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Ultrasonographic evaluation of inflammatory swellings of buccal space

Article in Indian Journal of Dental Research · October 2009

DOI: 10.4103/0970-9290.59454 · Source: PubMed

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Original Research

Ultrasonographic evaluation of inflammatory

swellings of buccal space

K Srinivas, KN Sumanth1, SS Chopra2

Departments of Oral Medicine

and Radiology, Oxford Dental
ABSTRACT
College & Hospital, Bangalore, Objectives: The main objective of the study was a) to differentiate cellulitis and abscess in buccal
1
MCODS, KMC LHH Road,
Hampankatta, Karnataka,
space region, b) to study the ultrasonographic anatomy of cheek region and c) to investigate the
2
Dental College & Hospital, use of ultrasound in the diagnosis of inflammatory swellings of cheek region.
Sriganganagar, India Patients and Methods: The study consisted of 25 patients with unilateral buccal space
inflammatory swellings of odontogenic origin. The contra lateral side was used as control.
Toshiba ultrasonographic device with a linear array transducer (5-8 MHz) was used. The areas
of interest were scanned under both transverse and longitudinal sections and were interpreted
by a single observer. The clinical diagnosis of cellulitis or abscess was confirmed by the absence
or presence of pus respectively both sonographically and by aspiration. Also various anatomical
structures present in buccal space were studied.
Results: Clinically 23(92%) were diagnosed as buccal space abscess and 2 (8%) were cellulitis.
Ultrasonographically and therapeutically 24 (96%) were buccal space abscess and 1 (4%) was
cellulits. The sensitivity of clinical criteria over ultrasonographic diagnosis was 96% with a
specificity of 100%. Also the cheek thickness in males and females varied from 8.2 to 17.1mm
with a mean of 11.6mm±2.1 (SD) and 8.2 mm to 14.2 mm with a mean of 11±1.8 (SD). The
subcutaneous tissue appeared moderately echogenic, buccinator - highly echogenic, deep adipose
tissue - less echogenic and parotid duct was appreciated as a thin hyperechogenic band crossing
the buccinator muscle. Buccal space, masticator space and parotid space were appreciated.
Conclusion: This study supports the ultrasonographic method of imaging of orofacial
inflammatory swellings with high sensitivity and specificity. This imaging modality can also
Received : 24-07-07 help in aspiration of pus in different spaces. We have described the ultrasonographic anatomy
Review completed : 21-11-07
of the above mentioned spaces which can help a beginner in this field.
Accepted : 04-12-07
PubMed ID : ***
DOI: 10.4103/0970-9290.59454 Key words: Ultrasonography, imaging, buccal space, cellulitis

For many years, ultrasonography has played a major role as
a diagnostic tool in various medical fields. Only recently has
it been used for maxillofacial imaging. It has still not found
its place as a routine diagnostic aid in this field.[1] When
one considers that the majority of structures and associated
pathologies in the head and neck region lie only between 1
and 5 cm below the skin surface, it is not surprising that
ultrasound is gaining in popularity in the field of head and
neck imaging.[2]
Imaging of soft tissue infections has traditionally been a
challenging and difficult task. The concept of fascial spaces
is based on the knowledge of anatomists that all spaces exist
only potentially, until fascia is separated by pus, blood,
drain or surgeon’s finger. In case of odontogenic infections,
fascial spaces may become involved when the infection
spreads deeply into the soft tissue rather than exiting
Address for correspondence:
Dr. KN Sumanth,
E-mail: sumikn@rediffmail.com
Indian J Dent Res, 20(4), 2009
superficially through oral and cutaneous routes.[3] In case
of acute odontogenic infection, we need to know whether
the inflammatory process is in a stage of abscess formation
requiring primary evacuation of pus and administration of
antibiotics, or a cellulitis that can generally be treated with
antibiotics alone.[4] Since the examination of inflammatory
facial swellings is largely restricted to clinical techniques of
evaluation, such as palpation and the inflammatory processes
leading to abscess formation is not defined in space and time,
it is difficult to diagnose the stage of infection and to locate
its exact anatomic location. CT and MRI can be used to
diagnose these conditions. An alternative diagnostic tool that
is widely available, relatively inexpensive (in imagiological
terms) and non-invasive is ultrasonography.[4]
The buccal space is bordered medially by buccinator muscle,
which attaches to the outer cortex of the maxillary alveolar
ridge. It is tucked away between the maxillary alveolar ridge
medially, the masticator space posteriorly and parotid space
laterally. Anteriorly, the buccal space is separated from the
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Ultrasonographic evaluation of inflammatory swellings of buccal space
subcutaneous tissues of the face by the plane formed by the
superficial muscles of facial expression (greater and lesser
zygomaticus muscles, risorius) and the investing fascia.
The buccal space does not have complete fascial coverings
that separate it from adjacent spaces. The lack of defined
boundaries allows extensions of clinically overt and occult
infections through the buccal space. Inferiorly, the buccal
space blends imperceptibly with the submandibular space.
The deep fat of buccal space joins into the fat of the postero-
lateral portion of the masticator space (suprazygomatic
masticator space, infratemporal fossa). This extension passes
deep to the zygomatic arch and ascends superiorly and
laterally to surround the coronoid process of mandible and
the insertion of the temporalis muscles, which are part of
the masticator space.
The contents of the buccal space are adipose tissue,
buccinator muscle, lymph nodes, parotid duct, minor
salivary gland tissue, facial vein, facial and buccal artery
and buccal branch of the facial nerve.
The adipose tissue of deep buccal space is distinct from the
fat within the anterior buccal space and subcutaneous
tissue. The fat of the deep buccal space is a special form
of adipose tissue known as ‘syssarcoses’. This is likely the
remnant of the succatory pad of infants that aids in muscular
motion needed to open and close the mouth.[5]
The objectives of this clinical study were
1. To study the ultrasonographic anatomy of the cheek
region.
2. To subject the inflammatory swellings of the buccal
space to ultrasonographic examination before medical
or surgical management.
3. To investigate the use of ultrasound in the diagnosis of
inflammatory swellings of cheek region.
PATIENTS AND METHODS
The study was conducted at Department of Oral Medicine
and Radiology, P.M.N.M. Dental College and Hospital,
Bagalkot and Shirur Maternity Home, Bagalkot. The study
consisted of 25 patients suffering from inflammatory
swellings of buccal space (unilateral) with normal
contralateral buccal space taken as control.
The subjects were selected based on the following criteria:
• No age and sex bar.
• Patients suffering only from buccal space infection
(unilateral), with normal contralateral buccal space and
clinically diagnosed as either cellulitis or abscess due to
odontogenic origin were included in the study.
• The diagnosis of buccal space infection, whether it is
cellulitis or abscess was done according to the criteria
given by Peterson Larry J. et al.[6] and the diagnosis was
radiographically confirmed.
459
Srinivas, et al.
• Those patients who were willing to participate in the
study were only included.
• Patients with pathologies other than cellulitis and
abscess were excluded from the study.
• The contralateral buccal spaces of the patients with
pathologies most likely to show ultrasonographic
changes were excluded from the study.
The ECCOCEE diagnostic ultrasound system (Toshiba
Corporation, Japan model No. SSA - 340A) and a linear
array transducer (Toshiba Corporation, Japan model
No. PLF- 805ST), which is a multi-frequency probe
(5-8 MHz) was used. In the present study, 8 MHz probe
was used for all the scans.
All sonographic examinations were performed in a
darkened room and performed by single examiner. Patients
positioning for sonographic examination was carried out
according to methodology described by Ahuja and Rhodri.[2]
The areas of interest were scanned under both transverse and
longitudinal sections. For measurement of cheek thickness
of the normal side, the transducer was placed transversely
on an imaginary line drawn between corners of the mouth
to the tragus of the ear for all patients.
The sonographic pictures were interpreted by a single
observer according to the guidelines given by various
authors.[1,4,7,8,9] Ultrasonographically, patients diagnosed as
cellulitis were given appropriate antibiotic therapy, and for
the patients diagnosed as suffering from abscess, pus was
aspirated and patients were referred to Department of Oral
and Maxillofacial Surgery for incision and drainage and
antibiotic therapy. All the patients were called for follow-up
after 5 days and the condition of the patients were evaluated.
RESULTS
The study consisted of a total number of 25 patients with
buccal space inflammatory swellings. The condition of the
subjects was diagnosed clinically and ultrasonographically.
The age of 25 patients who participated in the study ranged
from 17 to 46 years and there were 13 males and 12 females
in the study.
Clinical findings on the pathological side (buccal
space)
On extraoral examination, on inspection, all 25 patients
had swelling in the buccal space region. Thirteen (52%)
had swelling on the right side and 12 (48%) on the left side
of the face.
On intraoral examination, 9 patients had buccal space
infection due to carious lesion involving either 16 or 17;
12 patients had buccal space infection due to carious
lesion involving either 26 or 27, except one case, which
had periodontal abscess in relation to 26 and 27; 1 patient
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Ultrasonographic evaluation of inflammatory swellings of buccal space Srinivas, et al.

had buccal space infection due to carious lesion involving
36 and 3 patients had buccal space infection due to
carious lesion involving either 46 or 47. The diagnosis was
confirmed by radiographic examination except for one
case in which patient had periodontal abscess, as there
is no pathgnomonic radiographic feature for periodontal
abscess. Twenty three (92%) patients were diagnosed
clinically as buccal space abscess, out of which 13 were males
and 10 were females and 2 (8%) patients were diagnosed
clinically as suffering from cellulitis and both of them were
females.
• Out of these 24 cases with focal lesions, 1 (4.2%) was
roughly oval in shape and rest of 23 (95.8%) were
irregular in shape.
• The contents of the focal lesion in buccal space were
either hypoechoic or anechoic. Thirteen (54.2%) cases
had hypoechoic pattern of the lesion and 11 (45.8%) had
anechoic pattern of the lesion [Figure 5]. All the 24 cases
had acoustic accentuation indicative of presence of fluid.
• Mass effect was appreciated in 3 (12.5%) of cases and
absent in 21 (87.5%) cases [Table 1].

Ultrasonographic findings of the control side DISCUSSION

(Buccal space)
The diagnosis of cellulitis in orofacial region is a clinical
The normal anatomical features appreciated ultrasono-
graphically were subcutaneous tissue, buccinator muscle, one that requires urgent attention, as a fulminating course
parotid duct and deep adipose tissue. The subcutaneous may occur, resulting in severe tissue destruction or life-
tissue appeared as moderately echogenic, uniformly thick threatening bacteremia.[9] Previous reports had indicated
band followed by buccinator muscle, which appeared highly that ultrasonography is widely accepted non-invasive
echogenic (but not hyperechoic). The buccinator muscle technique for imaging cellulitis, fascial space infections
was identified ultrasonographically by asking the patient to and abscess.[8]
blow his cheek and the increase in echogenicity confirmed
The present study aids in confirming the diagnosis of
the position of buccinator. Deep to the buccinator muscle,
another band of echogenic area was observed, which was cellulitis and abscess through sonographic imaging and also
comparatively less echogenic than that of subcutaneous to study the ultrasonographic anatomy in the buccal space
tissue, which was the special type of deep adipose tissue region. Buccal space was chosen because, for a beginner
[Figures 1 and 2]. in ultrasound, it is difficult to study the spaces such as
suprahyoid spaces where there are too many structures,
The thickness of the deep adipose tissue (Syssarcosis) was and there is a difficulty of interpretation of images in such
more in chubby cheeked patients when compared to normal a situation. The discussion is written under three headings:
flat cheeked patients [Figures 1 and 2]. The parotid duct A. Clinical findings of the pathology side.
was appreciated as a thin hyperechogenic band crossing B. Ultrasonographic findings of the control side.
the buccinator muscle, which could be appreciated clearly C. Ultrasonographic findings of the pathology side.
only in four cases. The masticator space which borders
buccal space posteriorly was observed sonographically Clinical findings of the pathology side (buccal space)
as echogenic area immediately behind the buccal space Clinically 23 (92%) patients were diagnosed as having
[Figure 3]. The parotid space that borders the buccal space buccal space abscess and 2 (8%) patients were diagnosed
laterally was observed lateral to buccal space on sonography as having cellulitis involving the buccal space. Though
with clear demarcating hyperechoic parotid capsule 23 (92%) swellings did not have pointing surface as described
[Figure 4]. The zygomatic buttress and arch were observed as a clinically for a classical abscess,[10] because of the well-
well-defined hyperechoic area superior to buccal space. defined borders, soft consistency and presence of fluctuation,
Skin, minor salivary glands, lymph nodes, facial vessels and
Table 1: Ultrasonographic findings of buccal space
nerves were not appreciated in this study.
swellings
Characteristics USG findings No. of Percentage
Ultrasonographic findings of the pathology side cases
(Buccal space) Distance of soft tissue Increased 25 100
Ultrasonographically there was increased distance from from skin to oral mucosa
skin to oral mucosa on the pathology side in all cases. The Anatomical features Well defined 25 100
Integrity of subcutaneous Absent 25 100
following ultrasonographic observations were seen: tissue/muscle
• Anatomical features namely subcutaneous tissue and Focal lesions Present/Absent 24/1 96/4
buccinator muscle were well defined without any
abnormal echo patterns in all cases. Shape of focal lesion Irregular/Oval 23/1 95.8/4.2
• The integrity of subcutaneous tissue and/or muscle was
Contents of focal lesion Hypoechoic/ 13/11 54.2/45.8
lost in all cases [Figure 4]. Anechoic
• Except in one case all other 24 cases showed focal lesions Acoustic accentuation Present 24 100
with good definition. Mass effect Present/Absent 3/21 12.5/87.5

Indian J Dent Res, 20(4), 2009 460

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Ultrasonographic evaluation of inflammatory swellings of buccal space
1
2
Figure 1: Ultrasonographic picture showing less echogenic
subcutaneous tissue (1), highly echogenic buccinators (2) and
moderately echogenic deep adipose tissue (3). (USG, 8 MH2 probe)
Figure 3: Ultrasonographic picture showing masticator space (MAS)
and buccal space (BS). (USG, 8 MH2 probe)
Figure 5: Ultrasonography picture showing anechoic lesion in the
region of buccal space suggesting of buccal space abscess. (USG,
8 MH2 probe)
these cases were diagnosed as buccal space abscess.
As quoted by Rosenfield et al ., [11] Fields and Dunn
(1973) stated that collagen is considered major source
461
Srinivas, et al.
Figure 2: Schematic representation of Figure 1 showing less echogenic
subcutaneous tissue (1), highly echogenic buccinators (2) and
moderately echogenic deep adipose tissue (3)
Figure 4: Ultrasonography picture showing hyperechoic parotid capsule
(PC) and buccal space (BS). (USG, 8 MH2 probe)
of echogenicity in tissues. The supporting tissues are
characterized by a bulk modulus that is 10,000 times that
of surrounding tissues. Since collagen and other similar
proteins form the fibrous skeleton of soft tissues, different
organs would be expected to display different internal echo
patterns based to some extent on their collagenous content.
The echogenicity of the various landmarks in decreasing
order are,
• Parotid duct: Thin hyperechogenic band.
• Contracted buccinator: Highly echogenic.
• Relaxed buccinator: Less highly echogenic.
• Subcutaneous tissue: Moderately echogenic.
• Deep adipose tissue: Less echogenic.
The thickness of the deep adipose tissue was more in chubby
cheeked individuals when compared to normal flat cheeked
individuals. Thus the lessening of echogenicity of the deep
adipose tissue indicates the decreased collagen content and
may aid in plastic surgeries for reduction of chubbiness.
Indian J Dent Res, 20(4), 2009
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Ultrasonographic evaluation of inflammatory swellings of buccal space
The location of parotid duct and its echogenicity can help
in cases of sialodochitis and sialolithiasis as there will be
increase in the echogenicity along the entire course of the
duct or localized area, respectively.
The borders of the buccal space were identified anteriorly,
medially, posteriorly, laterally and superiorly, which may
aid in the definition of any lesion and spread of inflammation
and malignancy adjacent to the buccal space.
The frequency used in the present study was 8 MHz and with
this frequency, structures like skin, minor salivary glands,
lymph nodes, facial vessels, nerves cannot be appreciated.
Since we have not applied Doppler, facial vessels were not
appreciated. Buccal lymph nodes may be present along
with the afferent vessels, which drain the cheek region to
submandibular lymph nodes;[12] since the control side was
free from inflammation and infection, the lymph nodes were
not visualized. Also it is not a regular anatomical feature[12]
and hence was not appreciable in any of the cases studied.
Ultrasonographically, there was increased distance from
skin to oral mucosa on the affected side, which denoted
the third dimension of the swelling and could help in
quantification of pus or inflammatory zone. The integrity
of the subcutaneous tissue and/or muscle was lost in all the
cases; proves the theoretical explanation that the enzymes
of the bacteria break down the interstitial tissues which is
similar to that of Chao Hsun – Chin et al.[9]
Thirteen (54.2%) of the 24 cases had hypoechoic pattern
and 11 (45.8%) had anechoic pattern of the lesion indicative
of consistency of pus. None of the cases showed isoechoic
pattern. According to Loyer et al.[8] pus can be anechoic,
hypoechoic and isoechoic, and if at all isoechoic patterns are
seen, then gentle intermittent digital palpation or pressure
applied with the transducer over an area of swelling can
identify true echogenicity of the pus by inducing motion
of the purulent content.
All the 24 cases had acoustic accentuation indicative
of presence of fluid. According to various ultrasound
experts,[13,14] acoustic accentuation is a pathognomonic
indicator for the presence of fluid.
Mass effect was appreciated in three cases. None of the
studies have mentioned or discussed about the mass effect in
inflammatory swellings of head and neck region. In abscess
formation, pus accumulation tends to put pressure giving
the surrounding tissues a curvaceous presentation on the
ultrasound, this appearance is called mass effect. Among the
three cases, which had mass effect none of them presented
with any distinctive ultrasonographic findings to suggest
the cause for the presence of mass effect; however, it could
Indian J Dent Res, 20(4), 2009
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Srinivas, et al.
be explained by the fact that in these cases probably the
quantity of pus was more [Table 1].
CONCLUSION
We have described the normal echogenicity of the
anatomical structures in cheek region which can facilitate an
inexperienced radiologist to identify the pathology by using
ultrasound. However, further studies based on large samples
with space infection in the maxillofacial region along with
usage of color Doppler and high-frequency transducer needs
to be undertaken, as they can alter the treatment approach
for providing better patient care.
ACKNOWLEDGMENT
The authors sincerely thank Dr. Herenjal for his help by providing
the ultrasonographic equipment for conducting the study. Also
we thank our statistician, Mr. Sangam for his help.
REFERENCES
1. Siegert R. Ultrasonography of inflammatory soft tissue swellings of
the head and neck. J Oral Maxillofac Surg 1987;45:842-6.
2. Ahuja AT, Rhodri E, editors. Practical head and neck ultrasound. Hong
Kong: GMM Publications; 1996. p. 1-32.
3. Struk DW, Munk PL, Lee MJ, Ho SG, Worsley DF. Imaging of soft tissue
infections. Radiol Clin North Am 2001;39:277-303.
4. Peleg M, Heyman Z, Ardekian L, Taicher S. The use of ultrasonography as
a diagnostic tool for superficial facial space infections. J Oral Maxillofac
Surg 1998:56:1129-31.
5. Mukherji SK, Castillo M. A simplified approach to the spaces of the
suprahyoid neck. Radiol Clin North Am 1998;36:761-79.
6. Peterson LJ, editor. Contemporary oral and maxillofacial surgery. 2nd
ed. Bangalore: Harcourt Brace and Company, Asia Pvt. Ltd; 1997. p.
414-25.
7. Leopold GR. Ultrasonography of superficially located structures. Radiol
Clin North Am 1980;18:161-73.
8. Loyer EM, Kaur H, David CL, DuBrow R, Eftekhari FM. Importance of
dynamic assessment of the soft tissues in the sonographic diagnosis
of ecogenic superficial abscesses. J Ultrasound Med 1995;14:669-71.
9. Chao HC, Lin SJ, Huang YC, Lin TY. Sonographic evaluation of cellulitis
in children. J Ultrasound Med 2000;19:743-9.
10. Cotran RS, Vinaykumar, Tucker C, editors. Robin’s pathologic basis of
disease. 6th ed. Noida; W.B. Saunders Company: 2000. p. 75.
11. Rosenfield AT, Taylor KJ, Jaffe CC. Clinical applications of ultrasound
tissue characterization. Radiol Clin North Am 1980;18:31-58.
12. Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE,
et al, editors. Gray’s anatomy. 38th ed., Edinburg: Churchill Livingstone;
2000. p. 75-90 and 1612.
13. Carol RM, Stephanie IW, Charbineau JW, editors. Diagnostic ultrasound.
USA: Mosby Publications: 1991. p. 1-41.
14. Hagen-Ansert SL, editors. Textbook of diagnostic ultrasound V-I. 5th ed.
Philadelphia: C.V. Mosby Company; 2001. p. 3-15.
How to cite this article: Srinivas K, Sumanth KN, Chopra SS. Ultrasonographic
evaluation of inflammatory swellings of buccal space. Indian J Dent Res
2009;20:458-62.
Source of Support: Nil, Conflict of Interest: None declared.
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