Diagnostic Imaging of Salivary, Parathyroid and Thyroid Glands

1. Head & Neck
Salivary, Parathyroid and
Thyroid Glands

2. Mohamed Zaitoun
Assistant Lecturer-Diagnostic Radiology
Department , Zagazig University Hospitals
Egypt
FINR (Fellowship of Interventional
Neuroradiology)-Switzerland
zaitoun82@gmail.com

5. Knowing as much as
possible about your enemy
precedes successful battle
and learning about the
disease process precedes
successful management

6. Salivary, Parathyroid and Thyroid
Glands
a) Salivary Glands
b) Parathyroid Glands
c) Thyroid Gland

7. a) Salivary Glands :
1-Sialolithiasis
2-Sialosis
3-Sialoadenitis
4-Sjogren Disease
5-Cystic Salivary Lesions
6-Parotid Tumors

8. 1-Sialolithiasis : (Calculi)
a) Incidence
b) Location
c) Radiographic Features

9. a) Incidence :
-Refers to formation of concrements (sialoliths)
inside the ducts or parenchyma of salivary
glands and most commonly occurs in
the submandibular glands and their ducts
-Most common disease of salivary glands
accounting for approximately 50% of all major
salivary gland pathology
-Disease of adults , typically between 30 and 60
years of age , there is a male predilection

10. b) Location :
-Submandibular gland , 80% :
Most calculi are radiopaque (80%-90%)
-Parotid , 20% :
50% of calculi are radiopaque

11. c) Radiographic Features :
-Radiopaque calculi can often be seen on
plain films or CT
-Radiolucent calculi are best demonstrated
by sialography, typically shows a contrast
filling defect and ductal dilatation
-U/S : stones appear as strongly
hyperechoic lines or points with distal
acoustic shadowing represent stone

14. CT+C of the neck demonstrates a stone (blue arrow) in the
submandibular region of a dilated Wharton's Duct (red arrow)

15. RT Wharton duct stone

16. LT Wharton duct

17. RT Wharton duct stone

21. Submandibular duct (Wharton duct), lateral-oblique conventional
sialography confirms the presence of a 2-mm calculus (arrowhead),
the proximal portion of the Wharton duct is better visualized
because of retrograde filling of the ductal system (arrow)

22. Lateral-oblique conventional sialography shows a filling defect that
corresponds to a small calculus (arrow)

23. Parotid gland duct (stensen duct), AP conventional sialography
obtained shows a filling defect that suggests a small calculus
(arrow)

26. Submental US image confirms the diagnosis of a 3-mm calculus
(arrowhead), crosshairs indicate lateral borders of the stone,
SMG = submandibular gland, W = Wharton duct

27. Transverse US image confirms the diagnosis of a 3-mm calculus
(arrow), crosshairs indicate borders of stone. S = dilated Stensen
duct

28. MRI (Transverse 3D-EXPRESS source image) shows a 3-mm calculus (large
arrow) in the right Wharton duct at the level of the posterior edge of the
mylohyoid muscle. Small arrow points to the normal opposite Wharton duct

29. MR sialography shows 2-4-mm stones (arrowheads) within the anterior
third of the Wharton duct and shows ductal dilatation and associated
sialodochitis with a small diverticular outpouching (arrow)

30. 2-Sialosis :
-Recurrent noninflammatory enlargement of
parotid gland (acinar hypertrophy, fatty
replacement)
-Causes :
1-Cirrhosis
2-Malnutrition, alcoholics
3-D.M.
4-Drugs (thiourea, reserpine, phenylbutazone &
heavy metal)

31. -Radiographic Features :
1-Sialography :
-Sparse peripheral ducts
2-U/S :
-Reveals enlarged, hyperechoic salivary glands with a
poorly visible deep lobe but without focal lesions or
increased blood flow
3-CT &MRI :
-Normal or enlarged gland
-Normal density throughout most of the disease
-End stage glands may be diffusely dense and large

32. (a) MRI showing normal parotid gland, (b) MRI showing bilateral
enlarged parotids in sialosis

33. 3-Sialoadenitis :
a) Incidence
b) Etiology
c) Radiographic Features

34. a) Incidence :
-Refers to inflammation of the salivary
glands
-It may acute or chronic and has a wide
range of causes
-The submandibular glands are the most
commonly affected

35. b) Etiology :
1-Acute Sialoadenitis :
-Bacterial or viral
-Abscess may form
2-Chronic (Recurrent) Sialoadenitis :
-Recurrent infection due to poor oral hygiene
-Sialography : multiple sites of peripheral ductal
dilatation
-Small gland
3-Granulomatous Inflammation :
-Causes : sarcoid , TB , actinomycosis , cat-
scratch disease & toxoplasmosis
-Produces intraglandular masses indistinguishable
from tumors , biopsy is therefore required

36. HRUS images show bilateral diffusely hypoechoic parotid gland with
small hypoechoic nodular lesions in a patient of granulomatous
parotitis

37. Non-contrast T1 axial images show intraparotid adenopathy (white
arrows) with altered appearance in a case of tuberculosis of left
parotid gland

38. c) Radiographic Features :
1-Sialography
2-U/S
3-CT
4-MRI

39. 1-Sialography :
-Sialography is contraindicated in acute sialadenitis
because it can worsen the infection
2-U/S :
-In acute sialadenitis the affected gland appears enlarged,
hypoechoic and hyperaemiac
-In chronic infective forms the affected gland appears
atrophic and diffusely hypoechoic with irregular margins,
the ultrasound appearances have been likened to that of
a “cirrhotic” liver, may contain multiple small, oval,
hypoechoic areas

40. Power Doppler US image shows an acutely inflamed right
submandibular gland (arrows) containing a stone (arrowhead), the
gland is enlarged and hypoechoic with rounded edges and
increased blood flow

41. Power Doppler US image shows chronic inflammation of the left
submandibular gland (arrowheads), the gland is inhomogeneous
with decreased parenchymal echogenicity but without increased
blood flow, arrows = stones

42. Gray-scale US image shows an acutely inflamed right parotid gland
(arrows) in a 5-year-old child, the gland is enlarged and
inhomogeneous with multiple small, oval, hypoechoic areas
(arrowheads)

43. 3-CT :
-Enlarged salivary gland with abnormal
attenuation, indistinct margin and vivid contrast
enhancement with associated adjacent fat
stranding and/or thickening of deep cervical
fascia that is typically unilateral
-Dilated duct from sialolithiasis or stenosis
-Enlarged intra or extra-glandular lymph nodes
may also be seen but this is non-specific and
can occur in other conditions such as
malignancy
-Abscesses are hypodense fluid collections which
may or may not be loculated

44. Acute submandibular sialadenitis, (a) Axial CT+C shows inflammation and
asymmetric enhancement of the right submandibular gland, (b) Axial CT+C
shows dilatation of the main submandibular duct, which contains a sialolith
(arrow)

45. CT+C shows hypodense, enlarged right submandibular gland with
calculus (thick white arrow) and thickening of adjacent fascia (thin
white arrow)

46. Coronal and sagittal CT images show an enlarged left submandibular
gland with two well-defined rim enhancing fluid collections in the
anterior aspect of the gland, representing abscesses, there is
adjacent subcutaneous fat stranding

47. Acute suppurative parotiditis, CT+C shows marked enlargement of the
right parotid gland, glandular parenchyma demonstrates diffuse
enhancement, and irregular areas of low attenuation are seen, a
finding indicative of intraparotid abscesses

48. 4-MRI :
-The salivary gland is often enlarged
-The affected gland can range from well defined to poorly
defined
-Signal characteristics in majority of cases tend to be
heterogenous
*T1 :
Acute : low signal
Chronic : inhomogenous low signal
*T2 :
Acute : high signal
Chronic : low to intermediate due to fibrosis
*T1+C :
Vivid contrast enhancement

49. Acute right-sided parotitis, T1+C, fat-saturated shows marked
enhancement of the right parotid gland (thick and thin arrows)
compared with the left, the superficial subcutaneous tissue is also
inflamed

50. T1+C shows severe parotitis on left side (white arrows)

51. 4-Sjogren Disease :
a) Incidence
b) Clinical Picture
c) Radiographic Features

52. a) Incidence :
-It is a chronic autoimmune disorder
involving mainly the salivary and lacrimal
glands
-It is the 2nd commonest autoimmune
disorder after rheumatoid arthritis
-More in females, F:M = 9:1
-Patients typically present around the 4th to
5th decades

53. b) Clinical Picture :
-Sicca complex : dry eyes
(keratoconjunctivitis sicca) & xerostomia
(dry mouth)
-Bilateral parotid enlargement
-Systemic disease : rheumatoid arthritis

54. c) Radiographic Features :
1-Sialography
2-U/S
3-CT
4-MRI

55. 1-Sialography :
-Sialography patterns :
1-Punctate : normal central and peripheral ductal
system, punctate (1 mm) parenchymal contrast
collections
2-Globular : normal central system, peripheral duct
system does not opacify, larger (>2 mm)
extraductal collections
3-Cavitary : >2 mm extraductal collections
4-Destructive : ductal structures not opacified

56. MR sialogram of the normal parotid gland duct in a healthy volunteer,
main duct and intraglandular ducts are well seen.

57. MR sialography in a patient with Sjogren syndrome, diffuse areas of
punctate high signal intensity 1 mm or less in diameter are
distributed through the duct (stage 1 punctate appearance)

58. MR sialogram in a patient with Sjogren syndrome, areas of spherical
high signal intensity 1 to 2 mm in diameter are evident (stage 2,
globular appearance)

59. MR sialogram in a patient with Sjogren syndrome, large and irregular
areas of high signal intensity up to 1 cm in diameter are noted
(stage 3, cavitary appearance)

60. MR sialogram in a patient with Sjogren syndrome, the main duct shows
marked dilatation and irregular branching (stage 4, destructive
appearance)

61. MR Sialography: sialoadenitis classification in Sjogren syndrome.
Stage I (A), stage II (B), stage III (C), stage IV (D)

62. 2-U/S :
-Early : enlarged and hyperechoic
-Late : multicystic or reticular pattern within
an atrophic gland
3-CT & MRI :
-Parotid gland enlargement
(lymphoepithelial proliferation), 50%
-Parenchymal heterogeneity, cystic
degeneration & fatty replacement

63. Gray-scale (a) and power Doppler (b) US images show advanced-
stage Sjögren syndrome in the parotid gland, the gland has an
inhomogeneous structure with multiple small, oval, hypoechoic
areas (arrowheads) and increased blood flow, the position of the US
probe is shown in the inset diagram

64. Sialography (A and B) and sonography (C and D) of the parotid glands in patients who
presented with sicca syndrome (dry eyes and dry mouth), normal glands (A and C),
and glands affected by Sjogren syndrome (B and D) are shown for comparison,
sialography of the parotid glands with Sjogren syndrome shows characteristic
globular (B) staining patterns, sonography of the parotid glands with Sjogren
syndrome shows irregular echogenicity and multiple hyperechoic bands and
hypoechoic areas in the gland (D)

65. Sjögren disease, while both parotid glands (arrowheads) show cystic
changes in and enlargement of the gland on this coronal T2, the left
side also shows periparotid adenopathy (arrow)

66. 5-Cystic Salivary Lesions :
a) Mucus Retention Cyst
b) Ranula
c) Mucocele
d) Benign lymphoepithelial cysts (BLCs)
e) Cystic tumors (Warthin's)

67. a) Mucus Retention Cyst :
-True cyst with epithelial lining

68. Parotid retention cyst

69. b) Ranula :
1-Incidence
2-Types
3-Radiographic Features
4-Differential Diagnosis

70. 1-Incidence :
Retention cyst from sublingual glands in floor of
mouth
2-Types :
a) Simple Ranula :
-Confined to the sublingual space
b) Plunging Ranula :
-Also known as diving ranula or cervical ranula
-As a simple ranula enlarges it dissects along
facial planes beyond the confines of the
sublingual space

71. Simple ranula

72. Plunging ranula, CT+C shows a non-enhancing, water-density mass from the
right sublingual space displacing the tongue to the left, a large component of
the mass extends posterolaterally into the submandibular space (small
arrow), It is non-enhancing, homogenous, smoothly-marginated, and without
internal septations, smooth tapering anteriorly into the sublingual space,
forming the “tail sign” (large arrow)

73. 3-Radiographic Features :
-The key to diagnosing a ranula, especially
in cases where they are large and have
dissected some distance away form their
origin is identification of a connection to
the sublingual space, this may be no more
than a thin tail of fluid or a significant local
fluid collection

74. a) U/S :
-Thin walled cystic lesion and can be
imaged both from the skin or trans-orally
with a small probe
-If infected the walls are thicker and the fluid
content more echogenic
b) CT & MRI :
-Like branchial cleft and thyroglossal cysts

75. US shows space occupying mass with 62×25 mm, which
was cyst like with capsule

76. CT scan shows a large mucous retention cyst arising from
the sublingual gland (ranula)

78. Plunging ranula

79. Plunging ranula, CT+C shows a cystic attenuation lesion (arrows) in
the floor of the mouth with a characteristic 'tail sign' extending into
the submandibular space

80. Simple ranula, (a) In the right sublingual gland, the hyperintense lesion (arrow)
on this transverse T2 could represent a pleomorphic adenoma or a cyst,
(b) The absence of enhancement on this fat-saturated, T1+C suggests a
cystic lesion, in this case a simple ranula of the sublingual gland

81. Plunging ranula, (A) Axial T1 and the (B) Coronal T2 show a cystic
lesion having a fluid signal in the floor of the mouth

82. c) Mucocele :
-Extravasation cyst
-Results from ductal rupture and mucous
extravasation
-Not a true cyst, composed of granulation
tissue

83. Mucocele of submandibular gland, (a) Noncontrast axial CT
image shows a hypodense lesion in the left
submandibular region, (b) CT+C image shows a
mucocele of submandibular gland on left side

84. d) Benign lymphoepithelial cysts (BLCs) :
-HIV+ patients
-Associated adenopathy and lymphoid
hyperplasia
-They typically present as bilateral parotid
cysts, superficial in location, in lymph
nodes

85. HIV-related lesions, CT+C depicts a right-sided parotid cyst (straight
arrow) and multiple small nodules in the left parotid gland (curved
arrow) in this patient who was HIV positive

86. e) Cystic tumors (Warthin's) :
1-Incidence
2-Radiographic Features

87. 1-Incidence :
-They are the 2nd most common (up to 10% of all
parotid tumors) benign parotid tumor
(after pleomorphic adenoma) and are the
commonest bilateral or multifocal benign parotid
tumor
-It typically occurs in the elderly (6th decade)
-Usually solitary, unilateral, and slow growing
-Bilateral in 10%
-Male > female
-Has a greater tendency to undergo cystic change
(~30%) than any other salivary gland tumor
-Accumulation of pertechnetate

88. 2-Radiographic Features :
a) US :
-Well-defined, lobulated, intermediate signal intensity mass
with cystic areas
b) CT :
-Classic appearance is a cystic lesion posteriorly within the
parotid with a focal tumor nodule
-Relatively well defined
-Cystic changes appear as intra lesional lower attenuation
-No calcification

89. Gray-scale US image shows the typical appearance of a Warthin tumor
(arrows), the lesion, which is located in the lower pole of the parotid
gland, is oval, well defined, hypoechoic, and inhomogeneous with
multiple irregular anechoic areas (arrowheads) and posterior
acoustic enhancement

90. CT+C shows a tumor with well defined margins and heterogenous
contrast enhancement with multifocal cystic portion

91. RT warthin tumor

92. c) MRI :
-Well defined and can be bilateral.
*T1 : low to intermediate signal with cyst
containing cholesterol components
containing focal high signal 2
*T2 : heterogenous and variable signal
intensity
*T1+C : usually no contrast enhancement

93. (a) STIR shows the tumor with moderate-to-high signal intensity, the high-
signal-intensity area is a cystic lesion (*); the area showed no enhancement
on contrast-enhanced images (c, region of interest 2), (b) T1 shows a
hypointense tumor, (c) Fat suppression T1+C shows solid (region of
interest 1) and cystic (region of interest 2) tumor in the inferior pole of the
parotid gland

94. Bilateral Warthin tumors, bilateral parotid masses (arrows) are seen on
this transverse, contrast material-enhanced, fat-saturated T1, the
multiplicity and location at the tail of the parotid gland (near the
lower mandible) are typical features of this tumor

95. Bilateral parotid Wartin tumor, cervical MRI: axial (a, b) unenhanced T1, (c) T2 and (d)
T1+C fat-saturated : two intraparotid masses, the right mass is ovoid and well
circumscribed with an intermediate signal on T1 and intermediate and homogeneous
signal on T2.The left mass is lobuled and heterogenous with high signal areas on T1,
low signal intensity on T2 and a moderate contrast enhancement

96. 6-Parotid Tumors :
a) Benign : 80 %
1-Pleomorphic adenoma (most common), 70%
2-Warthin's tumor
3-Rare : oncocytoma, hemangioma & adenoma
b) Malignant : 20 %
1-Mucoepidermoid carcinoma, 5%
2-Carcinoma arising from pleomorphic adenoma, 5%
3-Adenoid cystic carcinoma (cylindroma), 2%
4-Adenocarcinoma, 4%
5-SCC, 2%
6-Oncocytic carcinoma, 1%

97. -Pleomorphic Adenoma : (Mixed Tumor)
a) Incidence
b) Location
c) Radiographic Features
d) Differential Diagnosis

98. a) Incidence :
-The most common salivary gland tumors
-Account for 70-80% of benign salivary
gland tumors and are especially common
in the parotid gland

99. b) Location :
-Parotid gland : 84% , commoner in the
superficial lobe
-Submandibular gland : 8%
-Minor salivary glands : 6.5% , widely
distributed including the nasal cavity ,
pharynx , larynx & trachea
-Sublingual glands : 0.5%

100. c) Radiographic Features :
1-U/S
2-CT
3-MRI

101. 1-U/S :
-Typically hypoechoic
-May show a lobulated distinct border +/-
posterior acoustic enhancement
-Useful in guiding biopsy (both FNAC and
core biopsies) but needs to be carried out
with care to avoid facial nerve damage

102. Gray-scale US image shows the typical appearance of a pleomorphic
adenoma (arrows), the lesion is hypoechoic and lobulated with
distinct borders and posterior acoustic enhancement

103. US image shows an inhomogeneous pleomorphic
adenoma (arrows)

104. Power Doppler US image shows a pleomorphic adenoma (arrows) in
the lower pole of the parotid gland, no blood vessels are visible in
the lesion

105. 2-CT :
-Well-circumscribed encapsulated mass
-Calcification in a parotid mass is very
suggestive of pleomorphic adenoma
-Moderate enhancement

106. Submandibular pleomorphic adenoma, CT+C shows that the
pleomorphic adenoma (A) arises in the right submandibular gland.
The attenuation characteristics leave little indication as to whether
the lesion is benign or malignant

107. Pleomorphic adenoma in the parotid gland in a 29-year-old woman,
(a) Transverse early phase helical CT scan shows a well-defined mass
(arrows) in the superficial lobe of the right parotid gland. There is mild
enhancement of the tumor, (b) Transverse delayed phase scan shows
homogeneous and strong enhancement of the tumor (arrows)

108. Axial CT (encircled area enlarged) showing, (a) well-defined,
hypodense, heterogeneous mass in the left parotid gland (white
arrow) with poorly defined anteromedial margin (black arrow); (b)
variable areas of low attenuation seen on the posterior aspect of the
superficial lobe (white arrow)

109. 3-MRI :
*T1 : low
*T2 : high, often have a rim of decreased signal intensity on
T2 representing the surrounding fibrous capsule
*T1+C : homogenous enhancement
-MRI characteristics that suggest malignancy :
1-Irregular margins
2-Heterogeneous signal
3-Lymphadenopathy
4-Adjacent soft tissue or bone invasion
5-Facial perineural spread

110. Pleomorphic adenomas, (a) T1 shows the mass (P) to be well highlighted
against the normal hyperintensity of the parotid gland, the margination is not
particularly sharp, yet the diagnosis was pleomorphic adenoma, (b) The
mass (P) is hyperintense T2, (c) The mass (P) enhances on this T1+C,
though it has a central nonenhancing component

111. Pleomorphic adenoma, (a) T2 shows that the lesion (*) is hyperintense, this
may raise the question of a cyst versus a pleomorphic adenoma, (b) With
administration of a gadolinium-containing contrast agent and fat saturation,
the mass (*) is seen to enhance avidly on this coronal T1+C, compatible
with a solid mass

112. Pleomorphic adenoma of the superficial lobe of the left parotid gland.
Cerical MRI, Coronal (a) T1 and (b) fat-supressed T2 : well
circumscribed intra parotid mass with low and heterogenous
intensity on T1 and a very high signal on T2

113. Non-contrast T2 & T1 axial images (upper row) and T2 coronal & DW
axial images (lower row) show pleomorphic adenoma of right parotid
gland (white arrows)

114. d) Differential Diagnosis :
-When in the parotid gland consider :
1-Warthin tumor
2-Mucoepidermoid carcinoma
3-Myoepithelioma
4-Adenoid cystic carcinoma (ACC)
5-Parotid nodal metastasis
6-Parotid non-Hodgkin lymphoma
7-Intra parotid facial nerve schwannoma

115. -Malignant Tumors :
1-Mucoepidermoid carcinoma
2-Carcinoma arising from pleomorphic
adenoma
3-Adenoid cystic carcinoma (cylindroma)
4-Adenocarcinoma
5-SCC
6-Oncocytic carcinoma
*Areas of necrosis due to infarction (rapid
growth)
*Locally invasive and aggressive
*Lymph node metastases

116. Mucoepidermoid carcinoma of the parotid gland, transverse CT scan
shows an ill-defined mass (C) that has less attenuation than that of
enhancing parotid tissue in the right parotid gland

117. (A) CT+C shows a heterogeneously enhancing lesion in the right the
parotid gland in a case of Mucoepidermoid carcinoma, the (B) Axial
CT scan in an adenoidocystic carcinoma shows a multi-cystic
infiltrating lesion in the left parotid region

118. Mucoepidermoid carcinoma of the parotid gland, (a) T2 shows an
intermediate-signal-intensity mass (arrow) slightly lower in intensity
than that of the native parotid tissue, (b) The ill-defined nature of the
mass (arrow), the diagnosis was high-grade Mucoepidermoid
carcinoma

119. Parotid Mucoepidermoid carcinoma, cervical MRI: axial (a) T2 and (b) T1+C fat-
saturated : ovoid and well-circumscibed mass of the right parotid gland, this
lesion has an hetrogenous signal with predominantly low signal on T1 and
high signal on T2, and enhances heterogeneously after injection of
Gadolinium (b)

120. CT+C shows malignant pleomorphic adenoma of right
parotid gland (white arrows)

121. Non-contrast T2 & T1 axial images (upper row) and T2 coronal & DW
axial images (lower row) show pleomorphic adenoma of right parotid
gland (white arrows)

122. CT+C shows enlarged left submandibular gland (thick white arrow)
associated with destruction of the adjacent mandible (thin white
arrow) in a case of adenoid cystic carcinoma

123. b) Parathyroid Glands :
1-Hyperparathyroidism
2-Parathyroid Adenoma
3-Hypoparathyroidism

124. 1-Hyperparathyroidism :
a) Incidence
b) Types
c) Clinical Picture
d) Effect of PTH
e) Radiographic Features

125. a) Incidence :
-Usually detected by increased serum
calcium during routine biochemical
screening
-Incidence : 0.2% of the general population
-Female > male

126. b) Types :
1-Primaryhyperparathyroidism :
-Adenoma, 80%
-Hyperplasia, 20%
-Parathyroid carcinoma, rare
2-Secondary hyperparathyroidism :
-Renal failure
-Ectopic parathormone (PTH) production by
hormonally active tumors
3-Tertiary hyperparathyroidism : results from
autonomous glandular function after long-
standing renal failure

127. c) Clinical Picture :
-GI complaints
-Musculoskeletal symptoms
-Renal calculi

128. d) Effect of PTH :
-Increases vitamin D metabolism
-Increases renal calcium reabsorption
(hypercalcemia)
-Increases bone resorption
-Decreases renal PO4 resorption
(hypophosphatemia)

129. e) Radiographic Features :
1-Parathyroid :
-Single parathyroid adenoma, 80%
-Hyperplasia of all 4 glands, 20%
2-Bone :
-Osteopenia
-Subperiosteal resorption (virtually
pathognomonic)
-Brown tumors
-Soft tissue calcification
3-Renal :
-Calculi (due to hypercalciuria)

130. 55-year-old woman with primary hyperparathyroidism due to large left
superior adenoma, sonogram shows hypoechoic nodule suspected
of being parathyroid medial to common carotid artery (arrow)

131. 15-year-old girl with hyperparathyroidism due to parathyroid
hyperplasia, sonograms show four slightly enlarged parathyroid
glands (arrows): right superior (A), right inferior (B), left superior (C),
and left inferior (D)

132. Subperiosteal resorption

133. Subperiosteal resorption that has resulted in severe tuftal resorption
(white arrows) , also note the subperiosteal and intracortical
resorption of the middle phalanges (black arrows)

134. Subperiosteal resorption that has resulted in severe tuftal
resorption (arrows)

135. Brown tumor

136. Brown tumor

137. Brown tumor

138. Brown tumors

139. 2-Parathyroid Adenoma :
a) Incidence
b) Radiographic Features

140. a) Incidence :
-Adenomas may consist of pure or mixed
cell types, with the most common variant
composed principally of chief cells
-Some cases are associated with the
multiple endocrine neoplasia (MEN) I
syndrome
-80% single, 20% multiple

141. Diagram shows posterior view of typical locations of paired superior (white
arrows) and inferior (arrowheads) parathyroid glands and their relationship
to thyroid gland and surrounding structures, note close relationship
parathyroid glands have with recurrent laryngeal nerves (black arrows),
illustrating why nerve injury is a significant concern of endocrine surgeons,
particularly with four-gland explorations

142. b) Radiographic Features :
1-Detection :
-US and scintigraphy are the best screening
modalities
-Adenomas are hypoechoic on US
-If US is negative, further evaluation with CT or
MRI may be helpful
-Angiography is reserved for patients with negative
neck explorations and persistent symptoms

143. -Location :
*Adjacent to thyroid lobes
*Thoracic inlet
*Prevascular space in mediastinum (not in
posterior mediastinum); the inferior glands follow
the descent of the thymus (also a 3rd pouch
derivative)
2-Angiography :
-Adenomas are hypervascular
-Arteriography is most often performed after
unsuccessful surgery and has a 60% success
rate in that setting
-Venous sampling and venography: 80% success
rate after unsuccessful neck explorations

145. Parathyroid adenoma : CT+C through the neck at the level of the
thyroid gland reveals an enhancing nodule posterior to the inferior
right thyroid lobe, compatible with a parathyroid adenoma

146. Axial CT images in noncontrast (A) early post-contrast (B) and delayed post-
contrast (C) phases demonstrate an intrathyroidal lesion with subtle
hypodensity on precontrast imaging and delayed enhancement, this
enhancement pattern is seen less commonly than early enhancement and
washout

147. A 63-year-old woman with primary hyperparathyroidism, CT demonstrates
avidly enhancing lesions in the orthotopic superior location (arrows)
bilaterally with rapid washout of contrast greater than that of the adjacent
thyroid gland (A and D: noncontrast phase; B and E: initial postcontrast
“arterial” phase; C and F: delayed postcontrast phase), this patient
underwent bilateral exploration, and bilateral superior parathyroid adenomas
were found at surgery

148. 3-Hypoparathyroidism :
a) Etiology
b) Types
c) Radiographic Features

149. a) Etiology :
1-Idiopathic :
-Rare; associated with cataracts, mental
retardation, dental hypoplasia, obesity, dwarfism
2-Secondary :
Surgical removal (most common)
-Radiation
-Carcinoma
-Infection

150. b) Types :
1-Hypoparathyroidism :
-Surgical removal (most common cause)
2-Pseudohypoparathyroidism :
-End-organ resistance to PTH (hereditary)
3-Pseudo-pseudohypoparathyroidism :
-Only skeletal abnormalities (Albright's
hereditary osteodystrophy)

151. c) Radiographic Features :
-Generalized increase in bone density, 10%
-Calcifications in basal ganglia
-Other calcifications: soft tissues, ligaments,
tendon insertion sites

152. Marked bone sclerosis with the presence of lines parallel to the cortex
of the vertebral bodies giving rise to an image of a small copy of the
vertebral body within the body, a sign called “bone within a bone”

154. C) Thyroid :
1-Thyroid Nodule
2-Thyroid Follicular Adenoma
3-Thyroiditis
4-Grave’s Disease
5-Thyroid Cyst
6-Ectopic Thyroid
7-Thyroid Cancer
8-Photopenic Areas in Radionuclide Thyroid
Scanning

155. 1-Thyroid Nodule :
-Benign nodule versus Malignant nodule
a) Nodule Characters
b) Peripheral Halo
c) Nodule Margin
d) Calcification
e) Doppler Flow
f) Metastases

156. Transverse US image shows the homogeneous echogenicity of the
normal thyroid tissue and the normal thickness of the isthmus

157. A. Malignant, longitudinal US image of papillary thyroid carcinoma in 42-year-old woman
shows marked hypoechogenicity, spiculated margin, microcalcifications, and taller-
than-wide shape for nodule, B. Suspicious for malignancy, longitudinal US image of
papillary thyroid carcinoma in 42-year-old woman shows marked hypoechogenicity,
smooth margin, and ovoid shape, C. Borderline, transverse US image of nodular
hyperplasia in 60-year-old woman shows macrocalcification in peripheral portion of
nodule, patient underwent right lobectomy of thyroid, despite benign cytology upon
US-guided fine-needle aspiration, for pathologic confirmation. D. Probably benign,
longitudinal US image of benign nodule in 57-year-old woman shows isoechogenicity
and smooth margin. E. Benign, longitudinal US image of benign nodule in 46-year-old
woman shows ovoid shape, isoechogenicity, and smooth margin

158. a) Nodule Characters :
1-Benign :
-Cystic nodule +/- debris +/- septations
-Posterior acoustic shadowing
-Hyperechoic halo
-Comet tail artifact (colloid nodule)
-Multiple isoechoic nodules (MNG)
-Multiple hypoechoic nodules (Hashimoto
thyroiditis)
-Intermediate : a solid well defined nodule +/-
cystic components

159. 2-Malignant :
-Solid nodules
-No posterior acoustic shadowing
-In a solid hyperechoic nodule the incidence
of malignancy is 5%
-In a solid isoechoic nodule the incidence of
malignancy is 25%
-In a solid hypoechoic nodule the incidence
of malignancy is 65%

160. Cystic lesion with mural nodule, the mural nodule has a
homogenous echotexture

161. Thyroid nodule in longitudinal and transverse planes within calipers that
has a homogeneous echogenicity is also isoechoic to the
surrounding thyroid gland parenchyma

162. Malignant thyroid nodule demonstrating two suspicious ultrasound
features - marked hypoechogenicity (compared to strap muscle) and
taller than wide (AP diameter > transverse diameter)

163. b) Peripheral Halo :
1-Benign :
-Thin uniform halo
2-Malignant :
-An incomplete , irregular or thickened halo

164. Transverse US image shows a predominantly solid 2.4-cm nodule with
well-circumscribed margins and a surrounding halo (benign US
features)

165. c) Nodule Margin :
1-Benign :
-Smooth regular margins
2-Malignant :
-An irregular , lobulated or poorly defined margin
d) Calcification :
1-Benign :
-This is generally absent (eggshell calcification may be
present)
2-Malignant :
-Microcalcification fine or coarse calcification (commonly▶
papillary or medullary carcinomas)

166. Gray scale image of a benign nodule in a patient with thyrotoxicosis
(within calipers), this nodule has a regular margin and is
heterogeneous with no calcification, color Doppler revealed normal
blood flow, final diagnosis was colloid goiter

167. Thyroid nodule with an irregular margin

168. Thyroid nodule with macrocalcifications

169. Thyroid nodule (within calipers) with microcalcifications

170. (a) Gray scale image of a malignant nodule with heterogeneous
echogenicity and microcalcifications, (b) Color Doppler image of the
same nodule demonstrates increased central blood flow

171. e) Doppler Flow :
-Intranodular flow (usually malignant)
f) Metastases :
-Invasion of the adjacent tissues , enlarged
ipsilateral or bilateral cervical lymph nodes
(malignant)

172. Thyroid nodule with central increased blood flow

173. Thyroid nodule with peripheral increased blood flow

174. 2-Thyroid Follicular Adenoma :
-Represents 5% of thyroid nodules
-Appears as solid masses with surrounding
halo
-Difficult to differentiate from follicular cancer
by cytology, thus, these lesions need to be
surgically resected

175. Follicular adenoma in a 36-year-old woman, longitudinal
color Doppler sonogram of the right lobe of the thyroid
shows perinodular flow around a follicular adenoma

176. Follicular adenoma in a 30-year-old woman, transverse sonogram of
the left lobe of the thyroid shows a follicular adenoma with a
hypoechoic halo (arrows)

178. 3-Thyroiditis :
a) Types
b) Radiographic Features

179. a) Types :
1-Subacute granulomatous thyroiditis (de
Quervain's) :
-Postviral
2-Subacute lymphocytic thyroiditis :
-Autoimmune
-Postpartum
3-Hashimoto's thyroiditis :
-Autoimmune

180. b) Radiographic Features :
-Enlargement of thyroid
-Hypoechogenicity

181. Acute thyroiditis in a 12-year-old female patient, who presented with acute
onset fever, neck pain and swelling, transverse gray-scale ultrasound neck
(a) shows bilaterally enlarged thyroid lobes with heterogeneous echo
pattern, color Doppler sonogram (b) demonstrates increased parenchymal
vascularity in both lobes of the thyroid

182. Diffuse Hashimoto's thyroiditis in a 35-year-old female patient, transverse gray-
scale ultrasound neck (a) demonstrates diffuse enlargement of thyroid gland
with heterogeneous echotexture, multiple tiny and discrete hypoechoic
nodules (micronodules, arrows) and few linear echogenic septae
(arrowhead) are also noted, color Doppler sonogram (b) demonstrates
mildly increased parenchymal vascularity

183. 4-Grave’s Disease : (Diffuse Goiter)
a) Incidence
b) Clinical Picture
c) Radiographic Findings

184. a) Incidence :
-Autoimmune thyroid disease and is the
commonest cause of thyrotoxicosis
-There a strong female predilection with the
F:M ratio of at least 5:1
-Typically presents in middle age

185. b) Clinical Picture :
1-Thyrotoxicosis
2-Goiter
3-Ophthalmopathy
4-Dermopathy : pretibial myxedema

186. c) Radiographic Findings :
1-U/S
2-Scintigraphy

187. 1-U/S :
-Enlarged thyroid and can be hyperechoic
2-Scintigraphy :
-Homogeneously increased activity in an
enlarged thyroid gland

189. 5-Thyroid Cyst :
-Fluid filled cavities (cysts) in the thyroid
most commonly result from degenerating
thyroid adenomas
-Cysts are usually benign but they
occasionally contain malignant solid
components

191. 6-Ectopic Thyroid :
-This may occur anywhere from the foramen caecum (the
base of the tongue) and via the thyroglossal tract, to the
pretracheal, mediastinal or pericardiac areas
-By far the most common location is near its embryological
origin at the foramen caecum, resulting in a lingual
thyroid, this accounts for 90% of all cases of ectopic
thyroids
-Thyroglossal Duct Cyst : Like ectopic thyroids, thyroglossal
duct cysts are found along the thyroglossal duct, they
are the most common thyroglossal duct lesion, and
approximately 20%-25% are suprahyoid in location

192. Normal adult neck, sagittal CT+C shows the normal anatomic course of the
thyroglossal duct (magenta line), the thyroid primordium originates as the
median thyroid anlage (•) at the foramen cecum (white arrow), the path of
the primordial descent wraps anteriorly, inferiorly, and posteriorly to the
hyoid bone (black arrow) and courses anteriorly to the thyrohyoid membrane
and thyroid cartilage (arrowhead)

193. Arrows point to the ectopic thyroid tissue at the tongue base, above the
epiglottis (arrowhead) on this sagittal-reformatted CT image

194. Lingual thyroid tissue at the base of the tongue of a 29-year-old woman, CT+C
through the base of the tongue shows lingual thyroid tissue that contains
multiple low-attenuation foci corresponding to thyroid nodules (white arrow)
and calcification (black arrow), nodules within ectopic thyroid tissue are
identical in appearance to nodules within orthotopic thyroid tissue

195. Incidentally discovered thyroglossal duct cyst at the base of the tongue of a 13-
month-old boy with transverse myelitis, (a) Sagittal T1+C shows a round,
well-circumscribed, nonenhancing low-signal-intensity lesion (arrow) at the
foramen cecum, (b) Axial T2 depicts the cystic high-signal-intensity nature
of the thyroglossal duct cyst (arrow)

196. Sagittal T2 (a) and T1+C (b) MR images show a thyroglossal duct cyst

197. Thyroid ectopia at the base of the tongue in two patients, (a) Sagittal CT+C of a 22-year-
old woman with a history of dysphagia shows lingual thyroid tissue that obscures the
epiglottic vallecula (white arrow) and displaces the epiglottis (black arrow) posteriorly
and inferiorly, (b) Sagittal CT+C of a 3-month-old male infant shows a thyroglossal
duct cyst in the base of the tongue that obscures the epiglottic vallecula (white arrow)
and displaces the epiglottis (black arrow)

198. Long-standing palpable mass, which had recently enlarged, in the anterior
portion of the neck of a 48-year-old man, CT+C depicts a thyroglossal duct
cyst (black arrow) within the infrahyoid portion of the neck, the
histopathologic findings from fine-needle aspiration of the associated
enhancing nodule (white arrow) disclosed a thyroid carcinoma, papillary type

199. 7-Thyroid Cancer :
a) Incidence
b) Types
c) Staging
d) Radiographic Features

200. a) Incidence :
-A malignant tumor arising from the thyroid
or parafollicular C cells
-It is an uncommon tumor (accounting for
0.5% of all cancer deaths)

201. b) Types :
1-Papillary, 60 %
2-Follicular, 25 %
3-Medullary, 5 %
4-Anaplastic, 10 %
5-Epidermoid, < 1 %
6-Other (Lymphoma & Mets), < 1 %

202. Papillary thyroid carcinoma, transverse sonogram of the right lobe of
the thyroid demonstrates punctate echogenic foci without posterior
acoustic shadowing, findings indicative of microcalcifications
(arrows)

203. Papillary carcinoma and cystic lymph node metastasis in a 28-year-old
woman, longitudinal sonogram of the right lobe of the thyroid shows
an irregular hypoechoic tumor with microcalcifications

204. Follicular carcinoma in a 60-year-old woman, (a) Transverse sonogram
of the left lobe of the thyroid shows a partially cystic tumor with solid
internal projections (arrows) and thick walls, (b) Color Doppler
sonogram (shown in black and white) depicts increased vascularity
in the solid parts of the tumor (arrow)

205. Medullary thyroid carcinoma in a 32-year-old man, (a) Transverse
sonogram of the right lobe of the thyroid shows a large nodule with
coarse calcification and posterior acoustic shadowing (arrows),
(b) Axial CT shows the nodule with an internal focus of coarse
calcification (arrows)

206. Anaplastic thyroid carcinoma in an 84-year-old woman, (a) Transverse
sonogram of the left lobe of the thyroid shows an advanced tumor
with infiltrative posterior margins (arrows) and invasion of
prevertebral muscle, (b) Axial CT+C shows a large tumor that has
invaded the prevertebral muscle (arrows)

207. B cell lymphoma of the thyroid in a 73-year-old woman with Hashimoto
thyroiditis, transverse sonogram of the left lobe of the thyroid shows
a large heterogeneous mass (between calipers) with marked
hypoechogenicity when compared with the strap muscles (SM), a
normal isthmus (arrow) also is visible. IJV = internal jugular vein

208. Renal cell carcinoma metastases to the thyroid in a 69-year-old
woman, (a) Longitudinal sonogram of the right lobe of the thyroid
shows a round hypoechoic nodule (arrows) and an irregular-shaped
hypoechoic nodule (arrowheads), (b) Color Doppler sonogram of
the round nodule shows increased internal vascularity

209. c) Staging :
-T :
*T1 :
T1a : nodule < 4 cm
T1b : nodule > 4 cm
*T2 : nodule with partial fixation
*T3 : nodule with complete fixation

210. -N :
*N1 : Regional nodes
1a : ipsilateral
1b : contralateral
1c : bilateral 2c
*N2 : Fixed regional lymph nodes
-M :
*Mo : no mets
*M1 : distant metastases

211. d) Radiographic Features :
1-U/S
2-Scintigraphy
3-CT
4-PET-CT
5-MRI

212. 1-U/S :
-A hypoechoic nodule with an irregular ill-
defined border
-Cervical adenopathy
-Destruction of any adjacent structures

213. Papillary carcinoma and cystic lymph node metastasis in a 28-year-old woman,
(a) Longitudinal sonogram of the right lobe of the thyroid shows an irregular
hypoechoic tumor with microcalcifications, (b) Longitudinal sonogram of the
right neck shows a cystic nodal metastasis with internal septation and foci of
calcification (arrows), (c) CT+C shows the metastasis (arrow)

214. 2-Scintigraphy :
-Cold nodule (hypofunctioning)
3-CT :
-This is not routinely used
-it can assess metastatic nodal involvement , the
presence of distant metastases
-Thyroid nodules appear as low attenuation lesions
(particularly after IV contrast medium)

215. There is a 1cm solid primary tumor in the right lobe of the thyroid with
fine calcifications (arrow), simple cyst (arrowheads) that actually
represents a right nodal metastasis

216. 4-PET-CT :
-This is used for detecting recurrent or
metastatic disease
5-MRI :
-This can be used for the detection of
recurrent disease

217. 8-Photopenic Areas in Radionuclide
Thyroid Scanning :
a) Localized :
1-Colloid cyst
2-Adenoma
3-Carcinoma
4-MNG

218. 5-Local Thyroiditis (may show increased uptake) :
-Acute
-De Quervain’s
-Hashimoto’s
-Riedel’s
6-Vascular
7-Abscess
8-Artefact

219. b) Generalized :
1-Concurrent medication
2-Hypothyroidism
3-Ectopic hormone production
4-De Quervain’s thyroiditis
5-Ectopic thyroid