Technical aspects of thyroid ultrasound

Author
Manfred Blum, MD, FACP
Section Editor
Douglas S Ross, MD
Deputy Editor
Jean E Mulder, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Apr 2013. | This topic last updated: May 7, 2013.
INTRODUCTION — Current methods of ultrasonography permit "real-time" identification of
structures as small as 2 mm in diameter, thereby allowing the visualization of very small tumors of
the thyroid and parathyroid glands. These methods also permit estimates of overall and regional
blood flow to the thyroid. This topic review will discuss the basic technology of thyroid
ultrasonography. The clinical use of thyroid ultrasonography is reviewed elsewhere. (See
"Overview of the clinical utility of ultrasonography in thyroid disease".)

PRINCIPLES AND METHODS — Thyroid ultrasonography is a technique that requires

experience and an understanding of thyroid anatomy and pathology. It cannot be optimally
performed by a technician who simply takes pictures and then submits the photographs for later
interpretation. Instead, cost-effective testing requires input from both the ordering clinician and
the interpreting clinician. The ordering clinician should specify the precise clinical question that
must be answered.

Some endocrinologists prefer to perform the sonogram themselves, while others refer the patient
to a sonographer or a radiologist. In some cases improved efficiency may be obtained when the
endocrinologist or surgeon actually performs the sonogram. The endocrinologist, surgeon, or
radiologist who does thyroid sonograms must master thyroid palpation, anatomy, and
pathophysiology; have special training in ultrasound procedures; meticulous attention to detail;
and adequate time to perform a full examination. They must be willing to invest in costly and
sophisticated equipment, and perform an adequate number of studies to achieve expertise. They
cannot merely examine films or digital images. No matter who does the test, results can
sometimes be equivocal and misleading.

Gray-scale ultrasonography — Gray-scale ultrasonography involves the intermittent generation

of a pulse of sound energy and the reception of reflected echoes to produce an image of the
structures traversed by the sound. Current technology produces high-resolution thyroid images by
using sound frequencies between 5 and 13 million cycles per second (megahertz, MHz). These
frequencies are well above the range audible by humans and are safe. Sound waves of this
frequency pass through air poorly and, therefore, the transducer, the device that generates the
sound and receives the echo, must be coupled to the skin with a medium that excludes air.
The sound waves penetrate tissues, and a portion of the energy is reflected at tissue interfaces
up to a depth of 5 cm. The thyroid gland is well within this distance in most patients.

Current transducers provide high resolution of structures as small as 2 mm, providing their echo-
density is different or they are separated by an interface. In contrast, other imaging methods such
as computed tomography, magnetic resonance imaging, and radionuclide scanning detect only
nodules that are considerably larger, almost to the centimeter range.

Some of the technical factors that limit the usefulness of ultrasonography include:

 Attenuation of the high-frequency sound waves in deeper tissues, which may make
evaluation of very large goiters difficult
 Distortion by air-filled structures such as the trachea
 Blockade of the signals by calcific deposits in the thyroid, cartilage, or bone
 Nonvisualization of portions of the thyroid gland that lie substernally

Images are best obtained with the patient lying supine with the neck hyper-extended. Care should
be taken to avoid overextension in patients with limited range of motion in the neck. Landmarks
such as the trachea, sternal notch, and the thyroid gland, and thyroid abnormalities should be
carefully palpated and their locations noted. The entire region should be examined completely in
the transverse plane, starting at the chin and extending to the sternal notch, and in the
longitudinal (or “sagittal”) plane, starting in the midline and extending well laterally.

A 5 to 7 MHz transducer often is used initially to determine the size of the thyroid gland and to
assess the regional anatomy (image 1). Then higher energy transducers of 7.5 to 14 MHz are
used to assess details such as nodules and vessels. There are protocols to assemble a mosaic of
images to depict a very large thyroid lobe or goiter. A modification of conventional ultrasound,
panoramic ultrasound, has been reported to produce images with a large anatomic field of view
that displays both lobes of the thyroid gland on a single image [1].

A 10 to 13 MHz transducer may be used to delineate nodules that are 2 to 3 mm in diameter. The
value of detecting nodules of this size is debatable, as discussed below, because they are too
small to aspirate for cytological examination, and their image may be difficult to reproduce.
However, some information is obtained, notably the presence of microcalcifications, reproducible
changes in size, or the emergence of a multinodular pattern.

Doppler techniques can be added to differentiate cystic and vascular structures.

Three-dimensional ultrasonography — Three-dimensional ultrasonography (3D) is a technical

advance that promises to improve the analysis of anatomic structures and tumors relative to their
environment and may enhance diagnosis as well.

Color-flow Doppler ultrasonography — Color-flow Doppler imaging is based upon the change
in pitch (wave frequency) of a sound that increases when it approaches a listener (the ear or, in
the case of ultrasonography, a transducer) and decreases as it departs. Doppler imaging provides
information about blood flow to a static gray-scale image and, when superimposed on the real-
time gray-scale image, indicates both the direction and the velocity of blood flow [2,3]. The
assignment of color is designed to depict flow in opposite directions as red or blue to indicate
arteries and veins. The shade of the color is a semiquantitative indicator of flow velocity. By
convention, darker shades indicate slow flow and lighter shades high flow; black signifies no flow
or an excessively oblique angle of the Doppler signal to the vascular structure. When viewed in
the gray-scale mode, the Doppler flow signal is intensely bright.

B-flow imaging — B-flow ultrasonic imaging (BFI) is a non-Doppler technology that depicts
motion within anatomic structures. Adjacent ultrasound beams, separated by a specified distance,
are transmitted; the reflected signals, which are separated from each other by a shorter
predetermined distance, are then detected; overlapping pairs of signals are then assembled and
processed. The information correlates with motion, which in the thyroid is blood-flow. BFI may
avoid artifacts that limit the value of Doppler imaging and thus supplement it.

In addition, BFI may identify rapidly flashing bright spots, called "twinkling," which seem to be
generated by microcalcifications and may correlate with thyroid cancer. This was illustrated in a
study of 479 nodules with histologic confirmation, the presence of four or more B-flow twinkling
signs at a distance of greater than 2 mm was associated with 99.6 percent specificity and 65.2
percent sensitivity for papillary thyroid cancer [4,5].

Ultrasound contrast agents — Ultrasonography is likely to improve when images are enhanced
with contrast agents. One such agent involves gas-filled microbubbles with a mean diameter less
than that of a red blood corpuscle injected intravenously [6]. In one report, a galactose-based
ultrasonographic contrast agent, Levovist (Schering AG, Berlin, Germany), showed promise in
differentiating benign from malignant thyroid nodules. Cancers showed a significantly earlier
arrival time of Levovist than nodular hyperplastic benign nodules and adenomas [7,8]. Similar
results were seen with a different ultrasonographic contrast agent, sulphur-hexafluoride [9].

Estimation of tissue elasticity by ultrasound — Elastography examines the stiffness of tissue,

which may correlate with the palpable consistency of anatomic structures. Using echography, one
may infer the deformation of a tissue by observing change in Doppler signal in response to
externally applied pressure or vibrations, or by tracking something called shear wave
propagation. Investigators are gathering data about the elastic qualities of many different organs
and tissues, including the thyroid, to assess the clinical diagnosis of benign and malignant
conditions. Elastography may enhance the cancer-predictive value of sonography of non-cystic
non-calcified thyroid nodules [10,11].

ESTIMATION OF THYROID GLAND VOLUME — Thyroid ultrasonography is used to answer

questions about the size and anatomy of the thyroid gland and adjacent structures in the neck.
Using two-dimensional images, a skilled ultrasonographer is able to reconstruct the thyroid in
three dimensions. The structural information becomes optimally useful in management when it is
integrated with other clinical data.

Using a low frequency transducer, the dimensions of each lobe should be determined in the
sagittal and transverse planes to determine the length (L), anterior-posterior depth (D), and
transverse width (W) of the gland. The volume of the thyroid gland, lobe, or nodule can then be
calculated using a simplified formula for a prolate ellipse:

Volume = 0.5 x (L x D x W)

The size of a nodule or a lobe can be measured fairly accurately based on a scale on the
sonographic screen or, with advanced equipment, the sonographer can place marks on the image
to calculate the dimensions electronically. One study reported imperfect concordance between
the dimensions of thyroid nodules as revealed by ultrasound examination when compared with
surgical excision. Concordance was 78.5 percent with nodules equal to or smaller of than 1 cm
and significantly less for larger nodules [12].

Minimizing differences between ultrasonographers when estimating the size of large goiters or
nodules has been reported when curved-array transducers rather than linear-array equipment is
employed [13]. Accuracy in estimating volume becomes important when one uses ultrasound
measurements to calculate an isotope dose, as an index of iodine intake in epidemiologic studies,
or to compare size changes in a nodule over time. Using planimetry from three-dimensional
images reportedly has lower intra-observer variability (3.4 percent) and higher repeatability (96.5
percent) than the standard ellipsoid model for nodules and lobes (14.4 percent variability and
84.8 percent repeatability) [14].

Nevertheless, one must be especially cautious when interpreting reported changes in the volume
of nodules based upon ultrasonic volume assessments because it is difficult to reproduce
identical two-dimensional image planes for follow-up studies. The variation of ultrasonic thyroid
nodule volume determinations among three ultrasonographers with certified experience in thyroid
ultrasound was examined in a prospective blinded trial of 42 patients (eight men, 34 women) with
25 uninodular and 17 multinodular thyroid glands. The inter-observer variation for the
determination of thyroid nodule volume (n = 38) was 48.96 percent for the ellipsoid method of
assessing size and 48.64 percent for the planimetric method. Furthermore, the authors reported
that a regression analysis revealed that the probability that all three sonographers would identify
the same nodule in nodular thyroid glands was 90 percent, if the nodule is at least 15 mm in
greatest diameter [15].

The accuracy of thyroid volume assessment of thyroid volume and improved intra-observer
variability and repeatability appears to be achieved with three-dimensional echography [16].

CHARACTERIZATION OF THYROID NODULES — High-resolution ultrasonography provides a

detailed map of thyroid nodules and helps to characterize the nodules. Solid nodules should be
described by using normal thyroid tissue as a reference. Among solid nodules, the intensity of the
 echo pattern relative to the extranodular thyroid lobe depends upon the transmission or reflection
of the ultrasonic signal by the nodule. Hypoechoic solid nodules transmit the sound energy with
minimal reflection while hyperechoic nodules reflect a greater proportion of the signal. Isoechoic
nodules interact with the ultrasound in the same way as normal thyroid tissue. The clinical use of
ultrasound to identify and characterize nodules is reviewed in detail separately. (See "Overview of
the clinical utility of ultrasonography in thyroid disease", section on 'Thyroid nodules'.)

SUMMARY

 Gray-scale ultrasonography involves the intermittent generation of a pulse of sound

energy (sound frequencies between 5 and 13 million cycles per second [megahertz,
MHz]) and the reception of reflected echoes to produce an image of the structures
traversed by the sound. (See 'Gray-scale ultrasonography' above.)
 Current transducers provide high resolution of structures as small as 2 mm, providing
their echo-density is different or they are separated by an interface. (See 'Gray-scale
ultrasonography' above.)
 Color-flow Doppler imaging is based upon the change in pitch (wave frequency) of a
sound that increases when it approaches a listener (the ear or, in the case of
ultrasonography, a transducer) and decreases as it departs. Doppler imaging provides
information about blood flow to a static gray-scale image and, when superimposed on the
real-time gray-scale image, indicates both the direction and the velocity of blood flow.
(See 'Color-flow Doppler ultrasonography' above.)
 B-flow ultrasonic imaging (BFI) is a non-Doppler technology that depicts motion within
anatomic structures. (See 'B-flow imaging' above.)
 Thyroid ultrasonography is used to answer questions about the size and anatomy of the
thyroid gland. The volume of the thyroid gland, lobe, or nodule can be calculated using
the simplified formula for a prolate ellipse: Volume = 0.5 x (L x D x W). (See
'Estimation of thyroid gland volume' above.)

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REFERENCES
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2. Foley WD. Physical principles and instrumentation. In: Color Doppler Flow Imaging, Foley
WD (Ed), Andover Medical Publishers, Boston 1991. p.3.
3. Clark KJ, Cronan JJ, Scola FH. Color Doppler sonography: anatomic and physiologic
assessment of the thyroid. J Clin Ultrasound 1995; 23:215.
4. Brunese L, Romeo A, Iorio S, et al. A new marker for diagnosis of thyroid papillary
cancer: B-flow twinkling sign. J Ultrasound Med 2008; 27:1187.
5. Brunese L, Romeo A, Iorio S, et al. Thyroid B-flow twinkling sign: a new feature of
papillary cancer. Eur J Endocrinol 2008; 159:447.
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8. Menna S, Di Virgilio MR, Burke P. [Ultrasonography contrast media Levovist and power
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11. Rago T, Santini F, Scutari M, et al. Elastography: new developments in ultrasound for
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measured by ultrasound and gross pathology examination: effect on patient management. Diagn
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13. Peeters EY, Shabana WM, Verbeek PA, Osteaux MM. Use of a curved-array transducer
to reduce interobserver variation in sonographic measurement of thyroid volume in healthy adults.
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14. Lyshchik A, Drozd V, Reiners C. Accuracy of three-dimensional ultrasound for thyroid
volume measurement in children and adolescents. Thyroid 2004; 14:113.
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volume measurement in children and adolescents. Thyroid 2004; 14:113.

Topic 15313 Version 4.0

GRAPHICS
Thyroid ultrasound showing thyroid anatomy
Sonogram of the thyroid region in the transverse plane that shows the local
anatomy.
L: thyroid lobe; I: isthmus; T: tracheal ring (dense white arc is calcification, distal to it is artifact);
C: carotid artery (note the enhanced echoes deep to the fluid-filled blood vessel); J: jugular vein: S:
sternocleidomastoid muscle; M: strap muscle; E: esophagus.
Courtesy of Manfred Blum, MD.
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