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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 3  |  Page : 313-319
The use of ultrasonography in diagnosis and management of superficial fascial space infections


1 Department of Oral and Maxillofacial Surgery, S.M.B.T Dental College and Hospital, Amrutnagar, Sangamner, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Rural Dental College and Hospital, Pravaranagar, Loni, Maharashtra, India

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Date of Submission12-May-2010
Date of Decision01-Mar-2011
Date of Acceptance13-Oct-2011
Date of Web Publication11-Oct-2012
 

   Abstract 

Aims and Objectives: To evaluate the role of ultrasonography as a diagnostic aid to differentiate cellulitis from abscess; and efficacy of ultrasound-guided surgical drainage of superficial abscesses in the maxillofacial region.
Materials and Methods: a total of 26 patients with acute facial swellings were included in the study. Clinical examination confirmed the presence of space infection. Ultrasonographic examination of the swelling was then performed. If ultrasound images showed no collection and only thickness of subcutaneous tissue and muscle involved were increased, then the diagnosis was made as cellulitis. When collection was identified, diagnosis was made as abscess. Dimensions of abscess cavity, amount of pus collected, and depth of the center of the abscess cavity from the skin surface were recorded. Pus evacuation was then prime consideration either by needle aspiration or by incision and drainage. The amount of collection recorded on ultrasonography was compared with that drained at the time of surgery.
Results: of 26 patients, 14 patients were diagnosed with cellulitis and the remaining 12 patients with abscesses in the maxillofacial region. Five of 12 cases of abscess were managed with ultrasound-guided needle aspiration; rest seven cases underwent the incision and drainage procedure. Clinical specificity (69.23%) was found to be poorer than ultrasound specificity (100 %), both clinical and ultrasound showed the same percentage of sensitivity (92.30%)
Conclusions: from our experience we can conclude that ultrasonography is an inexpensive and non-invasive diagnostic technique that should be used to supplement clinical examination in patients with superficial fascial space infection.

Keywords: Fascial space infection, maxillofacial infection, ultrasonography, ultrasound guided drainage of abscess, USG

How to cite this article:
Mukhi PU, Mahindra UR. The use of ultrasonography in diagnosis and management of superficial fascial space infections. Indian J Dent Res 2012;23:313-9

How to cite this URL:
Mukhi PU, Mahindra UR. The use of ultrasonography in diagnosis and management of superficial fascial space infections. Indian J Dent Res [serial online] 2012 [cited 2020 Jul 3];23:313-9. Available from: http://www.ijdr.in/text.asp?2012/23/3/313/102211
Some of the most common soft tissue alterations of the head and neck region are inflammatory swellings such as space infections of the odontogenic origin, diseases of salivary glands and lymph node reactions. [1]

With a high-resolution scanner, there is more definition (resolution) and less depth of penetration. [2] Ultrasonography is useful in differentiating soft-tissue tumors, cysts, salivary stones, relationship of swelling to adjacent structures, consistency whether solid or cystic, and also it is extremely suitable for follow-up examination of tumor patients. [3]

Although spatially confined, purulent material may spread deeply into contiguous fascial spaces. Severe compli­cations can result if the infection is not recognized and treated promptly and properly. Mediastinitis, intracra­nial abscesses, and parapharyngeal spread with airway obstruction can develop. Thus, early diagnosis and treatment are mandatory. [4]

Fluids return no echoes and thus ultrasonogra­phy is very sensitive in detecting fluid collection. The diagnostic accuracy has significantly improved with the use of ultrasonography. It had saved the patients from unnecessary drainage procedures and ensures fewer errors that would have occurred if abscesses were mistaken as cellulitis and vice versa. [5]

Initially at the time of introduction in maxillofacial field, ultrasonography was used only for the diagnosis of abscess and localization of pus; nowadays it is also considered a therapeutic modality. Advantages of US-guided (USG) drainage include preservation of important vital structures that can be damaged during blind exploration of abscess, minimal or no scar formation and the procedure can be performed under local anesthesia or conscious sedation. [6]

This study was carried out to evaluate the efficacy of ultrasonography in the diagnosis and management of superficial fascial space infections and its predictability in detecting the stage of infection.


   Materials and Methods Top


A total of 26 patients with acute facial swellings were included in the study.

Patients excluded from the study were: patients suffering from deep-space infections (like pterygomandibular space infection) were excluded from study because of the inability of ultrasound to scan the past bone. Radiographs were taken to identify the foci of infection. Informed and written consents were obtained from all the patients. Ultrasonographic examination of the swelling was then performed.

Procedure for ultrasonographic examination

Position of patient

All examinations were performed with the patient in the supine position.

Transducer used

A 9 MHz linear array probe (Logiq 400 Proseries, G.E-Medical system) was used. Ultrasound transmission gel (Hi-Care ® HI-TECH Surgical Systems) was used as a coupling agent. Transducer was directly applied over the skin, covering the suspected area in transverse and axial sections to determine the presence or absence of the fluid collection; if dimensions of the abscess cavity were present, depth from the skin surface up to the centre of cavity and amount of collection were recorded.

If ultrasound images showed no collection and only thickness of subcutaneous tissue and muscle involved were increased, then the diagnosis was made as cellulitis. In such cases conservative management was of prime consideration. Any foci of infection if present were removed and patients kept on supportive care to help their own body defenses in combating the infection.

When collection was identified, diagnosis was made as abscess. Dimensions of abscess cavity, amount of pus collected and depth of the center of abscess cavity from the skin surface were recorded. Pus evacuation was then prime consideration either by needle aspiration or by incision and drainage.

Ultrasound-guided needle aspiration

Procedure

USG aspiration was carried out with a high-resolution ultrasound scanner using a 9 MHz linear array probe in direct contact with the skin surface, which was prepared and draped. The area of interest was carefully scanned for the presence, location, and extent of the abscess cavity. A sterile ultrasound gel was used as the coupling agent.

Under ultrasound guidance, a sterile 14-gauge Jelco cannula was inserted through the skin up to the center of the abscess cavity that was predetermined by ultrasound evaluation. The cannula was inserted freehand into the abscess. The patients were asked not to move, breathe deeply, or swallow during the cannula insertion to avoid shifting of image. On reaching the abscess cavity, USG-guided aspiration was performed with 10 cc syringe attached to the cannula in place. After aspiration, the disposable plastic syringe was dismounted, recapped, and labeled. In each patient, the aspirate was sent for microbiologic culture and antibiotic sensitivity tests.

Trocar was withdrawn leaving the cannula in site for further aspiration and irrigation of the abscess cavity. The cannula was carefully taped to the skin and covered with a dressing. Aspiration and irrigation of abscess cavity was done 12 hourly for 48 h or till the pus discharge was minimal. All patients were started with empirical intravenous antibiotic therapy and analgesics as per the routine till the antibiotic sensitivity test results were received.

After 24 h later, the course of infection was monitored in each patient. Infection was considered to be resolving when the following criteria were met:

  • Ceased or minimal drainage
  • Decreased swelling
  • Normal temperature
  • Minimal pain and/or tenderness
  • Improved Interincisal opening
Patient with non-resolving infection had their abscesses incised and drained.


   Results Top


Of the 26 patients [Table 1], 14 patients (03 males, 11 females) were diagnosed as suffering from cellulitis and the remaining 12 patients (5 males, 7 females) were suffering from abscesses in the maxillofacial region [Table 2].
Table 1: Master chart

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Table 2: Staging of the superficial fascial space infections

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The mean age of patients was 30 years (28.16 for cellulitis and 33.08 for abscess).

The male to female ratio was 1 : 2.25 (1 : 3.67 for cellulitis cases and 1 : 1.4 for abscess cases) [Table 3].
Table 3: Sex distribution

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[Table 4] shows the ultrasonographic findings in patient with cellulitis. All the cases had ill-defined edges, heterogeneous pattern, and were hypoechoic in intensity.
Table 4: Ultrasonographic findings-cellulitis

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[Table 5] shows the ultrasonographic findings in patient with abscess. All cases showed well-defined edges and hypoechoic intensity. All cases had the homogeneous pattern except in one case (case no 5) which showed the heterogenous pattern. Dimensions of abscess cavity, depth from skin up to center of abscess cavity and amount of pus was recorded.
Table 5: Ultrasonographic findings abscess

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Five cases (case no 10, 11, 14, 18, and 26) were managed with USG needle aspiration, rest seven cases underwent incision and drainage procedure under general anesthesia

Clinical, ultrasonographic and final diagnosis together with management of each patient is tabulated [Table 6].
Table 6: Clinical, ultrasonographic, and final diagnosis for each patient

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Although on clinical examination, 16 cases were diagnosed as suffering from abscesses, ultrasonographic examination showed only 11 of these cases as abscesses and rest five as cellulitis. In four cases ultrasonographic findings were found to be positive as there was no pus discharge on incision and drainage in three of these cases (case no. 1, 3, and 4) and one case (case no. 24) was managed with antibiotics only and the patient showed rapid response to antibiotics.

In one case (case no. 8) however the ultrasonographic findings of cellulitis failed as there was some amount of pus discharge on incision and drainage. In this case, the clinical diagnosis was superior to that of ultrasound.

In rest 10 cases, both clinical and ultrasonographic findings were suggestive of cellulitis, and in all cases patient settled down with antibiotics only.

The sensitivity and specificity of clinical and ultrasound examination is summarized in [Table 7]. Clinical specificity (69.23%) was found to be poorer than ultrasound specificity (100%), but both clinical and ultrasound showed the same percentage of sensitivity (92.30%)
Table 7: Sensitivity and specificity of clinical and ultrasound for diagnosing abscess

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In case no. 10, 11, 14, 18, 26 [Table 6] USG needle aspiration was helpful as it prevented need for incision and drainage, thus, avoiding scar especially in young patients. Cannula was left in place and stabilized with tape to skin surface that provided an easy way for further aspiration of pus and irrigation of the abscess cavity. Patient showed spontaneous improvement.

Thus, not only was ultrasound examination helpful in management of patients with superficial fascial space infection, it also helped us in differentiating cellulitis from abscess.


   Discussion Top


Ultrasonographic examination of all the patients was carried out preoperatively after clinical examination. Repeat ultrasonography had to be performed in one patient who was diagnosed as suffering from abscess. She had already undergone incision and drainage but did not show complete improvement. Repeat USG showed collection in sub-massetric space that was drained under local anesthesia and patient showed spontaneous improvement. In the study by Peleg et al. [4] 22 of 50 patients suffering from acute odontogenic infections of superficial fascial space showed signs of collection on ultrasonographic examination. In these cases, prime consideration was evacuation of pus. Rest 28 patients suffering from cellulitis were treated conservatively depending on the physiologic response to the infection process of which six patients required a repeated ultrasonographic scan, per­formed 3 days after the initial study because of lack of clinical improvement. In four patients abscess formation was diagnosed.

According to Sakaguchi M et al. [7] infection still in the cellulitis stage can be successfully treated with antimicrobials alone; surgical intervention is indicated when an abscess is established. In this study, patients suffering from cellulitis also showed good response to antimicrobial therapy.

The male to female ratio was 1 : 2.25 (1 : 3.67 for cellulitis cases and 1 : 1.4 for abscess cases). Similar results were shown in the study of 15 patients by Yeow et al. [8]

The amount of collection recorded on ultrasonography was compared with that drained at time of surgery. We found ultrasonography as a helpful tool for quantitative estimation of the abscess cavity.

USG ultrasound drainage was performed with 14 guage Jelco catheter and 10 mL disposable plastic syringe. After aspiration of pus, cannula was left in place and taped to the skin (for further aspiration and irrigation of cavity) and was covered with a dressing. On the literature survey, we found authors using different techniques for USG ultrasound drainage. Yusa et al, [9] in their series of eight patients with odontogenic infection used 18 guage needle with 10 mL syringe for the USG needle aspiration of pus. After aspiration, they placed an incision alongside the needle, through which a corrugated drain was inserted into the abscess cavity. Al-Belasy FA [6] reported a series of 11 patients with sub-massetric space abscess that were managed with USG needle aspiration. They used a sterile 16 guage intravenous catheter with a trocar needle and a sterile syringe. After complete aspiration, trocar was withdrawn leaving the catheter in site. The catheter was taped to skin and covered with a dressing.

In treating patients with USG needle aspiration, real time US guidance helps to centre the tip of needle within the liquefied pus and confirms the completeness of liquefied pus evacuation during needle aspiration. Otherwise, the physician is often uncertain where the tip is when a dry tap is noted. As a result, some patients are subjected to unnecessary drainage procedures and some may have prolonged hospitalizations where an abscess is not recognized and is inappropriately managed with antibiotics alone. USG needle aspiration prevents the aforementioned situation and appears promising sparing the patients from open surgical drainage. The technique appeared safe and effective with good results. In our study, swelling of 4 of 5 patients (80%) resolved after USG needle aspiration. Similar results were achieved by Yeow et al. [8] In their series 13 of 15 patients (87%) with uniloculated neck abscesses resolved after USG needle aspiration.

Ultrasonographic picture in the cases of cellulitis showed ill-defined edges with heterogenous pattern and hypoechoic intensity also there was increase in the thickness of involved muscle and subcutaneous tissue [Figure 1]. While in the cases of abscess, the edges were well defined with the homogenous pattern and hypoechoic intensity, with posterior acoustic enhancement suggestive of some collection [Figure 2]. Even the same findings were confirmed in the study conducted by Loyer et al. [10]
Figure 1: Ultrasonographic findings in cases of cellulitis

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Figure 2: Ultrasonographic findings in cases of abscess

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To analyze the sensitivity and specificity of ultrasonography, the pretherapeutic clinical and sonographic diagnosis were compared with the intraoperative findings and the clinical course. The sensitivity for diagnosing an abscess was the same for the clinical and sonographic (91%) examinations. However, specificity of ultrasound (100%) was found to be much superior to clinical specificity (92%). This figure compares favorably with the previous studies by Scott et al. [5] and Siegert Ralf [1] and shows that ultrasound offers considerably more information than that gained on clinical diagnosis alone. However, the experience of the clinician would definitely affect the clinical specificity; in our case clinical examination was carried by oral and maxillofacial surgeon with more than 8 years of experience in the field.


   Summary and Conclusion Top


Ultrasonography is a valuable diagnostic as well as therapeutic help in the management of superficial fascial space infections. Sometimes clinical diagnosis alone is difficult to differentiate between cellulitis and abscess; in such cases ultrasonography provides accurate imaging of the superficial structures of head and neck region, delimited medially by a bony skeleton. Compared to clinical examination, ultrasound is much superior in defining the exact location of abscess because of its real-time processing.

USG needle aspiration is a safe and effective procedure. In a selected group of patients, this technique appeared to be a reliable alternative to surgical incision and drainage. With proper case selection, traditional open surgical incision and drainage can be avoided.

From our experience, we can conclude that B-scan sonography is an inexpensive and noninvasive diagnostic technique with relative high sensitivity and specificity that should be used to supplement clinical examination in patients with inflammatory soft tissue swellings of many regions in head and neck. It can be used to help locate abscess cavities and thereby give hints for the surgical approach. It can be used to follow the course of the disease and its response to the nonsurgical treatment.

 
   References Top

1.Siegert R. Ultrasonography of inflammatory soft tissue swelling of the head and neck. J Oral Maxillofac Surg 1987;45:842-6.  Back to cited text no. 1
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2.Chodosh PL, Hillside, Silbey R, Oen KT, Elizabeth. Diagnostic use of ultrasound in diseases of head and neck. Laryngoscope 1980;90:814-21.  Back to cited text no. 2
    
3.Hell B. B-scan sonography in maxillo-facial surgery. J Craniomaxillofac Surg 1989;17:39-45.  Back to cited text no. 3
[PUBMED]    
4.Peleg M, Heyman Z, Ardekian L, Taicher S. Use of ultrasonography as a diagnostic tool for superficial fascial space infections. J Oral Maxillofac Surg 1998;56:1129-31.  Back to cited text no. 4
[PUBMED]    
5.Scott PM, Loftus WK, Kew J, Ahuja A, Hasselt CA. Diagnosis of peritonsillar infections: A prospective study of ultrasound, computerized tomography and clinical diagnosis. J Laryngol Otol 1999;113:229-32.  Back to cited text no. 5
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6.Al-Belasy FA. Ultrasound-guided drainage of submassetric space abscesses. J Oral Maxillofac Surg 2005;63:36-41   Back to cited text no. 6
    
7.Sakaguchi M, Sato S, Ishiyama T, Katsuno S, Taguchi K. Characterization and management of deep neck infections. Int J Oral Maxillofac Surg 1997;26:131-4.   Back to cited text no. 7
[PUBMED]    
8.Yeow KM, Liao CT, Hao SP. Us-guided needle aspiration and catheter drainage as an alternative to open surgical drainage for uniloculated neck abscess. J Vasc Interv Radiol 2001;12:589-94.   Back to cited text no. 8
[PUBMED]    
9.Yusa H, Yoshida H, Ueno E, Onizawa K, Yanagawa T. Ultrasound-guided surgical drainage of face and neck abscesses. Int J Oral Maxillofac Surg 2002;31:327-9.  Back to cited text no. 9
[PUBMED]    
10.Loyer EM, Dubrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft tissue infections: Sonographic findings in cases of cellulitis and abscess. AJR Am J Roentgenol 1996;166:149-52.  Back to cited text no. 10
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Correspondence Address:
Pravin U Mukhi
Department of Oral and Maxillofacial Surgery, S.M.B.T Dental College and Hospital, Amrutnagar, Sangamner, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.102211

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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