Diagnosis of Head and Neck Lesions With Ultrasonography

Updated: Feb 02, 2023
Author: Javed Ahmad, MBBS; Chief Editor: Mahan Mathur, MD 



Practice essentials

Ultrasonography is one of the few diagnostic modalities that can be done at the bedside and offers many advantages over other modalities. It is readily accessible and portable, and images are viewed in real time. In addition, it is less expensive and noninvasive than other modalities. Sedation and contrast dye are rarely needed; however, newer studies with contrast are emerging. Most importantly, it is a safe study and, thus, is the first recommended imaging of choice for pregnant women and children.[1]

Ultrasonography does have some limitations. The accuracy and effectiveness relies on the experience and skill of the operator for image acquisition and the physician for image interpretation. Furthermore, it is a study whose resulting outcome varies, depending on the patient’s body habitus and cooperation. Lastly, ultrasonography requires a window that is unimpeded by bone or air, limiting the type of evaluations it offers, when compared with CT scanning or MRI.

For the head or neck evaluation, a high-resolution, small-part transducer with higher frequencies is used, most commonly between 7.5 and 10 MHz, but ranging from 5-20 MHz. The higher the frequency, the better the spatial resolution. According to American Institute of Ultrasound in Medicine (AIUM) recommendations, mean frequencies of 10-14 MHz or greater are preferred.[2]

Point-of-care ultrasound (POCUS) of the head and neck plays an important role in the diagnosis and treatment of upper airway stenosis, swelling, and painful diseases of the neck, as well as evaluation for swallowing problems. A linear probe with a frequency of around 10 MHz and a field of view of around 40 mm is suitable for head and neck POCUS. Upper airway POCUS should also be performed for dyspnea.[3]

Ultrasound-guided nerve blocks are commonly performed by pain physicians because of advantages over fluoroscopy in that ultrasonography is portable, is radiation-free, and offers real-time imaging.[4]

Ultrasound-guided fine-needle aspiration cytology (FNAC) for head and neck malignancy has been found to be highly reliable and specific. In a study by Petrone et al, only 8 samples of 301 lesions (2.6%) were considered nondiagnostic. Cytologic-histologic correspondence was 89%. Overall sensitivity was 92.75, and specificity was 94.6%.[5]

Ultrasound-guided core needle biopsy (USCNB) for head and neck lymphoma has been shown to be a successful diagnostic technique. In one study, by Cuenca-Himenez, USCNB was diagnostic of lymphoma in 215 of 226 (95.1%) patients. Eleven patients required a subsequent surgical excision biopsy for diagnosis.[6]  

Thyroid-stimulating hormone, free T4, and parathyroid hormone testing are useful screening tests for patients with clinical concern for thyroid disease or hyperparathyroidism, respectively.

B-mode ultrasonography shows the texture and tissue borders as black and white pictures. Color duplex ultrasonography allows for visualization of moving tissues and blood flow. Doppler ultrasonography allows differentiation of the vessels. With the different modalities combined, it allows the reader to evaluate for hyperemia, vessels relative to pathologic findings, inflammatory changes, and the components of the structure being investigated.

Transcranial Doppler ultrasonography is used to assess intracranial blood flow velocity, emboli, stenosis, and vasospasm secondary to subarachnoid hemorrhage. It is also used to diagnose right-to-left cardiac shunting, most commonly a patent foramen ovale, in patients after a stroke.

Definitions and guidelines

Basic understanding is needed of the structures of the head and neck as well as knowledge of how sound waves create real-time images. Key principles and definitions of ultrasound are described:

  • Echogenicity is the ability of a surface to bounce an echo or return a signal. Hyperechoic structures are more “bright” than their surroundings, whereas hypoechoic structures are less “bright” than their surroundings. Anechoic structures appear black, without echoes; whereas isoechoic structures have the same echoes as their surroundings, which means it appears as bright as its surroundings.
  • Acoustic impedance is transmission and reflection across 2 different boundaries/surfaces. Acoustic shadowing shows areas through which sound waves fail to propagate. Acoustic enhancement is when no echoes are reflected and sound is allowed to pass through, allowing echoes deep to the anechoic structures to be visible. Fluid-filled structures provide acoustic enhancement, making the structures/area inferior to it brighter. 
  • Refraction is produced from the multiple reflections from an object if the acoustical impedances of tissue layers are too different. Attenuation is the reduction of the ultrasound beam as it passes through a medium.

The American Institute of Ultrasound in Medicine (AIUM), in conjunction with the American Academy of Otolaryngology–Head and Neck Surgery, has published guidelines on the use of head and neck ultrasound examination for the following[7] :

  • Salivary glands
  • Lymph nodes
  • Congenital lesions
  • Miscellaneous mass lesions
  • Infection and trauma
  • Endocrine glands

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has described training requirements for head and neck ultrasound on the basis of 3 EFSUMB competency levels, as follows[8] : 

  • Level 1 involves the knowledge and skills needed to perform essential head and neck ultrasound examinations independently.
  • Level 2 describes the skills needed to perform ultrasound-guided interventions. Practitioners who need to perform ultrasound-guided interventions in clinical work would be expected to hold Level I and Level 2 competencies and skills.
  • Level 3 involves training and practice on a more advanced level and requires additional knowledge of advanced ultrasound technologies and engagement in education or research.


Initial screening and diagnostic studies using ultrasonography have become more favored, especially with increasing evidence supporting future potential harm with the use of ionizing radiation. Ultrasonography is highly useful for many disease processes and many organ systems. Specifically, it is an effective clinical tool to evaluate head and neck anatomy and pathology. It can play an important role in the workup, staging, treatment planning, and posttreatment follow-up of patients with diseases involving the head and neck.

Specific indications include the following:

  • Evaluation of head and neck anatomy

  • Evaluation of masses

  • Evaluation of nodal disease in the head or neck region

  • Assessment of infections or abscesses in the head or neck region

  • Evaluation of cysts or glandular pathology in the head or neck[9]

  • Neoplasms arising from the head or neck

  • Procedural guidance for central line placement, tissue biopsy, fine-needle aspiration

Technical Considerations

Ultrasonography is especially useful when a patient has had recent exposure to radiation or when evaluating a pediatric patient for whom you want to spare radiation. In addition, ultrasonography is highly useful in the pregnant population.

Use a high-frequency linear array probe for head and neck applications because structures of interest are superficial.

All written reports should be in accordance with American Institute of Ultrasound in Medicine (AIUM) practice parameters for ultrasound examination documentation. In the event that a delay would have an adverse effect on the patient's outcome, direct verbal or electronic communication between the interpreting provider and the patient's health care provider is required.[10]  

Complications arise when using ultrasonography to guide procedures into the neck. Avoid mistaking a cyst for a vessel by rotating the probe 90° to visualize the vessel in long axis. Use color/spectral Doppler ultrasonography to assess flow and waveform.


Periprocedural Care


For all ultrasound examinations of the head and neck, the high-frequency linear array transducer provides the best visualization, given that all objects of interest are superficial.

According to the American Institute of Ultrasound in Medicine (AIUM), ultrasound equipment should operate at the highest clinically appropriate frequency. Lower-frequency transducers may be used in select patients for increased depth perception. For assessing inferior central or upper mediastinal adenopathy and inferior parathyroid glands, a curved linear tranducer may be useful.[2]  

Patient Preparation

Anesthesia is usually not indicated for head and neck ultrasonography examinations.

For all ultrasound examinations of the head and neck, the patient is to be supine. The head of the bed can be arranged to any angle for patient and sonographer comfort. Having patients turn their head to the left or right and/or swallowing may help evaluate some thyroid lesions and aid in performing the examination.



Fetal and Neonatal Ultrasonography

Ultrasonography is the study of choice in infants with open fontanelles and sutures and can be used to evaluate premature fetuses for various intracranial pathologies or malformations, such as hydrocephalus or hemorrhage. Particularly, brain ultrasonography is a well-established method that is useful for both the initial evaluation and the follow-up of intraventricular hemorrhage, parenchymal hemorrhage infarct, and periventricular leukomalacia.

The differential diagnoses for the different types of hemorrhagic brain diseases may be limited with ultrasonography; thus, MRI may be preferable.[11]

Neonatal head ultrasonography reveals the following:

  • Germinal matrix hemorrhage

  • Ventricular measurements

  • Normal variants (eg, choroid plexus cysts, benign macrocrania)

Using the high-frequency linear transducer and placing the probe over each of the open fontanelles allows visualization of the coronal and transverse views of the brain. Depth and gain adjustments commonly need to be made in order to visualize the entire structure of interest.


Hemangiomas are the most common congenital lesions found in neonates, and the most affected sites are the head and neck. They can present as palpable subcutaneous masses, cutaneous skin lesions, or a combination of both. They tend to grow rapidly for months and then spontaneously resolve over the next several years.

Although these lesions are infrequently imaged, ultrasonography is the initial study of choice for these lesions because it is noninvasive, safe, and easy to perform on infants. Hemangiomas are microscopically vascular lesions and rarely show up as vascular lesions on US imaging. However, when these lesions are visible, color duplex ultrasonography shows heavy vascularization within the lesion. The depth of the lesion varies but can also be measured with ultrasonography using the calibrations on the side of the screen.

Using the high-frequency linear transducer, the probe is placed over the structure of interest, fanning through the lesion using B mode and color duplex for enhanced visualization.

Thyroid Evaluation

Thyroid diseases are one of the most common indications for head and neck ultrasonography. Ultrasonography can identify structures as small as 2 mm in diameter. Ultrasonography assists with tissue characterization, helps determine the etiology, assists in evaluating whether a mass is benign or malignant, and can aid in the treatment of either medical or surgical thyroid-related diseases.[12, 13, 14, 15, 16, 17, 18]

Ultrasonography applications for thyroid investigation include the following:

  • Normal thyroid anatomy

  • Lymphadenopathy

  • Goiter

  • Thyroiditis

  • Autoimmune disease

  • Fine-needle aspiration for histologic determination[19]

  • Routine screening for thyroid cancer[20]

The thyroid gland is a highly vascular gland that is composed of 2 bilateral elongated lobes with superior and inferior poles connected by an isthmus. Usually, 2 pairs of parathyroid glands lie in proximity to the thyroid gland. On ultrasonography, thyroid tissue has a homogeneous, medium-gray echotexture.[21]

Hemorrhage within the thyroid tissue is hypoechoic. Debris appears as heterogeneous echoes within the tissue. Cystic structures appear anechoic and have a thin wall with posterior acoustic enhancement. Calcifications are hyperechoic and create "shadowing," obstructing the tissue plane behind it.

Ultrasonography is the imaging study of choice for thyroid nodules, providing the following:

  • The ability to examine nodules that are too small to be palpated

  • Identification of multiple nodules

  • Precise nodule measurements and ultrasonographic characteristics for monitoring and disease classification

Solid appearance, increased vascularity, microcalcifications, irregular margins, and the absence of a halo are features associated with malignancy.[22]

The ultrasonographic appearance of the affected gland reflects the histopathologic changes that occur: diffuse infiltration of the thyroid parenchyma with lymphocytes and fibrosis. Thus, on ultrasonography, the thyroid parenchyma appears heterogeneous, dotted with small hypoechoic nodules, usually measuring a few millimeters in diameter and separated by echogenic septae.[21]

Using a low-frequency transducer, the dimensions of each lobe should be determined in the sagittal and transverse planes to determine length, anterior posterior depth, and transverse width of gland. Then this formula for volume can be applied: V = 0.5 x (L x D x W).

The total volume of the thyroid gland is obtained by summing the volumes of the 2 lobes. This measurement is an estimate and may become increasingly inaccurate the larger the gland.[23]

When a thyroid nodule has been detected, an ultrasound examination, with or without fine-needle aspiration, should be the first test performed. Ultrasonography can reliably identify solid nodules of more than 3 mm and cystic nodules of more than 2 mm.

Ultrasound characteristics of benign thyroid nodules include the following:

  • Clear, demarcated edges of the nodule

  • Cystic structure - Thin walled, fluid filled, anechoic (no echoes inside, without tissue or vessels)

  • If many cysts throughout thyroid – Benign multinodular goiter

Ultrasound characteristics of malignant nodules have the opposite characteristics. Usually, they are solid, hypoechoic, and taller than wide and may or may not be hypervascular on color Doppler imaging.

Thyroid ultrasound with gray-scale and color Doppler imaging has been shown to be successful at differentiating normal thyroid parenchyma from diffuse or nodular thyroid disease by evaluating gland size, echogenicity, echotexture, margins, and vascularity.[12]

Ultrasound-based classification systems exist for stratification of thyroid nodules based on risk of malignancy, such as the Thyroid Imaging Reporting and Data System (TIRADS). According to a systematic review by Mistry et al, for TIRADS, the mean values for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 90.0%, 57.4%, 49.0%, and 91.0%, respectively.[13, 15]

Biopsy-proven carcinoma of the right thyroid gland Biopsy-proven carcinoma of the right thyroid gland, nodule shown between the arrows.


Thyroiditis on Doppler imaging of the right thyroi Thyroiditis on Doppler imaging of the right thyroid gland showing hypervascularity. (Image A)
Normal thyroid vascularity on color Doppler imagin Normal thyroid vascularity on color Doppler imaging. (Image B)


The incidence of goiter using ultrasonography is about 5%. Iodine deficiency contributes to the incidence far more in developing countries. Other causes include autoimmune thyroid disorders and inflammatory diseases of the thyroid gland. The development of goiter is one of progressive thyroid enlargement, which may result in worsening dyspnea and dysphagia. Substernal goiters may cause progressive compression of major vascular and airway structures.[24] Hormone therapies are first-line treatments to reduce the size of the goiter. However, in many cases, surgical intervention is needed.

Ultrasound elastography

Ultrasound elastography is an imaging technique that has been used in the diagnostic workup of nodular thyroid disease to further investigate the tissue for malignancy. Strain elastography indicates the stiffness in tissues, which is defined as the change in length during compression divided by the length before compression (E = stress/strain). The World Federation for Ultrasound in Medicine and Biology (WFUMB) has produced guidelines for the use of elastography techniques. According to the WFUMB, for shear wave elastography (SWE), some systems require a lower-frequency transducer (9 MHz), and in such cases, the high-frequency transducer should be used for the B-mode, and the lower-frequency probe should be used for SWE.[25, 26, 16, 17, 18]

Evaluation of Neck Masses

Ultrasonography is the imaging modality of choice for differentiating whether a neck mass is cystic or solid and whether it is thyroidal or extra-thyroidal. It is also routinely used for guiding fine-needle aspiration and abscess drainage. Using the high-frequency linear transducer, place the probe along the affected area for visualization, avoiding the cervical spine because visualization is poor distal to bone.

Malignant lymphoma

Lymphomas include histologically different diseases of the lymphatic tissues, such as Hodgkin lymphoma and non-Hodgkin lymphoma. Patients often present with general conditions of malaise, fever, weight loss, and anemia and either single or multiple lymph node swelling. Lymph node swelling is often found in the cervical or inguinal region. Ultrasonography findings show enlargement and hyperemia of the lymph nodes, generally along the cervical chain in the neck.[1, 27]

Thyroglossal duct cyst

These are the most common congenital anomalies of thyroid development found on ultrasonography and are usually diagnosed by 20 years of age. They are usually located in the midline anywhere from the base of the tongue to the thyroid isthmus and develop when the duct fails to completely atrophy after the thyroid descends into position and can have the potential to become malignant.[28, 29]

Ultrasonography findings include a hypoechoic or anechoic, well-circumscribed cystic structure in the anterior floor of the mouth.

Occasionally the lesions can be multicystic; in 1% of cases, papillary adenocarcinoma can develop. In these cases, ultrasonography reveals an increase in size of the cysts, and solid tumor tissue fills the cystic lesion.[1]

(See the images below.)

Sagittal and axial section of the left parotid gla Sagittal and axial section of the left parotid gland showing anechoic rounded lesion suggestive of simple benign cyst.
Sagittal image of the right parotid gland showing Sagittal image of the right parotid gland showing homogeneous normal parenchyma.

Branchial cleft cyst

Branchial cleft cyst (BCC) anomalies may develop in any of the 4 branchial clefts. They are usually in the lateral cervical region, ventrolateral to the carotid bifurcation. Type II BCC constitutes 95% of all BCCs.

Ultrasonography findings include a fluid-filled, anechoic, compressible structure lateral to the carotid artery. Ultrasonography can often show a fine granular echo pattern caused by cellular debris or crystals of cholesterol within the fluid.[1]

Lymph node disease/metastasis

Up to 80% of malignant lymph node metastases originate from squamous cell carcinoma (SCC), often originating in the oropharyngeal cavity. Patients usually present with painful cervical swelling.

Ultrasonography findings include the following:

  • The center of the lymph node is echo free (more hypoechoic than normal), consistent with necrosis.

  • Compression or invasion into the internal jugular vein may be visible.

  • Metastases from SCC are often not highly vascular, varying from thyroid lesions, although vascularity of a node is difficult to assess.[1]

Sensitivity of ultrasonography in the diagnosis of cervical lymph node metastases is approximately 89-95%, whereas specificity is about 80-95%. The lower specificity is due to the difficulties in differentiating between enlarged nodes of lymphoid hyperplasia and enlarged metastatic nodes. The most important criterion in the ultrasonographic diagnosis of metastatic nodal disease is having the round to spherical shape when compared to nonmetastatic nodal disease.[30, 31, 32, 33]


Generally, a normal parathyroid gland is not well visualized on ultrasonography because of its deep location and small size. However, parathyroid adenomas larger than 1 cm should be visible. Ultrasonography findings of parathyroid adenomas include the following:

  • Usually circular to ovoid solid lesions with well-defined margins

  • Homogeneously hypoechoic (unlike lymph nodes)

  • Usually highly vascular, reflected on color duplex sonography

Parathyroid carcinomas are difficult to differentiate from adenomas by ultrasonography alone; thus, biopsies are helpful in this situation.[34]

Characteristics of malignancy include the following:

  • Cystic degeneration

  • Local tissue invasion

  • Calcifications or increased internal heterogeneity

Parathyroid cysts are ultrasonographically similar in appearance to other cysts of the head and neck.[35]

Axial section of the right lower thyroid gland sho Axial section of the right lower thyroid gland showing a hypoechoic nodule inferior to the thyroid gland consistent with parathyroid adenoma (between the arrows).

Evaluation of Facial Masses

For lesions in the parotid, submandibular, and sublingual glands, ultrasonography is an ideal tool for initial assessment, since these structures are relatively superficial. By using high-resolution techniques, one can obtain excellent resolution and tissue characterization without unnecessary radiation hazard. For the deeper and more minor glands or for further investigation, CT or MRI is the modality of choice.[36, 37] Below is a brief overview of common processes involving the salivary glands. Of special consideration, the role of ultrasonography in evaluating facial structures, such as salivary glands, is neither sensitive nor specific and is most valuable in acutely ill patients to assess for infectious processes such as abscess or obstruction.

When using ultrasound-guided FNA to diagnose lesions of the salivary gland, the adequacy of the sample depends on the lesion's composition or vascularity.[38]

The normal parotid gland has a homogeneous echo texture, comparable to that of the thyroid gland, and can (as a normal variant) demonstrate numerous intraparenchymal lymph nodes.[39]

Acute parotitis can result from either viral or bacterial infections. If bacterial, which is less frequent, it is usually unilateral. Whereas viral parotitis on ultrasonography is relatively hypoechoic with a heterogeneous texture, bacterial parotitis demonstrates areas of suppuration in the gland as anechoic or hypoechoic foci, possibly with enlarged intraparotid lymph nodes.[39]

Malignant neoplasms of the parotid gland

The most common malignancies of the salivary gland include mucoepidermoid carcinoma, acinus cell carcinoma, adenocarcinoma, and adenocystic carcinoma (in descending order).[40, 41]

Patients often present with swelling and pain, compared with benign lesions. If found in the parotid gland, when compared with benign lesions, the incidence of facial nerve involvement is increased.

Ultrasonographic findings of malignant tumors show irregular borders and heterogeneity of structures. Shadowing may be observed behind the lesions, and infiltration or invasion into adjacent soft-tissue structures and surrounding muscles is often observed.[1]

High-resolution ultrasonography is the first-line examination for parotid gland diffuse disease and focal lesions, normally using gray-scale and color Doppler ultrasonography.[41]

Pleomorphic adenoma

Pleomorphic adenomas are the most common benign salivary gland tumors. Incidence is highest in the parotid gland. They present clinically as firm mobile swellings of the gland; they are often painless and spare the facial nerve. They are composed histologically of mixed tissues.

Ultrasonographic findings are varied as well. Usually well circumscribed, homogeneous patterns with decreased echogenicity are evident. Adenomas are usually noncompressible structures with a regular border. Occasionally, the tumor is hyperechoic, and cystic areas or calcifications may be seen within the mixed tissue.

Warthin tumor

Warthin tumor is the second most common salivary gland tumor and is usually found in bilateral parotid glands, with a strong male predominance. Ultrasonography usually reveals multiple cystic changes in respective glands.

Sialoliths of the salivary gland

Sialoliths are the most common cause of salivary obstruction.[42, 38] They are usually found in the submandibular gland. Patients usually present with pain, redness, and swelling. The glands may demonstrate inflammatory changes throughout the years and have the potential to get infected and form abscesses.

Ultrasonographic findings include the following:

  • Hyperechoic sialolith with a posterior shadow

  • Duct dilation


Sialadenitis, like sialoliths, usually affects the submandibular gland, rather than the parotid gland. As in acute parotitis, patients often present with pain, redness, and marked swelling. This condition can be caused by radiation or viral and bacterial infections.

Ultrasonographic findings include the following:

  • Massive enlargement of the gland

  • Irregular echogenic structures

  • Hyperemia

  • Possible sclerotic changes