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Description : Check out this medical presentation on Radiology and Imaging, which is titled "ULTRASOUND IMAGING", to know about ultrasound imaging and its applications in head and neck.

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ULTRASOUND IMAGING APPLICATIONS IN HEAD AND NECK Dr Aparna PG, Dept of Oral Medicine & Radiology, SDM College of Dental Sciences and Hospital
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Contents: PART I: BASICS Introduction History and evolution of diagnostic ultrasound USG – basic physics Parts of an ultrasound unit Image Acquisition Modes Tissue characterization Ultrasound guided Needle PART II : Buccal mucosa 2 US techniques Normal US appearance OSMF Early Malignant changes Carcinoma Cheek Salivary Glands US techniques Normal gland appearance Inflammatory diseases neoplasms PART III: Lymph nodes Normal US appearance Metastatic node Tuberculous node TMJ Vascular malformations Head and neck swellings- DD at US
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BUCCAL MUCOSA 3
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Fields and Dunn (1973) stated that Collagen is the major source of echogenicity in tissues Different organs display varied echo pattern due to their varying collagen content Contracted buccinator: Highly echogenic. Relaxed buccinator: Less highly echogenic. Subcutaneous tissue: Moderately echogenic. Deep adipose tissue: Less echogenic 4
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Methods for evaluation of buccal mucosa Resting and Puffed Cheek Technique Makes the layers taut and increases visibility Accurately defines size of the lesion 5
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Methods for evaluation of buccal mucosa Tongue Touch Technique Better visualisation of details. To evaluate superficial mucosal lesions involving the buccal mucosa and lesions involving the anterior half of the tongue and its lateral borders. 6
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Methods for evaluation of buccal mucosa Fruit Jelly Technique Fruit jellies’ in oval or conical shapes were placed in upper and lower gingivo-buccal sulcus (groove between the gingiva and the buccal mucosa) 7
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Scanning levels 8
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A1. Lower Border of The Mandible 9
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A2. Angle of the Mouth to the Ear Lobule 10
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A3. Nasal ala to the tragus 11
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C1. Vertically from mandible up to the lateral canthus: 12
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C2: approximately one- inch posterior to C1 13
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C3. Extends from the angle of mandible to temporal region 14
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Buccal space infection Abscess vs Cellulitis – Different treatment modes To pinpoint the relation of the abscess to the overlying skin, To accurately measure the dimensions of the abscess cavity and its precise depth below the skin surface . The vessels of the inflammatory tissue which has a higher blood volume due to increased permeability of the vessel wall are depicted as a colour flow signal on Color Doppler images.
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Different stages of infection : Edematous changes: the echogenicities of the tissues are isoechoic, similar to the normal or uninfected side but with an increase in the fluid contents. Cellulitis: the echogenicities of the tissues are higher (hyperechoic) than normal because of massive inflammatory infiltration to the infected region. Preabscess stage: the echogenicities of the tissues are mixed (hypoechoic and hyperechoic) at the end of cellulitis stage and the beginning of abscess formation stage. Abscess stage: the echogenicities of the tissues were absent (anechoic) because of the abscess cavity, which can be solitary or multiple well-defined foci of pus.
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Appearance on US images ABSCESS The gray-scale appearance of an abscess is a heterogeneic, anechoic, or hypoechoic mass containing a variable amount of internal echoes. Generally spherical in shape with poorly defined borders Compression of the mass with the transducer may demonstrate movement or ‘‘swirling’’ of pus. CELLULITIS US shows thickening and diffuse hyperechogenicity of the subcutaneous fat Obliteration of the interface between the echogenic fat and the dermis. This is commonly referred to as ‘‘cobblestoning’
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CELLULITIS ABSCESS
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ORAL SUBMUCOUS FIBROSIS USG demonstrates the number, length, thickness of the fibrotic bands and pattern of overall vascularity in the affected area The band of hypoechogenicity between the hyperechoic mucosa and the muscle layer is measured as submucosa There is increase in the collagen fibres in OSMF this could be the most possible reason of increase echogenecity and increased submucosal thickness in USG
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EARLY MALIGNANT CHANGES
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Evaluation of Tumour Depth or Thickness 22 Taylor et al. found that the ultrasound-measured thickness was comparable to histologically measured thickness; between the two modalities, the difference was within one mm in 81% cases, and the difference was within two mm in 93% cases Tumours as small as one mm were detected and ultrasound could detect tumour shape and invasion, whereas tumour thickness measured on CT and MRI was more than that measured on ultrasound and histology
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SCC of buccal mucosa 23
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SALIVARY GLANDS 24
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TECHNIQUE 25 Highest-frequency transducer possible. 5–12-mhz wide-band linear transducers (median frequency, 7–7.5 mhz or more) are used Large tumors and lesions located in deep portions of the glands, 5–10-mhz transducers may be useful When combined with color Doppler imaging, it helps in assessing the vascularity and nature of the lesion
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Entire salivary glands and all lesions have to be evaluated in at least two perpendicular planes during a US examination
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The parotid gland 27
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The border between the superficial and deep parotid lobes is created by a plane in which the facial nerve and its branches are located. Branches of the facial nerve are not visible at US. Parts of the trunk of this nerve may be demonstrated only with high-frequency probes (above 10 MHz) RETROMANDIBULAR VEIN – US LANDMARK The deep parotid lobe can be visualized only partially at US. Some areas of glandular parenchyma and possible lesions may be hidden in the acoustic shadow behind the mandibular ramus 28
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Left parotid gland and part of the cheek 29
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Normal US appearance Normal echogenicity of all major salivary glands is generally homogeneous and varies from very bright and markedly hyperechoic to only slightly hyperechoic in comparison to adjacent muscles. Depends on the amount of intraglandular fatty tissue. Salivary glands with high fat content are hyperechoic in comparison to surrounding muscles and markedly suppress ultrasound waves, so that the deep lobe is inaccessible for us assessment
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Stenson duct 33 After leaving the parotid gland, the main excretory duct (Stenson duct) lies on the masseter muscle, about 1 cm below the zygomatic arch, then crosses the buccal muscle and has its orifice in the parotid papilla at the level of the upper second molar. The length of the Stenon duct usually varies between 3 and 5 cm. A nondilated duct is usually not visible during US examination
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34
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Lymph nodes in Parotid 35 In the parenchyma of the parotid gland, lymph nodes may be found . They are localized mainly in the area of the upper and lower poles of the gland. Normal intraparotid lymph nodes may be oval or have a longitudinal shape The presence of a hyperechoic hilum is one of the important criteria for the normality of parotid lymph nodes . Their short axis should not exceed 5–6 mm in the normal state With the application of sensitive power Doppler US, central vessels may be seen in normal parotid lymph nodes.
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Parotid lymph nodes 36
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The submandibular gland 37
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Generally, the shape of the submandibular gland in longitudinal and transverse sections is close to a triangle 38
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Facial vessels The facial artery may cross the parenchyma of the submandibular gland in its tortuous course The facial vein runs along the anterosuperior part of the submandibular gland. Medially to the submandibular gland run the lingual artery and vein. 39
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Wharton’s duct In general, a nondilated duct is not visible at us, but sometimes in slim individuals it may be visible 40
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Sublingual Gland 41
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On transverse sections, the shape of the sublingual gland is close to an oval ; on sections parallel to the body of the mandible, the shape is longitudinal and lentiform. Along its medial part runs the excretory duct of the submandibular gland. 42
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INFLAMMATORY DISEASES OF SALIVARY GLANDS 43
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Acute Inflammation 44 Salivary glands are enlarged and hypoechoic. They may be inhomogeneous; May contain multiple small, oval, hypoechoic areas May have increased blood flow at US Enlarged lymph nodes with increased central blood flow may be observed in acute inflammation of salivary glands
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Chronic Sialadenitis 46 Salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous Usually do not have increased blood flow at US
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At US, chronic and sometimes acute sialadenitis in children , as well as acalculous submandibular gland sialadenitis in adults show multiple small, round or oval, hypoechoic areas or lesions distributed throughout glandular parenchyma
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Granulomatous Sialadenitis US features of granulomatous sialadenitis are nonspecific: single or multiple hypoechoic areas in an enlarged or normally sized gland or diffuse low echogenicity . Blood flow may be increased Mycobacterial disease of major salivary glands may manifest as a salivary gland mass, clinically indistinguishable from a neoplasm 48
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Sialosis Bilateral, diffuse, and painless enlargement of the salivary gland referred to as sialosis occurs in diabetes mellitus, chronic alcoholism, hypothyroidism, malnutrition, and rarely secondary to certain drugs (antibiotic, antipsychotics. And diuretics). US reveals a hyperechoic gland without increased vascularity or focal lesions.
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Sialolithiasis 50 US features of sialolithiasis include strongly hyperechoic lines or points with distal acoustic shadowing, which represent stones In symptomatic cases with duct occlusion, dilated excretory ducts are visible Sialolithiasis of the submandibular gland • US may demonstrate whether the stone is located in the glandular parenchyma or in the Wharton duct In chronic ductal sialolithiasis complicated by chronic or recurrent inflammation, the gland may lose its function. At this stage of disease, stones located in a nondilated duct may be difficult to demonstrate
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Hyperechoic bubbles of air mixed with saliva may mimic stones in the Wharton duct and thus be a diagnostic pitfall 52
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Sjo¨gren Syndrome 53 Advanced stages of Sjo¨gren syndrome may be recognizable at US examination of the parotid and submandibular glands US features - inhomogeneous structure of the gland with scattered multiple small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow Hypoechoic or anechoic areas are believed to represent infiltration by lymphatic cells, destroyed salivary parenchyma, and dilated ducts. DD in US: Non Hodgkin lymphoma ,granulomatous disease (eg, sarcoidosis), hematogenous metastases, and benign lymphoepithelial lesions in HIV-positive patients
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NEOPLASMS IN SALIVARY GLAND
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Benign Neoplasms The most common benign neoplasms of major salivary glands are pleomorphic adenomas (mixed tumor) and warthin tumors Definitive differential diagnosis is usually not possible with US even between benign and malignant tumors.
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Pleomorphic adenoma At US, pleomorphic adenomas are hypoechoic, well-defined, lobulated tumors with posterior acoustic enhancement They may contain calcifications The feature of lobulated shape is emphasized in differential diagnosis Peripheral vascularity with hypovascular central area in the tumoral lesion is highly suggestive of pleomorphic adenoma
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Pleomorphic adenoma
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Warthin Tumor Warthin tumors are oval, hypoechoic, well-defined tumors and often contain multiple anechoic areas May also appear in the form of a simple cyst at US
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DD at US Macroscopic cystic structures, which appear as anechoic areas at US Other Benign Tumors Malignant Tumors (Mucoepidermoid Carcinoma, Acinic Cell Carcinoma) Abscessed Or Necrotic Metastatic Node Simple cystic appearance Cystic Carcinomas (Mucoepidermoid Carcinoma, Acinic Cell Carcinoma) Benign Cysts (Lymphoepithelial Cysts
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Malignant Neoplasms The most common malignant neoplasms occurring in salivary glands are mucoepidermoid carcinoma and adenoid cystic carcinoma less than 30% of focal lesions in the parotid gland are malignant, whereas almost 50% of focal lesions in the submandibular gland are malignant US features of malignant salivary neoplasms : An Irregular Shape, Irregular Borders, Blurred Margins, Hypoechoic Inhomogeneous Structure
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Malignant tumors may also be homogeneous and well defined The internal structure may be not only solid but also cystic or cystic with a mural solid nodule Malignant tumors may have a lobulated shape, similar to that of pleomorphic adenomas The presence of metastatic-appearing lymph nodes accompanying a tumor in the salivary gland strongly suggests a malignancy
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ACC of Parotid gland
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Checkpoint!!! An important problem in US is caused by small malignant neoplasms and metastases, less than 20 mm in diameter, and well-differentiated malignant neoplasms because they may demonstrate benign features: clear, even margins and homogeneous structure
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Metastases Salivary glands are very uncommon sites of metastases. Primary tumors metastasizing to salivary glands may be located in the head and neck region, as well as in more distant parts of the body Melanoma , spinocellular cancer, breast cancer, and lung cancer may produce metastases to intraparotid lymph nodes
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At US, metastases may be well defined and oval. DD at US: Sjogren syndrome, Granulomaous diseases
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Lymphoma Primary involvement of salivary glands is rare; they are usually one of the sites of systemic disease A solitary, hypoechoic, homogeneous or inhomogeneous lesion, which is oval or lobulated or has irregular margins Sometimes contains echogenic septa or stripes Lymphomatous lymph nodes may demonstrate all the US features of a simple cyst
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Effects of Irradiation After irradiation, salivary glands become hypoechoic and inhomogeneous at US The salivary glands enlarge in the acute phase and later become smaller because of atrophy
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To summarise: 69 In acute inflammation, salivary glands are enlarged and hypoechoic with increased blood flow; they may contain multiple small, oval, hypoechoic areas In chronic inflammation, salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. Sialosis appears as enlarged hyperechoic glands without focal lesions or increased blood flow. Advanced Sjo¨gren syndrome include inhomogeneous salivary glands with scattered small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow
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To summarise: 70 Pleomorphic adenomas are usually hypoechoic, well-defined, lobulated lesions with posterior acoustic enhancement that may contain calcifications Warthin tumors are usually oval, hypoechoic, well-defined lesions that often contain anechoic areas and are often hypervascularized. Malignant neoplasms of the salivary glands may have irregular shapes, irregular borders, blurred margins, and a hypoechoic inhomogeneous structure or may have a benign appearance. Salivary gland cysts have well-defined margins, anechoic contents, posterior acoustic enhancement, and no internal blood flow
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REFERENCES: 71 Joshi SK, Kamalapur MG, Joshi AS, Et Al. Ultrasonographic Evaluation Of Carcinoma Of Buccal Mucosa: Ultrasound Technique And Evaluation Of Neoplastic Conditions. J. Evid. Based Med. Healthc. 2016; 3(34), 1649-1655. Doi: 10.18410/Jebmh/2016/369 Taylor SM, Drover C, Maceachern R, Et Al. Is Preoperative Ultrasonography Accurate In Measuring Tumour Thickness And Predicting The Incidence Of Cervical Metastasis In Oral Cancer? Oral Oncology 2010;46(1):38-41. Loyer M, Du Brow R. Imaging Of Superficial Soft-tissue Infections: Sonographic Findings In Cases Of Cellulitis And Abscess AJR 1996;i66:149-i52 0361-803X/96/1661-149 Krithika C, Ramanathan S, Koteeswaran D, Sridhar C, Satheesh Krishna J,shiva Shankar MP. Ultrasonographic Evaluation Of Oral Submucous Fibrosis In Habitual Areca Nut Chewers. Dentomaxillofac Radiol 2013; 42: 20120319 Srinivas K, Sumanth Kn, Chopra Ss. Ultrasonographic Evaluation Of Inflammatory Swellings Of Buccal Space. Indian J Dent Res 2009;20:458-62.
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REFERENCES: Shintani S, Yoshihama Y, Ueyama Y, Et Al. The Usefulness Of Intraoral Ultrasonography In The Evaluation Of Oral Cancer. Int J Oral Maxillofac Surg 2001;30(2):139-143. Sumi M, Ohki. M, Nakamura T. Comparison Of Sonography And CT For Differentiating Benign From Malignant Cervical Lymph Nodes In Patients With Squamous Cell Carcinoma Of The Head And Neck. American Journal Of Roentgenology 2001;176:1019-1024. Yonetsu K, Sumi M, Izumi M, Et Al. Contribution Of Doppler Sonography Blood Flow Information To The Diagnosis Of Metastatic Cervical Nodes In Patients With Head And Neck Cancer: Assessment In Relation To Anatomic Levels Of The Neck. Am J Neuroradiol 2001;22(1):163–169. Palmer PE. Manual Of Diagnostic Ultrasound 3rd Ed 2002 Szabo T. Diagnostic Ultrasound Imaging : Inside Out. 2nd Ed. 2004 D.C. Howletta, F. Alyasa, K.T. Wongb, K. Lewisc, M. Williamsc, A.B. Moodyc, A.T. Ahuja.Sonographic Assessment Of The Submandibular Space. Clinical Radiology (2004) 59, 1070–1078
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REFERENCES: Benjamin T, Fox Christian. ABSCESS: Applied Bedside Sonography For Convenient Evaluation Of Superficial Soft Tissue Infections. Pandey Pk, Umarani M, Kotrashetti S, Baliga S. Evaluation Of Ultrasonography As A Diagnostic Tool In Maxillofacial Space Infections. J Oral Maxillofac Res 2011;2(4):e4 Mansi Tiwari, Abhijeet Deoghare . Evaluation Of OSMF With Ultrasonography . International Journal Of Oral Health Dentistry; July-september 2017;3(3):169-17 E Bialek, W Jakubowski. US of the Major Salivary Glands: Anatomy and Spatial Relationships, Pathologic Conditions, and Pitfalls. RadioGraphics 2006; 26:745–763 Rastogi R, Bhargava S, Mallarajapatna GJ, Singh SK. Pictorial essay: Salivary gland imaging. Indian J Radiol Imaging 2012;22:325-33. JE Brown, MP Escudier. Intra-oral ultrasound imaging of a submandibular duct calculus. Dentomaxillofacial Radiology (1997) 26, 252-205. F ALYAS, K LEWIS, M WILLIAMS.Diseases of the submandibular gland as demonstrated using high resolution ultrasound. The British Journal of Radiology, 78 (2005), 362–369 E 2005 The British Institute of Radiology
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