Charecterisation of Soft Tissue Lesions in Ultrasonography

CHARACTERISATION OF SOFT TISSUE LESIONS IN

ULTRASONOGRAPHY

BY UTHARA MENONI MDS

CONTENTS• INTRODUCTION• DEFINITION• 20 MHZ US PROBE• DESCRIPTON OF SWELLING• ADVANTAGES OVER OTHER MODALITIES• USES• ULTRASONOGRAPHY FOR SOFT TISSUE LESIONS• CONCLUSION

INTRODUCTION• Ultrasound clinical studies in the literature of the 1980s

and 1990s can roughly be divided into 4 regions: • neoplastic and inflammatory processes in major

salivary glands,• neoplastic and non-neoplastic neck masses,• inflammatory and abscess localization in oral

and facial soft tissues, and • intraoral soft tissue neoplasms.

DEFINITION • ‘‘Sonography’’ means imaging with ultrasound; • ‘‘ultra’’means beyond or in excess; ‘‘sound’’ means

audible sound energy.• The term ultrasound means the form of sound energy

beyond audible range.

• DEFINITION: The imaging of deep structures of the body by recording the echoes of pulses of ultrasonic waves directed into the tissues and reflected by tissue planes where there is a change in density.

Dentomaxillofacial Radiology (2011) 40, 213–221

20 MHZ US PROBEThis scanner emits pulsed echo signals at a frequency of 20 MHz with water as the coupling medium. The transducer moves with a high level of precision over a distance of 12.8 mm (eight- fold magnification) to record a two-dimensional B-scan. The intensity of the echoes is recorded as 256 grey levels and is represented as 256 grey colors in color-coded images. The axial resolution of the system is approximately 80 mm and the lateral resolution 200 mm. .

Cont.. The system permits the evaluation of fine differences in the echogenicity of skin structures at a depth of up to 7 mm (24-fold magnification). This means that the zones of dignostic interest in dermatology are covered, i.e.epidermis, corium, and subcutaneous fatty tissue

Dentomaxillofacial Radiology (1999) 28, 290 ± 294

• Us used to detect this rare neoplasm of salivary gland like Cystadenocarcinoma, massetric hypertrophy

Photograph of the head of the 20 MHz US probe showing the transducer and water chamber. The handpiece includes a stepper motor moving the transducer. Water is continously pumped through the water chamber with an inflow and a drain through the two tubes


• Ultrasound wave is a form of longitudinal mechanical wave that needs a medium to transmit from one place to another.

• Ultrasound is produced by vibrating piezoelectric crystals using a high-frequency electrical pulse which causes mechanical oscillation and produces ultrasound waves.

• Therefore, electrical energy is converted into mechanical energy.


• Cont..

• Diagnostic ultrasound utilizes a transducer which generates a narrow focus beam.

• This beam is reflected from the tissue and sent back to the same transducer, which assembles these echoes into an image that can be visualized and recorded


The following features were considered in describing the ultrasonographic images of swelling.• shape: oval, lobular, round, polygonal, irregular;• boundary: very clear, relatively clear, partially unclear, ill

defined;• echo intensity: anechoic, isoechoic, hypoechoic,

hyperechoic, mixed;• ultrasound architecture of lesion: homogeneous,

heterogeneous;• presence of necrosis: eccentric, central• presence of calcification: macrocalcification,

microcalcification;• posterior echoes: enhanced, unchanged, attenuated; and• ultrasound characteristic of tissues: cystic, solid, mixed. Dentomaxillofacial Radiology (2011) 40, 213–221

TISSUE CLASSIFICATION BASED ON

ECHOGENICITY• HYPERECHOIC OR ECHOGENIC - BONE,CARTILAGE (BRIGHT OR WHITE)• MODERATELY ECHOGENIC – GLANDULAR TISSUE (MODERATELY BRIGHT)• HYPOECHOIC – MUSCLES,BLOOD

VESSELS (FAIRLY DARK)• ANECHOIC – AIR OR FLUID (DARK OR BLACK)

well-defined, ovoid, Hypoechoic and primarily homogeneous, but with a slight internal echo, mass lesion with posterior acoustic enhancement

Panoramic radiograph showing a radiolucent lesion on the right of themaxilla

Ultrasound image showing anechoic lesion

without internal echoes

Panoramic radiograph showing a radiolucent lesion on the leftof the mandible

• Ultrasound image showing complex cyst with dense internal echoes.

Panoramic radiograph showing a radiolucent lesion on the right anteriormaxilla

Ultrasound image showing semisolid lesion

Panoramic radiograph showing a radiolucent lesion on the rightposterior mandible

• Ultrasound image showing solid lesion

Ultrasonography of the left parotid region showing a uniformly hypoechoeic mass (arrowhead) arising from the superficial lobe of the left parotid gland. Smaller surrounding hypoechoeicintraparotid lymph nodes are seen (long white arrows)

Transverse ultrasound scan. A focal lesion is seen within the tail of the right parotid gland (P). The lesion is hypoechoic but heterogeneous. Discrete echogenic streaks are observed within the lesion (small arrows). The deep margins are poorly defined (large arrows)

Advantages over othermodalities

• It is harmless• It uses no ionizing radiation,• It is widely available, • It is easy-to-use, • It is non-invasive, • It is inexpensive• It is unaffected by metal artefacts such as dental

restorations.• It causes no health problems and may be repeated

as often as necessary.

• Dentomaxillofacial Radiology (2011) 40, 213–221

USES• Used in evaluation for neoplasm in the thyroid,

parathyroid or lymphnodes for stones in salivary glands or ducts, sjogrens syndrome and the vessels of the neck, including the carotid for atherosclerotic plaques.

• Used to guide fine needle aspiration in the neck.• Doppler sosography for evaluation of blood flow.

• On-screen nodal measurement is possible.

• Ultrasound is capable of differentiating cystic from solid lesions and is also helpful in diagnosing malignant vs benign masses.

• It is helpful in delineating the presence of multiple lymph nodes and the course of resolution of infectious diseases.

• It is used to visualize the presence and extent of facial abscesses.

• It can be used in cases of oral carcinoma to observe the presence of regional lymph node metastasis.

• Ultrasound is helpful in detecting sialoliths and in the diagnosis of conditions involving the salivary gland.


ULTRASONOGRAPHY FOR SOFT TISSUE

LESIONS

Head and neck swellings

• The use of real-time ultrasonography with high frequency transducers can significantly improve the evaluation of patients with various types of head and neck swellings.

• Therefore, ultrasonographic examinations , should be used to supplement clinical examination in patients with head and neck swellings to arrive at a final diagnosis.

• Eg; Lipoma appeared on ultrasound as a solid homogeneous mass of similar echogenicity to that of subcutaneous fat

Inflammatory swelling—submandibular lymphadenitis (ultrasonographic image)

Well defined cystic lesion with eccentric hyperechoic nodule

Inflammatory swelling—cysticercosis cellulosae(ultrasonographic image)

Cystic swelling—infected dental cyst (ultrasonographic image)

• Benign neoplasm—cystic hygroma (ultrasonographic image)

Benign neoplasm—cystic hygroma (ultrasonographic image)

Malignant neoplasm—high-grade mucoepidermoid carcinoma (ultrasonographicimage)

Palatal tumors • Intraoral ultrasonography of palatal tumors can be used

to determine the localization and condition of the tumors by close analysis of the echogram.

• The internal echo pattern on the ultrasonogram of a palatal tumor was found to reflect the pathologic structure of the tumor.

• Ultrasonography can therefore be a quite useful technique for the preoperative evaluation of palatal salivary gland tumors.

• Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:39-43

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:39-43

Tumorprobe (12 × 30 mm

water or jelly

Congenital VascularLesions of the Head and

Neck

• Doppler US is a widely available, non-invasive and relatively inexpensive technique which can be used to characterize the flow of head and neck vascular anomalies and thus differentiate hemangiomas from other vascular malformations.

Dentomaxillofacial Radiology (2002) 31, 2±6. DOI: 10.1038/sj/dmfr/4600650

Grey-scale ultrasound image of a well-delimited (arrows),oval, mixed echogenicity lesion, consistent with an hypoechoic soft-tissue mass with anechoic internal areas which corresponded to vascular spaces on subsequent Doppler studies. The lesion was ahemangioma of lower lip

Two examples of highly vascular lesions. (A) Numerous vessels are visible within an hemangioma of the tongue in Colour Doppler mode. (B) Low-¯ow Power Doppler visualisation of a high- density vascular lesion in the supracilliary region, which was a hemangioma in proliferative phase

A B

Neurogenic tumours in the head and

neck

region• Ultrasound examination showed a well-defined,

ovoid or round hypoechoic mass. • Lobulation was observed ,cystic changes were

observed.. • No vascularity was seen in power Doppler images

(PDIs) obtained percutaneously.

Dentomaxillofacial Radiology (2012) 41, 18–23. doi: 10.1259/dmfr/81000210

Ultrasonography showed a mass that was ovoid, smoothly marginated, hypoechoic and primarily homogeneous with a slight internal echo, buthad no echogenic region in the centre (arrowheads). Power Doppler images did not reveal internal vascularity. A longitudinal sonogram showed athickened nerve that was producing tapering at the end of the mass (arrow)

Masseter cysticercosis• High-resolution ultrasound, being noninvasive

and non-ionizing, plays an important role in establishing the diagnosis in patients with muscular cysticercosis.

• If lesions with the morphological characteristics are encountered on ultrasound, the diagnosis of cysticercosis can be made with great confidence, and in muscular and subcutaneous cysticercosis no further investigation is required.

Ultrasound of the swelling showing well-defined cyst with echogenic scolex and surrounding hypoechoic area in the left masseter muscle

Ultrasound of the swelling showing well-defined cyst withechogenic scolex and surrounding hypoechoic area in the left massetermuscle

Follow-up ultrasound showing the calcified cyst in themasseter muscle without evidence of surrounding inflammatoryphlegmon

Benignity and malignancy

of parotid masses• Ultrasound plays an important role in the diagnosis of

space-occupying lesions

• Ultrasound was able to differentiate between benign and malignant parotid masses with high accuracy.

• Ultrasound-guided FNA is used for differentiating between benign and malignant parotid gland masses.

• Arch Otolaryngol Head Neck Surg 2003; 129: 929–933.• J Clin Ultrasound 2004; 32: 78–81• Br J Radiol 2003; 76: 271–277.• Ultrasound Med Biol 2004; 30: 567–574 Dentomaxillofacial Radiology (2012) 41, 131–135.

Sonographic image shows a heterogeneous hypoechoic ovoid mass in the left parotid in a 68-year-old female with punctate calcifications, circumscribed margin, posterior echogenicity enhancement and distinct edge refraction. The presumed diagnosis was benign lesion and the pathological diagnosis was Warthin’s tumour

Sonographic image shows a heterogeneous hypoechoic ovoid mass in the left parotid in a 36-year-old male with well-defined margin, posterior echogenicity enhancement and mild edge refraction. The presumed diagnosis was benign lesion and the pathological diagnosis was pleomorphic adenoma

Sonographic image shows a heterogeneous hypoechoic ovoid mass in the right parotid in a 27-year-old male with punctate calcifications, well-defined margin, posterior echogenicity enhancement and distinct edge refraction. The presumed diagnosis was probably malignant lesion and the pathological diagnosis was lymphatic tuberculosis

Labial minor salivary gland sialoliths

• Ultrasound imaging provided real-time dynamic guidance for the surgeon, thus facilitating the localisation and retrieval of the remaining sialoliths.

• Imaging also identified the position of the labial artery, which is important in order to avoid accidental haemorrhage.


Ultrasound image of some of the sialoliths in the right upper lip. Scan obtained in the axial plane. The probe is in contact with the skin surface (uppermost). The two arrows denote the mucosa/air interface. The sialoliths appear as three hyperechoic foci of about 1mm in size but their overall shape is not readily identified. There is distal acoustic shadowing which is not immediately obvious due to the small size of the calcification but is most evident as a reduced mucosa/air interface echo.

Changes of PAROTID AND SUBMANDIBULAR GLANDS caused by radiotherapy

• Radiotherapy may change the • Echotexture , from homogenic to heterogenic• Echogenicity, from hyperechoic to hypoechoic And• margins of the salivary glands, from regular to

irregular• may reduce their size.


Doppler sonogram of a parotid gland showing measurement of blood flow velocity (peak systolic velocity and end diastolic velocity) and vascular resistance (resistive index) of the gland.

Bilateral parotid swelling

• Not only Confirmation or exclusion of the presence of a mass, but in many cases the nature of underlying disease may also be suggested on the basis of US.

• Diagnosis of CRP, SS, HIV sialopathy, Warthin’s tumour, lymphoma and sarcidosis

• Pseudolesions such as masseteric hypertrophy can be confidently diagnosed.

• Dentomaxillofacial Radiology (2011) 40, 403–41

Axial ultrasound of the right parotid gland reveals multiple hypoechoicareas in the enlarged glands.

Primary Sjogren’s syndrome

• Salivary gland US is a useful method in visualizing glandular structural changes in patients suspected of having pSS and it may represent a good option as a first-line imaging tool in the diagnostics of the disease.

• Colour Doppler US has been used to evaluate the vascular anatomy of the salivary glands and to analyse the physiological changes in blood flow that occur during salivary stimulation in the diseased glands of SS patients.

Rheumatology 2008;47:1244–1249

¨

Gland with severe structural changes. Arrows indicate parotid gland borders;arrowheads indicate hyperechoic reflections; *hypoechoic areas.s, subcutaneus tissue; p, parotid gland.

Early stage oral tongue

carcinoma• Ultrasound Is useful in the management of

cervical metastases in early stage oral tongue carcinoma. But ,

• Ultrasound of the submandibular triangle has limited ability in detecting malignant nodes and may be of little value in predicting which patients have positive nodes.


Primary tumor thickness in carcinoma of the tongue to subsequent lymph node metastasis.

• Intra-oral ultrasonography (US) is as useful as CT or MRI in measuring the thickness of the tumor.

• Primary tumor thickness measured with CT or intra-oral sonography is valuable for predicting subsequent lymph node metastasis in patients with stage I/II tongue carcinoma.

• Prophylactic neck dissection is indicated when primary tumor thickness exceeds 5 mm.


Intra-oral US of a 60-year-old woman with squamous cell carcinoma on the left side of her tongue (stage II), demonstrates awedge-shaped primary tumor as hypoechoic region with a relatively ill-defined margin (arrow). Tumor thickness is 7 mm.

A longitudinal US of a middle internal jugular lymph node on the left side of the same patient obtained 5 months after glossectomy at the 7th follow-up. Note the hyperechoic area with an ill-defined margin (arrow) within the node.This finding was not observed on previous examination.The minimal axial diameter is 6 mm. A diagnosis of lymph node metastasis was made.

Metastatic cervical lymph nodes in oral squamous cell

carcinoma• The presence of definite internal echoes is a specifc US

finding for cervical metastasis. • On the other hand, the presence of hilar echoes is an

important means of differentiating benign from metastatic nodes.

• Dentomaxillofacial Radiology (2000) 29, 238 ± 244

a lymph node showing definiteinternal echoes.

a lymph node showing no definite internal echoes.

a lymph node showing hilar echoes

• In the case of lymph nodes with neither definite internal or hilar echoes, lymph nodes measuring 10 mm or more in the short axis were metastatic, whereas those with a L/S ratio of 3.5 or more were more likely to be benign.

Schematic diagram showing the US Findings.

The longest length of each lymph node was defined as the `long axis'. Next, the longest distance perpendicular to `long axis' was defined as the `short axis'.

The homogeneous echogenic structure is the so-called `hilar echo' and corresponds to the fatty tissue around the hilar of the lymph node.

The echoes of the parenchyma were defined as internal echoes

• .

Flowchart for Differentiating malignant from benign Cervical lymphadenopathy in oral squamous cell carcinoma

Percutaneous drainage of

cervicofacial

infections• US-guided drainage is a good alternative for the treatment

of odontogenic abscess. • There is no scarring, the stay in hospital is shorter and a

general anaesthetic is avoided. • The technique is potentially useful in patients with acute

trismus in whom intubation can be very difficult. JM Toranzo, JMM Martinez, MA Metlich and JAH Hurtado Department of Oral and Maxillofacial Surgery University of San Louis Potosi SLP Mexico 78260, Mexico

Ultrasonogram of a submandibular abscess, outlined by the two + signs and D1, showing the Teflon catheter (D2) in situ

Cervical lymphadenopathy

• Nodal vascularity can be used to differentiate benign from malignant lymphadenopathy.

• Proper judicious CDUS examination provides an opportunity to eliminate the need for biopsy/FNAC in reactive nodes.

Colour Doppler sonogram with Doppler spectral waveform showing benign cervical lymph node with central colour Doppler flow and low resistivity index and pulsatility index

Dentomaxillofacial Radiology (2008) 37, 205–212. doi: 10.1259/dmfr/57023901

Colour Doppler sonogram with Doppler spectral waveform showing malignant cervical lymph node with peripheral colour Doppler flow and high resistivity index and pulsatility index.

• The presence of high intranodal vascular resistance had been used as a key

feature to differentiate benign from malignant nodes

• The presence of blood flow signals in the centre of node (this indirectly denotes the existence of the converging sinuses) suggests that the node is benign.

• The presence of peripheral flow suggests a malignant nature

Vascularity within cervical lymph nodes in patients with oral cancer• An increase in vascularity is a characteristic of

Doppler ultrasound findings in small metastatic lymph nodes during the early stages of metastasis..

• As the metastatic lymph node size increases, blood flow signals become scattered.(scattering index)


Metastatic lymph node from a 69-year-old man with squamous cell carcinoma of the right cheek. The lymph node short axis diameter measures 4 mm (Group 1), and the vascular index is 62.

Fibrosis of the oral mucosa(systemic sclerosis)

• US has been used in SSc to determine the thickness of sclerotic Plaques.

• Compared with healthy patients it was found a substantial increase in echogenicity in the submucosal connective tissue.

• Fibroepithelial polyp emphasises excellent correlation between sonographic and histological findings


Temporomandibular joint Effusion

• US has good diagnostic accuracy in detecting disc position abnormalities compared with MRI

• US is also useful in evaluating condylar range of motion.Reliable in case of disc displacements.

• US showed a good accuracy in identifying clinically painful TMJs.

• The most reliable parameter to detect painful joints appeared to be the presence of capsular distension greater than 3 mm.

• US appears to be a very promising technique in the study of TMJ effusion,


Longitudinal ultrasound scan of a left temporomandibularjoints with a capsular width of 4.8 mm. The joint was painful to palpationand MRI depicted effusion

Longitudinal ultrasound scans of both temporomandibular joints in a patient with bilateral pain and effusion. Capsular width is 1.7 mm (left)and 4.8 mm (right)

Maxillofacial SoftTissue Vascular

Anomalies• Nonenhanced MRI with ultrasound/color Doppler

can be substituted for enhanced MRI to provide the best diagnostic information and at reduced cost.

• Ultrasound/color Doppler is an important adjuvant to CT and MRI in the diagnosis of vascular or suspected vascular anomalies.

• US/Doppler capability can differentiate venous and arterial malformations and flow characteristics.

J Oral Maxillofac Surg 61:19-31, 2003

CONCLUSION• A single imaging modality is frequently unable to

provide sufficient diagnostic information to allow confident clinical management of lesions.

• Ultrasound/color Doppler is an important adjuvant to CT and MRI in the diagnosis of soft tissue lesions.

THANK YOU

Charecterisation of Soft Tissue Lesions in Ultrasonography

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