CASE 16853 Published on 03.07.2020

Cervical ultrasound pitfall


Head & neck imaging

Case Type

Anatomy and Functional Imaging


Paula Concejo Iglesias, Jimena Cubero Carralero, Wilmar Antonio Ocampo Toro, María Pilar Núñez Valentín, María Azahara Hoyas García, Carlos Bartels Urvina, Cristian Rodríguez Robles, Concepción Ferreiro Argüelles

Hospital Universitario Severo Ochoa, Avda. de Orellana s/n, 28911. Leganés; Madrid; Spain


23 years, female

Area of Interest Anatomy, Head and neck, Salivary glands, Soft tissues / Skin ; Imaging Technique Ultrasound
Clinical History

A 23-year-old female without relevant medical history. A cervical ultrasound was performed to rule out goiter.

Imaging Findings

A hypoechogenic well defined structure with striated appearance was demonstrated on grey-scale ultrasound with small air foci inside the lesion. The submandibular gland and mylohyoid muscle are unremarkable.


The palatine tonsils are part of the Waldeyer´s ring, lymphoid tissue located in the nasopharynx and oropharynx [1, 2, 3]. The Waldeyer´s ring is especially important in the pediatric population since they have more tendency to suffer from infectious or inflammatory processes [1]. When bigger than normal, they may be a cause of sleep apnea [1].

Ultrasound is an excellent imaging technique in the neck exploration of pediatric and young population because of its availability, the fact that it is a noninvasive technique and the lack of ionizing radiation, ionidated intravenous contrast or sedation necessity [1, 2, 3, 4].

On ultrasound a palatine tonsil is seen as a hypoechogenic well-circumscribed lesion [1,3-5] with a typical internal striated appearance. It is in the pharyngeal mucosal space, deep to the submandibular gland and the mylohyoid muscle [2, 3]. The characteristic internal striated appearance with alternating hypo- and hyperechogenic linear bands is due to the presence of tonsillar crypts [1 - 4]. Inside the crypts, small air foci can be also seen [2, 3].

When an inflammatory process is developing, such as tonsillar cellulitis or abscess, the striated appearance disappears [1]. In tonsillar cellulitis an enlarged tonsil with obscured borders may be visualized, while abscess is defined by an anechogenic cystic lesion inside the tonsil or in the paratonsillar tissue [2, 3, 5].

There are no differences in size between males and females [4] and there are also no commonly accepted normal values for the dimension of the palatine tonsils. Maximum size is usually during puberty [1- 4], up to 2 cm in longitudinal dimension [2, 3, 5].

Knowledge of the normal ultrasound characteristics and features of the palatine tonsil is mandatory for radiologists in order to avoid misdiagnosis [2, 3].   

Differential Diagnosis List
Normal palatine tonsil
Uncomplicated tonsillitis
Tonsillar abscess
Developmental cyst
Final Diagnosis
Normal palatine tonsil
Case information
ISSN: 1563-4086