Sono of the Week: Neck Swelling

Author: Allison Lee, MD
Images obtained by: John Kilpatrick, MD

CASE
A 60-year-old woman is being evaluated in the Emergency Department for hypotension and hyperglycemia.  She receives 3 liters of fluids without improvement followed by a left internal jugular central venous catheter and vasopressors.  At change of shift, the new team notices she has right-sided neck swelling, and a palpable mass just lateral to midline. The following images are obtained:

Diagnosis: Right-sided thyroid cyst
(Note that the cystic area does not light up with color doppler; top figure.)

Normal thyroid tissue – thyroid tissue will have similar echogenicity to liver tissue and lies medial to the carotid artery and lateral to the trachea.

Normal thyroid tissue.[1] Image modified.

Other causes of neck mass:

Lymph Node – Will typically look like a small “kidney” with a hyperechoic center and a hypoechoic cortex.

Normal lymph node.[2] Image modified.

Enlarged lymph node.[3] Image modified.

Vessel / Carotid Artery Abnormality – If concerned about a vessel, remember to put color flow over the area.

Femoral Artery Pseudoaneurysm.[4] Image modified. Note the swirling of flow in two different directions.

Carotid dissection.[5] Image modified.

Abscess.[6] Image modified.

Deep Cellulitis with Phlegmon.[7] Image modified.

Learning Point:

POCUS can be a quick way to extend the physical exam deeper than skin level if you are unsure what you are palpating.

**Select images modified from source to include labels.**

References

1. Kopinksi H, Davis L. Thyroid Right Lobe. The POCUS Atlas. April 27, 2018. Accessed August 1, 2022. https://www.thepocusatlas.com/softtissuemsk/5ss6kdjsch9y9l8wl3gltd4ulz11k0
2. Dialani V, James DF, Slanetz PJ. A practical approach to imaging the axilla. Insights Imaging. 2015;6(2):217-229. doi:10.1007/s13244-014-0367-8
3. Hogan, Geoff. Supraclavicular Lymphadenopathy. The POCUS Atlas. Accessed August 1, 2022. https://www.thepocusatlas.com/softtissuemsk/supraclavicular-lymphadenopathy
4. Jones, R. Pseudoaneurysm. The POCUS Atlas. April 30, 2020. Accessed August 1, 2022. https://www.thepocusatlas.com/dvt/pseudoaneurysm
5. Cover, M. Carotid Dissection. The POCUS Atlas. Accessed August 1, 2022. https://www.thepocusatlas.com/dvt/carotid-dissection-2
6. Donselaar K, Heberer C, Botta S. Abscess Identification. The POCUS Atlas. Accessed August 1, 2022. https://www.thepocusatlas.com/softtissuemsk/g8dplvxg0xlek0ict5lypd3tmic0uu
7. Le, N. Deep Cellulitis with Phlegmon. The POCUS Atlas. Accessed August 1, 2022. https://www.thepocusatlas.com/softtissuemsk/deep-cellulitis-with-phlegmon

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nicanthony

Associate Editor at County EM Blog

Nicole Anthony is a Kings County/SUNY Downstate EM Resident in the Class of 2023 whose prior life included EMS, a failed app, and a Creative Writing minor. Most of her heart is in Prague, but you can also find a part of it in the 2 Hallway column.

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