Journal of Indian Academy of Oral Medicine and Radiology

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 29  |  Issue : 3  |  Page : 200--204

Ultrasonography as a diagnostic tool in orofacial swellings


Sunidhi Garg1, Mysore K Sunil2, Sahil Jindal3, Ashwarya Trivedi1, Eeraian N Guru4, Sugandha Verma5,  
1 Department of Oral Medicine, Diagnosis and Maxillofacial Radiology, Guru Nanak Dev Dental College and Research Institute, Sunam, Punjab, India
2 Department of Oral Medicine, Diagnosis and Maxillofacial Radiology, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, Guru Nanak Dev Dental College and Research Institute, Sunam, Punjab, India
4 Department of Oral Medicine, Diagnosis and Maxillofacial Radiology, Vishnu Dental College, Bheemavaram, Andhra Pradesh, India
5 Department of Oral Medicine and Radiology, Hazaribag College of Dental Sciences, Hazaribag, Jharkhand, India

Correspondence Address:
Sunidhi Garg
Department of Oral Medicine, Diagnosis and Maxillofacial Radiology, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab
India

Abstract

Introduction: For several years, ultrasonography has played a major role as a diagnostic and therapeutic tool in various medical fields. Only recently has it been used for maxillofacial imaging. Aims and Objectives: To evaluate the reliability of ultrasonography as an alternative tool in the diagnosis of swellings in the orofacial region. Materials and Methods: Ultrasonographic examination of 30 patients of both the sexes aged between 8 and 70 years with swelling in the orofacial region was conducted. Doppler investigation was done in some cases to evaluate the vascularity. The following six sonographic parameters were recorded: shape, boundary echo, internal echo, distribution of internal echoes, posterior wall echoes, and vascularity. Following the clinical and ultrasonographic diagnosis, the lesion was subjected to histopathological examination and a final diagnosis was made. The ultrasonographic diagnosis was correlated with the clinical and histopathological diagnosis. Results: A significant association was observed between both clinical and histopathological diagnosis and ultrasonographic diagnosis (contingency = 0.888, P value = 0.000). Conclusion: Along with clinical and histopathological examinations, ultrasonography works out as a valuable adjunct in the diagnosis of orofacial swellings as it provides several advantages like it is non-invasive, easily reproducible, widely available, rapid, and inexpensive.



How to cite this article:
Garg S, Sunil MK, Jindal S, Trivedi A, Guru EN, Verma S. Ultrasonography as a diagnostic tool in orofacial swellings.J Indian Acad Oral Med Radiol 2017;29:200-204


How to cite this URL:
Garg S, Sunil MK, Jindal S, Trivedi A, Guru EN, Verma S. Ultrasonography as a diagnostic tool in orofacial swellings. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 Dec 5 ];29:200-204
Available from: https://www.jiaomr.in/text.asp?2017/29/3/200/218706


Full Text

 Introduction



The jaw is a common anatomic site for either odontogenic or non-odontogenic lesions.[1] In this region, swellings can arise from virtually any structure but the World Health Organisation broadly categorizes them as: benign and malignant tumours, hamartomas and vascular malformations, cysts and inflammatory swellings.[2] A definitive diagnosis of any disease or pathology is obtained with the help of various diagnostic aids like imaging, laboratory findings, and histopathological investigations, etc. Many advanced imaging techniques are available today apart from the routinely used conventional radiography.[3] Some of them are ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), radionuclide imaging, etc., Although CT scan and MRI are valuable diagnostic aids, both are expensive and not available universally.[3]

For several years, ultrasonography has played a major role as a diagnostic and therapeutic tool in various medical fields. Only recently has it been used for maxillofacial imaging.[4] Ultrasound may assist diagnosis by guiding needle aspirations for all types of superficial lesions in this region.[5] Ultrasonography can be used for bone and soft tissue examination, either normal (or) pathological lesions, temporomandibular joint (TMJ) imaging, detection of fractures and vascular lesions.[6] The use of ultrasonography is of importance in evaluating the solid and cystic components of jaw lesions and furthermore in guiding the exact site of biopsy when necessary.[1] Ultrasonography has several advantages over other modalities as it is harmless, uses no ionizing radiation, is widely available, easy-to-use, non-invasive, inexpensive, and unaffected by metal artefacts such as dental restorations.[7] The purpose of the present study is to evaluate the reliability of ultrasonography as an alternative tool in the diagnosis of swellings in the orofacial region.

 Materials and Methods



The study group comprised of 30 patients of both the sexes aged between 8 and 70 years with swelling in the orofacial region. Patients were from routine outpatients at our institute, Guru Nanak Dev Dental College and Research Institute, Sunam. The patients were informed about the procedure modality provided to them and they agreed and signed the consent form. A detailed case history and clinical examination were carried out and the relevant data were entered in the proforma and provisional diagnosis (working diagnosis) was noted. The required radiographic and blood investigations were done and patients were subjected to ultrasonographic examination. It was done using a LOGIQP5 'GE' Doppler high resolution, real-time multiplanar diagnostic ultrasound system. B-Mode transcutaneous ultrasonic imaging device with a transducer frequency of 7.5 MHz was used. The ultrasonic investigations were done in conjunction with the radiologist. All patients were investigated in the supine position on a couch while a lubricating/ultrasonic transmission gel was applied on the surface of the swellings to remove air from the interphase between the skin/mucosa and probe. Doppler investigation was done in some cases to evaluate the vascularity. The following six sonographic parameters were then recorded: shape, boundary echo, internal echo, distribution of internal echoes, posterior wall echoes, and vascularity. The sonographic images were interpreted and reported by a sonologist. Following the clinical and ultrasonographic diagnosis, the patient was subjected to punch/incisional biopsy/fine-needle aspiration cytology procedures.[3] The obtained biopsy specimens were submitted for histopathological examination and a final diagnosis was made. The obtained results were tabulated and statistically analyzed.

 Results



The study comprised of a total of 30 patients (18 males, 60%, and 12 females, 40%) with swelling in the orofacial region.

Clinical diagnosis versus ultrasonographic diagnosis

A significant association was observed between clinical diagnosis and ultrasonographic diagnosis (contingency = 0.888, P value = 0.000) [Table 1]. Out of the 30 orofacial swellings [Figure 1] and [Figure 2], three were clinically diagnosed as salivary gland tumours, out of which two cases positively correlated with the ultrasonographic diagnosis, whereas one case was ultrasonographically diagnosed as cystic lesion. A total of 13 cases were diagnosed clinically as inflammatory swellings, out of which 12 correlated with the ultrasonographic diagnosis, whereas one case was diagnosed ultrasonographically as sialolithiasis with surrounding granuloma. Two cases were diagnosed clinically as A-V malformation/hemangioma, which correlated with the ultrasonographic diagnosis. A total of three cases were clinically diagnosed as malignant swellings, which definitely correlated with the ultrasonographic diagnosis. One case was clinically diagnosed as lymphadenitis, whereas ultrasonographic diagnosis showed no lymphadenitis. A total of 6 cases of benign neoplasms were diagnosed clinically; four correlated ultrasonographically, whereas two cases were diagnosed ultrasonographically as cystic swelling. Two cases were diagnosed clinically as cystic swelling, which correlated with the ultrasonographic diagnosis.{Figure 1}{Figure 2}{Table 1}

Histopathological diagnosis versus ultrasonographic diagnosis

A significant association was observed between histopathological diagnosis and ultrasonographic diagnosis (contingency = 0.888, P value = 0.000) [Table 2]. Out of 30 orofacial swellings, three were histopathologically diagnosed as salivary gland tumours, out of which two cases positively correlated with the ultrasonographic diagnosis, whereas one case was ultrasonographically diagnosed as cystic lesion. A total of 13 cases were diagnosed histopathologically as inflammatory swellings, out of which 12 correlated with the ultrasonographic diagnosis, whereas one case was diagnosed ultrasonographically as sialolithiasis with surrounding granuloma. Two cases were diagnosed histopathologically as A-V malformation/hemangioma, which correlated with the ultrasonographic diagnosis. A total of three cases were diagnosed histopathologically as malignant swellings, which correlated with the ultrasonographic diagnosis. One case was histopathologically diagnosed as lymphadenitis, whereas ultrasonographic diagnosis showed no lymphadenitis. A total of 6 cases of benign neoplasms were diagnosed histopathologically, out of which four correlated ultrasonographically, whereas two cases were diagnosed ultrasonographically as cystic swelling. Two cases were diagnosed histopathologically as cystic swelling which correlated with the ultrasonographic diagnosis.{Table 2}

 Discussion



Ultrasonography has for long remained the preserve of basic research, but over the past few years it has emerged as an important tool for various applications in the field of medicine. It has been applied for diagnosis in the orofacial region in recent years but is not routinely used.[3] The ultrasonographic images are identified in terms of echoes as hypoechoic, hyperechoic, and anechoic images. A mass is hypoechoic if it has intensity lower than that of adjacent tissue; it is hyperechoic if it has higher intensity; and isoechoic with intensity is similar to adjacent tissue. The appearance of a hypoehoic mass is darker, whereas the hyperechoic masses appear rather bright, and the isoechoic ones have a similar appearance. A calcified mass appears hyperechoic and clear fluid or blood appears anechoic.[3] Ultrasonography has several advantages over other modalities as it is harmless, uses non-ionizing radiation, is widely available, easy-to-use, non-invasive, inexpensive, and unaffected by metal artefacts such as dental restorations. Ultrasound causes no health problems and may be repeated as often as necessary.[7]

In this study, pleomorphic adenoma appeared with clear boundary, lobulated shape, slightly hypoechoic echo intensity level, homogeneous internal echoes and enhanced posterior echoes, which are in accordance with the studies done by Gritzmann,[8] Martinoli,[9] Shimizu et al.,[10] and Chandak et al.[7] Ultrasonographically, one case did not match with the clinical and histopathological diagnoses. This case appeared anechoic in most of the lesion with hypoechoic echo intensity in its posterior region, with other features such as well defined, round, clear boundary, homogeneous echo texture, and with enhanced posterior echoes.

The inflammatory swellings appeared with clear boundaries, irregular shapes, hypoechoic echo intensity, and homogeneous ultrasound architecture of lesion and the posterior echoes appeared enhanced. Out of the 13 cases with inflammatory swellings, 12 cases correlated ultrasonographically, which is in accordance with the studies done by Gritzmann,[8] Sivarajasingam et al.,[11] Srinivas et al.,[4] Shafer,[12] and Chandak et al.,[7] whereas one case was diagnosed as salivary gland swelling due to sialolithiasis with surrounding granuloma.

Two cases were diagnosed ultrasonographically as hemangioma that correlated with the clinical as well as histopathological diagnosis. It appeared ultrasonographically as heterogenous mass with multiple anechoic areas, which showed blood flow on colour Doppler in accordance with the findings of Zhao et al.,[13] Gold et al.,[14] Neville,[15] and Chandak et al.[7]

The three cases with malignant swellings appeared ultrasonographically as irregularly shaped, ill-defined border, hyperecoic to hypoechoic echo intensity level, heterogenous internal echoes, and attenuated posterior echoes. These findings correlate with the previous studies done by Akinbami et al.,[2] Natori et al.,[16] Bagewadi et al.,[3] Shah,[17] and Chandak et al.[7] In the present study, one case was clinically diagnosed as lymphadenitis, whereas the ultrasonographic diagnosis did not match as it was reported as cystic lesion. Histopathologically, it was confirmed as granulomatous lymphadenitis. Ultrasonographically, this lesion appeared hypoechoic, well defined, round, clear boundary, homogeneous echo texture, and the posterior echoes appeared enhanced. Hence, ultrasonographic diagnosis did not match with the clinical diagnosis as well as histopathological diagnosis, as reported by Akinbami et al.[2]

In the present study, four cases of benign neoplasms were diagnosed ultrasonographically. Out of the two cases of lipomas, one was a case of benign tumour of alveolar ridge and one was a case of benign tumour of buccal mucosa. The ultrasonographic features of lipoma appeared as hypoechoic internal echo pattern, homogenous internal echoes, and the posterior wall echo was unchanged. The cases of benign tumour of alveolar ridge and buccal mucosa presented with unclear boundaries, irregular shapes and hypoechoic echo intensity with homogenous ultrasound architecture, posterior echoes appeared enhanced and ultrasound characteristics were solid in nature. These findings are in accordance with the previous studies done by Akinbami et al.,[2] Bagewadi et al.,[3] and Chandak et al.[7] Out of the total of 30 orofacial swelling cases, two cases were clinically diagnosed as cystic swellings. Ultrasonographically, 6 cases were diagnosed as cystic swellings (the cases of one salivary gland tumour, one benign tumour of alveolar ridge, one lymphadenitis case, and one spindle cell lipoma case appeared as cystic on ultrasound), and histopathologically two cases were confirmed as radicular cysts. Thus, clinical, ultrasonographic, and histopathological diagnoses were correlated, which is in accordance with Shear [18] and Bagewadi et al.[3]

 Conclusion



This present study concludes that along with clinical and histopathological examinations, ultrasonography works out as a valuable adjunct in the diagnosis of orofacial swellings as it provides several advantages like it is non-invasive, easily reproducible, widely available, rapid, inexpensive, and has ability to detect non-calcified pathological entities such as sialoliths. Further studies with larger sample size may be required towards reinforcing the efficacy of diagnostic ultrasonography in the orofacial swellings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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