1. Advantages of ultrasound imaging include: A. Imaging modality of choice for thyroid B. Doppler sonography can be used for assessment of blood flow C. Scanning in the sagittal plane offers optimal visualization D. A and B E. All of the above D Transverse/axial plane better for visualization

2. Features suggestive of malignancy in a thyroid nodule include all of the following EXCEPT: A. Hyperechoic B. Microcalcifications C. Increased blood flow on Doppler D. Tail shape E. Irregular border A. Also hypoechoic, absence of halo, tail shape

3. Parathyroid imaging on ultrasound: A Is less accurate than sestamibi scans in localizing a solitary adenomas B. Normal parathyroid glands can be visualized with high resolution ultrasonography C. Parathyroid adenomas are hyperechoic relative to the thyroid gland D. Superior parathyroid glands are on a deeper plane than the inferior glands E. Ectopic parathyroid gland may be visualized on ultrasound in the posterior mediastinum D. US accurate in localizing PTH adenoma in 90%, normal glands <40 mg not visualized with US of 7-15 Mhz, adenomas hypoechoic, unable to visualize posterior mediastinum with US, superior PTH gland deep to recurrent nerve (inf thyroid artery or posterior sfc of common carotid)

4. Ultrasound imaging of salivary glands: A. Is useful for differentiating sialadenitis from neoplasms and lymphadenopathy B. Is useful for imaging deep lobe parotid tumors C. Shows similar echogenicity to the thyroid D. A and C E. All of the above D. Unable to image deep lobe and parapharyngeal space due to mandible

5. Ultrasound characteristics of salivary malignancies include: A. Calcifications B. Smooth shape C. Increased vascularity on Doppler imaging D. Ovoid lesion with short axis less than 5 mm E. Homogeneous echostructure C Normal lymph node– ovoid hypoechoic lesion with echogenic hilum, short axis less than 5-6 mm

6. Ultrasound imaging for head and neck cancer: A. Can detect metastatic lymph nodes not detected by CT or MRI B. Round shape of lymph node suggests malignancy C. Intranodal cystic degeneration suggests malignancy D. Can be used to avoid elective neck dissection in NO necks E. All of the above E

7. Ultrasound-guided fine needle aspiration: A. Is done using a 27 gauge needle B. Aspiration is performed first C. Bevel of the needle is pointed away from the transducer D. Needle should be irrigated with fixative prior to insertion E. The needle should be used to shave cells along the needle path E. 22 G needle, capillary action 1st , (Hold needle in place to allow for capillary action, also rotate tip), bevel toward the transducer to increase echogenicity of the tip, after irrigation of needle with fixative should be discarded

Sagittal US image of nodule (arrowheads) containing multiple fine echogenicities (arrow) with no comet-tail artifact. These are highly suggestive of malignancy. FNA and surgery confirmed papillary carcinoma.

Punctate echogenicities in thyroid nodules. Punctate echogenicities in thyroid nodules. (a) Sagittal US image of nodule (arrowheads) containing multiple fine echogenicities (arrow) with no comet-tail artifact. These are highly suggestive of malignancy. FNA and surgery confirmed papillary carcinoma. (b) Transverse US image of nodule (arrowheads) containing cystic areas with punctate echogenicities and comet-tail artifact (arrow) consistent with colloid crystals in a benign nodule. Frates M C et al. Radiology 2005;237:794-800 ©2005 by Radiological Society of North America

Sagittal image of solid nodule (arrowheads), which proved to be papillary carcinoma.

Sagittal image of predominantly solid nodule (arrowheads), which proved to be benign at cytologic examination

Transverse image of mixed solid and cystic nodule (calipers), which proved to be benign at cytologic examination

Sagittal image of predominantly cystic nodule (calipers), which proved to be benign at cytologic examination

Sagittal image of cystic nodule (arrowheads) Sagittal image of cystic nodule (arrowheads). FNA of this presumed benign lesion was not performed

Transverse gray-scale image of predominantly solid thyroid nodule (calipers).

Addition of color Doppler mode shows marked internal vascularity, indicating increased likelihood that nodule is malignant. This was a papillary carcinoma.

Abnormal cervical lymph nodes Abnormal cervical lymph nodes. (a) Sagittal US image of enlarged node (calipers) with central punctate echogenicities, consistent with microcalcifications, shows mass effect on internal jugular vein (V). Node was proved to be metastatic papillary carcinoma

Sagittal US image of enlarged node (calipers) with cystic component Sagittal US image of enlarged node (calipers) with cystic component. Node was proved to be metastatic papillary carcinoma.

8. Normal paraganglia contain all of the following EXCEPT: A. Sustentacular cells B. Cells which stain positively with S-100 C. Schwann cells D. Chief cells E. Catecholamine-containing cells c

9. The following is true about paragangliomas: A. The most common type is the pheochromocytoma B. 10% occur in the head and neck C. Secretion of epinephrine from head and neck paragangliomas may occur D. Vagal paragangliomas are more common than jugulotympanic paragangliomas. E. Familial paragangliomas occur in MEN 1, Carney’s triad, and von Hippel-Lindau disease A 90% of paragangliomas arise from adrenal gland, remaining 10% extra-adrenal (abdomen 85%, thorax 12%, H&N 3%), H&N paragangliomas lack the enzyme to convert norepinephrine to epinephrine (phenylethanolamine-N-methyltransferase), Carotid body>jugulotympanic>vagal, MEN2a and b, NF1, vHL (retinal angiomas, cerebellar hemangioblastomas, Carney (gastric leiomyosarcoma, pulmonary chondroma, paraganglioma)

10. Carotid body tumors A. A positive Fontaine’s sign indicates movement of a lateral neck mass laterally but not vertically B. Increased mitotic rate and capsular invasion indicate malignancy C. Malignancy is determined by histology D. Diagnosis can be made radiographically by posterior displacement of the internal and external carotid arteries E. Classification of tumors is based on size A Shamblin Classification –group 1 localized, minimal attachment to carotid, group II adherent or partially surrounding carotid, Group III completely encasing carotid

11. Recommended treatment of carotid body tumors: A. Requires preoperative embolization before surgical removal B. Results in permanent cranial nerve deficit(s) in 50% of cases C. Observation is an option for some patients with carotid body tumors. D. Radiation therapy can reduce the size of the tumor. E. Surgical resection is preferred over radiation therapy for multicentric tumors C CN deficits in 15-20% XRT arrests growth Try to save vagus and hypoglossal on 1 side, baroreflex failure syndrome after removal of bilateral CB tumors

12. Vagal paragangliomas: A. Arise from the inferior vagal ganglion B. Arise from the nodose ganglion C. Arise from the jugular ganglion D. A and B E. All of the above E Inferior= nodose most common Superior=jugular ganglion

13. Peripheral nerve neoplasms: A. Neurofibromas are encapsulated and may occur singly or multiply B. Schwannomas most commonly occur in the head and neck region C. Antoni type A areas contain loosely arranged hypocellular zones D. Malignant transformation is more common in multiple neurofibromas than in solitary E. Cranial neuropathies are rare following resection of schwannomas D Half occur in H&N, Antoni A compact spindle cells, verocay bodies—palisading of nuclei

14. Metastatic disease to the neck: A. Location of the metastatic node in level 5 are most commonly associated with a hypopharyngeal primary B. Fine needle aspiration biopsy diagnosis of adenocarcinoma indicates a primary in a salivary gland C. The most common distant site to metastasize to the neck is from a lung primary D. B and C E. All of the above C Level 5-nasopharynx, adenoca—possible GI, breast or prostate source--rare

15. Sarcomas of the neck: A. 80% of head and neck sarcomas are derived from soft tissues of the neck B. Occur most commonly in children C. Staging for bone sarcomas is based on size D. Staging for soft tissue sarcomas is based on site of origin E. The most common sarcoma in the head and neck is the malignant fibrous histiocytoma A. 20% are from bone 80% occur in adults, staging for bone—within or beyond cortex Staging for soft tissue based on size, Most common type of H&N sarcoma in children is RMS, adults- osteo, angio, MFH, fibro

16. Rhabdomyosarcoma A. Accounts for 50% of sarcomas in all age groups B. Most common site in the head and neck is in the neck C. Metastatic disease is present in 80% of cases at presentation D. Primary treatment is surgical resection E. Highest incidence occurs in first decade of life E A (20% in all age groups), b (face, orbit, nasal), c 33%, d combined modality

17. Rare sarcomas of the neck: A. Osteosarcoma of the mandible frequently metastasizes to the neck B The most common site of fibrosarcoma in the head and neck is in the neck C. Alveolar soft part sarcoma is associated with the fusion gene ASPL-TFE3 D. Epithelioid hemangioendothelioma exhibits extremely aggressive behavior E. Liposarcoma is the most common soft tissue sarcoma in the head and neck in adults C B(paranasal sinus), d(range from benign to aggressive), e (Osteo is most common)

18. Rarer sarcomas of the neck: A. Malignant hemangiopericytoma (MPC) arise from the cells of Zimmerman, around capillaries and postcapillary venules B. Majority of HPCs occur in the paranasal sinuses C. Malignant peripheral nerve sheath tumor (MPNST) can occur either spontaneously or with NF-1 D. MPNST has recurrence rates of more than 40% despite aggressive treatment E. All of the above e

19. Review these before the in-service A. Synovial sarcoma Typically arises in the hypopharyngeal and retropharyngeal region B. Malignant giant cell tumor Radiation induced after treatment for a benign giant cell tumor, sinonasal region and mandible most common sites C. Ewing’s sarcoma Derived from primitive neuro-ectoderm, 2nd most common bone tumor in children, mandible, maxilla, skull D. Solitary Fibrous Tumor Desmoid fibromatosis frequent in head and neck, in children, high local recurrence rate but low mortality