through the the
[00:56] lecture so we'll run through the the different contents the different spaces
[00:58] different contents the different spaces and infrahyoid neck or at least the main
[01:00] and infrahyoid neck or at least the main ones and talk about some of the
[01:03] ones and talk about some of the different structures and some of the
[01:04] different structures and some of the pathologies that can occur here.
[01:08] pathologies that can occur here so I have no disclosures to make wish I.
[01:11] so I have no disclosures to make wish I had some financial disclosures but alas.
[01:13] had some financial disclosures but alas I do not.
[01:15] I do not I would like to acknowledge several people.
[01:18] would like to acknowledge several people who were kind enough to to share some.
[01:21] who were kind enough to to share some content with me for this talk first and.
[01:23] content with me for this talk first and foremost Rick Wiggins and and Rick horns.
[01:25] foremost Rick Wiggins and and Rick horns Berger both of whom over the years have.
[01:27] Berger both of whom over the years have shared a lot of Education and learning.
[01:29] shared a lot of Education and learning with me but have also provided some of.
[01:32] with me but have also provided some of the graphics as well as a couple of the.
[01:35] the graphics as well as a couple of the cases that you'll find in this.
[01:36] cases that you'll find in this presentation so thanks to both Rick and.
[01:39] presentation so thanks to both Rick and Rick for for the kindness and sharing.
[01:40] Rick for for the kindness and sharing these over the years I'd also like I.
[01:42] these over the years I'd also like I think Jim Milburn and Todd come both of.
[01:46] think Jim Milburn and Todd come both of whom provided some additional content.
[01:48] whom provided some additional content for this lecture as well and and you'll.
[01:51] for this lecture as well and and you'll see that here in a few minutes so again.
[01:53] see that here in a few minutes so again lots of parties can't take credit for.
[01:55] lots of parties can't take credit for our everything that you're seeing here.
[01:57] our everything that you're seeing here in this talk but you know in the spirit.
[01:59] in this talk but you know in the spirit of sharing this I do want to thank them.
[02:02] of sharing this I do want to thank them for everything that they've done to help.
[02:04] for everything that they've done to help out with this as well.
[02:06] out with this as well okay so let's get started.
[02:09] okay so let's get started the infrahyoid net covers a lot of the infrahyoid net covers a lot of ground.
[02:12] there are a lot of different spaces that are involved each of which contain multiple anatomic structures and for that reason there's really a lot of pathology that can occur here.
[02:19] in fact the thing that I think is most challenging but at the same time most interesting about the infrahyoid neck is just the diversity of pathologies that can occur here.
[02:28] so one of the key things really maybe the most important thing to take home from this talk is whenever you're approaching a generic lesion a generic Mass you name it whatever it is that you encounter in the neck try to figure out where it's coming from what is the space of origin where it's arising from because if you can do that that's immediately going to narrow down your differential diagnosis.
[02:52] another thing to keep in mind if you see something that is extending between multiple spaces or if it's multi spatial or trans spatial think about congenital etiologies as well as aggressive ideologies things like infection or malignancy because those are the types.
[03:07] malignancy because those are the types of things that tend to cross those spatial boundaries.
[03:12] Okay, so that was sort of the very brief introduction and there's a lot of content to cover here so I'm just going to dig right in.
[03:21] So first we're talking about a space-based differential diagnosis and run through some common and uncommon things that we encounter in the visceral space.
[03:29] Now as you look at the visceral space, as you can see here, there's a lot of contents within it and each of these will have different pathologies that can occur.
[03:40] So I'm not gonna talk specifically about the larynx and I'm really only barely gonna dabble into the hypopharynx.
[03:47] Those two are sort of an entity into themselves and it's sort of a separate talk that would cover all of the many things that can happen here.
[03:56] So we're not going to talk about those, but instead we're gonna start with the trachea.
[04:01] And the trachea is something that I think that head and neck radiologists tend not to embrace anywhere near the same way that the
[04:09] anywhere near the same way that the chest radiologists do and I think that chest radiologists do and I think that that's something that we really need to that's something that we really need to be thinking about and having at least a basic understanding of some of the pathologies that can occur here.
[04:19] so the first thing to talk about is tracheal stenosis and that's because it's such a common indication for imaging these patients will often present with dis Nia and I think that when I approach one of these cases some of the key things that I want to think about is am i dealing with a child or an adult because with a child you're thinking more commonly anyway of congenital things an adult much more common to be dealing with acquired etiologies.
[04:43] critically has the patient had prior surgery have they had a prior intubation was it a prolonged intubation or traumatic intubation when I look at it is this a short segment is it very focal or is it a long segment process and then importantly things to report would be how narrow does it get what's the narrowest diameter because that's something that the surgeons that the pulmonologist may want to know about and we're near dealing with a lesion a mass.
[05:12] we're near dealing with a lesion a mass you want to try to decipher am i dealing
[05:15] you want to try to decipher am i dealing with endo luminal obstruction something
[05:17] with endo luminal obstruction something that's contained within the trachea
[05:19] that's contained within the trachea itself or is this extrinsic compression
[05:21] itself or is this extrinsic compression something on the outside
[05:22] something on the outside smashing it down and then when you look
[05:25] smashing it down and then when you look at it you want to look and see does it
[05:27] at it you want to look and see does it look like some sort of a smooth
[05:29] look like some sort of a smooth contoured thing or is it something that
[05:32] contoured thing or is it something that looks ratty and aggressive
[05:35] so when we're dealing acquired trachea
[05:37] so when we're dealing acquired trachea lore subglottic stenosis as you can see
[05:40] lore subglottic stenosis as you can see on this slide there are a lot of
[05:41] on this slide there are a lot of intrinsic causes but far and away the
[05:44] intrinsic causes but far and away the most comic the most common intrinsic
[05:47] most comic the most common intrinsic cause of stenosis that I see relates to
[05:50] cause of stenosis that I see relates to prior intubation and prior tracheostomy
[05:52] prior intubation and prior tracheostomy but there's a lot of things and we'll
[05:54] but there's a lot of things and we'll talk about some of them during the talk
[05:55] talk about some of them during the talk as far as extrinsic causes in my
[05:59] as far as extrinsic causes in my experience here and in my shop the thing
[06:01] experience here and in my shop the thing that I see most commonly are thyroid
[06:04] that I see most commonly are thyroid lesions thyroid masses whether it's a
[06:07] lesions thyroid masses whether it's a goiter or a true malignancy that are
[06:09] goiter or a true malignancy that are externally compressing it but again you
[06:12] externally compressing it but again you can see here there are lots of potential
[06:13] can see here there are lots of potential extrinsic causes of tracheal stenosis as extrinsic causes of tracheal stenosis as well
[06:18] well so this is an example of a tracheostomy related tracheal stenosis you can see related tracheal stenosis you can see where that yellow arrow is pointing
[06:24] where that yellow arrow is pointing that's just just right sort of at and and maybe slightly below the level of
[06:31] where the I'm sorry right at and above the level of where the tracheostomy is entering
[06:35] and you can see just how narrow that tracheal diameter is no compared to the more normal distal downstream caliber
[06:41] and you can see that's a really significant difference between those two
[06:44] now you may say well it doesn't really matter he's had a tracheostomy tube in and in fact you're right they're protecting the airway now
[06:49] but let's say they want to get to the point where they're gonna take that tracheostomy out
[06:54] they need to know about that stenosis because this is a patient that's going to get themselves into trouble because of that very tight stenosis related to the prior tracheostomy
[07:06] this is another patient this is a patient who previously had had a prolonged intubation and you can see that they have a very focal area where
[07:14] that they have a very focal area where you have sort of a shouldering a narrowing of the trachea probably related to that prior prolonged intubation so again you want to find it you want to identify outlook for sort of that hourglass configuration in which you in this case have a very focal waist or very focal narrowing and report that tell them tell the surgeons tell the pulmonologist how long it extends over and what the sort of the nadir of the narrowing is
[07:41] next we've malignant trachea masses now fortunately primary tracheal tumors are quite rare we're talking literally something that's about a one-in-a-million diagnosis and of these squamous cell carcinoma is going to be the most common culprit followed by adenoid cystic carcinoma
[07:57] now the imaging is quite limited in terms of trying to predict what the final histopathology is and that's okay these patients are going to need an indolent i'll by op c to figure it out that's not your job so I can't look at the imaging and say oh this is clearly a scam or this is an adenoid cystic you
[08:15] scam or this is an adenoid cystic you can play the odds and say that scream is
[08:17] can play the odds and say that scream is more likely but instead is the
[08:19] more likely but instead is the radiologist your job is to look for
[08:22] radiologist your job is to look for invasion of surrounding structures look
[08:24] invasion of surrounding structures look for invasion of those other visceral
[08:26] for invasion of those other visceral space structures that are in close
[08:27] space structures that are in close proximity so
[08:29] proximity so this is a patient who had tracheal
[08:31] this is a patient who had tracheal squamous cell carcinoma you can see
[08:33] squamous cell carcinoma you can see there's a mass on the left side and it's
[08:36] there's a mass on the left side and it's denoted here by the yellow arrow and
[08:39] denoted here by the yellow arrow and it's ugly its aggressive you can see
[08:41] it's ugly its aggressive you can see it's really markedly narrowing the
[08:42] it's really markedly narrowing the airway but if you look at the coronal
[08:44] airway but if you look at the coronal image you can see importantly it does
[08:45] image you can see importantly it does look like it's extending out into the
[08:48] look like it's extending out into the surrounding soft tissues and probably
[08:49] surrounding soft tissues and probably starting to invade the thyroid itself
[08:51] starting to invade the thyroid itself there's nothing that I can say on this
[08:53] there's nothing that I can say on this imaging that will tell me that this is
[08:55] imaging that will tell me that this is certainly a squamous cell carcinoma that
[08:57] certainly a squamous cell carcinoma that just happens to be the most likely
[08:59] just happens to be the most likely diagnosis based on the statistics
[09:02] diagnosis based on the statistics here's another patient with malignant
[09:04] here's another patient with malignant trachea mass this was an adenoids cystic
[09:07] trachea mass this was an adenoids cystic carcinoma again I can't look at this and
[09:09] carcinoma again I can't look at this and tell you that's what the diagnosis is
[09:10] tell you that's what the diagnosis is that's okay that's what the biopsy tells
[09:13] you but rather what I can do is look at
[09:15] you but rather what I can do is look at this and describe where the tumor is
[09:17] this and describe where the tumor is going how big is the tumor and in this case this is a nice example of how CT and MRI can be complimentary in staging disease
[09:27] we can tell them the CT yeah it looks like tumors getting out of the trachea MRI is much more specific in terms of telling us where it's going
[09:32] we get that tissue contrast resolution superiority that helps us to better stage where the tumor is at
[09:39] next diagnosis is relapsing polycondritis
[09:42] this is a rare diagnosis and it's an autoimmune disorder in which patients have recurrent cartilage inflammation and eventually most commonly it leads to cartilaginous destruction
[09:54] it can be a very focal process or it can be a very diffuse process it can affect multiple different cartilages within the body and certainly the trachea is one of those structures that contains cartilaginous rings so it can be involved
[10:08] now classically this involves the anterior and lateral tracheal walls or even then the airway
[10:17] tracheal walls or even then the airway walls you can use the same application
[10:19] walls you can use the same application down once you get below the clavicles
[10:22] down once you get below the clavicles into the chest but it has sparing of
[10:24] into the chest but it has sparing of that posterior trachea yem brain or the
[10:27] that posterior trachea yem brain or the posterior airway membrane because that's
[10:29] posterior airway membrane because that's a non cartilaginous structure so as we
[10:31] a non cartilaginous structure so as we look at this case we can see sort of
[10:33] look at this case we can see sort of thickening and a little bit of
[10:34] thickening and a little bit of irregularity of the walls of the trachea
[10:36] irregularity of the walls of the trachea anteriorly and laterally but if you look
[10:39] anteriorly and laterally but if you look carefully you can see that this spare is
[10:41] carefully you can see that this spare is that posterior wall or that posterior
[10:43] that posterior wall or that posterior tracheal membrane
[10:45] tracheal membrane overtime the classic trajectory of this
[10:48] overtime the classic trajectory of this is to lead to cartilage collapse and you
[10:52] is to lead to cartilage collapse and you can get really severe airway narrowing
[10:56] can get really severe airway narrowing as a result of this now sometimes and
[10:59] as a result of this now sometimes and this is quite rare sometimes you can
[11:01] this is quite rare sometimes you can actually get enlargement of the
[11:03] actually get enlargement of the cartilaginous structures due to that
[11:05] cartilaginous structures due to that sort of chronic repetitive
[11:07] sort of chronic repetitive chondral inflammation and this is such a
[11:11] chondral inflammation and this is such a case of that this is an atypical
[11:13] case of that this is an atypical appearance of relapsing polycon Rytas
[11:15] appearance of relapsing polycon Rytas and what should really jump out at you
[11:17] and what should really jump out at you is you can see the image on the left on the axial CT.
[11:19] look how thickened that thyroid cartilage is.
[11:22] image on the right look at this cricoid cartilage just how thick and knobby this is.
[11:25] it's not getting destroyed but it's markedly enlarged.
[11:26] don't burn this into your mind as the typical appearance because more typically will see cartilaginous destruction over time.
[11:30] this happens to be one of those really oddball cases that resulted in cartilaginous enlargement.
[11:34] and importantly really the critical thing here is when you have that cartilage getting that enlarged it can compromise the airway.
[11:41] so always be on the lookout for airway narrowing.
[11:43] always be reporting that something that can look a little bit like this is amyloidosis.
[11:45] and this is a rare disorder.
[11:48] it's of abnormal protein folding and it can be primary or secondary or localized or diffuse.
[11:49] and when it involves the airway it's more commonly going to be the localized variety.
[11:51] that that specifically is just
[12:17] variety that that specifically is just involving the airway but you can have involving the airway but you can have sort of the diffuse involvement or even sort of the diffuse involvement or even secondary amyloidosis resulting in secondary amyloidosis resulting in airway disease as well but this occurs airway disease as well but this occurs when you get deposition of the amyloid when you get deposition of the amyloid fibril proteins into otherwise normal fibril proteins into otherwise normal tissues and so it can be very diffuse it tissues and so it can be very diffuse it can be multifocal but importantly it can can be multifocal but importantly it can involve the posterior wall of the involve the posterior wall of the trachea and the posterior wall of the of trachea and the posterior wall of the of the Airways the smaller Airways in the the Airways the smaller Airways in the lung as well so that's sort of an lung as well so that's sort of an contour distinction to what we saw with contour distinction to what we saw with relapsing polycon gitis and it gives you relapsing polycon gitis and it gives you these submucosal masses so here we see these submucosal masses so here we see sort of that heaped up soft tissue along sort of that heaped up soft tissue along the posterior tracheal membrane the posterior tracheal membrane on this axial non-contrast CT imaging as on this axial non-contrast CT imaging as you can see right where that arrow is you can see right where that arrow is pointing it's associated with some pointing it's associated with some calcification as well so these calcification as well so these submucosal masses can be calcified if submucosal masses can be calcified if you do MRI they have a characteristic you do MRI they have a characteristic dark t2 signal so they're hypo intense dark t2 signal so they're hypo intense on t2 that's an important thing to keep on t2 that's an important thing to keep in mind if you give contrast on MRI you
[13:19] in mind if you give contrast on MRI you may have enhancement as well.
[13:22] may have enhancement as well this is another patient who had tracheal.
[13:24] this is another patient who had tracheal amyloidosis this is path proven and you.
[13:27] amyloidosis this is path proven and you can see that this is instead of being.
[13:29] can see that this is instead of being more of a sort of a smooth diffuse.
[13:31] more of a sort of a smooth diffuse infiltrating soft tissue this is sort of.
[13:33] infiltrating soft tissue this is sort of a multi nodular appearance but as you.
[13:36] a multi nodular appearance but as you look this is involving sort of the.
[13:39] look this is involving sort of the posterior and posterolateral walls of.
[13:41] posterior and posterolateral walls of the cervical trachea and it's multifocal.
[13:43] the cervical trachea and it's multifocal sort of heaped-up submucosal masses and.
[13:47] sort of heaped-up submucosal masses and you can see if you look carefully.
[13:49] you can see if you look carefully there's a little bit of calcification.
[13:50] there's a little bit of calcification associated with this as well so the.
[13:53] associated with this as well so the calcification doesn't give you a ton of.
[13:54] calcification doesn't give you a ton of specificity but it is an important.
[13:56] specificity but it is an important finding to be looking for and recognize.
[13:58] finding to be looking for and recognize that tracheal amyloidosis can in fact.
[14:00] that tracheal amyloidosis can in fact have calcification now interestingly.
[14:03] have calcification now interestingly it's something that if you you fdg-pet.
[14:06] it's something that if you you fdg-pet you they also see some hypermetabolism.
[14:08] you they also see some hypermetabolism with it so therefore it can potentially.
[14:10] with it so therefore it can potentially mimic malignancy as well so sort of keep.
[14:13] mimic malignancy as well so sort of keep that in mind that tracheal amyloidosis.
[14:15] that in mind that tracheal amyloidosis can be a bit of a diagnosis that that.
[14:17] can be a bit of a diagnosis that that acts as a mimic and can cause some.
[14:20] acts as a mimic and can cause some consternation.
[14:22] Next we have granulomatosis with.
[14:25] Next we have granulomatosis with polyangiitis and this is an autoimmune.
[14:26] polyangiitis and this is an autoimmune necrotizing granulomatous vasculitis and.
[14:29] necrotizing granulomatous vasculitis and these patients will have anti neutrophil.
[14:31] these patients will have anti neutrophil cytoplasmic antibodies or ANCA and we.
[14:34] cytoplasmic antibodies or ANCA and we always think of it in the head and neck.
[14:36] always think of it in the head and neck world as being a sign of nasal process.
[14:38] world as being a sign of nasal process and it is I mean that's the most common.
[14:40] presentation but it can involve any of the Airways and the trachea is no.
[14:42] the Airways and the trachea is no exception these patients will get.
[14:44] exception these patients will get cartilaginous erosion they can even have.
[14:47] cartilaginous erosion they can even have like these mass like soft tissue.
[14:49] like these mass like soft tissue thickened areas along the Airways so.
[14:51] thickened areas along the Airways so here as you can see on the left side of.
[14:53] here as you can see on the left side of the proximal cervical trachea we see.
[14:55] the proximal cervical trachea we see sort of that heaped up in what was an.
[14:57] sort of that heaped up in what was an enhancing soft tissue component has a.
[14:59] enhancing soft tissue component has a little bit of alteration within it as.
[15:01] little bit of alteration within it as well if I saw this I would have to lead.
[15:03] well if I saw this I would have to lead with malignancy I mean you have to bring.
[15:06] with malignancy I mean you have to bring that up as a as a potential here and.
[15:09] that up as a as a potential here and this is going to need biopsied too to.
[15:10] this is going to need biopsied too to discern the difference now it's a case.
[15:13] discern the difference now it's a case in point where you want to look at other.
[15:16] in point where you want to look at other imaging if they have sign of nasal.
[15:18] imaging if they have sign of nasal involvement certainly be thinking about.
[15:19] involvement certainly be thinking about.
[15:21] involvement certainly be thinking about granular granulomatosis with
[15:23] granular granulomatosis with polyangiitis but it certainly can mimic
[15:27] polyangiitis but it certainly can mimic malignancy as well and that's something
[15:28] malignancy as well and that's something that you need to consider
[15:32] next is something that's benign and
[15:34] next is something that's benign and something that we see quite commonly
[15:35] something that we see quite commonly this is a tracheal diverticulum this is
[15:38] this is a tracheal diverticulum this is simply mucosa herniation through a
[15:40] simply mucosa herniation through a defect in the tracheal wall
[15:42] defect in the tracheal wall you can see right here we sort of have
[15:44] you can see right here we sort of have this this air density structure sitting
[15:49] this this air density structure sitting to the right side of the trachea these
[15:51] to the right side of the trachea these are usually incidental findings they
[15:52] are usually incidental findings they usually are quite small they're single
[15:55] usually are quite small they're single sometimes though they can have sort of a
[15:56] sometimes though they can have sort of a larger multilocular appearance like this
[15:58] larger multilocular appearance like this one I showed this just because it's such
[16:00] one I showed this just because it's such a nice example to drive home the point
[16:02] a nice example to drive home the point of what they look like perhaps a little
[16:03] of what they look like perhaps a little bit more exaggerated than we typically
[16:05] bit more exaggerated than we typically see and these are usually on the right
[16:07] see and these are usually on the right side I have not a clue why but you'll
[16:10] side I have not a clue why but you'll find that yes you can have them
[16:11] find that yes you can have them bilaterally yes you can have them on the
[16:13] bilaterally yes you can have them on the left side but most commonly you'll see
[16:15] left side but most commonly you'll see it on the right side one thing that I do
[16:17] it on the right side one thing that I do think is an important discriminator is
[16:19] think is an important discriminator is look for an air fluid level these should
[16:23] look for an air fluid level these should not have an air fluid level I repeat not have an air fluid level I repeat these should not have an air fluid level
[16:28] these should not have an air fluid level if you see an air fluid level be thinking about esophageal diverticula
[16:32] thinking about esophageal diverticula and and that is sort of my segue into discussing
[16:35] that is sort of my segue into discussing the esophagus
[16:38] the esophagus so we're gonna start with the bad boy esophageal carcinoma and you probably don't need me to tell you this if you've done radiology for any time at all but
[16:46] done radiology for any time at all but cross-sectional imaging is not great for evaluating for esophageal carcinoma it just simply isn't
[16:51] this is a diagnosis that really we rely most heavily on endoscopy in this day and age certainly
[16:56] endoscopy in this day and age certainly esophagram ZAR are useful you can pick them up on esophagram in this case you can see sort of that classic apple core appearance and so yes be able to recognize these on Asafa grams they're oftentimes much more subtle than what I'm showing here in this example but in general while you can't see it on cross-sectional imaging it's not our best modality for looking what you may see on the cross-sectional studies like CT would be thickening of the wall of
[17:24] CT would be thickening of the wall of the esophagus oftentimes looking a bit smudgy or ill-defined but really where I think the important role is for those of us doing CT imaging is to look for things that upstage your disease you're looking for invasion of surrounding structures in the visceral space as well as looking for metastatic adeno ethey so just to show you how challenging it can be on CT imaging here we see this relatively short segment of the distal cervical esophagus in which the wall is just a little bit thick in just a little bit smudgy obviously much easier to see on this fdg-pet where you can see that it's markedly hypermetabolic this was path proven esophageal carcinoma
[18:08] I mentioned esophageal diverticula before now we're gonna talk a little bit more in depth about them you can have true diverticula which contain all of the layers of the wall or you can have false dye particular pseudo diverticulum and that contains the mucosa and submucosa that herniates through a defect in the
[18:26] that herniates through a defect in the muscularis layer so a true diverticulum
[18:28] muscularis layer so a true diverticulum has all of those layers the false
[18:30] has all of those layers the false diverticulum lacks the muscularis
[18:32] diverticulum lacks the muscularis because the mucosa and submucosa
[18:34] because the mucosa and submucosa herniate through it
[18:36] herniate through it and the things that we oftentimes refer
[18:39] and the things that we oftentimes refer to as esophageal diverticula such as
[18:41] to as esophageal diverticula such as zinc or diverticula or Achille and
[18:43] zinc or diverticula or Achille and jameson those are actually a pseudo
[18:45] jameson those are actually a pseudo diverticula
[18:46] diverticula you can also classify esophageal
[18:49] you can also classify esophageal diverticula as being traction or Polzin
[18:52] diverticula as being traction or Polzin with the traction diverticulum due to
[18:54] with the traction diverticulum due to extrinsic pulling on the wall of the
[18:57] extrinsic pulling on the wall of the esophagus and opposing diverticulum is
[19:00] esophagus and opposing diverticulum is due to intraluminal pushing causing that
[19:02] due to intraluminal pushing causing that protrusion I
[19:04] protrusion I said I wasn't going to talk about the
[19:06] said I wasn't going to talk about the hypopharynx
[19:07] hypopharynx that's a slight lie that I that I told
[19:10] that's a slight lie that I that I told you I am going to talk about the
[19:12] you I am going to talk about the hypopharynx here but sort of lump it
[19:14] hypopharynx here but sort of lump it under the esophagus just because these
[19:16] under the esophagus just because these are such closely related
[19:18] are such closely related entities and so we'll talk about
[19:20] entities and so we'll talk about hypopharyngeal diverticulum and this
[19:23] hypopharyngeal diverticulum and this goes by the eponym of a zinc or
[19:25] goes by the eponym of a zinc or diverticulum this is a technically a
[19:27] diverticulum this is a technically a Polzin pseudo diverticulum in which you
[19:29] Polzin pseudo diverticulum in which you have mucosa that herniates above the
[19:32] have mucosa that herniates above the level of the cricopharyngeal usually at
[19:35] level of the cricopharyngeal usually at about c5 c6 so you can see here in this
[19:37] about c5 c6 so you can see here in this diagram we've got our yellow arrow
[19:39] diagram we've got our yellow arrow pointing at this zinc ER or
[19:41] pointing at this zinc ER or hypopharyngeal diverticulum where it's
[19:43] hypopharyngeal diverticulum where it's herniating out through the through a
[19:46] herniating out through the through a defect just above the Crego fringes and
[19:48] defect just above the Crego fringes and this is associated with esophageal
[19:50] this is associated with esophageal dismal tea
[19:52] dismal tea typically it's going to involve the
[19:53] typically it's going to involve the midline posterior wall of the esophagus
[19:55] midline posterior wall of the esophagus but it may extend off to the left side
[19:57] but it may extend off to the left side or more commonly to the left side when
[19:59] or more commonly to the left side when they get larger but again I want to
[20:01] they get larger but again I want to stress the importance look for that air
[20:03] stress the importance look for that air fluid level that really should help you
[20:06] fluid level that really should help you to recognize that you're dealing with
[20:07] to recognize that you're dealing with something that's containing contents of
[20:09] something that's containing contents of the gut or the digestive tract and these
[20:13] the gut or the digestive tract and these are associated with dysphasia as well as
[20:15] are associated with dysphasia as well as an increased risk of aspiration
[20:18] an increased risk of aspiration so here's an example on an oblique
[20:20] so here's an example on an oblique barium esophagram you can see that fluid
[20:23] barium esophagram you can see that fluid and barium and gas contained within this
[20:25] and barium and gas contained within this hypopharyngeal diverticulum you can sort
[20:27] hypopharyngeal diverticulum you can sort of see that slip
[20:29] of see that slip down at the bottom of it that is sort of
[20:34] down at the bottom of it that is sort of the imprint at the level of the
[20:35] the imprint at the level of the cricopharyngeal
[20:36] cricopharyngeal but then on the cross-sectional the
[20:39] but then on the cross-sectional the axial CT that we're looking here you can
[20:42] axial CT that we're looking here you can see that really large
[20:44] see that really large zinc or diverticulum containing an air
[20:46] zinc or diverticulum containing an air fluid level denoted again by the yellow
[20:48] fluid level denoted again by the yellow arrow
[20:51] now these are different than Killian
[20:53] now these are different than Killian Jamison diverticula Killian Jamison
[20:56] Jamison diverticula Killian Jamison diverticulum is is also a pole j'en
[20:59] diverticulum is is also a pole j'en pseudo diverticulum
[21:01] pseudo diverticulum but this occurs below the level of the
[21:04] but this occurs below the level of the cricopharyngeal so this is
[21:08] cricopharyngeal so this is a herniation that protrudes out into
[21:11] a herniation that protrudes out into what's called the Killian jamison space
[21:13] what's called the Killian jamison space and i honest to god I hate eponyms I
[21:16] and i honest to god I hate eponyms I could not find a good nun eponymous term
[21:18] could not find a good nun eponymous term to use for a Killian Jamison
[21:20] to use for a Killian Jamison diverticulum or this space but it is
[21:23] diverticulum or this space but it is important especially for the residents
[21:25] important especially for the residents out there to recognize what sort of
[21:28] out there to recognize what sort of makes up this Killian Jamison space and
[21:32] makes up this Killian Jamison space and it's defined superiorly by the
[21:34] it's defined superiorly by the cricopharyngeal so it's that's going to
[21:36] cricopharyngeal so it's that's going to be sort of a superior border of it
[21:38] be sort of a superior border of it anteriorly it's going to be made up of
[21:40] anteriorly it's going to be made up of the cricoid cartilage and then the it's
[21:44] the cricoid cartilage and then the it's a triangle so the third side is going to
[21:46] a triangle so the third side is going to be the esophageal suspensory ligament
[21:48] be the esophageal suspensory ligament which sort of sits in fro immediately
[21:50] which sort of sits in fro immediately these more commonly occur on the left
[21:52] these more commonly occur on the left side than on the right side and these
[21:54] side than on the right side and these protrusions can a pooch out along the
[21:56] protrusions can a pooch out along the anterolateral wall of the esophagus
[21:59] anterolateral wall of the esophagus rather than the the posterior midline
[22:01] rather than the the posterior midline wall like the the zinc ER the
[22:03] wall like the the zinc ER the hypopharyngeal diverticulum but again
[22:06] hypopharyngeal diverticulum but again look for the air fluid level I think
[22:08] look for the air fluid level I think that's a helpful feature to tell you
[22:09] that's a helpful feature to tell you you're dealing with gut contents and
[22:12] you're dealing with gut contents and then these patients are oftentimes
[22:14] then these patients are oftentimes asymptomatic so this is frequently more
[22:17] asymptomatic so this is frequently more of an incidental finding than a zinc or
[22:19] of an incidental finding than a zinc or diverticulum
[22:21] diverticulum you can also have lateral esophageal
[22:24] you can also have lateral esophageal diverticula and these are not exactly
[22:27] diverticula and these are not exactly the same as the killing and Jameson
[22:29] the same as the killing and Jameson because they don't come out through the
[22:30] because they don't come out through the the true killing jameson space but you
[22:32] the true killing jameson space but you can have them occur really anywhere
[22:33] can have them occur really anywhere along the course of the esophagus and
[22:35] along the course of the esophagus and here you can see one on this barium
[22:37] here you can see one on this barium esophagram it's it's partially a
[22:39] esophagram it's it's partially a pacified st. patient just to sort of
[22:41] pacified st. patient just to sort of give you the coronal CT correlate we can
[22:44] give you the coronal CT correlate we can see this really large diverticula
[22:47] see this really large diverticula mooching out of the right lateral side
[22:49] mooching out of the right lateral side of the esophagus and you can see that
[22:51] of the esophagus and you can see that debris contained within it
[22:55] the next important anatomic structure
[22:57] the next important anatomic structure that it lives in the visceral space is
[22:59] that it lives in the visceral space is the recurrent laryngeal nerve and this
[23:01] the recurrent laryngeal nerve and this sort of warrants a little bit of a
[23:03] sort of warrants a little bit of a sidebar discussion
[23:05] sidebar discussion so where does it live within the
[23:08] so where does it live within the visceral space what lives within the
[23:10] visceral space what lives within the tracheal esophageal groove bilaterally
[23:12] tracheal esophageal groove bilaterally so here these white arrows are pointing
[23:14] so here these white arrows are pointing at the recurrent laryngeal nerves and
[23:16] at the recurrent laryngeal nerves and it's important to know the course of the
[23:19] it's important to know the course of the recurrent laryngeal nerve so this is
[23:23] recurrent laryngeal nerve so this is sort of a branch off of the vagus nerve
[23:26] sort of a branch off of the vagus nerve and in this diagram we're looking sort
[23:28] and in this diagram we're looking sort of from the back looking forward and we
[23:31] of from the back looking forward and we know that we're looking from the back
[23:32] know that we're looking from the back forward because you can see the thyroid
[23:33] forward because you can see the thyroid with the parathyroid the four
[23:36] with the parathyroid the four parathyroid glands so we know we're
[23:38] parathyroid glands so we know we're looking at the back side of things so
[23:40] looking at the back side of things so what's on the image on the left
[23:45] what's on the image on the left the I'm sorry the the right side of the
[23:47] the I'm sorry the the right side of the image
[23:48] image corresponds with the patient's right
[23:50] corresponds with the patient's right side sort of by radiology definitions
[23:54] side sort of by radiology definitions here so the bottom line is follow along
[23:56] here so the bottom line is follow along the branches of the vagus nerve so
[23:58] the branches of the vagus nerve so you're gonna work your way down the
[23:59] you're gonna work your way down the carotid space on the left side here
[24:03] carotid space on the left side here denoted by the white arrow image left
[24:05] denoted by the white arrow image left patients true left because again we're
[24:07] patients true left because again we're looking from the back you need to look
[24:09] looking from the back you need to look all the way down to the aorta pulmonary
[24:10] all the way down to the aorta pulmonary window which is where that branch comes
[24:13] window which is where that branch comes off and then it's gonna work its way
[24:15] off and then it's gonna work its way back north and the tricky esophageal
[24:17] back north and the tricky esophageal groove on the patient's right side here
[24:20] groove on the patient's right side here shown on image right you can see that it
[24:22] shown on image right you can see that it loops under the subclavian artery before
[24:24] loops under the subclavian artery before recurring up that trachea esophageal
[24:26] recurring up that trachea esophageal groove and the critically important
[24:29] groove and the critically important thing to know about the recurrent
[24:31] thing to know about the recurrent laryngeal nerve is that it innervates
[24:32] laryngeal nerve is that it innervates the intrinsic muscle of the larynx with
[24:35] the intrinsic muscle of the larynx with the exception of the cricothyroid
[24:39] so as we look here
[24:42] so as we look here the question is which side is abnormal
[24:45] the question is which side is abnormal we have an axial fused fdg-pet CT
[24:48] we have an axial fused fdg-pet CT so let's run through the imaging
[24:50] so let's run through the imaging findings we've got marked increased
[24:52] findings we've got marked increased metabolism here within the right true
[24:55] metabolism here within the right true vocal fold
[24:57] vocal fold we've got our cricoarytenoid here also
[24:59] we've got our cricoarytenoid here also shows FDG uptake so as the right side
[25:02] shows FDG uptake so as the right side abnormal or as the left side well look
[25:04] abnormal or as the left side well look at the left side
[25:05] at the left side here's our true vocal fold really no
[25:08] here's our true vocal fold really no metabolic activity and this is a muscle
[25:10] metabolic activity and this is a muscle okay so there should be some metabolic
[25:13] okay so there should be some metabolic activity here we also have sort of an a
[25:15] activity here we also have sort of an a trophic look to the to the
[25:17] trophic look to the to the cricoarytenoid back here which is also
[25:19] cricoarytenoid back here which is also not showing any FDG uptake if you look
[25:23] not showing any FDG uptake if you look carefully through this I know it's tough
[25:24] carefully through this I know it's tough with a fused image but you can see that
[25:26] with a fused image but you can see that it's a little bit fatty replaced and we
[25:28] it's a little bit fatty replaced and we also have dilatation of the ipsilateral
[25:31] also have dilatation of the ipsilateral laryngeal ventricle giving us that
[25:34] laryngeal ventricle giving us that classic spinnaker sale sign and so that
[25:37] classic spinnaker sale sign and so that tells us that the problem here is on the
[25:39] tells us that the problem here is on the patient's left side follow the course of
[25:41] patient's left side follow the course of the recurrent laryngeal nerve we can see
[25:44] the recurrent laryngeal nerve we can see this nodal conglomerate so this patient
[25:47] this nodal conglomerate so this patient has left side of vocal cord paralysis
[25:49] has left side of vocal cord paralysis from metastasis nono Matassa see is
[25:51] from metastasis nono Matassa see is there that are encroaching upon the left
[25:54] there that are encroaching upon the left recurrent laryngeal nerve
[25:57] recurrent laryngeal nerve all right next we're gonna move on and
[25:59] all right next we're gonna move on and talk about the thyroid gland
[26:02] talk about the thyroid gland and this is probably the biggest portion
[26:05] and this is probably the biggest portion of this talk because there is just so
[26:06] of this talk because there is just so much that happens here and so much to
[26:08] much that happens here and so much to say but just as a very brief overview
[26:11] say but just as a very brief overview the thyroid gland is an endocrine organ
[26:13] the thyroid gland is an endocrine organ has two lobes that are connected at
[26:16] has two lobes that are connected at midline via an isthmus sometimes
[26:17] midline via an isthmus sometimes patients will have a midline pyramidal
[26:19] patients will have a midline pyramidal lobe as well now in terms of imaging
[26:22] lobe as well now in terms of imaging really our first line modality is
[26:23] really our first line modality is ultrasound because that is our most
[26:26] ultrasound because that is our most sensitive sequence it really images it
[26:28] sensitive sequence it really images it better than anything else plus you can
[26:31] better than anything else plus you can sort of marry that with a needle and
[26:33] sort of marry that with a needle and there you have your answer if you really
[26:35] there you have your answer if you really need to figure out what something is you
[26:36] need to figure out what something is you can use an ultrasound and guide a needle
[26:39] can use an ultrasound and guide a needle into it and take a biopsy so really
[26:40] into it and take a biopsy so really ultrasound upfront that's our first line
[26:43] ultrasound upfront that's our first line modality here CT is important you may do
[26:46] modality here CT is important you may do it with contrast you may do it without
[26:48] it with contrast you may do it without in some circumstances because of iodine
[26:51] in some circumstances because of iodine load considerations when you're dealing
[26:53] load considerations when you're dealing with differentiated thyroid carcinoma
[26:55] with differentiated thyroid carcinoma it's a bit controversial it remains a
[26:57] it's a bit controversial it remains a bit controversial but oftentimes we are
[27:01] bit controversial but oftentimes we are wanting to minimize the amount of iodine
[27:03] wanting to minimize the amount of iodine that patients with differentiated
[27:05] that patients with differentiated thyroid carcinoma get because that will
[27:08] thyroid carcinoma get because that will sort of drive down the body's resorption
[27:12] sort of drive down the body's resorption of iodine and when you go to treat them
[27:13] of iodine and when you go to treat them with radio iodine you want them to be
[27:15] with radio iodine you want them to be iodine starved and taking up every last
[27:18] iodine starved and taking up every last bit of that radio iodine so when you're
[27:20] bit of that radio iodine so when you're dealing with differentiated thyroid
[27:21] dealing with differentiated thyroid carcinoma that is a consideration you
[27:23] carcinoma that is a consideration you have to make
[27:25] have to make we do use MRI
[27:28] we do use MRI really I feel like pretty frequently
[27:30] really I feel like pretty frequently anymore looking at the thyroid in
[27:33] anymore looking at the thyroid in patients with differentiated thyroid
[27:34] patients with differentiated thyroid carcinoma particularly those who have
[27:37] carcinoma particularly those who have iodine considerations and then nuclear
[27:41] iodine considerations and then nuclear medicine also plays a very very
[27:42] medicine also plays a very very important role here as you can see there
[27:44] important role here as you can see there are lots of agents I 123 I 139 Tech 99
[27:48] are lots of agents I 123 I 139 Tech 99 in pertechnetate as well as FDG and more
[27:54] in pertechnetate as well as FDG and more recently dota
[27:56] recently dota okay so let's talk a little bit about
[27:59] okay so let's talk a little bit about thyroid pathology well here's the good
[28:00] thyroid pathology well here's the good news
[28:01] news most of the times when you encounter a
[28:03] most of the times when you encounter a nodule in the thyroid it's going to be
[28:05] nodule in the thyroid it's going to be benign in fact the vast majority like
[28:08] benign in fact the vast majority like may be on the order of 95% of the time
[28:10] may be on the order of 95% of the time other good news it's a pretty
[28:13] other good news it's a pretty superficial organ and therefore it's
[28:16] superficial organ and therefore it's easy biopsied with ultrasound and in
[28:18] easy biopsied with ultrasound and in general when you have cancer of the
[28:21] general when you have cancer of the thyroid gland most of the time not all
[28:23] thyroid gland most of the time not all of the time but most of the time it's
[28:25] of the time but most of the time it's treatable very treatable cancer at least
[28:27] treatable very treatable cancer at least relative to other types of malignancy
[28:29] relative to other types of malignancy these are cancers that patients may very
[28:33] these are cancers that patients may very well die with rather than die of again
[28:35] well die with rather than die of again that's not a universal statement there
[28:38] that's not a universal statement there are certainly some bad things that occur
[28:39] are certainly some bad things that occur here but in general of the cancers
[28:42] here but in general of the cancers thyroid is one of the more treatable
[28:44] thyroid is one of the more treatable ones however there is bad news and that
[28:48] ones however there is bad news and that is to say whenever thyroid cancer is
[28:52] is to say whenever thyroid cancer is ugly it's really really ugly
[28:56] so as I mentioned ultrasound is really
[28:59] so as I mentioned ultrasound is really our first line modality now here's the
[29:02] our first line modality now here's the problem I'm a head and neck radiologist
[29:04] problem I'm a head and neck radiologist and I know very few head and neck
[29:07] and I know very few head and neck radiologists out there that just love to
[29:09] radiologists out there that just love to deal with thyroid ultrasounds right
[29:12] deal with thyroid ultrasounds right for some reason this is like this is
[29:15] for some reason this is like this is something that in most shops is really
[29:18] something that in most shops is really sort of under the purview of the body
[29:20] sort of under the purview of the body imagers and I think most had a neck
[29:22] imagers and I think most had a neck radiologists are kind of okay with that
[29:24] radiologists are kind of okay with that so here's a here's a meme that that my
[29:26] so here's a here's a meme that that my friend Todd comes sent me and I think
[29:28] friend Todd comes sent me and I think this really totally hits the nail on the
[29:30] this really totally hits the nail on the head like yes the thyroid is a head and
[29:33] head like yes the thyroid is a head and neck structure yes the metastases go in
[29:36] neck structure yes the metastases go in the head and neck for some reason head
[29:38] the head and neck for some reason head and neck radiologists are like going to
[29:40] and neck radiologists are like going to complete freakout mode if they have to
[29:42] complete freakout mode if they have to deal with a thyroid ultrasound and I'm
[29:44] deal with a thyroid ultrasound and I'm as guilty as anybody else with that so
[29:46] as guilty as anybody else with that so maybe we do need to know a little bit
[29:48] maybe we do need to know a little bit more about it and so I'm gonna do just
[29:49] more about it and so I'm gonna do just sort of a quick overview of some of the
[29:51] sort of a quick overview of some of the high points of thyroid ultrasound I'm
[29:53] high points of thyroid ultrasound I'm certainly not an expert I'm not
[29:55] certainly not an expert I'm not pretending to be able to make anybody an
[29:57] pretending to be able to make anybody an expert on thyroid ultrasound during this
[29:59] expert on thyroid ultrasound during this brief talk but there are some important
[30:01] brief talk but there are some important points that I think heading in head and
[30:02] points that I think heading in head and neck imagers need to be aware of
[30:05] neck imagers need to be aware of okay so
[30:07] okay so first up let's talk about reporting
[30:11] first up let's talk about reporting thyroid ultrasounds because this is an
[30:13] thyroid ultrasounds because this is an area where I think that there's actually
[30:15] area where I think that there's actually some really nice guidance that can be
[30:17] some really nice guidance that can be found and you can have right at your
[30:18] found and you can have right at your fingertips and the first is the thyroid
[30:20] fingertips and the first is the thyroid imaging reporting and data system or ty
[30:23] imaging reporting and data system or ty rads which comes from the ACR the
[30:25] rads which comes from the ACR the American College of Radiology and and
[30:27] American College of Radiology and and I'd like this because it's a really
[30:30] I'd like this because it's a really nice concise risk stratification and
[30:32] nice concise risk stratification and biopsy tool
[30:33] biopsy tool it's a paradigm really and and so the
[30:36] it's a paradigm really and and so the things that you need to look at sort of
[30:39] things that you need to look at sort of have to do with the composition of the
[30:40] have to do with the composition of the nodule what does it look like on
[30:43] nodule what does it look like on ultrasound in terms of its echogenicity
[30:45] ultrasound in terms of its echogenicity its shape what are the margins look like
[30:48] its shape what are the margins look like whether it has an internal echogenic
[30:50] whether it has an internal echogenic fossa as well as the size of the nodule
[30:54] fossa as well as the size of the nodule and so really it's it's a bit analogous
[30:56] and so really it's it's a bit analogous to by rats at the breast imagers use a
[30:58] to by rats at the breast imagers use a lot of the same sort of sonographic
[31:00] lot of the same sort of sonographic features i think are a translational
[31:03] features i think are a translational skillset it's not exactly parallel but
[31:06] skillset it's not exactly parallel but but the same kind of lessons that that
[31:09] but the same kind of lessons that that we can learn from mammographer x' and
[31:11] we can learn from mammographer x' and breast imagers I like to I like to tell
[31:12] breast imagers I like to I like to tell the trainees take things that you
[31:13] the trainees take things that you learned while on mamo and apply it to
[31:15] learned while on mamo and apply it to the head and neck because I really think
[31:17] the head and neck because I really think that they as a as a subspecialty have
[31:20] that they as a as a subspecialty have figured out how to really use data good
[31:23] figured out how to really use data good data to drive clinical practice and and
[31:25] data to drive clinical practice and and so that's what Tai razz attempts now I'm
[31:29] so that's what Tai razz attempts now I'm not going to go through this whole flow
[31:31] not going to go through this whole flow chart you can find this in in the Thai
[31:33] chart you can find this in in the Thai rads reference that I had on the last
[31:35] rads reference that I had on the last slide but basically you look at each of
[31:38] slide but basically you look at each of those categories and you do some scoring
[31:40] those categories and you do some scoring and you add up your aggregate score and
[31:42] and you add up your aggregate score and that tells you sort of your your triage
[31:45] that tells you sort of your your triage risk assessment of a thyroid nodule and
[31:47] risk assessment of a thyroid nodule and whether or not it needs to go to biopsy
[31:49] whether or not it needs to go to biopsy for further evaluation and management
[31:54] another paradigm which is broadly uses
[31:57] another paradigm which is broadly uses the American Thyroid Association or ATA
[32:00] the American Thyroid Association or ATA paradigm and this is also for risk
[32:03] paradigm and this is also for risk stratification and trying to figure out
[32:05] stratification and trying to figure out management and biopsy needs and this
[32:09] management and biopsy needs and this relies more on specific imaging patterns
[32:11] relies more on specific imaging patterns as well as the size of lesions as well
[32:14] as well as the size of lesions as well so I think for all the residents out
[32:17] so I think for all the residents out there you probably have seen this a
[32:20] there you probably have seen this a thousand times right this is in every
[32:22] thousand times right this is in every body reading room you can see this
[32:24] body reading room you can see this usually it's posted on the wall or in
[32:26] usually it's posted on the wall or in cubicles and these are just sort of the
[32:29] cubicles and these are just sort of the the standard-issue
[32:32] the standard-issue imaging appearance of different thyroid
[32:34] imaging appearance of different thyroid nodules and if you look at the bottom of
[32:36] nodules and if you look at the bottom of the image you can see you know the
[32:37] the image you can see you know the benign appearance and as you work your
[32:40] benign appearance and as you work your way up to the top these are imaging
[32:42] way up to the top these are imaging patterns on ultrasound that confer risk
[32:44] patterns on ultrasound that confer risk of malignancy so while I think ty rads
[32:47] of malignancy so while I think ty rads is a little bit more simplified and this
[32:49] is a little bit more simplified and this may be a little bit more
[32:50] may be a little bit more at your discretion and in terms of how
[32:53] at your discretion and in terms of how you interpret the images the thing that
[32:56] you interpret the images the thing that ata makes really nice is it has a great
[32:59] ata makes really nice is it has a great decision tree that's built into it and
[33:01] decision tree that's built into it and based upon all of these different
[33:03] based upon all of these different variables and and you know how highly
[33:05] variables and and you know how highly suspicious the ultrasound pattern is it
[33:08] suspicious the ultrasound pattern is it really is a nice way to plug in and sort
[33:10] really is a nice way to plug in and sort of just work through the system and
[33:11] of just work through the system and figure out what the next appropriate
[33:13] figure out what the next appropriate step is so I won't again go through this
[33:15] step is so I won't again go through this entirety of the spreadsheet or this flow
[33:17] entirety of the spreadsheet or this flow sheet just be aware of it and check out
[33:20] sheet just be aware of it and check out the atas guidelines and make sure that
[33:22] the atas guidelines and make sure that you sort of have an understanding of how
[33:24] you sort of have an understanding of how to use them
[33:26] to use them okay so let's talk about some specific
[33:28] okay so let's talk about some specific thyroid pathologies first up is a
[33:30] thyroid pathologies first up is a thyroid adenoma
[33:31] thyroid adenoma so you can have true adenoma that have a
[33:33] so you can have true adenoma that have a defined capsule and histopathology or
[33:36] defined capsule and histopathology or you can have adenomatous hyperplasia
[33:39] you can have adenomatous hyperplasia that has an incomplete capsule I still
[33:42] that has an incomplete capsule I still tend to lump these together and think
[33:43] tend to lump these together and think about them in the same way but what do
[33:46] about them in the same way but what do they look like on imaging well
[33:48] they look like on imaging well unfortunately it's a whole lot of
[33:50] unfortunately it's a whole lot of nonspecific stuff so on CT the
[33:52] nonspecific stuff so on CT the enhancement pattern can be variable they
[33:55] enhancement pattern can be variable they may or may not have calcification they
[33:57] may or may not have calcification they may or may not contain hemorrhage on MRI
[33:59] may or may not contain hemorrhage on MRI same boat variable signal intensity
[34:02] same boat variable signal intensity variable enhancement this is an area
[34:04] variable enhancement this is an area where I think ultrasound is much more
[34:06] where I think ultrasound is much more helpful on ultrasound the majority of
[34:09] helpful on ultrasound the majority of them tend to be solid and homogeneous
[34:11] them tend to be solid and homogeneous usually they're sort of on the isotype
[34:13] usually they're sort of on the isotype oh I'm sorry hyper echoic side of the
[34:16] oh I'm sorry hyper echoic side of the spectrum and importantly the majority of
[34:20] spectrum and importantly the majority of them will have a hypo ekiden a halo
[34:22] them will have a hypo ekiden a halo around them
[34:25] around them this is a time to throw on your color
[34:27] this is a time to throw on your color Doppler take a look at the flow because
[34:29] Doppler take a look at the flow because these will oftentimes have a peri
[34:32] these will oftentimes have a peri nodular so-called spoke wheel
[34:34] nodular so-called spoke wheel vascularity pattern and I'll show that
[34:36] vascularity pattern and I'll show that on the next slide
[34:37] on the next slide so here the image on the left this is
[34:39] so here the image on the left this is our transverse grayscale the image on
[34:41] our transverse grayscale the image on the right is our color Doppler you can
[34:43] the right is our color Doppler you can see that sort of ISO - maybe slightly
[34:46] see that sort of ISO - maybe slightly hyper a co ik circumscribe nodule it has
[34:48] hyper a co ik circumscribe nodule it has that hypoechoic halo around it and then
[34:51] that hypoechoic halo around it and then on color Doppler you get that spoke
[34:53] on color Doppler you get that spoke wheel pattern of vascularity with
[34:55] wheel pattern of vascularity with pérignon
[34:56] pérignon increased vascularity and then some sort
[34:59] increased vascularity and then some sort of streaking vascularity going through
[35:00] of streaking vascularity going through it now important to keep in mind is
[35:03] it now important to keep in mind is despite what these look like on imaging
[35:06] despite what these look like on imaging they end up getting biopsied and
[35:08] they end up getting biopsied and unfortunately even the pathologist can't
[35:10] unfortunately even the pathologist can't tell you definitively that it's an
[35:11] tell you definitively that it's an adenoma unless it's completely resected
[35:13] adenoma unless it's completely resected and they can actually section it they
[35:16] and they can actually section it they can only give you sort of a best guess
[35:19] can only give you sort of a best guess based upon a biopsy so to confirm it it
[35:21] based upon a biopsy so to confirm it it these need to come out
[35:23] these need to come out what do they look like on nuke studies
[35:25] what do they look like on nuke studies well unfortunately they can be variable
[35:27] well unfortunately they can be variable in FDG but they may be avid
[35:30] in FDG but they may be avid these are lesions that oftentimes are
[35:33] these are lesions that oftentimes are hot on I 123 or pertechnetate studies so
[35:38] hot on I 123 or pertechnetate studies so whenever we see a hot nodule the vast
[35:40] whenever we see a hot nodule the vast majority of time it's benign that's a
[35:42] majority of time it's benign that's a very reassuring finding it's really the
[35:44] very reassuring finding it's really the cold nodules that we worry about having
[35:46] cold nodules that we worry about having risk of malignancy
[35:49] risk of malignancy so here's an example of a thyroid
[35:52] so here's an example of a thyroid adenoma you can see on the axial
[35:54] adenoma you can see on the axial contrast-enhanced CT sort of this
[35:56] contrast-enhanced CT sort of this heterogeneous but maybe slightly hypo
[35:59] heterogeneous but maybe slightly hypo dense or hypo enhancing nodule if we
[36:01] dense or hypo enhancing nodule if we look at our fused fdg-pet yeah it looks
[36:04] look at our fused fdg-pet yeah it looks like maybe it's a little bit FDG avid a
[36:06] like maybe it's a little bit FDG avid a little bit tough to tease out from the
[36:08] little bit tough to tease out from the background thyroid uptake this is a nice
[36:10] background thyroid uptake this is a nice area to look at your actual source pet
[36:12] area to look at your actual source pet data and we can see unequivocally this
[36:14] data and we can see unequivocally this is a has FDG uptake it's it's avidly
[36:17] is a has FDG uptake it's it's avidly taking it up so just keep in mind tired
[36:20] taking it up so just keep in mind tired adenoma is there uptake on FDG is
[36:22] adenoma is there uptake on FDG is variable so whenever you encounter one
[36:25] variable so whenever you encounter one on a pet
[36:27] on a pet anytime you you're catching a nodule
[36:28] anytime you you're catching a nodule that's hypermetabolic like this it's
[36:31] that's hypermetabolic like this it's going to need an ultrasound and then
[36:33] going to need an ultrasound and then based upon its ultrasound appearance it
[36:35] based upon its ultrasound appearance it may or may not need a biopsy
[36:37] may or may not need a biopsy next up is the thyroid colloid nodule or
[36:40] next up is the thyroid colloid nodule or a colloid cyst these tend to have
[36:42] a colloid cyst these tend to have sharply defined margins they tend to be
[36:45] sharply defined margins they tend to be largely fluid-filled on CT they're
[36:49] largely fluid-filled on CT they're oftentimes low-density and circumscribed
[36:51] oftentimes low-density and circumscribed this is fairly circumscribed it's not
[36:53] this is fairly circumscribed it's not perfect on MRI these often have variable
[36:57] perfect on MRI these often have variable signal intensity frequently TT bright
[36:59] signal intensity frequently TT bright but it sort of depends on protein
[37:01] but it sort of depends on protein content and and such but these are not
[37:04] content and and such but these are not enhancing ultrasound is an area that can
[37:07] enhancing ultrasound is an area that can be quite helpful as well
[37:10] be quite helpful as well these are anechoic they will show
[37:12] these are anechoic they will show posterior coup stick enhancement and be
[37:15] posterior coup stick enhancement and be on the lookout for comet tail artifact
[37:17] on the lookout for comet tail artifact that confirms to you that it contains
[37:20] that confirms to you that it contains colloid crystal within it
[37:23] colloid crystal within it so here's a colloid nodule on CT this
[37:26] so here's a colloid nodule on CT this was path proven
[37:28] was path proven circumscribed but kind of heterogeneous
[37:30] circumscribed but kind of heterogeneous and it's attenuation and enhancement so
[37:32] and it's attenuation and enhancement so you know CT frankly kind of sucks for
[37:35] you know CT frankly kind of sucks for trying to figure out what's going on on
[37:38] trying to figure out what's going on on ultrasound different patient but this is
[37:41] ultrasound different patient but this is sort of a classic appearance of a
[37:42] sort of a classic appearance of a colloid nodule you can see it's anechoic
[37:44] colloid nodule you can see it's anechoic it's circumscribed when you throw in
[37:46] it's circumscribed when you throw in that color Doppler it really accentuates
[37:48] that color Doppler it really accentuates that comet tail artifact look for that
[37:51] that comet tail artifact look for that artifact because that confirms that
[37:52] artifact because that confirms that you're dealing with colloid and you know
[37:54] you're dealing with colloid and you know you're dealing with something benign
[37:57] you're dealing with something benign so hopefully after me blabbering on
[38:00] so hopefully after me blabbering on there for the last couple of minutes
[38:01] there for the last couple of minutes you'll realize that ultrasound really is
[38:04] you'll realize that ultrasound really is far superior to CT and MRI and assessing
[38:07] far superior to CT and MRI and assessing the risk of malignancy with incidental
[38:09] the risk of malignancy with incidental thyroid nodules I mean CT and MRI they
[38:11] thyroid nodules I mean CT and MRI they honestly they just kind of suck for this
[38:13] honestly they just kind of suck for this the question is do you need to get an
[38:16] the question is do you need to get an ultrasound every time you catch one of
[38:17] ultrasound every time you catch one of these on MRI or on CT and I think we've
[38:21] these on MRI or on CT and I think we've got some pretty good data now to suggest
[38:23] got some pretty good data now to suggest that the answer is no there was a nice
[38:26] that the answer is no there was a nice paper published by Jenny Wong and
[38:28] paper published by Jenny Wong and colleagues in J ACR a few years back
[38:31] colleagues in J ACR a few years back it's the white paper on incidental
[38:33] it's the white paper on incidental thyroid nodules really a great example
[38:35] thyroid nodules really a great example of using data to dictate how we should
[38:38] of using data to dictate how we should practice but they were able to
[38:40] practice but they were able to demonstrate that just by looking at a
[38:42] demonstrate that just by looking at a couple of variables namely the age and
[38:45] couple of variables namely the age and the size of the nodule as well as
[38:48] the size of the nodule as well as whether or not there are any other
[38:49] whether or not there are any other suspicious findings like extra thyroid
[38:51] suspicious findings like extra thyroid extension or suspicious lymph nodes that
[38:53] extension or suspicious lymph nodes that would have automatically made it
[38:54] would have automatically made it suspicious but looking at just the
[38:57] suspicious but looking at just the variables of age in size you can
[38:59] variables of age in size you can actually quite nicely risk stratify
[39:02] actually quite nicely risk stratify these patients as far as who needs to
[39:03] these patients as far as who needs to get an ultrasound for incidentally
[39:05] get an ultrasound for incidentally discovered thyroid nodules on CT and MRI
[39:09] discovered thyroid nodules on CT and MRI this is a flow sheet from that paper
[39:12] this is a flow sheet from that paper again you can find this in J ACR I'm not
[39:15] again you can find this in J ACR I'm not gonna go through all of this just to
[39:17] gonna go through all of this just to show you it's out there it's quite
[39:19] show you it's out there it's quite simple to go through but I'll hit the
[39:21] simple to go through but I'll hit the high points of it if there are no
[39:24] high points of it if there are no suspicious features in other words it
[39:26] suspicious features in other words it doesn't look like this nodule has extra
[39:28] doesn't look like this nodule has extra thyroid 'el invasion it's not blown its
[39:30] thyroid 'el invasion it's not blown its way out of the thyroid if there are no
[39:32] way out of the thyroid if there are no suspicious lymph nodes that look like
[39:34] suspicious lymph nodes that look like metastatic nodes and if there are no
[39:37] metastatic nodes and if there are no comorbidities or limited life expectancy
[39:39] comorbidities or limited life expectancy which albeit is tough to figure out if
[39:41] which albeit is tough to figure out if you're a radiologist
[39:43] you're a radiologist but if those criteria are met then you
[39:46] but if those criteria are met then you can look at the patient's age and the
[39:48] can look at the patient's age and the size of the nodule and figure out what
[39:49] size of the nodule and figure out what needs to happen next so if the patient
[39:51] needs to happen next so if the patient is under the age of 35 and if the nodule
[39:55] is under the age of 35 and if the nodule is less than a centimeter in size we can
[39:57] is less than a centimeter in size we can ignore it if they're under the age of 35
[40:00] ignore it if they're under the age of 35 and it's a centimeter or greater in size
[40:02] and it's a centimeter or greater in size they need an ultrasound and that's
[40:04] they need an ultrasound and that's simply because differentiated thyroid
[40:06] simply because differentiated thyroid carcinoma is a disease that
[40:08] carcinoma is a disease that disproportionately affects younger
[40:10] disproportionately affects younger adults people in there in sort of that
[40:13] adults people in there in sort of that 20s and 30s age range so we take those
[40:16] 20s and 30s age range so we take those nodules much more seriously once you get
[40:19] nodules much more seriously once you get over the age of 35 we get a little bit
[40:21] over the age of 35 we get a little bit more lacks in our in our guidelines if a
[40:23] more lacks in our in our guidelines if a nodule is less than a centimeter and a
[40:25] nodule is less than a centimeter and a half in size we can ignore it and if a
[40:28] half in size we can ignore it and if a nodule is 1.5 centimeters are greater
[40:30] nodule is 1.5 centimeters are greater they need an ultrasound so I think the
[40:34] they need an ultrasound so I think the ACR white paper really nicely simplifies
[40:36] ACR white paper really nicely simplifies how to deal with these thyroid nodules
[40:38] how to deal with these thyroid nodules it's something that I put into practice
[40:40] it's something that I put into practice ever since reading that paper a couple
[40:41] ever since reading that paper a couple years ago and I think a lot of people
[40:43] years ago and I think a lot of people have have really embraced this as well
[40:47] have have really embraced this as well next topic is a multinodular goiter this
[40:50] next topic is a multinodular goiter this is as the name might imply diffuse multi
[40:53] is as the name might imply diffuse multi nodular enlargement of the thyroid and
[40:54] nodular enlargement of the thyroid and this is due to chronic tsa over
[40:56] this is due to chronic tsa over stimulation the problem with goiters is
[40:59] stimulation the problem with goiters is it's reported that about 5% of the time
[41:01] it's reported that about 5% of the time they Harbor malignancy if I ask my
[41:03] they Harbor malignancy if I ask my pathologists here at IU they tell me
[41:05] pathologists here at IU they tell me they can find it virtually in all of
[41:07] they can find it virtually in all of them given enough time find that needle
[41:09] them given enough time find that needle in the haystack but again that's because
[41:11] in the haystack but again that's because thyroid cancer often times as a
[41:13] thyroid cancer often times as a diagnosis that's indolent not always but
[41:16] diagnosis that's indolent not always but often times
[41:18] often times things about multinodular goiter x' that
[41:21] things about multinodular goiter x' that you need to know as an imager well
[41:23] you need to know as an imager well despite the fact that they are big they
[41:25] despite the fact that they are big they tend to have defied margins so it
[41:27] tend to have defied margins so it doesn't look like it's aggressively
[41:29] doesn't look like it's aggressively invading structures around it rather
[41:31] invading structures around it rather they sort of push things away they may
[41:34] they sort of push things away they may or may not have internal calcifications
[41:35] or may not have internal calcifications they may or may not have internal
[41:37] they may or may not have internal hemorrhage for that matter but things
[41:39] hemorrhage for that matter but things that you really need to be looking for
[41:41] that you really need to be looking for and reporting in your reports are what's
[41:44] and reporting in your reports are what's it doing to the trachea is it causing
[41:46] it doing to the trachea is it causing airway narrowing is it displacing it
[41:48] airway narrowing is it displacing it just how bad is that narrowing getting
[41:50] just how bad is that narrowing getting is it over a short segment or a long
[41:52] is it over a short segment or a long segment and then also report whether or
[41:54] segment and then also report whether or not there is retrosternal extension
[41:57] not there is retrosternal extension so in this nice case lens to me by Rick
[41:59] so in this nice case lens to me by Rick Wiggins you can see this ginormous
[42:01] Wiggins you can see this ginormous goiter sending down into the mediastinum
[42:03] goiter sending down into the mediastinum it's important to let the surgeons know
[42:06] it's important to let the surgeons know about this ahead of time because when
[42:08] about this ahead of time because when they go to take this out or debulk it
[42:10] they go to take this out or debulk it this goes from being in Otolaryngology
[42:12] this goes from being in Otolaryngology case do a combined Otolaryngology and
[42:15] case do a combined Otolaryngology and cardiothoracic
[42:16] cardiothoracic case because of the the mediastinal
[42:19] case because of the the mediastinal extent that needs to be dealt with
[42:22] extent that needs to be dealt with alright let's talk about thyroid
[42:23] alright let's talk about thyroid malignancy as you can see on this slide
[42:26] malignancy as you can see on this slide there are multiple different types of
[42:27] there are multiple different types of thyroid cancer we're gonna start talking
[42:29] thyroid cancer we're gonna start talking about start with talking about the
[42:30] about start with talking about the differentiated thyroid carcinoma
[42:33] differentiated thyroid carcinoma okay so differentiated thyroid carcinoma
[42:36] okay so differentiated thyroid carcinoma the vast majority are gonna be papillary
[42:38] the vast majority are gonna be papillary number two would be follicular this is
[42:42] number two would be follicular this is more common in women than in men it's
[42:43] more common in women than in men it's about three to one ratio and I say said
[42:46] about three to one ratio and I say said before this is a disease that
[42:48] before this is a disease that disproportionately affects younger
[42:50] disproportionately affects younger adults you certainly can get it in older
[42:51] adults you certainly can get it in older adults but it has a high incidence in
[42:54] adults but it has a high incidence in young adults peak age somewhere in the
[42:56] young adults peak age somewhere in the third and fourth decades and that again
[42:58] third and fourth decades and that again is sort of what drives the the acrs
[43:02] is sort of what drives the the acrs white paper on how to deal with
[43:03] white paper on how to deal with incidental thyroid nodules
[43:07] incidental thyroid nodules the primary tumor oftentimes is solid
[43:11] the primary tumor oftentimes is solid but it can't have cystic components or
[43:13] but it can't have cystic components or it can be mixed solid and cystic not
[43:15] it can be mixed solid and cystic not infrequently has calcification you can
[43:17] infrequently has calcification you can see this yellow arrow is sort of
[43:18] see this yellow arrow is sort of pointing at that fine curd of
[43:20] pointing at that fine curd of curvilinear calcification but
[43:22] curvilinear calcification but interestingly the lymph nodes the
[43:24] interestingly the lymph nodes the metastatic nodes in the neck look a lot
[43:28] metastatic nodes in the neck look a lot like the primary tumor not always but
[43:29] like the primary tumor not always but oftentimes they do and you can sort of
[43:32] oftentimes they do and you can sort of appreciate that with sort of these mixed
[43:34] appreciate that with sort of these mixed solid and cystic lymph nodes here
[43:37] solid and cystic lymph nodes here denoted by the yellow arrows if you do
[43:39] denoted by the yellow arrows if you do MRI oftentimes these will be t1 bright
[43:42] MRI oftentimes these will be t1 bright that's because
[43:44] that's because with differentiated thyroid carcinoma
[43:47] with differentiated thyroid carcinoma it's so well differentiated that the
[43:50] it's so well differentiated that the nodal metastases are in fact churning
[43:52] nodal metastases are in fact churning out I read proteins like thyroid
[43:54] out I read proteins like thyroid globulin and those nodes may also have
[43:56] globulin and those nodes may also have calcification within them as well
[43:59] calcification within them as well here's a patient that has papillary
[44:02] here's a patient that has papillary thyroid carcinoma you can see this sort
[44:04] thyroid carcinoma you can see this sort of hypo attenuating or hypo enhancing
[44:07] of hypo attenuating or hypo enhancing infiltrating mass on the left side of
[44:09] infiltrating mass on the left side of the thyroid it does look like it's
[44:10] the thyroid it does look like it's invading some of the surrounding soft
[44:11] invading some of the surrounding soft tissues
[44:13] tissues and you can see there are some stippled
[44:15] and you can see there are some stippled calcifications within it as well denoted
[44:17] calcifications within it as well denoted here by the yellow arrow and
[44:19] here by the yellow arrow and as we look there is this sort of cystic
[44:23] as we look there is this sort of cystic peering visceral space or Delphian or
[44:26] peering visceral space or Delphian or level 6 lymph node and importantly look
[44:29] level 6 lymph node and importantly look at that node this is a t1 pre contrast
[44:31] at that node this is a t1 pre contrast image it's pretty bright and that's
[44:34] image it's pretty bright and that's probably because of the fact that this
[44:35] probably because of the fact that this thing has so much protein content
[44:37] thing has so much protein content because it's churning out thyroid
[44:38] because it's churning out thyroid proteins here's our fused axial fluorine
[44:42] proteins here's our fused axial fluorine 18 fdg-pet CT and you can see just how
[44:45] 18 fdg-pet CT and you can see just how hypermetabolic that node is so things
[44:48] hypermetabolic that node is so things that I think are helpful clues when
[44:49] that I think are helpful clues when you're dealing with papillary thyroid
[44:50] you're dealing with papillary thyroid carcinoma look for an invasive mass or a
[44:53] carcinoma look for an invasive mass or a potentially invasive mass look for micro
[44:55] potentially invasive mass look for micro calcifications keep in mind that those
[44:58] calcifications keep in mind that those nodal metastases oftentimes look quite a
[45:00] nodal metastases oftentimes look quite a lot like the primary tumor may have
[45:03] lot like the primary tumor may have micro calcifications within them may be
[45:05] micro calcifications within them may be t1 bright due to the fact that it's
[45:07] t1 bright due to the fact that it's churning out fara globulin or other
[45:08] churning out fara globulin or other thyroid proteins
[45:11] thyroid proteins here's another patient that has
[45:13] here's another patient that has papillary thyroid carcinoma and in this
[45:16] papillary thyroid carcinoma and in this case
[45:17] case we have this cystic appearing right
[45:21] we have this cystic appearing right retro Ferengi Oh lymph node okay it's
[45:24] retro Ferengi Oh lymph node okay it's sort of oval certainly enlarged no doubt
[45:26] sort of oval certainly enlarged no doubt about it sitting sort of between the the
[45:30] about it sitting sort of between the the fringy mucosal space which is seen more
[45:33] fringy mucosal space which is seen more medially in between the carotid space
[45:35] medially in between the carotid space which is sort of getting displaced
[45:36] which is sort of getting displaced postural laterally by it so we look at
[45:39] postural laterally by it so we look at our fdg-pet CT
[45:41] our fdg-pet CT it's not metabolic at all I mean it's
[45:44] it's not metabolic at all I mean it's there's no FDG uptake so when you see
[45:46] there's no FDG uptake so when you see that it's benign right don't worry about
[45:48] that it's benign right don't worry about it
[45:49] it wrong that's absolutely wrong this is
[45:52] wrong that's absolutely wrong this is one of the critical things to recognize
[45:54] one of the critical things to recognize about cystic or necrotic lymph nodes
[45:56] about cystic or necrotic lymph nodes they are still metastatic lymph nodes
[46:00] they are still metastatic lymph nodes but in order to have FDG uptake you have
[46:03] but in order to have FDG uptake you have to have at least a base level of solid
[46:06] to have at least a base level of solid tumor component within it and when
[46:08] tumor component within it and when something gets very cystic or very
[46:10] something gets very cystic or very necrotic it can drive down that FDG
[46:13] necrotic it can drive down that FDG signals so when you see that it does
[46:15] signals so when you see that it does need to get biopsied and so how do you
[46:16] need to get biopsied and so how do you biopsy this this is one that I did a
[46:18] biopsy this this is one that I did a trans facial approach under CT guidance
[46:21] trans facial approach under CT guidance it looks a little barbaric but this is
[46:23] it looks a little barbaric but this is honestly a very safe approach and it's
[46:25] honestly a very safe approach and it's tolerated well by the patients and so
[46:28] tolerated well by the patients and so just find a safe window that you can put
[46:30] just find a safe window that you can put the needle in obviously avoiding putting
[46:32] the needle in obviously avoiding putting it through the carotid artery because
[46:33] it through the carotid artery because that is certainly poor form but whenever
[46:37] that is certainly poor form but whenever you biopsy these you may not get a lot
[46:39] you biopsy these you may not get a lot of cells but instead make sure they're
[46:41] of cells but instead make sure they're running a thyroglobulin washout on it
[46:43] running a thyroglobulin washout on it because if it contains thyroglobulin you
[46:45] because if it contains thyroglobulin you know you're dealing with a metastatic
[46:47] know you're dealing with a metastatic node so a classic pitfall that we see
[46:50] node so a classic pitfall that we see not infrequently with papillary thyroid
[46:52] not infrequently with papillary thyroid carcinoma look for those cystic retro
[46:55] carcinoma look for those cystic retro pharyngeal nodes or cystic nodes in
[46:56] pharyngeal nodes or cystic nodes in general but thyroids bizarre it gives
[46:59] general but thyroids bizarre it gives nodal Mets and sort of unexpected places
[47:02] nodal Mets and sort of unexpected places retro Ferengi lymph nodes even though
[47:03] retro Ferengi lymph nodes even though they're sort of geographically removed
[47:05] they're sort of geographically removed that's a nodal station that can be
[47:08] that's a nodal station that can be involved so when you see a cystic retro
[47:11] involved so when you see a cystic retro Ferengi a lymph node think about
[47:12] Ferengi a lymph node think about differentiated thyroid cancer these
[47:14] differentiated thyroid cancer these cystic nodes again are oftentimes cold
[47:17] cystic nodes again are oftentimes cold on fdg-pet it's incumbent upon you as
[47:21] on fdg-pet it's incumbent upon you as the radiologist to suggest that that may
[47:22] the radiologist to suggest that that may be what's going on and this is where you
[47:24] be what's going on and this is where you can add value add service by offering to
[47:27] can add value add service by offering to put a needle into it
[47:29] put a needle into it one more interesting papillary thyroid
[47:31] one more interesting papillary thyroid carcinoma case this was a patient who
[47:34] carcinoma case this was a patient who had known papillary thyroid carcinoma
[47:36] had known papillary thyroid carcinoma had previously been resected but they
[47:39] had previously been resected but they had an increasing thyroglobulin level we
[47:42] had an increasing thyroglobulin level we have our axial conventional CT on the
[47:44] have our axial conventional CT on the left you can see in this node here it's
[47:47] left you can see in this node here it's not really all that enlarged but maybe
[47:49] not really all that enlarged but maybe it looks ever so slightly more dense
[47:51] it looks ever so slightly more dense compared to its contralateral
[47:53] compared to its contralateral counterpart with the red arrow this is
[47:55] counterpart with the red arrow this is an area where you can use dual energy or
[47:57] an area where you can use dual energy or spectral CT and play off of the physics
[48:00] spectral CT and play off of the physics use that those low mono kV sequences
[48:04] use that those low mono kV sequences sort of get down as low as you can
[48:06] sort of get down as low as you can toward the K edge of iodine and that's
[48:09] toward the K edge of iodine and that's going to bring up your signal so here we
[48:11] going to bring up your signal so here we can see that that right side and lymph
[48:13] can see that that right side and lymph node is really really bright whenever we
[48:15] node is really really bright whenever we are
[48:16] are using this mono ke v40 sequence here and
[48:22] using this mono ke v40 sequence here and then compare that to the contralateral
[48:24] then compare that to the contralateral normal lymph node which
[48:26] normal lymph node which not as bright so that tells us that that
[48:28] not as bright so that tells us that that note on the right side is taking up more
[48:30] note on the right side is taking up more iodine and we can even prove that by
[48:32] iodine and we can even prove that by doing an iodine subtraction map that's
[48:34] doing an iodine subtraction map that's the pathologic node they're denoted by
[48:37] the pathologic node they're denoted by the yellow arrow we can see how it has a
[48:39] the yellow arrow we can see how it has a signal void where it's dropping out the
[48:40] signal void where it's dropping out the iodine compare that to the contralateral
[48:42] iodine compare that to the contralateral normal lymph node that doesn't this was
[48:44] normal lymph node that doesn't this was a path proven non enlarged metastatic
[48:47] a path proven non enlarged metastatic lymph node that we can see really using
[48:51] lymph node that we can see really using spectral CT or dual-energy CT you could
[48:53] spectral CT or dual-energy CT you could accomplish the same thing to look for
[48:56] accomplish the same thing to look for those lymph nodes that contain increased
[48:59] those lymph nodes that contain increased iodine in patients with Denver treated
[49:01] iodine in patients with Denver treated thyroid carcinoma
[49:04] here's just one example of a follicular
[49:06] here's just one example of a follicular thyroid carcinoma again it's a another
[49:09] thyroid carcinoma again it's a another subset of difference you did thyroid
[49:10] subset of difference you did thyroid carcinoma this I'm showing you just to
[49:13] carcinoma this I'm showing you just to drive home the point that sometimes the
[49:14] drive home the point that sometimes the primary tumor is quite small and quite
[49:17] primary tumor is quite small and quite you know relatively benign looking just
[49:19] you know relatively benign looking just a small little nodule on the right side
[49:21] a small little nodule on the right side giant nodal conglomerate on the right as
[49:24] giant nodal conglomerate on the right as well sort of has a similar appearance
[49:26] well sort of has a similar appearance though to the primary tumor but big
[49:29] though to the primary tumor but big nodes tiny primary thyroid cancer
[49:31] nodes tiny primary thyroid cancer sometimes does that it's a weird bird it
[49:34] sometimes does that it's a weird bird it does weird things like I said you know
[49:37] does weird things like I said you know it gives you nodes and places that you
[49:39] it gives you nodes and places that you don't necessarily expect it to but
[49:42] don't necessarily expect it to but importantly sometimes the primary tumor
[49:44] importantly sometimes the primary tumor doesn't look that impressive compared to
[49:46] doesn't look that impressive compared to the nodal disease
[49:48] the nodal disease next up is medullary thyroid carcinoma
[49:51] next up is medullary thyroid carcinoma this is a rare neuroendocrine carcinoma
[49:53] this is a rare neuroendocrine carcinoma of the thyroid this arises from the para
[49:56] of the thyroid this arises from the para follicular C cells these are the cells
[49:58] follicular C cells these are the cells that produce calcitonin therefore our
[50:00] that produce calcitonin therefore our serum marker in this case is calcitonin
[50:03] serum marker in this case is calcitonin so for differentiated thyroid carcinoma
[50:05] so for differentiated thyroid carcinoma we use thyroid globulin is our serum
[50:07] we use thyroid globulin is our serum marker for medullary thyroid carcinoma
[50:09] marker for medullary thyroid carcinoma we use calcitonin as one of our primary
[50:12] we use calcitonin as one of our primary serum markers
[50:14] serum markers these tend to be heterogeneous masses
[50:16] these tend to be heterogeneous masses but usually they're fairly circumscribed
[50:19] but usually they're fairly circumscribed in this case nicely shows just how
[50:20] in this case nicely shows just how circumscribed this right lobe thyroid
[50:22] circumscribed this right lobe thyroid mass is they may or may not have
[50:24] mass is they may or may not have calcification in comparison to
[50:26] calcification in comparison to differentiated thyroid carcinoma the
[50:28] differentiated thyroid carcinoma the nodal metastases are more commonly solid
[50:31] nodal metastases are more commonly solid it's not a perfect paradigm you
[50:33] it's not a perfect paradigm you certainly can get solid nodes but
[50:35] certainly can get solid nodes but differentiated you can get you know sort
[50:37] differentiated you can get you know sort of cystic or necrotic looking nodes for
[50:38] of cystic or necrotic looking nodes for medullary but in general they're more
[50:40] medullary but in general they're more solid with medullary thyroid carcinoma
[50:42] solid with medullary thyroid carcinoma than with differentiated
[50:44] than with differentiated this is also an area because it's a
[50:47] this is also an area because it's a neuroendocrine carcinoma in which some
[50:50] neuroendocrine carcinoma in which some of the fancy nuclear medicine agents may
[50:51] of the fancy nuclear medicine agents may play a role things like dota Tate or MIB
[50:53] play a role things like dota Tate or MIB G and I really think dota at least at
[50:55] G and I really think dota at least at our shop and I know a lot of academic
[50:57] our shop and I know a lot of academic centers has really sort of supplanted mi
[51:00] centers has really sort of supplanted mi bici just because of the fact you can
[51:01] bici just because of the fact you can get such nice images with dota
[51:04] get such nice images with dota so here's a patient with a medullary
[51:06] so here's a patient with a medullary thyroid carcinoma sort of a
[51:07] thyroid carcinoma sort of a heterogeneous nodule on the right you
[51:10] heterogeneous nodule on the right you can see the image on the right as our
[51:13] can see the image on the right as our fuse to axial PET CT image you can see
[51:15] fuse to axial PET CT image you can see that this one was FDG avid just keep in
[51:18] that this one was FDG avid just keep in mind that the degree of FDG avidity can
[51:21] mind that the degree of FDG avidity can be quite variable with medullary thyroid
[51:22] be quite variable with medullary thyroid carcinoma
[51:25] carcinoma this is a patient who has medullary
[51:27] this is a patient who has medullary thyroid carcinoma
[51:28] thyroid carcinoma we can see the image on the left the
[51:30] we can see the image on the left the axial contrast CT component there's sort
[51:33] axial contrast CT component there's sort of a little nodule and the patient's
[51:36] of a little nodule and the patient's left-side not super impressive on CT
[51:38] left-side not super impressive on CT imaging here's our fused gallium 68 dota
[51:42] imaging here's our fused gallium 68 dota scan you can see yet does have a little
[51:44] scan you can see yet does have a little bit of asymmetric increased DOTA uptake
[51:46] bit of asymmetric increased DOTA uptake those with ego eyes in the audience
[51:49] those with ego eyes in the audience might recognize oh that's not good we
[51:51] might recognize oh that's not good we have a lymph node not an enlarged lymph
[51:53] have a lymph node not an enlarged lymph node but we do have a left level 5b node
[51:57] node but we do have a left level 5b node back here that is also dota avid and so
[52:01] back here that is also dota avid and so this is a patient who had medullary
[52:03] this is a patient who had medullary thyroid carcinoma with nodal metastasis
[52:07] thyroid carcinoma with nodal metastasis next is anaplastic thyroid carcinoma and
[52:10] next is anaplastic thyroid carcinoma and this is truly a lethal tumor if you
[52:12] this is truly a lethal tumor if you carry this diagnosis your stage 4
[52:14] carry this diagnosis your stage 4 disease at baseline this can arise from
[52:17] disease at baseline this can arise from differentiated thyroid carcinoma that
[52:19] differentiated thyroid carcinoma that sort of breaks bad and gets really bad
[52:21] sort of breaks bad and gets really bad and what does it look like on imaging
[52:24] and what does it look like on imaging it's ugly I mean there's no other way to
[52:25] it's ugly I mean there's no other way to describe it these are large they're
[52:28] describe it these are large they're heterogeneous masses they're invasive
[52:30] heterogeneous masses they're invasive infiltrating you can see this is taking
[52:32] infiltrating you can see this is taking up the entirety of the left lobe of a
[52:33] up the entirety of the left lobe of a thyroid it's invading out into the
[52:35] thyroid it's invading out into the surrounding structures as well these
[52:37] surrounding structures as well these patients commonly have nodal and even
[52:40] patients commonly have nodal and even distant metastatic disease because we
[52:42] distant metastatic disease because we don't use radio iodine to treat these
[52:44] don't use radio iodine to treat these patients iodine load is not a
[52:46] patients iodine load is not a consideration so it's fine to do a
[52:47] consideration so it's fine to do a contrast and hit CT
[52:50] contrast and hit CT this is another patient with anaplastic
[52:52] this is another patient with anaplastic thyroid carcinoma you can see this
[52:54] thyroid carcinoma you can see this really ugly right thigh roid mass it's
[52:57] really ugly right thigh roid mass it's partially necrotic it's invading in out
[52:59] partially necrotic it's invading in out into the surrounding soft tissues and
[53:01] into the surrounding soft tissues and speaking of those surrounding soft
[53:02] speaking of those surrounding soft tissues you can see it's invaded the
[53:04] tissues you can see it's invaded the internal jugular vein which has a long
[53:06] internal jugular vein which has a long segment of internal thrombus
[53:10] you can also get metastases to the
[53:12] you can also get metastases to the thyroid clinically these are thought to
[53:15] thyroid clinically these are thought to be uncommon but perhaps they're a bit
[53:17] be uncommon but perhaps they're a bit under recognized the problem with it is
[53:19] under recognized the problem with it is the imaging findings are truly and
[53:21] the imaging findings are truly and utterly nonspecific there's no way I can
[53:24] utterly nonspecific there's no way I can look at this and tell you on the CT that
[53:26] look at this and tell you on the CT that this is a metastasis rather than it
[53:28] this is a metastasis rather than it being a thyroid primary malignancy and
[53:31] being a thyroid primary malignancy and it really runs a gamut these can be
[53:33] it really runs a gamut these can be small to find nodules to a large
[53:35] small to find nodules to a large infiltrating mass like this the common
[53:37] infiltrating mass like this the common culprits are simply the common culprits
[53:40] culprits are simply the common culprits the ones that are more prone to be seen
[53:42] the ones that are more prone to be seen and to be seen with advanced disease
[53:44] and to be seen with advanced disease such as breast kidney colon lung
[53:46] such as breast kidney colon lung melanoma the usual suspects here and I
[53:50] melanoma the usual suspects here and I would say probably the best advice here
[53:52] would say probably the best advice here would be use your clues if they have a
[53:55] would be use your clues if they have a known cancer they've got a rapidly
[53:56] known cancer they've got a rapidly enlarging thyroid mass they have known
[53:58] enlarging thyroid mass they have known systemic Mets elsewhere it should be on
[54:00] systemic Mets elsewhere it should be on the radar but at the end of the day
[54:02] the radar but at the end of the day you're gonna have to biopsy it to get
[54:04] you're gonna have to biopsy it to get the answer
[54:06] the answer this is a patient that had a large left
[54:10] this is a patient that had a large left lobe thyroid metastatic lesion I think
[54:12] lobe thyroid metastatic lesion I think if I remember right the history here was
[54:14] if I remember right the history here was renal cell carcinoma you can see where
[54:16] renal cell carcinoma you can see where the yellow is pointing sort of an ugly
[54:18] the yellow is pointing sort of an ugly left lobe thyroid mass
[54:20] left lobe thyroid mass could for all the world have been a an
[54:24] could for all the world have been a an anaplastic thyroid carcinoma but in this
[54:27] anaplastic thyroid carcinoma but in this case biopsy demonstrated that it was
[54:30] case biopsy demonstrated that it was metastatic disease sort of an
[54:32] metastatic disease sort of an interesting feature in this case was
[54:34] interesting feature in this case was there was also in the same slice you
[54:36] there was also in the same slice you could see this little bone lesion if you
[54:38] could see this little bone lesion if you do some Hounds field measurements you
[54:40] do some Hounds field measurements you can see it's similar to the thyroid but
[54:42] can see it's similar to the thyroid but again that doesn't really tell you that
[54:43] again that doesn't really tell you that that it is a met to the fire but it very
[54:46] that it is a met to the fire but it very well could have been a thyroid cancer
[54:48] well could have been a thyroid cancer with a bone met you just have to put a
[54:50] with a bone met you just have to put a needle in it to know
[54:53] needle in it to know next up is thyroid lymphoma most
[54:56] next up is thyroid lymphoma most commonly this is going to be a diffuse
[54:57] commonly this is going to be a diffuse large b-cell lymphoma important
[54:59] large b-cell lymphoma important take-home point this has a high
[55:01] take-home point this has a high association with chronic lymphocytic
[55:03] association with chronic lymphocytic thyroiditis
[55:05] thyroiditis in fact it's thought somewhere on the
[55:06] in fact it's thought somewhere on the order of a 70 times life 70 times
[55:09] order of a 70 times life 70 times lifetime risk of developing non-hodgkin
[55:12] lifetime risk of developing non-hodgkin lymphoma in patients who have
[55:14] lymphoma in patients who have lymphocytic thyroiditis or Hashimoto
[55:16] lymphocytic thyroiditis or Hashimoto thyroiditis now these patients do
[55:19] thyroiditis now these patients do however tend to have pretty good
[55:21] however tend to have pretty good survivals unless there is extra thyroid
[55:24] survivals unless there is extra thyroid extension of tumor what does look like
[55:26] extension of tumor what does look like an imaging well as this coronal CT shows
[55:28] an imaging well as this coronal CT shows these tend to be fairly homogeneous
[55:30] these tend to be fairly homogeneous relatively low density and importantly
[55:33] relatively low density and importantly this is a non surgical disease unless
[55:36] this is a non surgical disease unless there's airway compromise in which case
[55:38] there's airway compromise in which case they will do thyroidectomies because of
[55:40] they will do thyroidectomies because of the fact that you can't compromise the
[55:42] the fact that you can't compromise the airway long enough to let the
[55:44] airway long enough to let the chemotherapy do its effect era
[55:46] chemotherapy do its effect era protecting the airway is really critical
[55:49] protecting the airway is really critical so again dealing with a thyroid lymphoma
[55:52] so again dealing with a thyroid lymphoma you can see it's diffusely enlarged
[55:55] you can see it's diffusely enlarged maybe asymmetric to the left largely
[55:57] maybe asymmetric to the left largely low-density this one's even creeping its
[55:58] low-density this one's even creeping its way down to the mediastinum and again
[56:01] way down to the mediastinum and again typically these are not surgical cases
[56:03] typically these are not surgical cases unless there is urgent airway compromise
[56:05] unless there is urgent airway compromise I
[56:07] I can't talk about thyroid lymphoma
[56:09] can't talk about thyroid lymphoma without talking a little bit about
[56:11] without talking a little bit about chronic lymphocytic or Hashimoto
[56:13] chronic lymphocytic or Hashimoto thyroiditis
[56:13] thyroiditis this in this disease patients have
[56:16] this in this disease patients have anti-thyroid Auto antibodies and that's
[56:18] anti-thyroid Auto antibodies and that's really how you make the diagnosis they
[56:20] really how you make the diagnosis they need to check those sera serological
[56:23] need to check those sera serological labs but as I said before we're talking
[56:26] labs but as I said before we're talking about coexistence with
[56:28] about coexistence with non-hodgkin lymphoma maybe setting these
[56:31] non-hodgkin lymphoma maybe setting these patients up to a seventy times increased
[56:33] patients up to a seventy times increased risk
[56:35] risk ultrasound is really our modality of
[56:38] ultrasound is really our modality of choice here early on you'll see diffuse
[56:41] choice here early on you'll see diffuse enlargement of the thyroid tends to be
[56:43] enlargement of the thyroid tends to be hypoechoic and hyper vascular is it
[56:47] hypoechoic and hyper vascular is it absolutely specific no you can get a
[56:49] absolutely specific no you can get a similar appearance with Graves disease
[56:51] similar appearance with Graves disease or subacute thyroiditis but suffice to
[56:54] or subacute thyroiditis but suffice to say this is the general imaging
[56:55] say this is the general imaging appearance enlarged hypo hypo echoic and
[56:58] appearance enlarged hypo hypo echoic and hyper vascular in the late stage when it
[57:01] hyper vascular in the late stage when it starts to burn out the thyroid gets
[57:03] starts to burn out the thyroid gets small and hyper echoic and the CT
[57:05] small and hyper echoic and the CT findings really parallel this well early
[57:08] findings really parallel this well early on in the disease process the thyroid
[57:10] on in the disease process the thyroid tends to be diffusely enlarged in
[57:11] tends to be diffusely enlarged in relatively low density
[57:13] relatively low density later in the disease process it becomes
[57:16] later in the disease process it becomes a trophic and maybe a little bit hyper
[57:17] a trophic and maybe a little bit hyper dense
[57:18] dense here's a nice case on ultrasound of what
[57:21] here's a nice case on ultrasound of what it looks like you can see diffuse
[57:23] it looks like you can see diffuse enlargement of the thyroid on the
[57:25] enlargement of the thyroid on the grayscale image it's very hypoechoic and
[57:28] grayscale image it's very hypoechoic and then you put on your color Doppler and
[57:30] then you put on your color Doppler and look how vascular this is so that's a
[57:33] look how vascular this is so that's a good look for chronic lymphocytic
[57:34] good look for chronic lymphocytic thyroiditis the imaging is suggestive
[57:37] thyroiditis the imaging is suggestive you need the serology to confirm it
[57:41] you need the serology to confirm it next topic is acute suppurative
[57:43] next topic is acute suppurative thyroiditis and this is quite a rare
[57:47] thyroiditis and this is quite a rare diagnosis and that's because the thyroid
[57:49] diagnosis and that's because the thyroid is typically pretty resistant to
[57:50] is typically pretty resistant to infection because it's an encapsulated
[57:52] infection because it's an encapsulated organ that makes it harder to infect and
[57:54] organ that makes it harder to infect and it has its own preservative in it it
[57:57] it has its own preservative in it it contains high iodine content which is
[57:59] contains high iodine content which is bacteria Sidle typically this is found
[58:03] bacteria Sidle typically this is found on the patient's left side due to an
[58:06] on the patient's left side due to an underlying fourth brachial cleft anomaly
[58:08] underlying fourth brachial cleft anomaly I'll talk about that here in a minute
[58:09] I'll talk about that here in a minute but it's not always the case but most
[58:12] but it's not always the case but most commonly it's gonna be found on the left
[58:14] commonly it's gonna be found on the left side these are not always going to be
[58:17] side these are not always going to be associated with that fourth brachial
[58:19] associated with that fourth brachial cleft anomaly but that that is really
[58:21] cleft anomaly but that that is really the biggest predisposing feature
[58:24] the biggest predisposing feature just like everything else we've talked
[58:27] just like everything else we've talked about with a thyroid ultrasound is
[58:28] about with a thyroid ultrasound is really our first line modality this is a
[58:30] really our first line modality this is a nice case lent to me by Jim Milburn down
[58:32] nice case lent to me by Jim Milburn down at an ER and you can see this thyroid is
[58:36] at an ER and you can see this thyroid is effectively a pus pocket it's hypoechoic
[58:39] effectively a pus pocket it's hypoechoic there's some posterior acoustic
[58:40] there's some posterior acoustic enhancement it's enlarged and thickened
[58:42] enhancement it's enlarged and thickened an ultrasound can give you the answers
[58:45] an ultrasound can give you the answers and tell you yeah it looks like we've
[58:47] and tell you yeah it looks like we've got a big boggy fluid filled thyroid bed
[58:50] got a big boggy fluid filled thyroid bed but importantly it's also the tool by
[58:53] but importantly it's also the tool by which you can put a needle into it and
[58:55] which you can put a needle into it and aspirate the pus sending for diagnosis
[58:58] aspirate the pus sending for diagnosis and culture and all the important things
[59:00] and culture and all the important things that are helpful for for figuring out
[59:03] that are helpful for for figuring out the the treatment profile and which
[59:05] the the treatment profile and which antibiotics need to be used
[59:07] antibiotics need to be used can you use CT sure CT is a helpful tool
[59:12] can you use CT sure CT is a helpful tool it's probably better than ultrasound in
[59:14] it's probably better than ultrasound in some ways for looking for extra thyroid
[59:16] some ways for looking for extra thyroid extension and better defining the extent
[59:19] extension and better defining the extent of infection and inflammation in the
[59:20] of infection and inflammation in the neck
[59:21] neck but thyroid ultrasound really is kind of
[59:23] but thyroid ultrasound really is kind of our first line modality in these
[59:25] our first line modality in these patients so this is the same patient
[59:27] patients so this is the same patient again thanks to Jim Milburn for lending
[59:30] again thanks to Jim Milburn for lending me the case and you can see the entirety
[59:32] me the case and you can see the entirety of the thyroid bed is hypo dense hypo
[59:36] of the thyroid bed is hypo dense hypo enhancing but this interestingly enough
[59:39] enhancing but this interestingly enough was asymmetric to the right and as I
[59:41] was asymmetric to the right and as I told you before the fourth brachial
[59:43] told you before the fourth brachial cleft anomaly those are virtually always
[59:45] cleft anomaly those are virtually always to my knowledge always on the left side
[59:47] to my knowledge always on the left side I've never seen a right-sided one if
[59:48] I've never seen a right-sided one if someone's got one please share it with
[59:50] someone's got one please share it with me I'd love to see it so this one
[59:53] me I'd love to see it so this one probably not due to an underlying fourth
[59:56] probably not due to an underlying fourth brachial cleft anomaly you know
[59:57] brachial cleft anomaly you know diabetics immunocompromised patients
[01:00:00] diabetics immunocompromised patients patients with direct penetrating trauma
[01:00:02] patients with direct penetrating trauma certainly can get acute suppurative
[01:00:03] certainly can get acute suppurative thyroiditis without having the
[01:00:06] thyroiditis without having the underlying predisposing congenital
[01:00:08] underlying predisposing congenital Leeson lesion to set them up for it
[01:00:11] Leeson lesion to set them up for it so I talked about it enough already but
[01:00:14] so I talked about it enough already but let's show you what it looks like this
[01:00:15] let's show you what it looks like this is that fourth branchial cleft anomaly
[01:00:17] is that fourth branchial cleft anomaly again a congenital lesion typically this
[01:00:20] again a congenital lesion typically this is going to present in a child or a
[01:00:21] is going to present in a child or a young adult and these are virtually
[01:00:24] young adult and these are virtually always or honestly to my knowledge these
[01:00:26] always or honestly to my knowledge these are always on the left side I've never
[01:00:28] are always on the left side I've never seen one on the right side I've never
[01:00:30] seen one on the right side I've never seen one in a textbook or a journal
[01:00:32] seen one in a textbook or a journal article on the right side and I'm sure
[01:00:33] article on the right side and I'm sure someone's got a case and if you've got
[01:00:34] someone's got a case and if you've got it please please share it with me I'd
[01:00:36] it please please share it with me I'd love to see it
[01:00:37] love to see it but what does it look like on imaging
[01:00:40] but what does it look like on imaging well look for the Associated things like
[01:00:42] well look for the Associated things like separate of thyroiditis I just showed
[01:00:44] separate of thyroiditis I just showed you what that looked like on ultrasound
[01:00:45] you what that looked like on ultrasound and CT you may or may not have a true
[01:00:48] and CT you may or may not have a true intra thyroid or parathyroid or abscess
[01:00:51] intra thyroid or parathyroid or abscess but then also look for this piriform
[01:00:54] but then also look for this piriform sinus fistula so in this nice diagram
[01:00:56] sinus fistula so in this nice diagram you can see that where this dotted line
[01:00:59] you can see that where this dotted line is that there is an actual fistula
[01:01:01] is that there is an actual fistula Streck connecting the apex of the
[01:01:03] Streck connecting the apex of the piriformis eyeness down to the thyroid
[01:01:05] piriformis eyeness down to the thyroid bed and that's what sets you up to have
[01:01:08] bed and that's what sets you up to have that spread of infection from the
[01:01:09] that spread of infection from the aerodigestive tract down into the
[01:01:11] aerodigestive tract down into the thyroid back and thyroid bed in the left
[01:01:14] thyroid back and thyroid bed in the left anterior neck
[01:01:17] anterior neck so what does it look like on imaging
[01:01:18] so what does it look like on imaging this is a case that was given to me a
[01:01:21] this is a case that was given to me a handful of years ago now by Rick horns
[01:01:23] handful of years ago now by Rick horns burger when I was putting together a
[01:01:24] burger when I was putting together a talk for a conference and this is a
[01:01:28] talk for a conference and this is a patient that has a fourth branchial
[01:01:30] patient that has a fourth branchial cleft anomaly with a thyroid abscess and
[01:01:32] cleft anomaly with a thyroid abscess and so here the image on the left the axial
[01:01:34] so here the image on the left the axial CT image were at the level of the
[01:01:36] CT image were at the level of the piriform scientists you can see all that
[01:01:37] piriform scientists you can see all that in inflammation and in thickening and
[01:01:40] in inflammation and in thickening and enhancement around it the coronal image
[01:01:43] enhancement around it the coronal image you can see that there's that sort of
[01:01:45] you can see that there's that sort of multilocular abscess within the left
[01:01:47] multilocular abscess within the left thyroid bed and then look carefully
[01:01:49] thyroid bed and then look carefully where that yellow arrow is pointing at
[01:01:51] where that yellow arrow is pointing at now you can see the opening to that to
[01:01:55] now you can see the opening to that to that fistula going from the piriform
[01:01:58] that fistula going from the piriform sinus all the way down to the thyroid
[01:01:59] sinus all the way down to the thyroid bed
[01:02:01] bed this is another patient that had a
[01:02:04] this is another patient that had a fourth brachial cleft anomaly and
[01:02:06] fourth brachial cleft anomaly and developed a thyroid and parathyroid
[01:02:07] developed a thyroid and parathyroid abscess I'm just showing you this to
[01:02:09] abscess I'm just showing you this to show you the value of doing in a softer
[01:02:11] show you the value of doing in a softer gram or a barium swallow you can
[01:02:12] gram or a barium swallow you can actually see where that yellow arrow is
[01:02:14] actually see where that yellow arrow is pointing at contrast egressing into that
[01:02:17] pointing at contrast egressing into that into that fistula tract and here in the
[01:02:20] into that fistula tract and here in the left lower neck we can see this fluid
[01:02:22] left lower neck we can see this fluid and gas pocket where the patient had a
[01:02:25] and gas pocket where the patient had a brewing abscess
[01:02:28] now the most common congenital neck
[01:02:30] now the most common congenital neck lesion that we encounter is a
[01:02:31] lesion that we encounter is a thyroglossal duct cyst these have sort
[01:02:35] thyroglossal duct cyst these have sort of a bell-shaped distribution where 25%
[01:02:37] of a bell-shaped distribution where 25% of the time they're found in the
[01:02:38] of the time they're found in the suprahyoid neck and in the suprahyoid
[01:02:40] suprahyoid neck and in the suprahyoid neck they're found at midline about half
[01:02:42] neck they're found at midline about half the time they're found at and around the
[01:02:44] the time they're found at and around the level of the hyoid bone and then the
[01:02:46] level of the hyoid bone and then the other fourth of the time they're found
[01:02:47] other fourth of the time they're found in the infrahyoid neck and when they're
[01:02:50] in the infrahyoid neck and when they're in the infrahyoid neck they sort of fan
[01:02:51] in the infrahyoid neck they sort of fan out Pera midline sort of following the
[01:02:54] out Pera midline sort of following the expected location of the the thyroid
[01:02:58] expected location of the the thyroid lobe so again in the suprahyoid neck you
[01:03:01] lobe so again in the suprahyoid neck you find these at midline going from the
[01:03:03] find these at midline going from the foramen cecum at the base of the tongue
[01:03:05] foramen cecum at the base of the tongue all the way down to the hyoid bone and
[01:03:06] all the way down to the hyoid bone and in the infrahyoid neck these are a pair
[01:03:09] in the infrahyoid neck these are a pair of midline and location these look like
[01:03:12] of midline and location these look like simple cysts unless they're infected or
[01:03:15] simple cysts unless they're infected or inflamed
[01:03:16] inflamed so here's an example just sort of your
[01:03:19] so here's an example just sort of your standard-issue thyroglossal duct system
[01:03:22] standard-issue thyroglossal duct system it'd line it's sort of just in the
[01:03:23] it'd line it's sort of just in the immediate infrahyoid location sort of
[01:03:26] immediate infrahyoid location sort of embedded between the strap musculature
[01:03:27] embedded between the strap musculature this one on this contrast-enhanced CT
[01:03:30] this one on this contrast-enhanced CT just looks like a benign non inflamed
[01:03:33] just looks like a benign non inflamed cyst
[01:03:35] cyst this one is in a patient similar
[01:03:39] this one is in a patient similar location just in the immediate
[01:03:40] location just in the immediate infrahyoid neck but this patient had had
[01:03:42] infrahyoid neck but this patient had had a antecedent upper respiratory tract
[01:03:45] a antecedent upper respiratory tract infection and because these can sort of
[01:03:47] infection and because these can sort of have that that conduit connecting back
[01:03:49] have that that conduit connecting back to the to the to the base of tongue and
[01:03:51] to the to the to the base of tongue and because of their embryologic origin and
[01:03:54] because of their embryologic origin and development these can get inflamed with
[01:03:56] development these can get inflamed with with upper respiratory tract infections
[01:03:58] with upper respiratory tract infections and so when you see sort of this rim of
[01:04:01] and so when you see sort of this rim of enhancement around it it may be either
[01:04:03] enhancement around it it may be either infected or inflamed because of a recent
[01:04:05] infected or inflamed because of a recent infection does that mean that it's
[01:04:08] infection does that mean that it's cancer because it has this enhancing rim
[01:04:11] cancer because it has this enhancing rim around it no it doesn't could it be
[01:04:13] around it no it doesn't could it be cancer well maybe we'll talk about that
[01:04:16] cancer well maybe we'll talk about that momentarily
[01:04:18] momentarily so thyroglossal duct sister Sonoma is a
[01:04:22] so thyroglossal duct sister Sonoma is a critically important thing that head and
[01:04:23] critically important thing that head and neck imagers be aware of and this is a
[01:04:26] neck imagers be aware of and this is a malignant tumor that arises from a
[01:04:27] malignant tumor that arises from a thyroid Glaus old duct cyst and
[01:04:30] thyroid Glaus old duct cyst and fortunately these are rare we're talking
[01:04:31] fortunately these are rare we're talking about probably less than 2% of
[01:04:33] about probably less than 2% of thyroglossal duct system entually if
[01:04:36] thyroglossal duct system entually if given you know the full natural history
[01:04:38] given you know the full natural history would break that and become a
[01:04:40] would break that and become a thyroglossal duct sistar Sonoma the vast
[01:04:43] thyroglossal duct sistar Sonoma the vast vast majority probably more than 95% of
[01:04:46] vast majority probably more than 95% of the time these are gonna be papillary
[01:04:48] the time these are gonna be papillary thyroid carcinoma so differentiated
[01:04:49] thyroid carcinoma so differentiated thyroid cancer is your prime actor here
[01:04:51] thyroid cancer is your prime actor here much less commonly will see squamous
[01:04:54] much less commonly will see squamous cell carcinoma
[01:04:56] cell carcinoma what do you want to look for on imaging
[01:04:58] what do you want to look for on imaging what's your tip-off that tells you that
[01:05:00] what's your tip-off that tells you that you should be worried well you want to
[01:05:02] you should be worried well you want to be looking for solid components and in
[01:05:05] be looking for solid components and in particular you really want to be looking
[01:05:07] particular you really want to be looking for calcification so when you see soft
[01:05:09] for calcification so when you see soft tissue within a thyroglossal duct cyst
[01:05:12] tissue within a thyroglossal duct cyst it is a nonspecific finding it may be
[01:05:15] it is a nonspecific finding it may be the sequela of prior infection or
[01:05:18] the sequela of prior infection or inflammation or it may be cancer
[01:05:21] inflammation or it may be cancer the imaging has low specificity whenever
[01:05:26] the imaging has low specificity whenever you see calcification that is always
[01:05:29] you see calcification that is always concerning for cancer let me say that
[01:05:32] concerning for cancer let me say that one more time if you see calcification
[01:05:35] one more time if you see calcification within a thyroid Glassell duct cyst that
[01:05:37] within a thyroid Glassell duct cyst that is always concerning for cancer
[01:05:41] is always concerning for cancer so here's a patient that had a
[01:05:43] so here's a patient that had a fiberglass old duct cisco sonoma we see
[01:05:46] fiberglass old duct cisco sonoma we see sort of this large almost by lobed
[01:05:48] sort of this large almost by lobed appearing infrahyoid neck cystic lesion
[01:05:50] appearing infrahyoid neck cystic lesion the cystic mass
[01:05:52] the cystic mass denoted here by the yellow arrow you'll
[01:05:55] denoted here by the yellow arrow you'll notice there's some frond like soft
[01:05:57] notice there's some frond like soft tissue component to it that gets us a
[01:05:59] tissue component to it that gets us a little suspicious you know maybe it's
[01:06:01] little suspicious you know maybe it's prior inflammation but that frond like
[01:06:03] prior inflammation but that frond like appearance looks kind of papillary but
[01:06:06] appearance looks kind of papillary but pay close attention we actually see
[01:06:08] pay close attention we actually see stippled calcification within this and
[01:06:10] stippled calcification within this and so this is one eye biopsy this is path
[01:06:12] so this is one eye biopsy this is path proven papillary thyroid carcinoma
[01:06:16] proven papillary thyroid carcinoma next we'll talk a little bit about the
[01:06:19] next we'll talk a little bit about the parathyroid
[01:06:20] parathyroid and really the hallmark lesion to know
[01:06:23] and really the hallmark lesion to know about here is a parathyroid adenoma this
[01:06:25] about here is a parathyroid adenoma this is a benign neoplasm it does secrete
[01:06:27] is a benign neoplasm it does secrete parathormone so these patients will have
[01:06:29] parathormone so these patients will have elevated calcium or elevated free
[01:06:31] elevated calcium or elevated free calcium levels when we image these with
[01:06:34] calcium levels when we image these with tech 99 assess them maybe
[01:06:38] tech 99 assess them maybe you see early uptake and it sort of
[01:06:41] you see early uptake and it sort of stays late you can combine that with
[01:06:44] stays late you can combine that with SPECT CT to have a much more sensitive
[01:06:46] SPECT CT to have a much more sensitive evaluation as well we also like to do
[01:06:49] evaluation as well we also like to do dynamic or multi-phase CT imaging so
[01:06:51] dynamic or multi-phase CT imaging so looking at this in the non-contrast the
[01:06:53] looking at this in the non-contrast the arterial and the venous washout phases
[01:06:55] arterial and the venous washout phases and that's because classically these are
[01:06:58] and that's because classically these are reported to have rapid arterial
[01:06:59] reported to have rapid arterial enhancement and venous washout but it
[01:07:03] enhancement and venous washout but it doesn't always follow the rules you know
[01:07:05] doesn't always follow the rules you know I've talked to some people at other
[01:07:06] I've talked to some people at other places there's some been some papers
[01:07:09] places there's some been some papers published on this as well you know it's
[01:07:12] published on this as well you know it's variable I feel like where I work only a
[01:07:14] variable I feel like where I work only a minority of these have that true classic
[01:07:17] minority of these have that true classic rapid wash and washout enhancement
[01:07:20] rapid wash and washout enhancement characteristic but you know depending on
[01:07:22] characteristic but you know depending on where you practice that maybe that's a
[01:07:24] where you practice that maybe that's a higher number but there are the
[01:07:27] higher number but there are the important take-home point is they don't
[01:07:29] important take-home point is they don't always have that classic appearance so
[01:07:32] always have that classic appearance so here's one that does have that classic
[01:07:33] here's one that does have that classic appearance we can see in the left tricky
[01:07:35] appearance we can see in the left tricky esophageal groove we have on this
[01:07:38] esophageal groove we have on this non-contrast phase we have a subtle
[01:07:40] non-contrast phase we have a subtle nodule it enhances like gangbusters
[01:07:43] nodule it enhances like gangbusters during the arterial phase and it washes
[01:07:45] during the arterial phase and it washes out during the venous phase so this is
[01:07:47] out during the venous phase so this is that classic appearance rapid arterial
[01:07:49] that classic appearance rapid arterial enhancement and wash out during the
[01:07:51] enhancement and wash out during the venous phase this is the the textbook
[01:07:53] venous phase this is the the textbook version of what a pair Harrod adenoma
[01:07:55] version of what a pair Harrod adenoma looks like again the problem being they
[01:07:58] looks like again the problem being they don't always look like this
[01:08:01] don't always look like this is there a role for MRI well here's one
[01:08:04] is there a role for MRI well here's one that was found incidentally on a on just
[01:08:07] that was found incidentally on a on just a routine contrast CT of the neck so
[01:08:10] a routine contrast CT of the neck so this is sort of the Venus phase pretty
[01:08:12] this is sort of the Venus phase pretty subtle right I mean I don't I don't know
[01:08:14] subtle right I mean I don't I don't know how it was I picked this up other than
[01:08:15] how it was I picked this up other than things looked a little full back here
[01:08:17] things looked a little full back here but there was this sort of this nodule
[01:08:20] but there was this sort of this nodule nodular thickening honestly wasn't sure
[01:08:22] nodular thickening honestly wasn't sure if I was dealing with a parathyroid
[01:08:23] if I was dealing with a parathyroid adenoma or an enlarged lymph node or
[01:08:26] adenoma or an enlarged lymph node or whether or not this was just some funny
[01:08:28] whether or not this was just some funny look to the pre vertebral musculature
[01:08:30] look to the pre vertebral musculature and so recommended an MRI and you can
[01:08:32] and so recommended an MRI and you can see very t2 bright that's commonly seen
[01:08:35] see very t2 bright that's commonly seen in parathyroid adenomas s-- and yes it
[01:08:37] in parathyroid adenomas s-- and yes it is enhancing so MRI is sometimes helpful
[01:08:39] is enhancing so MRI is sometimes helpful for identifying or troubleshooting CT
[01:08:41] for identifying or troubleshooting CT when dealing with parathyroid and an
[01:08:43] when dealing with parathyroid and an adenoma is or potential parathyroid
[01:08:45] adenoma is or potential parathyroid adenoma x' and here's just a totally
[01:08:48] adenoma x' and here's just a totally oddball case in this case we have a
[01:08:51] oddball case in this case we have a diffused system inspect CT it looks like
[01:08:54] diffused system inspect CT it looks like there's some increased uptake sort of
[01:08:56] there's some increased uptake sort of sitting back behind the thyroid you look
[01:08:58] sitting back behind the thyroid you look at the imaging we have sort of this
[01:08:59] at the imaging we have sort of this low-density circumscribed mass that if
[01:09:02] low-density circumscribed mass that if you put Hounsfield units on it there are
[01:09:04] you put Hounsfield units on it there are certain spots within it that contain
[01:09:06] certain spots within it that contain true fat density so this was a sort of a
[01:09:08] true fat density so this was a sort of a lipid-rich parathyroid adenoma or a lipo
[01:09:12] lipid-rich parathyroid adenoma or a lipo adenoma so sometimes these parathyroid
[01:09:15] adenoma so sometimes these parathyroid adenomas are low-density and cystic
[01:09:17] adenomas are low-density and cystic sometimes there are even lower density
[01:09:20] sometimes there are even lower density and fatty they don't always hyper
[01:09:22] and fatty they don't always hyper enhance so don't be fooled okay they can
[01:09:24] enhance so don't be fooled okay they can have a variable imaging appearance if
[01:09:26] have a variable imaging appearance if you really dogmatically follow the rules
[01:09:29] you really dogmatically follow the rules of oh it has to rapidly enhance the
[01:09:31] of oh it has to rapidly enhance the arterial phase and then wash out during
[01:09:33] arterial phase and then wash out during the venous face you're gonna miss some
[01:09:34] the venous face you're gonna miss some of these okay you're probably gonna miss
[01:09:36] of these okay you're probably gonna miss a significant number of them but
[01:09:38] a significant number of them but whenever they have that history of an
[01:09:40] whenever they have that history of an elevated parathormone and elevated free
[01:09:42] elevated parathormone and elevated free calcium levels you really need to be
[01:09:44] calcium levels you really need to be looking and looking at exhaustively
[01:09:45] looking and looking at exhaustively until you find one
[01:09:48] you can also have cancer involving the
[01:09:51] you can also have cancer involving the parathyroid so a parathyroid carcinoma
[01:09:53] parathyroid so a parathyroid carcinoma this is a low-grade malignancy by the
[01:09:55] this is a low-grade malignancy by the w-h-o usually these are quite large two
[01:09:58] w-h-o usually these are quite large two to three centimeters in size is pretty
[01:10:01] to three centimeters in size is pretty common and
[01:10:03] common and unfortunately these are oftentimes
[01:10:06] unfortunately these are oftentimes indistinguishable from parathyroid Nomis
[01:10:08] indistinguishable from parathyroid Nomis and the only way that you can tell
[01:10:10] and the only way that you can tell definitively on imaging is if you see
[01:10:13] definitively on imaging is if you see invasion of adjacent structures so these
[01:10:16] invasion of adjacent structures so these are all going to get surgical resection
[01:10:17] are all going to get surgical resection but your job is really to look for that
[01:10:20] but your job is really to look for that those things for staging like what's it
[01:10:22] those things for staging like what's it invading
[01:10:24] invading and so here we again see this sort of
[01:10:28] and so here we again see this sort of low-density mass in the visceral space
[01:10:30] low-density mass in the visceral space really indistinguishable from the pre
[01:10:32] really indistinguishable from the pre retiro musculature and the esophagus so
[01:10:35] retiro musculature and the esophagus so this is a place where MRI can be
[01:10:38] this is a place where MRI can be complimentary in trying to better
[01:10:39] complimentary in trying to better evaluate the extent of tumor and so in
[01:10:41] evaluate the extent of tumor and so in this case you can sort of get a better
[01:10:43] this case you can sort of get a better sense of where it's extending and where
[01:10:45] sense of where it's extending and where we have still preserved tissue planes on
[01:10:46] we have still preserved tissue planes on the t1 pre contrast imaging
[01:10:50] the t1 pre contrast imaging here's another patient with a
[01:10:53] here's another patient with a parathyroid
[01:10:54] parathyroid lesion thought based upon its size and
[01:10:57] lesion thought based upon its size and its appearance that this very well could
[01:10:59] its appearance that this very well could be a parathyroid carcinoma you can see
[01:11:02] be a parathyroid carcinoma you can see on CT sort of low density kind of has
[01:11:04] on CT sort of low density kind of has that infiltrating almost invasive look
[01:11:06] that infiltrating almost invasive look to it and it was markedly bright on
[01:11:10] to it and it was markedly bright on sestamibi so this came out and I thought
[01:11:14] sestamibi so this came out and I thought that the the actual path note which had
[01:11:17] that the the actual path note which had sort of a you know some some caveats to
[01:11:19] sort of a you know some some caveats to it really was was helpful for my better
[01:11:22] it really was was helpful for my better understanding these tumors so and that's
[01:11:25] understanding these tumors so and that's why I want to share these with you so
[01:11:26] why I want to share these with you so based upon the 2017 w-h-o classification
[01:11:30] based upon the 2017 w-h-o classification of endocrine tumors in order to make a
[01:11:34] of endocrine tumors in order to make a pathologic diagnosis of a parathyroid
[01:11:36] pathologic diagnosis of a parathyroid carcinoma you have to have some things
[01:11:38] carcinoma you have to have some things you have to be able to see and
[01:11:41] you have to be able to see and demonstrate some things and those things
[01:11:42] demonstrate some things and those things all have to do with the invasion of
[01:11:44] all have to do with the invasion of serling soft tissues so you want to be
[01:11:46] serling soft tissues so you want to be able to you wanna you have to be able I
[01:11:48] able to you wanna you have to be able I shouldn't say you want in order to make
[01:11:50] shouldn't say you want in order to make this diagnosis you have to see presence
[01:11:52] this diagnosis you have to see presence of extra capsular blood vessel or
[01:11:54] of extra capsular blood vessel or perineural invasion or invasion into the
[01:11:58] perineural invasion or invasion into the adjacent structures and that would
[01:12:01] adjacent structures and that would include the surrounding soft tissues or
[01:12:02] include the surrounding soft tissues or the thyroid or you have to have
[01:12:04] the thyroid or you have to have documented metastasis and
[01:12:07] documented metastasis and even the pathologists can't make all of
[01:12:09] even the pathologists can't make all of those calls and so this is one where the
[01:12:12] those calls and so this is one where the cathode is actually said correlate
[01:12:14] cathode is actually said correlate clinically I mean that's not just a
[01:12:15] clinically I mean that's not just a radiology thing so importantly you need
[01:12:18] radiology thing so importantly you need to be looking for where these are going
[01:12:20] to be looking for where these are going and what they are doing and what getting
[01:12:22] and what they are doing and what getting into you because you literally cannot
[01:12:24] into you because you literally cannot make the diagnosis of a parathyroid
[01:12:26] make the diagnosis of a parathyroid carcinoma unless you can show invasion
[01:12:29] carcinoma unless you can show invasion or metastasis
[01:12:31] or metastasis so the last structure to talk about in
[01:12:33] so the last structure to talk about in the visceral space is
[01:12:35] the visceral space is and it contains the level 6 lymph nodes
[01:12:38] and it contains the level 6 lymph nodes which are subdivided into a parrot
[01:12:40] which are subdivided into a parrot racheal group which is important because
[01:12:42] racheal group which is important because this is the first-order nodal drainage
[01:12:44] this is the first-order nodal drainage of the thyroid and it's how you get
[01:12:46] of the thyroid and it's how you get spread of thyroid cancer down into the
[01:12:47] spread of thyroid cancer down into the mediastinum there's also a pre laryngeal
[01:12:50] mediastinum there's also a pre laryngeal and pre trachea group as well
[01:12:53] and pre trachea group as well okay so that was the visceral space now
[01:12:55] okay so that was the visceral space now we're gonna talk about the carotid space
[01:12:57] we're gonna talk about the carotid space and each of these will be quicker than
[01:12:58] and each of these will be quicker than the last one just so much stuff happens
[01:13:00] the last one just so much stuff happens in the visceral space all right carotid
[01:13:02] in the visceral space all right carotid space I'm a thorough sclerosis and
[01:13:06] space I'm a thorough sclerosis and dissection and pseudoaneurysm that's
[01:13:08] dissection and pseudoaneurysm that's like a separate vascular talk all
[01:13:09] like a separate vascular talk all together I want to focus on just a few
[01:13:11] together I want to focus on just a few thing and first of all talk about tipic
[01:13:14] thing and first of all talk about tipic syndrome versus vasculitis so what is
[01:13:17] syndrome versus vasculitis so what is tip extend room this stands for
[01:13:18] tip extend room this stands for transient Perry vascular inflammation of
[01:13:21] transient Perry vascular inflammation of the carotid this is what used to be
[01:13:23] the carotid this is what used to be called carotid any in fact stat DX for
[01:13:26] called carotid any in fact stat DX for some reason still calls this Quraan
[01:13:28] some reason still calls this Quraan edenia even though the International
[01:13:31] edenia even though the International Headache community for like the last 14
[01:13:33] Headache community for like the last 14 years it says has said please stop
[01:13:35] years it says has said please stop calling it this carotid inia that's a
[01:13:37] calling it this carotid inia that's a term we should throw away so I've been
[01:13:39] term we should throw away so I've been trying to get our residents or fellows
[01:13:40] trying to get our residents or fellows or faculty to stop using the term
[01:13:42] or faculty to stop using the term carotid enniaa and instead favoring the
[01:13:45] carotid enniaa and instead favoring the terminology typic syndrome because
[01:13:46] terminology typic syndrome because that's really what's considered to be
[01:13:48] that's really what's considered to be the standard standard working definition
[01:13:51] the standard standard working definition now but this is a disorder of idiopathic
[01:13:54] now but this is a disorder of idiopathic inflammation don't know what causes it
[01:13:56] inflammation don't know what causes it but these patients while time's present
[01:13:59] but these patients while time's present with tenderness swelling or even a
[01:14:00] with tenderness swelling or even a pulsatile mass in the neck what does it
[01:14:03] pulsatile mass in the neck what does it look like on imaging on CT you can see
[01:14:05] look like on imaging on CT you can see denoted here by the yellow arrow we have
[01:14:07] denoted here by the yellow arrow we have circumferential but eccentric wall
[01:14:10] circumferential but eccentric wall thickening along the carotid and it's
[01:14:12] thickening along the carotid and it's usually not flow limiting if you look at
[01:14:14] usually not flow limiting if you look at the caliber of this involved right
[01:14:16] the caliber of this involved right carotid artery it's no different than
[01:14:18] carotid artery it's no different than the contralateral side so despite the
[01:14:20] the contralateral side so despite the fact that you have this peri vascular
[01:14:21] fact that you have this peri vascular inflammation the soft tissue component
[01:14:23] inflammation the soft tissue component typically it doesn't narrow the luminal
[01:14:26] typically it doesn't narrow the luminal caliber
[01:14:27] caliber what does it look like on MRI well it
[01:14:29] what does it look like on MRI well it tends to be t to bright if you give
[01:14:31] tends to be t to bright if you give contrast like in this case it tends to
[01:14:33] contrast like in this case it tends to enhance pretty avidly and typically this
[01:14:37] enhance pretty avidly and typically this is going to involve the carotid bulbs
[01:14:38] is going to involve the carotid bulbs and extend up into the proximal internal
[01:14:41] and extend up into the proximal internal carotid arteries as well this is a
[01:14:43] carotid arteries as well this is a disorder that gets treated fairly
[01:14:45] disorder that gets treated fairly conservatively they hit these patients
[01:14:47] conservatively they hit these patients within SEDs and sometimes steroids and
[01:14:49] within SEDs and sometimes steroids and then repeat imaging just to make sure
[01:14:51] then repeat imaging just to make sure it's going away because this is a
[01:14:52] it's going away because this is a self-limited disease process the problem
[01:14:56] self-limited disease process the problem is
[01:14:57] is it can look very similar to something
[01:14:59] it can look very similar to something that's a bit more heinous and needs more
[01:15:02] that's a bit more heinous and needs more aggressive management and that's large
[01:15:05] aggressive management and that's large vessel vasculitis so it large vessel
[01:15:07] vessel vasculitis so it large vessel vasculitis can really look a lot like
[01:15:09] vasculitis can really look a lot like tipic syndrome and some of the ones that
[01:15:11] tipic syndrome and some of the ones that can do this because it's a large vessel
[01:15:13] can do this because it's a large vessel vasculitis you'd be thinking about
[01:15:14] vasculitis you'd be thinking about takayasu and a younger patient or giant
[01:15:16] takayasu and a younger patient or giant cell arteritis and an older patient but
[01:15:19] cell arteritis and an older patient but because the stakes are so high because
[01:15:21] because the stakes are so high because the consequences can be devastating if
[01:15:24] the consequences can be devastating if that doesn't get treated appropriately
[01:15:25] that doesn't get treated appropriately it probably is worth at least
[01:15:28] it probably is worth at least considering getting these patients
[01:15:30] considering getting these patients plugged in to see a Rheumatologist even
[01:15:32] plugged in to see a Rheumatologist even if you think it's high likelihood of
[01:15:33] if you think it's high likelihood of tipic syndrome they probably need to get
[01:15:36] tipic syndrome they probably need to get followed and I think Rheumatology may be
[01:15:37] followed and I think Rheumatology may be the best person to at least get the ball
[01:15:40] the best person to at least get the ball rolling on it I don't know that's not
[01:15:42] rolling on it I don't know that's not well established but at least they are
[01:15:44] well established but at least they are the ones that can can run point if it
[01:15:46] the ones that can can run point if it does turn out to be a vasculitis so here
[01:15:49] does turn out to be a vasculitis so here we can see sort of this soft tissue
[01:15:51] we can see sort of this soft tissue along the carotid bifurcation as well
[01:15:54] along the carotid bifurcation as well and something that looked an awful lot
[01:15:56] and something that looked an awful lot like typic syndrome
[01:15:57] like typic syndrome same patient when we look on the axial
[01:16:01] same patient when we look on the axial CT when jestingly this was bilateral and
[01:16:03] CT when jestingly this was bilateral and this was extending really up and down
[01:16:05] this was extending really up and down the common carotid artery and not just
[01:16:07] the common carotid artery and not just the internal carotid artery and so you
[01:16:10] the internal carotid artery and so you know sort of saying well maybe this this
[01:16:12] know sort of saying well maybe this this is typically it's just sort of an odd
[01:16:14] is typically it's just sort of an odd presentation but then take a closer look
[01:16:16] presentation but then take a closer look whenever you see something like this
[01:16:18] whenever you see something like this make sure to hawk all the vessels
[01:16:20] make sure to hawk all the vessels looking at the aortic arch and the take
[01:16:22] looking at the aortic arch and the take offs of the great vessels Gadda we have
[01:16:24] offs of the great vessels Gadda we have that same sort of low-density wall
[01:16:26] that same sort of low-density wall thickening this was a patient who had
[01:16:28] thickening this was a patient who had takayasu arteritis and so it's just
[01:16:31] takayasu arteritis and so it's just exert some caution whenever you see one
[01:16:34] exert some caution whenever you see one of these before you just blow it off as
[01:16:35] of these before you just blow it off as being tip Accor carotid iniya if you're
[01:16:37] being tip Accor carotid iniya if you're gonna use that bad terminology but
[01:16:39] gonna use that bad terminology but probably should be making sure that
[01:16:41] probably should be making sure that you're not dealing with a large vessel
[01:16:42] you're not dealing with a large vessel vasculitis is you know a lesson that
[01:16:45] vasculitis is you know a lesson that I've kind of learned over time
[01:16:46] I've kind of learned over time all right next is jugular vein
[01:16:48] all right next is jugular vein thrombosis this is quite simply clot
[01:16:51] thrombosis this is quite simply clot forming in the jug
[01:16:53] forming in the jug certainly is not uncommon we see it all
[01:16:55] certainly is not uncommon we see it all the time usually these are
[01:16:57] the time usually these are straightforward diagnoses and the
[01:16:58] straightforward diagnoses and the challenges lie not in making the
[01:16:59] challenges lie not in making the diagnosis but rather trying to figure
[01:17:01] diagnosis but rather trying to figure out what the etiology was that caused it
[01:17:03] out what the etiology was that caused it and then to look for any Associated
[01:17:06] and then to look for any Associated pathologies and any associated
[01:17:08] pathologies and any associated complications
[01:17:09] complications most commonly we see this in ill
[01:17:11] most commonly we see this in ill patients patients that may have an
[01:17:13] patients patients that may have an implanted cardiac pacemaker
[01:17:15] implanted cardiac pacemaker defibrillator or an indwelling catheter
[01:17:17] defibrillator or an indwelling catheter those are the patients who typically
[01:17:19] those are the patients who typically have these but not the only patients
[01:17:21] have these but not the only patients what does it look like on imaging you
[01:17:23] what does it look like on imaging you look for an entry luminal filling defect
[01:17:25] look for an entry luminal filling defect within the jugular vein itself in the
[01:17:27] within the jugular vein itself in the acute phase that oftentimes dilates up
[01:17:29] acute phase that oftentimes dilates up the caliber of the vessel so it's an
[01:17:31] the caliber of the vessel so it's an enlarged diameter you may have
[01:17:34] enlarged diameter you may have engorgement of the vaso of a sorem so if
[01:17:36] engorgement of the vaso of a sorem so if you look where this yellow arrow is
[01:17:37] you look where this yellow arrow is pointing it almost looks like a doughnut
[01:17:39] pointing it almost looks like a doughnut sign of increased density along the
[01:17:41] sign of increased density along the vessel wall that's because those vessels
[01:17:43] vessel wall that's because those vessels that supply the vessel wall to vasive a
[01:17:45] that supply the vessel wall to vasive a Sorum they're engorged with blood
[01:17:47] Sorum they're engorged with blood and in a chronic phase it tends to
[01:17:50] and in a chronic phase it tends to shrink down and you get a small caliber
[01:17:52] shrink down and you get a small caliber vessel in the acute phase we more
[01:17:56] vessel in the acute phase we more commonly see peri vascular edema denoted
[01:17:58] commonly see peri vascular edema denoted here by the yellow arrow and almost
[01:18:00] here by the yellow arrow and almost immediately you'll see bypass collateral
[01:18:02] immediately you'll see bypass collateral starting to crop up because there
[01:18:03] starting to crop up because there there's so much redundancy in the venous
[01:18:05] there's so much redundancy in the venous system that if you clot off one blood is
[01:18:08] system that if you clot off one blood is gonna figure out a way to get back to
[01:18:09] gonna figure out a way to get back to the heart the problem we oftentimes I
[01:18:12] the heart the problem we oftentimes I shouldn't say often that's the problem
[01:18:13] shouldn't say often that's the problem that we sometimes get into is what do
[01:18:16] that we sometimes get into is what do you do with enhancing clot so enhancing
[01:18:19] you do with enhancing clot so enhancing thrombus is problematic and so here you
[01:18:22] thrombus is problematic and so here you can see the yellow arrow is pointing to
[01:18:24] can see the yellow arrow is pointing to an area within the clot that's a little
[01:18:25] an area within the clot that's a little bit higher density and at the poles the
[01:18:27] bit higher density and at the poles the upper and lower Pole it's it's lower
[01:18:29] upper and lower Pole it's it's lower density thrombus with the red arrows and
[01:18:31] density thrombus with the red arrows and it may be something benign like
[01:18:33] it may be something benign like organizing thrombus and we're starting
[01:18:35] organizing thrombus and we're starting to detect some of those recanalization
[01:18:36] to detect some of those recanalization channels or
[01:18:39] channels or unfortunately could also be tumor
[01:18:40] unfortunately could also be tumor thrombus and so differentiating those
[01:18:44] thrombus and so differentiating those two can sometimes be a bit challenging
[01:18:45] two can sometimes be a bit challenging you may have to rely on multimodality
[01:18:47] you may have to rely on multimodality imaging or short interval follow-up
[01:18:50] imaging or short interval follow-up certainly it if you have a mass in the
[01:18:53] certainly it if you have a mass in the neck or the upper chest that's growing
[01:18:54] neck or the upper chest that's growing into the jug well then maybe have you
[01:18:56] into the jug well then maybe have you but this was a patient who had jugular
[01:18:59] but this was a patient who had jugular vein thrombosis you can see it on the
[01:19:01] vein thrombosis you can see it on the left on the contrasting at CT it's it's
[01:19:04] left on the contrasting at CT it's it's not a pacified but the image you can see
[01:19:08] not a pacified but the image you can see that FDG uptake our next we'll talk
[01:19:10] that FDG uptake our next we'll talk about nerve sheath to
[01:19:12] about nerve sheath to these are gonna be schwannomas or
[01:19:15] these are gonna be schwannomas or neurofibromas and i suppose i get there
[01:19:17] neurofibromas and i suppose i get there one malignant peripheral nerve sheath
[01:19:18] one malignant peripheral nerve sheath tumor as well but with the benign nerve
[01:19:21] tumor as well but with the benign nerve sheath the tumors we're dealing with
[01:19:22] sheath the tumors we're dealing with circumscribed in fusiform masses they
[01:19:25] circumscribed in fusiform masses they can look quite similar sometimes
[01:19:26] can look quite similar sometimes neurofibromas are lower density on CT
[01:19:29] neurofibromas are lower density on CT more common to have a true target sign
[01:19:32] more common to have a true target sign to them because they grow
[01:19:33] to them because they grow sort of throughout the nerve they grow
[01:19:36] sort of throughout the nerve they grow centrally within the nerve rather than
[01:19:38] centrally within the nerve rather than schwannomas that grow eccentric to the
[01:19:40] schwannomas that grow eccentric to the nerve
[01:19:42] nerve there is a lot written about and talked
[01:19:46] there is a lot written about and talked about with displacement patterns that
[01:19:48] about with displacement patterns that can help you to predict the nerve of
[01:19:49] can help you to predict the nerve of origin so if you're dealing with a vagus
[01:19:52] origin so if you're dealing with a vagus nerve schwannoma or neurofibroma it's
[01:19:54] nerve schwannoma or neurofibroma it's thought to push the internal carotid
[01:19:55] thought to push the internal carotid artery intro medially and push the
[01:19:57] artery intro medially and push the posterior cervical space postural
[01:19:59] posterior cervical space postural laterally that's in Contra distinction
[01:20:02] laterally that's in Contra distinction to a sympathetic trunk schwannoma or
[01:20:04] to a sympathetic trunk schwannoma or neurofibroma that tend to push the ica
[01:20:06] neurofibroma that tend to push the ica and IJ v together as one link in this
[01:20:09] and IJ v together as one link in this case is showing you know i don't know
[01:20:11] case is showing you know i don't know how much stock i put into that you can
[01:20:13] how much stock i put into that you can certainly go through the mental
[01:20:13] certainly go through the mental gymnastics and i think it's not a bad
[01:20:15] gymnastics and i think it's not a bad idea to talk about and let the surgeons
[01:20:17] idea to talk about and let the surgeons know what you think the nerve of origin
[01:20:19] know what you think the nerve of origin is that's probably wise just know it's
[01:20:22] is that's probably wise just know it's not perfect and you're not gonna have
[01:20:25] not perfect and you're not gonna have great predictive value in being
[01:20:27] great predictive value in being absolutely certain that that's the nerve
[01:20:28] absolutely certain that that's the nerve of origin
[01:20:30] of origin lastly I want to say just a few words
[01:20:32] lastly I want to say just a few words about lymph nodes along the carotid
[01:20:35] about lymph nodes along the carotid space so there are no true carotid space
[01:20:38] space so there are no true carotid space lymph nodes okay but they're nodes
[01:20:39] lymph nodes okay but they're nodes they're not contained within it they run
[01:20:41] they're not contained within it they run along it they're affiliated with it so
[01:20:43] along it they're affiliated with it so the internal jugular nodal chain is in
[01:20:46] the internal jugular nodal chain is in close proximity to the superior the
[01:20:48] close proximity to the superior the superficial margin of the carotid space
[01:20:50] superficial margin of the carotid space and therefore they can exert mass effect
[01:20:53] and therefore they can exert mass effect upon the carotid space and if you have
[01:20:56] upon the carotid space and if you have extra nodal extention of tumor like you
[01:20:58] extra nodal extention of tumor like you know swims in the neck that sometimes do
[01:21:00] know swims in the neck that sometimes do that or thyroid carcinoma with nodal
[01:21:02] that or thyroid carcinoma with nodal mats they can blow outside of the the
[01:21:04] mats they can blow outside of the the thyroid the nodal capsule that can
[01:21:06] thyroid the nodal capsule that can invade the carotid space and that can
[01:21:08] invade the carotid space and that can set the patient up to bad consequences
[01:21:11] set the patient up to bad consequences like arterial rupture and
[01:21:14] like arterial rupture and exsanguinations or even vagal neuropathy
[01:21:16] exsanguinations or even vagal neuropathy so I'm not gonna say much more about
[01:21:18] so I'm not gonna say much more about lymph nodes just know that the internal
[01:21:20] lymph nodes just know that the internal jugular chain lymph nodes a little along
[01:21:21] jugular chain lymph nodes a little along the carotid space that are not truly
[01:21:23] the carotid space that are not truly contained within it and when they act
[01:21:26] contained within it and when they act badly when they're poorly behaved there
[01:21:29] badly when they're poorly behaved there can be consequences for the carotid
[01:21:30] can be consequences for the carotid space structures
[01:21:33] space structures all right the next space to talk about
[01:21:35] all right the next space to talk about is the retro fringy all in danger space
[01:21:37] is the retro fringy all in danger space and
[01:21:39] and these are sort of the pathologies that
[01:21:41] these are sort of the pathologies that can involve it at least the common and
[01:21:44] can involve it at least the common and we'll start out talking about infection
[01:21:45] we'll start out talking about infection because that's really sort of a primary
[01:21:47] because that's really sort of a primary thing that we oftentimes are trying to
[01:21:49] thing that we oftentimes are trying to deal so that infection can be phlegmon
[01:21:51] deal so that infection can be phlegmon or it can be a okay so how do we draw
[01:21:55] or it can be a okay so how do we draw this distinction between retro fringe
[01:21:56] this distinction between retro fringe whoa phlegmon and abscess and really it
[01:21:57] whoa phlegmon and abscess and really it has to do with looking for LOC ulation
[01:21:59] has to do with looking for LOC ulation and that rind of enhancement that rim of
[01:22:02] and that rind of enhancement that rim of enhancement that's forming so this image
[01:22:04] enhancement that's forming so this image on the left you can see there's a lot of
[01:22:06] on the left you can see there's a lot of fluid within the retro ferengi of a sitz
[01:22:07] fluid within the retro ferengi of a sitz also sort of extending out into the
[01:22:09] also sort of extending out into the other deep spaces of the neck here here
[01:22:12] other deep spaces of the neck here here we can see it in the retro fringe alert
[01:22:13] we can see it in the retro fringe alert danger space but we don't see any rim
[01:22:15] danger space but we don't see any rim enhancement so that's flegman the image
[01:22:19] enhancement so that's flegman the image on the right you can see fluid in the
[01:22:21] on the right you can see fluid in the retro fringe alert danger space but it's
[01:22:22] retro fringe alert danger space but it's also starting to develop a rind of
[01:22:24] also starting to develop a rind of enhancement around it in a patient who
[01:22:26] enhancement around it in a patient who has a true abscess
[01:22:29] next up is the goiter talked about
[01:22:32] next up is the goiter talked about goiters before so I'm not gonna belabor
[01:22:34] goiters before so I'm not gonna belabor the point just know the takings sort of
[01:22:37] the point just know the takings sort of curve their way up and in extend up
[01:22:39] curve their way up and in extend up along the retro for in geospatial eaters
[01:22:42] along the retro for in geospatial eaters get big we absolutely and quite
[01:22:44] get big we absolutely and quite frequently see retro pharyngeal
[01:22:45] frequently see retro pharyngeal extension so here you can see just an
[01:22:48] extension so here you can see just an example of that I don't want to believe
[01:22:49] example of that I don't want to believe at this point
[01:22:51] at this point next up our life this is simply an
[01:22:55] next up our life this is simply an uncommon location of a common tumor and
[01:22:57] uncommon location of a common tumor and you know what lipomas look like these
[01:22:58] you know what lipomas look like these look like lipomas elsewhere they're fat
[01:23:00] look like lipomas elsewhere they're fat density they're t1 bride if you use fat
[01:23:02] density they're t1 bride if you use fat saturation or stir they're gonna null in
[01:23:04] saturation or stir they're gonna null in signal they're circumscribed they're not
[01:23:07] signal they're circumscribed they're not enhancing and here we can see just sort
[01:23:09] enhancing and here we can see just sort of this almost Lin shape appearance this
[01:23:12] of this almost Lin shape appearance this benign circumscribed retro fringy old
[01:23:15] benign circumscribed retro fringy old lipoma it's t1 bright
[01:23:17] lipoma it's t1 bright impatient just looking at different
[01:23:19] impatient just looking at different planes you can see how nicely
[01:23:21] planes you can see how nicely circumscribed this is it's sort of
[01:23:23] circumscribed this is it's sort of insinuating between the structures it's
[01:23:25] insinuating between the structures it's not invading anything its t1 bright the
[01:23:28] not invading anything its t1 bright the image on the right you can see that it's
[01:23:30] image on the right you can see that it's fat density easy-peasy it's a lipoma
[01:23:35] fat density easy-peasy it's a lipoma next topic is the media lized carotid
[01:23:37] next topic is the media lized carotid artery
[01:23:38] artery this is just a normal anatomic variant
[01:23:41] this is just a normal anatomic variant okay and this is just when that carotid
[01:23:43] okay and this is just when that carotid artery has more of a media lized course
[01:23:45] artery has more of a media lized course it sort of pooches its way into the
[01:23:47] it sort of pooches its way into the retro for NGO space this is not a
[01:23:49] retro for NGO space this is not a pathologic finding whatsoever but it's
[01:23:52] pathologic finding whatsoever but it's important because you want to let the
[01:23:53] important because you want to let the surgeons know about this on preoperative
[01:23:55] surgeons know about this on preoperative exams if they're going to be doing a
[01:23:57] exams if they're going to be doing a surgery involving the pharynx or the
[01:24:00] surgery involving the pharynx or the larynx they're gonna be getting down to
[01:24:02] larynx they're gonna be getting down to this region even a diskectomy infusion
[01:24:04] this region even a diskectomy infusion you want to let them know about this
[01:24:06] you want to let them know about this okay just to make it safe for the
[01:24:08] okay just to make it safe for the patient
[01:24:10] patient we can also have a topic parathyroid
[01:24:13] we can also have a topic parathyroid glands involving the retro fringe
[01:24:17] glands involving the retro fringe the parathyroid glands usually sit
[01:24:19] the parathyroid glands usually sit posterior to the thyroid so here we have
[01:24:21] posterior to the thyroid so here we have a nice example of that and their embryo
[01:24:24] a nice example of that and their embryo logic descent of the inferior
[01:24:26] logic descent of the inferior parathyroid extends along the thymus Rin
[01:24:28] parathyroid extends along the thymus Rin geoduck tract and that really goes from
[01:24:31] geoduck tract and that really goes from the angle of the mandible above down to
[01:24:33] the angle of the mandible above down to the anterior mediastinum below so sort
[01:24:36] the anterior mediastinum below so sort of encompassed within that one of the
[01:24:39] of encompassed within that one of the places where you can on rare rare
[01:24:41] places where you can on rare rare occasion find ectopic the parathyroid
[01:24:43] occasion find ectopic the parathyroid tissue is truly within the retro fringy
[01:24:45] tissue is truly within the retro fringy low space so it's just something to
[01:24:47] low space so it's just something to include in your search pattern
[01:24:49] include in your search pattern alright the last space I'm going to talk
[01:24:51] alright the last space I'm going to talk about is the posterior cervical space
[01:24:53] about is the posterior cervical space I'm not going to talk about the peri
[01:24:54] I'm not going to talk about the peri vertebral space because that's sort of a
[01:24:56] vertebral space because that's sort of a topic in and of itself as well
[01:24:58] topic in and of itself as well but they're just a few things to be
[01:25:00] but they're just a few things to be thinking about with the posterior
[01:25:01] thinking about with the posterior cervical space first of all is lymph
[01:25:04] cervical space first of all is lymph nodes so this is where we find our
[01:25:06] nodes so this is where we find our spinal accessory chain nodes or a level
[01:25:08] spinal accessory chain nodes or a level five lymph nodes and they can come in a
[01:25:10] five lymph nodes and they can come in a lot of flavors and they can wear a lot
[01:25:11] lot of flavors and they can wear a lot of hats right they can be reactive lymph
[01:25:13] of hats right they can be reactive lymph nodes you can have separate of lymph
[01:25:15] nodes you can have separate of lymph nodes I kind of talked a little bit
[01:25:16] nodes I kind of talked a little bit about that when I was talking about
[01:25:18] about that when I was talking about abscesses you can have metastatic nodes
[01:25:21] abscesses you can have metastatic nodes of head and neck primary or systemic
[01:25:23] of head and neck primary or systemic primary as well and you can have
[01:25:26] primary as well and you can have lymphoma nodes so each of those sort of
[01:25:28] lymphoma nodes so each of those sort of has a little bit of a different look to
[01:25:30] has a little bit of a different look to them and this is not a lymph node talk
[01:25:31] them and this is not a lymph node talk that's another thing to maybe in the
[01:25:33] that's another thing to maybe in the future I'll put together to share with
[01:25:35] future I'll put together to share with you but I really just want to stress be
[01:25:37] you but I really just want to stress be looking for lymph nodes in the posterior
[01:25:39] looking for lymph nodes in the posterior cervical space that should be in your
[01:25:40] cervical space that should be in your nodal search pattern this was a patient
[01:25:43] nodal search pattern this was a patient who had so-called signal nodes or a vir
[01:25:46] who had so-called signal nodes or a vir kal node I know classically it's taught
[01:25:47] kal node I know classically it's taught that a vir cow or signal node needs to
[01:25:49] that a vir cow or signal node needs to be on the left side but guess what you
[01:25:51] be on the left side but guess what you can have them on the right as well so
[01:25:53] can have them on the right as well so whenever I see a cluster of sort of
[01:25:55] whenever I see a cluster of sort of necrotic nodes like this isolated just
[01:25:58] necrotic nodes like this isolated just right super clavicular light right level
[01:26:00] right super clavicular light right level 5b or left super clavicular left level
[01:26:03] 5b or left super clavicular left level 5b really be thinking about systemic
[01:26:05] 5b really be thinking about systemic metastasis from a chest or or a breast
[01:26:08] metastasis from a chest or or a breast or lung or gut some other spot in the
[01:26:11] or lung or gut some other spot in the head and neck yes of course you want to
[01:26:14] head and neck yes of course you want to search all of your nodal stations in the
[01:26:16] search all of your nodal stations in the neck when you see this but if it's
[01:26:18] neck when you see this but if it's isolated just to this be thinking about
[01:26:19] isolated just to this be thinking about systemic malignancy and that's exactly
[01:26:21] systemic malignancy and that's exactly what this patient had this was colon
[01:26:23] what this patient had this was colon cancer if I remember right
[01:26:27] next you can have lipomas involving the
[01:26:29] next you can have lipomas involving the posterior cervical space and that's
[01:26:31] posterior cervical space and that's simply because the main constituent
[01:26:33] simply because the main constituent feature or contents of the posterior
[01:26:36] feature or contents of the posterior cervical space is fat and so you can
[01:26:38] cervical space is fat and so you can have lipomas live there here's a lipoma
[01:26:40] have lipomas live there here's a lipoma fat density on the Left it's t2 bright
[01:26:42] fat density on the Left it's t2 bright on the right this was not a fat
[01:26:43] on the right this was not a fat saturated sequence therefore it's still
[01:26:45] saturated sequence therefore it's still bright if it was fat saturated it would
[01:26:47] bright if it was fat saturated it would drop out you know what they look like
[01:26:50] drop out you know what they look like you can also get nerve sheath tumors
[01:26:53] you can also get nerve sheath tumors occurring here this is simply a
[01:26:55] occurring here this is simply a relatively uncommon side of a common
[01:26:57] relatively uncommon side of a common mass it may be a schwannoma or a
[01:26:59] mass it may be a schwannoma or a neurofibroma they look like nerve sheath
[01:27:01] neurofibroma they look like nerve sheath tumors elsewhere they're circumscribed
[01:27:02] tumors elsewhere they're circumscribed they're fusiform in shape much much much
[01:27:05] they're fusiform in shape much much much more commonly to be sporadic than
[01:27:07] more commonly to be sporadic than syndromic although if you start seeing
[01:27:09] syndromic although if you start seeing multiple do you think about syndromes
[01:27:10] multiple do you think about syndromes like nf1 for neurofibromas or nf2 or
[01:27:14] like nf1 for neurofibromas or nf2 or schwannomatosis if there's one Oma's and
[01:27:17] schwannomatosis if there's one Oma's and keep in mind after the brachial plexus
[01:27:20] keep in mind after the brachial plexus dives out from between the
[01:27:23] dives out from between the scalene musculature it courses through
[01:27:26] scalene musculature it courses through the posterior cervical space so these
[01:27:30] the posterior cervical space so these may be nerve sheath tumors are rising
[01:27:32] may be nerve sheath tumors are rising from the brachial plexus
[01:27:35] from the brachial plexus this is a patient with multiple
[01:27:37] this is a patient with multiple neurofibromas you can see on the colonel
[01:27:40] neurofibromas you can see on the colonel ster image some of them are quite bright
[01:27:42] ster image some of them are quite bright the one on the patient's left or on the
[01:27:44] the one on the patient's left or on the right side of the image that the yellow
[01:27:46] right side of the image that the yellow arrows pointing to you has sort of that
[01:27:47] arrows pointing to you has sort of that target sign in these enhance avidly but
[01:27:52] target sign in these enhance avidly but maybe a little heterogeneous leaf or
[01:27:53] maybe a little heterogeneous leaf or some of them so multiple be thinking
[01:27:56] some of them so multiple be thinking about syndrome Ike this was an in f1
[01:27:57] about syndrome Ike this was an in f1 patient
[01:27:59] patient this patient had a brachial plexus
[01:28:01] this patient had a brachial plexus schwannoma you can see it's sort of
[01:28:04] schwannoma you can see it's sort of pooching out from between the anterior
[01:28:06] pooching out from between the anterior and middle scalene muscle group into the
[01:28:08] and middle scalene muscle group into the posterior cervical space its
[01:28:11] posterior cervical space its circumscribed it's heterogeneous leety
[01:28:13] circumscribed it's heterogeneous leety too bright nice look fresh one OMA a
[01:28:16] too bright nice look fresh one OMA a couple other tumors or I should say a
[01:28:19] couple other tumors or I should say a tumor in some lesions that can involve
[01:28:22] tumor in some lesions that can involve this space as well but ER by no means
[01:28:24] this space as well but ER by no means specific to this space just something
[01:28:26] specific to this space just something that can show up here and thought this
[01:28:27] that can show up here and thought this would be a good time to talk about them
[01:28:29] would be a good time to talk about them first is a hemangioma
[01:28:32] first is a hemangioma hemangiomas are tumors okay they are
[01:28:35] hemangiomas are tumors okay they are tumors
[01:28:38] tumors they are vascular tumors they are benign
[01:28:41] they are vascular tumors they are benign but they're tumors these are not
[01:28:43] but they're tumors these are not vascular malformations these are
[01:28:45] vascular malformations these are typically gluten one positive so on
[01:28:48] typically gluten one positive so on histopathological assessment they look
[01:28:50] histopathological assessment they look for that these are usually in a parent
[01:28:53] for that these are usually in a parent at birth but present soon after and they
[01:28:55] at birth but present soon after and they go through a proliferative phase and
[01:28:57] go through a proliferative phase and then usually a regression phase there is
[01:29:00] then usually a regression phase there is an association with facies as well to be
[01:29:03] an association with facies as well to be thinking about in in newborns and what
[01:29:07] thinking about in in newborns and what do they look like on imaging they tend
[01:29:10] do they look like on imaging they tend to be avidly enhancing and TT bright I
[01:29:11] to be avidly enhancing and TT bright I showed a GRE here for a reason and
[01:29:14] showed a GRE here for a reason and that's to say there are no flea Willis
[01:29:15] that's to say there are no flea Willis within this so it's a large sort of GRE
[01:29:18] within this so it's a large sort of GRE therefore sort of t2 bright mass within
[01:29:21] therefore sort of t2 bright mass within the left posterior cervical space but
[01:29:25] the left posterior cervical space but there's no flea ballasts there's no big
[01:29:27] there's no flea ballasts there's no big vessels going to this either I'm sorry
[01:29:30] vessels going to this either I'm sorry there this one we can't say the big
[01:29:31] there this one we can't say the big vessels solely for contrast this one may
[01:29:33] vessels solely for contrast this one may have big vessels but there are no flea
[01:29:36] have big vessels but there are no flea beliefs in patient here we get to the
[01:29:39] beliefs in patient here we get to the coronal stur we can see the flow voids
[01:29:41] coronal stur we can see the flow voids of the big vessels they're associated
[01:29:43] of the big vessels they're associated with it it is enhancing maybe not
[01:29:45] with it it is enhancing maybe not enhancing like gangbusters but it is
[01:29:46] enhancing like gangbusters but it is enhancing this is a good look for a
[01:29:48] enhancing this is a good look for a he-man the critical thing to keep in
[01:29:50] he-man the critical thing to keep in mind these are tumors benign tumors
[01:29:53] mind these are tumors benign tumors vascular tumors but nonetheless tumors
[01:29:56] vascular tumors but nonetheless tumors these are not vascular malformations
[01:29:58] these are not vascular malformations these are not what we call hemangiomas
[01:30:00] these are not what we call hemangiomas in the spine don't get me ranting about
[01:30:02] in the spine don't get me ranting about that that's a separate subject
[01:30:04] that that's a separate subject altogether oh let's talk about that
[01:30:06] altogether oh let's talk about that subjects that separate subject vascular
[01:30:08] subjects that separate subject vascular malformations these are not tumors
[01:30:13] malformations these are not tumors these are vascular malformations these
[01:30:16] these are vascular malformations these are mountain now formative lesions of
[01:30:18] are mountain now formative lesions of the vessels these are defined by their
[01:30:20] the vessels these are defined by their slow are they no flow such as a
[01:30:23] slow are they no flow such as a lymphatic malformation are they low flow
[01:30:25] lymphatic malformation are they low flow such as a venous malformation or are
[01:30:28] such as a venous malformation or are they high flow such as an arteriovenous
[01:30:29] they high flow such as an arteriovenous malformation or a dural AV fistula okay
[01:30:32] malformation or a dural AV fistula okay this one had no enhancement this one had
[01:30:34] this one had no enhancement this one had no flow this is case lent to me by Rick
[01:30:36] no flow this is case lent to me by Rick Wiggins this is a large lymphatic
[01:30:39] Wiggins this is a large lymphatic malformation in the posterior cervical
[01:30:40] malformation in the posterior cervical space the ISS VA has really done a good
[01:30:45] space the ISS VA has really done a good job of defining what these are I think
[01:30:48] job of defining what these are I think every trainee out there needs to go to
[01:30:49] every trainee out there needs to go to the ISS VA website just read over the
[01:30:53] the ISS VA website just read over the nomenclature words matter we need to
[01:30:55] nomenclature words matter we need to make sure we're reporting these
[01:30:56] make sure we're reporting these accurately to our to our referring
[01:30:58] accurately to our to our referring clinicians these are not tumors these
[01:31:02] clinicians these are not tumors these are vascular malformations and as such
[01:31:06] are vascular malformations and as such they can be trans or multi spatial
[01:31:09] they can be trans or multi spatial because we're dealing with a congenital
[01:31:10] because we're dealing with a congenital lesion
[01:31:11] lesion this was a lymphatic venous malformation
[01:31:14] this was a lymphatic venous malformation we oftentimes in radiology throw the
[01:31:17] we oftentimes in radiology throw the term V no lymphatic malformation out
[01:31:19] term V no lymphatic malformation out there all willy-nilly truth be told that
[01:31:22] there all willy-nilly truth be told that is an extraordinarily rare
[01:31:24] is an extraordinarily rare diagnosis okay
[01:31:27] diagnosis okay this one was a true lymphatic venous
[01:31:31] this one was a true lymphatic venous malformation and we can say that because
[01:31:33] malformation and we can say that because it has elements of both so this has
[01:31:36] it has elements of both so this has fluid fluid levels on the t2-weighted
[01:31:38] fluid fluid levels on the t2-weighted image that's a feature that we often
[01:31:40] image that's a feature that we often times seen with lymphatic malformations
[01:31:42] times seen with lymphatic malformations it does show true areas of enhancement a
[01:31:46] it does show true areas of enhancement a lymphatic malformation may have some
[01:31:48] lymphatic malformation may have some peripheral faint enhancement and when
[01:31:50] peripheral faint enhancement and when they aggregate together like a multi
[01:31:52] they aggregate together like a multi cystic kind of look it can look like
[01:31:55] cystic kind of look it can look like internal septal enhancement but that's
[01:31:56] internal septal enhancement but that's usually quite fine micro cystic
[01:31:59] usually quite fine micro cystic lymphatic malformations because they're
[01:32:01] lymphatic malformations because they're little cysts are so tightly packed
[01:32:02] little cysts are so tightly packed didn't so small it can give it more of
[01:32:04] didn't so small it can give it more of an enhancing look but that looks
[01:32:06] an enhancing look but that looks different than this this actually has
[01:32:07] different than this this actually has splotchy enhancement that if you tracked
[01:32:10] splotchy enhancement that if you tracked it out through delayed phases sort of
[01:32:12] it out through delayed phases sort of washes in and also this has flee beliefs
[01:32:16] washes in and also this has flee beliefs so this has components of lymphatic and
[01:32:18] so this has components of lymphatic and components of venous malformation but
[01:32:20] components of venous malformation but again I want to throw out there using
[01:32:23] again I want to throw out there using the term V no lymphatic malformation we
[01:32:26] the term V no lymphatic malformation we really should be cautious of using it
[01:32:27] really should be cautious of using it true lymphatic venous malformations like
[01:32:30] true lymphatic venous malformations like this exist but they are rare you can see
[01:32:33] this exist but they are rare you can see septal enhancement of macro cystic and
[01:32:35] septal enhancement of macro cystic and micro cystic lymphatic malformations and
[01:32:37] micro cystic lymphatic malformations and when they sort of are aggregated
[01:32:39] when they sort of are aggregated together that can look a little bit more
[01:32:41] together that can look a little bit more enhancing and those are incorrectly
[01:32:44] enhancing and those are incorrectly termed as Aveeno lymphatic malformations
[01:32:46] termed as Aveeno lymphatic malformations and it matters for management purposes
[01:32:49] and it matters for management purposes okay so that was a lot of content that
[01:32:53] okay so that was a lot of content that was sort of a whirlwind overview of the
[01:32:55] was sort of a whirlwind overview of the infrahyoid neck spaces we talked a
[01:32:56] infrahyoid neck spaces we talked a little bit about the anatomic contents
[01:32:58] little bit about the anatomic contents we talked a lot about common pathologies
[01:33:00] we talked a lot about common pathologies some don't let miss lesions as well
[01:33:02] some don't let miss lesions as well really some take-home points here know
[01:33:04] really some take-home points here know the contents of each of these anatomic
[01:33:06] the contents of each of these anatomic spaces and try to identify the space of
[01:33:08] spaces and try to identify the space of origin of an unknown lesion within the
[01:33:11] origin of an unknown lesion within the neck and the infrahyoid neck because
[01:33:13] neck and the infrahyoid neck because there's so much going on there it's
[01:33:14] there's so much going on there it's really critical to try to figure out
[01:33:16] really critical to try to figure out where it's coming from and that will
[01:33:18] where it's coming from and that will help you to generate a succinct
[01:33:20] help you to generate a succinct appropriate differential diagnosis so as
[01:33:23] appropriate differential diagnosis so as always thank you so much for tuning in I
[01:33:25] always thank you so much for tuning in I know it's a tough time right now we're
[01:33:28] know it's a tough time right now we're really seeing an escalation of Corona
[01:33:30] really seeing an escalation of Corona virus going on and I know we're not the
[01:33:32] virus going on and I know we're not the only ones there's a lot of people around
[01:33:34] only ones there's a lot of people around the country that are experiencing this
[01:33:35] the country that are experiencing this and to a much greater degree than we are
[01:33:37] and to a much greater degree than we are currently but it's it's a problem we're
[01:33:39] currently but it's it's a problem we're all dealing with and you know hang in
[01:33:41] all dealing with and you know hang in there try to stay positive stay safe
[01:33:43] there try to stay positive stay safe stay healthy stay sane and
[01:33:46] stay healthy stay sane and you know share share educational
[01:33:49] you know share share educational resources if you're stuck at home in
[01:33:51] resources if you're stuck at home in quarantine or unfurl oh as a resident or
[01:33:54] quarantine or unfurl oh as a resident or a fellow this is a great opportunity to
[01:33:57] a fellow this is a great opportunity to try to to learn to read textbooks and
[01:34:00] try to to learn to read textbooks and and there's a lot of great educational
[01:34:02] and there's a lot of great educational content out there with free open access
[01:34:05] content out there with free open access on the internet and on social media so
[01:34:09] on the internet and on social media so continue hanging in there and we'll all
[01:34:12] continue hanging in there and we'll all get through this eventually and we'll
[01:34:15] get through this eventually and we'll get to it working together so thank you
[01:34:17] get to it working together so thank you so much for tuning in take care of
[01:34:19] so much for tuning in take care of yourselves

Infrahyoid Neck

https://www.youtube.com/watch?v=Dn7-jsMxk18
Translation: pt-BR

[00:04] Olá, bem-vindo de volta, meu nome é Nick Koontz
[00:06] Olá, bem-vindo de volta, meu nome é Nick Koontz e sou um neurorradiologista e chefe e
[00:08] e sou um neurorradiologista e imagiologista de cabeça e pescoço na Indiana University School
[00:09] imagiologista de pescoço na Indiana University School of Medicine e estou de volta com mais uma
[00:11] de Medicina e estou de volta com mais uma aula completa de radiologia que eu gravei
[00:14] aula completa de radiologia que eu gravei e assim como as outras o
[00:16] gravei e assim como as outras o o propósito destas é apenas ter
[00:18] o propósito destas é apenas ter algum conteúdo educacional que possamos
[00:20] algum conteúdo educacional que possamos compartilhar com os estagiários os residentes
[00:22] compartilhar com os estagiários os residentes os fellows os estudantes de medicina certo
[00:25] os fellows os estudantes de medicina agora é que temos estagiários que estão
[00:26] agora é que temos estagiários que estão potencialmente em quarentena ou ou sendo
[00:28] potencialmente em quarentena ou ou sendo dispensados enquanto nos ajustamos
[00:31] dispensados enquanto nos ajustamos à nova realidade do que está acontecendo com
[00:33] a nova realidade do que está acontecendo com esta crise crescente de kovat então apenas
[00:36] esta crise crescente de kovat então apenas querendo fazer a minha parte colocar algum algum
[00:38] querendo fazer a minha parte colocar algum algum conteúdo educacional lá fora para compartilhar
[00:40] conteúdo educacional lá fora para compartilhar livremente entre as pessoas que estão interessadas
[00:42] livremente entre as pessoas que estão interessadas nisso espero que todos estejam bem
[00:44] nisso espero que todos estejam bem permanecendo saudáveis permanecendo sãos o este
[00:48] permanecendo saudáveis permanecendo sãos o este tópico para a conversa de hoje vai focar
[00:50] tópico para a conversa de hoje vai focar no pescoço infra-hióideo e é meio que
[00:53] no pescoço infra-hióideo e é meio que vai ser uma aula baseada em diagnóstico diferencial
[00:54] vai ser uma aula baseada em diagnóstico diferencial então vamos passar pelo pelo
[00:56] aula então vamos passar pelo pelo diferentes conteúdos os diferentes espaços
[00:58] diferentes conteúdos os diferentes espaços e pescoço infra-hióideo ou pelo menos os principais
[01:00] e pescoço infra-hióideo ou pelo menos os principais e falar sobre algumas das
[01:03] principais e falar sobre algumas das diferentes estruturas e algumas das
[01:04] estruturas diferentes e algumas das patologias que podem ocorrer aqui.
[01:08] patologias que podem ocorrer aqui, então não tenho nenhuma divulgação a fazer, gostaria de.
[01:11] então não tenho nenhuma divulgação a fazer, gostaria de ter algumas divulgações financeiras, mas, infelizmente.
[01:13] tinha algumas divulgações financeiras, mas, infelizmente, não tenho.
[01:15] eu não tenho, gostaria de agradecer a várias pessoas.
[01:18] gostaria de agradecer a várias pessoas que foram gentis o suficiente para compartilhar um pouco.
[01:21] que foram gentis o suficiente para compartilhar algum conteúdo comigo para esta palestra, primeiramente e.
[01:23] conteúdo comigo para esta palestra, primeiramente e acima de tudo Rick Wiggins e Rick Hornsberger.
[01:25] acima de tudo Rick Wiggins e Rick Hornsberger, ambos que ao longo dos anos têm.
[01:27] Berger, ambos que ao longo dos anos compartilharam muita educação e aprendizado.
[01:29] compartilharam muito aprendizado e educação comigo, mas também forneceram parte.
[01:32] comigo, mas também forneceram alguns dos gráficos, bem como alguns dos.
[01:35] os gráficos, bem como alguns dos casos que você encontrará nesta.
[01:36] casos que você encontrará nesta apresentação, então obrigado a ambos Rick e.
[01:39] apresentação, então obrigado a ambos Rick e Rick pela gentileza e por compartilhar.
[01:40] Rick pela gentileza e por compartilhar isso ao longo dos anos, eu também gostaria de.
[01:42] isso ao longo dos anos, eu também gostaria de agradecer a Jim Milburn e Todd Come, ambos.
[01:46] agradecer a Jim Milburn e Todd Come, ambos que forneceram algum conteúdo adicional.
[01:48] que forneceram algum conteúdo adicional para esta palestra também, e você.
[01:51] para esta palestra também, e você verá isso aqui em alguns minutos, então novamente.
[01:53] verá isso aqui em alguns minutos, então novamente, muitas partes não podem levar o crédito por.
[01:55] muitas partes não podem levar o crédito por tudo o que você está vendo aqui.
[01:57] tudo o que você está vendo aqui nesta palestra, mas você sabe, no espírito.
[01:59] nesta palestra, mas você sabe, no espírito de compartilhar isso, eu quero agradecê-los.
[02:02] de compartilhar isso, eu quero agradecê-los por tudo o que eles fizeram para ajudar.
[02:04] por tudo o que eles fizeram para ajudar com isso também.
[02:06] Fora com isso também, ok, então vamos começar.
[02:09] Ok, então vamos começar. A rede infra-hioide cobre muito, a rede infra-hioide cobre muito terreno.
[02:12] Existem muitos espaços diferentes envolvidos, cada um dos quais contém múltiplas estruturas anatômicas e, por essa razão, há realmente muita patologia que pode ocorrer aqui.
[02:19] Na verdade, a coisa que eu acho mais desafiadora, mas ao mesmo tempo mais interessante sobre o pescoço infra-hioide, é apenas a diversidade de patologias que podem ocorrer aqui.
[02:28] Então, uma das coisas chave, talvez a coisa mais importante para levar desta palestra é: sempre que você estiver abordando uma lesão genérica, uma massa genérica, chame do que for, que você encontrar no pescoço, tente descobrir de onde ela está vindo, qual é o espaço de origem de onde ela está surgindo, porque se você puder fazer isso, isso imediatamente vai estreitar seu diagnóstico diferencial.
[02:52] Outra coisa a ter em mente é: se você vir algo que está se estendendo entre múltiplos espaços ou se for multiespacial ou transespacial, pense em etiologias congênitas, bem como em ideologias agressivas, como infecção ou malignidade, porque esses são os tipos.
[03:07] malignidade porque esses são os tipos de coisas que tendem a cruzar essas fronteiras espaciais.
[03:12] Ok, então essa foi meio que a introdução muito breve e há muito conteúdo para cobrir aqui, então vou direto ao ponto.
[03:21] Então, primeiro estamos falando sobre um diagnóstico diferencial baseado em espaço e vamos repassar algumas coisas comuns e incomuns que encontramos no espaço visceral.
[03:29] Agora, ao olhar para o espaço visceral, como você pode ver aqui, há muitos conteúdos dentro dele e cada um desses terá patologias diferentes que podem ocorrer.
[03:40] Então, não vou falar especificamente sobre a laringe e realmente vou apenas superficialmente abordar a hipofaringe.
[03:47] Esses dois são meio que uma entidade em si mesmos e é meio que uma conversa separada que cobriria todas as muitas coisas que podem acontecer aqui.
[03:56] Então, não vamos falar sobre esses, mas em vez disso, vamos começar com a traqueia.
[04:01] E a traqueia é algo que eu acho que os radiologistas de cabeça e pescoço tendem a não abraçar nem de perto da mesma forma que os
[04:09] em perto da mesma forma que os radiologistas de tórax fazem e eu acho que os radiologistas de tórax fazem e eu acho que isso é algo que realmente precisamos pensar e ter pelo menos um entendimento básico de algumas das patologias que podem ocorrer aqui.
[04:19] então a primeira coisa a falar é estenose traqueal e isso porque é uma indicação tão comum para imagem que esses pacientes muitas vezes apresentarão dispneia e eu acho que quando eu abordo um desses casos, algumas das coisas chave que eu quero pensar é se estou lidando com uma criança ou um adulto porque com uma criança você está pensando mais comumente de qualquer forma em coisas congênitas, um adulto muito mais comum lidar com etiologias adquiridas.
[04:43] criticamente o paciente teve cirurgia prévia, eles tiveram intubação prévia, foi uma intubação prolongada ou intubação traumática, quando eu olho para isso, é um segmento curto, é muito focal ou é um processo de segmento longo e então, importantemente, as coisas a relatar seriam o quão estreito fica, qual o diâmetro mais estreito porque isso é algo que os cirurgiões, os pneumologistas podem querer saber e estamos perto de lidar com uma lesão, uma massa.
[05:12] estamos perto de lidar com uma lesão uma massa que você quer tentar decifrar estou lidando
[05:15] você quer tentar decifrar estou lidando com obstrução endoluminal algo
[05:17] com obstrução endoluminal algo que está contido dentro da traqueia
[05:19] que está contido na própria traqueia ou é esta compressão extrínseca
[05:21] própria ou é esta compressão extrínseca algo do lado de fora
[05:22] algo do lado de fora esmagando-a e então quando você olha
[05:25] esmagando-a e então quando você olha para ela você quer olhar e ver se ela
[05:27] para ela você quer olhar e ver se ela parece algum tipo de lisa
[05:29] parece algo de contorno liso ou é algo que
[05:32] de contorno ou é algo que parece feio e agressivo
[05:35] então quando estamos lidando com traqueia adquirida
[05:37] então quando estamos lidando com estenose traqueal adquirida lore subglótica como você pode ver
[05:40] lore subglótica como você pode ver neste slide há muitas
[05:41] neste slide há muitas causas intrínsecas mas de longe a
[05:44] causas intrínsecas mas de longe a mais cômica a mais comum intrínseca
[05:47] a causa intrínseca mais cômica e mais comum de estenose que eu vejo está relacionada a
[05:50] causa de estenose que eu vejo está relacionada a intubação prévia e traqueostomia prévia
[05:52] intubação prévia e traqueostomia prévia mas há muitas coisas e nós
[05:54] mas há muitas coisas e falaremos sobre algumas delas durante a conversa
[05:55] falaremos sobre algumas delas durante a conversa quanto a causas extrínsecas na minha
[05:59] quanto a causas extrínsecas na minha experiência aqui e no meu local a coisa
[06:01] experiência aqui e no meu local a coisa que eu vejo com mais frequência são tireóide
[06:04] que eu vejo com mais frequência são lesões de tireóide massas de tireóide se é um
[06:07] lesões massas de tireóide se é um bócio ou uma malignidade verdadeira que estão
[06:09] bócio ou uma malignidade verdadeira que estão comprimindo externamente mas novamente você
[06:12] comprimindo externamente mas novamente você pode ver aqui há muitas potenciais
[06:13] podemos ver aqui que há muitas causas extrínsecas potenciais de estenose traqueal como causas extrínsecas de estenose traqueal também
[06:18] bem então este é um exemplo de estenose traqueal relacionada à traqueostomia você pode ver estenose traqueal relacionada você pode ver onde aquela seta amarela está apontando
[06:24] onde aquela seta amarela está apontando está bem ali mais ou menos e talvez um pouco abaixo do nível de
[06:31] onde a desculpe bem ali e acima do nível onde a traqueostomia está entrando
[06:35] e você pode ver o quão estreito é o diâmetro traqueal não em comparação com o calibre mais normal distal a jusante
[06:41] e você pode ver que essa é uma diferença realmente significativa entre os dois
[06:44] agora você pode dizer bem não importa muito ele teve um tubo de traqueostomia e de fato você está certo eles estão protegendo as vias aéreas agora
[06:49] mas digamos que eles querem chegar ao ponto em que vão remover essa traqueostomia
[06:54] eles precisam saber sobre essa estenose porque este é um paciente que vai se meter em problemas por causa dessa estenose muito apertada relacionada à traqueostomia anterior
[07:06] este é outro paciente este é um paciente que anteriormente teve uma intubação prolongada e você pode ver que eles têm uma área muito focal onde
[07:14] que eles têm uma área muito focal onde você tem uma espécie de ombro, um estreitamento da traqueia, provavelmente relacionado àquela intubação prolongada anterior, então, novamente, você quer encontrá-lo, você quer identificar a perspectiva daquela configuração de ampulheta em que você, neste caso, tem uma cintura muito focal ou um estreitamento muito focal e relate isso, diga a eles, diga aos cirurgiões, diga ao pneumologista o quanto ele se estende e qual é a espécie de nadir do estreitamento.
[07:41] em seguida, temos massas traqueais malignas. Agora, felizmente, os tumores traqueais primários são bastante raros. Estamos falando literalmente de algo que é um diagnóstico de um em um milhão e, destes, o carcinoma de células escamosas será o culpado mais comum, seguido pelo carcinoma cístico adenóide.
[07:57] Agora, a imagem é bastante limitada em termos de tentar prever qual é a histopatologia final e tudo bem. Esses pacientes precisarão de uma biópsia indolente para descobrir. Esse não é o seu trabalho, então não posso olhar para a imagem e dizer, oh, isso é claramente um golpe ou isso é um cístico adenóide, você
[08:15] golpe ou este é um cístico adenoide você pode jogar as probabilidades e dizer que o grito é
[08:17] pode jogar as probabilidades e dizer que o grito é mais provável, mas em vez disso é o
[08:19] mais provável, mas em vez disso é o radiologista, seu trabalho é procurar
[08:22] radiologista, seu trabalho é procurar invasão das estruturas circundantes, procure
[08:24] invasão das estruturas circundantes, procure invasão dessas outras vísceras
[08:26] para invasão dessas outras estruturas do espaço visceral que estão próximas
[08:27] estruturas espaciais que estão em estreita proximidade, então
[08:29] proximidade, então este é um paciente que teve traqueal
[08:31] este é um paciente que teve carcinoma de células escamosas traqueal, você pode ver
[08:33] carcinoma de células escamosas, você pode ver que há uma massa no lado esquerdo e está
[08:36] há uma massa no lado esquerdo e está indicada aqui pela seta amarela e
[08:39] indicada aqui pela seta amarela e é feio, é agressivo, você pode ver
[08:41] é feio, é agressivo, você pode ver que está realmente estreitando acentuadamente a
[08:42] está realmente estreitando acentuadamente a via aérea, mas se você olhar para a coronal
[08:44] via aérea, mas se você olhar para a imagem coronal, você pode ver, importante, que parece
[08:45] imagem, você pode ver, importante, que parece estar se estendendo para os
[08:48] olhar como se estivesse se estendendo para os tecidos moles circundantes e provavelmente
[08:49] tecidos moles circundantes e provavelmente começando a invadir a própria tireoide
[08:51] começando a invadir a própria tireoide, não há nada que eu possa dizer nesta
[08:53] não há nada que eu possa dizer nesta imagem que me diga que isso é
[08:55] imagem que me diga que isso é certamente um carcinoma de células escamosas que
[08:57] certamente um carcinoma de células escamosas que por acaso é o mais provável
[08:59] por acaso é o diagnóstico mais provável com base nas estatísticas
[09:02] diagnóstico com base nas estatísticas, aqui está outro paciente com maligno
[09:04] aqui está outro paciente com massa traqueal maligna, este foi um cístico adenoide
[09:07] massa traqueal, este foi um carcinoma cístico adenoide novamente, não posso olhar para isso e
[09:09] carcinoma novamente, não posso olhar para isso e dizer que esse é o diagnóstico
[09:10] dizer que esse é o diagnóstico, tudo bem, é o que a biópsia diz
[09:13] a você, mas em vez disso, o que posso fazer é olhar para
[09:15] você, mas em vez disso, o que posso fazer é olhar para isso e descrever onde o tumor está
[09:17] isso e descreve para onde o tumor está indo, quão grande é o tumor e, neste caso, este é um bom exemplo de como a TC e a RM podem ser complementares na estadiamento da doença
[09:27] podemos dizer a eles que a TC, sim, parece que os tumores estão saindo da traqueia, a RM é muito mais específica em termos de nos dizer para onde está indo
[09:32] obtemos essa superioridade de resolução de contraste de tecido que nos ajuda a estadiar melhor onde o tumor está
[09:39] o próximo diagnóstico é condrite recidivante
[09:42] este é um diagnóstico raro e é uma doença autoimune na qual os pacientes têm inflamação recorrente da cartilagem e, eventualmente, o mais comum é que leve à destruição cartilaginosa
[09:54] pode ser um processo muito focal ou pode ser um processo muito difuso, pode afetar múltiplas cartilagens diferentes dentro do corpo e, certamente, a traqueia é uma dessas estruturas que contém anéis cartilaginosos, então pode ser envolvida
[10:08] agora, classicamente, isso envolve as paredes traqueais anterior e lateral ou até mesmo a via aérea
[10:17] paredes traqueais ou mesmo então as paredes das vias aéreas você pode usar a mesma aplicação
[10:19] paredes você pode usar a mesma aplicação para baixo assim que você passar abaixo das clavículas
[10:22] para baixo assim que você passar abaixo das clavículas para o peito, mas tem poupação de
[10:24] para o peito, mas tem poupação daquela traqueia posterior, cérebro de yem ou a
[10:27] aquela traqueia posterior, cérebro de yem ou a membrana posterior da via aérea porque isso é
[10:29] membrana posterior da via aérea porque isso é uma estrutura não cartilaginosa, então, à medida que
[10:31] uma estrutura não cartilaginosa, então, à medida que olhamos para este caso, podemos ver uma espécie de
[10:33] olhamos para este caso, podemos ver uma espécie de espessamento e um pouco de
[10:34] espessamento e um pouco de irregularidade das paredes da traqueia
[10:36] irregularidade das paredes da traqueia anteriormente e lateralmente, mas se você olhar
[10:39] anteriormente e lateralmente, mas se você olhar atentamente, pode ver que esta poupa
[10:41] atentamente, pode ver que esta poupa é aquela parede posterior ou aquela posterior
[10:43] aquela parede posterior ou aquela membrana traqueal posterior
[10:45] membrana traqueal ao longo do tempo, a trajetória clássica disso
[10:48] ao longo do tempo, a trajetória clássica disso é levar ao colapso da cartilagem e você
[10:52] é levar ao colapso da cartilagem e você pode ter um estreitamento muito grave das vias aéreas
[10:56] pode ter um estreitamento muito grave das vias aéreas como resultado disso, agora às vezes e
[10:59] como resultado disso, agora às vezes e isso é bastante raro, às vezes você pode
[11:01] isso é bastante raro, às vezes você pode realmente ter um aumento do
[11:03] realmente ter um aumento das estruturas cartilaginosas devido a isso
[11:05] estruturas cartilaginosas devido a essa espécie de repetitivo crônico
[11:07] espécie de inflamação condral repetitiva crônica e este é um caso de
[11:11] inflamação condral e este é um caso de isso é uma
[11:13] caso disso, esta é uma aparência atípica de policonrite recidivante
[11:15] aparência de policonrite recidivante e o que realmente deveria chamar sua atenção
[11:17] e o que realmente deve chamar sua atenção é que você pode ver a imagem à esquerda na TC axial.
[11:19] veja como essa cartilagem tireóidea está espessada.
[11:22] imagem à direita, olhe para esta cartilagem cricóide, quão espessa e nodosa ela é.
[11:25] não está sendo destruída, mas está acentuadamente aumentada.
[11:26] não grave isso em sua mente como a aparência típica, porque mais tipicamente veremos destruição cartilaginosa ao longo do tempo.
[11:30] este acontece de ser um daqueles casos realmente incomuns que resultaram em aumento cartilaginoso.
[11:34] e importantemente, realmente a coisa crítica aqui é que quando você tem essa cartilagem ficando tão aumentada, ela pode comprometer a via aérea.
[11:41] então esteja sempre atento ao estreitamento da via aérea.
[11:43] sempre relate algo que pode parecer um pouco com isso, que é amiloidose.
[11:45] e este é um distúrbio raro.
[11:48] é de dobramento de proteína anormal e pode ser primário ou secundário ou localizado ou difuso.
[11:49] e quando envolve a via aérea, é mais comumente a variedade localizada.
[11:51] que especificamente é apenas
[12:17] variedade que que especificamente envolve apenas as vias aéreas, mas você pode ter envolvimento das vias aéreas, mas você pode ter um envolvimento difuso ou até mesmo um envolvimento difuso ou até mesmo amiloidose secundária resultando em amiloidose secundária resultando em doença das vias aéreas também, mas isso ocorre doença das vias aéreas também, mas isso ocorre quando há deposição da amiloide quando há deposição das proteínas fibrilares de amiloide em tecidos normalmente normais e, portanto, pode ser muito difuso, pode ser multifocal, mas, importante, pode envolver a parede posterior da parede posterior da traqueia e a parede posterior das vias aéreas, as vias aéreas menores no pulmão também, então essa é uma distinção de contorno do que vimos com a poligondrite recidivante e isso lhe dá essas massas submucosas, então aqui vemos essas massas submucosas, então vemos esse acúmulo de tecido mole ao longo da membrana traqueal posterior nesta imagem de TC axial sem contraste, como você pode ver bem onde a seta está apontando, está associado a alguma calcificação também, então essas massas submucosas podem ser calcificadas se você fizer ressonância magnética, elas têm um sinal T2 escuro característico, então são hipointensas em T2, isso é algo importante a se ter em mente se você administrar contraste na ressonância magnética você
[13:19] em mente se você der contraste na ressonância magnética, você também pode ter realce.
[13:22] pode ter realce também este é outro paciente que teve traqueal.
[13:24] este é outro paciente que teve amiloidose traqueal esta é comprovada patologicamente e você.
[13:27] amiloidose esta é comprovada patologicamente e você pode ver que isto é em vez de ser.
[13:29] pode ver que isto é em vez de ser mais de um tipo de difuso liso.
[13:31] mais de um tipo de tecido mole infiltrativo difuso liso este é um tipo de.
[13:33] tecido mole infiltrativo este é um tipo de aparência multinodular mas como você.
[13:36] uma aparência multinodular mas como você olha isto está envolvendo o tipo de.
[13:39] olha isto está envolvendo o tipo de as paredes posterior e posterolateral de.
[13:41] paredes posterior e posterolateral da traqueia cervical e é multifocal.
[13:43] a traqueia cervical e é multifocal tipo de massas submucosas empilhadas e.
[13:47] tipo de massas submucosas empilhadas e você pode ver se você olhar atentamente.
[13:49] você pode ver se você olhar atentamente há um pouco de calcificação.
[13:50] há um pouco de calcificação associada a isto também então a.
[13:53] associada a isto também então a calcificação não lhe dá muita.
[13:54] calcificação não lhe dá muita especificidade mas é um importante.
[13:56] especificidade mas é um achado importante a ser procurado e reconhecer.
[13:58] achado a ser procurado e reconhecer que a amiloidose traqueal pode de fato.
[14:00] que a amiloidose traqueal pode de fato ter calcificação agora interessantemente.
[14:03] ter calcificação agora interessantemente é algo que se você você fdg-pet.
[14:06] é algo que se você você fdg-pet você eles também veem algum hipermetabolismo.
[14:08] você eles também veem algum hipermetabolismo com isso então portanto pode potencialmente.
[14:10] com isso então portanto pode potencialmente mimetizar malignidade também então tipo de manter.
[14:13] mimetizar malignidade também então tipo de manter isso em mente que a amiloidose traqueal.
[14:15] isso em mente que a amiloidose traqueal pode ser um pouco de um diagnóstico que que.
[14:17] pode ser um pouco de um diagnóstico que que age como um mímico e pode causar alguma.
[14:20] age como um mímico e pode causar alguma consternação.
[14:22] Em seguida, temos a granulomatose com.
[14:25] Em seguida, temos a granulomatose com poliangiite e esta é uma autoimune.
[14:26] poliangiite e esta é uma vasculite necrosante granulomatosa autoimune e.
[14:29] vasculite necrosante granulomatosa e esses pacientes terão anti neutrófilos.
[14:31] esses pacientes terão anticorpos citoplasmáticos anti-neutrófilos ou ANCA e nós.
[14:34] anticorpos citoplasmáticos ou ANCA e nós sempre pensamos nisso na área de cabeça e pescoço.
[14:36] sempre pensamos nisso no mundo da cabeça e pescoço como um sinal de processo nasal.
[14:38] mundo como um sinal de processo nasal e é, quero dizer, essa é a apresentação mais comum.
[14:40] apresentação, mas pode envolver qualquer uma das vias aéreas e a traqueia não é exceção.
[14:42] as vias aéreas e a traqueia não é exceção, esses pacientes terão.
[14:44] exceção, esses pacientes terão erosão cartilaginosa, eles podem até ter.
[14:47] erosão cartilaginosa, eles podem até ter como esses espessamentos de tecido mole semelhantes a massas.
[14:49] semelhantes a massas ao longo das vias aéreas, então.
[14:51] áreas espessadas ao longo das vias aéreas, então aqui, como você pode ver no lado esquerdo da.
[14:53] a traqueia cervical proximal, vemos.
[14:55] uma espécie de acúmulo no que era um componente de tecido mole realçador.
[14:57] tem um pouco de alteração dentro dele também.
[14:59] se eu visse isso, teria que considerar.
[15:01] malignidade, quero dizer, você tem que levantar isso como uma possibilidade aqui.
[15:03] e isso também precisará de biópsia para discernir a diferença.
[15:06] agora é um caso em questão onde você quer olhar outras imagens.
[15:09] se eles tiverem sinais de envolvimento nasal, certamente pensaremos sobre.
[15:10] agora é um caso em questão onde você quer olhar outras imagens.
[15:13] se eles tiverem sinais de envolvimento nasal, certamente pensaremos sobre.
[15:16] agora é um caso em questão onde você quer olhar outras imagens.
[15:18] se eles tiverem sinais de envolvimento nasal, certamente pensaremos sobre.
[15:19] envolvimento, certamente pensaremos sobre.
[15:21] o envolvimento certamente pensaremos em granulomatose com
[15:23] granulomatose com poliangeíte, mas certamente pode mimetizar
[15:27] poliangeíte, mas certamente pode mimetizar malignidade também, e isso é algo
[15:28] malignidade também, e isso é algo que você precisa considerar
[15:32] o próximo é algo benigno e
[15:34] o próximo é algo benigno e algo que vemos com bastante frequência
[15:35] algo que vemos com bastante frequência, este é um divertículo traqueal, este é
[15:38] este é um divertículo traqueal, esta é simplesmente uma hérnia de mucosa através de um
[15:40] simplesmente uma hérnia de mucosa através de um defeito na parede traqueal
[15:42] defeito na parede traqueal, você pode ver aqui, nós meio que temos
[15:44] você pode ver aqui, nós meio que temos esta estrutura de densidade de ar sentada
[15:49] esta estrutura de densidade de ar sentada no lado direito da traqueia, estes
[15:51] no lado direito da traqueia, estes são geralmente achados incidentais, eles
[15:52] são geralmente achados incidentais, geralmente são bem pequenos, são únicos
[15:55] geralmente são bem pequenos, são únicos, às vezes, no entanto, podem ter uma aparência
[15:56] às vezes, no entanto, podem ter uma aparência multilocular maior como esta
[15:58] aparência multilocular maior como esta, eu mostrei esta apenas porque é um exemplo tão
[16:00] um exemplo tão bom para reforçar o ponto
[16:02] de como eles se parecem, talvez um pouco
[16:03] um pouco mais exagerado do que normalmente
[16:05] vemos, e estes geralmente estão no lado direito
[16:07] vemos, e estes geralmente estão no lado direito, eu não tenho a menor ideia do porquê, mas você
[16:10] lado, eu não tenho a menor ideia do porquê, mas você descobrirá que sim, você pode tê-los
[16:11] descobrirá que sim, você pode tê-los bilateralmente, sim, você pode tê-los no
[16:13] lado esquerdo, mas mais comumente você verá
[16:15] lado esquerdo, mas mais comumente você verá no lado direito, uma coisa que eu
[16:17] no lado direito, uma coisa que eu acho que é um discriminador importante é
[16:19] acho que é um discriminador importante é procurar um nível ar-líquido, estes devem
[16:23] procure um nível de ar-líquido, estes não devem ter um nível de ar-líquido, repito, não devem ter um nível de ar-líquido, repito, estes não devem ter um nível de ar-líquido
[16:28] estes não devem ter um nível de ar-líquido, se você vir um nível de ar-líquido, pense em divertículos esofágicos
[16:32] pensando em divertículos esofágicos e e essa é meio que a minha deixa para discutir
[16:35] essa é meio que a minha deixa para discutir o esôfago
[16:38] o esôfago, então vamos começar com o vilão, o carcinoma esofágico, e você provavelmente não precisa que eu lhe diga isso se você trabalha com radiologia há algum tempo, mas
[16:46] trabalha com radiologia há algum tempo, mas a imagem transversal não é ótima para avaliar o carcinoma esofágico, simplesmente não é
[16:51] este é um diagnóstico em que realmente confiamos mais na endoscopia nos dias de hoje, certamente
[16:56] endoscopia nos dias de hoje, certamente os esofagogramas são úteis, você pode identificá-los no esofagograma, neste caso, você pode ver meio que aquela aparência clássica de anel de maçã, e então sim, ser capaz de reconhecer isso em esofagogramas, eles são muitas vezes muito mais sutis do que o que estou mostrando aqui neste exemplo, mas em geral, embora você não possa vê-lo na imagem transversal, não é nossa melhor modalidade para olhar o que você pode ver nos estudos transversais como a TC seria o espessamento da parede de
[17:24] A TC seria o espessamento da parede do esôfago, muitas vezes parecendo um pouco esbatido ou mal definido, mas realmente onde acho que o papel importante é para aqueles de nós que fazem exames de TC é procurar coisas que agravem a sua doença, você está procurando invasão de estruturas circundantes no espaço visceral, bem como procurando adeno ethey metastático, então, apenas para mostrar o quão desafiador pode ser em exames de TC, aqui vemos este segmento relativamente curto do esôfago cervical distal em que a parede está apenas um pouco espessa e um pouco esbatida, obviamente muito mais fácil de ver neste FDG-PET onde você pode ver que é marcadamente hipermetabólico, isso foi carcinoma esofágico comprovado por patologia.
[18:08] Mencionei divertículos esofágicos antes, agora vamos falar um pouco mais a fundo sobre eles, você pode ter divertículos verdadeiros que contêm todas as camadas da parede ou você pode ter falsos divertículos, pseudo divertículo, e isso contém a mucosa e a submucosa que herniam através de um defeito na.
[18:26] que hernia através de um defeito na camada muscular, então um divertículo verdadeiro
[18:28] camada muscular, então um divertículo verdadeiro tem todas essas camadas, o falso
[18:30] tem todas essas camadas, o divertículo falso carece da muscular
[18:32] divertículo carece da muscular porque a mucosa e a submucosa
[18:34] porque a mucosa e a submucosa hernias através dele
[18:36] hernias através dele e as coisas que frequentemente nos referimos
[18:39] e as coisas que frequentemente nos referimos como divertículos esofágicos, como
[18:41] a divertículos esofágicos, como divertículos de zinco ou ou Achille e
[18:43] divertículos de zinco ou ou Achille e jameson, esses são na verdade um pseudo
[18:45] jameson, esses são na verdade pseudo divertículos
[18:46] divertículos, você também pode classificar esofágicos
[18:49] você também pode classificar divertículos esofágicos como sendo de tração ou Polzin
[18:52] divertículos como sendo de tração ou Polzin, com o divertículo de tração devido a
[18:54] com o divertículo de tração devido a puxões extrínsecos na parede do
[18:57] puxões extrínsecos na parede do esôfago e o divertículo oposto é
[19:00] esôfago e o divertículo oposto é devido a empurrões intraluminais causando essa
[19:02] devido a empurrões intraluminais causando essa protrusão eu
[19:04] protrusão eu disse que não ia falar sobre a
[19:06] disse que não ia falar sobre a hipofaringe
[19:07] hipofaringe, essa é uma pequena mentira que eu que eu contei
[19:10] essa é uma pequena mentira que eu que eu contei a você, eu vou falar sobre a
[19:12] você, eu vou falar sobre a hipofaringe aqui, mas meio que agrupá-la
[19:14] hipofaringe aqui, mas meio que agrupá-la sob o esôfago apenas porque estas
[19:16] sob o esôfago apenas porque estas são entidades tão intimamente relacionadas
[19:18] são entidades tão intimamente relacionadas e então falaremos sobre
[19:20] entidades e então falaremos sobre divertículo hipofaríngeo e este
[19:23] divertículo hipofaríngeo e este é conhecido pelo epônimo de um zinco ou
[19:25] é conhecido pelo epônimo de um divertículo de zinco ou, tecnicamente, é um
[19:27] divertículo este é tecnicamente um pseudo divertículo de Polzin no qual você
[19:29] pseudo divertículo de Polzin no qual você tem mucosa que hernia acima do
[19:32] tem mucosa que hernia acima do nível do cricofaríngeo geralmente em
[19:35] nível do cricofaríngeo geralmente em cerca de c5 c6 então você pode ver aqui neste
[19:37] cerca de c5 c6 então você pode ver aqui neste diagrama temos nossa seta amarela
[19:39] diagrama temos nossa seta amarela apontando para este divertículo faringoesofágico ou
[19:41] apontando para este divertículo faringoesofágico ou hipofaríngeo onde está
[19:43] divertículo hipofaríngeo onde está herniando através de um
[19:46] herniando através de um defeito logo acima das franjas de Crego e
[19:48] defeito logo acima das franjas de Crego e isso está associado a disfagia esofágica
[19:50] isso está associado a disfagia esofágica
[19:52] disfagia tipicamente envolverá a
[19:53] tipicamente envolverá a parede posterior da linha média do esôfago
[19:55] parede posterior da linha média do esôfago, mas pode se estender para o lado esquerdo
[19:57] mas pode se estender para o lado esquerdo ou mais comumente para o lado esquerdo quando
[19:59] ou mais comumente para o lado esquerdo quando ficam maiores, mas novamente quero
[20:01] ficam maiores, mas novamente quero enfatizar a importância, procure por aquele ar
[20:03] enfatizar a importância, procure por aquele nível de ar e líquido que realmente deve ajudá-lo
[20:06] nível de ar e líquido que realmente deve ajudá-lo a reconhecer que você está lidando com
[20:07] a reconhecer que você está lidando com algo que contém conteúdo
[20:09] algo que contém conteúdo do intestino ou do trato digestivo e estes
[20:13] o intestino ou o trato digestivo e estes estão associados à disfagia, bem como
[20:15] estão associados à disfagia, bem como a um risco aumentado de aspiração
[20:18] um risco aumentado de aspiração, então aqui está um exemplo em uma
[20:20] então aqui está um exemplo em uma esofagografia baritada oblíqua, você pode ver aquele fluido
[20:23] esofagografia baritada, você pode ver aquele fluido e bário e gás contidos dentro deste
[20:25] e bário e gás contidos dentro deste divertículo hipofaríngeo você pode classificar

Infrahyoid Neck

https://www.youtube.com/watch?v=Dn7-jsMxk18
Translation: pt-BR

[00:04] hi welcome back my name is Nick Koontz
Olá, bem-vindo de volta, meu nome é Nick Koontz

[00:06] hi welcome back my name is Nick Koontz and I'm a neuro radiologist and head and
Olá, bem-vindo de volta, meu nome é Nick Koontz e sou um neurorradiologista e chefe e

[00:08] and I'm a neuro radiologist and head and neck imager at Indiana University School
e sou um neurorradiologista e imagiologista de cabeça e pescoço na Indiana University School

[00:09] neck imager at Indiana University School of Medicine and I'm back with another
imagiologista de pescoço na Indiana University School of Medicine e estou de volta com mais uma

[00:11] of Medicine and I'm back with another full-length radiology lecture that I've
de Medicina e estou de volta com mais uma aula completa de radiologia que eu gravei

[00:14] full-length radiology lecture that I've recorded and just like the others the
aula completa de radiologia que eu gravei e assim como as outras o

[00:16] recorded and just like the others the the purpose of these is just to have
gravei e assim como as outras o o propósito destas é apenas ter

[00:18] the purpose of these is just to have some educational content that we can
o propósito destas é apenas ter algum conteúdo educacional que possamos

[00:20] some educational content that we can share with the trainees the residents
algum conteúdo educacional que possamos compartilhar com os estagiários os residentes

[00:22] share with the trainees the residents the fellows the medical students right
compartilhar com os estagiários os residentes os fellows os estudantes de medicina certo

[00:25] the fellows the medical students right now is we have trainees that are
os fellows os estudantes de medicina agora é que temos estagiários que estão

[00:26] now is we have trainees that are potentially in quarantine or or being
agora é que temos estagiários que estão potencialmente em quarentena ou ou sendo

[00:28] potentially in quarantine or or being furloughed as we're sort of adjusting to
potencialmente em quarentena ou ou sendo dispensados enquanto nos ajustamos

[00:31] furloughed as we're sort of adjusting to the new reality of what's going on with
dispensados enquanto nos ajustamos à nova realidade do que está acontecendo com

[00:33] the new reality of what's going on with this escalating kovat crisis so just
a nova realidade do que está acontecendo com esta crise crescente de kovat então apenas

[00:36] this escalating kovat crisis so just wanting to do my part put some some
esta crise crescente de kovat então apenas querendo fazer a minha parte colocar algum algum

[00:38] wanting to do my part put some some educational content out there to share
querendo fazer a minha parte colocar algum algum conteúdo educacional lá fora para compartilhar

[00:40] educational content out there to share freely among people who are interested
conteúdo educacional lá fora para compartilhar livremente entre as pessoas que estão interessadas

[00:42] freely among people who are interested in it hope everybody's doing well
livremente entre as pessoas que estão interessadas nisso espero que todos estejam bem

[00:44] in it hope everybody's doing well staying healthy staying sane the this
nisso espero que todos estejam bem permanecendo saudáveis permanecendo sãos o este

[00:48] staying healthy staying sane the this topic for today's talk is going to focus
permanecendo saudáveis permanecendo sãos o este tópico para a conversa de hoje vai focar

[00:50] topic for today's talk is going to focus on the infrahyoid neck and it's sort of
tópico para a conversa de hoje vai focar no pescoço infra-hióideo e é meio que

[00:53] on the infrahyoid neck and it's sort of gonna be a differential diagnosis based
no pescoço infra-hióideo e é meio que vai ser uma aula baseada em diagnóstico diferencial

[00:54] gonna be a differential diagnosis based lecture so we'll run through the the
vai ser uma aula baseada em diagnóstico diferencial então vamos passar pelo pelo

[00:56] lecture so we'll run through the the different contents the different spaces
aula então vamos passar pelo pelo diferentes conteúdos os diferentes espaços

[00:58] different contents the different spaces and infrahyoid neck or at least the main
diferentes conteúdos os diferentes espaços e pescoço infra-hióideo ou pelo menos os principais

[01:00] and infrahyoid neck or at least the main ones and talk about some of the
e pescoço infra-hióideo ou pelo menos os principais e falar sobre algumas das

[01:03] ones and talk about some of the different structures and some of the
principais e falar sobre algumas das diferentes estruturas e algumas das

[01:04] different structures and some of the pathologies that can occur here.
estruturas diferentes e algumas das patologias que podem ocorrer aqui.

[01:08] pathologies that can occur here so I have no disclosures to make wish I.
patologias que podem ocorrer aqui, então não tenho nenhuma divulgação a fazer, gostaria de.

[01:11] so I have no disclosures to make wish I had some financial disclosures but alas.
então não tenho nenhuma divulgação a fazer, gostaria de ter algumas divulgações financeiras, mas, infelizmente.

[01:13] had some financial disclosures but alas I do not.
tinha algumas divulgações financeiras, mas, infelizmente, não tenho.

[01:15] I do not I would like to acknowledge several people.
eu não tenho, gostaria de agradecer a várias pessoas.

[01:18] would like to acknowledge several people who were kind enough to to share some.
gostaria de agradecer a várias pessoas que foram gentis o suficiente para compartilhar um pouco.

[01:21] who were kind enough to to share some content with me for this talk first and.
que foram gentis o suficiente para compartilhar algum conteúdo comigo para esta palestra, primeiramente e.

[01:23] content with me for this talk first and foremost Rick Wiggins and and Rick horns.
conteúdo comigo para esta palestra, primeiramente e acima de tudo Rick Wiggins e Rick Hornsberger.

[01:25] foremost Rick Wiggins and and Rick horns Berger both of whom over the years have.
acima de tudo Rick Wiggins e Rick Hornsberger, ambos que ao longo dos anos têm.

[01:27] Berger both of whom over the years have shared a lot of Education and learning.
Berger, ambos que ao longo dos anos compartilharam muita educação e aprendizado.

[01:29] shared a lot of Education and learning with me but have also provided some of.
compartilharam muito aprendizado e educação comigo, mas também forneceram parte.

[01:32] with me but have also provided some of the graphics as well as a couple of the.
comigo, mas também forneceram alguns dos gráficos, bem como alguns dos.

[01:35] the graphics as well as a couple of the cases that you'll find in this.
os gráficos, bem como alguns dos casos que você encontrará nesta.

[01:36] cases that you'll find in this presentation so thanks to both Rick and.
casos que você encontrará nesta apresentação, então obrigado a ambos Rick e.

[01:39] presentation so thanks to both Rick and Rick for for the kindness and sharing.
apresentação, então obrigado a ambos Rick e Rick pela gentileza e por compartilhar.

[01:40] Rick for for the kindness and sharing these over the years I'd also like I.
Rick pela gentileza e por compartilhar isso ao longo dos anos, eu também gostaria de.

[01:42] these over the years I'd also like I think Jim Milburn and Todd come both of.
isso ao longo dos anos, eu também gostaria de agradecer a Jim Milburn e Todd Come, ambos.

[01:46] think Jim Milburn and Todd come both of whom provided some additional content.
agradecer a Jim Milburn e Todd Come, ambos que forneceram algum conteúdo adicional.

[01:48] whom provided some additional content for this lecture as well and and you'll.
que forneceram algum conteúdo adicional para esta palestra também, e você.

[01:51] for this lecture as well and and you'll see that here in a few minutes so again.
para esta palestra também, e você verá isso aqui em alguns minutos, então novamente.

[01:53] see that here in a few minutes so again lots of parties can't take credit for.
verá isso aqui em alguns minutos, então novamente, muitas partes não podem levar o crédito por.

[01:55] lots of parties can't take credit for our everything that you're seeing here.
muitas partes não podem levar o crédito por tudo o que você está vendo aqui.

[01:57] our everything that you're seeing here in this talk but you know in the spirit.
tudo o que você está vendo aqui nesta palestra, mas você sabe, no espírito.

[01:59] in this talk but you know in the spirit of sharing this I do want to thank them.
nesta palestra, mas você sabe, no espírito de compartilhar isso, eu quero agradecê-los.

[02:02] of sharing this I do want to thank them for everything that they've done to help.
de compartilhar isso, eu quero agradecê-los por tudo o que eles fizeram para ajudar.

[02:04] for everything that they've done to help out with this as well.
por tudo o que eles fizeram para ajudar com isso também.

[02:06] out with this as well okay so let's get started.
Fora com isso também, ok, então vamos começar.

[02:09] okay so let's get started the infrahyoid net covers a lot of the infrahyoid net covers a lot of ground.
Ok, então vamos começar. A rede infra-hioide cobre muito, a rede infra-hioide cobre muito terreno.

[02:12] there are a lot of different spaces that are involved each of which contain multiple anatomic structures and for that reason there's really a lot of pathology that can occur here.
Existem muitos espaços diferentes envolvidos, cada um dos quais contém múltiplas estruturas anatômicas e, por essa razão, há realmente muita patologia que pode ocorrer aqui.

[02:19] in fact the thing that I think is most challenging but at the same time most interesting about the infrahyoid neck is just the diversity of pathologies that can occur here.
Na verdade, a coisa que eu acho mais desafiadora, mas ao mesmo tempo mais interessante sobre o pescoço infra-hioide, é apenas a diversidade de patologias que podem ocorrer aqui.

[02:28] so one of the key things really maybe the most important thing to take home from this talk is whenever you're approaching a generic lesion a generic Mass you name it whatever it is that you encounter in the neck try to figure out where it's coming from what is the space of origin where it's arising from because if you can do that that's immediately going to narrow down your differential diagnosis.
Então, uma das coisas chave, talvez a coisa mais importante para levar desta palestra é: sempre que você estiver abordando uma lesão genérica, uma massa genérica, chame do que for, que você encontrar no pescoço, tente descobrir de onde ela está vindo, qual é o espaço de origem de onde ela está surgindo, porque se você puder fazer isso, isso imediatamente vai estreitar seu diagnóstico diferencial.

[02:52] another thing to keep in mind if you see something that is extending between multiple spaces or if it's multi spatial or trans spatial think about congenital etiologies as well as aggressive ideologies things like infection or malignancy because those are the types.
Outra coisa a ter em mente é: se você vir algo que está se estendendo entre múltiplos espaços ou se for multiespacial ou transespacial, pense em etiologias congênitas, bem como em ideologias agressivas, como infecção ou malignidade, porque esses são os tipos.

[03:07] malignancy because those are the types of things that tend to cross those spatial boundaries.
malignidade porque esses são os tipos de coisas que tendem a cruzar essas fronteiras espaciais.

[03:12] Okay, so that was sort of the very brief introduction and there's a lot of content to cover here so I'm just going to dig right in.
Ok, então essa foi meio que a introdução muito breve e há muito conteúdo para cobrir aqui, então vou direto ao ponto.

[03:21] So first we're talking about a space-based differential diagnosis and run through some common and uncommon things that we encounter in the visceral space.
Então, primeiro estamos falando sobre um diagnóstico diferencial baseado em espaço e vamos repassar algumas coisas comuns e incomuns que encontramos no espaço visceral.

[03:29] Now as you look at the visceral space, as you can see here, there's a lot of contents within it and each of these will have different pathologies that can occur.
Agora, ao olhar para o espaço visceral, como você pode ver aqui, há muitos conteúdos dentro dele e cada um desses terá patologias diferentes que podem ocorrer.

[03:40] So I'm not gonna talk specifically about the larynx and I'm really only barely gonna dabble into the hypopharynx.
Então, não vou falar especificamente sobre a laringe e realmente vou apenas superficialmente abordar a hipofaringe.

[03:47] Those two are sort of an entity into themselves and it's sort of a separate talk that would cover all of the many things that can happen here.
Esses dois são meio que uma entidade em si mesmos e é meio que uma conversa separada que cobriria todas as muitas coisas que podem acontecer aqui.

[03:56] So we're not going to talk about those, but instead we're gonna start with the trachea.
Então, não vamos falar sobre esses, mas em vez disso, vamos começar com a traqueia.

[04:01] And the trachea is something that I think that head and neck radiologists tend not to embrace anywhere near the same way that the
E a traqueia é algo que eu acho que os radiologistas de cabeça e pescoço tendem a não abraçar nem de perto da mesma forma que os

[04:09] anywhere near the same way that the chest radiologists do and I think that chest radiologists do and I think that that's something that we really need to that's something that we really need to be thinking about and having at least a basic understanding of some of the pathologies that can occur here.
em perto da mesma forma que os radiologistas de tórax fazem e eu acho que os radiologistas de tórax fazem e eu acho que isso é algo que realmente precisamos pensar e ter pelo menos um entendimento básico de algumas das patologias que podem ocorrer aqui.

[04:19] so the first thing to talk about is tracheal stenosis and that's because it's such a common indication for imaging these patients will often present with dis Nia and I think that when I approach one of these cases some of the key things that I want to think about is am i dealing with a child or an adult because with a child you're thinking more commonly anyway of congenital things an adult much more common to be dealing with acquired etiologies.
então a primeira coisa a falar é estenose traqueal e isso porque é uma indicação tão comum para imagem que esses pacientes muitas vezes apresentarão dispneia e eu acho que quando eu abordo um desses casos, algumas das coisas chave que eu quero pensar é se estou lidando com uma criança ou um adulto porque com uma criança você está pensando mais comumente de qualquer forma em coisas congênitas, um adulto muito mais comum lidar com etiologias adquiridas.

[04:43] critically has the patient had prior surgery have they had a prior intubation was it a prolonged intubation or traumatic intubation when I look at it is this a short segment is it very focal or is it a long segment process and then importantly things to report would be how narrow does it get what's the narrowest diameter because that's something that the surgeons that the pulmonologist may want to know about and we're near dealing with a lesion a mass.
criticamente o paciente teve cirurgia prévia, eles tiveram intubação prévia, foi uma intubação prolongada ou intubação traumática, quando eu olho para isso, é um segmento curto, é muito focal ou é um processo de segmento longo e então, importantemente, as coisas a relatar seriam o quão estreito fica, qual o diâmetro mais estreito porque isso é algo que os cirurgiões, os pneumologistas podem querer saber e estamos perto de lidar com uma lesão, uma massa.

[05:12] we're near dealing with a lesion a mass you want to try to decipher am i dealing
estamos perto de lidar com uma lesão uma massa que você quer tentar decifrar estou lidando

[05:15] you want to try to decipher am i dealing with endo luminal obstruction something
você quer tentar decifrar estou lidando com obstrução endoluminal algo

[05:17] with endo luminal obstruction something that's contained within the trachea
com obstrução endoluminal algo que está contido dentro da traqueia

[05:19] that's contained within the trachea itself or is this extrinsic compression
que está contido na própria traqueia ou é esta compressão extrínseca

[05:21] itself or is this extrinsic compression something on the outside
própria ou é esta compressão extrínseca algo do lado de fora

[05:22] something on the outside smashing it down and then when you look
algo do lado de fora esmagando-a e então quando você olha

[05:25] smashing it down and then when you look at it you want to look and see does it
esmagando-a e então quando você olha para ela você quer olhar e ver se ela

[05:27] at it you want to look and see does it look like some sort of a smooth
para ela você quer olhar e ver se ela parece algum tipo de lisa

[05:29] look like some sort of a smooth contoured thing or is it something that
parece algo de contorno liso ou é algo que

[05:32] contoured thing or is it something that looks ratty and aggressive
de contorno ou é algo que parece feio e agressivo

[05:35] so when we're dealing acquired trachea
então quando estamos lidando com traqueia adquirida

[05:37] so when we're dealing acquired trachea lore subglottic stenosis as you can see
então quando estamos lidando com estenose traqueal adquirida lore subglótica como você pode ver

[05:40] lore subglottic stenosis as you can see on this slide there are a lot of
lore subglótica como você pode ver neste slide há muitas

[05:41] on this slide there are a lot of intrinsic causes but far and away the
neste slide há muitas causas intrínsecas mas de longe a

[05:44] intrinsic causes but far and away the most comic the most common intrinsic
causas intrínsecas mas de longe a mais cômica a mais comum intrínseca

[05:47] most comic the most common intrinsic cause of stenosis that I see relates to
a causa intrínseca mais cômica e mais comum de estenose que eu vejo está relacionada a

[05:50] cause of stenosis that I see relates to prior intubation and prior tracheostomy
causa de estenose que eu vejo está relacionada a intubação prévia e traqueostomia prévia

[05:52] prior intubation and prior tracheostomy but there's a lot of things and we'll
intubação prévia e traqueostomia prévia mas há muitas coisas e nós

[05:54] but there's a lot of things and we'll talk about some of them during the talk
mas há muitas coisas e falaremos sobre algumas delas durante a conversa

[05:55] talk about some of them during the talk as far as extrinsic causes in my
falaremos sobre algumas delas durante a conversa quanto a causas extrínsecas na minha

[05:59] as far as extrinsic causes in my experience here and in my shop the thing
quanto a causas extrínsecas na minha experiência aqui e no meu local a coisa

[06:01] experience here and in my shop the thing that I see most commonly are thyroid
experiência aqui e no meu local a coisa que eu vejo com mais frequência são tireóide

[06:04] that I see most commonly are thyroid lesions thyroid masses whether it's a
que eu vejo com mais frequência são lesões de tireóide massas de tireóide se é um

[06:07] lesions thyroid masses whether it's a goiter or a true malignancy that are
lesões massas de tireóide se é um bócio ou uma malignidade verdadeira que estão

[06:09] goiter or a true malignancy that are externally compressing it but again you
bócio ou uma malignidade verdadeira que estão comprimindo externamente mas novamente você

[06:12] externally compressing it but again you can see here there are lots of potential
comprimindo externamente mas novamente você pode ver aqui há muitas potenciais

[06:13] can see here there are lots of potential extrinsic causes of tracheal stenosis as extrinsic causes of tracheal stenosis as well
podemos ver aqui que há muitas causas extrínsecas potenciais de estenose traqueal como causas extrínsecas de estenose traqueal também

[06:18] well so this is an example of a tracheostomy related tracheal stenosis you can see related tracheal stenosis you can see where that yellow arrow is pointing
bem então este é um exemplo de estenose traqueal relacionada à traqueostomia você pode ver estenose traqueal relacionada você pode ver onde aquela seta amarela está apontando

[06:24] where that yellow arrow is pointing that's just just right sort of at and and maybe slightly below the level of
onde aquela seta amarela está apontando está bem ali mais ou menos e talvez um pouco abaixo do nível de

[06:31] where the I'm sorry right at and above the level of where the tracheostomy is entering
onde a desculpe bem ali e acima do nível onde a traqueostomia está entrando

[06:35] and you can see just how narrow that tracheal diameter is no compared to the more normal distal downstream caliber
e você pode ver o quão estreito é o diâmetro traqueal não em comparação com o calibre mais normal distal a jusante

[06:41] and you can see that's a really significant difference between those two
e você pode ver que essa é uma diferença realmente significativa entre os dois

[06:44] now you may say well it doesn't really matter he's had a tracheostomy tube in and in fact you're right they're protecting the airway now
agora você pode dizer bem não importa muito ele teve um tubo de traqueostomia e de fato você está certo eles estão protegendo as vias aéreas agora

[06:49] but let's say they want to get to the point where they're gonna take that tracheostomy out
mas digamos que eles querem chegar ao ponto em que vão remover essa traqueostomia

[06:54] they need to know about that stenosis because this is a patient that's going to get themselves into trouble because of that very tight stenosis related to the prior tracheostomy
eles precisam saber sobre essa estenose porque este é um paciente que vai se meter em problemas por causa dessa estenose muito apertada relacionada à traqueostomia anterior

[07:06] this is another patient this is a patient who previously had had a prolonged intubation and you can see that they have a very focal area where
este é outro paciente este é um paciente que anteriormente teve uma intubação prolongada e você pode ver que eles têm uma área muito focal onde

[07:14] that they have a very focal area where you have sort of a shouldering a narrowing of the trachea probably related to that prior prolonged intubation so again you want to find it you want to identify outlook for sort of that hourglass configuration in which you in this case have a very focal waist or very focal narrowing and report that tell them tell the surgeons tell the pulmonologist how long it extends over and what the sort of the nadir of the narrowing is
que eles têm uma área muito focal onde você tem uma espécie de ombro, um estreitamento da traqueia, provavelmente relacionado àquela intubação prolongada anterior, então, novamente, você quer encontrá-lo, você quer identificar a perspectiva daquela configuração de ampulheta em que você, neste caso, tem uma cintura muito focal ou um estreitamento muito focal e relate isso, diga a eles, diga aos cirurgiões, diga ao pneumologista o quanto ele se estende e qual é a espécie de nadir do estreitamento.

[07:41] next we've malignant trachea masses now fortunately primary tracheal tumors are quite rare we're talking literally something that's about a one-in-a-million diagnosis and of these squamous cell carcinoma is going to be the most common culprit followed by adenoid cystic carcinoma
em seguida, temos massas traqueais malignas. Agora, felizmente, os tumores traqueais primários são bastante raros. Estamos falando literalmente de algo que é um diagnóstico de um em um milhão e, destes, o carcinoma de células escamosas será o culpado mais comum, seguido pelo carcinoma cístico adenóide.

[07:57] now the imaging is quite limited in terms of trying to predict what the final histopathology is and that's okay these patients are going to need an indolent i'll by op c to figure it out that's not your job so I can't look at the imaging and say oh this is clearly a scam or this is an adenoid cystic you
Agora, a imagem é bastante limitada em termos de tentar prever qual é a histopatologia final e tudo bem. Esses pacientes precisarão de uma biópsia indolente para descobrir. Esse não é o seu trabalho, então não posso olhar para a imagem e dizer, oh, isso é claramente um golpe ou isso é um cístico adenóide, você

[08:15] scam or this is an adenoid cystic you can play the odds and say that scream is
golpe ou este é um cístico adenoide você pode jogar as probabilidades e dizer que o grito é

[08:17] can play the odds and say that scream is more likely but instead is the
pode jogar as probabilidades e dizer que o grito é mais provável, mas em vez disso é o

[08:19] more likely but instead is the radiologist your job is to look for
mais provável, mas em vez disso é o radiologista, seu trabalho é procurar

[08:22] radiologist your job is to look for invasion of surrounding structures look
radiologista, seu trabalho é procurar invasão das estruturas circundantes, procure

[08:24] invasion of surrounding structures look for invasion of those other visceral
invasão das estruturas circundantes, procure invasão dessas outras vísceras

[08:26] for invasion of those other visceral space structures that are in close
para invasão dessas outras estruturas do espaço visceral que estão próximas

[08:27] space structures that are in close proximity so
estruturas espaciais que estão em estreita proximidade, então

[08:29] proximity so this is a patient who had tracheal
proximidade, então este é um paciente que teve traqueal

[08:31] this is a patient who had tracheal squamous cell carcinoma you can see
este é um paciente que teve carcinoma de células escamosas traqueal, você pode ver

[08:33] squamous cell carcinoma you can see there's a mass on the left side and it's
carcinoma de células escamosas, você pode ver que há uma massa no lado esquerdo e está

[08:36] there's a mass on the left side and it's denoted here by the yellow arrow and
há uma massa no lado esquerdo e está indicada aqui pela seta amarela e

[08:39] denoted here by the yellow arrow and it's ugly its aggressive you can see
indicada aqui pela seta amarela e é feio, é agressivo, você pode ver

[08:41] it's ugly its aggressive you can see it's really markedly narrowing the
é feio, é agressivo, você pode ver que está realmente estreitando acentuadamente a

[08:42] it's really markedly narrowing the airway but if you look at the coronal
está realmente estreitando acentuadamente a via aérea, mas se você olhar para a coronal

[08:44] airway but if you look at the coronal image you can see importantly it does
via aérea, mas se você olhar para a imagem coronal, você pode ver, importante, que parece

[08:45] image you can see importantly it does look like it's extending out into the
imagem, você pode ver, importante, que parece estar se estendendo para os

[08:48] look like it's extending out into the surrounding soft tissues and probably
olhar como se estivesse se estendendo para os tecidos moles circundantes e provavelmente

[08:49] surrounding soft tissues and probably starting to invade the thyroid itself
tecidos moles circundantes e provavelmente começando a invadir a própria tireoide

[08:51] starting to invade the thyroid itself there's nothing that I can say on this
começando a invadir a própria tireoide, não há nada que eu possa dizer nesta

[08:53] there's nothing that I can say on this imaging that will tell me that this is
não há nada que eu possa dizer nesta imagem que me diga que isso é

[08:55] imaging that will tell me that this is certainly a squamous cell carcinoma that
imagem que me diga que isso é certamente um carcinoma de células escamosas que

[08:57] certainly a squamous cell carcinoma that just happens to be the most likely
certamente um carcinoma de células escamosas que por acaso é o mais provável

[08:59] just happens to be the most likely diagnosis based on the statistics
por acaso é o diagnóstico mais provável com base nas estatísticas

[09:02] diagnosis based on the statistics here's another patient with malignant
diagnóstico com base nas estatísticas, aqui está outro paciente com maligno

[09:04] here's another patient with malignant trachea mass this was an adenoids cystic
aqui está outro paciente com massa traqueal maligna, este foi um cístico adenoide

[09:07] trachea mass this was an adenoids cystic carcinoma again I can't look at this and
massa traqueal, este foi um carcinoma cístico adenoide novamente, não posso olhar para isso e

[09:09] carcinoma again I can't look at this and tell you that's what the diagnosis is
carcinoma novamente, não posso olhar para isso e dizer que esse é o diagnóstico

[09:10] tell you that's what the diagnosis is that's okay that's what the biopsy tells
dizer que esse é o diagnóstico, tudo bem, é o que a biópsia diz

[09:13] you but rather what I can do is look at
a você, mas em vez disso, o que posso fazer é olhar para

[09:15] you but rather what I can do is look at this and describe where the tumor is
você, mas em vez disso, o que posso fazer é olhar para isso e descrever onde o tumor está

[09:17] this and describe where the tumor is going how big is the tumor and in this case this is a nice example of how CT and MRI can be complimentary in staging disease
isso e descreve para onde o tumor está indo, quão grande é o tumor e, neste caso, este é um bom exemplo de como a TC e a RM podem ser complementares na estadiamento da doença

[09:27] we can tell them the CT yeah it looks like tumors getting out of the trachea MRI is much more specific in terms of telling us where it's going
podemos dizer a eles que a TC, sim, parece que os tumores estão saindo da traqueia, a RM é muito mais específica em termos de nos dizer para onde está indo

[09:32] we get that tissue contrast resolution superiority that helps us to better stage where the tumor is at
obtemos essa superioridade de resolução de contraste de tecido que nos ajuda a estadiar melhor onde o tumor está

[09:39] next diagnosis is relapsing polycondritis
o próximo diagnóstico é condrite recidivante

[09:42] this is a rare diagnosis and it's an autoimmune disorder in which patients have recurrent cartilage inflammation and eventually most commonly it leads to cartilaginous destruction
este é um diagnóstico raro e é uma doença autoimune na qual os pacientes têm inflamação recorrente da cartilagem e, eventualmente, o mais comum é que leve à destruição cartilaginosa

[09:54] it can be a very focal process or it can be a very diffuse process it can affect multiple different cartilages within the body and certainly the trachea is one of those structures that contains cartilaginous rings so it can be involved
pode ser um processo muito focal ou pode ser um processo muito difuso, pode afetar múltiplas cartilagens diferentes dentro do corpo e, certamente, a traqueia é uma dessas estruturas que contém anéis cartilaginosos, então pode ser envolvida

[10:08] now classically this involves the anterior and lateral tracheal walls or even then the airway
agora, classicamente, isso envolve as paredes traqueais anterior e lateral ou até mesmo a via aérea

[10:17] tracheal walls or even then the airway walls you can use the same application
paredes traqueais ou mesmo então as paredes das vias aéreas você pode usar a mesma aplicação

[10:19] walls you can use the same application down once you get below the clavicles
paredes você pode usar a mesma aplicação para baixo assim que você passar abaixo das clavículas

[10:22] down once you get below the clavicles into the chest but it has sparing of
para baixo assim que você passar abaixo das clavículas para o peito, mas tem poupação de

[10:24] into the chest but it has sparing of that posterior trachea yem brain or the
para o peito, mas tem poupação daquela traqueia posterior, cérebro de yem ou a

[10:27] that posterior trachea yem brain or the posterior airway membrane because that's
aquela traqueia posterior, cérebro de yem ou a membrana posterior da via aérea porque isso é

[10:29] posterior airway membrane because that's a non cartilaginous structure so as we
membrana posterior da via aérea porque isso é uma estrutura não cartilaginosa, então, à medida que

[10:31] a non cartilaginous structure so as we look at this case we can see sort of
uma estrutura não cartilaginosa, então, à medida que olhamos para este caso, podemos ver uma espécie de

[10:33] look at this case we can see sort of thickening and a little bit of
olhamos para este caso, podemos ver uma espécie de espessamento e um pouco de

[10:34] thickening and a little bit of irregularity of the walls of the trachea
espessamento e um pouco de irregularidade das paredes da traqueia

[10:36] irregularity of the walls of the trachea anteriorly and laterally but if you look
irregularidade das paredes da traqueia anteriormente e lateralmente, mas se você olhar

[10:39] anteriorly and laterally but if you look carefully you can see that this spare is
anteriormente e lateralmente, mas se você olhar atentamente, pode ver que esta poupa

[10:41] carefully you can see that this spare is that posterior wall or that posterior
atentamente, pode ver que esta poupa é aquela parede posterior ou aquela posterior

[10:43] that posterior wall or that posterior tracheal membrane
aquela parede posterior ou aquela membrana traqueal posterior

[10:45] tracheal membrane overtime the classic trajectory of this
membrana traqueal ao longo do tempo, a trajetória clássica disso

[10:48] overtime the classic trajectory of this is to lead to cartilage collapse and you
ao longo do tempo, a trajetória clássica disso é levar ao colapso da cartilagem e você

[10:52] is to lead to cartilage collapse and you can get really severe airway narrowing
é levar ao colapso da cartilagem e você pode ter um estreitamento muito grave das vias aéreas

[10:56] can get really severe airway narrowing as a result of this now sometimes and
pode ter um estreitamento muito grave das vias aéreas como resultado disso, agora às vezes e

[10:59] as a result of this now sometimes and this is quite rare sometimes you can
como resultado disso, agora às vezes e isso é bastante raro, às vezes você pode

[11:01] this is quite rare sometimes you can actually get enlargement of the
isso é bastante raro, às vezes você pode realmente ter um aumento do

[11:03] actually get enlargement of the cartilaginous structures due to that
realmente ter um aumento das estruturas cartilaginosas devido a isso

[11:05] cartilaginous structures due to that sort of chronic repetitive
estruturas cartilaginosas devido a essa espécie de repetitivo crônico

[11:07] sort of chronic repetitive chondral inflammation and this is such a
espécie de inflamação condral repetitiva crônica e este é um caso de

[11:11] chondral inflammation and this is such a case of that this is an atypical
inflamação condral e este é um caso de isso é uma

[11:13] case of that this is an atypical appearance of relapsing polycon Rytas
caso disso, esta é uma aparência atípica de policonrite recidivante

[11:15] appearance of relapsing polycon Rytas and what should really jump out at you
aparência de policonrite recidivante e o que realmente deveria chamar sua atenção

[11:17] and what should really jump out at you is you can see the image on the left on the axial CT.
e o que realmente deve chamar sua atenção é que você pode ver a imagem à esquerda na TC axial.

[11:19] look how thickened that thyroid cartilage is.
veja como essa cartilagem tireóidea está espessada.

[11:22] image on the right look at this cricoid cartilage just how thick and knobby this is.
imagem à direita, olhe para esta cartilagem cricóide, quão espessa e nodosa ela é.

[11:25] it's not getting destroyed but it's markedly enlarged.
não está sendo destruída, mas está acentuadamente aumentada.

[11:26] don't burn this into your mind as the typical appearance because more typically will see cartilaginous destruction over time.
não grave isso em sua mente como a aparência típica, porque mais tipicamente veremos destruição cartilaginosa ao longo do tempo.

[11:30] this happens to be one of those really oddball cases that resulted in cartilaginous enlargement.
este acontece de ser um daqueles casos realmente incomuns que resultaram em aumento cartilaginoso.

[11:34] and importantly really the critical thing here is when you have that cartilage getting that enlarged it can compromise the airway.
e importantemente, realmente a coisa crítica aqui é que quando você tem essa cartilagem ficando tão aumentada, ela pode comprometer a via aérea.

[11:41] so always be on the lookout for airway narrowing.
então esteja sempre atento ao estreitamento da via aérea.

[11:43] always be reporting that something that can look a little bit like this is amyloidosis.
sempre relate algo que pode parecer um pouco com isso, que é amiloidose.

[11:45] and this is a rare disorder.
e este é um distúrbio raro.

[11:48] it's of abnormal protein folding and it can be primary or secondary or localized or diffuse.
é de dobramento de proteína anormal e pode ser primário ou secundário ou localizado ou difuso.

[11:49] and when it involves the airway it's more commonly going to be the localized variety.
e quando envolve a via aérea, é mais comumente a variedade localizada.

[11:51] that that specifically is just
que especificamente é apenas

[12:17] variety that that specifically is just involving the airway but you can have involving the airway but you can have sort of the diffuse involvement or even sort of the diffuse involvement or even secondary amyloidosis resulting in secondary amyloidosis resulting in airway disease as well but this occurs airway disease as well but this occurs when you get deposition of the amyloid when you get deposition of the amyloid fibril proteins into otherwise normal fibril proteins into otherwise normal tissues and so it can be very diffuse it tissues and so it can be very diffuse it can be multifocal but importantly it can can be multifocal but importantly it can involve the posterior wall of the involve the posterior wall of the trachea and the posterior wall of the of trachea and the posterior wall of the of the Airways the smaller Airways in the the Airways the smaller Airways in the lung as well so that's sort of an lung as well so that's sort of an contour distinction to what we saw with contour distinction to what we saw with relapsing polycon gitis and it gives you relapsing polycon gitis and it gives you these submucosal masses so here we see these submucosal masses so here we see sort of that heaped up soft tissue along sort of that heaped up soft tissue along the posterior tracheal membrane the posterior tracheal membrane on this axial non-contrast CT imaging as on this axial non-contrast CT imaging as you can see right where that arrow is you can see right where that arrow is pointing it's associated with some pointing it's associated with some calcification as well so these calcification as well so these submucosal masses can be calcified if submucosal masses can be calcified if you do MRI they have a characteristic you do MRI they have a characteristic dark t2 signal so they're hypo intense dark t2 signal so they're hypo intense on t2 that's an important thing to keep on t2 that's an important thing to keep in mind if you give contrast on MRI you
variedade que que especificamente envolve apenas as vias aéreas, mas você pode ter envolvimento das vias aéreas, mas você pode ter um envolvimento difuso ou até mesmo um envolvimento difuso ou até mesmo amiloidose secundária resultando em amiloidose secundária resultando em doença das vias aéreas também, mas isso ocorre doença das vias aéreas também, mas isso ocorre quando há deposição da amiloide quando há deposição das proteínas fibrilares de amiloide em tecidos normalmente normais e, portanto, pode ser muito difuso, pode ser multifocal, mas, importante, pode envolver a parede posterior da parede posterior da traqueia e a parede posterior das vias aéreas, as vias aéreas menores no pulmão também, então essa é uma distinção de contorno do que vimos com a poligondrite recidivante e isso lhe dá essas massas submucosas, então aqui vemos essas massas submucosas, então vemos esse acúmulo de tecido mole ao longo da membrana traqueal posterior nesta imagem de TC axial sem contraste, como você pode ver bem onde a seta está apontando, está associado a alguma calcificação também, então essas massas submucosas podem ser calcificadas se você fizer ressonância magnética, elas têm um sinal T2 escuro característico, então são hipointensas em T2, isso é algo importante a se ter em mente se você administrar contraste na ressonância magnética você

[13:19] in mind if you give contrast on MRI you may have enhancement as well.
em mente se você der contraste na ressonância magnética, você também pode ter realce.

[13:22] may have enhancement as well this is another patient who had tracheal.
pode ter realce também este é outro paciente que teve traqueal.

[13:24] this is another patient who had tracheal amyloidosis this is path proven and you.
este é outro paciente que teve amiloidose traqueal esta é comprovada patologicamente e você.

[13:27] amyloidosis this is path proven and you can see that this is instead of being.
amiloidose esta é comprovada patologicamente e você pode ver que isto é em vez de ser.

[13:29] can see that this is instead of being more of a sort of a smooth diffuse.
pode ver que isto é em vez de ser mais de um tipo de difuso liso.

[13:31] more of a sort of a smooth diffuse infiltrating soft tissue this is sort of.
mais de um tipo de tecido mole infiltrativo difuso liso este é um tipo de.

[13:33] infiltrating soft tissue this is sort of a multi nodular appearance but as you.
tecido mole infiltrativo este é um tipo de aparência multinodular mas como você.

[13:36] a multi nodular appearance but as you look this is involving sort of the.
uma aparência multinodular mas como você olha isto está envolvendo o tipo de.

[13:39] look this is involving sort of the posterior and posterolateral walls of.
olha isto está envolvendo o tipo de as paredes posterior e posterolateral de.

[13:41] posterior and posterolateral walls of the cervical trachea and it's multifocal.
paredes posterior e posterolateral da traqueia cervical e é multifocal.

[13:43] the cervical trachea and it's multifocal sort of heaped-up submucosal masses and.
a traqueia cervical e é multifocal tipo de massas submucosas empilhadas e.

[13:47] sort of heaped-up submucosal masses and you can see if you look carefully.
tipo de massas submucosas empilhadas e você pode ver se você olhar atentamente.

[13:49] you can see if you look carefully there's a little bit of calcification.
você pode ver se você olhar atentamente há um pouco de calcificação.

[13:50] there's a little bit of calcification associated with this as well so the.
há um pouco de calcificação associada a isto também então a.

[13:53] associated with this as well so the calcification doesn't give you a ton of.
associada a isto também então a calcificação não lhe dá muita.

[13:54] calcification doesn't give you a ton of specificity but it is an important.
calcificação não lhe dá muita especificidade mas é um importante.

[13:56] specificity but it is an important finding to be looking for and recognize.
especificidade mas é um achado importante a ser procurado e reconhecer.

[13:58] finding to be looking for and recognize that tracheal amyloidosis can in fact.
achado a ser procurado e reconhecer que a amiloidose traqueal pode de fato.

[14:00] that tracheal amyloidosis can in fact have calcification now interestingly.
que a amiloidose traqueal pode de fato ter calcificação agora interessantemente.

[14:03] have calcification now interestingly it's something that if you you fdg-pet.
ter calcificação agora interessantemente é algo que se você você fdg-pet.

[14:06] it's something that if you you fdg-pet you they also see some hypermetabolism.
é algo que se você você fdg-pet você eles também veem algum hipermetabolismo.

[14:08] you they also see some hypermetabolism with it so therefore it can potentially.
você eles também veem algum hipermetabolismo com isso então portanto pode potencialmente.

[14:10] with it so therefore it can potentially mimic malignancy as well so sort of keep.
com isso então portanto pode potencialmente mimetizar malignidade também então tipo de manter.

[14:13] mimic malignancy as well so sort of keep that in mind that tracheal amyloidosis.
mimetizar malignidade também então tipo de manter isso em mente que a amiloidose traqueal.

[14:15] that in mind that tracheal amyloidosis can be a bit of a diagnosis that that.
isso em mente que a amiloidose traqueal pode ser um pouco de um diagnóstico que que.

[14:17] can be a bit of a diagnosis that that acts as a mimic and can cause some.
pode ser um pouco de um diagnóstico que que age como um mímico e pode causar alguma.

[14:20] acts as a mimic and can cause some consternation.
age como um mímico e pode causar alguma consternação.

[14:22] Next we have granulomatosis with.
Em seguida, temos a granulomatose com.

[14:25] Next we have granulomatosis with polyangiitis and this is an autoimmune.
Em seguida, temos a granulomatose com poliangiite e esta é uma autoimune.

[14:26] polyangiitis and this is an autoimmune necrotizing granulomatous vasculitis and.
poliangiite e esta é uma vasculite necrosante granulomatosa autoimune e.

[14:29] necrotizing granulomatous vasculitis and these patients will have anti neutrophil.
vasculite necrosante granulomatosa e esses pacientes terão anti neutrófilos.

[14:31] these patients will have anti neutrophil cytoplasmic antibodies or ANCA and we.
esses pacientes terão anticorpos citoplasmáticos anti-neutrófilos ou ANCA e nós.

[14:34] cytoplasmic antibodies or ANCA and we always think of it in the head and neck.
anticorpos citoplasmáticos ou ANCA e nós sempre pensamos nisso na área de cabeça e pescoço.

[14:36] always think of it in the head and neck world as being a sign of nasal process.
sempre pensamos nisso no mundo da cabeça e pescoço como um sinal de processo nasal.

[14:38] world as being a sign of nasal process and it is I mean that's the most common.
mundo como um sinal de processo nasal e é, quero dizer, essa é a apresentação mais comum.

[14:40] presentation but it can involve any of the Airways and the trachea is no.
apresentação, mas pode envolver qualquer uma das vias aéreas e a traqueia não é exceção.

[14:42] the Airways and the trachea is no exception these patients will get.
as vias aéreas e a traqueia não é exceção, esses pacientes terão.

[14:44] exception these patients will get cartilaginous erosion they can even have.
exceção, esses pacientes terão erosão cartilaginosa, eles podem até ter.

[14:47] cartilaginous erosion they can even have like these mass like soft tissue.
erosão cartilaginosa, eles podem até ter como esses espessamentos de tecido mole semelhantes a massas.

[14:49] like these mass like soft tissue thickened areas along the Airways so.
semelhantes a massas ao longo das vias aéreas, então.

[14:51] thickened areas along the Airways so here as you can see on the left side of.
áreas espessadas ao longo das vias aéreas, então aqui, como você pode ver no lado esquerdo da.

[14:53] here as you can see on the left side of the proximal cervical trachea we see.
a traqueia cervical proximal, vemos.

[14:55] the proximal cervical trachea we see sort of that heaped up in what was an.
uma espécie de acúmulo no que era um componente de tecido mole realçador.

[14:57] sort of that heaped up in what was an enhancing soft tissue component has a.
tem um pouco de alteração dentro dele também.

[14:59] enhancing soft tissue component has a little bit of alteration within it as.
se eu visse isso, teria que considerar.

[15:01] little bit of alteration within it as well if I saw this I would have to lead.
malignidade, quero dizer, você tem que levantar isso como uma possibilidade aqui.

[15:03] well if I saw this I would have to lead with malignancy I mean you have to bring.
e isso também precisará de biópsia para discernir a diferença.

[15:06] with malignancy I mean you have to bring that up as a as a potential here and.
agora é um caso em questão onde você quer olhar outras imagens.

[15:09] that up as a as a potential here and this is going to need biopsied too to.
se eles tiverem sinais de envolvimento nasal, certamente pensaremos sobre.

[15:10] this is going to need biopsied too to discern the difference now it's a case.
agora é um caso em questão onde você quer olhar outras imagens.

[15:13] discern the difference now it's a case in point where you want to look at other.
se eles tiverem sinais de envolvimento nasal, certamente pensaremos sobre.

[15:16] in point where you want to look at other imaging if they have sign of nasal.
agora é um caso em questão onde você quer olhar outras imagens.

[15:18] imaging if they have sign of nasal involvement certainly be thinking about.
se eles tiverem sinais de envolvimento nasal, certamente pensaremos sobre.

[15:19] involvement certainly be thinking about.
envolvimento, certamente pensaremos sobre.

[15:21] involvement certainly be thinking about granular granulomatosis with
o envolvimento certamente pensaremos em granulomatose com

[15:23] granular granulomatosis with polyangiitis but it certainly can mimic
granulomatose com poliangeíte, mas certamente pode mimetizar

[15:27] polyangiitis but it certainly can mimic malignancy as well and that's something
poliangeíte, mas certamente pode mimetizar malignidade também, e isso é algo

[15:28] malignancy as well and that's something that you need to consider
malignidade também, e isso é algo que você precisa considerar

[15:32] next is something that's benign and
o próximo é algo benigno e

[15:34] next is something that's benign and something that we see quite commonly
o próximo é algo benigno e algo que vemos com bastante frequência

[15:35] something that we see quite commonly this is a tracheal diverticulum this is
algo que vemos com bastante frequência, este é um divertículo traqueal, este é

[15:38] this is a tracheal diverticulum this is simply mucosa herniation through a
este é um divertículo traqueal, esta é simplesmente uma hérnia de mucosa através de um

[15:40] simply mucosa herniation through a defect in the tracheal wall
simplesmente uma hérnia de mucosa através de um defeito na parede traqueal

[15:42] defect in the tracheal wall you can see right here we sort of have
defeito na parede traqueal, você pode ver aqui, nós meio que temos

[15:44] you can see right here we sort of have this this air density structure sitting
você pode ver aqui, nós meio que temos esta estrutura de densidade de ar sentada

[15:49] this this air density structure sitting to the right side of the trachea these
esta estrutura de densidade de ar sentada no lado direito da traqueia, estes

[15:51] to the right side of the trachea these are usually incidental findings they
no lado direito da traqueia, estes são geralmente achados incidentais, eles

[15:52] are usually incidental findings they usually are quite small they're single
são geralmente achados incidentais, geralmente são bem pequenos, são únicos

[15:55] usually are quite small they're single sometimes though they can have sort of a
geralmente são bem pequenos, são únicos, às vezes, no entanto, podem ter uma aparência

[15:56] sometimes though they can have sort of a larger multilocular appearance like this
às vezes, no entanto, podem ter uma aparência multilocular maior como esta

[15:58] larger multilocular appearance like this one I showed this just because it's such
aparência multilocular maior como esta, eu mostrei esta apenas porque é um exemplo tão

[16:00] one I showed this just because it's such a nice example to drive home the point
um exemplo tão bom para reforçar o ponto

[16:02] a nice example to drive home the point of what they look like perhaps a little
de como eles se parecem, talvez um pouco

[16:03] of what they look like perhaps a little bit more exaggerated than we typically
um pouco mais exagerado do que normalmente

[16:05] bit more exaggerated than we typically see and these are usually on the right
vemos, e estes geralmente estão no lado direito

[16:07] see and these are usually on the right side I have not a clue why but you'll
vemos, e estes geralmente estão no lado direito, eu não tenho a menor ideia do porquê, mas você

[16:10] side I have not a clue why but you'll find that yes you can have them
lado, eu não tenho a menor ideia do porquê, mas você descobrirá que sim, você pode tê-los

[16:11] find that yes you can have them bilaterally yes you can have them on the
descobrirá que sim, você pode tê-los bilateralmente, sim, você pode tê-los no

[16:13] bilaterally yes you can have them on the left side but most commonly you'll see
lado esquerdo, mas mais comumente você verá

[16:15] left side but most commonly you'll see it on the right side one thing that I do
lado esquerdo, mas mais comumente você verá no lado direito, uma coisa que eu

[16:17] it on the right side one thing that I do think is an important discriminator is
no lado direito, uma coisa que eu acho que é um discriminador importante é

[16:19] think is an important discriminator is look for an air fluid level these should
acho que é um discriminador importante é procurar um nível ar-líquido, estes devem

[16:23] look for an air fluid level these should not have an air fluid level I repeat not have an air fluid level I repeat these should not have an air fluid level
procure um nível de ar-líquido, estes não devem ter um nível de ar-líquido, repito, não devem ter um nível de ar-líquido, repito, estes não devem ter um nível de ar-líquido

[16:28] these should not have an air fluid level if you see an air fluid level be thinking about esophageal diverticula
estes não devem ter um nível de ar-líquido, se você vir um nível de ar-líquido, pense em divertículos esofágicos

[16:32] thinking about esophageal diverticula and and that is sort of my segue into discussing
pensando em divertículos esofágicos e e essa é meio que a minha deixa para discutir

[16:35] that is sort of my segue into discussing the esophagus
essa é meio que a minha deixa para discutir o esôfago

[16:38] the esophagus so we're gonna start with the bad boy esophageal carcinoma and you probably don't need me to tell you this if you've done radiology for any time at all but
o esôfago, então vamos começar com o vilão, o carcinoma esofágico, e você provavelmente não precisa que eu lhe diga isso se você trabalha com radiologia há algum tempo, mas

[16:46] done radiology for any time at all but cross-sectional imaging is not great for evaluating for esophageal carcinoma it just simply isn't
trabalha com radiologia há algum tempo, mas a imagem transversal não é ótima para avaliar o carcinoma esofágico, simplesmente não é

[16:51] this is a diagnosis that really we rely most heavily on endoscopy in this day and age certainly
este é um diagnóstico em que realmente confiamos mais na endoscopia nos dias de hoje, certamente

[16:56] endoscopy in this day and age certainly esophagram ZAR are useful you can pick them up on esophagram in this case you can see sort of that classic apple core appearance and so yes be able to recognize these on Asafa grams they're oftentimes much more subtle than what I'm showing here in this example but in general while you can't see it on cross-sectional imaging it's not our best modality for looking what you may see on the cross-sectional studies like CT would be thickening of the wall of
endoscopia nos dias de hoje, certamente os esofagogramas são úteis, você pode identificá-los no esofagograma, neste caso, você pode ver meio que aquela aparência clássica de anel de maçã, e então sim, ser capaz de reconhecer isso em esofagogramas, eles são muitas vezes muito mais sutis do que o que estou mostrando aqui neste exemplo, mas em geral, embora você não possa vê-lo na imagem transversal, não é nossa melhor modalidade para olhar o que você pode ver nos estudos transversais como a TC seria o espessamento da parede de

[17:24] CT would be thickening of the wall of the esophagus oftentimes looking a bit smudgy or ill-defined but really where I think the important role is for those of us doing CT imaging is to look for things that upstage your disease you're looking for invasion of surrounding structures in the visceral space as well as looking for metastatic adeno ethey so just to show you how challenging it can be on CT imaging here we see this relatively short segment of the distal cervical esophagus in which the wall is just a little bit thick in just a little bit smudgy obviously much easier to see on this fdg-pet where you can see that it's markedly hypermetabolic this was path proven esophageal carcinoma
A TC seria o espessamento da parede do esôfago, muitas vezes parecendo um pouco esbatido ou mal definido, mas realmente onde acho que o papel importante é para aqueles de nós que fazem exames de TC é procurar coisas que agravem a sua doença, você está procurando invasão de estruturas circundantes no espaço visceral, bem como procurando adeno ethey metastático, então, apenas para mostrar o quão desafiador pode ser em exames de TC, aqui vemos este segmento relativamente curto do esôfago cervical distal em que a parede está apenas um pouco espessa e um pouco esbatida, obviamente muito mais fácil de ver neste FDG-PET onde você pode ver que é marcadamente hipermetabólico, isso foi carcinoma esofágico comprovado por patologia.

[18:08] I mentioned esophageal diverticula before now we're gonna talk a little bit more in depth about them you can have true diverticula which contain all of the layers of the wall or you can have false dye particular pseudo diverticulum and that contains the mucosa and submucosa that herniates through a defect in the
Mencionei divertículos esofágicos antes, agora vamos falar um pouco mais a fundo sobre eles, você pode ter divertículos verdadeiros que contêm todas as camadas da parede ou você pode ter falsos divertículos, pseudo divertículo, e isso contém a mucosa e a submucosa que herniam através de um defeito na.

[18:26] that herniates through a defect in the muscularis layer so a true diverticulum
que hernia através de um defeito na camada muscular, então um divertículo verdadeiro

[18:28] muscularis layer so a true diverticulum has all of those layers the false
camada muscular, então um divertículo verdadeiro tem todas essas camadas, o falso

[18:30] has all of those layers the false diverticulum lacks the muscularis
tem todas essas camadas, o divertículo falso carece da muscular

[18:32] diverticulum lacks the muscularis because the mucosa and submucosa
divertículo carece da muscular porque a mucosa e a submucosa

[18:34] because the mucosa and submucosa herniate through it
porque a mucosa e a submucosa hernias através dele

[18:36] herniate through it and the things that we oftentimes refer
hernias através dele e as coisas que frequentemente nos referimos

[18:39] and the things that we oftentimes refer to as esophageal diverticula such as
e as coisas que frequentemente nos referimos como divertículos esofágicos, como

[18:41] to as esophageal diverticula such as zinc or diverticula or Achille and
a divertículos esofágicos, como divertículos de zinco ou ou Achille e

[18:43] zinc or diverticula or Achille and jameson those are actually a pseudo
divertículos de zinco ou ou Achille e jameson, esses são na verdade um pseudo

[18:45] jameson those are actually a pseudo diverticula
jameson, esses são na verdade pseudo divertículos

[18:46] diverticula you can also classify esophageal
divertículos, você também pode classificar esofágicos

[18:49] you can also classify esophageal diverticula as being traction or Polzin
você também pode classificar divertículos esofágicos como sendo de tração ou Polzin

[18:52] diverticula as being traction or Polzin with the traction diverticulum due to
divertículos como sendo de tração ou Polzin, com o divertículo de tração devido a

[18:54] with the traction diverticulum due to extrinsic pulling on the wall of the
com o divertículo de tração devido a puxões extrínsecos na parede do

[18:57] extrinsic pulling on the wall of the esophagus and opposing diverticulum is
puxões extrínsecos na parede do esôfago e o divertículo oposto é

[19:00] esophagus and opposing diverticulum is due to intraluminal pushing causing that
esôfago e o divertículo oposto é devido a empurrões intraluminais causando essa

[19:02] due to intraluminal pushing causing that protrusion I
devido a empurrões intraluminais causando essa protrusão eu

[19:04] protrusion I said I wasn't going to talk about the
protrusão eu disse que não ia falar sobre a

[19:06] said I wasn't going to talk about the hypopharynx
disse que não ia falar sobre a hipofaringe

[19:07] hypopharynx that's a slight lie that I that I told
hipofaringe, essa é uma pequena mentira que eu que eu contei

[19:10] that's a slight lie that I that I told you I am going to talk about the
essa é uma pequena mentira que eu que eu contei a você, eu vou falar sobre a

[19:12] you I am going to talk about the hypopharynx here but sort of lump it
você, eu vou falar sobre a hipofaringe aqui, mas meio que agrupá-la

[19:14] hypopharynx here but sort of lump it under the esophagus just because these
hipofaringe aqui, mas meio que agrupá-la sob o esôfago apenas porque estas

[19:16] under the esophagus just because these are such closely related
sob o esôfago apenas porque estas são entidades tão intimamente relacionadas

[19:18] are such closely related entities and so we'll talk about
são entidades tão intimamente relacionadas e então falaremos sobre

[19:20] entities and so we'll talk about hypopharyngeal diverticulum and this
entidades e então falaremos sobre divertículo hipofaríngeo e este

[19:23] hypopharyngeal diverticulum and this goes by the eponym of a zinc or
divertículo hipofaríngeo e este é conhecido pelo epônimo de um zinco ou

[19:25] goes by the eponym of a zinc or diverticulum this is a technically a
é conhecido pelo epônimo de um divertículo de zinco ou, tecnicamente, é um

[19:27] diverticulum this is a technically a Polzin pseudo diverticulum in which you
divertículo este é tecnicamente um pseudo divertículo de Polzin no qual você

[19:29] Polzin pseudo diverticulum in which you have mucosa that herniates above the
pseudo divertículo de Polzin no qual você tem mucosa que hernia acima do

[19:32] have mucosa that herniates above the level of the cricopharyngeal usually at
tem mucosa que hernia acima do nível do cricofaríngeo geralmente em

[19:35] level of the cricopharyngeal usually at about c5 c6 so you can see here in this
nível do cricofaríngeo geralmente em cerca de c5 c6 então você pode ver aqui neste

[19:37] about c5 c6 so you can see here in this diagram we've got our yellow arrow
cerca de c5 c6 então você pode ver aqui neste diagrama temos nossa seta amarela

[19:39] diagram we've got our yellow arrow pointing at this zinc ER or
diagrama temos nossa seta amarela apontando para este divertículo faringoesofágico ou

[19:41] pointing at this zinc ER or hypopharyngeal diverticulum where it's
apontando para este divertículo faringoesofágico ou hipofaríngeo onde está

[19:43] hypopharyngeal diverticulum where it's herniating out through the through a
divertículo hipofaríngeo onde está herniando através de um

[19:46] herniating out through the through a defect just above the Crego fringes and
herniando através de um defeito logo acima das franjas de Crego e

[19:48] defect just above the Crego fringes and this is associated with esophageal
defeito logo acima das franjas de Crego e isso está associado a disfagia esofágica

[19:50] this is associated with esophageal dismal tea
isso está associado a disfagia esofágica

[19:52] dismal tea typically it's going to involve the
disfagia tipicamente envolverá a

[19:53] typically it's going to involve the midline posterior wall of the esophagus
tipicamente envolverá a parede posterior da linha média do esôfago

[19:55] midline posterior wall of the esophagus but it may extend off to the left side
parede posterior da linha média do esôfago, mas pode se estender para o lado esquerdo

[19:57] but it may extend off to the left side or more commonly to the left side when
mas pode se estender para o lado esquerdo ou mais comumente para o lado esquerdo quando

[19:59] or more commonly to the left side when they get larger but again I want to
ou mais comumente para o lado esquerdo quando ficam maiores, mas novamente quero

[20:01] they get larger but again I want to stress the importance look for that air
ficam maiores, mas novamente quero enfatizar a importância, procure por aquele ar

[20:03] stress the importance look for that air fluid level that really should help you
enfatizar a importância, procure por aquele nível de ar e líquido que realmente deve ajudá-lo

[20:06] fluid level that really should help you to recognize that you're dealing with
nível de ar e líquido que realmente deve ajudá-lo a reconhecer que você está lidando com

[20:07] to recognize that you're dealing with something that's containing contents of
a reconhecer que você está lidando com algo que contém conteúdo

[20:09] something that's containing contents of the gut or the digestive tract and these
algo que contém conteúdo do intestino ou do trato digestivo e estes

[20:13] the gut or the digestive tract and these are associated with dysphasia as well as
o intestino ou o trato digestivo e estes estão associados à disfagia, bem como

[20:15] are associated with dysphasia as well as an increased risk of aspiration
estão associados à disfagia, bem como a um risco aumentado de aspiração

[20:18] an increased risk of aspiration so here's an example on an oblique
um risco aumentado de aspiração, então aqui está um exemplo em uma

[20:20] so here's an example on an oblique barium esophagram you can see that fluid
então aqui está um exemplo em uma esofagografia baritada oblíqua, você pode ver aquele fluido

[20:23] barium esophagram you can see that fluid and barium and gas contained within this
esofagografia baritada, você pode ver aquele fluido e bário e gás contidos dentro deste

[20:25] and barium and gas contained within this hypopharyngeal diverticulum you can sort
e bário e gás contidos dentro deste divertículo hipofaríngeo você pode classificar

[20:27] hypopharyngeal diverticulum you can sort of see that slip

[20:29] of see that slip down at the bottom of it that is sort of

[20:34] down at the bottom of it that is sort of the imprint at the level of the

[20:35] the imprint at the level of the cricopharyngeal

[20:36] cricopharyngeal but then on the cross-sectional the

[20:39] but then on the cross-sectional the axial CT that we're looking here you can

[20:42] axial CT that we're looking here you can see that really large

[20:44] see that really large zinc or diverticulum containing an air

[20:46] zinc or diverticulum containing an air fluid level denoted again by the yellow

[20:48] fluid level denoted again by the yellow arrow

[20:51] now these are different than Killian

[20:53] now these are different than Killian Jamison diverticula Killian Jamison

[20:56] Jamison diverticula Killian Jamison diverticulum is is also a pole j'en

[20:59] diverticulum is is also a pole j'en pseudo diverticulum

[21:01] pseudo diverticulum but this occurs below the level of the

[21:04] but this occurs below the level of the cricopharyngeal so this is

[21:08] cricopharyngeal so this is a herniation that protrudes out into

[21:11] a herniation that protrudes out into what's called the Killian jamison space

[21:13] what's called the Killian jamison space and i honest to god I hate eponyms I

[21:16] and i honest to god I hate eponyms I could not find a good nun eponymous term

[21:18] could not find a good nun eponymous term to use for a Killian Jamison

[21:20] to use for a Killian Jamison diverticulum or this space but it is

[21:23] diverticulum or this space but it is important especially for the residents

[21:25] important especially for the residents out there to recognize what sort of

[21:28] out there to recognize what sort of makes up this Killian Jamison space and

[21:32] makes up this Killian Jamison space and it's defined superiorly by the

[21:34] it's defined superiorly by the cricopharyngeal so it's that's going to

[21:36] cricopharyngeal so it's that's going to be sort of a superior border of it

[21:38] be sort of a superior border of it anteriorly it's going to be made up of

[21:40] anteriorly it's going to be made up of the cricoid cartilage and then the it's

[21:44] the cricoid cartilage and then the it's a triangle so the third side is going to

[21:46] a triangle so the third side is going to be the esophageal suspensory ligament

[21:48] be the esophageal suspensory ligament which sort of sits in fro immediately

[21:50] which sort of sits in fro immediately these more commonly occur on the left

[21:52] these more commonly occur on the left side than on the right side and these

[21:54] side than on the right side and these protrusions can a pooch out along the

[21:56] protrusions can a pooch out along the anterolateral wall of the esophagus

[21:59] anterolateral wall of the esophagus rather than the the posterior midline

[22:01] rather than the the posterior midline wall like the the zinc ER the

[22:03] wall like the the zinc ER the hypopharyngeal diverticulum but again

[22:06] hypopharyngeal diverticulum but again look for the air fluid level I think

[22:08] look for the air fluid level I think that's a helpful feature to tell you

[22:09] that's a helpful feature to tell you you're dealing with gut contents and

[22:12] you're dealing with gut contents and then these patients are oftentimes

[22:14] then these patients are oftentimes asymptomatic so this is frequently more

[22:17] asymptomatic so this is frequently more of an incidental finding than a zinc or

[22:19] of an incidental finding than a zinc or diverticulum

[22:21] diverticulum you can also have lateral esophageal

[22:24] you can also have lateral esophageal diverticula and these are not exactly

[22:27] diverticula and these are not exactly the same as the killing and Jameson

[22:29] the same as the killing and Jameson because they don't come out through the

[22:30] because they don't come out through the the true killing jameson space but you

[22:32] the true killing jameson space but you can have them occur really anywhere

[22:33] can have them occur really anywhere along the course of the esophagus and

[22:35] along the course of the esophagus and here you can see one on this barium

[22:37] here you can see one on this barium esophagram it's it's partially a

[22:39] esophagram it's it's partially a pacified st. patient just to sort of

[22:41] pacified st. patient just to sort of give you the coronal CT correlate we can

[22:44] give you the coronal CT correlate we can see this really large diverticula

[22:47] see this really large diverticula mooching out of the right lateral side

[22:49] mooching out of the right lateral side of the esophagus and you can see that

[22:51] of the esophagus and you can see that debris contained within it

[22:55] the next important anatomic structure

[22:57] the next important anatomic structure that it lives in the visceral space is

[22:59] that it lives in the visceral space is the recurrent laryngeal nerve and this

[23:01] the recurrent laryngeal nerve and this sort of warrants a little bit of a

[23:03] sort of warrants a little bit of a sidebar discussion

[23:05] sidebar discussion so where does it live within the

[23:08] so where does it live within the visceral space what lives within the

[23:10] visceral space what lives within the tracheal esophageal groove bilaterally

[23:12] tracheal esophageal groove bilaterally so here these white arrows are pointing

[23:14] so here these white arrows are pointing at the recurrent laryngeal nerves and

[23:16] at the recurrent laryngeal nerves and it's important to know the course of the

[23:19] it's important to know the course of the recurrent laryngeal nerve so this is

[23:23] recurrent laryngeal nerve so this is sort of a branch off of the vagus nerve

[23:26] sort of a branch off of the vagus nerve and in this diagram we're looking sort

[23:28] and in this diagram we're looking sort of from the back looking forward and we

[23:31] of from the back looking forward and we know that we're looking from the back

[23:32] know that we're looking from the back forward because you can see the thyroid

[23:33] forward because you can see the thyroid with the parathyroid the four

[23:36] with the parathyroid the four parathyroid glands so we know we're

[23:38] parathyroid glands so we know we're looking at the back side of things so

[23:40] looking at the back side of things so what's on the image on the left

[23:45] what's on the image on the left the I'm sorry the the right side of the

[23:47] the I'm sorry the the right side of the image

[23:48] image corresponds with the patient's right

[23:50] corresponds with the patient's right side sort of by radiology definitions

[23:54] side sort of by radiology definitions here so the bottom line is follow along

[23:56] here so the bottom line is follow along the branches of the vagus nerve so

[23:58] the branches of the vagus nerve so you're gonna work your way down the

[23:59] you're gonna work your way down the carotid space on the left side here

[24:03] carotid space on the left side here denoted by the white arrow image left

[24:05] denoted by the white arrow image left patients true left because again we're

[24:07] patients true left because again we're looking from the back you need to look

[24:09] looking from the back you need to look all the way down to the aorta pulmonary

[24:10] all the way down to the aorta pulmonary window which is where that branch comes

[24:13] window which is where that branch comes off and then it's gonna work its way

[24:15] off and then it's gonna work its way back north and the tricky esophageal

[24:17] back north and the tricky esophageal groove on the patient's right side here

[24:20] groove on the patient's right side here shown on image right you can see that it

[24:22] shown on image right you can see that it loops under the subclavian artery before

[24:24] loops under the subclavian artery before recurring up that trachea esophageal

[24:26] recurring up that trachea esophageal groove and the critically important

[24:29] groove and the critically important thing to know about the recurrent

[24:31] thing to know about the recurrent laryngeal nerve is that it innervates

[24:32] laryngeal nerve is that it innervates the intrinsic muscle of the larynx with

[24:35] the intrinsic muscle of the larynx with the exception of the cricothyroid

[24:39] so as we look here

[24:42] so as we look here the question is which side is abnormal

[24:45] the question is which side is abnormal we have an axial fused fdg-pet CT

[24:48] we have an axial fused fdg-pet CT so let's run through the imaging

[24:50] so let's run through the imaging findings we've got marked increased

[24:52] findings we've got marked increased metabolism here within the right true

[24:55] metabolism here within the right true vocal fold

[24:57] vocal fold we've got our cricoarytenoid here also

[24:59] we've got our cricoarytenoid here also shows FDG uptake so as the right side

[25:02] shows FDG uptake so as the right side abnormal or as the left side well look

[25:04] abnormal or as the left side well look at the left side

[25:05] at the left side here's our true vocal fold really no

[25:08] here's our true vocal fold really no metabolic activity and this is a muscle

[25:10] metabolic activity and this is a muscle okay so there should be some metabolic

[25:13] okay so there should be some metabolic activity here we also have sort of an a

[25:15] activity here we also have sort of an a trophic look to the to the

[25:17] trophic look to the to the cricoarytenoid back here which is also

[25:19] cricoarytenoid back here which is also not showing any FDG uptake if you look

[25:23] not showing any FDG uptake if you look carefully through this I know it's tough

[25:24] carefully through this I know it's tough with a fused image but you can see that

[25:26] with a fused image but you can see that it's a little bit fatty replaced and we

[25:28] it's a little bit fatty replaced and we also have dilatation of the ipsilateral

[25:31] also have dilatation of the ipsilateral laryngeal ventricle giving us that

[25:34] laryngeal ventricle giving us that classic spinnaker sale sign and so that

[25:37] classic spinnaker sale sign and so that tells us that the problem here is on the

[25:39] tells us that the problem here is on the patient's left side follow the course of

[25:41] patient's left side follow the course of the recurrent laryngeal nerve we can see

[25:44] the recurrent laryngeal nerve we can see this nodal conglomerate so this patient

[25:47] this nodal conglomerate so this patient has left side of vocal cord paralysis

[25:49] has left side of vocal cord paralysis from metastasis nono Matassa see is

[25:51] from metastasis nono Matassa see is there that are encroaching upon the left

[25:54] there that are encroaching upon the left recurrent laryngeal nerve

[25:57] recurrent laryngeal nerve all right next we're gonna move on and

[25:59] all right next we're gonna move on and talk about the thyroid gland

[26:02] talk about the thyroid gland and this is probably the biggest portion

[26:05] and this is probably the biggest portion of this talk because there is just so

[26:06] of this talk because there is just so much that happens here and so much to

[26:08] much that happens here and so much to say but just as a very brief overview

[26:11] say but just as a very brief overview the thyroid gland is an endocrine organ

[26:13] the thyroid gland is an endocrine organ has two lobes that are connected at

[26:16] has two lobes that are connected at midline via an isthmus sometimes

[26:17] midline via an isthmus sometimes patients will have a midline pyramidal

[26:19] patients will have a midline pyramidal lobe as well now in terms of imaging

[26:22] lobe as well now in terms of imaging really our first line modality is

[26:23] really our first line modality is ultrasound because that is our most

[26:26] ultrasound because that is our most sensitive sequence it really images it

[26:28] sensitive sequence it really images it better than anything else plus you can

[26:31] better than anything else plus you can sort of marry that with a needle and

[26:33] sort of marry that with a needle and there you have your answer if you really

[26:35] there you have your answer if you really need to figure out what something is you

[26:36] need to figure out what something is you can use an ultrasound and guide a needle

[26:39] can use an ultrasound and guide a needle into it and take a biopsy so really

[26:40] into it and take a biopsy so really ultrasound upfront that's our first line

[26:43] ultrasound upfront that's our first line modality here CT is important you may do

[26:46] modality here CT is important you may do it with contrast you may do it without

[26:48] it with contrast you may do it without in some circumstances because of iodine

[26:51] in some circumstances because of iodine load considerations when you're dealing

[26:53] load considerations when you're dealing with differentiated thyroid carcinoma

[26:55] with differentiated thyroid carcinoma it's a bit controversial it remains a

[26:57] it's a bit controversial it remains a bit controversial but oftentimes we are

[27:01] bit controversial but oftentimes we are wanting to minimize the amount of iodine

[27:03] wanting to minimize the amount of iodine that patients with differentiated

[27:05] that patients with differentiated thyroid carcinoma get because that will

[27:08] thyroid carcinoma get because that will sort of drive down the body's resorption

[27:12] sort of drive down the body's resorption of iodine and when you go to treat them

[27:13] of iodine and when you go to treat them with radio iodine you want them to be

[27:15] with radio iodine you want them to be iodine starved and taking up every last

[27:18] iodine starved and taking up every last bit of that radio iodine so when you're

[27:20] bit of that radio iodine so when you're dealing with differentiated thyroid

[27:21] dealing with differentiated thyroid carcinoma that is a consideration you

[27:23] carcinoma that is a consideration you have to make

[27:25] have to make we do use MRI

[27:28] we do use MRI really I feel like pretty frequently

[27:30] really I feel like pretty frequently anymore looking at the thyroid in

[27:33] anymore looking at the thyroid in patients with differentiated thyroid

[27:34] patients with differentiated thyroid carcinoma particularly those who have

[27:37] carcinoma particularly those who have iodine considerations and then nuclear

[27:41] iodine considerations and then nuclear medicine also plays a very very

[27:42] medicine also plays a very very important role here as you can see there

[27:44] important role here as you can see there are lots of agents I 123 I 139 Tech 99

[27:48] are lots of agents I 123 I 139 Tech 99 in pertechnetate as well as FDG and more

[27:54] in pertechnetate as well as FDG and more recently dota

[27:56] recently dota okay so let's talk a little bit about

[27:59] okay so let's talk a little bit about thyroid pathology well here's the good

[28:00] thyroid pathology well here's the good news

[28:01] news most of the times when you encounter a

[28:03] most of the times when you encounter a nodule in the thyroid it's going to be

[28:05] nodule in the thyroid it's going to be benign in fact the vast majority like

[28:08] benign in fact the vast majority like may be on the order of 95% of the time

[28:10] may be on the order of 95% of the time other good news it's a pretty

[28:13] other good news it's a pretty superficial organ and therefore it's

[28:16] superficial organ and therefore it's easy biopsied with ultrasound and in

[28:18] easy biopsied with ultrasound and in general when you have cancer of the

[28:21] general when you have cancer of the thyroid gland most of the time not all

[28:23] thyroid gland most of the time not all of the time but most of the time it's

[28:25] of the time but most of the time it's treatable very treatable cancer at least

[28:27] treatable very treatable cancer at least relative to other types of malignancy

[28:29] relative to other types of malignancy these are cancers that patients may very

[28:33] these are cancers that patients may very well die with rather than die of again

[28:35] well die with rather than die of again that's not a universal statement there

[28:38] that's not a universal statement there are certainly some bad things that occur

[28:39] are certainly some bad things that occur here but in general of the cancers

[28:42] here but in general of the cancers thyroid is one of the more treatable

[28:44] thyroid is one of the more treatable ones however there is bad news and that

[28:48] ones however there is bad news and that is to say whenever thyroid cancer is

[28:52] is to say whenever thyroid cancer is ugly it's really really ugly

[28:56] so as I mentioned ultrasound is really

[28:59] so as I mentioned ultrasound is really our first line modality now here's the

[29:02] our first line modality now here's the problem I'm a head and neck radiologist

[29:04] problem I'm a head and neck radiologist and I know very few head and neck

[29:07] and I know very few head and neck radiologists out there that just love to

[29:09] radiologists out there that just love to deal with thyroid ultrasounds right

[29:12] deal with thyroid ultrasounds right for some reason this is like this is

[29:15] for some reason this is like this is something that in most shops is really

[29:18] something that in most shops is really sort of under the purview of the body

[29:20] sort of under the purview of the body imagers and I think most had a neck

[29:22] imagers and I think most had a neck radiologists are kind of okay with that

[29:24] radiologists are kind of okay with that so here's a here's a meme that that my

[29:26] so here's a here's a meme that that my friend Todd comes sent me and I think

[29:28] friend Todd comes sent me and I think this really totally hits the nail on the

[29:30] this really totally hits the nail on the head like yes the thyroid is a head and

[29:33] head like yes the thyroid is a head and neck structure yes the metastases go in

[29:36] neck structure yes the metastases go in the head and neck for some reason head

[29:38] the head and neck for some reason head and neck radiologists are like going to

[29:40] and neck radiologists are like going to complete freakout mode if they have to

[29:42] complete freakout mode if they have to deal with a thyroid ultrasound and I'm

[29:44] deal with a thyroid ultrasound and I'm as guilty as anybody else with that so

[29:46] as guilty as anybody else with that so maybe we do need to know a little bit

[29:48] maybe we do need to know a little bit more about it and so I'm gonna do just

[29:49] more about it and so I'm gonna do just sort of a quick overview of some of the

[29:51] sort of a quick overview of some of the high points of thyroid ultrasound I'm

[29:53] high points of thyroid ultrasound I'm certainly not an expert I'm not

[29:55] certainly not an expert I'm not pretending to be able to make anybody an

[29:57] pretending to be able to make anybody an expert on thyroid ultrasound during this

[29:59] expert on thyroid ultrasound during this brief talk but there are some important

[30:01] brief talk but there are some important points that I think heading in head and

[30:02] points that I think heading in head and neck imagers need to be aware of

[30:05] neck imagers need to be aware of okay so

[30:07] okay so first up let's talk about reporting

[30:11] first up let's talk about reporting thyroid ultrasounds because this is an

[30:13] thyroid ultrasounds because this is an area where I think that there's actually

[30:15] area where I think that there's actually some really nice guidance that can be

[30:17] some really nice guidance that can be found and you can have right at your

[30:18] found and you can have right at your fingertips and the first is the thyroid

[30:20] fingertips and the first is the thyroid imaging reporting and data system or ty

[30:23] imaging reporting and data system or ty rads which comes from the ACR the

[30:25] rads which comes from the ACR the American College of Radiology and and

[30:27] American College of Radiology and and I'd like this because it's a really

[30:30] I'd like this because it's a really nice concise risk stratification and

[30:32] nice concise risk stratification and biopsy tool

[30:33] biopsy tool it's a paradigm really and and so the

[30:36] it's a paradigm really and and so the things that you need to look at sort of

[30:39] things that you need to look at sort of have to do with the composition of the

[30:40] have to do with the composition of the nodule what does it look like on

[30:43] nodule what does it look like on ultrasound in terms of its echogenicity

[30:45] ultrasound in terms of its echogenicity its shape what are the margins look like

[30:48] its shape what are the margins look like whether it has an internal echogenic

[30:50] whether it has an internal echogenic fossa as well as the size of the nodule

[30:54] fossa as well as the size of the nodule and so really it's it's a bit analogous

[30:56] and so really it's it's a bit analogous to by rats at the breast imagers use a

[30:58] to by rats at the breast imagers use a lot of the same sort of sonographic

[31:00] lot of the same sort of sonographic features i think are a translational

[31:03] features i think are a translational skillset it's not exactly parallel but

[31:06] skillset it's not exactly parallel but but the same kind of lessons that that

[31:09] but the same kind of lessons that that we can learn from mammographer x' and

[31:11] we can learn from mammographer x' and breast imagers I like to I like to tell

[31:12] breast imagers I like to I like to tell the trainees take things that you

[31:13] the trainees take things that you learned while on mamo and apply it to

[31:15] learned while on mamo and apply it to the head and neck because I really think

[31:17] the head and neck because I really think that they as a as a subspecialty have

[31:20] that they as a as a subspecialty have figured out how to really use data good

[31:23] figured out how to really use data good data to drive clinical practice and and

[31:25] data to drive clinical practice and and so that's what Tai razz attempts now I'm

[31:29] so that's what Tai razz attempts now I'm not going to go through this whole flow

[31:31] not going to go through this whole flow chart you can find this in in the Thai

[31:33] chart you can find this in in the Thai rads reference that I had on the last

[31:35] rads reference that I had on the last slide but basically you look at each of

[31:38] slide but basically you look at each of those categories and you do some scoring

[31:40] those categories and you do some scoring and you add up your aggregate score and

[31:42] and you add up your aggregate score and that tells you sort of your your triage

[31:45] that tells you sort of your your triage risk assessment of a thyroid nodule and

[31:47] risk assessment of a thyroid nodule and whether or not it needs to go to biopsy

[31:49] whether or not it needs to go to biopsy for further evaluation and management

[31:54] another paradigm which is broadly uses

[31:57] another paradigm which is broadly uses the American Thyroid Association or ATA

[32:00] the American Thyroid Association or ATA paradigm and this is also for risk

[32:03] paradigm and this is also for risk stratification and trying to figure out

[32:05] stratification and trying to figure out management and biopsy needs and this

[32:09] management and biopsy needs and this relies more on specific imaging patterns

[32:11] relies more on specific imaging patterns as well as the size of lesions as well

[32:14] as well as the size of lesions as well so I think for all the residents out

[32:17] so I think for all the residents out there you probably have seen this a

[32:20] there you probably have seen this a thousand times right this is in every

[32:22] thousand times right this is in every body reading room you can see this

[32:24] body reading room you can see this usually it's posted on the wall or in

[32:26] usually it's posted on the wall or in cubicles and these are just sort of the

[32:29] cubicles and these are just sort of the the standard-issue

[32:32] the standard-issue imaging appearance of different thyroid

[32:34] imaging appearance of different thyroid nodules and if you look at the bottom of

[32:36] nodules and if you look at the bottom of the image you can see you know the

[32:37] the image you can see you know the benign appearance and as you work your

[32:40] benign appearance and as you work your way up to the top these are imaging

[32:42] way up to the top these are imaging patterns on ultrasound that confer risk

[32:44] patterns on ultrasound that confer risk of malignancy so while I think ty rads

[32:47] of malignancy so while I think ty rads is a little bit more simplified and this

[32:49] is a little bit more simplified and this may be a little bit more

[32:50] may be a little bit more at your discretion and in terms of how

[32:53] at your discretion and in terms of how you interpret the images the thing that

[32:56] you interpret the images the thing that ata makes really nice is it has a great

[32:59] ata makes really nice is it has a great decision tree that's built into it and

[33:01] decision tree that's built into it and based upon all of these different

[33:03] based upon all of these different variables and and you know how highly

[33:05] variables and and you know how highly suspicious the ultrasound pattern is it

[33:08] suspicious the ultrasound pattern is it really is a nice way to plug in and sort

[33:10] really is a nice way to plug in and sort of just work through the system and

[33:11] of just work through the system and figure out what the next appropriate

[33:13] figure out what the next appropriate step is so I won't again go through this

[33:15] step is so I won't again go through this entirety of the spreadsheet or this flow

[33:17] entirety of the spreadsheet or this flow sheet just be aware of it and check out

[33:20] sheet just be aware of it and check out the atas guidelines and make sure that

[33:22] the atas guidelines and make sure that you sort of have an understanding of how

[33:24] you sort of have an understanding of how to use them

[33:26] to use them okay so let's talk about some specific

[33:28] okay so let's talk about some specific thyroid pathologies first up is a

[33:30] thyroid pathologies first up is a thyroid adenoma

[33:31] thyroid adenoma so you can have true adenoma that have a

[33:33] so you can have true adenoma that have a defined capsule and histopathology or

[33:36] defined capsule and histopathology or you can have adenomatous hyperplasia

[33:39] you can have adenomatous hyperplasia that has an incomplete capsule I still

[33:42] that has an incomplete capsule I still tend to lump these together and think

[33:43] tend to lump these together and think about them in the same way but what do

[33:46] about them in the same way but what do they look like on imaging well

[33:48] they look like on imaging well unfortunately it's a whole lot of

[33:50] unfortunately it's a whole lot of nonspecific stuff so on CT the

[33:52] nonspecific stuff so on CT the enhancement pattern can be variable they

[33:55] enhancement pattern can be variable they may or may not have calcification they

[33:57] may or may not have calcification they may or may not contain hemorrhage on MRI

[33:59] may or may not contain hemorrhage on MRI same boat variable signal intensity

[34:02] same boat variable signal intensity variable enhancement this is an area

[34:04] variable enhancement this is an area where I think ultrasound is much more

[34:06] where I think ultrasound is much more helpful on ultrasound the majority of

[34:09] helpful on ultrasound the majority of them tend to be solid and homogeneous

[34:11] them tend to be solid and homogeneous usually they're sort of on the isotype

[34:13] usually they're sort of on the isotype oh I'm sorry hyper echoic side of the

[34:16] oh I'm sorry hyper echoic side of the spectrum and importantly the majority of

[34:20] spectrum and importantly the majority of them will have a hypo ekiden a halo

[34:22] them will have a hypo ekiden a halo around them

[34:25] around them this is a time to throw on your color

[34:27] this is a time to throw on your color Doppler take a look at the flow because

[34:29] Doppler take a look at the flow because these will oftentimes have a peri

[34:32] these will oftentimes have a peri nodular so-called spoke wheel

[34:34] nodular so-called spoke wheel vascularity pattern and I'll show that

[34:36] vascularity pattern and I'll show that on the next slide

[34:37] on the next slide so here the image on the left this is

[34:39] so here the image on the left this is our transverse grayscale the image on

[34:41] our transverse grayscale the image on the right is our color Doppler you can

[34:43] the right is our color Doppler you can see that sort of ISO - maybe slightly

[34:46] see that sort of ISO - maybe slightly hyper a co ik circumscribe nodule it has

[34:48] hyper a co ik circumscribe nodule it has that hypoechoic halo around it and then

[34:51] that hypoechoic halo around it and then on color Doppler you get that spoke

[34:53] on color Doppler you get that spoke wheel pattern of vascularity with

[34:55] wheel pattern of vascularity with pérignon

[34:56] pérignon increased vascularity and then some sort

[34:59] increased vascularity and then some sort of streaking vascularity going through

[35:00] of streaking vascularity going through it now important to keep in mind is

[35:03] it now important to keep in mind is despite what these look like on imaging

[35:06] despite what these look like on imaging they end up getting biopsied and

[35:08] they end up getting biopsied and unfortunately even the pathologist can't

[35:10] unfortunately even the pathologist can't tell you definitively that it's an

[35:11] tell you definitively that it's an adenoma unless it's completely resected

[35:13] adenoma unless it's completely resected and they can actually section it they

[35:16] and they can actually section it they can only give you sort of a best guess

[35:19] can only give you sort of a best guess based upon a biopsy so to confirm it it

[35:21] based upon a biopsy so to confirm it it these need to come out

[35:23] these need to come out what do they look like on nuke studies

[35:25] what do they look like on nuke studies well unfortunately they can be variable

[35:27] well unfortunately they can be variable in FDG but they may be avid

[35:30] in FDG but they may be avid these are lesions that oftentimes are

[35:33] these are lesions that oftentimes are hot on I 123 or pertechnetate studies so

[35:38] hot on I 123 or pertechnetate studies so whenever we see a hot nodule the vast

[35:40] whenever we see a hot nodule the vast majority of time it's benign that's a

[35:42] majority of time it's benign that's a very reassuring finding it's really the

[35:44] very reassuring finding it's really the cold nodules that we worry about having

[35:46] cold nodules that we worry about having risk of malignancy

[35:49] risk of malignancy so here's an example of a thyroid

[35:52] so here's an example of a thyroid adenoma you can see on the axial

[35:54] adenoma you can see on the axial contrast-enhanced CT sort of this

[35:56] contrast-enhanced CT sort of this heterogeneous but maybe slightly hypo

[35:59] heterogeneous but maybe slightly hypo dense or hypo enhancing nodule if we

[36:01] dense or hypo enhancing nodule if we look at our fused fdg-pet yeah it looks

[36:04] look at our fused fdg-pet yeah it looks like maybe it's a little bit FDG avid a

[36:06] like maybe it's a little bit FDG avid a little bit tough to tease out from the

[36:08] little bit tough to tease out from the background thyroid uptake this is a nice

[36:10] background thyroid uptake this is a nice area to look at your actual source pet

[36:12] area to look at your actual source pet data and we can see unequivocally this

[36:14] data and we can see unequivocally this is a has FDG uptake it's it's avidly

[36:17] is a has FDG uptake it's it's avidly taking it up so just keep in mind tired

[36:20] taking it up so just keep in mind tired adenoma is there uptake on FDG is

[36:22] adenoma is there uptake on FDG is variable so whenever you encounter one

[36:25] variable so whenever you encounter one on a pet

[36:27] on a pet anytime you you're catching a nodule

[36:28] anytime you you're catching a nodule that's hypermetabolic like this it's

[36:31] that's hypermetabolic like this it's going to need an ultrasound and then

[36:33] going to need an ultrasound and then based upon its ultrasound appearance it

[36:35] based upon its ultrasound appearance it may or may not need a biopsy

[36:37] may or may not need a biopsy next up is the thyroid colloid nodule or

[36:40] next up is the thyroid colloid nodule or a colloid cyst these tend to have

[36:42] a colloid cyst these tend to have sharply defined margins they tend to be

[36:45] sharply defined margins they tend to be largely fluid-filled on CT they're

[36:49] largely fluid-filled on CT they're oftentimes low-density and circumscribed

[36:51] oftentimes low-density and circumscribed this is fairly circumscribed it's not

[36:53] this is fairly circumscribed it's not perfect on MRI these often have variable

[36:57] perfect on MRI these often have variable signal intensity frequently TT bright

[36:59] signal intensity frequently TT bright but it sort of depends on protein

[37:01] but it sort of depends on protein content and and such but these are not

[37:04] content and and such but these are not enhancing ultrasound is an area that can

[37:07] enhancing ultrasound is an area that can be quite helpful as well

[37:10] be quite helpful as well these are anechoic they will show

[37:12] these are anechoic they will show posterior coup stick enhancement and be

[37:15] posterior coup stick enhancement and be on the lookout for comet tail artifact

[37:17] on the lookout for comet tail artifact that confirms to you that it contains

[37:20] that confirms to you that it contains colloid crystal within it

[37:23] colloid crystal within it so here's a colloid nodule on CT this

[37:26] so here's a colloid nodule on CT this was path proven

[37:28] was path proven circumscribed but kind of heterogeneous

[37:30] circumscribed but kind of heterogeneous and it's attenuation and enhancement so

[37:32] and it's attenuation and enhancement so you know CT frankly kind of sucks for

[37:35] you know CT frankly kind of sucks for trying to figure out what's going on on

[37:38] trying to figure out what's going on on ultrasound different patient but this is

[37:41] ultrasound different patient but this is sort of a classic appearance of a

[37:42] sort of a classic appearance of a colloid nodule you can see it's anechoic

[37:44] colloid nodule you can see it's anechoic it's circumscribed when you throw in

[37:46] it's circumscribed when you throw in that color Doppler it really accentuates

[37:48] that color Doppler it really accentuates that comet tail artifact look for that

[37:51] that comet tail artifact look for that artifact because that confirms that

[37:52] artifact because that confirms that you're dealing with colloid and you know

[37:54] you're dealing with colloid and you know you're dealing with something benign

[37:57] you're dealing with something benign so hopefully after me blabbering on

[38:00] so hopefully after me blabbering on there for the last couple of minutes

[38:01] there for the last couple of minutes you'll realize that ultrasound really is

[38:04] you'll realize that ultrasound really is far superior to CT and MRI and assessing

[38:07] far superior to CT and MRI and assessing the risk of malignancy with incidental

[38:09] the risk of malignancy with incidental thyroid nodules I mean CT and MRI they

[38:11] thyroid nodules I mean CT and MRI they honestly they just kind of suck for this

[38:13] honestly they just kind of suck for this the question is do you need to get an

[38:16] the question is do you need to get an ultrasound every time you catch one of

[38:17] ultrasound every time you catch one of these on MRI or on CT and I think we've

[38:21] these on MRI or on CT and I think we've got some pretty good data now to suggest

[38:23] got some pretty good data now to suggest that the answer is no there was a nice

[38:26] that the answer is no there was a nice paper published by Jenny Wong and

[38:28] paper published by Jenny Wong and colleagues in J ACR a few years back

[38:31] colleagues in J ACR a few years back it's the white paper on incidental

[38:33] it's the white paper on incidental thyroid nodules really a great example

[38:35] thyroid nodules really a great example of using data to dictate how we should

[38:38] of using data to dictate how we should practice but they were able to

[38:40] practice but they were able to demonstrate that just by looking at a

[38:42] demonstrate that just by looking at a couple of variables namely the age and

[38:45] couple of variables namely the age and the size of the nodule as well as

[38:48] the size of the nodule as well as whether or not there are any other

[38:49] whether or not there are any other suspicious findings like extra thyroid

[38:51] suspicious findings like extra thyroid extension or suspicious lymph nodes that

[38:53] extension or suspicious lymph nodes that would have automatically made it

[38:54] would have automatically made it suspicious but looking at just the

[38:57] suspicious but looking at just the variables of age in size you can

[38:59] variables of age in size you can actually quite nicely risk stratify

[39:02] actually quite nicely risk stratify these patients as far as who needs to

[39:03] these patients as far as who needs to get an ultrasound for incidentally

[39:05] get an ultrasound for incidentally discovered thyroid nodules on CT and MRI

[39:09] discovered thyroid nodules on CT and MRI this is a flow sheet from that paper

[39:12] this is a flow sheet from that paper again you can find this in J ACR I'm not

[39:15] again you can find this in J ACR I'm not gonna go through all of this just to

[39:17] gonna go through all of this just to show you it's out there it's quite

[39:19] show you it's out there it's quite simple to go through but I'll hit the

[39:21] simple to go through but I'll hit the high points of it if there are no

[39:24] high points of it if there are no suspicious features in other words it

[39:26] suspicious features in other words it doesn't look like this nodule has extra

[39:28] doesn't look like this nodule has extra thyroid 'el invasion it's not blown its

[39:30] thyroid 'el invasion it's not blown its way out of the thyroid if there are no

[39:32] way out of the thyroid if there are no suspicious lymph nodes that look like

[39:34] suspicious lymph nodes that look like metastatic nodes and if there are no

[39:37] metastatic nodes and if there are no comorbidities or limited life expectancy

[39:39] comorbidities or limited life expectancy which albeit is tough to figure out if

[39:41] which albeit is tough to figure out if you're a radiologist

[39:43] you're a radiologist but if those criteria are met then you

[39:46] but if those criteria are met then you can look at the patient's age and the

[39:48] can look at the patient's age and the size of the nodule and figure out what

[39:49] size of the nodule and figure out what needs to happen next so if the patient

[39:51] needs to happen next so if the patient is under the age of 35 and if the nodule

[39:55] is under the age of 35 and if the nodule is less than a centimeter in size we can

[39:57] is less than a centimeter in size we can ignore it if they're under the age of 35

[40:00] ignore it if they're under the age of 35 and it's a centimeter or greater in size

[40:02] and it's a centimeter or greater in size they need an ultrasound and that's

[40:04] they need an ultrasound and that's simply because differentiated thyroid

[40:06] simply because differentiated thyroid carcinoma is a disease that

[40:08] carcinoma is a disease that disproportionately affects younger

[40:10] disproportionately affects younger adults people in there in sort of that

[40:13] adults people in there in sort of that 20s and 30s age range so we take those

[40:16] 20s and 30s age range so we take those nodules much more seriously once you get

[40:19] nodules much more seriously once you get over the age of 35 we get a little bit

[40:21] over the age of 35 we get a little bit more lacks in our in our guidelines if a

[40:23] more lacks in our in our guidelines if a nodule is less than a centimeter and a

[40:25] nodule is less than a centimeter and a half in size we can ignore it and if a

[40:28] half in size we can ignore it and if a nodule is 1.5 centimeters are greater

[40:30] nodule is 1.5 centimeters are greater they need an ultrasound so I think the

[40:34] they need an ultrasound so I think the ACR white paper really nicely simplifies

[40:36] ACR white paper really nicely simplifies how to deal with these thyroid nodules

[40:38] how to deal with these thyroid nodules it's something that I put into practice

[40:40] it's something that I put into practice ever since reading that paper a couple

[40:41] ever since reading that paper a couple years ago and I think a lot of people

[40:43] years ago and I think a lot of people have have really embraced this as well

[40:47] have have really embraced this as well next topic is a multinodular goiter this

[40:50] next topic is a multinodular goiter this is as the name might imply diffuse multi

[40:53] is as the name might imply diffuse multi nodular enlargement of the thyroid and

[40:54] nodular enlargement of the thyroid and this is due to chronic tsa over

[40:56] this is due to chronic tsa over stimulation the problem with goiters is

[40:59] stimulation the problem with goiters is it's reported that about 5% of the time

[41:01] it's reported that about 5% of the time they Harbor malignancy if I ask my

[41:03] they Harbor malignancy if I ask my pathologists here at IU they tell me

[41:05] pathologists here at IU they tell me they can find it virtually in all of

[41:07] they can find it virtually in all of them given enough time find that needle

[41:09] them given enough time find that needle in the haystack but again that's because

[41:11] in the haystack but again that's because thyroid cancer often times as a

[41:13] thyroid cancer often times as a diagnosis that's indolent not always but

[41:16] diagnosis that's indolent not always but often times

[41:18] often times things about multinodular goiter x' that

[41:21] things about multinodular goiter x' that you need to know as an imager well

[41:23] you need to know as an imager well despite the fact that they are big they

[41:25] despite the fact that they are big they tend to have defied margins so it

[41:27] tend to have defied margins so it doesn't look like it's aggressively

[41:29] doesn't look like it's aggressively invading structures around it rather

[41:31] invading structures around it rather they sort of push things away they may

[41:34] they sort of push things away they may or may not have internal calcifications

[41:35] or may not have internal calcifications they may or may not have internal

[41:37] they may or may not have internal hemorrhage for that matter but things

[41:39] hemorrhage for that matter but things that you really need to be looking for

[41:41] that you really need to be looking for and reporting in your reports are what's

[41:44] and reporting in your reports are what's it doing to the trachea is it causing

[41:46] it doing to the trachea is it causing airway narrowing is it displacing it

[41:48] airway narrowing is it displacing it just how bad is that narrowing getting

[41:50] just how bad is that narrowing getting is it over a short segment or a long

[41:52] is it over a short segment or a long segment and then also report whether or

[41:54] segment and then also report whether or not there is retrosternal extension

[41:57] not there is retrosternal extension so in this nice case lens to me by Rick

[41:59] so in this nice case lens to me by Rick Wiggins you can see this ginormous

[42:01] Wiggins you can see this ginormous goiter sending down into the mediastinum

[42:03] goiter sending down into the mediastinum it's important to let the surgeons know

[42:06] it's important to let the surgeons know about this ahead of time because when

[42:08] about this ahead of time because when they go to take this out or debulk it

[42:10] they go to take this out or debulk it this goes from being in Otolaryngology

[42:12] this goes from being in Otolaryngology case do a combined Otolaryngology and

[42:15] case do a combined Otolaryngology and cardiothoracic

[42:16] cardiothoracic case because of the the mediastinal

[42:19] case because of the the mediastinal extent that needs to be dealt with

[42:22] extent that needs to be dealt with alright let's talk about thyroid

[42:23] alright let's talk about thyroid malignancy as you can see on this slide

[42:26] malignancy as you can see on this slide there are multiple different types of

[42:27] there are multiple different types of thyroid cancer we're gonna start talking

[42:29] thyroid cancer we're gonna start talking about start with talking about the

[42:30] about start with talking about the differentiated thyroid carcinoma

[42:33] differentiated thyroid carcinoma okay so differentiated thyroid carcinoma

[42:36] okay so differentiated thyroid carcinoma the vast majority are gonna be papillary

[42:38] the vast majority are gonna be papillary number two would be follicular this is

[42:42] number two would be follicular this is more common in women than in men it's

[42:43] more common in women than in men it's about three to one ratio and I say said

[42:46] about three to one ratio and I say said before this is a disease that

[42:48] before this is a disease that disproportionately affects younger

[42:50] disproportionately affects younger adults you certainly can get it in older

[42:51] adults you certainly can get it in older adults but it has a high incidence in

[42:54] adults but it has a high incidence in young adults peak age somewhere in the

[42:56] young adults peak age somewhere in the third and fourth decades and that again

[42:58] third and fourth decades and that again is sort of what drives the the acrs

[43:02] is sort of what drives the the acrs white paper on how to deal with

[43:03] white paper on how to deal with incidental thyroid nodules

[43:07] incidental thyroid nodules the primary tumor oftentimes is solid

[43:11] the primary tumor oftentimes is solid but it can't have cystic components or

[43:13] but it can't have cystic components or it can be mixed solid and cystic not

[43:15] it can be mixed solid and cystic not infrequently has calcification you can

[43:17] infrequently has calcification you can see this yellow arrow is sort of

[43:18] see this yellow arrow is sort of pointing at that fine curd of

[43:20] pointing at that fine curd of curvilinear calcification but

[43:22] curvilinear calcification but interestingly the lymph nodes the

[43:24] interestingly the lymph nodes the metastatic nodes in the neck look a lot

[43:28] metastatic nodes in the neck look a lot like the primary tumor not always but

[43:29] like the primary tumor not always but oftentimes they do and you can sort of

[43:32] oftentimes they do and you can sort of appreciate that with sort of these mixed

[43:34] appreciate that with sort of these mixed solid and cystic lymph nodes here

[43:37] solid and cystic lymph nodes here denoted by the yellow arrows if you do

[43:39] denoted by the yellow arrows if you do MRI oftentimes these will be t1 bright

[43:42] MRI oftentimes these will be t1 bright that's because

[43:44] that's because with differentiated thyroid carcinoma

[43:47] with differentiated thyroid carcinoma it's so well differentiated that the

[43:50] it's so well differentiated that the nodal metastases are in fact churning

[43:52] nodal metastases are in fact churning out I read proteins like thyroid

[43:54] out I read proteins like thyroid globulin and those nodes may also have

[43:56] globulin and those nodes may also have calcification within them as well

[43:59] calcification within them as well here's a patient that has papillary

[44:02] here's a patient that has papillary thyroid carcinoma you can see this sort

[44:04] thyroid carcinoma you can see this sort of hypo attenuating or hypo enhancing

[44:07] of hypo attenuating or hypo enhancing infiltrating mass on the left side of

[44:09] infiltrating mass on the left side of the thyroid it does look like it's

[44:10] the thyroid it does look like it's invading some of the surrounding soft

[44:11] invading some of the surrounding soft tissues

[44:13] tissues and you can see there are some stippled

[44:15] and you can see there are some stippled calcifications within it as well denoted

[44:17] calcifications within it as well denoted here by the yellow arrow and

[44:19] here by the yellow arrow and as we look there is this sort of cystic

[44:23] as we look there is this sort of cystic peering visceral space or Delphian or

[44:26] peering visceral space or Delphian or level 6 lymph node and importantly look

[44:29] level 6 lymph node and importantly look at that node this is a t1 pre contrast

[44:31] at that node this is a t1 pre contrast image it's pretty bright and that's

[44:34] image it's pretty bright and that's probably because of the fact that this

[44:35] probably because of the fact that this thing has so much protein content

[44:37] thing has so much protein content because it's churning out thyroid

[44:38] because it's churning out thyroid proteins here's our fused axial fluorine

[44:42] proteins here's our fused axial fluorine 18 fdg-pet CT and you can see just how

[44:45] 18 fdg-pet CT and you can see just how hypermetabolic that node is so things

[44:48] hypermetabolic that node is so things that I think are helpful clues when

[44:49] that I think are helpful clues when you're dealing with papillary thyroid

[44:50] you're dealing with papillary thyroid carcinoma look for an invasive mass or a

[44:53] carcinoma look for an invasive mass or a potentially invasive mass look for micro

[44:55] potentially invasive mass look for micro calcifications keep in mind that those

[44:58] calcifications keep in mind that those nodal metastases oftentimes look quite a

[45:00] nodal metastases oftentimes look quite a lot like the primary tumor may have

[45:03] lot like the primary tumor may have micro calcifications within them may be

[45:05] micro calcifications within them may be t1 bright due to the fact that it's

[45:07] t1 bright due to the fact that it's churning out fara globulin or other

[45:08] churning out fara globulin or other thyroid proteins

[45:11] thyroid proteins here's another patient that has

[45:13] here's another patient that has papillary thyroid carcinoma and in this

[45:16] papillary thyroid carcinoma and in this case

[45:17] case we have this cystic appearing right

[45:21] we have this cystic appearing right retro Ferengi Oh lymph node okay it's

[45:24] retro Ferengi Oh lymph node okay it's sort of oval certainly enlarged no doubt

[45:26] sort of oval certainly enlarged no doubt about it sitting sort of between the the

[45:30] about it sitting sort of between the the fringy mucosal space which is seen more

[45:33] fringy mucosal space which is seen more medially in between the carotid space

[45:35] medially in between the carotid space which is sort of getting displaced

[45:36] which is sort of getting displaced postural laterally by it so we look at

[45:39] postural laterally by it so we look at our fdg-pet CT

[45:41] our fdg-pet CT it's not metabolic at all I mean it's

[45:44] it's not metabolic at all I mean it's there's no FDG uptake so when you see

[45:46] there's no FDG uptake so when you see that it's benign right don't worry about

[45:48] that it's benign right don't worry about it

[45:49] it wrong that's absolutely wrong this is

[45:52] wrong that's absolutely wrong this is one of the critical things to recognize

[45:54] one of the critical things to recognize about cystic or necrotic lymph nodes

[45:56] about cystic or necrotic lymph nodes they are still metastatic lymph nodes

[46:00] they are still metastatic lymph nodes but in order to have FDG uptake you have

[46:03] but in order to have FDG uptake you have to have at least a base level of solid

[46:06] to have at least a base level of solid tumor component within it and when

[46:08] tumor component within it and when something gets very cystic or very

[46:10] something gets very cystic or very necrotic it can drive down that FDG

[46:13] necrotic it can drive down that FDG signals so when you see that it does

[46:15] signals so when you see that it does need to get biopsied and so how do you

[46:16] need to get biopsied and so how do you biopsy this this is one that I did a

[46:18] biopsy this this is one that I did a trans facial approach under CT guidance

[46:21] trans facial approach under CT guidance it looks a little barbaric but this is

[46:23] it looks a little barbaric but this is honestly a very safe approach and it's

[46:25] honestly a very safe approach and it's tolerated well by the patients and so

[46:28] tolerated well by the patients and so just find a safe window that you can put

[46:30] just find a safe window that you can put the needle in obviously avoiding putting

[46:32] the needle in obviously avoiding putting it through the carotid artery because

[46:33] it through the carotid artery because that is certainly poor form but whenever

[46:37] that is certainly poor form but whenever you biopsy these you may not get a lot

[46:39] you biopsy these you may not get a lot of cells but instead make sure they're

[46:41] of cells but instead make sure they're running a thyroglobulin washout on it

[46:43] running a thyroglobulin washout on it because if it contains thyroglobulin you

[46:45] because if it contains thyroglobulin you know you're dealing with a metastatic

[46:47] know you're dealing with a metastatic node so a classic pitfall that we see

[46:50] node so a classic pitfall that we see not infrequently with papillary thyroid

[46:52] not infrequently with papillary thyroid carcinoma look for those cystic retro

[46:55] carcinoma look for those cystic retro pharyngeal nodes or cystic nodes in

[46:56] pharyngeal nodes or cystic nodes in general but thyroids bizarre it gives

[46:59] general but thyroids bizarre it gives nodal Mets and sort of unexpected places

[47:02] nodal Mets and sort of unexpected places retro Ferengi lymph nodes even though

[47:03] retro Ferengi lymph nodes even though they're sort of geographically removed

[47:05] they're sort of geographically removed that's a nodal station that can be

[47:08] that's a nodal station that can be involved so when you see a cystic retro

[47:11] involved so when you see a cystic retro Ferengi a lymph node think about

[47:12] Ferengi a lymph node think about differentiated thyroid cancer these

[47:14] differentiated thyroid cancer these cystic nodes again are oftentimes cold

[47:17] cystic nodes again are oftentimes cold on fdg-pet it's incumbent upon you as

[47:21] on fdg-pet it's incumbent upon you as the radiologist to suggest that that may

[47:22] the radiologist to suggest that that may be what's going on and this is where you

[47:24] be what's going on and this is where you can add value add service by offering to

[47:27] can add value add service by offering to put a needle into it

[47:29] put a needle into it one more interesting papillary thyroid

[47:31] one more interesting papillary thyroid carcinoma case this was a patient who

[47:34] carcinoma case this was a patient who had known papillary thyroid carcinoma

[47:36] had known papillary thyroid carcinoma had previously been resected but they

[47:39] had previously been resected but they had an increasing thyroglobulin level we

[47:42] had an increasing thyroglobulin level we have our axial conventional CT on the

[47:44] have our axial conventional CT on the left you can see in this node here it's

[47:47] left you can see in this node here it's not really all that enlarged but maybe

[47:49] not really all that enlarged but maybe it looks ever so slightly more dense

[47:51] it looks ever so slightly more dense compared to its contralateral

[47:53] compared to its contralateral counterpart with the red arrow this is

[47:55] counterpart with the red arrow this is an area where you can use dual energy or

[47:57] an area where you can use dual energy or spectral CT and play off of the physics

[48:00] spectral CT and play off of the physics use that those low mono kV sequences

[48:04] use that those low mono kV sequences sort of get down as low as you can

[48:06] sort of get down as low as you can toward the K edge of iodine and that's

[48:09] toward the K edge of iodine and that's going to bring up your signal so here we

[48:11] going to bring up your signal so here we can see that that right side and lymph

[48:13] can see that that right side and lymph node is really really bright whenever we

[48:15] node is really really bright whenever we are

[48:16] are using this mono ke v40 sequence here and

[48:22] using this mono ke v40 sequence here and then compare that to the contralateral

[48:24] then compare that to the contralateral normal lymph node which

[48:26] normal lymph node which not as bright so that tells us that that

[48:28] not as bright so that tells us that that note on the right side is taking up more

[48:30] note on the right side is taking up more iodine and we can even prove that by

[48:32] iodine and we can even prove that by doing an iodine subtraction map that's

[48:34] doing an iodine subtraction map that's the pathologic node they're denoted by

[48:37] the pathologic node they're denoted by the yellow arrow we can see how it has a

[48:39] the yellow arrow we can see how it has a signal void where it's dropping out the

[48:40] signal void where it's dropping out the iodine compare that to the contralateral

[48:42] iodine compare that to the contralateral normal lymph node that doesn't this was

[48:44] normal lymph node that doesn't this was a path proven non enlarged metastatic

[48:47] a path proven non enlarged metastatic lymph node that we can see really using