Head and Neck Ultrasonography Technique

Updated: Aug 21, 2015
  • Author: Yuemi An-Grogan, MD; Chief Editor: Gowthaman Gunabushanam, MD, FRCR  more...
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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 diagnosis between the different types of hemorrhagic brain diseases may be limited with ultrasonography; thus, MRI might be more helpful. [4]

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, visualization of the coronal and transverse views of the brain is seen. Depth and gain adjustments commonly need to be made in order to visualize the entire structure of interest.


Hemangiomas are the most common congenital lesion 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, initially for months, and then spontaneously resolve over the next several years.

Although 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 visible, findings using color duplex ultrasonography show 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.

For further information, the American Thyroid Association offers most recent diagnostic and treatment guidelines regarding the workup of thyroid related diseases. In addition, the American College of Radiology offers guidelines for all imaging modalities, including a list of disease processes that are best imaged by ultrasonography.

Ultrasonography applications for thyroid investigation include the following:

  • Normal thyroid anatomy
  • Lymphadenopathy
  • Goiter
  • Thyroiditis
  • Autoimmune disease
  • Fine needle aspiration for histologic determination
  • Routine screening for thyroid cancer

The thyroid gland is a highly vascular gland, composed of 2 bilateral elongated lobes with superior and inferior poles connected by an isthmus. Usually, 2 pairs of parathyroid glands lay in proximity to the thyroid gland. On ultrasonography, thyroid tissue has a homogenous, medium gray echotexture. [5]

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. [6]

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. [5]

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 two lobes. This measurement is an estimate and may become increasingly inaccurate the larger the gland. [7]

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 nodules concerning for malignancy have the opposite characteristics.


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 for 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. [8] Hormone therapies are first line to reduce the size of the goiter. However, in many cases surgical intervention is needed.

Ultrasonography shows solid lesions with echogenicity of normal thyroid tissue and/or nodules with cystic change. [9]

Ultrasound elastography

Ultrasound elastography is a newly developed imaging technique that has recently been used in the diagnostic workup of nodular thyroid disease to further investigate the tissue for malignancy. This examination is beyond the scope of this review. [10]


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]

Thyroglossal duct cyst

These are the most common congenital anomalies of thyroid development found on ultrasonography and are usually diagnosed by 20 years of life. 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 potential to become malignant. [11]

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]

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 comprises 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

Most malignant lymph node metastases originate from squamous cell carcinoma (SCC), up to 80%, often times 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.
  • Metastasis 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. [12, 13, 14]


Generally, a normal parathyroid gland is typically not well visualized on ultrasonography due to 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
  • Homogenously hypoechoic (unlike lymph nodes)
  • Usually highly vascular, reflected on color duplex sonography

Parathyroid carcinomas are difficult to differentiate from adenomas by ultrasonography alone and thus, biopsies are helpful in this situation.

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, except for their location in parathyroid tissue. [15]


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. [16] 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 not sensitive, nor specific and is most valuable in the acutely ill to assess for infectious processes such as abscess or obstructive processes.

The normal parotid gland has a homogenous echo texture, comparable to that of the thyroid gland, and can (as a normal variant) demonstrate numerous intraparenchymal lymph nodes. [17]

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 heterogenous texture, bacterial parotitis demonstrates areas of suppuration in the gland as anechoic or hypoechoic foci, possibly with enlarged intraparotid lymph nodes. [17]

Studies to date have failed to validate the use of ultrasonography in the diagnosis of sinusitis. [18, 19, 20]

Malignant neoplasms of parotid gland

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

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.

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

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 swelling of gland, often painless and sparing the facial nerve. They are composed histologically of mixed tissues.

Ultrasonography findings are varied as well. Usually well circumscribed, homogenous 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 strong male predominance. Ultrasonography usually reveals multiple cystic changes in respective gland.

Sialoliths of the salivary gland

Sialoliths are the most common cause of salivary obstruction. They are usually found in the submandibular gland. Patients usually present with pain, redness and swelling. Oftentimes, related to eating or drinking. Sometimes the glands can have inflammatory changes as it recurs throughout the years and has the potential to get infected and form abscesses.

Ultrasonography 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. Similar to acute parotitis, patients often presents with pain, redness and marked swelling. This condition can be caused by radiation or viral and bacterial infections.

Ultrasonography findings include the following:

  • Massive enlargement of the gland
  • Irregular echogenic structures
  • Hyperemia
  • Possible sclerotic changes

Transcranial Doppler Ultrasonography

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.