|Year : 2022 | Volume
| Issue : 1 | Page : 66-70
Efficacy of ultrasonography in the diagnosis of dento-maxillofacial swellings among an urban population in Nigeria
Yahuza Mansur Adamu1, Maryam Olaitan Hassan2, Mohammed Abba3, Olushola Amole4, Idris Garba2, Akintade Dare2
1 Department of Radiology, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Medical Radiography, Faculty of Allied Health Sciences, Bayero University, Kano, Nigeria
3 Department of Radiology, Bayero University Kano/Aminu Kano Teaching Hospital; Department of Medical Radiography, Faculty of Allied Health Sciences, Bayero University, Kano, Nigeria
4 Department of Oral and Maxillofacial Surgery, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||07-Feb-2021|
|Date of Decision||12-Oct-2021|
|Date of Acceptance||28-Feb-2022|
|Date of Web Publication||12-Jul-2022|
Dr. Mohammed Abba
Department of Medical Radiography, College of Health Sciences, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Context: Ultrasonography as an imaging modality in dentistry has been explored in recent years. It is particularly useful in the examination of superficial structures where the use of a high frequency linear transducer produces clearer sonographic images. Aim: To evaluate the efficacy of ultrasound when compared with other known diagnostic examinations. Materials and Methods: This was a prospective cross-sectional study involving patients with maxillofacial swellings in Aminu Kano Teaching Hospital. They were classified as malignant neoplasms, benign cysts, abscesses and infections and lymphoma, according to clinical, radiographic and ultrasound and diagnosis independently. The findings from these methods were then compared to the gold standard histologic findings. Chi-square test, Pearson contingency coefficient, and 2 x 2 contingency table were used in evaluating the diagnostic accuracy, sensitivity as well as the specificity of the examinations. Results: A total of 36 patients comprising 21 males and 15 females with mean age of 34.97 years were recruited. Diagnostic accuracy of ultrasound was 50% in the diagnosis of malignant tumors, 95.8% in benign cystic swellings, 50% in abscesses and infections, and 100% in lymphoma. Significant relationship exists between ultrasonography with histology, clinical and radiographic diagnosis with a contingency coefficient of 0.833, 0.759, and 0.798, respectively. Overall, the accuracy, sensitivity and specificity of ultrasound was 86.1%, 90.3%, and 60%, respectively. Conclusion: Ultrasonography provides accurate imaging of the maxillofacial region and provides information about the pathological characteristic of lesion, its extent, and relationship with the surrounding structures. Inclusion of ultrasonography to the clinical and histopathological examinations increases the accuracy of orofacial swelling diagnosis.
Keywords: Diagnosis, histopathology, maxillofacial swellings, radiography, ultrasound
|How to cite this article:|
Adamu YM, Hassan MO, Abba M, Amole O, Garba I, Dare A. Efficacy of ultrasonography in the diagnosis of dento-maxillofacial swellings among an urban population in Nigeria. Niger J Basic Clin Sci 2022;19:66-70
|How to cite this URL:|
Adamu YM, Hassan MO, Abba M, Amole O, Garba I, Dare A. Efficacy of ultrasonography in the diagnosis of dento-maxillofacial swellings among an urban population in Nigeria. Niger J Basic Clin Sci [serial online] 2022 [cited 2022 Nov 29];19:66-70. Available from: https://www.njbcs.net/text.asp?2022/19/1/66/350723
| Introduction|| |
Head and neck swellings are commonly encountered in oral and maxillofacial surgery. A number of disease processes which present clinically as swellings do affect the Dento-maxillofacial regions. Diseases which lead to such swellings are broadly classified as malignant or benign which could be solid or cystic in nature. Detailed medical history and clinical examination are the first line procedure in arriving at an informed diagnosis. However, in some cases such as chronic inflammation, abscess formation, deep-seated, or infected cystic lesion and neoplasms, clinical examination and palpation do not provide complete assessment of the exact origin and nature of swellings. Therefore, to get a diagnosis, clinical examination must be combined with other diagnostic procedures.
Various imaging modalities play an important role in the diagnosis of pathologic conditions of the head and neck. Plain radiographs, computed tomography (CT) scan, magnetic resonance imaging (MRI) and ultrasonography (USG) are the valuable diagnostic aids.,, These powerful diagnostic tools have minimized the diagnostic dilemma but still possess some drawbacks. Plain radiograph poses a problem in yielding soft tissue details due to the inherent super imposition of structures. The drawbacks of CT include its high costs, technique sensitivity, and unavailability in all healthcare centres, especially in resource limited settings like ours. There is increased doses of ionizing radiation in CT with its inability to differentiate the soft tissues of similar radiodensities with vastly different chemical compositions and artifacts from any metallic substances as well as motional blur., The drawbacks of MRI include its high costs, technique sensitivity, a longer scan time, unavailability of the machines to the average physicians, danger to the magnetic information storage (e.g. credit cards, tapes), relatively thick sections, and susceptibility to motion artifacts. The high static magnetic field also poses a danger to individuals with cardiac pacemakers, neurostimulator units, and intraocular foreign bodies. Ultrasound, as an imaging modality has been explored extensively. It is non-invasive, inexpensive, painless and well accepted by patient. Unlike x-rays, USG does not expose patient to harmful ionizing radiations. A number of indications and applications on the ability of ultrasound to detect various lesions around the dento-maxillofacial regions has been reported.,, Popular among these indications includes assessment of the salivary glands for cysts and tumors in the oral region, dental fractures or cracks, soft tissue lesions, cervical lymphadenopathy, and swelling in orofacial region.,,, Similarly, USG-guided needle biopsies are recommended as a safe and reliable technique in the diagnosis of cervico-facial masses. Another unique advantage of USG is its capability in differentiating cystic from solid lesions, and aiding in diagnosing malignant versus 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.
Histopathologic examination remains the gold standard in diagnosis of masses. The tissue characterization, nature, type, and origin can be correctly established. However, it is not readily available as its attendant time consumption, and possibility of tissue contamination during staining and fixation limits the timely decision of physicians in designing the proper course of management. In the other hand, the easy, timely, and efficient characterization of swellings on USG facilitates a timely surgical or medical intervention. In a resource limited setting such as the study site where the accessibility of USG is encouraging, the need to assess the efficacy and reliability of USG in the diagnosis of dento-maxillofacial swellings most be emphasized. This will therefore better the poor health indices in the diagnosis, prognosis, and management of swellings involving dento-maxillofacial swellings. The aim of this study is to evaluate the efficacy of USG in the diagnosis of dento-maxillofacial swellings among patients attending maxillofacial clinic in Aminu Kano Teaching Hospital (AKTH).
| Materials and Methods|| |
This was a prospective cross-sectional study that was conducted at Radiology Department of AKTH, Nigeria between October and December 2015. Ethical clearance to conduct the study was sought from the human research and ethics committee of AKTH. Purposive sampling method was used in recruiting consenting patients with clinical swellings in orofacial regions irrespective of age and socioeconomic class. Clinical diagnosis was only made following detailed extraoral and intraoral clinical examinations by a qualified maxillo-facial surgeon. Clinical diagnosis of malignant and benign swellings into cystic, abscess, space infections, and suspected lymphoma were included. Swellings secondary to trauma/fracture were easily excluded because clinical diagnosis of hematoma is obvious due to available history of trauma, obvious changes in skin color, and mucous membrane. Similarly, patients that were pregnant or nursing baby and those with history of antibiotic therapy were also excluded.
Patient grouping was based on their clinical diagnosis into group I, II, III, and IV representing those with suspected malignancy, benign cysts, abscess and space infections and suspected lymphoma swellings, respectively. Patients were then subjected to routine plain radiographic examination under standard protocol and projections for facial radiography. The radiographic diagnosis made was independent of clinical findings. To avoid variability, radiographic diagnosis was made by a joint decision between three qualified radiologists. Similarly, these patients were then examined with sonography using NORTEC CS-50 ultrasound machine with color Doppler function, wide ranged frequency facility (7.5-15MHz) using linear array transducer. All lesions were evaluated for location, shape, size, border, internal echoes, posterior wall echoes, Doppler flow, and echogenicity relative to adjacent tissues. Ultrasound images for each patient were evaluated by two radiologists separately and independently. Where there is difference, a third opinion is sort and the conclusions arrived. All sonographic examiners had no histopathology results at the time of examination and the sonograms were analyzed at the same time the technique was performed. Tissue sample for each recruited patient was then taken using USG guided biopsy and subjected to histopathological examination for definitive diagnosis.
Descriptive statistics was used to express data. Chi-square test and Pearson's contingency coefficient was employed to determine association between pairs of categorical variables. Sensitivity and specificity of ultrasound was calculated and diagnostic accuracy of each procedure was also calculated using 2 × 2 contingency table. All the statistical analysis was achieved using SPSS v20 (IBM corp. 2015). P value was set at ≤ 0.05.
| Results|| |
A total of 36 patients that satisfied all inclusion criteria were recruited into the study comprising 21 (58.3%) males and 15 (41.7%) females with age range of 3–70 years, mean age of 34.97 years. Histopathological diagnosis was considered the gold standard when comparing accuracy of diagnosis from other investigations. Of the 36 patients with maxillo-facial swellings, the highest diagnosis from histopathology were benign cystic swellings with 27 (75%), while the least were malignancies 2 (5.6%) [Table 1].
The association between the established clinical diagnosis and USG was found to be statistically significant (contingency coefficient = 0.759; P value = 0.0001). The results showed the association between clinical diagnosis and USG was 89.7% in benign cystic swellings, 66.7% in abscess and infections, 100% in lymphoma [Table 2]. Clinical diagnosis was not able to detect any case of malignancy, which ultrasound was able to diagnose 1 accurately. The diagnostic accuracy of ultrasound and clinical diagnosis when compared to histology was 86.1% and 80.5%, respectively.
In the current study, significant association was found between USG and radiographic diagnosis (Contingency coefficient = 0.798; P value = 0.01). The association of USG with radiographic diagnosis was found as 96.6%, 66.7%, and 66.7% in benign cystic swellings, abscess and lymphoma, respectively. Radiography was able to detect 1 case of malignancy which was not accurate, one detected by ultrasound was accurate [Table 3]. The diagnostic accuracy of ultrasound and radiography in diagnosis of maxillofacial swellings when compared to histopathological diagnosis was 86.1% and 83.3%, respectively.
Significant association was found between ultrasound and histopathological diagnosis (Contingency Coefficient = 0.833, P value < 0.001). The USG congruency with histopathology was 100%, 89.6%, 66.7%, and 100% in cases of malignancies, benign cystic swellings, abscesses, and lymphoma, respectively [Table 4]. Similarly, the diagnostic accuracy of ultrasound in the maxillofacial swellings was found to be 86.1% in comparison to [Table 5] presents a 2 x 2 contingency table of the comparison between ultrasound and radiographic diagnosis while maintaining histopathology findings as gold standard. The following were the estimates obtained for validity tests. Sensitivity = 90.3%, specificity = 60%, positive predictive value (PPV) = 93.3%, negative predictive value (NPV) = 50%, and diagnostic accuracy = 86.1%.
|Table 5: A 2×2 contingency table for comparison between ultrasound Vs radiographic diagnosis|
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From the overall cases, ultrasounds have the highest diagnostic accuracy (86.1%) than radiographic (83.3%) or clinical (80.5%) examinations in the diagnosis of maxillofacial swellings. The sensitivity and specificity of ultrasound diagnosis of maxillofacial swellings was also found to be 90.3% and 60%, respectively.
Findings show that ultrasound is comparable to histopathology's sensitivity and specificity in characterizing maxillofacial swellings. This may be further illustrated by the visual similarities of maxillofacial diagnosis across the different examinations analyzed [Figure 1].
|Figure 1: Comparative evaluation of the diagnosis by different examinations analyzed|
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| Discussion|| |
The various lesions manifesting in maxillofacial region have different treatment plans, and thus it is necessary to have accurate information on the pathological nature of the lesion. Since the application of X-rays in medical sciences, radiological examinations such as plain radiographic examinations have played important role in the diagnosis, treatment, and follow-up of maxillofacial lesions. Despite their usefulness, routine radiographic procedures use ionizing radiation, do not demonstrate reliably the presence of every lesion and do not show the real size of the lesion. The pathologic and spatial relationship with anatomical structures especially when image acquisition is on film-screen combination is another fit fall of radiographic diagnosis. On the other hand, USG has over the past few years emerged as an important tool for a variety of applications in the field of medicine and dentistry.
In the present study, Group 1 and 2 cases were diagnosed histopathologically as malignancies. This included one squamous cell carcinoma and one adenocystic carcinoma. Ultrasound could identify one malignant swelling correctly, whereas none was correctly diagnosed by either radiographic or clinical diagnosis. Similarly, one case which appeared to be cystic on clinical and radiographic examination was found to be malignant on USG as well as histopathology. No single malignant lesion was diagnosed clinically. This highlights the close association of diagnostic power similar among ultrasound and histopathologic examinations.
The present study reported a diagnostic accuracy of 50% for USG in diagnosis of malignant lesions. A higher diagnostic accuracy of 67% in differentiating benign cystic lesion from malignant lesions using ultrasound was also reported. However, this is still lower compared to values reported in literature ranging between 80 and 88%. The classical sonographic features of malignant tumors includes complex echo texture with heterogenous internal echo pattern and irregular boundaries. However, a common limitation of ultrasound is the operator dependency and differences in transducer frequency which obviously affects the image details, edge enhancement and contrast of adjacent structures. Perhaps, the transducer frequency differences across these studies might explain the variations across these studies.
The diagnostic accuracy of ultrasound in the diagnosis of benign cystic tumors was found 95.8%. This agrees with the study of Pallagatti et al. that reported 87.5%. The consistent findings across these studies highlighted the reliability of ultrasound in examining, characterizing, and diagnosing lesions around the maxillofacial region.
The Group III swellings were confirmed inflammatory cells histologically in the present study. Clinical, radiographic and ultrasound examinations were able to identify osteomyelitis and abscess but none of them detect the inflammatory cells. Two cases were correctly identified by ultrasound giving a diagnostic accuracy of 50%. The ultrasonographic patterns of abscess are similar to the soft tissue cystic swellings because of its pus content. However, it exhibits an irregular echogenic boundary. All cases have acoustic accentuation which is a pathognomonic indicator of presence of fluid. Ultrasound gave 100% accuracy in the diagnosis of all cases of osteomyelitis and abscess in the current study. Perhaps, the presence of fluid coupled with the established fact where no echoes are returned by fluid making it sonolucent could easily explain the sensitive of ultrasound in detecting fluid collection. This finding is similar to the study conducted by Peleg which concluded that USG is an effective diagnostic tool to confirm abscess formation in the superficial facial spaces and is highly predictable in detecting the stage of infection. The diagnostic accuracy of ultrasound in detecting abscess and osteomyelitis was 100% which is similar with the result of Pallagatti which reported ultrasound gave 100% accuracy in the diagnosis of abscess and space infections.
Similarly, in the present study, all cases of lymphoma were confirmed histologically and were also diagnosed correctly by ultrasound with a 100% diagnostic accuracy. A single swelling which was diagnosed as cellulites on radiography examination was however diagnosed as lymhadenopathy by clinical, ultrasound, and histological examinations. The superficial location of these masses enables clinicians during clinical examination ascertains the characteristic tissue component of these kind of superficial masses. Their outline and presumable tissue component (solid/cystic) nature of the masses can be ascertained on clinical examination. Similarly, ultrasound has been known to be excellent in characterizing both solid and cystic masses. These perhaps may be the reason of consistency between clinical and ultrasound examinations involving well defined superficial solid masses such as lymph nodes enlargements. Therefore, with ultrasound, physicians can evaluate important parameters such as lymph node shape, margins, internal structure, lymphagioma, and abnormal vascularization. Findings from the present study is in line with the studies of Pallagatti (100%), Bagewadi (100%), Dangore (92.85%), Yamamoto (96.5%).
In the current study, the sensitivity and specificity of ultrasound were found to be 86.1% and 90.3%, when compared with radiography. Similar range of values of sensitivity were reported among a number of similar studies., However, the specificity obtained in the present study varies remarkably with most published works. Lower value of specificity was obtained in comparison to its sensitivity. Most studies in the literature have been consistent in the higher specificity of ultrasound over its sensitivity.,,,,, The variation from the present study could be on account of difficulties in differentiating complex swellings with inconsistent patterns. This is an obvious encountered problem to most ultrasound practitioners even among the experienced. Thus, in diagnosing complex swellings with confusing features on ultrasound, an adjunct examination to have an alternative idea may further reduce one's differentials.
In conclusion, the study revealed the efficacy of USG in the diagnosis of most maxillofacial swellings with diagnostic accuracy, sensitivity, specificity, and positive predictive value of ultrasound as 86.1%, 90.3%, 60%, and 93.3%, respectively, when compared with radiography using histopathology as the gold standard. So, combined with clinical and histopathological examinations, real time ultrasound imaging works out as a valuable adjunct in the diagnosis of orofacial swellings. Results of the present study illustrate the usefulness of diagnostic ultrasound imaging and support the use of USG as an important imaging tool in the diagnosis of different swellings at the maxilla-facial region.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]