Hyperechoic Structure Research Articles

Periappendiceal Hyperechoic Structure on Sonography

We retrospectively investigated the clinical importance of the periappendiceal hyperechoic structure (PHS) using sonography in patients with appendicitis, which may reflect the omentum encapsulating the inflammation or spread of inflammation over the omental and adjacent mesenteric fat. We defined the positive finding of a PHS as a noncompressible and enlarged (>6 mm in its maximal outer diameter) appendix surrounded by the hyperechoic structure that was not visualized in the right lower quadrant on sonography. We compared this finding with surgical records and pathologic diagnosis in 25 patients who underwent an appendectomy for appendicitis. Of 25 patients, there were 7 patients with positive PHS findings. The positive PHS rates were 100% (2 of 2), 29% (5 of 17), and 0% (0 of 6) for gangrenous, phlegmonous, and early appendicitis, respectively. There was a statistically significant difference by the Spearman rank test. The incidence rates of perforation (57% versus 6%), macroscopic purulent exudate or abscess (57% versus 6%), and prominent adhesion to the periappendiceal tissue (100% versus 22%) were higher in the patients with positive PHS findings. The PHS may indicate the possibility of serious inflammation, and accurate diagnosis and appropriate treatment should be decided.

Liver abscess

A 54-year-old man presented with epigastric pain of 4 weeks' duration. There was tenderness to palpation in the epigastrium. EGD revealed an erosion with surrounding submucosal edema on the lesser curve of the mid gastric body (A, arrow). The patient was hospitalized the next day because of fever (39.3°C). The white blood cell count was 13.0×109/L (normal: 4-9×109/L), and total bilirubin was 3.6 mg/dL (0.2-1.2 mg/dL). US demonstrated a 2×3×4-cm hypoechoic lesion with an associated linear hyperechoic structure 1.5 cm in length in the left lateral segment of the liver (B, arrow). CT confirmed the diagnosis of liver abscess associated with a linear calcified foreign body (C, arrow). After US-guided percutaneous drainage of the abscess, imipenem/cilastatin were administered intravenously. Culture of the abscess fluid grew Streptococcus constellatus. The patient became afebrile, but US still demonstrated the foreign body. At laparotomy, the abscess was resected and was found to contain a 10-mm foreign body, consistent with a fish bone (D). The patient, who recovered uneventfully, recalled that he had eaten small fish whole a month earlier. View Large Image Figure Viewer View Large Image Figure Viewer View Large Image Figure Viewer

Localized histiocytic sarcoma in a dog: an uncommon diagnosis in forelimb lameness

SummaryThe clinical, ultrasonographic, arthrographic and histopathological aspects of a localized histiocytic sarcoma in the tendon sheath of the biceps brachii muscle in a Flat-Coated Retriever are described. An eight-year-old female Flat-Coated Retriever was referred for evaluation of chronic forelimb lameness. The orthopaedic examination revealed a painful shoulder joint. Ultrasonographic evaluation revealed distention of the tendon sheath of the biceps brachii muscle and the presence of multiple, hyperechoic structures in the distal portion of the sheath. The histological and immunohistochemical diagnosis of a biopsy taken during surgical exploration of the shoulder joint was histiocytic sarcoma. Palliative treatment with corticosteroids was administered but the dog was euthanized at the owner’s request four months following diagnosis due to progressing lameness. Post-mortem examination confirmed the diagnosis of histiocytic sarcoma without any evidence of metastases.

Ultrasonography for the interosseous membrane of the forearm.

The ability to improve the technique for an accurate clinical diagnosis of the injury of interosseous membrane of the forearm (IOM) associated with forearm fractures and dislocations is important for its treatment and prognosis. Ultrasound examination of the IOM in 46 forearms from 18 normal volunteers, five patients with restricted forearm pronation and supination, and two preoperative cases was performed to determine the usefulness and reproductivity of this examination. The intact IOM was observed as a continuous, slightly convex anteriorly and hyperechoic structure between the radius and ulna with both transverse and longitudinal views. IOMs with histories of forearm injuries were distinguished by the findings, which demonstrated a loss of continuity and were seen as hypoechoic traces from the others. This study confirmed that it is possible to trace the entire IOM and to detect differences between intact and disrupted IOMs with transverse and longitudinal views.

Intramural Gastric AbscessCase History and Review

Intramural Gastric AbscessCase History and Review

Gyriform Liver Foci in Chronic Hepatic Porphyria

A patient with suspected liver metastases detected by routine sonography of the abdomen was admitted to our clinic for further testing. Liver sonography disclosed multiple irregular gyriform foci of a hyperechoic structure with a maximum diameter of 3.5 cm. In magnetic resonance imaging, these foci appeared as hyperintense in T1-weighted images and isointense in T2-weighted images. A biopsy showed a discrete portal and periportal fibrosis. UV light fluorescence of the specimen was negative. Analysis of urine revealed an almost fourfold el-evation of total porphyrin of 591 µg/24 h, proving the diagnosis of chronic hepatic porphyria. Characteristic liver foci in hepatic porphyria are detected by sonography in some affected patients. Usually, they can also be depicted by magnetic resonance imaging and computed tomography. These foci often appear before any other symptoms of the disease and are reversible when triggering factors, such as certain drugs or alcohol, are discontinued.

Intracystic hemorrhage of a simple liver cyst mimicking a biliary cystadenocarcinoma

Simple liver cysts are rarely complicated by intracystic hemorrhage. We encountered a case of simple liver cyst that was morphologically similar to biliary cystadenocarcinoma, which was complicated by asymptomatic intracystic hemorrhage and successfully treated by right lobectomy. A large cystic lesion of the liver was detected in a 57-year-old woman during a mass screening health check. Abdominal ultrasonography (US) revealed that the cystic lesion, containing many hyperechoic papillary structures, occupied almost the entire region of the right hepatic lobe. In addition, a round mural nodule, measuring approximately 5 cm in diameter, was detected in the cystic wall. Abdominal computed tomography (CT) revealed that the inner part of the cystic lesion showed homogeneous low density, but CT did not show the round nodule detected by US. On T1-weighted sequence of magnetic resonance imaging (MRI), the lesion showed homogeneous high signals, together with a low-signal tumorous lesion in the cystic wall. T2-weighted sequence of MRI showed unhomogeneous high signals, together with high signals in the tumorous part. These findings did not exclude the possibility of a malignant cystic tumor, such as biliary cystadenocarcinoma. Therefore, right lobectomy was performed. Histological examinations of resected tissue specimens revealed that the lesion was a liver cyst containing a large amount of blood clot, and that the tumorous lesion detected by US and MRI was a large mass of blood clot which was partly liquefied. This case indicates the diagnostic importance of the morphological discordance between CT and US or MRI findings for liver cyst containing a large amount of blood clot.

Sonographic findings of Meckel's diverticulitis in children.

We know of only one previous study that has described the sonographic appearances of the inflamed Meckel's diverticulum in several cases (nine patients). Our study reviews sonographic, clinical, and pathologic findings in 10 patients with an inflamed Meckel's diverticulum. We also describe unique findings on color Doppler sonography for two of our patients. Sonographic findings of an inflamed Meckel's diverticulum may mimic findings for acute appendicitis or intestinal duplication. In patients with rectal bleeding due to diverticulitis, the visualization of a tubular hyperechoic structure on sonography is suggestive of Meckel's diverticulum. The inflamed Meckel's diverticulum may present as a cyst, but its mucosal layer is more irregular than that found in an intestinal duplication. We found that routine color Doppler sonography revealed anomalous vessels and signs of inflammation on the wall of the Meckel's diverticulum.

Diagnostic value of high-resolution B-mode and power-mode sonography in the follow-up of thyroid cancer

Objective: Ultrasonography is an established diagnostic modality in the follow-up of thyroid cancer. Color flow Doppler has been proposed by some authors as an additional tool for differentiating benign from malignant cervical lesions in various types of head and neck cancer. Over the last few years, a new generation of high-resolution ultrasound platforms with the ‘power-mode’ feature has become available, that also enables the imaging of small vessel blood flow. The objective of our study was to find ways of optimizing the differentiation of benign and malignant cervical tumors in thyroid cancer follow-up by means of sonography. Methods: Hundred and twelve cervical lesions in 90 patients with thyroid cancer were evaluated by high-end ultrasonography (Sonoline™ Elegra, Siemens) using a small-part transducer (7.5 L 40, Siemens). B-mode sonography was performed at a frequency of 8 MHz. The Solbiati index (SI= ratio of largest to smallest diameter), configuration, echogenicity, intranodular structures, and margins were assessed. Perinodular and intranodular blood flow was evaluated by color flow Doppler (PRF 1250 Hz for conventional color flow Doppler, 868 Hz for power-mode Doppler). Possible malignancy was validated by histology, cytology, scintigraphy, and follow-up. Thirty five lesions were benign (diameter 0.4–3.0 cm) and 77 were malignant (0.4–5.4 cm). The patients were randomized into a test group and a learning group to determine the diagnostic value of various ultrasound criteria by means of statistical analysis. In the learning group, decision rules based on the dichotomized criteria were developed using a logistic regression model. Sensitivity and specificity of these decision rules were then evaluated in the test group. Results: The presence of an echocomplex pattern or irregular hyperechoic small intranodular structures (criterion A) and the presence of an irregular diffuse intranodular blood flow (criterion B) are the best indicators of malignancy, whereas an SI≫2 is highly indicative of benign changes. Color flow Doppler is a useful addition to B-mode scanning for distinguishing benign and malignant neoplasms in the follow-up of thyroid cancer. Power-mode Doppler sonography significantly improves imaging of perinodular and intranodular blood flow when compared with conventional color flow Doppler. Conclusion: We propose the following decision rules based on a combination of the criteria above: (A) and (B) fulfilled: malignant, if SI≤4; (B) but not (A) fulfilled: malignant, if SI≤3; (A) but not (B) fulfilled: malignant, if SI≤2; neither (A) nor (B) fulfilled: malignant, if SI≈1 (sensitivity: 90%; specificity: 82%; accuracy 88%).

Ultrasonographic appearance of clinically healthy testicles and epididymides of rams

The clinically healthy testicles and epididymides of 31 rams were imaged inside and outside the breeding period, by using a real time ultrasound scanner. A scanning technique based on multiple imaging planes from the caudal and the lateral surface of the genitalia was employed. Optimum imaging was achieved by using a 6.0 MHz frequency sector transducer. The testicular parenchyma appeared homogeneous with a coarse medium echo-pattern. The mediastinum testis was present in 87% of rams and 77% of testicles; its median echogenicity score was 2 (range: 0–3) among rams aged 13 months or older and 1 among rams aged less than 13 months ( P=0.001). The tail of the epididymis was always clearly visible; it appeared less echoic than the testicular parenchyma and with a heterogeneous structure. The epididymal body was not visible, whilst the epididymal head was consistently partially imaged. The pampiniform plexus was clearly imaged as a dome-shaped structure masking the upper part of the head of the epididymis. The scrotal septum was seen in lateral sonograms as a highly echogenic line between the testicles. The scrotal skin formed a thick hyper-echoic peripheral structure.

Central aponeurosis tears of the rectus femoris: sonographic findings.

The purpose of this study was to review the normal and sonographic (US) anatomy of the central aponeurosis of the rectus femoris muscle, describe the sonographic appearance of its tears and correlate it with the MR findings. The rectus femoris internal architecture was evaluated by cadaveric dissection. To correlate the sonographic normal findings with cadaveric data, axial sections were compared with the corresponding US images. The normal in vivo sonographic appearance of rectus femoris was assessed in 20 healthy subjects (40 thighs). To evaluate the US findings in central aponeurosis tears we performed a retrospective review of 17 examinations of 17 patients suffering from acute injuries. Follow-up examinations were available in five patients. Sonographic findings were correlated with MR findings in eight patients. Anatomical dissection of the rectus femoris confirmed the presence of the central aponeurosis, a sagittally oriented fibrous band located within the proximal two-thirds of the muscle belly. In vitro US showed the central aponeurosis as a curvilinear hyperechoic structure whose shape correlated well with the cadaveric data, and in vivo US demonstrated it in all healthy subjects. In the retrospective analysis of the patient group, we classified the lesions into three groups according to the size at sonography: group 1 ( n=9), hyperechoic band surrounding an intact central aponeurosis; group 2 ( n=7), mixed hypo- and hyperechoic bands surrounding an intact central aponeurosis but associated with globular enlargement of the rectus femoris; group 3 ( n=1), complete discontinuity of the rectus femoris. These findings can reflect small partial tears, larger partial tears and complete musculotendonous junction tears respectively. In patients evaluated with both techniques, MRI confirmed the US findings. In five patients follow-up studies showed an irregular hyperechoic ill-defined area centred on the central aponeurosis that was compatible with a central scar. Sonography can demonstrate the normal internal anatomy of the rectus femoris and post-traumatic changes at the myotendinous junction of the central aponeurosis. Sonographic data correlate well with MR findings, and the low cost and wide availability of sonography make it the first-line technique in the evaluation of injuries of the rectus femoris.

Sonography of the finger.

1451 he development of high-frequency sonography probes has allowed the imaging of small superficial structures at resolutions of 300 μ m. Small “footprint” probes have improved the ability of radiologists to scan small curved surfaces such as a finger. Our purpose is to show the value of sonography in the evaluation of finger pathology. Sonography was performed with a broadband 7.5to 10-MHz linear array scan head with the transducer placed directly on the skin using abundant coupling gel. A 3-mm-thick standoff gel pad may be useful for assessment of superficial (e.g., cutaneous) lesions. We describe the main sonographic findings in a variety of lesions. Traumatic Lesions Foreign bodies that may be radiolucent on radiography, such as nonopaque glass fragments, wood splinters, and palm spikes, are accurately detected on sonography [1]. Wooden foreign bodies as small as 2.5 mm in length can be effectively localized [2]. They appear as hyperechoic structures with variable acoustic shadowing. If they have been present for more than a week, they develop a hypoechoic rim of variable thickness that represents a foreign body reaction or abscess formation (Fig. 1). Injuries to the ulnar collateral ligament (UCL) of the first metacarpophalangeal joint are common. The injury is often referred to as gamekeeper’s thumb or skier’s thumb. Sonography can identify a tear of the UCL and differentiate displaced and nondisplaced tears. Injuries in which the UCL is displaced superficially to the adductor aponeurosis (Stener lesion) may require surgical intervention, whereas nondisplaced tears can be treated conservatively [3]. With complete tears, the displaced UCL is seen as a linear echogenic structure that is redundant and retracted with a hypoechoic hematoma surrounding the redundant margin (Fig. 2). An avulsed fragment, if present, is seen as a small hyperechoic structure. With incomplete tears, the UCL may be markedly thickened but in a normal position. Previous studies have found that sonographic findings correspond to surgical findings in up Sonography of the Finger Girolamo Moschilla 1 and William Breidahl

Ocular complications of persistent hyperplastic primary vitreous in three dogs.

Persistent hyperplastic primary vitreous (PHPV) syndrome associated with either severe ocular complications or multiple ocular lesions was diagnosed in three young dogs, a Samoyed, a Spanish Pachon, and a mixed breed dog. Due to opacification of the anterior ocular structures, B-mode and color-flow Doppler ultrasonography were performed to aid diagnosis. The Samoyed presented with unilateral hyphema; the Spanish Pachon presented with unilateral secondary glaucoma associated with uveitis and hyphema OD and leucocoria OU; and the mixed breed presented with bilateral leucocoria. B-mode ultrasonography of the Samoyed revealed a subcapsular cataract and a hyperechoic tubular structure attached from the optic disk to the posterior lens capsule. In the Spanish Pachon B-mode ultrasonography of the right eye indicated microphakia, cataract formation, and a retrolental mass with a thin hyperechoic strand stretching from the optic disk to the posterior lens; and for the right eye cataract formation, PHPV, retinal detachment, and vitreous hemorrhage. In the mixed breed dog, B-mode ultrasonography of both eyes indicated microphthalmia, retrolental mass, and hyperechoic lenses. By color-flow Doppler imaging, blood flow was present in the retrolental mass of the right eye suggesting a persistent hyaloid artery.

Hyperechoic middle cerebral artery: acute occlusion detected by transcranial duplex ultrasonography.

The authors describe the appearance of acute thromboembolic occlusion of the middle cerebral artery (MCA) using transcranial duplex ultrasonography. Acute occlusion of the MCA commonly leads to severe cerebral infarction. In patients with acute MCA occlusion, secondary edema and elevated intracranial pressure are major causes of increased morbidity and mortality. Thus, the prompt detection of occlusion influences early therapy, including thrombolysis and increased control of intracranial pressure. The hyperdense appearance of the acutely occluded MCA as seen using computed tomography (CT) has been extensively reported in the literature. However, its appearance using transcranial duplex ultrasonography has not been reported. The authors report four patients who had clinical features of ischemia throughout the MCA territory. All patients were studied with CT and transcranial duplex ultrasonography within 6 hours of the onset of symptoms. Head CT of all four patients showed a hyperdense MCA sign with infarction of the MCA territory. Transcranial duplex studies using either pulsed Doppler or color Doppler sonography displayed a hyperechoic MCA with no evidence of flow. Subsequent duplex ultrasonography and magnetic resonance angiography showed all four patients had ipsilateral occlusion of the internal carotid artery. Transcranial duplex ultrasonography assists in the early diagnosis of acute MCA occlusion. The affected vessel is displayed as a hyperechoic structure associated with no flow using Doppler examination.

4541 Clinical significance of gastritis cystica polyposa and role of endoscopic ultrasonography.

Background:Gastritis cystica polyposa(GCP) is one of multiple cystic lesion in mucosa(superficialis) and/or submucosal layer(profunda) of stomach. This lesion has been regarded as a benign lesion. However, some authors have reported that gastric cancer and adenoma is arising from GCP, and gastric cancer associated with gastric cystic lesion has also been described. Endoscopic ultrasonography(EUS) is the best diagnostic tool to evaluate small gastric cystic lesion, and it can give exclusive information for gastric tumor lesions associated with gastric submucosal cystic lesion at preoperative state. The aim of this study was to evaluated the typical EUS findings of GCP, the efficacy of EUS as diagnostic tool in GCP and its related tumor lesions. Patient and method:From Jan 1995 to November 1999, we have tried 1350 cases of endoscopy and EUS to differentiate gastric protruding or elevated lesion, 9 cases of GCP was confirmed by endoscopic resection or operation. We analysis clinical features and diagnosis in gastrofiberoscopy and EUS, compare to histologic diagnosis. Results: Clinical symptoms of GCP are abdominal discomfort or indigestion in all GCP patients. Operative history of subtotal gastrectomy was noted in only 3 cases of GCP. Initial endoscopic diagnosis to GCP was incomplete in all cases. Endoscopic findings of GCP are various; 3 gastric polyp, 2 SMT, 2 flat elevated lesion, 1 hypertrophic gastritis, and 1 small polyp coexist with gastric cancer. We could diagnosed GCP in 8 patients through EUS(sensitivity 88.9%, positive predictable rate is 100%). EUS findings is characterized by 14.1mm(9-26) of mean size, multiple variable sized anechoic lesion with intervening hyperechoic structure(8 cases), irregular margin(7), musoca and submucosal thickening(6), and submucosal invasion(5 GCP profunda). In histologic findings, 6 GCP were associated with underlying gastritis only, but two gastric tubular adenomas were located in mucosa above cystic dilatation of gastric gland. One small GCP lesion was noted in other site of upper body in patient with early gatric cancer. Conclusions:EUS is an effective diagnostic tool to evaluate and differentiate GCP from the protruding and elevated gastric lesion, and an important role to decide method of management of GCP. EUS is monopolistic diagnostic procedure to evaluate GCP associated with gastric tumor lesions before resection, and more clinical usefulness of EUS is expected to lighten pathogenetic relationship in these two disease entities in future.

A comparative study of sonographic and histopathologic findings of tumorous lesions in the parotid gland

Objective. The purpose of this study was to clarify which histopathologic features are visualized on sonograms by comparing sonomorphologic and histopathologic analyses of parotid tumorous lesions on the same plane. Study Design. Boundaries, shapes, echo intensity level, distribution of internal echoes, and acoustic enhancement on sonograms of 86 parotid tumorous lesions were retrospectively compared with the histopathologic findings. Results. Unclear boundaries on sonograms corresponded to abundant connective tissue with scattered tumor cell nests. Polygonal shapes on sonograms were revealed to represent tumor cell infiltration on histopathologic sections. The “very hypoechoic” lesions showed significantly high ratio of cystic areas ( P < .05) in Warthin tumor. The weakly hyperechoic structures on sonograms were connective tissue, hyaline, and necrotic and keratinized materials. Attenuated posterior echoes were observed in malignant tumors with abundant connective tissue and metaplastic bone formation. Conclusions. To facilitate correct sonographic diagnosis, it is important to ascertain the correlation between sonomorphology and histopathology. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:723-37)

Triangular fibrocartilage of wrist: presentation on high resolution ultrasonography.

This study consisted of two parts. Part I is for detection of the normal triangular fibrocartilage by high resolution ultrasonography and Part II is a preliminary study to evaluate high resolution ultrasonography in the diagnosis of tears of the triangular fibrocartilage. Normally, the triangular fibrocartilage was seen in all cases in Part I as an inverse triangular structure of homogeneous hyperechogenicity on transverse and oblique sagittal scans at the level of the distal radioulnar joint. At its waist it measured from 2.3 to 4.2 mm (mean, 3.0 +/- 0.5 mm) on oblique sagittal scan and from 2.5 to 3.7 mm (mean, 3.2 +/- 0.4 mm) on transverse scan. Under normal conditions, the triangular fibrocartilage is thicker than 2.5 mm on both transverse and oblique sagittal sections with a confidence level of 95%. In Part II, eight of the 47 wrists were found to be hypoechoic in the triangular fibrocartilage region, which proved to be tears by arthrography. Six cases showed a homogeneous hyperchoic triangular fibrocartilage measuring from 1.8 to 2.8 mm (mean, 2.3 +/- 0.5 mm) in transverse section and from 0 to 2.2 mm (mean 1.2 +/- 1.1 mm) in oblique sagittal section; five of these proved to be tears by arthrography. In contrast, 33 wrists had a homogeneous hyperechoic triangular fibrocartilage measuring from 2.5 to 4 mm (mean, 3.1 +/- 0.4 mm) and 2.5 to 4.2 mm (mean, 3.1 +/- 0.6 mm) on transverse and oblique sagittal sections, respectively; 27 proved to be normal triangular fibrocartilage by arthrography. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 68.4%, 96.4%, 92.9%, 81.8%, and 85.1%, respectively. HRUS can display the normal triangular fibrocartilage as a homogeneous hyperechoic and inverted triangular structure. The torn triangular fibrocartilage appears as a hypoechoic region or as thinning (< 2.5 mm) of the hyperechoic structure on either transverse or oblique sagittal section. HRUS has an acceptable accuracy in the diagnosis of triangular fibrocartilage tear.

Vagus nerve imaging with ultrasound: Anatomic and in vivo validation

To provide the anatomic basis and demonstrate the reproducibility of ultrasound studies for the identification of the vagus nerve within its course in the carotid sheath in the neck, cadaveric and in vivo imaging studies were conducted. On transverse B-mode images of the neck, there is a centrally hypoechoic and peripherally hyperechoic structure between the common carotid artery and the jugular vein inside the carotid sheath. This structure was also identified in a fresh, nonpreserved cadaver and was marked with a hypodermic needle by means of a transdermal approach. Neck dissection was performed leaving the carotid sheath intact. B-mode imaging yielded detailed anatomic information about the structures in the carotid sheath. Further dissection showed the vagus nerve as the target of the needle. One hundred consecutive transverse carotid scans were reviewed, and the characteristic echo patterns of the vagus nerve were identified in 97 instances. A distinct and reproducible, round, hypoechoic structure was defined adjacent to the common carotid artery and jugular vein as the vagus nerve. On the basis of this study, a new, noninvasive, and highly reproducible method to locate the vagus nerve in the carotid sheath is introduced. This may lead to further clinical application such as presurgical localization or ultrasound-guided needle studies. Stimulation of the vagus nerve has been proposed for seizure therapy. The diagnosis of vagus nerve tumors may be improved. (Otolaryngol Head Neck Surg 1998;118:82-5.)

Localized esophageal leiomyoma and hypertrophic osteoarthropathy

The authors report the case study of a 13-year-old girl, suffering from epigastric pain related to an important infectious syndrome and from marked hypertrophic pneumosteopathy (clubbed fingers, diffuse cortical hyperostosis). Radiological examination (chest x-ray and computed tomography scan) showed a partly calcified right posterior mediastinal mass. The esophagoscopy showed a fistular emanation from the esophagus to the tumor. The biopsy results were of no diagnostic significance, and the samples demonstrated a bacterial and fungal colonization. An endoscopic sonogram showed an inhomogeneous mass with hyperechoic structures developed between the mucosa and the outer muscular coat of the esophagus. The patient underwent surgery, which showed a large intraparietal tumor of the esophagus, which, through pathological examination, was confirmed to be a benign leiomyoma. Postoperative follow-up was simple and the pneumosteopathic symptoms regressed rapidly. This disease is rare in children under 15 years of age. It is only exceptionally associated with a hypertrophic pneumosteopathy. This pathology is diagnostically challenging to the surgeon. The endoscopic ultrasonography is the best procedure in the assessment of subepithelial tumor and extrinsic compressions of the oesophagus.

Ultrasonographic examination of the posterior tibial tendon.

The posterior tibial tendons (PTTs) of 16 patients with PTT dysfunction and 10 age-matched healthy subjects were examined ultrasonographically, using a 10-MHz linear-array transducer. Normal PTTs appeared hyperechoic (more echogenic) and oval, with an average diameter of 7.8 mm x 3.7 mm at the medial malleolar level. Degenerated PTTs appeared hypoechoic (less echogenic) and swollen (9.8 mm x 5.0 mm). Peritendinitis presented as a hypoechoic rim on the longitudinal sonogram (along the long axis of the tendon) and a "target sign" (hyperechoic central structure with a hypoechoic halo) on the transverse sonogram (at the right angle to the long axis of the tendon). Complete rupture of the PTT revealed an empty tibial groove at the level of the medial malleolus on the transverse sonogram and a wavy fibril pattern over the distal end on the longitudinal sonogram. Compared with the operative findings or the results of the magnetic resonance imaging, ultrasonography was sensitive and specific in diagnosing tenosynovitis and complete rupture of the PTT.