CHARACTERISATION OF

SOFT TISSUE LESIONS IN

ULTRASONOGRAPHY

BY UTHARA MENON
I 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;
ultrameans 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, 213221

20 MHZ US PROBE
This 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 (24fold 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
Dentomaxillofacial Radiology (1999) 28, 290 294

 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.

Dentomaxillofacial Radiology (2011) 40, 213221

 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

Dentomaxillofacial Radiology (2011) 40, 213221

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, 213221

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 the

maxilla

Ultrasound image showing

anechoic lesion
without internal echoes

Panoramic radiograph showing a radiolucent lesion on the left

of the mandible

 Ultrasound image showing complex cyst with dense

internal echoes.

Panoramic radiograph showing a radiolucent lesion on the right anterior

maxilla

Ultrasound image showing semisolid lesion

Panoramic radiograph showing a radiolucent lesion on the right

posterior 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 hypoechoeic
intraparotid 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 other

modalities
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, 213221

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.

Dentomaxillofacial Radiology (2011) 40, 213221

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

Dentomaxillofacial Radiology (2011) 40, 213221

Inflammatory swellingsubmandibular lymphadenitis (ultrasonographic

image)

Well defined
cystic lesion with
eccentric
hyperechoic
nodule

Inflammatory swellingcysticercosis cellulosae

(ultrasonographic image)

Cystic swellinginfected dental cyst

(ultrasonographic image)

 Benign neoplasmcystic hygroma

(ultrasonographic image)
Benign neoplasmcystic
hygroma
(ultrasonographic image)

Malignant neoplasmhigh-grade mucoepidermoid carcinoma (ultrasonographic

image)

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

Tumor

probe (12 30 mm

water or jelly

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

Congenital Vascular
Lesions 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, 26. 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 a
hemangioma of lower lip

A
B
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

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, 1823. doi: 10.1259/dmfr/81000210

Ultrasonography showed a mass that was ovoid, smoothly marginated,

hypoechoic and primarily homogeneous with a slight internal echo, but
had no echogenic region in the centre (arrowheads). Power Doppler images
did not reveal internal vascularity. A longitudinal sonogram showed a
thickened 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 welldefined cyst with

echogenic scolex and surrounding
hypoechoic area in the left masseter
muscle

Follow-up ultrasound showing the

calcified cyst in the
masseter muscle without evidence of
surrounding inflammatory
phlegmon

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: 929933.

J Clin Ultrasound 2004; 32: 7881
Br J Radiol 2003; 76: 271277.
Ultrasound Med Biol 2004; 30: 567574
Dentomaxillofacial Radiology (2012) 41, 131135.

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 Warthins 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.

Dentomaxillofacial Radiology (2000) 29, 319 322

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.

Dentomaxillofacial Radiology (2012) 41, 379384

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, Warthins tumour,
lymphoma and sarcidosis
Pseudolesions such as masseteric hypertrophy can be
confidently diagnosed.

Dentomaxillofacial Radiology (2011) 40, 40341

Axial ultrasound of the right parotid gland reveals multiple hypoechoic

areas in the enlarged glands.

Primary Sjogrens

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 firstline 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;47:12441249

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.
Dentomaxillofacial Radiology (2003) 32, 156159

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 intraoral 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.
Dentomaxillofacial Radiology (2001) 30, 242 245

Intra-oral US of a 60-year-old
woman with squamous cell
carcinoma on the left side of her
tongue (stage II), demonstrates a
wedge-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 illdefined 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 definite

internal 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, 205212. 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)

Dentomaxillofacial Radiology (2011) 40, 415421

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
Dentomaxillofacial Radiology (1999) 28, 290 294

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,

Dentomaxillofacial Radiology (2003) 32, 359364

Longitudinal ultrasound scan of a left temporomandibular

joints with a capsular width of 4.8 mm. The joint was painful to palpation
and 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.