Small Parts Quiz 2: Thyroid and Other Neck Masses (pg. 41- 58)

What is the main function of the thyroid gland? 1) The production of calcium 2) The storage of fats and vitamins 3) Regulation of the basal metabolic rate 4) Production of antibodies

3) Regulation of the basal metabolic rate

Which of the following is NOT a strap muscle? 1) Sternothyroid muscle 2) Sternohyoid muscle 3) Sternocleidomastoid muscle 4) Omohyoid muscle

3) Sternocleidomastoid muscle

The size of the normal lateral lobes vary, but should measure approximately:

4 - 6 cm in its longest axis, 2 - 3 cm transversely, and 1 - 2 cm in AP diameter.

________ ______ ______ are encapsulated and exhibit transmitted pulsations from the artery. They are low-level echo reflectors that appear homogeneous. They may be bilateral, and are very vascular, often producing a bruit.

Carotid body tumors

What is strikingly characteristic of myxedema?

Facial changes such as swollen lips and thickened nose

_________ = a glycoprotein; the chief constituent of mucous.

Mucin

Appearance of DeQuervain's:

Multiple hypoechoic areas may be seen in the thyroid which tend to decrease in size over time. Diffuse lymphomatous infiltration of the thyroid may give a similar appearance.

Hyperthyroidism with diffuse goiter is called ________ _______.

Grave's disease

The thyroid has two lobes which straddle the trachea in an ____ or ____ shape

H or U

________ or ________-_____ ________ is perhaps the most reliable feature of a benign nodule

Peripheral or eggshell-like calcification

________ studies do not differentiate the different types of cold nodules.

Isotope

Adenomas may present sonographically as ______, _______, or _________. In a complex adenoma, scattered low-level echo reflections may be present within the echo-free spaces which may represent _______.

1. cystic, solid or complex 2. debris

As adenomas enlarge, they tend to _______ adjacent structures, and the trachea may be deviated from the midline, and as they enlarge, they tend to undergo areas of _______.

1. displace 2. degeneration

The thyroid gland is an ____________ gland which develops as a bud from the ventral surface of the ___________ ________.

1. endocrine 2. primitive pharynx

Wwhat is exophthalmos?

When the eyes are likely to protrude noticeably because of edematous swelling in the tissues behind them.

The presence of a peripheral rim with less echogenicity (due to edema) around the cystic area signifies _______ ____________ within a solid lesion rather than the presence of a simple cyst.

cystic degeneration

Many cysts represent:

cystic degeneration of a follicular adenoma.

Rapid enlargement of one area may represent:

hemorrhage into a nodule.

Clinical findings of Hashimoto's thyroiditis (Lymphocytic thyroiditis) include:

hoarseness, neck swelling, diffusely enlarged palpable thyroid, increased TSH, and decreased T3 and T4.

The majority of thyroid carcinomas image as:

hypoechoic solid masses relative to the normal gland. The margins of the tumor are often distinct but they may be irregular

Strap muscles include the:

infrahyoid muscles, the sternothyroid, sternohyoid, and omohyoid muscles

Before follicle cells can produce T3 and T4, they must be supplied with:

iodine salts (iodides)

An ultrasound examination of the thyroid is usually preceded by an:

isotope examination

The ________ is a thin section in the inferior portion which crosses in front of the trachea and covers the second, third, or fourth rings and connects the right and left lobes.

isthmus

An affected child with cretinism may appear normal at birth because :

it has received an adequate supply of thyroid hormones from its mother during pregnancy.

Cretinism is characterized by:

severe symptoms including stunted growth, abnormal bone formation, retarded mental development, low body temperature, and sluggishness. Without treatment with thyroid hormones within a month or so following birth, the child is likely to suffer from permanent mental retardation.

A circumscribed echo-free area with a well-defined and regular border, strongly echogenic posterior wall with posterior acoustic enhancement is the usual appearance of a:

thyroid cyst

_______ arrays may be better for imaging near the lower pole because they can more easily be angled beneath the clavicle or sternum when necessary (perhaps for imaging parathyroid glands that are not in the usual location).

Sector

_______ _______ = muscles of the neck, especially those of the thyroid cartilage and hyoid bone.

Strap muscles

Function of the acini cells:

The follicle cells produce and secrete hormones that may be stored in the colloid or released into the blood of nearby capillaries.

Sonographic appearance of Hashimoto's thyroiditis (Lymphocytic thyroiditis):

The gland is enlarged and firm (goiter) and may have a diffusely abnormal echo pattern. Gross variability in internal echo pattern may occur with areas of increased and decreased echogenicity, but the gland is usually primarily hypoechoic as compared to normal tissue. The sonographic appearance may not be distinguishable from multinodular goiter.

Functions of ultrasound related to the thyroid:

- Ultrasound is used to determine the nature of a nodule (single or multiple, solid or cystic, complex or calcified). - Ultrasound guidance of fine needle aspiration is another use. - Sonography is also performed to delineate the nature of a neck mass as thyroidal or extrathyroidal, to screen for occult malignancy, and for detection of recurrence in patients who have had prior surgery to treat thyroid cancer - Normal gland volume as a function of height can be determined by ultrasound.

Landmarks for identification on every thyroid scan are:

- the anterior wall of the trachea in the midline - the carotid sheath laterally - the strap muscles of the neck and sternocleidomastoid muscle anteriorly and laterally - the longus colli posteriorly.

More uses of ultrasound compared to nuclear medicine:

- to see if there are multinodular lesions where the nuclear medicine study showed only one or only one is suspected clinically. - Also sonography is used to look for occult malignancy of the thyroid when metastatic disease is found and the primary site is unknown.

The average parathyroid tumor is about ___ cm in length.

1 cm

On sonographic examination, your patient presents with an enlarged heterogeneous thyroid gland. The patient's lab work is normal and the patient is not experiencing any symptoms besides the palpable, enlarged gland. What is the most likely diagnosis? 1) Multinodular goiter 2) Graves' disease 3) Hashimoto thyroiditis 4) Thyrotoxicosis

1) Multinodular goiter

A patient presents for evaluation of the thyroid gland with a history of Hashimoto thyroiditis. Which of the following is NOT a common symptom of this condition? 1) Weight loss 2) Cold intolerance 3) Menstrual irregularities 4) Fatigue

1) Weight loss

Predominantly papillary carcinoma occurs most often in the ___ and ___ decades of life and is three times more frequent in __________.

1. 4th and 5th 2. females

There should be no mass between the lobe of the thyroid and the longus colli that is greater than __mm. Solid masses, at or less than (___) mm in size, must be differentiated from the recurrent *laryngeal nerve and inferior thyroid artery* in this groove ***(which is the _______ _________ _______).

1. 5 mm 2. minor neurovascular bundle

__________ is far more common than carcinoma so the first diagnosis that would come to mind with a _______ enlarged parathyroid gland is: ______ ______

1. Adenoma 2. single 3. benign adenoma

__________ are responsible for 80% of hyperparathyroid pathologies. They occur slightly more often in _______. An __________ serum calcium and _________ serum phosphate may alert the clinician to this pathology.

1. Adenomas 2. males 3. increased 4. decreased

_______, a jelly-like mucoprotein, forms in the nodular areas of goiters and appear as ____-____ _______ which do not have ____-________ margins. Areas of __________ are frequent.

1. Colloid 2. echo-free spaces 3. well-defined 4. calcification

Subacute thyroiditis is known as _______ _______ or ________ ________, and may be hard to distinguish from _______ _______.

1. DeQuervain's or granulomatous thyroiditis 2. acute thyroiditis

The MEN-___ syndrome [Wermer's Syndrome] is characterized by tumors of the parathyroid glands, pancreatic islets and the pituitary. ______________ is present in almost 90%, and _________ _________ is the most common manifestation.

1. I 2. Hyperparathyroidism 3. asymptomatic hypercalcemia

MEN-___[Sipple's Syndrome] is characterized by ________ _________ of the thyroid, pheochromocytoma, and hyperparathyroidism.

1. II 2. medullary carcinoma

MEN-___ consists of multiple mucosal neuromas, medullary carcinoma of the thyroid and pheochromocytoma, often associated with a _______ _______.

1. III 2. marfanoid habitus

________ ______ or ________ presenting as tender midline swellings give a similar appearance to thyroglossal duct cysts on sonographic exam. Dependent ______ may be seen with these. Fistulas may connect to the skin surface of the anterior neck when these infected cysts spontaneously drain.

1. Infected cysts or abscesses 2. debris

________________ may be unilateral or bilateral, and the patient presents with a palpable mass in the region of node enlargement. Sonographically nodular lesions of variable size can be seen. They usually appear as ___________, ____-_______ to __________ echoes. They may appear complex, primarily cystic, and they usually have: ____ _______ ________ _________

1. Lymphadenopathy 2. homogeneous, lowlevel to sonolucent 3. *no posterior acoustic enhancement*

______ or ______ _______ tests determine how much thyroid hormone is in a blood sample. They are generally __________ with hyperthyroidism and __________ with myxedema (hypothyroidism).

1. T3 or T4 uptake 2. increased 3. decreased

_____ is the primary hormone secreted by the thyroid (90%) and ___ represents a relatively smaller portion (around 10%).

1. T4 2. T3

A person with iodine deficiency is likely unable to produce thyroid hormones, which disallows inhibiting of the secretion of ______. If the pituitary gland releases this excessively the thyroid gland _________, but since the gland may still be unable to manufacture enough hormones, the condition is often accompanied by the symptoms of ____________. (So, a person with iodine deficiency can't inhibit TSH, and w/ excessive TSH the gland enlarges. However, the thyroid hormone levels stay normal.)

1. TSH 2. enlarges 3. hypothyroidism

In a person with Grave's Disease, overstimulation by ____ or _______ causes the thyroid cells to enlarge and secrete extra amounts of hormones. The affected person is said to have:

1. TSH (or LATS) 2. toxic goiter, also called thyrotoxicosis.

___________ in newborns occurring in the cervical region may be solid, cystic or mixed. The _________ region is the second most common location for these tumors (________region is first). Calcifications and acoustic shadowing is often seen with teratomas.

1. Teratomas 2. cervical 3. sacral

Subacute thyroiditis has basically the same signs and symptoms as _______ _______, but, there are two characteristic findings of DeQuervain's thyroiditis:

1. acute thyroiditis 2. a high ESR (erythrocyte sedimentation rate) and a low radioactive iodine uptake

There are no distinguishing characteristics to identify _________ (the most common mass) from _________ or _________

1. adenoma 2. hyperplasia or carcinoma

The ______ or _______ _______ of each lateral lobe begins at approximately the thyroid cartilage (Adam's apple) and extends __________.

1. apex or superior pole 2. inferiorly

Carotid body tumors are one of a group of paragangliomas which are characteristically ________ and which appear as ______ masses found at the upper end of the common carotid artery near the bifurcation

1. benign 2. solid

Most of the solid ones represent _______ ________ which can appear as cold nodules, although they more often appear _____

1. benign adenomas 2. hot.

A carotid body tumor is a *benign, round*, firm growth that develops at the _________ of the _______ _______ _______. The tumor usually has no effect, but it sometimes may cause ________, ________, and _________ especially if it impedes the flow of blood because pressure is increased in the vascular system

1. bifurcation of the common carotid artery 2. dizziness, nausea and vomiting,

Well defined, predominantly cystic masses with enhanced through transmission in the area of the angle of the jaw separate from the thyroid gland usually represent________ _______ ______, sometimes called _______ _______ _________. These embryonic remnants can contain gravity dependent debris, and sonographically they cannot be differentiated from _________.

1. brachial cleft cysts 2. lateral cervical cysts 3. abscess

The carotid sheath contains the ________ ________ artery medially, the ________ ________ vein laterally, and the ______ _______ between them posteriorly. These three structures make up the ________ ________ bundle.

1. common carotid 2. internal jugular 3. vagus nerve 4. major neurovascular

20% of non- or hypofunctioning nodules are reported to be ______ and 80% are ________.

1. cystic 2. solid

The thyroid hyperfunction is manifested by ________ of serum___ and ____ and an __________ rate of _________ _______ uptake.

1. elevation 2. T3 and T4 3. increased 4. radioactive iodine

The parathyroid tissue gives a _______ ______-______ pattern of slightly decreased amplitude when compared to that of thyroid tissue. Tumors are generally: __________, __________, and ________ _________.

1. fine echo-reflective 2. hypoechoic, discrete and sharply marginated

In the United States, iodine salts are normally obtained from _________, and after they have been absorbed from the intestine, they are carried by the _______ to the thyroid gland.

1. foods 2. blood

when multiple enlarged glands are imaged, __________ is the most likely diagnosis and when a single enlarged gland is imaged, _________ or ________ is more likely.

1. hyperplasia 2. adenoma or carcinoma

PTH causes an ______ in the blood calcium concentration and a ______ in the blood phosphate level. It does this by influencing three types of organs, the _______, the _______, and the ________.

1. increase 2. decrease 3. the bones, the intestines and the kidneys.

Warm or hot nodules are areas of ________ ________. These areas of _____________ activity are rarely ______.

1. increased uptake 2. hyperfunctioning 3. malignant (rarely)

Hypoparathyroidism can result from an _______ to the parathyroids or from ______ _______ of these glands or it can result from another underlying disease such as from the kidneys, bone or intestines, for example.

1. injury 2. surgical removal

Worldwide, the most common cause of thyroid disorders is ________ _________ which leads to ______ _______ and ________________.

1. iodine deficiency 2. goiter formation and hypothyroidism.

When the _______ _______ are in the follicle cells, they are used together with an _______ ______ in the synthesis of hormones

1. iodine salts 2. amino acid

The sternocleidomastoid (_______) and strap muscles (_______) of the neck appear _______ and _______ to the gland and are relatively _________ compared to the gland.

1. lateral 2. anterior 3. anterior and lateral 4. hypoechoic

As the level of blood calcium rises, ______ PTH is secreted. As the level of blood calcium drops, _____ PTH is released.

1. less 2. more

The incidence of malignancy in cystic thyroid lesions is thought to be (_____) around 7 %, although some authors report the incidence as low as 1 -2 %, and others report it as high as 19 - 20%. Therefore, these patients may be further tested by _______ _______ of the contents of the cyst to be safe.

1. low (7% or 1-2%) 2. needle aspiration

The ________ surface rests on the trachea which is ________ to the esophagus. Fairly often the esophagus is off-center and can be seen ______________ to the trachea, usually to the _______, otherwise it is obscured by the hyperechoic trachea and its' posterior shadowing due to air contained within it.

1. medial 2. anterior 3. posterolateral 4. left

An increase in PTH secretion stimulates excessive __________ (cells that destroy bone) activity, and as bone tissue is resorbed, the bones become ____, deformed, and subject to spontaneous fractures.

1. osteoclastic 2. soft

The MEN syndrome (multiple endocrine neoplasia syndromes) is associated with _______ _________. MEN Syndrome, type__ is a component of medullary carcinoma of the thyroid gland as well. MEN, type ____ is also associated with medullary carcinoma of the thyroid, but not hyperparathyroidism.

1. parathyroid hyperplasia 2. (type) II 3. (type) III

The ________ ______ produces Thyroid Stimulating Hormone (TSH), also called thyrotropin. The secretion of TSH is regulated by TSH releasing factor (thyrotropin releasing factor) which is produced by the ___________.

1. pituitary gland 2. hypothalamus

The parathyroid glands are located on the ________ surface of the thyroid gland. Although the number can vary, usually there are ______ of them, two associated with each of the thyroid's lateral lobes.

1. posterior 2. four

Another method for determining thyroid activity makes use of _______ _______ ________ (_____). (I-131 or I-123). This test helps determine if there is ___________ (above normal) activity. (Normal activity = _________; below normal activity = __________)

1. radioactive iodine uptake test (RAI) 2. hyperthyroid 3. euthyroid 4. hypothyroid

DeQuervain's is generally ______-_______ and _______ in a couple of months whereas bacterial thyroiditis may require _________.

1. self-limiting and subsides 2. treatment

The TGC is set at a ______ ______ - fairly steep because of the high frequency -- starting immediately at the _____ ______

1. smooth slope 2. skin surface

The anterior and lateral surfaces are covered by the ______________ and ________ muscles which include the infrahyoid muscles, the sternothyroid, sternohyoid, and omohyoid muscles. Another thin muscle is superficial to these and surrounds the neck. This is the very thin ____________, which blends into the skin sonographically and is not easily identified.

1. sternocleidomastoid and strap 2. platysma

Calcitonin is a short acting hormone that __________ controls blood calcium levels, whereas parathormone regulates _____ ______ blood calcium levels. Parathormone is a far more important regulator than calcitonin.

1. temporarily 2. long term

The thyroid gland is covered by a ______ _______ _______ that is adherent to it and a sheath from the pretracheal layer of _______ _______ _______.

1. thin fibrous capsule 2. deep cervical fascia

Longitudinal scans from the midline to the lateral margin of the gland on each side are performed. The ________ is the medial boundary and the ______ _______ is the lateral boundary

1. trachea 2. carotid artery

Functioning adenomas usually appear "______" or less often "____" on radionuclide scans.

1. warm 2. hot

A patient presents with a personal history of multiple endocrine neoplasia type 2 syndrome for an examination of the thyroid gland. Which type of thyroid cancer is seen in patients with this disorder? 1) Papillary carcinoma 2) Medullary carcinoma 3) Follicular carcinoma 4) Anaplastic carcinoma

2) Medullary carcinoma

What is the most common form of thyroid cancer? 1) Follicular 2) Papillary 3) Medullary 4) Anaplastic

2) Papillary

While performing an examination of the thyroid gland, a small, solid, oval, homogeneously hypoechoic mass is seen posterior to the mid-lateral lobe of the thyroid gland. This appears to be separate from the thyroid gland. What is the most likely diagnosis? 1) Hyperplasia of the parathyroid glands 2) Parathyroid adenoma 3) Papillary carcinoma 4) Multinodular goiter

2) Parathyroid adenoma

Which of the following is NOT a typical symptom of Graves' disease? 1) Hyperthyroidism 2) Elevated levels of T3 and T4 3) A shrunken echogenic thyroid gland 4) Bulging of the eyes

3) A shrunken echogenic thyroid gland

Fine needle aspiration is effective for diagnosing all of the following forms of thyroid carcinoma EXCEPT: 1) Papillary carcinoma 2) Medullary carcinoma 3) Follicular carcinoma 4) Anaplastic carcinoma

3) Follicular carcinoma

Which of the following characteristics increases the suspicion for malignancy in a thyroid nodule? 1) Eggshell calcifications 2) Hyperechogenicity 3) Microcalcifications 4) Peripheral

3) Microcalcifications

Which of the following is NOT a characteristic of a metastatic lymph node? 1) Increasing size on serial examinations 2) Microcalcifications 3) Prominent fatty hilum 4) Rounded, bulging shape

3) Prominent fatty hilum

Which of the following regarding the anatomy of the neck and thyroid gland is FALSE? 1) The strap muscles are anterolateral to the thyroid gland 2) The longus colli muscle is seen posterior to the thyroid gland 3) The trachea forms the lateral border of the thyroid gland 4) The common carotid artery and internal jugular vein are posterolateral to the thyroid gland

3) The trachea forms the lateral border of the thyroid gland

Benign tumors over __ cm in diameter often show cystic degeneration

4 cm

Which of the following transducers would be appropriate for evaluation of the thyroid gland and neck on an average patient? 1) 7.5 MHz curvilinear 2) 5 MHz phased array 3) 5 MHz linear array 4) 12 MHz linear array

4) 12 MHz linear array

A radioiodine scintigraphy examination can be used to evaluate thyroid nodules. Which of the following statements regarding this examination is FALSE? 1) Nodules may be classified as either hot or cold nodules 2) A hot nodule traps an excessive amount of isotope and is hyperfunctioning 3) A cold nodule does not absorb the isotope and demonstrates an area of decreased or absent activity 4) All cold nodules are malignant

4) All cold nodules are malignant

Which aggressive form of thyroid cancer has a tendency to compress and destroy the local structures of the neck? 1) Papillary carcinoma 2) Medullary carcinoma 3) Follicular carcinoma 4) Anaplastic carcinoma

4) Anaplastic carcinoma

What is the most common functional disorder of the thyroid gland? 1) Hyperthyroidism 2) Thyrotoxicosis 3) Graves' disease 4) Hypothyroidism

4) Hypothyroidism

What is the most common cause of primary hyperparathyroidism? 1) Breast or prostate cancer 2) Chronic renal insufficiency 3) Parathyroid carcinoma 4) Parathyroid adenoma

4) Parathyroid adenoma

Which of the following is NOT a characteristic of benign thyroid nodules? 1) A uniform hypoechoic halo 2) Avascularity 3) Well-defined, regular margins 4) Taller-than-wide shape

4) Taller-than-wide shape

Large thyroids weighing over ___ grams are called goiters

50 grams

*What is associated with benign adenomas?*

A hypoechoic rim that typically surrounds the nodule which gives a "halo effect". This rim appears vascular by color Doppler. This "halo" probably represents the fibrous capsule and the adjacent inflammatory changes. It is reported seen in approximately 60% of follicular adenomas.

Scanning techqniues and equipment used for scanning the thyroid:

A liberal amount of gel is applied to the neck and either a water path (stand-off pad) or a direct contact scanner is used. A 7.5 or 10 MHz transducer may be used (always use the highest frequency transducer that will give the needed penetration).

How does the thyroid gland form?

A mass forms at the base of the tongue and with fetal growth, migrates inferiorly in the midline to the base of the neck opposite the fifth to the seventh cervical vertebrae.

*___________ (________ or ________) represent the most common solid lesion of the thyroid gland.*

Adenomas (follicular or papillary)

___________ (undifferentiated) carcinoma is the most aggressive and deadly of thyroid carcinomas.

Anaplastic

_______ _______ ______ = minimum energy (measured in calories per hour per square meter of body surface - 14 - 18 hours after eating and at absolute rest) expended for the maintenance of respiration, circulation, peristalsis, muscle tonus, body temperature, glandular activity, and the other vegetative functions of the body.

Basal metabolic rate

_________ is a form of hypothyroidism that appears in infants when their thyroid glands fail to function normally.

Cretinism

______________ is a common disease associated with morbidity, including hypertension, renal stones, gout, peptic ulcers, pancreatitis, weakness, depression and lethargy.

Hyperparathyroidism

____________ can develop at any time in a person's life and is a clinical diagnosis which is caused by insufficient circulating thyroid hormones.

Hypothyroidism

The level of thyrotropin releasing factor (TSHRF) is controlled by the basal metabolic rate (BMR) as follows:

Low BMR ---> hypothalamus releases TSHRF ---> Anterior pituitary gland releases TSH ---> T3 and T4 released from thyroid gland ---> Increased BMR.

____________ is a condition characterized by a waxy-type of swelling with abnormal deposits of mucin in the skin.

Myxedema

_____________ is a word sometimes used interchangeably with hypothyroidism because of its association with it.

Myxedema

___________ is associated with a slight increase in thyroid volume, which is noted sonographically.

Pregnancy

How is 99Tc used?

Radionuclide studies using thyroid-tissue-specific tagged iodine are performed to identify the gland. Radioisotopes can be injected intravenously. A rectilinear scanner or gamma camera is used to detect the concentration of the radioisotope in the gland or nodule. Both the iodine uptake and imaging contribute to the evaluation of the gland's function and morphology. The size, location, and relative function of the gland or nodules within the gland are recorded. Glandular tissue in ectopic sites will also concentrate the radioactive iodine.

Process of RAI Uptake Test:

The person drinks some distilled water containing a small amount of I-131 (written 131I; I-123 is written as123I). Usually in 6 and 24 hours the radioactivity of the gland is measured using a scintillation counter. The results indicate how effectively the gland was able to remove iodine from the blood and concentrate it, thus giving an indication of the gland's condition. This test has disadvantages in cost, time, patient inconvenience and radiation exposure.

Function of the thyroid:

The thyroid gland produces several hormones that have marked effects on the metabolic rates of most body cells and one hormone that influences the level of blood calcium.

Functions of T3 and T4:

These act to increase the rate of energy release from carbohydrates, oxygen consumption of most body tissues, and the rate of protein synthesis. They also accelerate growth in young persons and stimulate activities of the nervous system

Characteristics of thyroglossal duct cysts:

They may extend from the base of the tongue to the isthmus of the gland in front of the trachea. These are rarely larger than 2 - 3 cm, and are usually palpable. They are typically nontender masses with a rubbery consistency.

_____________ is the gold standard for thyroid imaging.

Ultrasound

Effects of blood calcium levels rising (hypercalcemia):

With an abnormally high level of blood calcium (hypercalcemia), the nervous system becomes depressed. Consequently, muscle contractions are weak and reflexes are sluggish. The G.I. system, renal system and skeletal systems are affected. Renal failure, shock and death can result from severe hypercalcemia.

Sonographic appearance of thyroglossal duct cysts:

With ultrasound, solid tissue may be imaged along margins of the echo- free space or solid tissue may project into the echo-free space. The tissue has the fine, diffuse pattern similar to normal thyroid parenchyma.

_______ of _______ _______ _____ are are most often affected by Grave's Disease. Women are affected 8 times more often than men

Women of child bearing age

A thyroid disorder may develop at any time during a person's life as a result of:

a developmental problem, an injury, a disease, or a dietary deficiency.

To image these Riedel's struma:

a higher gain setting is used than required for a normal gland. High-level echoes are recorded, and the tissue has an inhomogeneous pattern.

The most common appearance of adenomas is:

a solitary, well-defined, oval or circular mass which may be hypoechoic, hyperechoic, or isoechoic when compared to normal thyroid tissue, with the hypoechoic halo surrounding it. Most are well-circumscribed and hyperechoic unless degeneration has occurred

The procedure of radioactive iodine for treating toxic goiter:

a sufficient dose of radioactive iodine is administered to destroy some of the thyroid secretory cells.

The thyroid gland is made up of many secretory follicles called ________ within glandular nodules.

acini

What are the functional and structural units of the thyroid gland?

acini

________ = pleural for acinus, which is a general term used in anatomic nomenclature to designate a small, sac-like dilatation, particularly one found in various glands --- found in liver, pancreas, kidney, prostate, lungs, etc

acini

Multiple endocrine neoplasia (MEN) syndromes, also called multiple endocrine adenomatosis [MEA] and familial endocrine adenomatosis = a group of genetically distinct familial diseases involving ______ ________ and _______ ______ ________ in several endocrine glands.

adenomatous hyperplasia and malignant tumor formation

The enlarged thyroid gland (goiter) and elevated thyroid hormones causes:

an accelerated basal metabolic rate.

Hashimoto's thyroiditis (Lymphocytic thyroiditis) is a fairly common chronic, progressive, inflammation of the thyroid gland which is thought to be caused by:

an autoimmune response

Hyperthyroidism is characterized by:

an elevated metabolic rate, abnormal weight loss, excessive perspiration due to intolerance to heat, tremors, muscular weakness, and generalized nervousness

Malignant lymph tumors or lymphomas that infiltrate the lymph nodes give an appearance of:

an enlarged gland with diffuse low-level echo reflections.

It is believed that Graves' Disease is caused by:

an excessive release of TSH from the anterior lobe of the pituitary gland

In areas not deficient in iodine (such as the United States), __________ ________ are believed to be the basis for most cases of thyroid disease, which ranges from hyperthyroidism to hypothyroidism.

autoimmune processes

Often palpable small nodules display an internal texture that is uniform and may be difficult to separate from the normal adjacent thyroid tissue. These usually represent ________ _________

benign adenomas

**Coarse calcifications generally occur in ______ ______ such as nodular goiters or cysts and other benign conditions such as postinflammatory thyroiditis and posthemorrhagic necrosis.

benign masses

In adults, thyroid volume is positively related to ________ _________.

body weight

The thyroid hormone that influences blood calcium levels is called:

calcitonin

These glands secrete a hormone that functions in the regulation of blood calcium and phosphate levels. They are called the:

calcium-sensing organs

________ ______ _______= tumors of cromaffin cells derived from neural ectoderm, occurring outside the adrenal medulla. The carotid body is a small structure containing neural tissue at the bifurcation of the carotid arteries found in or near the adventia layer. It monitors the oxygen content of the blood and assists in regulating respiration

carotid body tumors

Branchial cleft cysts are usually unilateral and solitary. The majority of patients presenting with this are ___________.

children

______ _______ _______ (_______ ________) is the least common inflammatory process of the thyroid, and usually occurs in older women

chronic fibrous thyroiditis (Riedel's struma)

A nonfunctioning adenoma would appear ______.

cold

Carcinoma shows up as a ______ nodule on a radionuclide scan.

cold

If an area of the gland does not take up the radioactive isotope, it is designated as a ________ nodule (this is old terminology but is still used -- habit, I guess. Other terms such as "area of no uptake" or "area of decreased uptake" are more modern. Another term used is "Photon deficient area".)

cold

Nonfunctioning adenomas will appear _____. Also, adenomas will appear ______ in areas of cystic degeneration

cold x2

Nodules found in the thyroid gland are classified as:

cold, warm or hot according to their functional status on radionuclide scanning.

The cavities of the follicles (acini cells) are lined with a single layer of cuboidal epithelial cells and are filled with a clear, viscous glycoprotein called _________

colloid

When its own thyroid gland fails to produce sufficient quantities of hormones, the child soon develops a condition called cretinism, which is _________ __________.

congenital hypothyroidism

Newborns or infants with lateral neck masses may demonstrate a fluid-filled, multiloculated cavity representing ________ _________. These are congenital in origin and consist of lymphoid tissue in the walls of fluid-filled (lymph fluid) spaces.

cystic hygroma

As an acute condition becomes chronic, the gland may:

decrease in size and become more echogenic.

Results of hypoparathyroidism:

decreased PTH secretion is reflected in reduced osteoclastic activity, and although the *bones remain strong, the blood calcium level drops,* producing the symptoms of hypocalcemia.

With chronic fibrous thyroiditis (Riedel's struma) there is replacement of the thyroid tissue by:

dense scar tissue and fibrous tissue.

The thyroid hyperfunction causes:

diffuse cellular hyperplasia.

Myxedema is a severe form of hypothyroidism marked by:

dry skin, brittle hair, puffy eyelids, swollen face, dull expression, mental sluggishness and muscle weakness.

Plasma calcitonin is __________ in medullary thyroid carcinoma.

elevated

The exam should include the region of the carotid artery and jugular vein lateral to the thyroid in order to identify:

enlarged cervical lymph nodes.

Other causes of hyperthyroidism such as toxic adenoma (a hyperfunctioning benign tumor) can also cause these symptoms; however, a clinical sign which is specific to Graves' Disease is _____________.

exophthalmos

The superior thyroid arteries arise from the:

external carotid arteries.

Subacute thyroiditis also occurs predominantly in:

females between the second and fifth decades of life.

The normal thyroid gland images as a:

fine homogeneous, granular reflective pattern of medium to high level uniform echoes.

The normal parathyroid glands are not usually seen by ultrasound, although, occasionally one can be seen (if you try hard). If one is seen at all, it appears as a:

flat, hypoechoic structure posterior and adjacent to the thyroid. They are bean-shaped or elongated, and measure about 4 x 3 x 1.5 mm.

One third of thyroglossal duct cysts will contain _________ thyroid tissue which can be imaged on radioisotope studies.

functioning thyroid tissue

Because of its variable appearance, and because rapid growth of the gland or hoarseness is suspicious signs that might indicate malignancy, what is required of goiters?

further investigation of goiters, either by fine needle aspiration or other pathological examination, may be needed to be certain of the diagnosis.

Any enlarged thyroid is a _______.

goiter

25% of solitary thyroid nodules are ____________

hyperfunctioning

Treatment for ______________ may include surgical removal of a tumor and orthopedic procedures to correct severe bone deformities.

hyperparathyroidism

Treatment of ____________ usually does not involve PTH because of undesirable side effects that may occur when it is administered. Instead, the patient may be given injections of calcium salts and massive doses of vitamin D, which promotes the absorption of calcium from the intestine, causing the blood calcium level to rise.

hypoparathyroidism

The release of T3 and T4 is controlled by the:

hypothalamus and pituitary gland

If the mass lesion is irregular in shape or has displaced or become adherent to the surrounding structures, ____________ may be suggested.

infiltration

Hypothyroidism can cause the physical symptoms of:

intolerance to cold, weakness, eyelid and facial droop, coarse, dry or scaly skin, weight gain, intellectual impairment, and a gradual personality change.

The advantages of thyroid sonography are:

it is safe, simple, of low cost, accurate, has a higher resolution than other modalities, is well tolerated, and has no radiation hazard. Because the resolution is superior, sonography may be used to identify nodules of the thyroid not apparent with nuclear medicine studies.

The recurrent ___________ nerve runs between the esophagus and trachea.

laryngeal

A different type of goiter, called simple or endemic goiter (or diffuse nontoxic goiter or colloid goiter), is the type of goiter which affects persons who:

live in regions where iodine is lacking in the soil and drinking water

A ______ ______ causes an increase in thyrotropin releasing factor because a (this) signals a low concentration of thyroid hormones

low BMR

Of the cold solid nodules, 10 - 30% are ___________.

malignant

Riedel's struma is rare, but, it does tend to progress to destruction of the gland. Some cases may be associated with:

mediastinal or retroperitoneal fibrosis or sclerosing cholangitis

It is important to evaluate the entire neck area when a mass is seen. because:

metastatic lymphadenopathy is seen in many patients with carcinoma of the thyroid, and is helpful in determining the probable diagnosis of malignancy.

Developmental thyroglossal duct cysts are present as:

midline masses

The recurrent laryngeal nerve and inferior thyroid artery make up the ________ _____________ bundle.

minor neurovascular

On a test, unless pretibial myxedema is specified, ___________ is to be considered hypothyroidism

myxedema

When hypothyroidism develops after growth and development have been completed, a condition called __________ results.

myxedema

A person with this condition (__________; _____________) has an abnormally low metabolic rate, is mentally slow, usually gains a considerable amount of weight, and has swollen tissues due to an accumulation of excess body fluid (edema).

myxedema; hypothyroidism

the secretion of PTH is regulated by a _______ ________ _______ operating directly between the glands and the blood calcium level.

negative feedback mechanism

Cold nodules are __________ or ____________.

nonfunctioning or hypofunctioning.

In acute and subacute thyroiditis, the patient will present with a thyroid that:

often appears hypoechoic compared to the normal gland. Diffuse enlargement due to swelling occurs and a low-amplitude uniform echo pattern is seen which is believed to represent inflammation and edema of the glandular tissue. The patient will also present with a firm, painful thyroid, often with the pain radiating to the ear or jaw. Fever and malaise is usually associated.

As was mentioned, calcitonin from the thyroid gland also acts in the regulation of blood calcium level, however its effect is exactly ________ that of PTH. (Calcitonin is not as important as PTH).

opposite

Most functional disorders of the thyroid gland are characterized by:

overactivity (hyperthyroidism) or underactivity (hypothyroidism) of the gland cells

**Fine granular calcifications (<1 mm) are associated with ___________ ___________.

papillary carcinoma

The ___________ _________ usually lie outside the thyroid capsule but may rest within it and be adjacent to the posterior thyroid tissue.

parathyroid glands

The only hormone known to be secreted by the parathyroid glands is a protein called:

parathyroid hormone (PTH) or parathormone

What happens in extreme cases of hyperparathyroidism:

portions of bone may disappear altogether, leaving large holes (osteoporosis) in place of the former solid structure. The excessive calcium released into the body fluids as a result of extra PTH secretion may be deposited in abnormal places, causing new problems such as kidney stones.

The _____________ surface is in contact with the paired parathyroid glands, the prevertebral muscle called the longus colli, the sympathetic trunk, and the carotid sheath.

posterior

The major neurovascular gland is _________ and _________ to the gland.

posterior and lateral

The common carotid artery is located in the carotid sheath along the _______ _______ margin of the thyroid

posterior lateral

Imaging of the longus colli muscles _________ (also relatively hypoechoic) marks adequate penetration for visualization of the entire thyroid gland area

posteriorly

What else is specific to Grave's Disease?

pretibial myxedema

Cold nodules can represent:

simple cysts, cystic degeneration or hemorrhage within solid tissue such as cystic degeneration in an adenoma, cystic degeneration or hemorrhage in hyperplasia, in thyroiditis or in a malignancy.

Salivary gland masses are generally imaged as _______ areas. There are three pairs:

solid 1) parotid glands - just anterior to TMJ along the angle and back of mandible (lower cheek). 2) submandibular glands - anterior to the angle of the jaw, between jaw and chin., and 3) sublinguinal glands - more anterior; right under tongue.

The echo appearance of goiter is variable, and includes:

solid, cystic and mixed nodules with an uneven echo pattern, which may have small or large areas of calcification.

Diffuse enlargement of salivary glands or localized nodules represents tumors, often the benign mixed type. They are seen as:

solitary, round or oval, 2 - 5 cm masses, and are well outlined and encapsulated.

Current high frequency transducers allow spatial resolution of 0.7 mm to 1.0 mm in some cases, which is better _________ __________ than is achieved by any other imaging modality.

spatial resolution

A ______ _____ can be used if needed to view very superficial nodules (might need one for the isthmus).

stand-off pad

Treatment for Grave's Disease may involve:

surgical removal of part or the entire enlarged gland, or the administration of a drug that blocks the production of thyroid hormones. Now the disease is very often controlled with medication (usually the first method of treatment and if it doesn't other approaches are tried.)

Imaging of the lower poles can be enhanced in some patients by asking them to ________, which momentarily raises the thyroid in the neck.

swallow

The chief contribution of ultrasound in the investigation of thyroid nodules is:

the differentiation of cystic from solid nodules

Effects of blood calcium level dropping (hypocalcemia):

the nervous system becomes abnormally excitable, and impulses may be triggered spontaneously. Muscles may undergo tetanic contractions, and the person may die due to a failure of respiration movements. Less severe effects are numbness and tingling of the feet, hands, lips and tongue, muscle aches or spasms, depression, psychoses and EKG changes

Patient position during US exam:

the patient is placed in a supine position with a folded pillow under the shoulder to hyperextend the neck.

When a nodule is found, what is the imaging technique?

the transducer is placed directly over the thyroid nodule and images at different gain settings are observed and recorded with the transducer in the same position. The focus should be set at the level of the nodule.

Linear array or convex linear array transducers are preferred to sector transducers because of:

the wider field of view near the face of the transducer.

The inferior thyroid arteries arise from the:

thyrocervical trunk of the subclavian artery.

Ectopic or aberrant tissue, when present, is found along the course of the __________ _________, from the back of the tongue to the midline anterior to the trachea and thyroid cartilage

thyroglossal duct

The _________ ________ normally obliterates during fetal life, but if it fails to do so, cysts may form along the tract.

thyroglossal duct

the triangular relationship between the _______ _______, ______ _______, and _______ _______ is an important area to check when searching for an enlarged parathyroid gland

thyroid lobe, carotid artery, and longus colli

Graves 'disease is also called:

thyrotoxicosis and toxic goiter.

Of the hormones that affect metabolic rates, the most important are:

thyroxine (T4) and triiodothyronine (T3)

Abscess and/or hematomas may develop in the neck following:

trauma or surgery.

Other granulomatous infections include:

tuberculosis, mycosis (any disease caused by a fungus), and syphilis

Hyperparathyroidism is most often caused by a ______ (mostly benign adenoma - 80 %) associated with a parathyroid gland.

tumor

Blood is supplied to the thyroid gland by:

two superior thyroid arteries and two inferior thyroid arteries

The thyroid lobes move _________ when a person swallows.

upward

Sonographically, Grave's disease shows increased ___________ (often referred to as "thyroid inferno").

vascularity

Both acute and subacute infections are probably ______ in origin.

viral

Grave's disease is thought to be __________ in origin.

autoimmune

_________ of the thyroid is far less common than benign lesions and affects females more often than males

*Carcinoma of the thyroid*

Transverse scans are made beginning just above the __________ notch and continuing to the ______ ______ of the gland

1. suprasternal 2. superior limits of the gland.

Masses larger than ___mm usually represent enlarged glands, either hyperplasia or tumor

5 mm

_______ ______ ______ ____________ can follow any bacterial or viral condition.

Benign lymph node enlargement

Relational anatomy of the thyroid:

The apex or superior pole of each lateral lobe begins at approximately the thyroid cartilage (Adam's apple) and extends inferiorly. The anterior and lateral surfaces are covered by the sternocleidomastoid and strap muscles which include the infrahyoid muscles, the sternothyroid, sternohyoid, and omohyoid muscles. (Strap muscles = muscles of the neck, especially those of the thyroid cartilage and hyoid bone.) Another thin muscle is superficial to these and surrounds the neck. This is the very thin platysma, (plah-tiz'-mah) which blends into the skin sonographically and is not easily identified. The medial surface rests on the trachea which is anterior to the esophagus. Fairly often the esophagus is off-center and can be seen posterolateral to the trachea, usually to the left, otherwise it is obscured by the hyperechoic trachea and its' posterior shadowing due to air contained within it. The recurrent laryngeal nerve runs between the esophagus and trachea. The recurrent laryngeal nerve and inferior thyroid artery make up the minor neurovascular bundle. The posterior surface is in contact with the paired parathyroid glands, the prevertebral muscle called the longus colli, the sympathetic trunk, and the carotid sheath. This sheath contains the common carotid artery medially, the internal jugular vein laterally, and the vagus nerve between them posteriorly. These three structures make up the major neurovascular bundle. This is posterior and lateral to the gland.

**__________ is the most common inflammatory process of the thyroid, and being chronic, is the most common cause of hypothyroidism in adults in the United States*

*Hashimoto's*

**The most common type of thyroid carcinoma is:**

*papillary or mixed papillary- follicular carcinoma*

Occasionally (10 - 40 percent of cases), an extra lobe, the _______ ______, extends upward from the isthmus in the midline, more frequently on the left. This can be regularly visualized in a number of younger patients, but it undergoes progressive atrophy in adulthood and often becomes invisible.

*pyramidal lobe*

__________ helps regulate the calcium level by inhibiting the rate at which calcium leaves the bones and enters the extracellular fluids.

Calcitonin

__________ is secreted by the parafollicular cells located between the follicles.

Calcitonin

___________ acts to lower the concentration of blood calcium, which is an effect exactly opposite that promoted by parathyroid hormone

Calcitonin