Submandibular Sialolithiasis: A Case Report

# Submandibular Sialolithiasis: An ultrasound Case Report

#Introduction

Sialolithiasis is a condition in which stones (calculi) form in the salivary glands or ducts, blocking the flow of saliva. It is the most common disease of the salivary glands, accounting for approximately 50% of all major salivary gland pathology¹. The submandibular gland is the most frequently affected site, followed by the parotid gland². Sialolithiasis can cause pain, swelling, infection, and reduced salivary function³.

Case study:

In this case report, we present a patient with acute onset pain and swelling of the right submandibular region due to a large calculus in the proximal Wharton's duct.

#Case Presentation:

A 45-year-old male presented to the emergency department with a history of sudden onset pain and swelling of the right submandibular region that started 12 hours ago. He reported that the pain was severe, throbbing, and radiating to the ear and neck. He also complained of dry mouth and difficulty swallowing. He denied any fever, chills, trauma, or previous episodes of similar symptoms. He had no history of smoking, alcohol consumption, or systemic diseases. His physical examination revealed a tender, firm, and enlarged right submandibular gland with overlying erythema. There was no palpable mass or lymphadenopathy. His oral cavity was dry and his tongue was coated. His vital signs were normal.

# Ultrasound Findings

An ultrasound examination of the right submandibular region was performed using a high-frequency linear transducer. The ultrasound showed a calculus of 8 mm in diameter in the proximal Wharton's duct with mild dilation of the duct (Figure 1 to 5). The calculus appeared as a hyperechoic structure with posterior acoustic shadowing. The submandibular gland parenchyma was normal in echotexture and vascularity. There was no evidence of abscess formation or sialadenitis.

[Figure 1 to 5]: Ultrasound image showing a calculus (arrow) in the proximal Wharton's duct with mild ductal dilation:

# Etiology

The exact etiology of sialolithiasis is unknown, but several factors have been proposed to contribute to its formation. These include:

- Dehydration: Reduced fluid intake or increased fluid loss can lead to decreased salivary flow and increased concentration of calcium and phosphate in saliva⁵.

- Smoking: Tobacco use can alter the composition and pH of saliva, as well as cause inflammation and fibrosis of the salivary ducts⁶.

- Diet: High intake of calcium or oxalate-rich foods can increase the risk of sialolithiasis by increasing the saturation of these minerals in saliva⁷.

- Medications: Certain drugs, such as antihistamines, diuretics, anticholinergics, and beta-blockers, can reduce salivary secretion and cause xerostomia.

- Infections: Bacterial or viral infections can cause inflammation and obstruction of the salivary ducts, as well as alter the pH and viscosity of saliva.

- Anatomical factors: The submandibular gland is more prone to sialolithiasis than other salivary glands because of its longer and tortuous duct, its alkaline and mucinous saliva, and its dependent position that favors gravity-dependent sedimentation.

For more visit:

Ultrasound imaging of salivary glands

# Management of sialolithiasis

The management of sialolithiasis depends on the size, location, number, and symptoms of the calculi. The main goals are to relieve pain, restore salivary flow, prevent infection, and remove the calculi. The possible treatment options include:

- Conservative measures: These include hydration, massage, heat application, sialogogues (substances that stimulate salivary secretion), antibiotics (if infection is present), and analgesics (for pain relief). These measures can be effective for small or distal calculi that can be spontaneously expelled.

- Sialendoscopy: This is a minimally invasive technique that involves inserting a small endoscope into the salivary duct to visualize and remove the calculi using micro-instruments or laser. This technique has high success rates and low complication rates for calculi located in the proximal or middle part of the duct.

- Extracorporeal shock wave lithotripsy (ESWL): This is a non-invasive technique that uses high-energy sound waves to break up the calculi into smaller fragments that can be flushed out by saliva. This technique can be used for large or multiple calculi that are not amenable to sialendoscopy.

- Surgery: This is the last resort for sialolithiasis that is refractory to other modalities or complicated by recurrent infections or glandular damage. The surgical options include ductal incision, calculus extraction, ductal dilation, or gland excision. Surgery has higher risks of complications, such as nerve injury, bleeding, infection, and salivary fistula.

# Prognosis of sialolithiasis in this case:

The prognosis of sialolithiasis is generally good, especially if the condition is diagnosed and treated early. Most patients achieve complete resolution of symptoms and restoration of salivary function after appropriate treatment. However, some patients may experience recurrence of sialolithiasis, especially if the underlying etiological factors are not addressed. The recurrence rate ranges from 5% to 15%. Recurrence can be prevented by maintaining adequate hydration, avoiding smoking, eating a balanced diet, and practicing good oral hygiene.

# Conclusion

Sialolithiasis is a common and benign condition that can cause pain and swelling of the salivary glands. Ultrasound is a useful imaging modality for diagnosing and evaluating sialolithiasis. The treatment options vary depending on the size, location, number, and symptoms of the calculi. The prognosis is generally good with timely and appropriate management. Recurrence can be prevented by modifying the risk factors and following up regularly.

(1) Sialolithiasis | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/sialolithiasis.

(2) Salivary Stones: Causes, Symptoms & Treatment - Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/24344-sialolithiasis.

(3) Submandibular Gland: Anatomy, Function, Conditions - Verywell Health. https://www.verywellhealth.com/submandibular-gland-5101463.

(4) Sialolithiasis - Wikipedia. https://en.wikipedia.org/wiki/Sialolithiasis.

(5) Sialolithiasis Symptoms, Diagnosis, and Treatments - Verywell Health. https://www.verywellhealth.com/everything-you-need-to-know-about-sialolithiasis-1192027.

(6) undefined. https://doi.org/10.53347/rID-2044.

(7) undefined. https://radiopaedia.org/articles/2044.

Ultrasound Case of the Week: Ovarian Cyst with Mural Nodule

Ultrasound Case of the Week: Ovarian Cyst with Mural Nodule

In this post we discuss a challenging case of a 50 year old female patient who presented with pelvic pain and irregular menstrual bleeding. She underwent a transvaginal ultrasound examination, which revealed a 4 cm cystic mass in the right adnexa with a 0.9 cm mural nodule. The cystic mass had thin walls and no septa, and the mural nodule was non-calcified and non-vascular. The left ovary was normal, and there was no ascites or lymphadenopathy.

Ultrasound images of the ovarian cyst:

Transabdominal ultrasound image shows an innocuous looking simple ovarian cyst. But endocavity ultrasound says otherwise. 🙄 

#Differential Diagnoses:

The differential diagnoses for an ovarian cyst with a mural nodule include:

- Ovarian mucinous cystic tumor with mural nodules: This is a rare type of ovarian tumor that consists of a cystic component lined by mucinous epithelium and solid nodules composed of anaplastic or sarcomatoid cells. The mural nodules are usually non-calcified and non-vascular, and may show papillary projections. This tumor has a high risk of malignant transformation and recurrence.

- Ovarian mucinous cystadenocarcinoma: This is a malignant epithelial ovarian tumor that is filled with mucin and may have thick septa, papillary projections, or mural nodules. The mural nodules are usually vascular and may show calcifications. This tumor has a poor prognosis and may spread to other organs.

- Ovarian endometrioid carcinoma: This is a malignant epithelial ovarian tumor that is associated with endometriosis and may have a cystic or solid appearance. The cystic component may have hemorrhagic fluid and mural nodules that are vascular and may show calcifications. The mural nodules may also have squamous differentiation or clear cell features. This tumor has a moderate prognosis and may invade the uterus or the fallopian tubes.

- Ovarian mature cystic teratoma: This is a benign germ cell ovarian tumor that contains elements from all three germ layers, such as skin, hair, teeth, bone, cartilage, or fat. The cystic component may have sebaceous fluid and mural nodules that are calcified and non-vascular. The mural nodules may also have immature components or somatic malignancies. This tumor has a low risk of malignancy and recurrence.

- Hydrosalpinx: This is a dilated fallopian tube filled with serous fluid due to inflammation, infection, or obstruction. It may mimic an ovarian cystic mass on ultrasound, especially if the longitudinal folds are not seen. The mural nodules may represent incomplete septa or debris within the tube. This condition is usually benign but may cause infertility or pelvic pain.

#Diagnostic Approach

To narrow down the differential diagnoses, we need to consider the following factors:

- Patient's age: The patient is 50 years old, which is postmenopausal for most women. This increases the likelihood of malignant tumors over benign ones.

- Patient's symptoms: The patient had pelvic pain and irregular menstrual bleeding, which are suggestive of hormonal imbalance or endometrial pathology. This may favor endometrioid carcinoma over other tumors.

- Cyst size: The cyst is 4 cm in diameter, which is relatively small for most ovarian tumors. However, this does not exclude malignancy, as some tumors can be small but aggressive.

- Cyst morphology: The cyst has thin walls and no septa, which are favorable features for benignity. However, the presence of a mural nodule raises suspicion for malignancy.

- Mural nodule characteristics: The mural nodule is non-calcified and non-vascular, which are features that can be seen in both benign and malignant tumors. However, the absence of calcifications and vascularity makes mucinous cystadenocarcinoma less likely. The size of the nodule is also important, as larger nodules (>1 cm) are more likely to be malignant than smaller ones (<1 cm).

- Other findings: The absence of ascites or lymphadenopathy is reassuring for benignity. However, these findings can be absent in early stages of malignancy.

Based on these factors, we can rank the differential diagnoses as follows:

- Ovarian endometrioid carcinoma: This is the most likely diagnosis, as it fits the patient's age, symptoms, cyst morphology, and mural nodule characteristics. It also has a moderate prognosis and may require surgery and chemotherapy.

- Ovarian mucinous cystic tumor with mural nodules: This is the second most likely diagnosis, as it also fits the patient's age, cyst morphology, and mural nodule characteristics. However, it is a rare tumor and has a high risk of malignancy and recurrence. It may also require surgery and chemotherapy.

- Ovarian mature cystic teratoma: This is the third most likely diagnosis, as it is a benign tumor that can have a cystic component and mural nodules. However, it is more common in younger women and the mural nodules are usually calcified and non-vascular. It may also have other components such as hair or teeth that can be seen on ultrasound. It usually requires surgery but has a low risk of recurrence.

- Hydrosalpinx: This is the fourth most likely diagnosis, as it can mimic an ovarian cyst on ultrasound. However, it is more common in women with a history of pelvic inflammatory disease or tubal ligation. It also has longitudinal folds that can be seen on ultrasound. It may cause infertility or pelvic pain but does not require surgery unless symptomatic.

- Ovarian mucinous cystadenocarcinoma: This is the least likely diagnosis, as it is a malignant tumor that usually has thick septa, papillary projections, or mural nodules that are vascular and calcified. It also has a poor prognosis and may spread to other organs. It requires surgery and chemotherapy.

#Prognosis and Management

The prognosis and management of the patient depend on the final diagnosis, which can be confirmed by MRI or biopsy. However, based on the ultrasound findings, we can assume that the patient has a malignant ovarian tumor that requires surgical removal and possibly chemotherapy. The prognosis will depend on the stage of the tumor, which can be determined by imaging or pathology. The survival rates for ovarian cancer vary depending on the type and stage of the tumor, but generally range from 10% to 90%.

The management of the patient will also depend on her fertility status and preferences. If she wishes to preserve her fertility, she may opt for conservative surgery that spares the uterus and the contralateral ovary. However, this may increase the risk of recurrence or metastasis. If she does not wish to preserve her fertility, she may opt for radical surgery that removes the uterus, both ovaries, both fallopian tubes, and any other affected organs or tissues. She may also need adjuvant chemotherapy to reduce the risk of recurrence or metastasis.

You may find this ebook interesting:

Ebook atlas of sonography of uterine fibroids

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Sonography of uterine fibroids Atlas format

I hope you enjoyed this blog post. Please leave your comments or questions below. Thank you for reading!

: Ovarian Mucinous Cystic Tumor with Mural Nodules. https://www.ncbi.nlm.nih.gov/medgen/269341.

: Ovarian mucinous borderline tumor with anaplastic carcinomatous nodules .... https://ovarianresearch.biomedcentral.com/articles/10.1186/s13048-022-01010-3.

: Ovarian cystic neoplasms | Radiology Reference Article - Radiopaedia.org. https://radiopaedia.org/articles/ovarian-cystic-neoplasms-1.

: Hydrosalpinx | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/hydrosalpinx.

: The Radiology Assistant : Roadmap to evaluate ovarian cysts. https://radiologyassistant.nl/abdomen/unsorted/roadmap-to-evaluate-ovarian-cysts.

Hashimoto's thyroiditis- fibrotic stage

Fibrotic stages of Hashimoto's thyroiditis in a young adult with hypothyroidism

Hashimoto's thyroiditis is an autoimmune disorder that causes inflammation of the thyroid gland. Over time, this inflammation can lead to scarring and fibrosis of the thyroid gland, which can impair its function. This can lead to hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormone.

Case study:

In this young adult with hypothyroidism, the likely diagnosis is the fibrotic stage of Hashimoto's thyroiditis. This condition is characterized by a small, fibrotic thyroid gland. On ultrasound, the thyroid gland appears hypoechoic (darker than surrounding tissue) and heterogeneous (with a non-uniform texture). The thyroid gland may also appears atrophic (shrunken).

Here are three ultrasound images of fibrotic stage of Hashimoto's thyroiditis:

[Image 1: Ultrasound image of a small, hypoechoic thyroid gland with a heterogeneous echotexture.] 

[Image 2: Ultrasound image of a small, fibrotic Rt lobe thyroid gland with dense echogenic fibrous septa.] 

[Image 3: Color Doppler ultrasound image of a small, fibrotic thyroid gland with normal vascularity.]

Various stages of Hashimoto's thyroiditis as seen on ultrasound:

• Early stage: The thyroid gland may be enlarged and have a heterogeneous echotexture, with hypoechoic and hyperechoic areas. There may be increased vascularity.
• Micronodular stage: Small, hypoechoic nodules (1-6 mm in diameter) are seen throughout the thyroid gland. This is a highly characteristic finding of Hashimoto's thyroiditis.
• Atrophic stage: The thyroid gland is shrunken and has a decreased echogenicity. This is seen in advanced cases of Hashimoto's thyroiditis.

Other ultrasound findings that may be seen in Hashimoto's thyroiditis include:

• Echogenic septations
• Lobulated contour
• Geographic hypoechogenicity without discrete nodules

Prognosis

The prognosis for the fibrotic stages of Hashimoto's thyroiditis is generally good. However, the condition is chronic and progressive, and may eventually lead to hypothyroidism that requires lifelong treatment with thyroid hormone replacement therapy.

Management

Management of the fibrotic stages of Hashimoto's thyroiditis is focused on treating the hypothyroidism. This is done with thyroid hormone replacement therapy, which typically involves taking a daily dose of levothyroxine (Levothroid, Synthroid).

In addition to thyroid hormone replacement therapy, there are a number of other things that people with the fibrotic stages of Hashimoto's thyroiditis can do to manage their condition, including:

• Eating a healthy diet
• Getting regular exercise
• Avoiding stress
• Avoiding smoking and excessive alcohol consumption

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Epicardial fat

What is epicardial fat?

- Epicardial fat pad is a normal structure that lies between the myocardium and the visceral pericardium¹.

- It is more prominent in obese patients and can be associated with coronary artery disease, diabetes, arrhythmias, and other cardiac conditions⁶.

- Ultrasound imaging: can show the epicardial fat as echogenic tissue around the right heart, especially on the subcostal view³.

- The following are two examples of ultrasound images showing the epicardial fat pad:

Image 1: A subcostal view of the heart showing a prominent epicardial fat pad (arrow) as a bright layer around the right ventricle (RV). The liver (L) is seen below the heart. The left ventricle (LV) and the pericardium (P) are also visible.

Image 2: Another subcostal view of the heart showing a large epicardial fat pad (arrow) extending from the right atrium (RA) to the apex of the right ventricle (RV). The liver (L) is seen below the heart. The left ventricle (LV) and the pericardium (P) are also visible.

- The prognosis and management of epicardial fat pad depend on the underlying cardiac condition and the presence of symptoms⁶.

- In most cases, conservative treatment with weight loss, exercise, and medications can reduce the amount of epicardial fat and improve cardiac function⁸.

- In rare cases, surgical removal of epicardial fat may be indicated for symptomatic patients.

For an ebook on interesting ultrasound imaging cases, on Amazon Kindle, you can download this:

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Assorted ultrasound cases ebook Indian download link

(1) Pericardial fat pads | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/pericardial-fat-pads-2.

(2) Epicardial Adipose Tissue: A Predictor of Coronary Artery Disease. https://www.healthline.com/health/coronary-artery-disease/epicardial-adipose-tissue-coronary-artery-disease.

(3) Potential Errors in the Diagnosis of Pericardial Effusion on Trauma .... https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2000.tb00472.x.

(4) Understanding Epicardial Fat | Premier Health. https://www.premierhealth.com/your-health/articles/health-topics/understanding-epicardial-fat.

(5) Epipericardial fat necrosis | Radiology Reference Article - Radiopaedia.org. https://radiopaedia.org/articles/epipericardial-fat-necrosis-1?lang=us.

(6) Epicardial fat pad | Radiology Case | Radiopaedia.org. https://radiopaedia.org/cases/epicardial-fat-pad.

(7) What does pericardial fat pad mean? - Studybuff.com. https://studybuff.com/what-does-pericardial-fat-pad-mean/.

(8) Pericardial effusion | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/pericardial-effusion.

(9) Pericardial cyst - Wikipedia. https://en.wikipedia.org/wiki/Pericardial_cyst.

Suprasternal view of aorta in echocardiography: A radiologist's perspective

Suprasternal view of aorta in echocardiography: 

Technique:

* Position the patient in a supine position with the head elevated on two pillows to extend the neck.

* Place the transducer in the suprasternal notch, with the index marker pointing towards the left shoulder.

* Angle the transducer slightly cephalad and to the left to obtain a long-axis view of the ascending aorta and aortic arch.

* Use color Doppler to identify the flow of blood through the aorta.

Anatomy:

The suprasternal view of the aorta allows visualization of the following structures:

* Ascending aorta

* Aortic arch

* Brachiocephalic artery

* Left common carotid artery

* Left subclavian artery

* Right pulmonary artery

Echocardiographic images of a case:

Significance of suprasternal view:

The suprasternal view is an important echocardiographic view for assessing the following:

* Aortic dimensions

* Aortic dissection

* Aortic aneurysm

* Aortic valve stenosis

* Aortic valve regurgitation

* Coarctation of the aorta

* Patent ductus arteriosus

* Aortic root abscess

Important points:

* The suprasternal view is a valuable tool for assessing the aorta in patients with a variety of cardiovascular conditions.

* It is important to obtain a high-quality image of the aorta in order to accurately assess its dimensions and morphology.

* Color Doppler can be used to identify the flow of blood through the aorta and to detect any abnormalities.

* The suprasternal view should be used in conjunction with other echocardiographic views to obtain a comprehensive assessment of the cardiovascular system.

Here are some additional important points:

* The suprasternal view is particularly useful for visualizing the aortic arch and its branches, as well as the right pulmonary artery.

* It is also a good view for assessing the aortic root and ascending aorta.

* The suprasternal view can be challenging to obtain in patients with a short neck or a thick chest wall.

* In some cases, it may be necessary to use a higher frequency transducer to obtain a clear image.

Conclusion:

The suprasternal view is an important echocardiographic view for assessing the aorta. It is a valuable tool for detecting and monitoring a variety of cardiovascular conditions.

This kindle ebook can help guide you. It is an atlas of different types of ultrasound cases. 

Ebook Assorted ultrasound cases

For readers in India:

Assorted ultrasound cases, Indian edition

Large Nabothian Cyst of Cervix

#Ultrasound Imaging of a Large Nabothian Cyst of Cervix

Nabothian cysts are benign cysts that form in the cervix, the lower part of the uterus. They are caused by the blockage of cervical mucus-producing gland cells. They are very common and usually do not cause any symptoms or complications. However, sometimes they can grow large enough to be seen on ultrasound imaging or interfere with cervical screening tests.

In this blog post, I will share a case of a 35-year-old female patient who underwent an ultrasound scan and was found to have a large Nabothian cyst of cervix. 

# Case Presentation:

The patient presented with no complaints or history of cervical pathology. She had regular menstrual cycles and no history of sexually transmitted infections. She had one previous normal vaginal delivery.

# Ultrasound imaging:

She underwent a routine pelvic ultrasound scan as part of her annual health check-up. The scan revealed a well-defined, round, anechoic (black) cystic lesion measuring 1.4 cm in diameter in the anterior wall of the cervix (Figure 1). The cyst showed no internal vascularity on color Doppler ultrasound (Figure 2). The rest of the pelvic organs were normal.

Figure 1: Transabdominal ultrasound image showing a large nabothian cyst (arrow) in the anterior wall of the cervix.

Figure 2: Color Doppler ultrasound image showing no internal blood flow within the nabothian cyst.

# Differential Diagnoses

The differential diagnoses for a cystic lesion in the cervix include:

- Nabothian cyst: This is the most likely diagnosis in this case, given the typical appearance and location of the cyst. Nabothian cysts are usually small (<1 cm), but they can occasionally grow larger (>2 cm) ¹. They are usually asymptomatic, but they can cause pelvic pain, dyspareunia (painful intercourse), abnormal vaginal bleeding or discharge, or difficulty in urination or defecation if they compress adjacent structures ².

- Cervical polyp: This is a benign growth that protrudes from the cervical canal into the vagina. It can be pedunculated (attached by a stalk) or sessile (flat). It can be single or multiple. It usually appears as a hypoechoic (gray) mass with internal vascularity on ultrasound ³. It can cause intermenstrual or postcoital bleeding, vaginal discharge, or infertility ⁴.

- Cervical cancer: This is a malignant tumor that arises from the cells lining the cervix. It can be squamous cell carcinoma (the most common type), adenocarcinoma, or other rare types. It can present as a solid or cystic mass with irregular margins and increased vascularity on ultrasound ⁵. It can cause abnormal vaginal bleeding or discharge, pelvic pain, weight loss, or metastatic symptoms ⁶.

- Endometrioma: This is a benign cyst that contains endometrial tissue (the lining of the uterus) outside the uterus. It can occur in various locations in the pelvis, including the cervix. It usually appears as a complex cyst with low-level echoes and fine septations on ultrasound ⁷. It can cause dysmenorrhea (painful periods), dyspareunia, chronic pelvic pain, or infertility ⁸.

- Other rare causes: These include cervical leiomyoma (fibroid), cervical abscess (infection), cervical ectopic pregnancy (implantation of a fertilized egg in the cervix), cervical lymphangioma (a benign tumor of lymphatic vessels), cervical dermoid cyst (a benign tumor that contains various types of tissues), or cervical metastasis (spread of cancer from another site) ⁹.

# Prognosis and Management:

The prognosis of nabothian cysts is excellent. They are not associated with any increased risk of malignancy or adverse pregnancy outcomes. They usually do not require any treatment unless they cause symptoms or interfere with cervical screening tests.

The management options for symptomatic or large nabothian cysts include:

- Observation: This is suitable for asymptomatic or mildly symptomatic cysts that do not interfere with cervical screening tests. The cysts may resolve spontaneously over time or remain stable in size ¹¹.

- Aspiration: This involves inserting a needle into the cyst and draining the fluid out. This can be done under local anesthesia in the office or under general anesthesia in the operating room. This can provide immediate relief of symptoms, but the cyst may recur ¹².

- Excision: This involves surgically removing the cyst and the surrounding tissue. This can be done by various techniques, such as electrocautery, laser, or scalpel. This can be done under local or general anesthesia in the office or in the operating room. This can provide a definitive cure and prevent recurrence, but it may cause scarring or stenosis (narrowing) of the cervix ¹³.

#Conclusion

Nabothian cysts are common and benign cysts that form on the surface of the cervix. They usually do not cause any symptoms or complications and do not require any treatment. However, sometimes they can grow large enough to be seen on ultrasound imaging or interfere with cervical screening tests. In such cases, they can be managed by observation, aspiration, or excision, depending on the patient's preference and reproductive plans.

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I hope you enjoyed reading my blog post. 😊

(1) Nabothian Cyst: Causes, Symptoms and Treatment - Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/22653-nabothian-cyst.

(2) Nabothian Cyst: Causes, Symptoms, and Treatments - Healthline. https://www.healthline.com/health/nabothian-cyst.

(3) Nabothian cyst: Causes, symptoms, complications, and treatment. https://www.medicalnewstoday.com/articles/327061.

(4) Nabothian Cysts - Harvard Health. https://www.health.harvard.eduwww.health.harvard.edu/a_to_z/nabothian-cysts-a-to-z.

(5) Nabothian cyst - Wikipedia. https://en.wikipedia.org/wiki/Nabothian_cyst.

(6) Differential diagnosis of a neck mass - UpToDate. https://www.uptodate.com/contents/differential-diagnosis-of-a-neck-mass.

(7) Differential diagnosis of cervical cystic lesions 

(11) Nabothian Cysts: Definition, Symptoms, Prognosis - Verywell Health. https://www.verywellhealth.com/nabothian-cysts-7107592.

(12) Nabothian cyst | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/nabothian-cyst.

(13) undefined. https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms.

(14) undefined. https://dx.doi.org/10.26044/ecr2022/C-16617.

Early 1st Trimester Viable Pregnancy with Right Ovarian Simple Cyst

This is a case of a patient who presented with a history of amenorrhea and mild right lower abdominal pain. She was suspected to have an early 1st trimester viable pregnancy with a maternal right ovarian simple cyst.

 Ultrasound Findings:

- The ultrasound scan showed an intrauterine gestational sac containing an embryo with a crown-rump length (CRL) of 6 mm and a fetal heart rate of 115 beats per minute, consistent with a gestational age of about 6 weeks.

- The gestational sac was well-defined and had a mean sac diameter (MSD) of 16 mm, which was within the normal range for the CRL.

- The yolk sac was visible within the gestational sac and measured 3 mm in diameter, which was also normal for the gestational age.

- The amnion was seen adjacent to the yolk sac, enclosing the embryo.

- No fetal anomalies were detected at this stage of the pregnancy.

- The maternal right ovary showed a simple cyst measuring 2.9 cm in diameter, with smooth walls and anechoic contents. No internal vascularity was seen on color Doppler ultrasound, indicating that the cyst was not likely to be malignant or endometriotic.

- The left ovary and the uterus were normal in size and appearance, with no evidence of any masses or abnormalities.

 Prognosis and Management:

- The ultrasound findings confirmed the diagnosis of an early 1st trimester viable pregnancy with a right ovarian simple cyst.

- The prognosis for the pregnancy was good, as there were no signs of pregnancy failure or complications. The patient was advised to have a follow-up ultrasound scan in two weeks to confirm the viability and growth of the embryo, and subsequent scans as well to assess the fetal anatomy and nuchal translucency.

- The prognosis for the ovarian cyst was also favorable, as most simple ovarian cysts resolve spontaneously during pregnancy or shortly after delivery . The patient was reassured that the cyst was unlikely to cause any harm to her or her baby, and that it did not require any treatment at this point. She was advised to report any symptoms such as severe pain, fever, or bleeding that could indicate a rupture or infection of the cyst.

- The patient was counseled about the importance of prenatal care, nutrition, and lifestyle modifications to ensure a healthy pregnancy outcome.

I hope you enjoyed reading this blog post. 

For more on this topic visit:

Sonography of early pregnancy

Isolated mammary duct ectasia, Ultrasound study

This is a case of mildly dilated mammary duct in a 35-year-old female patient who presented with right breast discomfort. I will describe the ultrasound findings, the diagnosis, the prognosis and the management of this condition.

 Ultrasound Findings

The patient underwent ultrasound imaging of her right breast, which revealed:

- A mildly dilated mammary duct of 1.4 mm diameter at 9 o clock position in the right breast

- No nipple discharge

- Color Doppler ultrasound showed no vascularity

- No breast masses seen

The ultrasound images are shown below:

Diagnosis:

Based on the ultrasound findings, the most likely diagnosis is solitary duct ectasia. This is a benign condition that occurs when one or more mammary ducts beneath the nipple widen and fill with fluid. The duct walls may thicken and become blocked or clogged with a sticky substance.

Mammary duct ectasia is more common in women during perimenopause (around age 45 to 55 years), but it can also occur after menopause. The exact cause of mammary duct ectasia is unknown, but some factors that may be associated with it are:

- Breast tissue changes due to aging

- Smoking

- Nipple inversion

- Previous breast surgery or trauma

More on solitary mammary duct ectasia:

Solitary duct ectasia is a rare type of asymmetric duct ectasia that is suspicious for malignancy and biopsy should be considered (BI-RADS 4) . It is the abnormal widening of one or more breast ducts to greater than 2 mm diameter, or 3 mm at the ampulla. It can be due to benign or malignant processes. On ultrasound, it appears as distended branching or tubular structures with anechoic contents measuring more than 2 mm diameter. Features that on ultrasound should raise suspicion for malignancy include nonsubareolar location, hypoechoic intraluminal contents, ductal wall irregularity or indistinctness, or solid parenchymal mass.

In our case:

A solitary duct ectasia of 1.4 mm breast on ultrasound imaging may not meet the criteria for duct ectasia, as it is less than 2 mm in diameter. However, it may still be a sign of intraductal malignancy, especially if it is associated with other suspicious features. In our patient, no other findings were observed. 

Symptoms:

Mammary duct ectasia often does not cause any signs or symptoms, but some people may experience:

- A dirty white, greenish or black nipple discharge from one or both nipples

- Tenderness in the nipple or surrounding breast tissue (areola)

- Redness of the nipple and areolar tissue

- A breast lump or thickening near the clogged duct

- A nipple that's turned inward (inverted).

In some cases, mammary duct ectasia may also lead to a bacterial infection called periductal mastitis, which causes breast pain, inflammation and fever.

Prognosis:

Mammary duct ectasia is not a risk factor for breast cancer, and it usually does not affect the ability to breastfeed. However, it may cause discomfort and distress for some women, especially if there is nipple discharge or infection.

The prognosis of mammary duct ectasia depends on the severity of the symptoms and the response to treatment. In most cases, mammary duct ectasia resolves without any treatment or with self-care measures. In some cases, antibiotics or surgery may be needed to treat an infection or remove the affected milk duct.

Management:

The management of mammary duct ectasia depends on the symptoms and preferences of the patient. Some options are:

- Self-care measures: These include applying warm compresses to the nipple and surrounding area, using breast pads or nursing pads to absorb nipple discharge, wearing a support bra to minimize breast discomfort, sleeping on the opposite side of the affected breast, and stopping smoking.

- Antibiotics: These may be prescribed for 10 to 14 days to treat an infection caused by mammary duct ectasia. It is important to take all the medication as prescribed, even if the symptoms improve or disappear.

- Surgery: This may be considered if an abscess has developed and antibiotics and self-care do not work, or if the symptoms are persistent and bothersome. The surgery involves making a tiny incision at the edge of the areola and removing the affected milk duct. The surgery rarely affects the appearance of the breast or nipple.

#Conclusion:

Mammary duct ectasia is a benign condition that occurs when one or more milk ducts beneath the nipple widen and fill with fluid. It often does not cause any symptoms, but it may cause nipple discharge, breast tenderness, inflammation or infection. It is not a risk factor for breast cancer, and it usually does not affect breastfeeding. The management of mammary duct ectasia depends on the symptoms and preferences of the patient. It may include self-care measures, antibiotics or surgery.

Disclaimer: This blog post is for informational purposes only.

For more, this kindle ebook on breast sonography:

Ebook atlas of breast ultrasound

For those in India:

Atlas of breast ultrasound

References:

(1) Mammary duct ectasia - Diagnosis & treatment - Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/mammary-duct-ectasia/diagnosis-treatment/drc-20374806.

(2) Mammary duct ectasia - Symptoms & causes - Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/mammary-duct-ectasia/symptoms-causes/syc-20374801.

(3) Duct Ectasia of the Breast - American Cancer Society. https://www.cancer.org/cancer/types/breast-cancer/non-cancerous-breast-conditions/duct-ectasia.html.

(4) Mammary Duct Ectasia: How Does it Impact Your Health? - WebMD. https://www.webmd.com/skin-problems-and-treatments/what-is-mammary-duct-ectasia.

(5) Mammary Duct Ectasia: Symptoms, Causes, Diagnosis, and Treatment. https://www.verywellhealth.com/mammary-duct-ectasia-is-a-benign-breast-condition-430687.

Dilated Mammary Duct: An ultrasound Case Report:

This is a case of a middle-aged female patient who presented with a history of left nipple discharge of one week. The discharge was clear, non-bloody, and occurred spontaneously. She had no history of breast trauma, surgery, or lactation. She had no family history of breast cancer or other breast diseases. She was not taking any medications or hormonal supplements.

On physical examination, the left nipple and areola were normal in appearance, with no signs of inflammation, retraction, or ulceration. There was no palpable mass or axillary lymphadenopathy. A small amount of clear fluid could be expressed from the left nipple on gentle pressure.

Ultrasound imaging:

We performed an ultrasound scan of the left breast, which showed a non-vascular linear anechoic structure at the 12 o'clock position, measuring 2.5 mm in diameter and 3 cm in length. It extended from the subareolar region to the upper outer quadrant of the breast. There was no evidence of any solid mass, cyst, or calcification in the breast parenchyma. The right breast was normal on ultrasound.

Ultrasound imaging findings:

The ultrasound findings were suggestive of a dilated mammary duct, also known as duct ectasia. This is a benign condition that occurs due to the widening and thickening of one or more breast ducts, usually near the nipple. It is more common in perimenopausal and postmenopausal women, and may be associated with smoking. The dilated ducts may contain proteinaceous fluid, debris, or blood, which can leak out through the nipple and cause discharge.

Further tests:

To confirm the diagnosis and rule out any associated malignancy, I ordered a magnetic resonance imaging (MRI) scan of the left breast. The MRI showed a dilated tubular structure with high signal intensity on T1- and T2-weighted images, converging towards the nipple without any overlying mass. There was no enhancement after contrast administration. The MRI findings were consistent with duct ectasia and did not show any features suspicious for malignancy.

The differential diagnosis: of dilated ducts on breast imaging includes physiological lactational changes, mammary duct infection (mastitis), intraductal papilloma, intraductal carcinoma, and Paget's disease of the nipple. The clinical history, physical examination, and imaging features can help to narrow down the possible causes and guide further management.

Prognosis:

The prognosis of duct ectasia is generally good, as it is a benign condition that does not increase the risk of breast cancer. However, it may cause some discomfort and distress to the patient due to the nipple discharge and possible infection. Most cases of duct ectasia resolve spontaneously without any treatment.

Management:

 Some self-care measures that can help to relieve the symptoms include applying warm compresses to the nipple, wearing breast pads to absorb the discharge, wearing a supportive bra, sleeping on the opposite side of the affected breast, and quitting smoking.

If there is evidence of infection, antibiotics may be prescribed for 10 to 14 days. If the symptoms persist or worsen despite conservative management, surgical removal of the affected duct may be considered as a last resort⁹. This procedure is done through a small incision at the edge of the areola and has minimal complications.

In conclusion, this case illustrates a typical presentation of duct ectasia in a middle-aged female patient with nipple discharge. Ultrasound and MRI are useful imaging modalities to diagnose this condition and exclude malignancy. Duct ectasia is a benign condition that usually resolves without treatment. However, some patients may require antibiotics or surgery if conservative measures fail.

For more, this kindle ebook on breast sonography:

Ebook atlas of breast ultrasound

For those in India:

Atlas of breast ultrasound

References:

(1) [Mammary duct ectasia | Radiology Reference Article | Radiopaedia.org]

(2) Mammary duct ectasia | Radiology Reference Article | Radiopaedia.org. https://radiopaedia.org/articles/mammary-duct-ectasia.

(3) Dilated ducts on breast imaging (differential) - Radiopaedia.org. https://radiopaedia.org/articles/dilated-ducts-on-breast-imaging-differential?lang=us.

(4) Mammary duct ectasia - Diagnosis & treatment - Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/mammary-duct-ectasia/diagnosis-treatment/drc-20374806.

Ultrasound Case Study: Gallbladder Adenomyomatosis with Calculi

In this case study, I will present the ultrasound findings of a 55-year-old female patient who presented with right upper quadrant pain and nausea. She had a history of cholelithiasis and chronic cholecystitis.

The ultrasound scan was performed using both curvilinear and linear probes and subcostal approach. The images showed the following features:

- Thickening of the gallbladder wall at the fundus, measuring about 6 mm in thickness (normal <3 mm).

- Multiple echogenic foci within the thickened wall, producing comet tail artifacts that extended into the lumen.

- Two calculi in the gallbladder, measuring about 4 mm each, causing acoustic shadowing.

The ultrasound images are shown below:

Image 1: ultrasound image of gallbladder showing thickened wall at fundus with comet tail artifacts.

Image 2: ultrasound image of gallbladder showing two calculi with acoustic shadowing.

More images are shown below:

Color Doppler image:

Color Doppler shows normal vascularity. However, twinkle artifacts are seen. 

Final diagnosis:

Based on these findings, the most likely diagnosis is gallbladder adenomyomatosis with calculi.

Gallbladder adenomyomatosis is a benign condition characterized by hyperplasia of the mucosa and muscularis of the gallbladder wall, resulting in the formation of intramural diverticula called Rokitansky-Aschoff sinuses . These sinuses may contain cholesterol crystals, which are highly reflective and produce the characteristic comet tail artifacts on ultrasound. The condition is more common in females and older patients, and is often associated with chronic inflammation and gallstones.

The differential diagnoses for gallbladder wall thickening include:

- Acute or chronic cholecystitis: inflammation of the gallbladder wall, usually caused by obstruction of the cystic duct by gallstones or sludge. The wall may appear edematous, hypervascular, and irregular. There may be pericholecystic fluid, gallbladder distension, and positive sonographic Murphy sign ⁷.

- Gallbladder carcinoma: malignant neoplasm of the gallbladder, usually arising from the epithelium. The wall may appear asymmetrically thickened, irregular, and infiltrative. There may be invasion of adjacent structures, lymphadenopathy, and metastases.

- Gallbladder polyps: benign or malignant projections from the gallbladder wall, usually sessile or pedunculated. They appear as echogenic foci without acoustic shadowing. They may be solitary or multiple, and vary in size and shape.

The prognosis and management of gallbladder adenomyomatosis depend on the presence and severity of symptoms, complications, and coexisting conditions. In most cases, adenomyomatosis is asymptomatic and does not require treatment. However, if there are symptoms such as pain, nausea, or jaundice, or complications such as cholecystitis, cholangitis, or pancreatitis, surgical removal of the gallbladder (cholecystectomy) may be indicated . Gallstones may also be treated by cholecystectomy or by nonsurgical methods such as oral dissolution therapy or extracorporeal shock wave lithotripsy .

For more on this topic visit:

Sonography of adenomyomatosis gallbladder

I hope you enjoyed this case study and learned something new about gallbladder ultrasound. If you have any questions or comments, please feel free to leave them below. Thank you for reading!

(1) Gallbladder wall thickening | Radiology Reference Article - Radiopaedia.org. https://radiopaedia.org/articles/gallbladder-wall-thickening.

(2) Diffuse gallbladder wall thickening (differential) | Radiology .... https://radiopaedia.org/articles/diffuse-gallbladder-wall-thickening-differential.

(3) Diffuse Gallbladder Wall Thickening | Radiology Key. https://radiologykey.com/diffuse-gallbladder-wall-thickening/.

Subcutaneous dirofilariasis

Subcutaneous dirofilariasis is a parasitic infection caused by the filarial worm Dirofilaria repens. Ultrasound imaging findings for subcutaneous dirofilariasis may include:

1. Hypoechoic (dark) or anechoic (black) linear or serpentine structures within the subcutaneous tissue, representing the presence of the parasitic worms or their larval tracks.

2. Surrounding inflammation and edema due to the body's immune response to the infection.

Color Doppler shows normal vascularity. 

Case Study: Subcutaneous Dirofilariasis Lesion on Ultrasound

Case study:

Patient Information:

- Age: 45 years

- Sex: Female

- Clinical Presentation: The patient presented with a painful, erythematous subcutaneous lesion on her abdomen that had been gradually increasing in size over the past two weeks. There was no history of recent travel or exposure to animals.

Ultrasound Findings:

- Ultrasound examination of the left forearm revealed a well-defined, hypoechoic (dark) subcutaneous lesion measuring approximately 1.5 cm in diameter.

- Within the lesion, there was a small cystic area with internal echoes, resembling a serpentine or linear pattern.

- Surrounding the lesion, there was evidence of mild inflammation with hypoechoic edema.

- No vascularity was noted within the lesion on color Doppler imaging.

Diagnosis:

Based on the characteristic ultrasound findings of a small cystic area with internal echoes and a serpentine pattern within the subcutaneous tissue, the diagnosis of subcutaneous dirofilariasis was seen. 

Conclusion:

Ultrasound imaging played a crucial role in diagnosing subcutaneous dirofilariasis by revealing the characteristic features of the parasitic infection. Timely surgical intervention and appropriate management led to the successful removal of the worm and a favorable outcome for the patient.

Differential diagnoses to consider for subcutaneous dirofilariasis on ultrasound include:

1. Subcutaneous Epidermoid Cyst: Epidermoid cysts typically appear as well-defined, oval-shaped, hypoechoic lesions with a hyperechoic wall, containing keratin debris. They lack the linear or serpentine appearance seen in dirofilariasis.

A punctum is seen on examining the epidermoid cyst. This is also called a sebaceous cyst. 

2. Abscess: Abscesses may appear as fluid-filled, hypoechoic masses with surrounding inflammation, but they lack the characteristic linear or serpentine structures seen in dirofilariasis.

Prognosis and management of subcutaneous dirofilariasis typically involve:

1. Surgical Removal: The primary treatment is surgical excision of the worm or larval tracks, along with any associated inflammation or abscesses.

2. Antibiotics: Antibiotics may be prescribed to prevent or treat secondary bacterial infections.

3. Follow-up: Patients are usually monitored for any signs of recurrence or complications.

The prognosis for subcutaneous dirofilariasis is generally good with prompt diagnosis and appropriate treatment. However, the exact outcome can vary depending on the extent of infection, the presence of secondary complications, and the patient's overall health.