Ultrasonographic Evaluation of Fascial Space

Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 8
Ultrasonographic evaluation of fascial space

infections of odontogenic origin
Mohit Sharma, Kathikeya Patil, Mahima V Guledgud
Department of Oral Medicine and Radiology, JSS Dental College and Hospital, Mysore, Karnataka, India
INTRODUCTION
Dental infection has plagued the human kind for as long
as our species has existed. When dental infection spreads
deeply into the soft tissue rather than exiting supercially
through oral or cutaneous routes, fascial spaces may be
affected. Following the path of least resistance through
connective tissue and along fascial planes, infections may
spread quite distantly from its dental source, causing
considerable morbidity and mortality. It is often difcult
to diagnose the stage of infection and to dene its exact
anatomic location based on clinical and conventional
radiographic examination alone.
[1]
In patients with acute
odontogenic infections, it is often difcult to clinically
determine, whether there is an abscess which requires
surgical intervention or cellulitis that can be managed
satisfactorily with antimicrobial therapy and supportive
care alone.
[2]
Finding of uctuance is often difcult on
clinical examination, especially in spaces such as the
submasseteric, where purulent material is deep within
the soft tissues and muscle.
The relative blind surgical incision and drainage performed
in such situations usually results in excessive harm through
unnecessary extensive incisions, and failure to locate and
evacuate the abscess cavity completely.
[2]
Radiographs and
other imaging studies can be used to diagnose the spreading
infections in the head and neck. However, plain radiographs
do not often provide good denition of soft tissue. Both
A B S T R A C T
Introduction: Dental infection has plagued the human kind for as long as our species has existed. It is often difcult to diagnose the
stage of infection. The relative blind surgical incision and drainage performed in such situations usually results in excessive harm
through unnecessary extensive incisions, and failure to locate and evacuate the abscess cavity completely. The potential use of
ultrasonography (USG) in fascial space infections of odontogenic origin has not been explored completely and deserves much more
intensive, high quality research. Objectives: (1) To elucidate the role of USG as an adjunctive diagnostic aid for fascial space infections
of odontogenic origin. (2) To aid in appropriate treatment planning and management of fascial space infections of odontogenic origin.
Materials and Methods: The study group comprised of 30 patients of either genders, irrespective of age and presented with unilateral
fascial space infection of odontogenic origin. After the clinical and radiographic examinations, patients underwent USG evaluation.
USG-guided intraoperative aspiration was done to conrm the diagnosis. All the ndings were tabulated and subjected to statistical
analysis. Results: USG was as accurate as USG-guided intraoral aspiration (Gold standard) in diagnosing fascial space infections
of odontogenic origin with sensitivity and specicity of 100%. In cases of abscess USG showed a well-dened homogenous anechoic
pattern, cellulitis cases showed an ill-dened heterogeneous hyperechoic pattern while edema showed an ill-dened isoechoic pattern.
Conclusion: The different stages of fascial space infections of odontogenic origin can be clearly depicted on the USG. USG can
be used as a reliable adjunctive imaging technique in the diagnosis of fascial space infection of odontogenic origin and thus aids in
appropriate treatment planning and management of such cases.
Key words: Fascial space infections, USG, USG guided intra operative aspiration
Address for correspondence: Dr. Mohit Sharma, Department of Oral Medicine and Radiology, JSS Dental College and Hospital, Mysore,
Karnataka, India. E-mail: msmohitcop@gmail.com
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DOI:
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Mohit, et al.: Ultrasonography of odontogenic fascial space infections
CT and MRI are expensive, time consuming and not easily
available.
[3]
Hence, we need adjunctive diagnostic aids to
correctly identify the stage of infections and to provide
appropriate management. Ultrasonography (USG) has
played a major role as a diagnostic tool in various medical
conditions. The sonographic images are identied in terms of
echoes as hypoechoic, hyperechoic and anechoic images. The
potential use of ultrasonography in fascial space infections
of odontogenic origin has not been explored completely
and deserves much more intensive, high-quality research.
MATERIALS AND METHODS
The study sample comprised of 30 subjects, presenting
to the Department of Oral Medicine and Radiology, J.S.S.
Dental College and Hospital, JSS University, Mysore, with
fascial space infections of odontogenic origin, satisfying the
following inclusion and exclusion criteria and those willing to
participate in the study were selected by purposive sampling.
Inclusion criteria
1. Subjects of either gender, irrespective of age, presenting
with unilateral fascial space infections of odontogenic
origin.
Exclusion criteria
1. Individuals who required immediate emergency
management.
2. Individuals who were non-ambulatory.
3. Individuals with bilateral involvement of fascial spaces.
Ethical clearance was obtained from the Institutional
Ethical review board prior to conducting the study.
The selected subjects were explained in detail about the
procedures involved and a written informed consent was
obtained from them.
The selected patients were made to sit comfortably on
the physiological dental chair with articial illumination.
Relevant history was noted down on a specially designed
proforma. A detailed extraoral and intraoral clinical
examination was carried out by adopting the methods of
Kerr, Ash and Millard
[4]
and relevant ndings ascertaining
the nature of fascial space infection, and its origin, were
noted on the individual proforma.
The subjects were then transferred to the radiology section
for radiographic examinations either intraoral periapical
(IOPA) or panoramic radiographs as deemed necessary
on a case to case basis to conrm the clinical ndings.
Both IOPA and panoramic radiographic examinations
were carried out adopting the methods of White and
Pharoah.
[5]
After evaluating the clinical and radiographic
ndings, a working diagnosis was made and noted down
in the individual proforma.
The patients were then subjected to USG examination using
a linear array transducer with a frequency of 6-10 MHz in
both transverse and axial sections to determine the nature
of fascial space infection. Bilateral images from both
infected and non-infected sides were taken for comparison.
The gray scale images were described as follows:
[6]
Hyperechoic (brighter)
Isoechoic (darker)
Anechoic (no internal echoes)
Mixed signals
This information was used to stage the infection from
acute edematous phase to complete abscess formation as
follows:
[6]
Edematous changes: The echogenicities of the tissues
were isoechoic, similar to the normal or uninfected side
but with an increase in the uid contents.
Cellulitis: The echogenicities of the tissues were
higher (hyperechoic) than normal because of massive
inammatory inltration to the infected region.
Preabscess stage: The echogenicities of the tissues
were mixed (hypoechoic and hyperechoic) at the
end of cellulitis stage and the beginning of abscess
formation stage.
Abscess stage: The echogenicities of the tissues were
absent (anechoic) because of the abscess cavity, which
can be solitary or multiple well-dened foci of pus.
The USG images were interpreted by the operator (Sonologist)
on the monitor and the USG diagnosis was obtained.
After the USG examination, the USG-guided intraoperative
aspiration was undertaken in all cases under aseptic
conditions. A high-resolution ultrasound scan was
performed using a 5.7 linear array probe in direct contact
with skin surface using sterile ultrasound gel as the coupling
agent. The patient was in the supine position with the head
tilted toward the unaffected side. After visualizing the
abscess cavity under the guidance of the ultrasound, the
probe position was adjusted so that the intended puncture
point of the abscess was aligned with the imaginary midline
of the probe and distance from skin surface to the required
depth of the needle insertion was measured accurately.
A 20-gauge needle mounted on sterile 10 ml disposable
plastic syringe was inserted freehand at an angle
perpendicular to the scanning plane. During the procedure
the patient was instructed not to move, breathe deeply, or
swallow during the needle insertion to avoid the shifting
of the image. The needle was withdrawn and the site was
covered with a temporary dressing. The aspirate collected
was sent for microbiological culture sensitivity tests.
The USG-guided intraoperative aspiration ndings served
as the gold standard for the denitive diagnosis.
Statistical analysis
The data thus obtained was subjected to statistical analysis
using SPSS version 16.0 for Windows. The statistical
methods used in this study were as follow.
1. Descriptive statistics
2. Crosstabs
3. Chi-square test
4. Fishers test
RESULTS
Among the 30 study subjects included in the study, 12
(40%) were males and 18 (60%) were females. The males
ranged in age from 9 to 58 years with a mean age of
31.5 years. The females ranged in age from 6 to 59 years
with a mean age of 29.9 years.
Of the 43 involved spaces, submandibular space was the
most commonly involved space (15, spaces 34.8%). The
second most commonly involved space was the buccal
space (10, 23.2%) and the third was the canine space (8,
18.6%), they were followed by submental (7, 16.2%) and
submasseteric space (3, 6.9%) [Table 1].
Single space involvement was noted in 17 (56.7%) cases
and multiple spaces were involved in 13 (43.3%) cases.
According to the ndings of ultrasonography, out of the
30 cases 6 (20%) were in edema stage, 10 (33.3%) in cellulitis
and 14 (46.7%) cases were noted to be in abscess stage. In all
the abscess cases USG showed well-dened edge denition
expect in 2 (14.3%) cases where the edge was not clearly
dened. The internal echo pattern was homogenous and
anechoic in all of the abscess cases [Table 2, Figure 1].
USG ndings in cases of cellulitis showed an ill-dened
edge denition with a heterogeneous hyperechoic internal
echo pattern. In six edema cases USG showed an ill-dened
edge denition and heterogeneous and isoechoic internal
echo pattern [Tables 3 and 4, Figures 2 and 3].
Out of the 30 cases of fascial space infections, 7 (23.3%)
cases were involving the deciduous dentition. Lower second
deciduous molar was the most commonly involved tooth.
In the permanent dentition lower second and third molars
were the most commonly involved teeth.
Comparison of clinical working diagnosis and
USG guided intra operative aspiration
Of the 30 subjects, a clinical working diagnosis of abscess
and cellulitis was rendered in 17 (56.7%) and 13 (43.3%)
cases, respectively.
Table 1: Ultrasonography results of fascial space
involvements
Fascial space
involved
Clinical
ndings (%)
USG
ndings(%)
Types of
fascial spaces
Submandibular space 15 (34.8) 15 (34.8) Supercial
Submental space 7 (16.2) 7 (16.2) Supercial
Buccal space 10 (23.2) 10 (23.2) Supercial
Canine space 8 (18.6) 8 (18.6) Supercial
Submasseteric space 3 (6.9) 3 (6.9) Supercial
Table 2: USG ndings in abscess cases
Patient
no.
Space involved Edge
denition
Internal echo
Pattern Intensity
Case no 2 Left submasseteric Well dened Homogenous Anechoic
Case no 3 Right canine Well dened Homogenous Anechoic
Case no 5 Right submandibular,
buccal
Well dened Homogenous Anechoic
Case no 7 Left buccal Ill dened Homogenous Anechoic
buccal
Case no 11 Left submandibular,
buccal
buccal
Ill dened Homogenous Anechoic
Case no 14 Right buccal,
submandibular
Case no 17 Left buccal Well dened Homogenous Anechoic
buccal
Case no 19 Left canine Well dened Homogenous Anechoic
buccal
Figure 1: USG changes with edema
On USG-guided intra operative aspiration of the
fascial space infections of all 30 subjects, 14 (46.7)
cases were found to be abscess and 16 (53.3%) were
found to be cellulitis.
On comparing the results of clinical working diagnosis
with USG-guided intra operative aspiration, a positive
correlation was found in 11 (64.7%) of the 17 cases
with a clinical working diagnosis of abscess. Six
(35.5%) cases with a clinical working diagnosis of
abscess were diagnosed as cellulitis on USG-guided
intraoperative aspiration.
with USG-guided intraoperative aspiration, a positive
correlation was found in 10 (76.9%) of the 13 cellulitis
cases. Three (23.1%) cases with clinical working diagnosis
of cellulitis were found to be abscess on USG-guided intra
operative aspiration.
The overall co-relation of results between clinical working
diagnosis and USG-guided intraoperative aspiration was
found to be signicant, with a P value of 0.03.
The overall sensitivity of diagnosing abscess and cellulitis
cases by clinical and radiographic examination alone
(i.e. clinical working diagnosis) was found to be 78.5%
with a specicity of 62.5%. A positive predictive value
of 64.7% and negative predictive value of 76.9% was
obtained [Table 5].
Compari son of the Ul trasonographi c
diagnosis and USG-guided intraoperative
aspiration
Of the 30 subjects, an USG diagnosis of abscess and
cellulitis was rendered in 14 (46.7%) cases and 16 (53.3%)
cases, respectively.
On comparing the results of USG diagnosis with USG-
guided intraoperative aspiration, a positive correlation was
found in all 14 abscess cases and all 16 cellulitis cases.
The overall co-relation of results between USG diagnosis
and USG-guided intra operative aspiration was found to
be very highly signicant, with a P value of 0.0001.
USG showed a sensitivity and specificity of 100%
for diagnosing the cases of fascial space infection of
odontogenic origin [Table 6].
Figure 2: USG changes with cellulitis Figure 3: USG changes with abscess
Table 3: USG ndings in cellulitis cases
Patient
no.
Space involved Edge
denition
Internal echo
Pattern Intensity
Case no 1 Right canine Ill dened Heterogeneous Hyperechoic
Case no 6 Left canine Ill dened Heterogeneous Hyperechoic
Case no 15 Left canine Ill dened Heterogeneous Hyperechoic
submental
Ill dened Heterogeneous Hyperechoic
Case no 22 Right submandibular Ill dened Heterogeneous Hyperechoic
Case no 23 Right submandibular Ill dened Heterogeneous Hyperechoic
submental
Ill dened Heterogeneous Hyperechoic
Case no 27 Left buccal Ill dened Heterogeneous Hyperechoic
Table 4: USG ndings in edema cases
Patient
no.
Space involved Edge
denition
Internal echo
Pattern Intensity
submental
Ill dened Heterogeneous Isoechoic
Case no 9 Right buccal, Ill dened Heterogeneous Isoechoic
submental
Case no 16 Left submandibular Ill dened Heterogeneous Isoechoic
Case no 20 Left submandibular, Ill dened Heterogeneous Isoechoic
buccal
Comparison of clinical working diagnosis and
the Ultrasonographic diagnosis
with USG diagnosis, a positive correlation was found in
11 (64.7%) of the 17 abscess cases. Six (35.5%) cases with
a clinical working diagnosis of abscess were diagnosed as
cellulitis on ultrasonography.
On comparing the results of clinical working diagnosis with
USG, a positive correlation was found in 10 (76.9%) of the
13 cellulitis cases. Three (23.1%) cases with clinical working
diagnosis of cellulitis were found to be abscess on USG.
The overall co-relation of results between clinical working
diagnosis and USG diagnosis was found to be signicant,
with a P value of 0.03 [Table 7].
DISCUSSION
The mean age of the distribution of patients was 31.5
15.6 years. There are no studies that show if age has an
impact on diagnosing fascial space infections. A study by
Cachovan et al. found the mean age of patients presenting
to the emergency department with odontogenic infections
in an 8-year epidemiologic analysis to be 34.8 16.8 years
and showed that patients in the 20-29 range age group
utilized emergency care more frequently. Similar ndings
were noted in our study also.
[7]
In the present study the most common primary space
involved was the submandibular space (34.8%) followed
by the buccal space (23.2%). The lower molars, primarily
second and third molars have roots which are below the
attachment of mylohyoid muscle, and the lingual cortical
plate is thinner as compared to the buccal cortical plate.
Odontogenic infections from these teeth will perforate
the lingual cortical plate in most cases, resulting in
submandibular facial space infection. Infections from
maxillary molar teeth and mandibular rst molar will result
in buccal facial space infection. The roots of permanent
maxillary molars are above the attachment of buccinator
muscle while the roots of mandibular permanent rst
molar are below the attachment of buccinator muscle.
In the maxilla the buccal cortical plate is thinner than
the palatal plate and fenestration in the buccal cortical
plate favors the spread of infection to the buccal space.
Rega et al. in their study reported that submandibular
space was involved in 30% cases followed by buccal space
which was involved in 27.5% cases. A different pattern was
Table 5: Comparison of Clinical working diagnosis and USG guided Intra operative aspiration by Crosstabs
Evaluation Condition % Count USG-guided Intra operative aspiration Total Signicance
Abscess Cellulitis
Clinical Abscess Count % of CWD* 11 6 17
working diagnosis 64.7% 35.3% 100.0%
Cellulitis Count % of CWD 3 10 13 0.03
23.1% 76.9% 100.0%
Total Count % of CWD 14 16 30
46.7% 53.3% 100.0%
Table 7: Comparison of clinical working diagnosis and ultrasonographic diagnosis by Crosstabs
Evaluation Condition % Count USG diagnosis Total Signicance
Abscess Cellulitis
Clinical Abscess Count % of CWD 11 6 17
working diagnosis 64.7% 35.3% 100.0%
Cellulitis Count % of CWD 3 10 13 0.03
23.1% 76.9% 100.0%
46.7% 53.3% 100.0%
Table 6: Comparison of the ultrasonographic diagnosis and USG-guided intra operative aspiration by Crosstabs
Evaluation Condition % Count USG-guided Intra operative aspiration Total Signicance
Abscess Cellulitis
Ultrasonographic diagnosis
(USGD)*
Abscess Count % of USGD 14 0 17
100.0% 0.0% 100.0%
Cellulitis Count % of USGD 0 16 13 0.001
0.0% 100.0% 100.0%
46.7% 53.3% 100.0%
observed by Bridgeman et al., where buccal space (52.6%)
was the most common space followed by submandibular
space (24%). Labriola et al. reported 24% of their patients
presented with submandibular space infections and 20%
with buccal space infections.
[8-10]
Out of the 30 cases, 17 (56.7%) had single space involvement
while in 13 (43.3%) multiple space involvement was
noted. Since many of fascial spaces of head and neck
communicate either directly or indirectly with each other,
spread of infection from one region to another can occur
when the balance between patient resistance and bacterial
virulence is unfavorable.
[6]
Various other studies have also shown the involvement of
multiple spaces in patients with fascial space infection of
odontogenic origin.
[6,11,12]
In the present study out of the 30 study subjects, a clinical
working diagnosis of abscess and cellulitis was rendered
in 17 (56.7%) cases and 13 (43.3%) cases, respectively. On
USG-guided intraoperative aspiration abscess cases were
found to be 14 (46.7%) and cellulitis cases were 16 (53.3%)
in number. Similar higher incidence of cellulitis cases was
found by Pelgel et al.
[2]
On comparing the results of clinical working diagnosis with
intraoperative aspiration procedure, a positive correlation
was found in 11 (64.7%) of the 17 abscess cases. Six
(35.5%) cases with a working diagnosis of abscess were
diagnosed as cellulitis on aspiration. A higher incidence of
diagnosing abscess clinically in comparison with diagnosing
cellulitis is also in accordance with study conducted by
Aarthi et al.
[12]
In addition, on comparing the results of clinical working
diagnosis with USG-guided intraoperative aspiration,
a positive correlation was found in 10 (76.9%) of the
13 cellulitis cases. Further, 3 (23.1%) cases with a clinical
working diagnosis of cellulitis turned out to be abscess
on intra operative aspiration. The overall comparison
of the clinical working diagnosis with USG-guided intra
operative aspiration diagnosis resulted in a highly signicant
with a P value of 0.03. This shows that with clinical and
radiographic examination alone a correct diagnosis was
made in 21cases out of 30 cases. The overall sensitivity
of diagnosing abscess and cellulitis cases by clinical and
radiographic examination alone (i.e. clinical working
diagnosis) was found to be 78.5% with a specicity of
62.5%. A positive predictive value of 64.7% and negative
predictive value of 76.9% was obtained. Similar results
were noted with various other studies.
[11-13]
Such results emphasize the role of good clinical and
radiographic acumen in the diagnosis of fascial space
infections of odontogenic origin.
In the present study, USG was correctly able to diagnose all
the cases of abscess, i.e. 14 (46.7%) cases as were diagnosed
with USG-guided intraoperative aspiration.
Similarly, all 16 (53.3%) cases of cellulitis were correctly
diagnosed with USG. This shows sensitivity and specicity
of 100% for diagnosing both abscess and cellulitis cases
by ultrasonography.
Similar results were found by Bassiony et al. In their
study USG had accurately revealed 76% of all involved
fascial spaces and 100% of involved supercial spaces.
This indicated that USG is reliable and has potential to
replace MRI in detection of buccal, canine, infraorbital,
submandibular, submental, and submasseteric spaces.
The authors concluded that USG was a valuable addition
in diagnosis of supercial fascial space infections and
in demonstrating the stages of infections. However,
MRI was superior to USG in assessment of deep fascial
space involvements, such as the parapharyngeal and
masticator spaces.
[6]
Since, in the present study all study subjects had supercial
fascial space infections; all were accurately diagnosed when
correlated with the USG-guided intraoperative aspiration
which was considered as the gold standard.
During the USG evaluation of the subjects the fascial
space infections were graded according to the description
given by Bassiony et al.,
[6]
and it was found that out of
30 cases 6(20%) were in the edema stage, 10 (33.3%)
were in the cellulitis stage and 14 (46.7%) were in the
abscess stage.
Ultrasonographic staging was not included during the
statistical analysis because it is not clear in the literature
what is expected to be found in the other stages upon
surgical intervention. For example, is pus expected to be
found in the preabscess stage since it is considered to be
between the cellulitis and abscess stages? The diagnoses
were made based upon whether the operator and expert
believed the swellings were mainly in the cellulitis or abscess
stage (i.e. whether the purulence was expressed upon intra
operative aspiration or not). Making a clear cut diagnosis
or knowing the stage of the swelling is important if the
treatment of the swellings is different. But for cases with
either cellulitis or edema the treatment rendered will be
the same.
Ultrasonographic images in the present study in the
cases of cellulitis showed ill-defined edges with the
heterogeneous pattern and hyperechoic intensity; also,
there was an increase in the thickness of involved muscle
and subcutaneous tissue [Figure 2]. While in the cases of
abscess, the edges were well dened with the homogenous
pattern and hypoechoic/anechoic intensity, with posterior
acoustic enhancement suggestive of some collection
[Figure 1]. The same ndings were conrmed in studies
conducted by various investigators.
[6,11-15]
The echogenicities of the tissues in the edematous phase
were isoechoic, similar to the normal or uninfected side
but with an increase in the uid content and with increased
thickness of skin and subcutaneous tissues [Figure 3].
with USG diagnosis, a positive correlation was found in
11 (64.7%) of the 17 abscess cases. Six (35.5%) cases with
a working diagnosis of abscess were diagnosed as cellulitis
on ultrasonography. In addition, on comparing the results
of working diagnosis with USG diagnosis, a positive
correlation was found in 10(76.9%) of the 13 cellulitis cases.
Further, 3 (23.1%) cases with a clinical working diagnosis
of cellulitis turned out to be abscess on USG evaluation.
The overall comparison of the clinical working diagnosis
with USG diagnosis was highly signicant with a P value
of 0.03. Aarthi et al. and various other investigators also
rendered similar results in their studies when a comparison
was made between clinical working diagnosis and USG
diagnosis.
[11-13]
CONCLUSION
The conclusions drawn from the study are as follows.
The different stages of fascial space infections of
odontogenic origin can be clearly depicted on the USG
USG displays utmost accuracy in the diagnosis of
fascial space infections of odontogenic origin.
USG can be used as a reliable adjunctive imaging
technique in the diagnosis of fascial space infection
of odontogenic origin and thus aids in appropriate
treatment planning and management of such cases.
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Cite this article as: Sharma M, Patil K, Guledgud MV. Ultrasonographic
evaluation of fascial space infections of odontogenic origin. J Oral Maxillofac
Radiol 2014;2:8-14.
Source of Support: Nil. Conict of Interest: None declared.

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Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 8

Ultrasonographic evaluation of fascial space

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