- Email: [email protected]
The use of ultrasonography as a diagnostic tool for superficial fascial space infections
] Oral Moxillofac %x1129-1131.
Surg 1998
The Use of Ultrasonography as a Diagnostic Tool for Superficial Fascial Space Infections Michael Peleg, DMD, * Zahava Heyman, MD, f Leon Ardekian, DMD,,f and Shlomo Taicher, DMDJ This study examined the value of ultrasonography as a diagnostic tool in the treatment of superficial acute odontogenic fascial space infections. Patients and Methods: The study group consisted of 50 patients in whom both radiographic and sonographic examinations, aswell as a needle aspiration, were performed. Purulent fluid was aspirated in 22 of the 50 patients. Six patients diagnosed as suffering from Results: cellulitis had a repeated ultrasonography scan. In four, abscessformation was diagnosed on the third day. Purpose:
Ultrasonography is an effective diagnostic tool to confirm abscess formation in the superficial fascial spacesand is highly predictable in detecting the stageof infection. Conclusions:
In casesof acute odontogenic infection, the oral and maxillofacial surgeon needs to know whether the inflammatory process is in a stage of abscessformation requiring primary evacuation of the pus and administration of antibiotics or a cellutitis that can generally be treated with antibiotics alone. It is often difficult to diagnose the stage of infection and to define its exact anatomic location. Plain radiographs, computed tomography (CT) scan, and magnetic resonance imaging (MRI) are valuable diagnostic aids1 However, the CT scan and MRI are both expensive. Also, CT scans expose the patient to relative large doses of radiation, and the MFU is time-consuming and not suitable for every patient. An alternative diagnostic tool that is widely available, relatively inexpensive, and noninvasive is ultrasonography. The purpose of this study was to examine the value of ultrasonography in the diagno-
*Attending, Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center, Tel Hashomer, and Goldschleger School
of Dental
Medicine,
i-Head, Ultrasound Chaim Sheba Medical *Former The Chaim
Tel Aviv I Jniversity,
Tel Aviv, Israel.
Unit, Department of Diagnostic Center, Tel Hashomer, Israel.
Resident, Department Sheba Medical Center,
of Oral and Maxillofacial Tel Hashomer, Israel.
CjHead, Department of Oral and Maxillofacial Surgery, Sheba Medical Center, Tel Hashomer, and Goldschleger
Dental
Medicine,
Tel Aviv
University,
Imaging,
l’el Aviv,
Tel Hashomer,
o 1998
American
Association
Surgery,
and
Methods
The study group consisted of 50 patients with acute odontogenic infections of the superficial fascial spaces treated in our department. Of the 50 patients, 24 were diagnosed clinically as suffering from buccal swelling, 15 had submandibular swelling, four had sublingual swelling, two had periorbital swelling, and five had infraorbital swelling. After meticulous clinical and radiographic examinations, including panoramic and periapical radiographs, a sonographic examination of the infected area was performed. A linear array probe, 7.5 Mhz (Acuson 128 X P/10, Mountain View, CA) was applied over the skin, covering the suspected area in transverse and axial sections to determine the presence or absence of fluid collection and its location. A sonically guided needle aspiration was then performed in all patients in the most inferior aspect of the swelling.
Results Under ultrasonography, fluid was identified in 22 of the 50 patients (Table 1) (Figs 1-S). Aspiration of pus was positive in all of these patients. In these cases,pus evacuation was the prime consideration, either by tooth extraction or by incision and drainage of the abscess. In the 28 patients suffering from cellulitis (Figs 4, 5) treatment depended on the physiologic response to the infectious process. All patients re-
The Chaim School of
Israel.
Israel. of Oral and Maxillofocial
Patients
The
Address correspondence and reprint requests to Dr Peleg: Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center,
sis and treatment of superficial odontogenic fascial space infections.
Surgeons
0278-2391/98/5610-0004$3.00/0
1129
1130
ULTRASONOGRAPHY FOR FACIAL SPACE INFECTIONS
Clinical Features Buccal swelling
Submandibular swelling Sublingual swelling Periorbital swelling Infraorbital swelling Total
No. of Patients 24
15 4 2 5
Fluid Location
No. of Patients
Buccal space Vestibular Submasseteric space Submandibular space Submental space Canine space Canine space Vestibular
50
2 7
2
-
5 2
1 1 2 22 FIGURE 2.
ceived comprehensive supportive care to aid their own body defenses in combating the infection. Of the 28 patients diagnosed as suffering from cellulitis, six had a repeated ultrasographic scan performed 3 days after the initial study because of lack of clinical improvement. In four patients, abscess formation was diagnosed.
Discussion Infections treated by the oral and maxillofacial surgeon are often odontogenic in origin. Although spatially confined, purulent material may spread deeply into contiguous fascial spaces, such as the submandibular, sublingual, and pterygomandibular. Severe complications can result if the infection is not recognized and treated promptly and properly. Mediastinitis, intracranial abscesses, and parapharyngeal spread with airway destruction can develop.* Thus, early diagnosis and treatment are mandatory. Evaluation of patients with acute odontogenic infec-
FIGURE 1. shown beneath
Scan performed along the left mandible. as a hypoechoic area, superficial to the the elevated masseteric muscle [arrows].
Fluid collection mandible and
is just
hypodense masseteric
CT scan shows the same well-defined area between the left mandible ramus muscle (arrows).
and
collection as a the elevated
tions can be difficult for the surgeon, who had to deal with the dilemma of whether there is, in fact, an abscessrequiring surgical intervention or a cellulitis that can be managed satisfactorilly with only supportive care. The finding of “fluctuance” is often difficult, especially in spacessuch asthe submasseteric,where the purulent material is deep within the soft tissues and muscle. In these cases,it is possible not to be able to elicit fluctuance. Over the last 15 years, the introduction of techniques such as ultrasonography,3 CT,* and MR15have revolutionized the field of diagnostic radiology. These powerful diagnostic tools have minimized the therapeutic dilemma for surgeons. CT scanning and MRI are effective in diagnosing inflammatory conditions,
FIGURE 3. Transverse sonographic shows a 7.5 x 14 mm hypoechoic mandible [arrows].
examination of the lower lip collection of fluid anterior to the
PELEG
1131
ET AL
FIGURE
4. Clinical
picture
of patient
with a swollen
cheek
and the choice between these two techniques usually depends on the area involved. However, both techniques are expensive and present some serious disadvantages.6 CT exposes the patient to large doses of radiation, especially if repeated follow-up examinations are to be performed. In addition, there are streak artifacts
produced by bone and metal that degrade images around the face. Another significant disadvantage is the poor contrast between the various soft tissues. Usually, an intravascular contrast medium must be used to distinguish pathologic processes from adjacent normal soft tissues. A major disadvantage of MRI is the prolonged time for image acquisition. Thus, the images may suffer from the effects of patient motion. The high static magnetic field also poses a danger to those individuals with cardiac pacemakers, neurostimulator units, and intraocular foreign bodies. Ultrasonographic examination has been used to evaluate various masses in the neck (including abscesses) and diseases of the salivary glands.7-9 To the best of our knowledge, this is the first study to use ultrasonography for the purpose of diagnosing intraoral odontogenic infections and infections of the superficial fascial spaces of the maxillofacial area. No echoes are returned by fluids, and thus ultrasonography is very sensitive in detecting fluid collection. Unlike radiography and MRI, adverse effects of ultrasonography have not yet been reported. In the current study of acute odontogenic infections, detecting the stage of infection was highly predictable. The method is quick, widely available, relatively inexpensive, painless, and can be repeated as often as necessary without risk to the patient. Thus, ultrasonography can be a valuable aid to the oral and maxillofacial surgeon.
References
FIGURE 5. Sonographic examination of the patient in Figure an echogenic ill-defined area corresponding with edematous No fluid collection is identified.
4 shows tissues.
1. Conway WF, Lame FJ, Blinder RA: Newer diagnostic imaging techniques. Oral Maxillofac Surg Clin North Am 3:259, 1991 2. Laskin DM, La&in JL: Odontogenic infections of the head and neck, in La&in DM (ed): Textbook of Oral and MaxiUofacial Surgery (~012). St Louis, MO, Mosby, 1985, pp 219-252 EW, Jefek BW, Johnson ML, et al: Ultrasonography in 3. Kreutzer the preoperative evaluation of neck abscesses. Head Neck Surg 4:290, 1982 4. Endicot JN, Nelson RJ, Saracena CA: Diagnosis and management decisions of the deep fascial spaces of the head and neck utilizing computerized tomography. Laryngoscope 92:630,1982 of a deep neck abscess with 5. Matt BH, Lusk RP: Delineation magnetic resonance imaging. Ann Otol Rhino1 Laryngol96:615, 1987 6. Van Rensburg LJ, Nortje LJ: Magnetic resonance imaging and computed tomography of malignant disease of the jaws. Oral Maxillofac Surg Clin North Am 4:75, 1992 7. Hell B: P-Scan sonography in maxillofacial surgery. J Craniomaxillofac Surg 17:39, 1989 8. Pogrel MA: The use of ultrasonography in the diagnosis of neck lumps. J Oral Maxillofac Surg 40:794, 1982 N, Schatter M, Traxler M, et al: Sonography and 9. Gritzman computed tomography in deep cervical lipomas and lipomatosis of the neck. Ultrasound Med Biol7:45 1, 1988 and ultrasonography in 10. Jensen C, Von Sydow C: Radiography paranasal sinusitis. Acta Radio1 28:31, 1987
Surg 1998
The Use of Ultrasonography as a Diagnostic Tool for Superficial Fascial Space Infections Michael Peleg, DMD, * Zahava Heyman, MD, f Leon Ardekian, DMD,,f and Shlomo Taicher, DMDJ This study examined the value of ultrasonography as a diagnostic tool in the treatment of superficial acute odontogenic fascial space infections. Patients and Methods: The study group consisted of 50 patients in whom both radiographic and sonographic examinations, aswell as a needle aspiration, were performed. Purulent fluid was aspirated in 22 of the 50 patients. Six patients diagnosed as suffering from Results: cellulitis had a repeated ultrasonography scan. In four, abscessformation was diagnosed on the third day. Purpose:
Ultrasonography is an effective diagnostic tool to confirm abscess formation in the superficial fascial spacesand is highly predictable in detecting the stageof infection. Conclusions:
In casesof acute odontogenic infection, the oral and maxillofacial surgeon needs to know whether the inflammatory process is in a stage of abscessformation requiring primary evacuation of the pus and administration of antibiotics or a cellutitis that can generally be treated with antibiotics alone. It is often difficult to diagnose the stage of infection and to define its exact anatomic location. Plain radiographs, computed tomography (CT) scan, and magnetic resonance imaging (MRI) are valuable diagnostic aids1 However, the CT scan and MRI are both expensive. Also, CT scans expose the patient to relative large doses of radiation, and the MFU is time-consuming and not suitable for every patient. An alternative diagnostic tool that is widely available, relatively inexpensive, and noninvasive is ultrasonography. The purpose of this study was to examine the value of ultrasonography in the diagno-
*Attending, Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center, Tel Hashomer, and Goldschleger School
of Dental
Medicine,
i-Head, Ultrasound Chaim Sheba Medical *Former The Chaim
Tel Aviv I Jniversity,
Tel Aviv, Israel.
Unit, Department of Diagnostic Center, Tel Hashomer, Israel.
Resident, Department Sheba Medical Center,
of Oral and Maxillofacial Tel Hashomer, Israel.
CjHead, Department of Oral and Maxillofacial Surgery, Sheba Medical Center, Tel Hashomer, and Goldschleger
Dental
Medicine,
Tel Aviv
University,
Imaging,
l’el Aviv,
Tel Hashomer,
o 1998
American
Association
Surgery,
and
Methods
The study group consisted of 50 patients with acute odontogenic infections of the superficial fascial spaces treated in our department. Of the 50 patients, 24 were diagnosed clinically as suffering from buccal swelling, 15 had submandibular swelling, four had sublingual swelling, two had periorbital swelling, and five had infraorbital swelling. After meticulous clinical and radiographic examinations, including panoramic and periapical radiographs, a sonographic examination of the infected area was performed. A linear array probe, 7.5 Mhz (Acuson 128 X P/10, Mountain View, CA) was applied over the skin, covering the suspected area in transverse and axial sections to determine the presence or absence of fluid collection and its location. A sonically guided needle aspiration was then performed in all patients in the most inferior aspect of the swelling.
Results Under ultrasonography, fluid was identified in 22 of the 50 patients (Table 1) (Figs 1-S). Aspiration of pus was positive in all of these patients. In these cases,pus evacuation was the prime consideration, either by tooth extraction or by incision and drainage of the abscess. In the 28 patients suffering from cellulitis (Figs 4, 5) treatment depended on the physiologic response to the infectious process. All patients re-
The Chaim School of
Israel.
Israel. of Oral and Maxillofocial
Patients
The
Address correspondence and reprint requests to Dr Peleg: Department of Oral and Maxillofacial Surgery, The Chaim Sheba Medical Center,
sis and treatment of superficial odontogenic fascial space infections.
Surgeons
0278-2391/98/5610-0004$3.00/0
1129
1130
ULTRASONOGRAPHY FOR FACIAL SPACE INFECTIONS
Clinical Features Buccal swelling
Submandibular swelling Sublingual swelling Periorbital swelling Infraorbital swelling Total
No. of Patients 24
15 4 2 5
Fluid Location
No. of Patients
Buccal space Vestibular Submasseteric space Submandibular space Submental space Canine space Canine space Vestibular
50
2 7
2
-
5 2
1 1 2 22 FIGURE 2.
ceived comprehensive supportive care to aid their own body defenses in combating the infection. Of the 28 patients diagnosed as suffering from cellulitis, six had a repeated ultrasographic scan performed 3 days after the initial study because of lack of clinical improvement. In four patients, abscess formation was diagnosed.
Discussion Infections treated by the oral and maxillofacial surgeon are often odontogenic in origin. Although spatially confined, purulent material may spread deeply into contiguous fascial spaces, such as the submandibular, sublingual, and pterygomandibular. Severe complications can result if the infection is not recognized and treated promptly and properly. Mediastinitis, intracranial abscesses, and parapharyngeal spread with airway destruction can develop.* Thus, early diagnosis and treatment are mandatory. Evaluation of patients with acute odontogenic infec-
FIGURE 1. shown beneath
Scan performed along the left mandible. as a hypoechoic area, superficial to the the elevated masseteric muscle [arrows].
Fluid collection mandible and
is just
hypodense masseteric
CT scan shows the same well-defined area between the left mandible ramus muscle (arrows).
and
collection as a the elevated
tions can be difficult for the surgeon, who had to deal with the dilemma of whether there is, in fact, an abscessrequiring surgical intervention or a cellulitis that can be managed satisfactorilly with only supportive care. The finding of “fluctuance” is often difficult, especially in spacessuch asthe submasseteric,where the purulent material is deep within the soft tissues and muscle. In these cases,it is possible not to be able to elicit fluctuance. Over the last 15 years, the introduction of techniques such as ultrasonography,3 CT,* and MR15have revolutionized the field of diagnostic radiology. These powerful diagnostic tools have minimized the therapeutic dilemma for surgeons. CT scanning and MRI are effective in diagnosing inflammatory conditions,
FIGURE 3. Transverse sonographic shows a 7.5 x 14 mm hypoechoic mandible [arrows].
examination of the lower lip collection of fluid anterior to the
PELEG
1131
ET AL
FIGURE
4. Clinical
picture
of patient
with a swollen
cheek
and the choice between these two techniques usually depends on the area involved. However, both techniques are expensive and present some serious disadvantages.6 CT exposes the patient to large doses of radiation, especially if repeated follow-up examinations are to be performed. In addition, there are streak artifacts
produced by bone and metal that degrade images around the face. Another significant disadvantage is the poor contrast between the various soft tissues. Usually, an intravascular contrast medium must be used to distinguish pathologic processes from adjacent normal soft tissues. A major disadvantage of MRI is the prolonged time for image acquisition. Thus, the images may suffer from the effects of patient motion. The high static magnetic field also poses a danger to those individuals with cardiac pacemakers, neurostimulator units, and intraocular foreign bodies. Ultrasonographic examination has been used to evaluate various masses in the neck (including abscesses) and diseases of the salivary glands.7-9 To the best of our knowledge, this is the first study to use ultrasonography for the purpose of diagnosing intraoral odontogenic infections and infections of the superficial fascial spaces of the maxillofacial area. No echoes are returned by fluids, and thus ultrasonography is very sensitive in detecting fluid collection. Unlike radiography and MRI, adverse effects of ultrasonography have not yet been reported. In the current study of acute odontogenic infections, detecting the stage of infection was highly predictable. The method is quick, widely available, relatively inexpensive, painless, and can be repeated as often as necessary without risk to the patient. Thus, ultrasonography can be a valuable aid to the oral and maxillofacial surgeon.
References
FIGURE 5. Sonographic examination of the patient in Figure an echogenic ill-defined area corresponding with edematous No fluid collection is identified.
4 shows tissues.
1. Conway WF, Lame FJ, Blinder RA: Newer diagnostic imaging techniques. Oral Maxillofac Surg Clin North Am 3:259, 1991 2. Laskin DM, La&in JL: Odontogenic infections of the head and neck, in La&in DM (ed): Textbook of Oral and MaxiUofacial Surgery (~012). St Louis, MO, Mosby, 1985, pp 219-252 EW, Jefek BW, Johnson ML, et al: Ultrasonography in 3. Kreutzer the preoperative evaluation of neck abscesses. Head Neck Surg 4:290, 1982 4. Endicot JN, Nelson RJ, Saracena CA: Diagnosis and management decisions of the deep fascial spaces of the head and neck utilizing computerized tomography. Laryngoscope 92:630,1982 of a deep neck abscess with 5. Matt BH, Lusk RP: Delineation magnetic resonance imaging. Ann Otol Rhino1 Laryngol96:615, 1987 6. Van Rensburg LJ, Nortje LJ: Magnetic resonance imaging and computed tomography of malignant disease of the jaws. Oral Maxillofac Surg Clin North Am 4:75, 1992 7. Hell B: P-Scan sonography in maxillofacial surgery. J Craniomaxillofac Surg 17:39, 1989 8. Pogrel MA: The use of ultrasonography in the diagnosis of neck lumps. J Oral Maxillofac Surg 40:794, 1982 N, Schatter M, Traxler M, et al: Sonography and 9. Gritzman computed tomography in deep cervical lipomas and lipomatosis of the neck. Ultrasound Med Biol7:45 1, 1988 and ultrasonography in 10. Jensen C, Von Sydow C: Radiography paranasal sinusitis. Acta Radio1 28:31, 1987