A Cheeky Diagnosis

HPI: 3 yo female with no PMH presenting for L sided facial pain and swelling x 1 day.

POCUS of affected side showed:

Note the hypoechoic spots within the gland that give it a “moth eaten” appearance. This is a classic finding in parotitis. Note the dilated ducts within which may represent a distal sialolithiasis.

Note nearby lymph nodes above.

Contralateral side for comparison:

Signs of parotitis on POCUS:

• Enlarged, heterogeneous gland compared to contralateral side

• Increased vascularity/color flow

• Duct dilation

• Increased quantity of surrounding lymph nodes

Case conclusion: The patient was diagnosed with likely viral parotitis. She was well appearing with no fever, overlying cellulitis, or trismus and was discharged with Pediatrician follow up!

Happy Scanning!

• The US Team

Learn more:

1. https://www.acep.org/sonoguide/advanced/ent

2. https://ultrasoundpaedia.com/parotid-gland-normal/

VOTW: A Hairy Situation

HPI: 21 yo male with no PMH presenting for bump noted in the gluteal cleft x 3 days.

The linear probe was placed on the area of interest and showed:

Dot-dash sign/pattern are hyperechoic lines and dots that represent hair. This is commonly seen in ovarian dermoid cysts but also can be seen in pilonidal abscesses from ingrown hair!

Also look carefully at the left side of the screen at the end of the attached video. You might notice the echogenic contents moving around internally as pressure is applied with the probe- this is “squish/swirl sign” AKA “pus-talsis” which is another sign you are looking at an abscess rather than a mass.

As a review of abscesses, you will generally see:

• A fluid filled irregularly shaped structure with internal septations or echogenic debris (vs a cyst will be contained and completely anechoic)

• Squish/swirl sign

• Posterior acoustic enhancement

• Surrounding tissue cellulitis (early sign: dermal thickening with hyperechoic subcutaneous layer and later sign: “cobblestoning” or edema between fat globules)

Case conclusion: Patient had a bedside I&D of his pilonidal abscess with purulent materials expressed.

Happy scanning!

• The US Team

Learn more:

1. https://www.pocus101.com/gynecology-pelvic-ultrasound-made-easy-step-by-step-guide/

2. https://www.acep.org/sonoguide/procedures/abscess-evaluation

3. https://coreultrasound.com/cellulitis-vs-abscess/

VOTW: HAND me the probe and let me FLEX my POCUS skills!

HPI: 44 year old male with no PMH presenting to the ED for worsening left 3rd finger pain and swelling after sustaining trauma and laceration to affected area 9 days ago. The team's differential included finger cellulitis, abscess, flexor tenosynovitis, and underlying fracture.

The patient’s hand was placed in a water bath and the following images were obtained using the linear probe:

POCUS evaluation of flexor tenosynovitis

1. Use a water barrier between probe and fingers to improve image quality(ex: plastic basin, emesis bag, glove filled with water, bag of NS/LR).

2. Use the linear probe on the flexor side of the fingers.

3. Evaluate the flexor tendon which overlies the bone. Look for fluid (anechoic) within the flexor tendon sheath surrounding the flexor tendon. Remember, tendons are anisotropic which means they can appear hyperechoic or hypoechoic depending on the angle of your probe. Hypoechoic areas can be confused for edema so it is important to fan through the entire tendon. If the area of concern remains consistently hypoechoic, that is more concerning for fluid/edema.

4. The tendon may also appear thicker compared to fingers. If you apply color doppler, you may see surrounding hyperemia.

5. You can scan an unaffected finger also for real time comparison on what “normal” should look like.

Case conclusion: After this bedside POCUS, orthopedics team was consulted for concern for flexor tenosynovitis!

Learn more about POCUS findings for flexor tenosynovitis here:

1. https://coreultrasound.com/fts/

2. https://www.ultrasoundgel.org/posts/q08ayJgg3rmHtiQgs9n82w