Ultrasound Scanning Planes

Fig. 15 Schematic representation of typical reverberations (R) occurring between strongly reflective interfaces (I). T = transducer

Fig. 16 Reverberations: Longitudinal scan of the uterus and bladder (B) with

__ "superimposed" parallel lines caused by

14 abdominal wall structures. Arrows = IUD

n Significance: Reverberations are consistently present in cystic organs but may also occur in solid structures. They are always troublesome and rarely helpful.

They can be eliminated by changing the direction of the beam.

n Definition: Lateral acoustic shadows caused by a tangential beam angle, scattering, refraction, attenuation, and extinction of the ultrasound beam at cyst walls n Description: Narrow hypoechoic bands or shadows at the edges of cystic structures, often showing a divergent pattern. n Significance: Edge shadowing is a useful criterion for diagnosing cysts. n Differentiation from a real object:

• Edge shadows can mimic stones, especially in the gallbladder fundus and cystic duct.

• Double-check the finding in a second scan plane.

Fig. 17 Edge shadowing: When sound waves encounter cyst walls at a tangential angle, they are scattered or refracted. T = transducer, C = cyst,

CE = cystic edge shadows

Ultrasound Scanning Planes

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Fig. 18 Edge shadowing. The refraction and attenuation of sound at cyst margins produces a divergent or convergent pattern of acoustic shadowing. Sound attenuation by the echogenic walls of cystic structures is not the only cause of this artifact, which may also result from deviation of the beam due to scattering and refraction. This explains the divergent pattern of edge shadowing that may be seen.

Ultrasound Scanning Planes

I 2 The Ultrasound Examination

E 2.1 Abdominal Sonography

"J Examination Conditions d

3 n Prerequisites: The patient should be examined in a darkened room with a quiet 8 atmosphere and comfortable ambient temperature. It is essential to select the ¡2 proper transducer (depending on the organ of interest) and use the correct moni-■Sj tor and scanner settings (p. 6). Other important keys to a successful examination: ^ • Address the clinical problem.

jC • Premedication with simeticone is rarely needed. When indicated, a high dose should be administered in liquid form.

• Use sufficient coupling gel between the skin and transducer, eliminating all air bubbles.

• Use a sterile film on fresh wounds (a cheaper option is a disposable glove without talcum).

• Reschedule if the examination conditions are poor.

n Positioning: Most organs are scanned with the patient supine. Less common positions are right or left lateral decubitus, sitting, standing, and the semiupright position (see also scanning tips). The examination couch should not be too soft. Bedside examinations are difficult.

n Introductory notes:

• The organs are displayed in "thin slices" as defined by the geometry of the beam (see Fig. 19).

• Standard ultrasound scan planes basically consist of longitudinal and transverse planes

• During the examination, the transducer should be oriented in a defined way referring to a special topographic anatomy (Figs. 21, 22, 35, 37, 38). This is important for anatomical orientation in the displayed image.

• The transducer position can be checked in the moving image to confirm right-left orientation. The image lines should be generated from right to left on the monitor when the transducer is moved to the left, and an acoustic shadow should appear on the left side when the examiner slips a finger beneath the left side of the probe.

n Transverse scan: In a transverse (axial) scan, the right side of the image should correspond to the anatomical left side, and the left side of the image to the anatomical right side. Structures that are closer to the transducer should appear at the top of the image, and structures farther from the transducer should appear at the bottom.

n Longitudinal scan: In a longitudinal scan, the left side of the image should be cranial (superior) and the right side caudal (inferior). Structures closer to the transducer should appear at the top of the image, and structures farther from the transducer should appear at the bottom (as in a transverse scan). n Overview: See Table 4.

Fig. 19 Schematic representation of a body slice

Table 4 ■ Overview of standard ultrasound scan planes

Standard scan planes Organs imaged

Transverse scans

Upper abdominal transverse scan

Liver, stomach, pancreas, vessels (Fig. 23)

Right subcostal oblique scan

Liver, gallbladder (Figs. 24, 30, 33)

Left subcostal oblique scan

Left lobe of liver, stomach, spleen (Fig. 34)

Lower abdominal transverse scan

Bladder, rectum, uterus, fallopian tubes, prostate

(Fig. 39)

Longitudinal scans

Intercostal scan (porta hepatis scan,

Liver, porta hepatis, gallbladder, bile ducts

shoulder-umbilicus scan)

(Figs. 25-27)

Right flank scan

Liver, kidney (Fig. 29)

Left flank scan

Spleen, kidney (Figs. 31, 32)

Upper abdominal longitudinal scan

Liver, stomach, pancreas, vessels (Figs. 28, 36)

Lower abdominal longitudinal scan

Bladder, rectum, uterus, prostate (Fig. 40)

n Beginners in particular should follow a systematic protocol in routine ultrasound examinations to ensure complete coverage. The scan planes shown in Fig. 20 can be imaged in the sequence indicated. n The examination proceeds in a counterclockwise direction. Longitudinal and transverse scans are carried out continuously along the vessels, working from the upper abdomen to the lower abdomen. n Possible sequence of standard scan planes: Upper abdominal transverse scan Right subcostal oblique scan Right intercostal scan Extended right intercostal scan Longitudinal paramedian scan Right flank scan

Right midabdominal transverse scan High left intercostal scan (high left flank scan) Left flank scan

Left midabdominal transverse scan Left subcostal oblique scan Upper abdominal longitudinal scan Lower abdominal longitudinal scan Lower abdominal transverse scan

Ultrasound Scanning Planes
Fig. 20 Standard and supplemental scan planes

n Relationship of the gallbladder to adjacent organs:

n Relationship of the gallbladder to adjacent organs:

Ultrasound Scanning Planes

Falciform ligament

Gallbladder Quadrate lobe

Fig. 21a, b a The gallbladder fundus extends past the inferior border of the liver. It lies to the right of the C-shaped duodenal loop and cranial to the right colic flexure. b Visceral surface: The caudate lobe is bounded by the superior border of the liver, falciform ligament, gallbladder, and vena cava. The quadrate lobe is bounded by the inferior border of the liver, falciform ligament, gallbladder, 20 and portal vein

Falciform ligament b

Gallbladder Quadrate lobe

Fig. 21a, b a The gallbladder fundus extends past the inferior border of the liver. It lies to the right of the C-shaped duodenal loop and cranial to the right colic flexure. b Visceral surface: The caudate lobe is bounded by the superior border of the liver, falciform ligament, gallbladder, and vena cava. The quadrate lobe is bounded by the inferior border of the liver, falciform ligament, gallbladder, 20 and portal vein n Topographic anatomy of the pancreas and bile ducts:

Head of pancreas

Duodenum

Celiac trunk

Splenic artery

Head of pancreas

Celiac trunk

Splenic artery

Borders And Surfaces Spleen

Spleen

Duodenum

Splenic vein

Inferior mesenteric vein

Body of pancreas

Superior mesenteric vein

Spleen

Splenic vein

Inferior mesenteric vein

Body of pancreas

Superior mesenteric vein

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Ultrasound Scanning Planes

Call-bladder b

Proper hepatic artery

Fig. 22a, b a The splenic artery runs posteriorly and superiorly, the splenic vein posteriorly and inferiorly. The tail of the pancreas extends toward the hilum of the spleen, and the head of the pancreas lies within the C-shaped loop of the duodenum. The left lobe of the liver is anterior to the pancreas, and the aorta is posterior. b Topographic anatomy of the bile ducts

Call-bladder b

Proper hepatic artery

Fig. 22a, b a The splenic artery runs posteriorly and superiorly, the splenic vein posteriorly and inferiorly. The tail of the pancreas extends toward the hilum of the spleen, and the head of the pancreas lies within the C-shaped loop of the duodenum. The left lobe of the liver is anterior to the pancreas, and the aorta is posterior. b Topographic anatomy of the bile ducts n Upper abdominal transverse scan:

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8 IS

n Upper abdominal transverse scan:

Ultrasound Scanning Planes
Fig. 23 The upper abdominal transverse scan displays the following structures from anterior to posterior: liver (L), splenic vein (SV), pancreas (P), aorta (AO)

n Anatomical guidelines for scanning the liver:

• The right and left lobes of the liver are separated by the falciform ligament. The ligament appears sonographically as an echogenic band (see Fig. 359), p. 252; scans through the right and left lobes).

• The separation of the two anatomical halves of the liver by the falciform ligament is most clearly appreciated when viewed from the posteroinferior direction.

• Based on the segmental anatomy of the liver, a line drawn from the gallbladder to the vena cava, marked by the interlobar fissure, separates the physiological right and left lobes of the liver.

• The gallbladder lies against the inferior surface of the right lobe of the liver.

• To locate the caudate and quadrate lobes more easily, imagine the letter H drawn on the visceral surface of the liver. One limb of the H is formed by a line connecting the gallbladder and vena cava (which lie in grooves in the liver); the other limb is formed by the falciform ligament. The crossbar is formed by the porta hepatis where the portal vein divides into its right and left main branches. The open areas of the H are occupied superiorly by the caudate lobe and inferiorly by the quadrate lobe (see Fig. 319), p. 231; visceral surface of the liver).

n Right subcostal oblique scan:

Fig. 24 The probe is placed below the right costal arch and angled laterally upward. The beam is directed postero-laterally and superiorly. The beam passes through the liver (L) and gives a longitudinal view of the hepatic veins, which open posteriorly into the vena cava. RHV = right hepatic vein, MHV = middle hepatic vein, LHV = left 22 hepatic vein

Ultrasound Scanning PlanesIntercostal Ultrasound Scanning
Fig. 25 The intercostal scan is placed on an imaginary line between the right shoulder and the umbilicus. From this point the beam can be swept across the liver (L) in a fan-shaped pattern. The kidney (K) is posterior

n Extended right intercostal scan:

Fig. 26 The extrahepatic bile ducts are defined in the porta hepatis scan by sliding the probe toward the umbilicus. The probe can be slightly angled and rotated to demonstrate the bile duct (BD), vena cava (Vc), and portal vein (Vp) in approximate longitudinal sections. These structures are easier to define in left lateral decubitus at full inspiration

Fig. 26 The extrahepatic bile ducts are defined in the porta hepatis scan by sliding the probe toward the umbilicus. The probe can be slightly angled and rotated to demonstrate the bile duct (BD), vena cava (Vc), and portal vein (Vp) in approximate longitudinal sections. These structures are easier to define in left lateral decubitus at full inspiration o c

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n Extended right intercostal scan:

n Extended right intercostal scan:

Ultrasound Scanning Planes
Fig. 27 Scanning in the same direction, the probe can be moved along the costal arch to define the gallbladder (Gb) in longitudinal section. The gallbladder is most easily located by keeping the inferior border of the liver in view while moving the probe. BD = bile duct

n Right longitudinal paramedian scan:

Ultrasound Scanning Planes

Fig. 28 The probe is oriented longitudinally and is placed lateral to the midline in an intercostal space or below the costal arch. The liver (L) is displayed in longitudinal section, and the shape of the (normally acute) inferior hepatic angle can be evaluated. The fundus of the gallbladder (Gb) projects past the inferior border of the liver. The vena cava (Vc) is displayed in longitudinal section and is posterior to the liver. Vena cava filling can be evaluated in this plane

Fig. 28 The probe is oriented longitudinally and is placed lateral to the midline in an intercostal space or below the costal arch. The liver (L) is displayed in longitudinal section, and the shape of the (normally acute) inferior hepatic angle can be evaluated. The fundus of the gallbladder (Gb) projects past the inferior border of the liver. The vena cava (Vc) is displayed in longitudinal section and is posterior to the liver. Vena cava filling can be evaluated in this plane

Ultrasound Scanning Planes
Fig. 29 The flank scan is obtained by moving the probe laterally from the para-median position. It is used to evaluate the pleural angle distal to the diaphragm (D) and displays a longitudinal section of the kidney (K) posterior to the liver (L)

n Right midabdominal transverse scan:

Ultrasound Scanning Planes

Fig. 30 While viewing the kidney in longitudinal section, the examiner rotates the probe to a midabdominal transverse position and slides it toward the midline. The kidney (K) is displayed in cross-section posterior to the liver (L). The vascular pedicle with the renal vein (Vr) and renal artery (Ar) can be identified from anterior to posterior at the level of the renal hilum, and the ureter may also be seen. In thin patients, one section may display the termination of the renal vein at the vena cava (Vc), the origin of the renal artery from the aorta (Ao), and the gallbladder (Gb) at the inferior border of the liver

Fig. 30 While viewing the kidney in longitudinal section, the examiner rotates the probe to a midabdominal transverse position and slides it toward the midline. The kidney (K) is displayed in cross-section posterior to the liver (L). The vascular pedicle with the renal vein (Vr) and renal artery (Ar) can be identified from anterior to posterior at the level of the renal hilum, and the ureter may also be seen. In thin patients, one section may display the termination of the renal vein at the vena cava (Vc), the origin of the renal artery from the aorta (Ao), and the gallbladder (Gb) at the inferior border of the liver

Kidney Ultrasound Scanning Planes

Fig. 31 The probe is placed in an intercostal space cranial to the left flank and is angled cephalad and medially to demonstrate the spleen (S) in longitudinal section. The upper pole of the spleen appears on the left side of the image, the lower pole on the right side. The probe is rotated, slid, and angled until the longest diameter is visualized. The length of the spleen and its thickness at the level of the splenic hilum are measured

Fig. 31 The probe is placed in an intercostal space cranial to the left flank and is angled cephalad and medially to demonstrate the spleen (S) in longitudinal section. The upper pole of the spleen appears on the left side of the image, the lower pole on the right side. The probe is rotated, slid, and angled until the longest diameter is visualized. The length of the spleen and its thickness at the level of the splenic hilum are measured n Left flank scan:

Fig. 32 As the probe is moved caudad from the high flank scan, the kidney (K) appears in longitudinal section posterior to the spleen (S). The orientation of the kidney, its posteriorly placed upper pole, and its anteriorly directed lower pole can be clearly identified

Ultrasound Scanning Planes

Fig. 33 While still over the kidney, the probe is rotated to a transverse position and is angled, rotated, and slid to a midabdominal transverse scan that displays the renal hilum with its vascular pedicle and may define the proximal ureter. The probe is then moved slowly down the kidney (K) from its upper to lower pole to survey the organ in transverse sections. Vr = renal vein

Fig. 33 While still over the kidney, the probe is rotated to a transverse position and is angled, rotated, and slid to a midabdominal transverse scan that displays the renal hilum with its vascular pedicle and may define the proximal ureter. The probe is then moved slowly down the kidney (K) from its upper to lower pole to survey the organ in transverse sections. Vr = renal vein n Left subcostal oblique scan:

Ultrasound Scanning Planes

Fig. 34 From the midabdominal transverse scan, the probe is slid to a position below the left costal arch to obtain a left subcostal oblique scan. The liver (L) is visible on the left side of the image. The spleen (S) appears posterolaterally on the right side of the image, displaying its true width and a foreshortened longitudinal diameter

Fig. 34 From the midabdominal transverse scan, the probe is slid to a position below the left costal arch to obtain a left subcostal oblique scan. The liver (L) is visible on the left side of the image. The spleen (S) appears posterolaterally on the right side of the image, displaying its true width and a foreshortened longitudinal diameter n Diagram of the major abdominal vessels:

n Diagram of the major abdominal vessels:

Intra Abdominal Structures
Fig. 35 Diagram of the arterial vessels arising from the aorta and the tributaries of the vena cava. These vessels can be distinguished sonographically and can provide useful landmarks for intra-abdominal scanning

n Upper abdominal longitudinal scan:

Fig. 36 The following structures can be identified from anterior to posterior: liver (L), pancreas (P), superior mesenteric vein (Vms), celiac trunk (Tc), and superior mesen-teric artery (Ams), the latter two arising from the aorta (AO). The spinal column (Sc) is visible posteriorly

Fig. 36 The following structures can be identified from anterior to posterior: liver (L), pancreas (P), superior mesenteric vein (Vms), celiac trunk (Tc), and superior mesen-teric artery (Ams), the latter two arising from the aorta (AO). The spinal column (Sc) is visible posteriorly

n Diagram of the female genital organs:
Suprapubiskateter

Fig. 37 Relationships of the lower abdominal organs in the female. This diagram aids in understanding how the ultrasound probe should be directed during the examination. The uterus lies posterior and superior to the bladder. The following structures appear in sagittal section from anterior to posterior: pubic symphysis (sound does not penetrate bone, so the probe must be placed above the sym-physis), bladder, uterus, and rectum. The probe can be angled downward to demonstrate the vagina

Fig. 37 Relationships of the lower abdominal organs in the female. This diagram aids in understanding how the ultrasound probe should be directed during the examination. The uterus lies posterior and superior to the bladder. The following structures appear in sagittal section from anterior to posterior: pubic symphysis (sound does not penetrate bone, so the probe must be placed above the sym-physis), bladder, uterus, and rectum. The probe can be angled downward to demonstrate the vagina

Lower Intestinal And Prostate
Fig. 38 The male pelvis has a similar structure. It is important to note that the prostate is inferior to the bladder, and the seminal vesicles are posteroinferior

n Lower abdominal transverse scan:

Fig. 39 The following structures are defined from anterior to posterior: abdominal wall, bladder (B), and uterus (U), which is flanked by the fallopian tubes (T)

n Lower abdominal longitudinal scan:

Fig. 40 From anterior to posterior: abdominal wall, bladder (B), and uterus (U), which is bounded by the fundus above and the vagina (V) below

Fig. 40 From anterior to posterior: abdominal wall, bladder (B), and uterus (U), which is bounded by the fundus above and the vagina (V) below

Seminal Vessels Ultrasound

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Arteries and veins, p. 188; cervical vessels, p. 214; liver, p. 231; kidney, p. 262; adrenal glands, p. 292; pancreas, p. 293; spleen, p. 312; bile ducts, p. 322; gallbladder, p. 334; gastrointestinal tract, p. 352; urogenital organs, p. 375; pleura and lung, p. 400; thyroid gland, p. 412; salivary glands, p. 425.

2.2 Ultrasound Imaging of Joints (Arthrosonography)

n Clinical importance: In recent years, ultrasonography of the musculoskeletal system has developed into a recognized and clinically important imaging modality. For investigations in rheumatology, ultrasound imaging is the next step in the diagnostic algorithm following the history and physical examination. The intra-and periarticular soft-tissue changes that are typical of inflammatory joint diseases can be detected much earlier by sonography than by physical examination or radiography. Sonography can make an important contribution to diagnosis (e.g., detecting clinically asymptomatic synovitis) as well as management (e.g., the prompt initiation of basic treatment for early destructive joint changes). n Capabilities of arthrosonography:

• Detection of exudative or proliferative articular synovitis

• Detection of exudative or proliferative tenosynovitis

• Detection of synovial cysts

• Early detection of erosive defects in bone and joint margins

• Detection of degenerative articular and soft-tissue changes such as marginal osteophytes, bursitis, periarticular ossification, and tendon lesions n Limitations of arthrosonography:

• Limited ability to image superficial joint structures, depending on individual anatomy

• Poor visualization of deeper joint structures, with an inability to evaluate intraarticular or subchondral lesions

• Limited ability to discriminate synovitis ("inflammatory substrates") in the B-mode image n Normal findings (Table 5):

Table 5 ■ Normal sonographic findings Structure Sonographic appearance

Synovial membrane Echogenic, normally difficult to delineate from connective tissue

Cartilage Anechoic, parallel to bone surface

Bone Very echogenic with an associated acoustic shadow

Tendons Echogenic when scanned at a perpendicular angle, but may appear hypoechoic (Fig. 41) when scanned at certain angles (acoustic aniso-tropism; compare with muscle) Muscle Hypoechoic; typical pennate pattern in longitudinal section; mottled echo pattern in transverse section m

Ultrasound Scanning Planes

Fig. 41a, b Anterior transverse scan of the shoulder. a When the long biceps tendon is perpendicular to the beam, it appears as a bright round echo (p). b When the long biceps tendon is scanned at a different angle, the sound waves are not reflected and the tendon groove (p) appears empty. ! Caution: Do not interpret this as a tendon rupture n Typical abnormal findings (Table 6):

Table 6 ■ Typical abnormal findings

Structure Sonographic appearance

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Joint effusion Anechoic or hypoechoic (Fig. 42)

"True" bone Constant surface discontinuity with echoes from the base of the erosion erosion (Fig. 43)

Pseudoerosion Apparent defect caused by beam obliquity relative to the bone surface; no base echoes

Pannus Erosive changes in articular surfaces with infiltration of tendons (Fig. 44)

Synovitis B-mode image: hypoechoic thickening of the joint capsule (the prolif-

("inflammatory erative and exudative components cannot be positively distinguished in substrate") most cases)

Color or power Doppler: increased vascularity (Fig. 45)

Tenosynovitis Anechoic or hypoechoic margin surrounding an echogenic tendon (Fig. 46)

Pannus = inflammatory exudate that can destroy articular cartilage and bone as well as tendons.

Synovitis ("inflammatory substrate") = synovial proliferation (proliferative component), usually associated with intra-articular effusion (exudative component) p joint swelling.

Ultrasound Scanning Planes

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Ultrasound Scanning Planes

Fig. 43 Echogenic base of an erosion: circumscribed erosive defect at the base of the first proximal phalanx (arrow) in erosive psoriatic arthritis

PIP Z LI

- H1 I

a

1) 2 LI

C HTP5R

HÏP5L

Fig. 44a-d Pannus. a, b Hypoechoic infiltration of the tendon by pannus tissue (arrows) due to pannous flexor tenosynovitis in a patient with chronic rheumatoid arthritis. a Survey image, b zoom image. c, d Fifth MTP joint with pannus in the right foot (c); compare with the same joint without pannus in the left foot (d)

Synovitis The Foot

Fig. 45a-c Synovitis in an arthritic knee. a Transverse B-mode image. b CDS demonstrates areas of boggy synovial thickening with increased vascularity.

c Doppler spectrum shows a typical increase in diastolic flow

Fig. 45a-c Synovitis in an arthritic knee. a Transverse B-mode image. b CDS demonstrates areas of boggy synovial thickening with increased vascularity.

c Doppler spectrum shows a typical increase in diastolic flow

Ultrasound Scanning Planes
Fig. 46a, b Tendovaginitis appears as a hypoechoic rim around the tendon of the extensor carpi ulnaris. a Transverse scan, b longitudinal scan over the distal ulna

n Transducers:

• High-frequency linear transducer (7.5-15 MHz): Used for examining superficial structures (e.g., tendons and ligaments) and small joints in the hands or feet.

• Low-frequency linear transducer (5 MHz): Used for scanning deeper joints (e.g., the hip and shoulder joints).

• Convex 3.5 MHz transducer: Necessary only in rare cases, as in very obese patients.

n Scanning tips:

• Use standard anatomical landmarks for orientation.

• Locate the static transverse and longitudinal scan planes.

• Use the RES function on the machine to zoom selected regions of interest while maintaining high resolution.

• For dynamic scanning, move the transducer continuously during active or passive motion of the scanned structures. Joint motion is often necessary in order to detect subtle abnormalities (e.g., mild degrees of exudation).

• Always compare the findings with the contralateral joint.

n The patient is examined in a sitting position with the arm hanging at the side, the elbow flexed 90°, and the forearm supinated. Dynamic scans are obtained with internal/external rotation and abduction of the shoulder joint. n Scan planes:

• Anterior longitudinal scan:

Ultrasound Scanning Planes

Fig. 47a, b Sonography of the shoulder: anterior longitudinal scan. a Scan plane, b normal findings. The humerus appears below the long biceps tendon, and above that is the deltoid muscle

Anterior transverse scan:

Anterior transverse scan:

Lumpy Adrenal Gland Pics
Fig. 48a, b Sonography of the shoulder: anterior transverse scan. a Scan plane, b normal findings. The greater tuberosity is on the left side of the image (2), adjacent to the biceps tendon groove. The lesser tuberosity is on the right (1); 3 = supraspinatus muscle, 4 = infraspinatus muscle

Posterior longitudinal scan:

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  • John
    What is subcostal scan ultrasound?
    2 years ago
  • michael
    What is the ultrasound scan plane?
    8 months ago
  • SIIRI
    How is ultrsound used in planes?
    4 days ago

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