Journal of Otology & RhinologyISSN: 2324-8785

All submissions of the EM system will be redirected to Online Manuscript Submission System. Authors are requested to submit articles directly to Online Manuscript Submission System of respective journal.
bahis siteleri bahis siteleri bahis siteleri casino siteleri

Research Article, J Otol Rhinol Vol: 2 Issue: 4

Head and Neck Ultrasound by an Otolaryngologist - The Experience with 4273 Cases Over 8 Years

Cheng-Ping Wang1,2*, Tseng-Cheng Chen2,3, Tsung-Lin Yang2, Li-Jen Liao4 and Fon-Jou Hsieh5
1Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan
2Department of Otolaryngology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
3Department of Otolaryngology, National Taiwan University Hospital- Yun-Lin Branch, Yun-Lin, Taiwan
4Department of Otolaryngology, Far Eastern Memorial Hospital, New Taipei city, Taiwan
5Division of Ultrasound, Department of Integrated Diagnostic & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
Corresponding author : Cheng-Ping Wang
Department of Otolaryngology, National Taiwan University Hospital, 7-Chung-Shan South Road, Taipei, Taiwan
Tel: +886 2 23123456 (63525); Fax: +886 2 23910905
E-mail: [email protected]
Received: July 03, 2013 Accepted: September 18, 2013 Published: October 01, 2013
Citation: Wang CP, Chen TC, Yang TL, Liao LJ, Hsieh FJ (2013) Head and Neck Ultrasound by an Otolaryngologist - The Experience with 4273 Cases Over 8 Years. J Otol Rhinol 2:4. doi:10.4172/2324-8785.1000134

Abstract

Head and Neck Ultrasound by an Otolaryngologist - The Experience with 4273 Cases Over 8 Years

Background: Head and neck ultrasound examination has frequently been performed by otolaryngologists in recent years. This article aims to report the experience of an otolaryngologist who has worked on head and neck ultrasound for the past 8 years.

Materials: An ultrasound with a 7-14 MHz linear transducer was operated to perform head and neck ultrasound examinations. The gray-scale technique with the scan set for the thyroid gland was first used to evaluate the morphology of the structures in the entire neck, and the Doppler mode was used if necessary. Fine needle aspiration (FNA) with a free-hand technique under ultrasound guidance was performed if indicated.

Results: Between October 2003 and May 2011, 4273 patients received an ultrasound examination: 1927 (45%) examinations were for the thyroid gland, 1658 (39%) for a non-thyroid or salivarygland neck mass, 388 (9%) for the major salivary gland and 300 (7%) for other indications. Of these patients, 2048 (48%) received FNA for cytology. In the first 5 years, there were only 1361 (31%) patients, in contrast with the 2912 (68%) patients during the last 3 years. Comparing the indications between the first 5 years and the last 3 years, the thyroid gland (47%) was the most common in the last 3 years, and the non-thyroid or salivary gland neck mass (44%) was the most common indication in the first 5 years (p<0.001).

Conclusion: Otolaryngologists are performing more head and neck ultrasound examinations, with more familiarity with the ultrasound equipment and interpretation.

Keywords: Ultrasonography; Neck mass; Thyroid gland; Lymph node; Salivary gland; Sonography

Keywords

Ultrasonography; Neck mass; Thyroid gland; Lymph node; Salivary gland; Sonography

Introduction

The ultrasound is one of the most common imaging diagnostic tools in the clinical practice of many specialties. Head and neck ultrasound has been performed by radiologists mostly for thyroid diseases for many years [1-3]. In the past decade, more and more otolaryngologists have performed ultrasound examinations by themselves for their clinical practice because of the need for differential diagnoses of mass in the head and neck regions and for some specific or surgical purposes [1,4]. In Europe, there have been many otolaryngologists performing the head and neck ultrasound for the evaluation of head and neck cancers [1]. In the United States, head and neck ultrasound training courses have been successfully delivered by the American Academy of Otolaryngology-Head and Neck Surgery and the American College of Surgeons for otolaryngologists and endocrine surgeons [1,5].
In Taiwan, head and neck ultrasound has almost exclusively focused on the thyroid gland in the past because most of the examiners were endocrinologists. Starting in 1996, Dr. Wu, an otolaryngologist, began to perform ultrasound examinations with gray-scale and power Doppler techniques to distinguish between benign and malignant cervical lymph nodes [6-9]. Since 2003, head and neck ultrasound examination has become a regular imaging examination at Department of Otolaryngology of the National Taiwan University Hospital for all types of neck masses, including thyroid nodules, cervical lymph nodes, lateral neck masses, salivary gland diseases and other specific conditions; this technique is no longer used only for research purposes. This article aims to report my experiences using head and neck ultrasound to examine approximately 4000 patients during the 8 years since 2003.

Patients and Methods

Patients who received a head and neck ultrasound examination at the Department of Otolaryngology of the National Taiwan University Hospital between June 2003 and May 2011 were enrolled in this study. This retrospective study was reviewed and approved by the institutional review board at the National Taiwan University Hospital. An ultrasound instrument (HDI 5000, Philips, Bothell, WA, USA, and Aplio™XG SSA-790A, Toshiba Medical Systems Co., Otawara, Japan) with a 7-14 MHz linear array transducer (L12-5 for HDI 5000, PLT-1204 BX for Aplio™ XG SSA-790A) was used. During the examination, the patient was supine on the bed with their head near the examiner and with a pillow under their head and neck to maintain a mild extension of the neck (Figure 1). The scanner was placed on the patient’s neck first in a transverse plane and then in a longitudinal plane if necessary. The gray-scale technique with the scan set for the thyroid gland was first used to evaluate the morphology of the structures in the neck. The power/color/spectral Doppler mode was used if necessary. All of the structures in the anterior and lateral neck were captured regardless of the main complaint of the patients; these structures include the thyroid gland, the carotid sheath from level IV to level II, the submandibular region and the parotid gland, level V along the spinal accessory nerve in the cephalocaudal direction, the supraclavicular region, the anterior neck from the thyroid gland up to the submental region and the contralateral side of the neck. The nuchal, occipital and head areas were examined only when a lesion was observed in that location. When a significant lesion was identified on the ultrasound, fine needle aspiration (FNA) or a core needle biopsy with the free-hand technique under ultrasound guidance was performed simultaneously, with the consent of the patient (Figure 1).
Figure 1: (A) The setting of the head and neck ultrasound at the Department of Otolaryngology of National Taiwan University Hospital. (B) The patient was in the supine position with a mild extension of the head and neck. (C) The free-hand ultrasound-guided fine needle aspiration technique. (D) The needle is clearly observed in the target tissue under the ultrasound guidance. Arrow: needle.

Results

A total of 4273 patients were examined between 2003 and 2011. They included 1366 male and 2907 female patients. The age distribution of the patients is shown in Figure 2. The patients’ ages ranged from 0 to 90 years, with a median age of 50 years (Figure 2). Most were adult patients. Only 183 (4%) patients were less than 20 years old when examined. The indications for ultrasound examination in all patients are shown in Figure 3A. There were 1927 (45%) patients who underwent ultrasound for the evaluation of thyroid disease, 1658 (39%) for a non-thyroid or salivary-gland neck mass, 388 (9%) for salivary gland diseases and 300 (7%) patients for other indications, including dysphonia or vocal fold paresis in 101 patients, dysphagia or lump sensation in the throat in 59 patients, a cancer work-up in 49 patients, neck pain in 39 patients, infection or abscess in 25 patients, mass in an area other than the neck in 14 patients, and other reasons in 13 patients.
Figure 2: The age distribution of the 4273 patients receiving head and neck ultrasounds at the Department of Otolaryngology of National Taiwan University Hospital from 2003 to 2011.
Figure 3: (A) The indications of 4273 patients receiving head and neck ultrasounds in the Department of Otolaryngology of the National Taiwan University Hospital from 2003 to 2011. (B) The change in the indications from the period of 2003-2008 to the period of 2009-2011.
The number of patients examined stratified by calendar year are shown in Figure 4. The number of patients was small and relatively stable in the first 5 years (2003-2008), when there were only 1361 (31%) patients in total. Since 2009, this number increased significantly, and there were 2912 (68%) patients from 2009 to 2011. Comparing the indications between the first 5 years and the last 3 years, non-thyroid or salivary-gland neck mass (44%) was the most common indication in the former period, and thyroid gland disease (47%) was the most common indication in the latter period (p<0.001). The indication for salivary gland disease increased in number (123 vs. 265), but the proportion was stable (9.0% vs. 9.1%) between the first 5 years and the last 3 years (Figure 3B). The other indications increased in both patient number (88 vs. 212) and proportion (6.5% vs. 7.2%) (Figure 3B). There were 2048 (48%) patients who received FNA for cytology. The FNA rates were similar between the first 5-year period and the last 3-year period (46% and 49%).
Figure 4: 4273 patients receiving head and neck ultrasounds between 2003 and 2011.

Discussion

In the past, otolaryngologists had no ultrasound training during their residency, so most are not familiar with the ultrasound examination and have to rely on the reports of thyroid gland disease from radiologists [1]. For cervical lymph nodes, salivary gland disease and other lateral neck masses, CT or MRI are much more commonly used imaging tools than is ultrasound in most hospitals. With the advances in ultrasound imaging processing and its operation in recent years, ultrasound examination is much easier to perform, and the ultrasound anatomy is also recognized much more easily [1]. Especially for otolaryngologists or head and neck surgeons, who are familiar with normal and pathological anatomies, it is easier to interpret the ultrasound images. Therefore, otolaryngologists are the good candidates to perform the ultrasound examination as well. It is a better way to learn the ultrasound technique and interpretation through a well training program or course, it is also possible for otolaryngologists to perform and be familiar with the ultrasound examination through self-learning. Based on my experience, the beginner can practice using the ultrasound on normal people and patients in great detail without a time limit at first, and then they can gradually increase the number to obtain the experience of normal variations and diseases with increasing confidence. The beginners are encouraged to perform fine needle aspiration (FNA) under the guidance of an ultrasound to improve the technique and to reduce the potential misinterpretation of the ultrasound findings. As an example, I examined only 200-300 patients per year in the first 5 years and performed FNA for almost half of them. Afterward, the beginner can do more examinations with more knowledge of the ultrasound. Certainly, with formal training during residency, the learning process will be easier and shorter, and the beginner can do around 1000 cases per year after 3-year practice [10].
The ultrasound has been the standard imaging method for thyroid gland disease and has been the most recommended imaging tool for thyroid nodules for many years [5,11]. However, general surgeons, not otolaryngologists, were in charge of surgery for thyroid tumors in Taiwan in the past. Therefore, non-thyroid or salivary-gland neck masses, mostly cervical lymph nodes, were the most common indications for head and neck ultrasound in the Department of Otolaryngology in the first years. With head and neck ultrasound being performed by an otolaryngologist, more and more patients with thyroid disease visited otolaryngology outpatient clinics, and thyroid surgery is becoming more and more common at the Department of Otolaryngology in recent years. By use of the ultrasound, we can evaluate a patient with thyroid nodules from the first visit to the follow-up with or without operation by ourselves. Thus, thyroid gland disease is now becoming the more common application of head and neck ultrasound than non-thyroid or salivary-gland neck mass. In total, thyroid gland disease is the most common indication for the head and neck ultrasound.
Despite some controversies over the accuracy and benefits of the ultrasound for the evaluation of cervical lymph nodes compared to those of CT and MRI, the evaluation of the cervical lymph nodes is the second most common indication for head and neck ultrasound. Thanks to the previous efforts of many sonographists on this issue, the cervical lymph nodes can be evaluated using ultrasound with a good accuracy [3,7,10,12,13]. Although CT and MRI are still nonreplaceable for the evaluation of the cervical lymph nodes, the ultrasound has at least three advantages over CT/MRI. First, because most of cervical lymph nodes are superficial, the high-frequency ultrasound scanner can be used for the detection of the lymph nodes and intranodal focal lesions with a 2 mm resolution, which is much better than the resolution achieved with CT or MRI. Therefore, the ultrasound can show smaller lymph nodes and their contents in detail, which can potentially assist in the nature of the lymph nodes. Second, the ultrasound can provide the information of the lymph nodes more than the morphology provided by CT/MRI, such as the vasculature and the hardness. The former includes the vascular distribution pattern and the hilum blood flow index (e.g., resistive index) for each lymph node, which are helpful for the differential diagnosis of malignant, normal and inflammatory processes. The elastography can show the hardness of the lymph nodes, which is theoretically well correlated with the malignancy, although this technology needs improvement [14,15]. More importantly, tissue diagnosis can be obtained, either cytology through FNA or pathology through core needle biopsy, under real-time ultrasound guidance. Especially for cervical lymph nodes, it is sometimes difficult to obtain the specimen through CT/MRI-guided aspiration or biopsy. This may be one of the reasons why head and neck oncologists in Europe frequently use the ultrasound to evaluate the neck for newly diagnosed head and neck cancer [16].
Salivary gland disease is another important indication for the head and neck ultrasound [17,18]. The parotid and submandibular glands are the most common salivary glands examined by the ultrasound [17]. Although it is still difficult for ultrasound to distinguish benign and malignant major salivary gland tumors, ultrasound seems better able to detect submandibular gland tumors or diseases than do CT/MRI. For example, chronic sclerosing sialadenitis, IgG4- related sialadenitis and some submandibular gland tumors are easily detected by ultrasound, but they are not obvious by CT/MRI [19,20]. Regarding the parotid gland, the ultrasound shows the tumor lesions in the superficial lobe well, but the deep lobe is the blind spot of the ultrasound when using a high-frequency scanner because the highfrequency ultrasound wave cannot travel through the whole thickness of the parotid gland [17]. In my experience, there is still a room for improvement in the application of the head and neck ultrasound in salivary gland disease.
When one is familiar with the ultrasound technique and the pathological anatomy of head and neck diseases, there are more and more new applications of the ultrasound in head and neck diseases in addition to those of the thyroid gland, cervical lymph nodes and salivary glands. Therefore, the patients receiving head and neck ultrasounds for other indications have increased significantly in recent years. Because our previous studies showed that vocal fold movement can be observed by the ultrasound, especially in women, and the ultrasound can identify the underlying diseases for adult unilateral vocal fold paralysis, vocal fold paresis and dysphonia are becoming more common indications for the head and neck ultrasound [21,22]. Although its role remains uncertain, dysphagia and lumping throat are also becoming more common indications for the use of ultrasound. Because otolaryngologists are specialists in the head and neck field and know the specific needs for clinical practice, otolaryngologists may be the best clinicians to develop new applications of the ultrasound in the head and neck field [1,23].
Certainly, the ultrasound technique still has some limitations for evaluation in the head and neck field. First, the deep lobe of the parotid gland and the upper level II near the skull base cannot be observed clearly by the ultrasound. Additionally, the pharynx cannot be observed clearly. The tongue can be seen clearly, but it requires a lower-frequency scanner. Second, the ultrasound is operatordependent, and the resulting pictures are sometimes difficult for nonoperators to interpret in the manner of a CT or MRI. This limitation can be overcome in part, however, through basic ultrasound training.

Conclusion

Thyroid gland, cervical neck mass and major salivary gland diseases can be the indications for head and neck ultrasound. Otolaryngologists are performing more and more head and neck ultrasound examinations in clinical practice and are more familiar with the ultrasound equipment, interpretation and indications and may be the best clinicians to develop new applications of the ultrasound in the head and neck field according to their needs.

Acknowledgement

This work was supported by the National Taiwan University Hospital (NTUH.98- M1238). We thank Division of Ultrasound, Department of Integrated Diagnostic & Therapeutics, National Taiwan University Hospital for supporting the ultrasound equipments during the study.

References
























Track Your Manuscript

Media Partners

Associations