Use of Sonography for Airway Assessment

Objective. The purpose of this study was to evaluate the feasibility of sonography in identifying the anatomic structures of the upper airway and to describe their appearance on sonography. Methods. We enrolled 24 healthy volunteers, placed them supine with their head extended and neck flexed (the “sniffing” position), and performed a systematic sonographic examination of their upper airway from the floor of the mouth to the suprasternal notch. Results. We were able to visualize all relevant anatomic structures in all of the participants using either a linear or curved transducer oriented in 1 of 3 planes: sagittal, parasagittal, and transverse. Bony structures (eg, the mandible and hyoid) were brightly hyperechoic with an underlying hypoechoic acoustic shadow. Cartilaginous structures (eg, the epiglottis, thyroid cartilage, cricoid cartilage, and tracheal rings) were hypoechoic, and their intraluminal surface was outlined by a bright air‐mucosa interface. The vocal cords were readily visualized through the thyroid cartilage. However, the posterior pharynx, posterior commissure, and posterior wall of the trachea could not be visualized because of artifacts created by an intraluminal air column. Conclusions. Sonography of the upper airway is capable of providing detailed anatomic information and has numerous potential clinical applications.     

First Experience Using 4‐Dimensional Hysterosalpingo‐Contrast Sonography With SonoVue for Assessing Fallopian Tube Patency

This study was conducted to describe our first experience using transvaginal 4‐dimensional (4D) hysterosalpingo‐contrast sonography with SonoVue (Bracco International BV, Amsterdam, the Netherlands) for diagnosis of fallopian tube patency. The study was prospective and conducted in a university hospital setting. The sonographic procedures included 2‐dimensional transvaginal sonography for evaluating uterine and ovarian mobility, observing intubation, and determining the initial plane and 4D hysterosalpingo‐contrast sonography for observing periovarian and pelvic diffusion. Ninety‐six outpatients visiting infertility clinics underwent 4D hysterosalpingo‐contrast sonography. All patients finished the examination successfully. A total of 192 fallopian tubes were assessed, of which 95 (49.5%) were classified as type A (the tube was patent, and the contrast agent flowed smoothly through it), 72 (37.5%) as type B (the tube was patent, but the contrast agent did not flow smoothly inside it), and 25 (13.0%) as type C (blocked). Sixteen patients underwent laparoscopy or laparoscopy combined with hysteroscopy; 28 tubes (87.5%) were concordant with laparoscopy. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index for 4D hysterosalpingo‐contrast sonography versus laparoscopy were 81.8%, 90.5%, 81.8%, 90.5%, and 0.72 respectively. In total, 92.7% of patients did not require a hospital stay after 4D hysterosalpingo‐contrast sonography, and none need resuscitation. The others stayed in the hospital for clinical observation because of a severe vasovagal reaction or severe pain but received only bed rest without any medical treatment. Forty patients (41.7%) felt slight pain; 39 (40.6%) felt moderate pain; and 15 (15.6%) had a vasovagal reaction. No procedure or postprocedure complications occurred in any patient. In conclusion, 4D hysterosalpingo‐contrast sonography with SonoVue is an available screening method for assessment of tubal patency and is tolerable for most patients.     

Three‐Dimensional Color‐Coded Duplex Sonography for Assessment of the Vertebral Artery Origin and Vertebral Artery Stenoses

Objective . The aim of the study was to assess the potential of 3‐dimensional (3D) color‐coded duplex sonography (CDS) for evaluation of the vertebral artery origin and stenoses in this location. Methods. To compare 2‐dimensional (2D) and 3D CDS, both techniques were performed in 25 healthy volunteers and in 18 patients with 21 stenoses of the vertebral artery origin. Stenoses were graded in line with hemodynamic criteria on 2D CDS and according to North American Symptomatic Carotid Endarterectomy Trial criteria on 3D CDS. In 6 patients, digital subtraction angiography (DSA) was performed additionally. Stenoses were graded according to North American Symptomatic Carotid Endarterectomy Trial criteria and compared with 2D and 3D sonographic data. Results. Overall correlation of both sonographic techniques concerning the grading of the stenoses was good (r = 0.69; P < .01). The interobserver correlation for assessment of stenoses by means of 3D CDS was high (r = 0.94; P < .01). Three‐dimensional CDS correlated excellently with DSA in 3 of 6 patients but showed only intermediate or no correlation in the remaining 3 patients. In contrast, spatial information on the stenotic morphologic characteristics was always very comparable with the results obtained by DSA. Conclusions. Three‐dimensional CDS represents a valuable tool for assessment of the origin of the vertebral artery, allowing important morphologic information on stenoses in this location. For grading of stenoses of the vertebral artery origin, 3D information should be combined with hemodynamic criteria obtained by spectral Doppler imaging in 2D CDS. Three‐dimensional CDS could be a valuable tool before interventional procedures of the proximal vertebral artery, saving time and avoiding iodinated contrast agents.     

A Novel Ultrasound‐Guided Technique for Hysteroscopic Adhesiolysis in High‐Risk Patients

Hysteroscopy is a common gynecologic surgical procedure. Certain diagnoses, notably intrauterine adhesions and cervical stenosis, make hysteroscopy more complicated because of an increased likelihood of complications. Three patients, 1 with cervical stenosis and 2 with Asherman syndrome, underwent ultrasound (US)‐guided adhesiolysis. Access to the uterine cavity was obtained by either direct balloon‐aided dilation or the US‐guided Seldinger technique, followed by balloon‐aided dilation to enter the endometrial cavity and disrupt intrauterine/intracervical adhesions. In this case series, we describe a novel approach of using US‐guided balloon dilation to safely and effectively treat intrauterine adhesions and to decrease the risk of perforation.     

Accuracy of Ultrasonography in the Evaluation of Tubal Sterilization Microinsert Positioning: Systematic Review and Meta‐analysis

The current reference standard to check the position of a tubal sterilization microinsert device after its insertion is hysterosalpingography. The objective of this study was to evaluate the accuracy of 2‐dimensional (2D) and 3‐dimensional (3D) ultrasonography (US) in the positioning of the tubal sterilization microinsert for definitive contraception. We searched MEDLINE, Embase, Cochrane, and Scopus databases through October 2017. Selection criteria included studies that analyzed the accuracy of 2D or 3D US, or both, with respect to the positioning of the microinsert. Data were displayed as forest plots and a summary receiver operating characteristic curves. Values for sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated. The pooled analysis produced sensitivity and specificity values for 2D US in the positioning of the microinsert of 0.88 (95% confidence interval [CI], 0.47–1.0) and 0.92 (95% CI, 0.88–0.95), respectively, with positive and negative LRs of 8.68 (95% CI, 1.63–46.1) and 0.35 (95% CI, 0.11–1.11), respectively. Three studies analyzed the performance of 3D US, showing sensitivity, specificity, and positive and negative LRs of 0.75 (95% CI, 0.35–0.97), 0.82 (95% CI, 0.77–0.87), 3.65 (95% CI, 2.31–5.75), and 0.46 (95% CI, 0.2–1.09). In conclusion, 2D and 3D US are methods that show good accuracy in tubal sterilization microinsert positioning.     

Use of 3‐Dimensional Sonography for Prenatal Evaluation and Follow‐up of Fetal Goitrous Hypothyroidism

Objective. Fetal goitrous hypothyroidism is a rare and potentially lethal condition. Consequently, its early diagnosis and treatment improve prognosis. Thyroid hormone measurement in either fetal serum or amniotic fluid implies important risks. Here we present a fetal goiter and the follow‐up procedure, both done by the traditional method and by using 3‐dimensional power Doppler (3DPD) imaging and virtual organ computer‐aided analysis (VOCAL). Methods. A single well‐documented case of fetal goiter was followed weekly from 22 weeks until delivery. Amniocentesis for thyrotropin (TSH) and free thyroxine (T₄) measurement as well as levothyroxine injections were performed at every control. In addition to amniocentesis, every control involved a sonographic evaluation, which included standard measurements of the gland and the capture of volume image sets in gray scale and 3DPD. Volume calculation of the gland was done using VOCAL software. Vascularization of the gland was evaluated by the vascularization index (VI) included in the software. Results. With treatment, TSH levels decreased progressively until normalization. Free T₄ levels increased toward the end of gestation. Sonographic measurements of the gland volume to estimated fetal weight ratio decreased across treatment as levels of TSH did. The VI clearly depicted the vascular regression of the goiter, decreasing throughout treatment in a consistent way until 24 hours before delivery. Conclusions. Gray scale and 3DPD evaluations of the thyroid gland have been validated under similar circumstances and might be reliable complements to the invasive methods used in the management of this fetal condition.     

Sonography for Locoregional Staging and Follow‐up of Cutaneous Melanoma

Objective. Sonography is being used with increasing frequency in the assessment of locoregional tumor spread in patients with melanoma. Nevertheless, to maximize its practical impact, sonography should be performed with state‐of‐the‐art equipment, by specifically trained operators, and using a careful exploration technique and well‐defined diagnostic criteria. In this “how I do it”–type article, we illustrate our practical approach to sonography of cutaneous melanoma. Methods. We first illustrate the basic and advanced technical requirements; then we describe our exploration methods and our image interpretation approach; and finally, we report on our use of sonography as a guidance tool for interventional procedures. Special emphasis is given to methodological and interpretative clues, tricks, and pitfalls. Results. Sonography can be used in the initial staging of patients with melanoma, particularly in the screening of patients scheduled for a sentinel lymph node biopsy procedure. Additionally, sonography can be used during patient follow‐up to detect locoregional recurrence earlier than palpation. Conclusions. Sonography plays a growing role in the assessment of the superficial spread of melanoma. Nevertheless, state‐of‐the‐art equipment and careful exploration by trained operators are necessary.