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Int. J. Oral Maxillofac. Surg. 2002; 31: 327–329 doi:10.1054/ijom.2002.0233, available online at http://www.idealibrary.com on

available online at http://www.idealibrary.com on Ultrasound-guided surgical drainage of face and neck

Ultrasound-guided surgical drainage of face and neck abscesses

H. Yusa, H. Yoshida, E. Ueno, K. Onizawa, T. Yanagawa: Ultrasound-guided surgical drainage of face and neck abscesses. Int. J. Oral Maxillofac. Surg. 2002; 31:

328–330. 2002 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights reserved.

Abstract. An ultrasound-guided surgical drainage technique in which grey-scale and colour Doppler ultrasonography were combined is described. The technique was performed for eight deep subcutaneous abscesses subsequent to odontogenic infection, and provided easy detection and accurate, reliable penetration of abscesses that were diicult to locate by physical examination. Colour Doppler ultrasonography is particularly useful for dierentiating blood vessels from the static space of abscesses.

Technical Note Oral Medicine

H.

Yusa 1 , H. Yoshida 1 , E. Ueno 2 ,

K.

Onizawa 1 , T. Yanagawa 1

1 Department of Oral and Maxillofacial Surgery; 2 Department of Metabolic and Endocrine Surgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan

Key words: ultrasound; grey-scale sonography; colour Doppler sonography; drainage; abscess.

Accepted for publication 9 January 2002

Introduction

Materials and methods

The subjects consisted of eight patients with odontogenic infection who were referred to our department from May 1999 through April 2000. Their skin surfaces were sterilized with a colourless and transparent disinfectant, and care- fully scanned for the presence, location, and extent of the abscess using an SSD- 2200 US system with a 10 MHz mechan- ical sector scanner or a 7.5 MHz linear array transducer (Aloka, Tokyo, Japan). A sterile ultrasound gel was used as the coupling agent. After visualizing the abscess by grey-scale US, colour Doppler US was performed to detect vessels close to the abscess and to exam- ine the mutual anatomical locations of the abscess and surrounding blood ves- sels. The colour Doppler setting was chosen to optimize the detection of low- velocity bloodflow with avoidance of the aliasing artifact. The probe position was adjusted so that the intended puncture point of the abscess was aligned with the

midline of the probe, and the distance from the skin surface to the required depth of needle insertion was measured accurately. Under local anaesthesia, aspiration was performed by inserting the needle to the depth that was predetermined by US evaluation, holding the probe in one hand and a 10 ml disposable syringe fitted with an 18 gauge needle in the other. The patient was asked not to move, breathe deeply, or swallow during the needle insertion to avoid shifting the image. The needle was inserted freehand into the abscess at an angle perpendicu- lar to the scanning plane, without the use of mechanical devices such as an aspir- ation adapter (Fig. 1). During needle insertion, care was taken not to injure the surrounding blood vessels. When the needle tip arrived at the predetermined depth, the retained pus was aspirated immediately and saved for culturing. An incision was made in the skin alongside the needle, through which a corrugated drain was inserted into the abscess.

The anatomical location of abscesses in patients with odontogenic infection is commonly determined by physical examination, but abscesses of the deep subcutaneous layer can be diicult to locate 1,3,5 . In these cases, careless surgi- cal drainage can result in vessel injury and reluctant bleeding 1 . Grey-scale ultrasonography (US) has been reported to be a quick, relatively inexpensive, non-invasive, sensitive, and accessible diagnostic tool for identifying the location and extent of head and neck abscesses 14,6,7 , but it cannot dieren- tiate an abscess from the surrounding vessels. Although colour Doppler US can be used to resolve this problem, there are few reports describing US-guided abscess drainage using colour Doppler US 1 . This paper describes an original method for US-guided surgical drainage of deep face and neck abscesses that uses both grey-scale and colour Doppler US.

0901-5027/02/030327+03 $35.00/0

2002 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Science Ltd. All rights reserved.

328 Yusa et al.

328 Yusa et al. Fig. 1. The needle is placed at the midline of the probe

Fig. 1. The needle is placed at the midline of the probe and inserted freehand into the abscess, perpendicular to the scanning plane.

Results

The abscesses of all eight patients were visualized with grey-scale US. Three were abscesses of the submandibular space; there were two each of the neck and buccal space, and one of the sub- mental space. The grey-scale images showed clear edge definition and a homogeneous internal echo pattern for three of the abscesses, ill-defined edge definition and a homogeneous internal echo pattern for three, and ill-defined edge definition and a heterogeneous internal echo pattern for two. The inten- sity of internal echoes in all cases was hypoechoic (Table 1). Colour Doppler imaging was useful in two cases (Nos 5 and 6): the common carotid artery and internal jugular vein in case 5 and the facial artery in case 6 were close to the abscesses (Fig. 2). In both cases the location and extent of the abscesses were clearly distinguished from the blood

Table 1. Details of abscesses of eight patients

vessels and surrounding inflammatory tissues using colour Doppler US; the latter were detected as a colour-flow signal, and the fluid that had collected in the abscesses as a no-colour signal. There was no diiculty in manoeu- vring the probe into the correct position to obtain dependent drainage of the abscesses, because the probe was adjusted so that the abscesses were delin- eated in the centre of the display screen. The predetermined distance from the skin surface to the abscess by US was from 11.8 mm to 23.7 mm, and the depth required for inserting the needle tip into the abscess was from 12 mm to 22 mm. The dierence between the measured and actual depth was less than 2.5 mm in all cases (Table 1). The needle tips were guided accurately into all the abscesses, which were penetrated easily, without misdirected and repetitive punctures, or injury to the vessels (Fig. 3). No patients complained of severe pain and there

were no complications during or after aspiration. For all the patients, the US-guided surgical drainage of the abscess and drain insertion were conclusive, and none required any additional or subsequent drainage.

Discussion

The relatively blind surgical incision and drainage of abscesses based on diagnosis by physical examination may result in excessive tissue trauma, unnecessarily extensive incisions, excess time, pain, and failure to locate and evacuate the abscess cavity 2 . To avoid such complica- tions, grey-scale US has been reported to be a useful diagnostic tool for delineat- ing the location and extent of abscess formation 14,6,7 , but it cannot dieren- tiate an abscess from surrounding blood vessels. Here we combined colour Doppler US with grey-scale US to over- come this problem. Because the target of colour Doppler imaging is the moving blood cells within the blood vessel, the vessels and inflammatory tissue, which has a higher blood volume due to increased permeability of the vessel wall, are depicted as a colour-flow signal. Blood flowing towards the US trans- ducer is displayed as red, and that mov- ing away from the transducer as blue. In contrast, the retained pus, which does not contain flowing blood cells, is delin- eated as a no-colour flow signal. This property of colour Doppler US allows it to dierentiate blood vessels from static regions in US images. In this study, the combination of colour Doppler with grey-scale US helped us to avoid injury to blood vessels in two cases. In the US-guided needle aspiration technique, the needle is typically inserted parallel to the plane of scanning, using aspiration adapters. The procedure has the advantage of enabling visualization

 

Grey-scale findings

 

Actual

 

Pre-determined

inserted

 

Age

Internal echo

distance

depth

No.

Sex

(years)

Site of abscesses

Edge definition

Pattern

Intensity

(mm)

(mm)

1

F

22

Submandibular space

Clear

Homo

Hypo

13.4

12

2

M

33

Submandibular space

Ill-defined

Homo

Hypo

22.3

20

3

M

44

Submandibular space

Ill-defined

Hetero

Hypo

14.4

15

4

M

60

Neck

Ill-defined

Homo

Hypo

11.8

12

5

F

28

Neck

Clear

Homo

Hypo

23.7

22

6

F

18

Buccal space

Clear

Homo

Hypo

12.8

12

7

F

72

Buccal space

Ill-defined

Homo

Hypo

19.5

20

8

M

29

Submental space

Ill-defined

Hetero

Hypo

13.7

15

M: male; F: female; Homo: homogeneous; Hetero: heterogeneous; Hypo: hypoechoic.

Ultrasound-guided surgical drainage of face and neck abscesses

329

surgical drainage of face and neck abscesses 329 Fig. 2. Grey-scale US image showing an abscess

Fig. 2. Grey-scale US image showing an abscess (arrowheads) of the buccal space in case No.

6 as a space with clear edge definition, and homogeneous and hypoechoic internal echo. Colour

Doppler image showing the fluid collected in the abscess as a no-colour signal, and the pulsating facial artery (arrows) as a colour-flow signal.

pulsating facial artery (arrows) as a colour-flow signal. Fig. 3. (A) Grey-scale US image showing a

Fig. 3. (A) Grey-scale US image showing a small abscess (arrowheads) of the neck in case No.

4 as a space with ill-defined edge definition, and homogeneous and hypoechoic internal echo.

The distance from the skin surface to the required depth of needle insertion is measured (dotted line). (B) The tip of the needle (arrow) is inserted into the abscess (arrowheads).

of the whole needle on the US display screen, but it is inconvenient if the needle needs to be inserted a long distance. The

technique presented here reduces the needle insertion distance by inserting it perpendicular to the scanning plane at

the midline of the probe. Although it is diicult to visualize the whole needle by this method, the location of the tip of the needle relative to the abscess is always visible on the US display. In addition, the reduced insertion distance decreases the risk of vessel injury and facilitates the introduction of a drain, compared with the Seldinger technique reported

previously1.

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Address:

Hiroshi Yusa DDS, PhD Department of Oral and Maxillofacial Surgery Institute of Clinical Medicine University of Tsukuba 1-1-1 Tennoudai Tsukuba, Ibaraki, 305-8575 Japan Tel: +81 298 53 3210 Fax: +81 298 53 3039 E-mail: y-yusa@md.tsukuba.ac.jp