|Year : 2009 | Volume
| Issue : 1 | Page : 12-16
Utility of ultrasonography as adjunct to diagnosis in certain orofacial lesions over the clinical and radiological evaluation: A comparative study
Vinod Vijay Chandar1, M Venkateswarlu2
1 Department of Oral Medicine and Radiology, BVU Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Narketpally, Andhra Pradesh, India
|Date of Web Publication||14-Nov-2009|
Vinod Vijay Chandar
Department of Oral Medicine and Radiology, BVU Dental College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : This study was aimed at evaluating the utility of ultrasonography in the diagnosis and treatment plan of certain orofacial lesions over the clinical and radiological evaluation of patients and to visualize advantages and disadvantages, if any, over conventional diagnostic methods. Study Design : The study consisted of 35 patients and according to the requirement, all these patients were clinically and radiologically diagnosed and then subjected to ultrasonographic evaluation. Results : Following the evaluation when the lesions were measured and compared, it was noticeable that clinical measurement was found to be relatively larger in all classes. Not many characteristics are found to be specific to any particular pathological lesions and it is not possible to establish the diagnosis of lesion by sonographic evaluation alone. The statistical analysis (ANOVA a ) and post Hoc test revealed statistical significance with regard to inflammatory and neoplastic conditions; others did not show significant values. Conclusion : Ultrasound can be used as a diagnostic tool in the diagnosis of certain orofacial lesions in the maxillofacial region, as this method is quick, widely available, relatively inexpensive, and easily reproducible without causing inconvenience to patients. However, careful analysis with through anatomical knowledge, could give an effective, early, and accurate diagnosis.
Keywords: Ultrasonography, diagnosis, radiological orofacial lesions
|How to cite this article:|
Chandar VV, Venkateswarlu M. Utility of ultrasonography as adjunct to diagnosis in certain orofacial lesions over the clinical and radiological evaluation: A comparative study. J Indian Acad Oral Med Radiol 2009;21:12-6
|How to cite this URL:|
Chandar VV, Venkateswarlu M. Utility of ultrasonography as adjunct to diagnosis in certain orofacial lesions over the clinical and radiological evaluation: A comparative study. J Indian Acad Oral Med Radiol [serial online] 2009 [cited 2019 Apr 20];21:12-6. Available from: http://www.jiaomr.in/text.asp?2009/21/1/12/57772
| Introduction|| |
Diagnostic ultrasound found its use in the medical fraternity after World War II in the late 1940s-1950s. By definition, ultrasound (USG) has a periodicity of greater than 20 KHz; diagnostic ultrasonography on clinical application employs vibratory frequencies in the range 1 to 20 MHz. , It has been used successfully in medical branches. 
USG has been applied in the head and neck region: lymph nodes,  abscess,  hematoma,  neoplasms,  etc. However, in cases of the oral and maxillofacial region, it was only applied in a few areas: temporomandibular joint, , masseter muscles, , tongue, , and teeth. 
In view of certain advantages and practical considerations, this study was conducted to throw some light on and evaluate the significance, if any, of USG in facilitating the diagnosis of orofacial lesions and evaluate its advantages, over conventional radiographs particularly, with reference to clarity, size, extent and boundaries of the lesion, relationship to adjacent structures, and the ability to differentiate between various lesions such as cysts, tumors, and infectious lesions of the jaw.
While studies of the utility of ultrasonography in salivary glands and diseases associated with it have been conducted by some authors, not many studies were done about the application of USG in other orofacial lesions.
Hence, this study is aimed at probing the utility of ultrasonography as a diagnostic aid in certain orofacial lesions in a more comprehensive manner.
| Materials and Methods|| |
This study included 35 patients who reported to the Oral Medicine and Radiology Department of the Government Dental College and Hospital in Hyderabad, India. These patients were clinically suspected of having inflammatory, cystic, or neoplastic lesions of the orofacial region. There were 20 males and 15 females in the age range of 10-60 years old with a mean age of 31.8 years. Patients were informed about the study pattern and procedure and informed consent was obtained after a thorough clinical and radiological evaluation. A radiologist experienced in ultrasonography (US) performed the examinations. USG images were obtained with Toshiba 32 B mode, real time ultrasound sector with a 7.5 MHz probe.
In this study, while evaluating by sonograph, the un-involved side of the face was used as a reference to differentiate from normal to that of the affected side whenever it was necessary.
The sonographic evaluation included visualization of the lesion in different sections (transverse and axial) to determine the site, shape, extent, contents, relation to the adjacent structures etc., After visualization, the most appropriate site was captured on the monitor along with reference side i.e., the normal appearance of the jaw. All the cases, wherever necessary, were taken for histopathologic evaluation for confirmation of the diagnosis.
In some cases, wherever necessary, such as in cases of abscess [Figure 1]c, ultrasonographical-guided needle aspiration was performed from the most reliable part of the swelling following visualization of the lesion on the monitor. Later, the pus was aspirated [Figure 1]d.
| Results|| |
A total of 35 patients clinically suspected of having inflammatory, cystic, or neoplastic lesions of the orofacial region were evaluated clinically, radiologically, and ultrasonographically in this study. It was noted that when all these cases were evaluated and their size was measured, the size measured clinically was found to be relatively large in all cases [Table 1].
One observation, which is worth noting is that there was a difference in the observation of the dimensional measurement of inflammatory lesions especially abscesses. In these conditions, the size of the abscess was consistently found to be larger sonographically when compared with the radiological picture.
Following the evaluation, when the lesions were measured and compared, it was noticeable that clinical measurement was found to be relatively larger in all classes. Not many characteristics were found to be specific to any particular pathological lesion and it is not possible to establish the diagnosis of lesion by sonographic evaluation alone. The statistical analysis (analysis of variance; ANOVA a ) and post Hoc test revealed statistical significance with inflammatory and neoplastic conditions, others did not show significant values.
This study also revealed that in the case of an abscess, the sonographic evaluation was very significant compared with radiological and clinical evaluations. However, as the sample consists of different types of lesions, a statistical analysis and comparison cannot be made between different types of lesions individually. Hence, a statistical test was applied between one group of lesions and another group of lesions.
Reparative lesions and lymph nodes did not reveal much of statistical significance as the lesions in this group were few and thereby no significant analysis could be concluded.
| Discussion|| |
The jaw is a frequent site for various odontogenic and non odontogenic lesions. Because of the occurrence of this wide range of lesions, the diagnosis of pathologic lesions of the jaw sometime proves difficult and problematic. While many imaging modalities are available to assist clinical diagnosis, radiographs still seem to be the first choice of every diagnostician as an aid to diagnosis. However, apart from conventional radiographs some advanced imaging modalities like computed tomography (CT) scan and magnetic resonance imaging (MRI) are available that have their own advantages and disadvantages. Both these investigations are expensive, not accessible to every common man, and have some inherent disadvantages.
Ultrasonography is the Phenomenon perceived as sound which is result of periodic changes in the presence of air against eardrum. In radiographs, the image is produced by transmitting radiation and the USG-reflected portion of the beam is known as "real time imaging".
In the head and neck region, USG has been applied to the following areas: lymph nodes,  abscess,  hematoma,  neoplasms  etc. However, in cases in the oral and maxillofacial region, it was only applied in few areas: temporomandibular joint, , masseter muscles, , tongue, , and teeth. 
The basic reasons for the selection of ultrasound as a diagnostic tool in this study are because of its absolute non ionizing nature, it is relatively inexpensive, easily accessible, painless, easy to reproduce, rapidity, performance of the technique is possible even at the patient's bedside, less discomfort, and better diagnostic value, etc. All these qualities have caused this technique to gain wide acceptance as a valuable diagnostic aid.
In view of certain advantages and practical considerations, this study was conducted to throw some light on and evaluate the significance, if any, of USG in facilitating the diagnosis of orofacial lesions. In this study, a low frequency (7.5 MHz) with high resolution linear sector probe was used to perform all the ultrasonic procedures for the selected cases. This probe was used because of its increased penetration into the tissue and better interpretation of the image on the screen.
Sonographic evaluation when performed in neoplastic lesions revealed a mixed echogenic pattern [Figure 2]c while in a few cases it was hyperechoic or revealed a hypoechoic pattern. Cystic lesions [Figure 3],[Figure 4] revealed mixed echoic pattern while all the abscess and reparative lesions revealed relatively hypoechoic pattern, as for the lymphnodes as they were majority of metastatic variety revealed hyperechoic pattern and [Table 2].
In one of the neoplastic cases evaluated, there was clinically trismus associated with a firm indurated mass on the left side of the jaw with significant submandibular lymphadenopathy, which was fixed and non tender. Clinically, [Figure 2] the lesion measured 5.5 Χ 4.9 cm. Radiographically, there was radiolucency associated with irregular erosion and margins with no evidence of fracture, however, sonographically a mixed echogenic pattern associated with discontinuity of both the cortical plates gave an impression of a pathological fracture [Figure 2]c left affected at the site of the lesion when compared with the reference side (right side). Sonographically, there was a well-defined hyperechoic band describing its normal pattern [Figure 2]c.
In the case of inflammatory conditions like abscesses [Figure 1], clinically the patient had a diffuse swelling measuring around 5.3 Χ 3.2 cm. The swelling was firm in consistency and was tender on palpation. Intra oral examination revealed grade II mobility in relation to tooth number(#)16, which was tender on percussion. Radiographically [Figure 1]b, radiolucency with the same tooth measuring around 0.8 Χ 0.5 cm [Table 1], however, sonographically a well-defined hypoechoic region indicated pus. Sonographically, the lesion measured approximately 3.8 Χ 1.9 cm [Figure 1]c. Under sonic guidance, an 18-gauge needle aspiration was performed guided by the image seen on the monitor and approximately 10-15 cc of frank pus was aspirated [Figure 1]d. Later, the lesion was measured again sonographically [Figure 1]c and it was 1.8 Χ 1.2 cm [Table 1].
From this study, it could be said that sonography could be used as an diagnostic tool in the diagnosis of certain orofacial lesions in the maxillofacial region as this method is quick, widely available, relatively inexpensive, painless, and easily reproducible without causing inconvenience to the patients. However, it requires consultation with sonologists, careful interpretation, and critical analysis with thorough anatomical knowledge, which could give an effective, early, and accurate diagnosis.
| Conclusion|| |
Ultrasound helps to distinguish between solid and cystic lesions. It also enables identification and differentiation of calcified and uncalcified bodies and in certain cases provides guidance for needle aspiration. The extent of the lesion and its relationship to adjacent normal tissues can be visualized and the two can be differentiated. Furthermore, it is also possible for one to estimate the appropriate extent of the lesion by visualizing it. Knowledge of anatomy of the region being imaged facilitates interpretation of the image and assessing relationship of the pathology to adjacent normal structures.
Evidence of early pathological fractures in the case of malignant lesions was better detected in an ultrasonographic picture rather than clinically or radiographically.
This procedure is economical, non invasive, and does not employ ionizing radiation. There are no significant damaging biologic effects to either the patient or the operator. In addition, this procedure is quick, simple, and facilities are readily available.
However, not many characteristics are found to be specific to any particular pathological lesion and it is not possible to establish the diagnosis of a lesion by sonographic evaluation alone. Hence, those lesions in which a diagnosis was not concluded were taken for histopathologic evaluation to confirm the diagnosis. Further study with a larger clinical sample size is necessary to ascertain the utility of ultrasonography in dentistry.
| References|| |
|1.||Christensen EF, Curry TS, Dowdey JE. An introduction to the physics of diagnostic radiology. 2 nd ed. Philadelphia: Lea and Febiger; 1978. p. 361-94. |
|2.||Delbalsoa M. Maxillofacial imaging. W.B Saundars Company; 1990. p. 409-15. |
|3.||Ernest F, Crocker. An introduction to ultrasonography in oral surgery. J Oral Surg Oral Med Oral Pathol 1985;59:236-41. |
|4.||Ferucci JT. Body ultrasonography. N Engl J Med 1979;300:590-9. |
|5.||Ying F, Ahiya A. Grey scale sonography in assessment of cervical lymphadenopathy: Review of sonographic appearance and features that may help beginner. Br J Oral Maxillofac Surg 2000;38:451-9. |
|6.||Freimanis AK. Ultrasonic imaging of Neoplasm's. J Cancer 1976;37:496-502. |
|7.||Ishikawa H, Ashi Y, Ono T, Makimoto K, Yamamoto K, Torizuka K. Evaluation of grey scale ultrasonography in investigation of oral and neck mass lesions. J Oral Maxillofac Surg 1983;41:775-81. |
|8.||Stefanoff V, Hausamen JE, Berghe PU. Ultrasound imaging of the TMJ disease in asymptomatic volunteers. J Craniomaxillofac Surg 1992;20:337-40. |
|9.||Sano K, Ninomiya H, Sekine JP, Inokuchi T. Application of magnetic resonance imaging and ultrasonography to preoperative evaluation of massetric hypertrophy. J Craniomaxfac Surg 1991;19:223-6. |
|10.||Gateno J, Miloro M, Hendler BH, Horrow M. The use of ultra sound to determine the position of the mandibular condyle. J Oral Maxillofac Surg 1993;51:81-6. |
|11.||Osammor JY, Cherry JR, Dalziel M. Lingual abscess: The value of ultrasound in diagnosis. J Laryngol Otol 1989;103:950-1. [PUBMED] [FULLTEXT] |
|12.||Ferguson SY, Payne MW, Slater PA. Ultrasonic studies of unblemished and artificially dematerliased enamel in extracted teeth: A new method of detecting early caries. J Dent 1988;16:201-9. |
|13.||Morse MH, Brown EF. Ultrasonic diagnosis of massetric hypertrophy. Dentomaxillofac Radiol 1990;19:18-20. [PUBMED] [FULLTEXT] |
|14.||Fruehwald F, Owitz S, Neuhold A, Pavelka R, Mailath G. Tongue cancer: Sonographic assessment of tumor stage. J Ultrasound Med 1987;6:121-37. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]