AIUM-ACR-SPR-SRU Practice Parameter for the Performance ...

1 Practice GUIDELINESAIUM ACR SPR SRU PracticeParameter for the Performance andInterpretation of a DiagnosticUltrasound Examination of theExtracranial Head and NeckPreambleThe American Institute of Ultrasound in Medicine (AIUM)is a multidisciplinary association dedicated to advancingthe safe and effective use of ultrasound in medicinethrough professional and public education, research, developmentof parameters, and AIUM represents the entire range of clinical and basicscience interests in medical diagnostic ultrasound, and, with hun-dreds of volunteers, the AIUM has promoted the safe and effectiveuse of ultrasound in clinical medicine since 1952. This documentand others like it will continue to advance this parameters of the AIUM are intended to provide themedical ultrasound community with parameters for the perfor-mance and recording of high-quality ultrasound examinations.

2 Theparameters reflect what the AIUM considers the minimum criteriafor a complete examination in each area but are not intended toestablish a legal standard of care. AIUM-accredited practices areexpected to generally follow the parameters with recognition thatdeviations from these parameters will be needed in some cases,depending on patient needs and available equipment. Practices areencouraged to go beyond the parameters to provide additional ser-vice and information as clinical aspects contained in specificsectionsofthispracticeparameter (Introduction, Indications, Specifications of the Examina-tion, and Equipment Specifications) were revised collaboratively bythe AIUM, the American College of Radiology (ACR), the Societyfor Pediatric Radiology (SPR), and the Society of Radiologists inUltrasound (SRU).

3 Recommendations for Qualifications andResponsibilities of Personnel; Written Request for the Examination;Documentation; and Quality Control and Improvement, Safety, 2018 by the American Institute of Ultrasound in Medicine|J Ultrasound Med 2018; 9999:1 7|0278-4297| Control, and Patient Education vary amongthe organizations and are addressed by each Practice Parameter is intended to assist prac-titioners performing ultrasound evaluations of theextracranial head and neck, including evaluation ofthe thyroid gland, parathyroid glands, parotid glands,submandibular glands, lymph nodes, and adjacent softtissues. (Sonographic evaluation of the major vascula-ture of the neck is addressed in a separate practiceparameter.)

4 Occasionally, an additional and/or spe-cialized examination with another modality may benecessary. Although it is not possible to detect everyabnormality, adherence to the following practiceparameters will maximize the probability of detectingmost abnormalities that occur in the extracranial headand for a head and neck ultrasound examina-tion include but are not limited to:1. Evaluation of the location and characteristics ofpalpable neck masses;2. Evaluation of abnormalities detected by otherimaging examinations, eg, a thyroid nodule orother neck mass detected on computed tomogra-phy, positron emission tomography computedtomography, magnetic resonance imaging, orother ultrasound examinations (eg, carotidultrasound)1;3.

5 Evaluation for causes of relevant laboratoryabnormalities, such as abnormalities of thyroid orparathyroid function;4. Evaluation of the presence, size, and location ofthe thyroid gland2;5. Evaluation of patients at high risk for thyroidmalignancy;6. Imaging of previously detected thyroid nodulesthat meet criteria for follow-up imaging3;7. Evaluation for regional nodal metastases inpatients with proven or suspected thyroid carci-noma prior to thyroidectomy4;8. Evaluation for recurrent disease or regional nodalmetastases after total or partial thyroidectomy forthyroid carcinoma5;9. Evaluation of the thyroid gland for malignancyprior to neck surgery for nonthyroid disease6;10. Evaluation of the thyroid gland for malignancyprior to radioiodine ablation of the gland;11.

6 Assessment of the location, number, and size ofenlarged parathyroid glands in patients withknown or suspected hyperparathyroidism or whohave undergone previous parathyroid surgery orablative therapy with recurrent signs or symp-toms of hyperparathyroidism7,8;12. Guidance for aspiration or biopsy of thyroidabnormalities or other masses of the neck or forother interventional procedures9,10;13. Localization of autologous parathyroid glandimplants;14. Evaluation of masses of the parotid and subman-dibular glands11,12;15. Evaluation of non-neoplastic conditions of theparotid and submandibular glands, including butnot limited to sialolithiasis, infection, and autoim-mune processes13 15;16. Nodal evaluation, including staging, evaluationof the response to therapy, and monitoringafter therapy, in select patients with head andneck malignancies, including but not limited tohead and neck primary squamous cell carci-noma, primary salivary malignancy, andmelanoma16 18;17.

7 Evaluation for supraclavicular nodal metastasis inpatients with lung cancer or other infraclavicularprimary malignancies at risk for metastasis19,20;18. Nodal evaluation in pediatric patients with cervi-cal lymphadenopathy, including but not limitedto evaluation for necrosis and abscess formationin the setting of acute lymphadenititis21,22;19. Imaging of sonographically accessible vascularanomalies (such as vascular tumors and vascularmalformations) of the head and neck23; and20. Evaluation of torticollis in neonates and infants24or other pediatric conditions, including but notlimited to thyroglossal duct cyst, branchial cleftcyst, lymphatic malformation, thymic ectopia/cyst, hemangioma, primary neck masses, includ-ing neurogenic tumors (neuroblastoma, schwan-noma, and neurofibroma), rhabdomyosarcoma,leukemia/lymphoma, metastatic disease (rhabdo-myosarcoma, neuroblastoma, and thyroidcancer),25and 2J Ultrasound Med 2018.

8 9999:1 7 Qualifications and Responsibilities ofPersonnelSee for AIUM Official Statements,includingStandards and Guidelines for the Accreditationof Ultrasound Practicesand relevant Physician Request for the ExaminationThe written or electronic request for an ultrasoundexamination should provide sufficient information toallow for the appropriate Performance and interpreta-tion of the examination. The request for the examina-tion must be originated by a physician or anotherappropriately licensed health care provider or underthe physician s or provider s direction. The accompa-nying clinical information should be provided by aphysician or other appropriate health care providerfamiliar with the patient s clinical situation and shouldbe consistent with relevant legal and local health carefacility of the ExaminationUltrasound evaluations of the neck may be compre-hensive (including all of the structures describedbelow) or may be problem focused, as appropriate forthe patient and clinical EvaluationThe examination should be performed with theneck in hyperextension, with as much extension astolerated by the patient.

9 Upright positioning maybe helpful in patients who cannot tolerate neckhyperextension in the supine position. The rightand left lobes of the thyroid gland should beimaged in the longitudinal and transverse images of the thyroid should includetransverse images of the superior, mid, and inferiorportions of the right and left thyroid lobes; longi-tudinal images of the medial, mid, and lateral por-tions of both lobes; and a transverse image of theisthmus. The size of each thyroid lobe should berecorded in 3 dimensions: anteroposterior (AP),transverse, and longitudinal. The thickness(AP measurement) of the isthmus on the trans-verse view should be recorded. A Doppler examina-tioncanbeusedtosupplementthegray scaleevaluation of either diffuse or focal abnormalitiesof the thyroid.

10 It is often necessary to extend imag-ing to include the soft tissue above the isthmus for example, to evaluate a possible pyramidal lobeof the thyroid to evaluate congenital abnormalitiessuch as a thyroglossal duct cyst, or to investigateany superior palpable abnormalities should be imaged in a waythat allows for reporting and documentation of thefollowing:1. The localized or diffuse nature of any thyroidabnormality, including assessment of overall glandvascularity28,29; and2. The sonographic features of any focal thyroidabnormality with respect to composition (degreeof solid or cystic components), echogenicity,shape, size (in AP, transverse, and longitudinaldimensions), margins (smooth or irregular),presence and type of echogenic foci and/or cal-cifications (if present), other relevant ultrasoundpatterns, and extrathyroidal extension of ,30 The ACR Thyroid Imaging Reportingand Data System provides a lexicon for describ-ing features of focal thyroid abnormalities withan associated management ,31,32An examination of relevant neck compartmentsfor adenopathy may be helpful in determiningthe need for biopsy in the setting of thyroidnodules.