Utility of Bedside Ultrasound in Percutaneous Tracheostomy.

Background: Percutaneous tracheostomy placement is a common procedure performed in the intensive care unit. The use of an anterior neck ultrasound exam is routinely performed preprocedure, allowing for vessel visualization in determining the safety and feasibility of performing the procedure bedside. This prospective observational cohort study was conducted to determine whether vasculature in the anterior neck, seen on bedside ultrasound exam, contributes to bleeding complications during or after percutaneous tracheostomy (PCT) placement. Research Question: Do the vessels identified on preprocedure neck ultrasound affect the risk of bleeding during and after bedside PCT placement? Study Design and Methods: Preprocedural ultrasound was used to identify standard anatomical landmarks and vascular structures in the anterior neck in all patients undergoing bedside PCT placement under bronchoscopic guidance. A blinded survey of our recorded preprocedural images was provided to an expert panel who regularly perform bedside PCTs to determine the influence the images have on their decision to perform the procedure at the bedside. Results: One out of 15 patients (7%) had intra-operative minimal bleeding which was not clinically significant and resolved by gauze compression for 30 s. None of the patients had post-procedural bleeding after tracheostomy placement. Based on the blinded interpretation of neck ultrasound, there was 0.214 inter-operator variability among the expert panelists for decision-making regarding performing bedside PCT. Interpretation: Vessels visualized with anterior neck ultrasound were found to be small venous structures and did not significantly contribute to bleeding risk in patients who underwent PCT placement. The size and location of veins on neck ultrasound may commonly contribute to abandoning bedside PCT. This study suggests that veins measuring 3.9 mm or smaller identified at the site of access do not increase the risk of bleeding in PCT placement.

Validating the virtual: a deep dive into ultrasound simulator metrics in otorhinolaryngology.

PURPOSE: This study aimed to assess the validity of simulation-based assessment of ultrasound skills for thyroid ultrasound. METHODS: The study collected validity evidence for simulation-based ultrasound assessment of thyroid ultrasound skills. Experts (n = 8) and novices (n = 21) completed a test containing two tasks and four cases on a virtual reality ultrasound simulator (U/S Mentor's Neck Ultrasound Module). Validity evidence was collected and structured according to Messick's validity framework. The assessments being evaluated included built-in simulator metrics and expert-based evaluations using the Objective Structured Assessment of Ultrasound Skills (OSAUS) scale. RESULTS: Out of 64 built-in simulator metrics, 9 (14.1%) exhibited validity evidence. The internal consistency of these metrics was strong (Cronbach's α = 0.805) with high test-retest reliability (intraclass correlation coefficient = 0.911). Novices achieved an average score of 41.9% (SD = 24.3) of the maximum, contrasting with experts at 81.9% (SD = 16.7). Time comparisons indicated minor differences between experts (median: 359 s) and novices (median: 376.5 s). All OSAUS items differed significantly between the two groups. The correlation between correctly entered clinical findings and the OSAUS scores was 0.748 (p < 0.001). The correlation between correctly entered clinical findings and the metric scores was 0.801 (p < 0.001). CONCLUSION: While simulation-based training is promising, only 14% of built-in simulator metrics could discriminate between novices and ultrasound experts. Already-established competency frameworks such as OSAUS provided strong validity evidence for the assessment of otorhinolaryngology ultrasound competence.

Preoperative neck ultrasound combined with pathological data can significantly impact the outcome of medullary thyroid carcinoma.

The diagnosis of medullary thyroid carcinoma (MTC) is challenging since the accuracy of ultrasound (US) and fine-needle aspiration cytology are suboptimal. As a result, MTC has a generally poor prognosis. The aim of this study was to analyze whether perioperative data can modify the risk of relapse in these patients. The institutional database of Turin Mauriziano Hospital was searched to extract records of MTCs diagnosed between 2000 and 2021. Kaplan-Meier curves and Cox and logistic regression analyses were performed, and the hazard ratio (HR) was calculated. Seventy-three MTC patients (median age 58 yr) were found. Disease-free survival was significantly different according to staging (HR: 9.12; p = 0.037), capsular status (HR: 5.49; p = 0.02), and neck US (HR: 9.19; p = 0.04). In the logistic regression analysis, CEA level (ß: -0.01; p = 0.043), histological multifocality (OR: 7.4; p = 0.034), and metastatic lymph nodes at histology (ß: -0.13; p = 0.006) were significantly associated with structural recurrence. Two logistic multivariate models best explained the variance in recurrence: 1) neck US presentation plus histological multifocality (AIC: 27; r2: 0.37; x2: 12.4; p = 0.002) and 2) number of neck metastases plus capsular invasion (AIC: 26; r2: 0.40; x2: 13.7; p = 0.001). Pathological data are associated with MTC prognosis. Preoperative neck US can significantly help to predict MTC outcome.

The Role of Surgeon-Performed Office and Preincision Ultrasounds in Localization of Parathyroid Adenomas in Primary Hyperparathyroidism.

OBJECTIVE: We studied the use of surgeon-performed office ultrasound (OU) and preincision ultrasound (PIU) in preoperatively localizing parathyroid adenomas in primary hyperparathyroidism (PHPT). METHODS: A retrospective chart review was performed for patients with PHPT who underwent parathyroidectomy between 2013 and 2015. The results of OU and PIU were recorded and compared with the final surgical pathology. RESULTS: Of 348 patients with PHPT, 285 (81.9%) had single-lesion disease, 49 (14.1%) had double-lesion disease, and 14 (4.0%) had multigland disease with 3 or more lesions. For single-lesion disease, the overall sensitivity and specificity of OU to correctly lateralize the lesion were 64.2% and 91.2%, while those of PIU were 89.4% and 93.6%, respectively. The sensitivity and specificity of PIU were comparable to those of 4-dimensional computed tomography (87.1% and 90.7%, respectively) and 99mTc-sestamibi scintigraphy (70.4% and 95.9%, respectively). While the majority of PIU cases were preceded by other imaging studies, the accuracy in localizing lesions was not largely affected by the presence of prior computed tomography and/or 99mTc-sestamibi scintigraphy, as opposed to ultrasounds only. For detecting the presence of multigland disease, the sensitivity and specificity of OU were 26% and 92.2%, while those of PIU were 64.3% and 94.7%, respectively. CONCLUSION: Surgeon-performed OU and PIU are valuable tools in preoperatively localizing the parathyroid adenoma in single-lesion disease, while their utility may be limited for double-lesion or multigland disease. PIU in particular yields high accuracy in detecting parathyroid lesions in combination with other imaging modalities.

Cervical Lymph Node Features Predictive of Suboptimal Adequacy During Ultrasound-Guided Fine-Needle Aspiration in Thyroid Cancer Patients.

PURPOSE: To determine the rate of cytologic and diagnostic adequacy and identify features associated with suboptimal tissue sampling in ultrasound-guided fine-needle aspiration (US-FNA) of suspected nodal disease in thyroid cancer patients. METHODS: A single-institution pathology database was queried for lymph node FNA reports in thyroid cancer patients from 2014 to 2019. Charts were reviewed for demographics, body mass index (BMI), prior thyroidectomy, cancer type, and subsequent surgery. Ultrasound images were retrospectively reviewed for location, size, depth from skin, cystic components, macrocalcification, echogenic foci, and internal vascularity score. Pathology reports were categorized as cellular and diagnostic, hypocellular/acellular but diagnostic with abnormal cells or thyroglobulin levels, or hypocellular and nondiagnostic. Correlation and multivariate regression analyses were performed. RESULTS: Initial query yielded 552 lesions in 343 subjects. Following exclusion, 377 lesions in 255 subjects were included. Mean patient age was 48.5 years (14-90), BMI 28.5, and 66.7% female and 33.3% male. The majority (95.3%) had papillary thyroid carcinoma (PTC); and 65.5% had prior thyroidectomy. 17.7% of lesions were hypocellular/acellular (suboptimal), and 5.6% nondiagnostic. Patient factors had no association (P >.05). Right-sidedness and hypovascularity were associated with hypocellularity (P <.05). Higher long/short-axis ratio and cystic foci were weakly associated. On multivariate analysis, right-sidedness (odds ratio [OR] 1.99; confidence interval [CI] 1.10-3.57) and lower vascularity score (OR 0.54; CI 0.39-0.73) were predictive of suboptimal sampling. CONCLUSION: US-FNA has high diagnostic yield and cellular sample rate. Lesion size had no effect. Right-sidedness and lower vascularity scores were predictive of suboptimal tissue. Identifying these features and expected sample adequacy rates can inform management decisions for thyroid cancer patients with cervical lymphadenopathy.

Trends in thyroid function testing, neck ultrasound, thyroid fine needle aspiration, and thyroidectomies in North-eastern Italy.

PURPOSE: Evidence of an increased diagnostic pressure on thyroid has emerged over the past decades. This study aimed to provide estimates of a wide spectrum of surveillance indicators for thyroid dysfunctions and diseases in Italy. METHODS: A population-based study was conducted in North-eastern Italy, including 11.7 million residents (20% of the total Italian population). Prescriptions for TSH testing, neck ultrasound or thyroid fine needle aspiration (FNA), surgical procedures, and drugs for hypo- or hyperthyroidism were extracted from regional health databases. Proportions and rates of selected examinations were calculated from 2010 to 2017, overall and by sex, calendar years, age, and region. RESULTS: Between 2010 and 2017 in North-eastern Italy, 24.5% of women and 9.8% of men received at least one TSH test yearly. In 2017, 7.1% of women and 1.5% of men were prescribed drugs for thyroid dysfunction, 94.6% of whom for hypothyroidism. Neck ultrasound examinations were performed yearly in 6.9% of women and 4.6% of men, with a nearly two-fold variation between areas. Thyroid FNA and thyroidectomies were three-fold more frequent in women (394 and 85 per 100,000) than in men (128 and 29 per 100,000) with a marked variation between areas. Both procedures decreased consistently after 2013. CONCLUSIONS: The results of this population-based study describe recent variations over time and between surrounding areas of indicators of 'diagnostic pressure' on thyroid in North-eastern Italy. These results emphasize the need to harmonize practices and to reduce some procedures (e.g., neck ultrasound and total thyroidectomies) in certain areas.

Utility of ultrasound-guided fine needle aspiration cytology in assessing malignancy in head and neck pathology.

OBJECTIVE: Fine needle aspiration cytology (FNAC) is a well-established diagnostic procedure for head and neck masses not clearly originating from mucosal or cutaneous surfaces. We analysed head and neck masses evaluated over a 2-year period, to assess the reliability of FNAC for the evaluation of malignancy. METHODS: We enrolled all patients undergoing FNAC, from April 2013 to July 2015, in a single service of a large Italian university hospital. Relevant clinical data and ultrasonographic parameters of the lesions were recorded. We performed both conventional and thin-prep smears. Clinical presentation, ultrasonographic features and final cytology diagnoses were analysed and correlated with histology. RESULTS: The series included 301 lesions in 285 patients, with a single (94.4%) or two (5.6%) lesions. Only eight samples were considered non-diagnostic/inadequate (2.6%). Among the cases, 139 FNAC (46.1%) underwent surgery. Cytological-histological correspondence was found in 89% of the cases. Concerning malignancy, we documented less than 4% false positives and less than 2.5% false negatives, with 92.7% sensitivity and 94.6% specificity. CONCLUSION: FNAC diagnosis can be highly specific. Most importantly, it is highly reliable in assessing malignancy, thus defining the priority and guiding the management procedures.

Plunging Ranulas and Prevalence of the "Tail Sign" in 126 Consecutive Cases.

OBJECTIVES: Plunging (or diving) ranulas are extravasation pseudocysts arising from the sublingual gland that present as soft submandibular swelling. The "tail sign" has been widely reported as pathognomonic for their diagnosis. It is described as a smooth tapering comet-shaped unilocular fluid mass with its "tail" in the collapsed sublingual space (SLS) and its "head" in the posterior submandibular space. This sign is based on the premise that extravasated saliva from the sublingual gland in the SLS escapes and plunges, over the posterior edge of the mylohyoid muscle into the submandibular space. Therefore, some fluid must be present in the posterior SLS in almost all patients with plunging ranulas. This study aimed to determine the frequency of fluid seen with ultrasound (US) in the posterior SLS to corroborate the tail sign. METHODS: A total of 126 consecutive cases of surgically proven plunging ranulas were investigated with US over 13 years. The findings were reviewed retrospectively for the prevalence of fluid in the posterior SLS. RESULTS: Thirteen patients (10.3%) showed SLS fluid on US images. Most showed fluid extension through a mylohyoid dehiscence. Only 2 patients (1.6%) showed fluid within the posterior SLS, and 1 patient alone in this entire study showed all of the components of the classically described tail sign. CONCLUSIONS: This largest ever radiologic study showed low prevalence of the tail sign in 2 of 126 patients. A mylohyoid dehiscence was the more common route for extravasation. Absence of the tail sign does not exclude the diagnosis of a plunging ranula.

Mild sporadic primary hyperparathyroidism: high rate of multiglandular disease is associated with lower surgical cure rate.

BACKGROUND: Mild primary hyperparathyroidism (serum calcium ≤ 2.85 mmol/L) is the most representative form of pHPT nowadays. The aim of this study was to evaluate its subtypes and the multiglandular disease (MGD) rate as it may lower the sensitivity of preoperative parathyroid scintigraphy and the surgical cure rate. METHODS: We retrospectively included patients with mild pHPT who underwent parathyroid dual-tracer scintigraphy with 99mTc-MIBI SPECT/CT and surgery between January 2013 and December 2015. Cure was defined as normalization of serum calcium (or PTH in the normocalcemic form) at 6 months. MGD was defined by either two abnormal resected glands or persistent disease after resection of at least one abnormal gland. RESULTS: We included 121 patients. Median preoperative serum calcium was 2.68 mmol/L and median PTH was 83.4 pg/mL. A total of 141 glands were resected (95 adenomas, 33 hyperplasias). The subtypes were 57% classic, 32.2% normohormonal, and 10.7% normocalcemic. MGD occurred in 23.5% of patients divided as 13%, 30%, and 64% respectively (p = 0.0011). The surgical cure rate was 85.2%. The normocalcemic form had lower cure rate than the normohormonal (45% vs 84%, p = 0.018) and classic forms (45% vs 93%, p = 0.0006). MIBI scintigraphy identified at least one abnormal lesion, later confirmed by the pathologist in 90/98 patients, making the sensitivity per patient 91.8% (95% CI 84.1-96.2%). CONCLUSIONS: MGD is strongly associated with mild pHPT, especially the normocalcemic form where it accounts for 64% of cases. Bilateral neck exploration should be performed in this population to improve the cure rate, even if the scintigraphy shows a single focus.

Amyloid Goiter: A Diagnosis to Consider in Diffuse Fatty Infiltration of the Thyroid.

An amyloid goiter is the presence of amyloid protein in the thyroid in sufficient amounts to produce enlargement of the gland, accompanied by fat deposition of varying extents. It can be seen in long-standing inflammatory disorders such as familial Mediterranean fever. Imaging findings depend on the amount of fat and amyloid deposition; however, the main imaging finding is diffuse fatty infiltration of the thyroid. Herein, the multimodality imaging features in 3 cases of amyloid goiters secondary to familial Mediterranean fever are presented.

Primary Malignant Fibrous Histiocytoma of the Thyroid: Two Case Reports and Review of the Literature.

Primary malignant fibrous histiocytoma of the thyroid is an uncommon malignancy of the thyroid. Because it is rare, fewer than 20 cases have been reported in the literature, and the sonographic features of only 2 cases have been reported between the 1980s and 2014. Here we report 2 cases of primary malignant fibrous histiocytoma of the thyroid with an emphasis on the sonographic findings, and we review the published literature.

Role of Superb Micro-Vascular Imaging in the Preoperative Evaluation of Thyroid Nodules: Comparison With Power Doppler Flow Imaging.

OBJECTIVES: To evaluate whether Superb Micro-Vascular Imaging (SMI; Toshiba Medical Systems Corporation, Tochigi, Japan) is superior to power Doppler flow imaging (PDFI) in depicting thyroid nodular vascularity and to primarily explore the diagnostic performance of vascularity on SMI integrated with grayscale sonographic features for diagnosis of malignant thyroid nodules. METHODS: Ninety-two resident patients with 113 nodules for surgery were included in the study. Thirty-four nodules were benign, and 79 nodules were malignant. Vascularity was classified as none, peripheral, mixed, and intranodular. Grayscale features, including calcifications, echogenicity, margins, shape, and internal components, were evaluated. The distribution of vascular patterns was compared between PDFI and SMI to determine the superior technique for diagnosing malignancy. A multivariate logistic regression analysis was used to evaluate the accuracy of SMI combined with grayscale sonography for thyroid malignancy. RESULTS: The 92 patients had a male-to-female ratio of 12:11 and a median age of 42 years (range, 20-75 years). Intranodular vascularity on SMI had 91.2% specificity and 75.9% sensitivity, which were superior to PDFI, at 82.3% and 41.8%, respectively (P < .01). We attribute this finding to the fact that peripheral vessels of many nodules on PDFI were actually intense small penetrating vessels around the lesion on SMI. A taller-than-wide shape, microcalcifications, and SMI intranodular vascularity were independent risk factors for thyroid malignancy. The area under the receiver operating characteristic curve for the logistic regression model was 0.92, which was higher than that for a single suspicious sonographic feature (P < .05). CONCLUSIONS: Intranodular vascularity on SMI is useful for determining thyroid carcinoma. Furthermore, a combination of SMI and grayscale features performs better than any single sonographic feature alone.

Value of Sonography in the Diagnosis of Sialolithiasis: Comparison With the Reference Standard of Direct Stone Identification.

OBJECTIVES: The aim of this study was to assess the effectiveness of sonography for diagnosing sialolithiasis in comparison with the existing reference standard of direct identification of a stone. METHODS: A total of 659 glands with signs of obstructive sialadenopathy were evaluated retrospectively. Sonographic examinations of the large head salivary glands had been performed initially in all cases. Direct depiction of a stone during sialoendoscopy or transoral ductal surgery or observation of stone fragmentation with discharge of concrements after extracorporeal shock wave lithotripsy, was regarded as definitive evidence and as the reference standard for the presence of sialolithiasis. The sonographic results were compared with those for direct identification of stones. RESULTS: The sensitivity of sonography was 94.7%, with specificity of 97.4%, a positive predictive value of 99.4%, and a negative predictive value of 79.6%. Stones that were not diagnosed correctly on sonography were most often located in the distal area of the duct. CONCLUSIONS: These results show that sialolithiasis can be diagnosed by sonography with a high degree of certainty. Sonography thus appears to be highly appropriate as the examination method of choice.

Sensitivity of 3-Dimensional Sonography in Preoperative Evaluation of Parathyroid Glands in Patients With Primary Hyperparathyroidism.

OBJECTIVES: Preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism facilitates targeted surgery. We assessed the sensitivity of 3-dimensional (3D) sonography for preoperative localization of abnormal parathyroid glands. METHODS: We conducted a retrospective review of patients who underwent parathyroidectomy for primary hyperparathyroidism at a single site at our institution. We compared preoperative 2-dimensional (2D) sonography, 3D sonography, and sestamibi scans with final gland localization at surgery. Two readers reviewed the sonograms to assess inter-reader variability. RESULTS: From January 2010 through April 2015, 52 patients underwent parathyroidectomy after preoperative 2D sonography, 3D sonography, and sestamibi scans. Three-dimensional sonography had sensitivity of 88-92% compared with 69-71% for 2D sonography for gland localization. In patients in whom sonography and sestamibi scans localized abnormalities to the same side, the sensitivities were 100% (43 of 43) for 3D sonography and 96% (48 of 50) for 2D sonography. Three-dimensional sonography had significantly higher sensitivity for localization of glands smaller than 500 mg compared with 2D sonography (88% versus 58%; P = .012). There was better inter-reader agreement between the radiologists when using 3D sonography (κ = 0.65) compared with 2D sonography (κ = 0.41). CONCLUSIONS: We found a significantly higher sensitivity and better inter-reader agreement for 3D sonography compared with 2D sonography for preoperative identification of abnormal parathyroid glands, especially among smaller glands.

Virtual Touch Tissue Imaging and Quantification in the Evaluation of Thyroid Nodules.

OBJECTIVES: To investigate the diagnostic performance of a 2-dimensional shear wave elastographic technique (Virtual Touch tissue imaging and quantification [VTIQ]; Siemens Medical Solutions, Mountain View, CA) for predicting thyroid malignancy. METHODS: A total of 302 thyroid nodules underwent conventional sonography and VTIQ before fine-needle aspiration examination or surgery. Compared with histopathologic or cytologic results in combination with follow-up, the diagnostic performance of various shear wave speed (SWS) indices (minimum [SWSmin ], maximum [SWSmax ], and mean [SWSmean ]) on VTIQ as well as conventional sonographic features for predicting thyroid malignancy was evaluated in all of the nodules. RESULTS: Sixty-five malignant and 237 benign thyroid nodules were histopathologically or cytologically confirmed. All SWS indices on VTIQ were lower in benign nodules than thyroid malignancy (all P < .001). For discrimination between malignant and benign nodules, all VTIQ SWS indices were better than conventional sonographic features, such as a solid component, a taller-than-wide shape, microcalcification, a poorly defined margin and hypoechogenicity, in predicting thyroid malignancy (all P < .05). By applying a cutoff SWSmean value of 2.60 m/s, VTIQ achieved sensitivity and negative predictive values of 84.6% and 94.3%, respectively, for differentiating nodules. The areas under the receiver operating characteristic curve of SWSmax (0.862 versus 0.717), SWSmin (0.866 versus 0.717), and SWSmean (0.891 versus 0.725) for nodules larger than 10 mm were higher than those for nodules of 10 mm or smaller (all P < .05). Interoperator and intraoperator reproducibility was proven to be excellent, with all interclass correlation coefficient values higher than 0.80 (range, 0.813-0.905) CONCLUSIONS: Virtual Touch tissue imaging and quantification is a useful and reproducible tool for predicting thyroid malignancy.

Ultrasound-Guided Core Needle Biopsy for Head and Neck Mass Lesions in Patients Undergoing Antiplatelet or Anticoagulation Therapy: A Preliminary Report.

OBJECTIVES: We compared the complications and diagnostic adequacy of ultrasound (US)-guided core needle biopsy (CNB) for head and neck mass lesions between patients who did and did not receive antiplatelet/anticoagulation therapy. METHODS: This study was designed as a prospective case study including 146 consecutive patients who underwent US-guided CNB for head and neck mass lesions. Of these, 32 patients were undergoing antiplatelet/anticoagulation therapy involving aspirin, clopidogrel, cilostazol, and warfarin. RESULTS: None of the patients had clinical bleeding/hematoma in either group. Subclinical bleeding/hematoma recognized only by a US examination was not significantly different between the groups (P = .229). No other complications were noticed. The rate of unsatisfactory sampling was also not different between the groups (P > .999). Furthermore, when patients receiving aspirin (n = 18) were reclassified into the no-antiplatelet/anticoagulation therapy group, there was still no significant difference in the incidences of complications compared with the patients receiving clopidogrel, cilostazol, or warfarin (n = 14). CONCLUSIONS: Our study suggests that US-guided CNB is safe and provides good diagnostic results without necessitating the discontinuation of antiplatelet/anticoagulation therapy in patients with head and neck mass lesions. However, as this was a preliminary study, the cohort was relatively small. Larger studies are needed to confirm our findings.

Surveillance Neck Sonography After Thyroidectomy for Papillary Thyroid Carcinoma: Pitfalls in the Diagnosis of Locally Recurrent and Metastatic Disease.

A sonographic examination of the neck performed 6 to 12 months after thyroid surgery in patients with differentiated thyroid cancer is strongly recommended by the American Thyroid Association and considered mandatory by the European Thyroid Association for locoregional surveillance. The aim of this article is to review the normal anatomic changes expected after thyroid surgery and the pathologic mimics of thyroid carcinoma recurrence in post-thyroidectomy patients as they appear on neck sonography. We hope to offer some pearls to increase diagnostic confidence in this setting.

Neck Sonography and Suppressed Thyroglobulin Have High Sensitivity for Identifying Recurrent/Persistent Disease in Patients With Low-risk Thyroid Cancer Treated With Total Thyroidectomy and Radioactive Iodine Ablation, Making Stimulated Thyroglobulin Unnecessary.

OBJECTIVES: Follow-up of patients with low-risk differentiated thyroid cancer treated with total thyroidectomy and radioiodine requires neck sonography and thyroglobulin (Tg). The need to stimulate Tg is controversial. The goal of this study was to compare the diagnostic performances of sonography plus suppressed or stimulated Tg in low-risk thyroid cancer. METHODS: After total thyroidectomy and radioiodine, patients with low-risk thyroid cancer were retrospectively identified as having structural or biochemical persistence/recurrence. We compared the diagnostic performance of suppressed and stimulated Tg to detect persistence/recurrence. RESULTS: We included 148 patients with low-risk thyroid cancer who were followed for a median of 3.7 years. Persistence/recurrence was found in 8 patients (5.4%; 5 structural disease and 3 biochemical disease). Thyroglobulin was not stimulated in 72 patients (group 1) and stimulated in 76 (group 2). In group 1, 5 patients (6.9%) had structural neck persistence/recurrence (3 with suppressed Tg ≥ 1 ng/mL and 2 with suppressed Tg < 1 ng/mL). Four patients underwent surgery, and 1 was surveilled. All 5 patients had suppressed Tg lower than 1 ng/mL at the end of follow-up. In group 2, stimulated Tg did not identify additional cases of structural persistence/recurrence but classified 3 patients (3.9%) as having biochemical persistence/recurrence. One patient received a second dose of radioiodine, and the other 2 were surveilled; all were without disease at the end of follow-up. Suppressed and stimulated Tg had negative predictive values for persistence/recurrence of 97% and 100%, respectively. CONCLUSIONS: In low-risk thyroid cancer treated with total thyroidectomy and radioiodine, sonography and suppressed or stimulated Tg have similar negative predictive values for persistence/recurrence. Importantly, the coexistence of negative sonographic findings and suppressed Tg lower than 1 ng/mL makes the addition of stimulated Tg unlikely to identify clinically important disease.

Ultrasound-Guided Injection of the Temporalis Tendon: A Novel Technique.

A novel technique, ultrasound-guided injection of the temporalis tendon in adults, is described. Ultrasound-guided injection of the temporalis tendon is based on visualization of the temporalis muscle, temporalis tendon, and coronoid process. A practical step-by-step guide to doing the procedure is given. This technique is effective and reproducible. Two patients successfully treated with this technique will be briefly discussed. The anatomic location and size of the temporalis tendon make it mandatory to use ultrasound to ensure precision.