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Normal Soft Tissue Neck Ultrasound Report Template
Normal soft tissue neck ultrasound report template: palpable-area survey with lymph node morphology, salivary gland and thyroid wording, plus nodal level notes.
EXAMINATION: Ultrasound of the soft tissues of the neck. CLINICAL HISTORY: [indication, e.g., palpable neck mass at [location]]. COMPARISON: None available. TECHNIQUE: Real-time grayscale and color Doppler imaging of the cervical soft tissues, targeted to the area of clinical concern. FINDINGS: Site of clinical concern: No discrete solid or cystic mass, abnormal fluid collection or abnormal vascularity. Lymph nodes: Scattered cervical lymph nodes with preserved echogenic fatty hila and normal oval morphology, the largest measuring [x] cm in short axis. No rounded, hypoechoic or necrotic node. No abnormal peripheral nodal vascularity. Salivary glands: The visualized submandibular and parotid glands are homogeneous, without mass or ductal dilatation. Thyroid: The visualized thyroid gland is unremarkable. No nodule. Soft tissues: No subcutaneous edema or focal fluid collection. IMPRESSION: 1. No discrete mass or morphologically abnormal lymph node at the site of clinical concern.
Dictation notes
- Judge nodes on short axis and morphology, not length — a long flat node with a fatty hilum is normal, while a rounded hypoechoic node without a hilum is suspicious at any size.
- Localize every described node by cervical level (I-VI) — that is the language the surgeon maps an FNA or dissection to.
- An incidental thyroid nodule found on a neck survey gets ACR TI-RADS scoring, not a “follow clinically” — route it like any dedicated thyroid study.
Related references
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