Int. J. Oral Maxillofac. Surg.

2002; 31: 327329

doi:10.1054/ijom.2002.0233, available online at http://www.idealibrary.com on

Technical Note
Oral Medicine
H. Yusa1, H. Yoshida1, E. Ueno2,
Ultrasound-guided surgical K. Onizawa1, T. Yanagawa1
1
2
Department of Oral and Maxillofacial Surgery;
Department of Metabolic and Endocrine

drainage of face and neck Surgery, Institute of Clinical Medicine,

University of Tsukuba, Tsukuba, Japan

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:
328330.  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 Key words: ultrasound; grey-scale
infection, and provided easy detection and accurate, reliable penetration of sonography; colour Doppler sonography;
abscesses that were diicult to locate by physical examination. Colour Doppler drainage; abscess.
ultrasonography is particularly useful for dierentiating blood vessels from the
static space of abscesses. Accepted for publication 9 January 2002

Introduction
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
locate1,3,5. In these cases, careless surgi-
cal drainage can result in vessel injury
and reluctant bleeding1. 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
abscesses14,6,7, 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 US1. 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.
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.
328 Yusa et al.

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.

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
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
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 cavity2. 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
formation14,6,7, 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

Table 1. Details of abscesses of eight patients

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

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
Fig. 3. (A) Grey-scale US image showing a small abscess (arrowheads) of the neck in case No. Surgery
4 as a space with ill-defined edge definition, and homogeneous and hypoechoic internal echo. Institute of Clinical Medicine
The distance from the skin surface to the required depth of needle insertion is measured (dotted University of Tsukuba
line). (B) The tip of the needle (arrow) is inserted into the abscess (arrowheads). 1-1-1 Tennoudai
Tsukuba, Ibaraki, 305-8575
Japan
of the whole needle on the US display technique presented here reduces the Tel: +81 298 53 3210
screen, but it is inconvenient if the needle needle insertion distance by inserting it Fax: +81 298 53 3039
needs to be inserted a long distance. The perpendicular to the scanning plane at E-mail: y-yusa@md.tsukuba.ac.jp