NEW SIGNS of PNEUMOTHORAX at LUNG ULTRASOUND

Sonographic signs of complex pneumothorax

Double lung point: when for some reason the air of a pneumothorax is not free to float inside the pleural space, a minimal amount of pleural air may remain in  the lateral or dorsal chest without migrating in the most superior area in a supine patient, which corresponds to the anterior-inferior chest zone. In this case, the operator may visualize two lung points, i.e. the alternating patterns of sliding and non-sliding lung intermittently appearing at the two opposite sides of the scan (Additional file 1) [7,8]. These two lung points represent the visualization of the two edges of the air trapped in the pleural space (Figure 1).

Pneumothorax with air trapping may be caused not only by pleural adherences in chronic pleural and pulmonary diseases but also by acute lung contusions in blunt torso trauma [9]. Even without abnormal pleural adherences, very small spontaneous pneumothoraces may not have enough pressure to allow complete detachment of the pleural layers and the floating of air towards the most superior chest areas [7]. Being aware of this condition or in case of strong suspicion, the operator should always complete the scan of the lateral chest in the supine patient to confirm lung siding even when this latter is first visualized in the parasternal anterior-inferior chest. In the unstable patient, this extension of  the technique is less important. Presence of lung sliding in the anterior-inferior chest may conclude the ultrasound examination, unless the patient is intubated for pressure ventilation or is going to be transported by helicopter [10]. In these two latter cases, the lateral chest should always be scanned to rule out even the smallest pneumothorax that may need to be monitored or warrant prophylactic drainage.

Figure 1: Visualization of the two edges of the air trapped in the pleural space.

Septate pneumothorax: recurrent pneumothoraces after invasive therapeutic procedures are often characterized by abnormal ultrasound findings. In patients with failed pleurodesis, it is quite common to observe the typical ultrasound pattern of septate pneumothorax [11]. In this case, the absence of sliding may be combined with the persistence of B lines and lung pulse in the same scan (Additional file 2). While, in the majority of patients, visualization of B lines and lung pulse rules out pneumothorax, there are rare cases where the negative predictive power of B lines and lung pulse may be misleading. In the context of absent lung sliding, the small areas showing B lines and lung pulse correspond to small lung regions where the parietal and visceral pleura are still touching due to  the presence of septa (Figure 2). Demonstration of a lung point in other areas of the chest is a decisive step to conclude the examination and diagnose pneumothorax. A sonographic pattern that combines an absence of lung sliding but presence of B lines and/or lung pulse with presence of  a lung point is diagnostic of septate pneumothorax.

Figure 2: The small areas showing B lines and lung pulse correspond to small pleural adherences.

Hydropneumothorax: iatrogenic pneumothorax following procedures of thoracentesis in pleural effusion is a well known complication. While interposition between the normally aerated lung and pneumothorax (air/air interface) is demonstrated in a lung ultrasound by the lung point sign, air/fluid interface in the pleural space gives a different sonographic pattern.

In hydropneumothorax, the pleural effusion is demonstrated by the visualization of space, usually anechoic, between the two pleural layers while pneumothorax gives the well-known A pattern, i.e. the reverberation of the chest wall image below the pleural line with A lines, absence of sliding or pulse and absence of B lines (Additional file 3). Opposition between these two patterns is the hydro-point (Figure 3). This recently  described sonographic sign shares the same diagnostic power with the lung point for the diagnosis of pneumothorax [12].

Figure 3: Opposition between the air/fluid patterns is the hydro-point.

Conclusion

Lung ultrasound is rapidly spreading as a safe bedside methodology for  the diagnosis of pneumothorax in different settings. Because of its increasing use  in the clinical practice, observations of some unusual and complicated cases are also emerging. The conventional step-by-step sonographic technique and the four conventional ultrasound signs of pneumothorax should be slightly modified to consider the possibility of facing complex cases. Complicated pneumothorax may be encountered in many different settings, such as trauma patients, spontaneous pneumothorax, recurrent pneumothorax after pleurodesis and post-procedural pneumothorax. The operator should be aware and know how to interpret unusual sonographic signs and patterns, such as the double lung point, the septate pneumothorax and the hydro-point.

 

ULTRASOUND SCANNING for AAA

 A British surgeon recently reported that men aged 65 and over can cut their risk of premature death by simply having an ultrasound scan, typical used for pregnancy monitoring.

Dr. Gareth Morris, a consultant vascular surgeon from Southampton General Hospital (UK; www.uhs.nhs.uk), reported that a simple 10-minute stomach ultrasound scan could diagnose or rule out abdominal aortic aneurysms (AAAs), which are responsible for 5,000 deaths – chiefly among older men – in England and Wales annually.

The disorder, which develops when the main blood vessel in the body weak-ens and expands, can be monitored through routine monitoring or fixed with surgery, but undetected large aneurysms (5.5 cm or more) can rupture and prove fatal in the majority of cases.

However, Dr. Morris said, the recent UK rollout of a screening program he helped to develop – the NHS [National Health Service] Abdominal Aortic Aneurysm Screening Program – could decrease the current death rate by 50%.

“There are so many avoidable deaths from abdominal aortic aneurysms and it is a real tragedy because we know a quick scan will save lives through either monitoring or corrective surgery, but timing is everything. The condition is often symptomless, so I would strongly advise men to consider the offer of a screening test, which is a simple scan similar to that offered to women in pregnancy, particularly if they are in a high risk group,” he stated.

Men are six times more likely than women to develop an abdominal aortic aneurysm, with current or former smokers, high blood pressure sufferers, or those with close family history (parent or sibling) of the condition most at risk.

Although the program launched in the United Kingdom in early July 2013, the Hampshire and the Isle of Wight AAA Screening Program, led by University Hospital Southampton NHS Foundation Trust, is already in its second year of operation.

More than 8,000 men underwent abdominal aortic aneurysms ultrasound across Hampshire and the Isle of Wight last year, with 18 referred for surgery to repair aneurysms of 5.5 cm or more.

Justin Sanders, AAA screening coordinator, Hampshire and the Isle of Wight, said, “While we had a very successful response to our invitations in the first year, there are many more men, particularly around the central Southampton area, we would like to see to either rule out the condition or diagnose and begin monitoring or treatment.”

At Medic Center, HCMC, Vietnam, using ultrasound to detect AAA had been conducted from 1990 and this topic was in training program for doctors of ultrasound every year.

Ultrasonography in the Diagnosis of Chronic Lateral Ankle Ligament Injury.

Objective: The aim of this study was to assess the accuracy of ultrasonography in the diagnosis of chronic lateral ankle ligament injury.

Methods: A total of 120 ankles in 120 patients with a clinical suspicion of chronic ankle ligament injury were examined by ultrasonography by using a 5- to 17-MHz linear array transducer before surgery. The results of ultrasonography were compared with the operative findings.

Results: There were 18 sprains and 24 partial and 52 complete tears of the anterior talofibular ligament (ATFL); 26 sprains, 27 partial and 12 complete tears of the calcaneofibular ligament (CFL); and 1 complete tear of the posterior talofibular ligament (PTFL) at arthroscopy and operation. Compared with operative findings, the sensitivity, specificity and accuracy of ultrasonography were 98.9%, 96.2% and 84.2%, respectively, for injury of the ATFL and 93.8%, 90.9% and 83.3%, respectively, for injury of the CFL. The PTFL tear was identified by ultrasonography. The accuracy of identification between acute-on-chronic and subacute–chronic patients did not differ. The accuracies of diagnosing three grades of ATFL injuries were almost the same as those of diagnosing CFL injuries.

Conclusion: Ultrasonography provides useful information for the evaluation of patients presenting with chronic pain after ankle sprain.

Advances in knowledge: Intraoperative findings are the reference standard. We demonstrated that ultrasonography was highly sensitive and specific in detecting chronic lateral ligments injury of the ankle joint.

 

THYROID PAPERS from AJR

ABSTRACT :

OBJECTIVE. We aimed to establish the malignancy rate of thyroid nodules initially characterized as atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) and whether they differ according to histologic subcategory. We also investigated the value of ultrasound features that predict malignancy and BRAF^V600E mutation analysis and suggest strategies for the management of AUS/FLUS nodules.

MATERIALS AND METHODS. A total of 165 AUS/FLUS nodules were investigated. There are nine histologic subcategories of AUS/FLUS nodules. We compared the risk of malignancy in thyroid nodules according to the histologic subcategory using ultrasound findings and of those exhibiting the BRAF^V600E mutation.

RESULTS. The malignancy rate of nodules with an initial diagnosis of AUS/FLUS was 55.2% (91/165). The malignancy rates by histologic subcategory were 0% in groups 1 (0/2), 2 (0/3), 4 (0/3), 7 (0/3), and 8 (0/1); 76.5% (13/17) in group 3; 83.1% (59/71) in group 5; and 29.2% (19/65) in group 9. The malignancy rate of nodules with suspicious ultrasound features was 79.3% (73/92), and the malignancy rate of nodules with indeterminate ultrasound features was 24.7% (18/73). AUS/FLUS nodules exhibiting taller-than-wide shape, illdefined margins, and microcalcifications or macrocalcifications showed significantly higher odds ratios. The likelihood of BRAF^V600E mutation–positive nodules showing malignancy was 97.5% (39/40), whereas 39.7% (25/63) of BRAF^V600E mutation–negative nodules were malignant (p < 0.05).

CONCLUSION. The malignancy rate of AUS/FLUS nodules in our study cohort was higher than previously reported. Nodules with suspicious features on ultrasound had a higher malignancy rate than did those with indeterminate features on ultrasound. The malignancy rate differed according to histologic subcategory; therefore, management of AUS/FLUS nodules should be tailored according to histologic subcategory.

Keywords: Bethesda System for Reporting Thyroid Cytopathology, BRAF^V600E mutation, thyroid gland, thyroid nodules, ultrasound

ABSTRACT :

OBJECTIVE. Fine-needle aspiration biopsy (FNAB) is the current primary test to risk stratify thyroid nodules. However, in up to one third of biopsies, cytology is indeterminate. The Bethesda System for Reporting Thyroid Cytopathology categorizes thyroid cytology findings into six groups, with each group assigned a putative malignancy risk. This article reviews the Bethesda System, emphasizing the key facts necessary to understand thyroid biopsy results and effectively manage patients after FNAB.

CONCLUSION. It is important to diagnose and stratify the risk of malignancy in thyroid nodules. A working knowledge of the Bethesda System permits accurate, evidence-based risk stratification of patients with thyroid nodules and thereby facilitates their management. Because it is a uniform diagnostic approach, the Bethesda System allows comparisons of different management strategies across different institutions.

Keywords: atypia of undetermined significance (AUS), Bethesda System for Reporting Thyroid Cytopathology, cytology, fine-needle aspiration biopsy, follicular lesion of undetermined significance (FLUS), follicular neoplasm, nondiagnostic thyroid biopsy, thyroid

Presented at the 2012 annual meeting of the Radiological Society of North America, Chicago, IL.

NUỐT KHÓ VÙNG KHẨU HẦU

Ultrasonography, a portable, noninvasive, and radiation-free technique, had been applied for assessment of oropharyngeal swallowing function for decades. The most common application is for observing the tongue, larynx, and hyoid-bone movement by B-mode ultrasonography. Although some studies describing techniques of ultrasonography have been published, its clinical application is still not well known. Other methods such as M-mode ultrasonography, Doppler ultrasonography, three-dimensional reconstruction, or pixel analysis had been reported without promising results. The techniques of ultrasonography examination of the tongue and larynx/hyoid movement are introduced in this work; in addition, a brief review about the methods and application of ultrasonography in assessing swallowing function in different groups of patients had been described. Ultrasonography, instead of a substitution of videofluoroscopic swallowing study (VFSS), may be able to complement VFSS as a rapid examination tool for screening and for follow-up of swallowing function. Further large-scale quantitative analyses that provide diagnostic value and correlation with functional outcome are mandatory.

Fig. 1.

(A) Anatomy of the oral cavity and position of the sector transducer. (B) Submental midsagittal ultrasonography image showing the genioglossus muscle (G), geniohyoid (arrows), and mylohyoid muscles (arrowheads) at the mouth floor. The tongue surface appears as hyperechoic lines (broad arrows).

Fig. 2.

Calculation of tongue thickness: The dashed lines “a” and “b” indicate the border of the ultrasonographic beam. The dashed line “c” is the bisection of the ultrasonographic beam, in which the midtongue thickness is measured (two-end arrow).

Fig. 3.

(A) B-mode ultrasonographic imaging of the tongue. M-mode ultrasonography was extracted at a vertical scan line (dashed line). The arrowheads indicate the tongue surface. (B) M-mode ultrasonography. Point a indicates the onset of tongue movement, while point b indicates the return of tongue to its resting position. The two-end arrow indicates the peak-to-peak amplitude of tongue movement at the scan line.

Fig. 4.

Transverse view of submental ultrasonography. The mylohyoid muscle (MH) is a thin layer of tissue. Below are the geniohyoid (GH) and genioglossus (GG) muscles; the cross-section of anterior belly of the digastric muscle (DG) appears as an hypoechoic, oval-shaped structure.

Fig. 5.

(A) The positioning of the transducer and (B) the anatomy of examination of thyroid–hyoid approximation. (C) Ultrasonography image showing the hyoid bone (H) and thyroid cartilage (T); the dashed line is the distance between the thyroid cartilage and the hyoid bone.

Fig. 6.

(A) Anatomy of the oral cavity and position of the curvilinear transducer. (B) Submental midsagittal ultrasonography image showing the hyoid bone (H) and the mandible (M) and muscles at the mouth floor (arrowheads). The tongue surface appears as hyperechoic lines (arrows).

Fig. 7.

Calculation of the hyoid bone displacement. (A) The position of the mandible (black arrow) was used as the reference point, and the resting position of the hyoid bone (white arrow) was designated as a pair of coordinates (X₁, Y₁). (B) During swallowing, the hyoid bone moves upward and forward into a new position (arrow) designated by X₂, Y₂, with the mandible as the reference point. The distance between the two coordinates before and after swallowing denotes the hyoid bone displacement (thin arrow).

SIÊU ÂM LÒNG HẬU MÔN và QUA NGẢ TRỰC TRÀNG

Anal (EcoA) and rectal endosonography (EcoEAR) is a useful test in the evaluation of patients with anorectal pathology. However, there is no clear consensus on its indications.

The aim of this study was to determine the opinion of clinicians regarding the current indications and usefulness of this diagnostic test in daily clinical practice. A cross-sectional observational study was conducted using a survey sent to the services of General surgery in a specific area of Spain. The clinical usefulness of the test was evaluated using an analog scale from 0 (lowest value) to 10 (maximum utility) for each pathology. Of the 47 hospitals, 23 responded to the questionnaire (48.9%). The average number of ultrasounds performed in these centers was 217 per year (standard deviation: 140.1, range 73–450) during the last 3 years. The most common indications for this test were: rectal tumor (85%), anal fistula (80%), and fecal incontinence (70%). This test was suggested more, depending on availability in the hospital itself.

In conclusion, anal and rectal endosonography remains a very useful diagnostic clinical test in the opinion of clinicians in general and digestive surgery, especially in the evaluation of patients with anal fistula, fecal incontinence, or rectal tumors.

Fig. 2: Anal endosonography imaging in a patient with fecal incontinence showing internal anal sphincter injury (arrows).

Fig. 3:  3D rectal endosonography imaging showing the presence of a rectal tumor (arrows).