Triple protocol approach: a modified extended approach of high resolution ultrasonography of cheek

Transcription

1 Triple protocol approach: a modified extended approach of high resolution ultrasonography of cheek Poster No.: C-0386 Congress: ECR 2011 Type: Scientific Paper Authors: B. M. P. Bharat, J. S. K. Joshi, S. D. Patil ; Dharwad/IN, Belgaum/IN Keywords: Head and neck, Ultrasound, Technical aspects, Neoplasia, Tissue characterisation DOI: /ecr2011/C-0386 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 37

2 Purpose To establish protocol based, reproducible High Resolution Ultrasound study technique for evaluation of anatomy and lesions of Cheek. Images for this section: Page 2 of 37

3 Page 3 of 37

4 Fig. 1: CHEEK CORONAL SECTION Fig. 2: MID PANORAMIC HRUSG VIEW OF CHEEK Page 4 of 37

5 Methods and Materials INCLUSION CRITERIA Histopathologically proven or clinically suspected cases of, Oral cavity Carcinoma( bucco-lingual, alveolus, tongue, floor of oral cavity ) Nonneoplastic buccal space, lip and superficial masticator space lesions Cases referred from Oro maxillofacial and Surgery Departments of SDM Dental and Medical Colleges. HRUSG done at Radiodiagnosis Department at SDM medical college. SAMPLE SIZE 58 cases,over 30 months duration from January 2006 to June 2009(Reference - Figure 1 and Figure 2). TECHNIQUE The study was established following a pilot run of the technique for one year duration. High resolution ultrasonography done with Mhz linear probe using high end Ultrasound machine. The study was given the name SDM - TRIPLE PROTOCOL APPROACH. The three protocol combination included, Rectangle/Triangle approach - Cheek divided into anterior two rectangles and one posterior triangle, Page 5 of 37

6 Cheek signature approach - Different layers of cheek standardised in comparision with histological layers and maneuvers like Blown cheek maneuver/tongue touch technique added to improve sensitivity, Planar approach -study done in coronal,axial and sagittal planes,reverse panorama technique adopted for root of tongue and sublingual space evaluation. Cheek is defined by standard concept of plastic surgery( Reference Figure 3). Mastoid tip, angle of mandible, angle of mouth, zygoma prominence and TMJ selected( Reference - Figure 4 ) as 4 reference points to define, upper, lower rectangle - parotid, masseter, parotid duct seen posterior vascular triangle - retromandibular paired vessels of external carotid artery, facial vein( landmark for facial nerve ) seen diagonal plane - representing masseter muscle. ( Reference - Figure 5, 12 and 13 ) The region antero-inferior to masseter ( buccal space ), used to define CHEEK SIGNATURE.( layers ) (Reference - Figure 5) The CHEEK is layered from outside in as shown in the figure( Reference -Figure 6 ). Two maneuvers, blown cheek ( better defines mucosal layer ) and tongue touch technique ( allows tongue evaluation and improved sensitivity of lesional evaluation ) ( Reference - Figure 7, 8 ) AXIAL,coronal and sagittal planes allows better multiplanar definition of anatomy and lesions. ( Reference -Figure 9 ) Each of the approach has unique advantage, RECTANGLE /TRIANGLE - allows systematic structure based protocol evaluation Page 6 of 37

7 CHEEK SIGNATURE - allows evaluation of involvement of specific layer of cheek, especially in carcinoma and submucosal fibrosis cases, allowing planning of conservative surgical technique. PLANAR /REVERSE PANORAMA - allows, better lesion characterization and extent evaluation. Steps of study Patient positioned supine with extended neck. Reference points identified and rectangle /triangle defined. Mid plane panorama scan done from mastoid tip to angle of mouth. Upper rectangle panorama done,post coffee powder tongue stimulation study, to open up parotid duct. Lower rectangle panorama scan done. Posterior triangle scan identifies retromandibular paired vessels, parotid gland. ( Reference -Figure 10,11 ) Buccal space anteroinferior to masseter identified and cheek signature established. Mucosa blurred by its interface with oral cavity air. The blown cheek allows direct mucosal visualisation. Patient asked to touch cheek with tip of tongue and window used to visualise tongue,and corresponding area of buccal mucosa. Mid plane panorama in coronal plane done for floor of oral cavity and it is reversed. It allows relationship based evaluation of sublingual space, submandibular space and root of tongue.( Reference - Figure 14 ) Structure visualization check list Page 7 of 37

8 Mid panorama plane - mastoid tip, initial portion of sternomastoid muscle, paired vessels, portion of deep lobe parotid, portion of masseter, cheek signature region. Upper rectangle - zygoma tip, parotid duct, TMJ, upper buccinator. Lower rectangle - buccal space, portions of masseter, parotid, lower buccinator. Posterior triangle - paired vessels, portion of deep lobe parotid. Signature region - layers of cheek. CASE BASED EVALUATION using triple protocol. BUCCAL CARCINOMA - Identified by lesion per se or if small, by pointing sign( tongue touch technique ). Lesion characterization, layer involvement evaluation, relation with adjacent structures, node details ALVEOLUS CARCINOMA - Above mentioned evaluation along with bone discontinuity ( good sensitivity ) TONGUE CARCINOMA - Identified by tongue touch technique, the lesion details, relation with median raphe, evaluated. FLOOR ORAL CAVITY CARCINOMA - Reverse panorama technique used for lesion evaluation. RETROMOLAR TRIGONE CARCINOMA - Poor evaluation sensitivity. BUCCAL SPACE PATHOLOGIES - Lesion characterization, relation with parotid duct, SUBMUCOSAL FIBROSIS - Cheek signature applied for extent involved Images for this section: Page 8 of 37

9 Fig. 1: STUDY SAMPLE Page 9 of 37

10 Fig. 2: MISCELLANEOUS CASE DISTRIBUTION OF STUDY SAMPLE Page 10 of 37

11 Fig. 3: CHEEK DEFINITION Page 11 of 37

12 Fig. 4: REFERENCE POINTS TO DEFINE CHEEK Page 12 of 37

13 Fig. 5: RECTANGLE, TRIANGLE ESTABLISHMENT Page 13 of 37

14 Fig. 6: CHEEK SIGNATURE - ILLUSTRATIVE COMPARISION Page 14 of 37

15 Fig. 7: BLOWN CHEEK TECHNIQUE Page 15 of 37

16 Fig. 8: TONGUE TOUCH TECHNIQUE Page 16 of 37

17 Fig. 9: PLANAR APPROACH Page 17 of 37

18 Fig. 10 Page 18 of 37

19 Fig. 11: POSTERIOR TRIANGLE Page 19 of 37

20 Fig. 12 Page 20 of 37

21 Fig. 13 Page 21 of 37

22 Fig. 14: REVERSE PANORAMA Page 22 of 37

23 Results The study provided excellent details with regards to lesion pick up, characterization and extent evaluation in all the cases which provided adequate window for the ultrasound transmission. The following summary allows sensitivity, specificity overview of the technique. Carcinoma of Oral cavity - Good in evaluation of the size,extent and its relation to adjacent structures. Floor of oral cavity( Reference figures 1,2,3 ) - Allows size evaluation, relation to intrinsic muscles of tongue, the sublingual space, the submandibular duct /gland and to an extent the bony involvement. The nodal evaluation improves the role of the ultrasound technique, Mandibular Alveolus( Reference figures 4, 5 ) - Unlike the perception, the technique definitely allowed good sensitivity for evaluation of even minimal cortical breach, thus improving its effectiveness in this scenario as well in any carcinoma towards evaluation of outer cortical involvement. Tongue ( Reference Figures 8, 9 )- Provided excellent localisation of the growth, by using the Tongue touch technique.the growth details, its relation to median raphe, vascularity were detailed with adequacy. Buccal mucosa ( Reference Figures 10, 11 ) - The Cheek signature technique allowed stratification of the layers of the cheek. The growth could be evaluated by its layer involvement. The nodal and bone status evaluation improved the role of the technique towards planning concervative surgery. The signature and tongue touch techniques in conjunction provided good technique in localizing and startification details. RetromolarTrigone - In view of inadequate window availability, growths in this region could not be evaluated. Oral Submucosal Fibrosis( Reference Figures 6, 7 ) - The cheek signature technique provided good window with improved sensitivity especially in advanced cases with restricted mouth opening where the clinical examination was difficult. In advanced cases, Page 23 of 37

24 not only does the technique allows evaluation the layers of cheek involved, but also picks up of any underlying growth or neoplasia which would otherwise have been missed. Miscellaneous lesions - Other conditions like retension cysts, minor salivary gland cell rests related growths in the buccal space( fat pad space ),could be characterized as solid, cystic in nature. The specificity in characterizing benign or malignant was relatively low. The study provided following inputs Buccal mucosal growths- pick up, layer involvement evaluation met with 100% specificity compared with histopathology. The technique is very sensitive and specific for the condition. Signature approach including tongue touch and blown cheek technique allowed very good evaluation, for preplanning conservative surgical approach like local excision or buccinator sparing surgeries, thus allowing relative functional sparing surgeries, Malignancies of oral cavity except for the Retromolar trigone growth, could be very well evaluated with clinically relevant information. Nonneoplastic lesions like Vascular malformations, benign cysts, minor salivary gland tumours could be evaluated with good sensitivity. Guided sampling of the lesions was an added advantage in some cases. Images for this section: Page 24 of 37

25 Fig. 1 Page 25 of 37

26 Fig. 2: FLOOR CARCINOMA -GROWTH EXTENT, LAYERS INVOLVED, BONE INVOLVEMENT, VASCULARITY. Page 26 of 37

27 Fig. 3: REVERSE PANORAMA IMAGE OF FLOOR CARCINOMA, SHOWING B/L SUBMANDIBULAR DUCT INVOLVEMENT, NODES, MALIGNANT LOW RI FLOOR IN LESION Page 27 of 37

28 Fig. 4 Page 28 of 37

29 Fig. 5: COMPARATIVE( HRUSG / CT ) BONE INVOLVEMENT DETAILS IN MANDIBULAR ALVEOLUS CARCINOMA Page 29 of 37

30 Fig. 6 Page 30 of 37

31 Fig. 7: VARIABLE FINDINGS IN OSMF Page 31 of 37

32 Fig. 8 Page 32 of 37

33 Fig. 9: TONGUE TOUCH TECHNIQUE FOR CARCINOMA TONGUE Page 33 of 37

34 Fig. 10 Page 34 of 37

35 Fig. 11: LESION WITH/ WITHOUT TONGUE TOUCH SUPPORT Page 35 of 37

36 Conclusion The High Resolution Ultrasonography Of Cheek using SDM Triple Protocol Technique allows, Standard protocol based technique. Improves systematic evaluation of the region. Allows stratification of the layers of the cheek. The tongue touch technique allows visualization of tongue per se, lesions of the tongue as well as buccal mucosa. Multiplanar, reverse panaroma techniques allows cross sectional imaging like establishment of standard planes of imaging, in order to carryout universally standard planes of evaluation. References 1. Greme F, Page D, Fleming I et al. American Joint Committee on Cancer th Staging Manual, 6 edition, New York. Springer - Verlag 2002 Lee JC, Kim JC, Lee JH, et al. Routine Surviellance tool for thedetection of recurrent head, neck squamous cell carcinoma- oral oncology2007, 43, Manoj Pandey, Mrudula Shukla, C S Nithya - Pattern of lymphatic spread from carcinoma buccal mucosa and its implication for less than radical surgery, American Association Of oral and maxillofacial surgery - Joint oral maxillofacial surgery. Micheal T Madison, Kent B Remley, Richard LAtchew. StevenMithcell Radiological diagnosis and stagingof head, neck squamous cell carcinoma, volume31, number 4, august otolaryngological clinics of north America. Raymond Scarpa - Surgical management of head and neck carcinoma Seminars in oncology nursing, volume 25, number 3 ( august 2009 ) pp Crispian Scully, JoseBagan et al- Oral squamous cell carcinoma overview Oral Oncology 45 ( 2009 ) YingM, Ahuja A, Metreweli C. Diagnostic accuracy of sonographic criteria for evaluation of cervical lymphadenopathy. J Ultrasound Med1998; 17: Page 36 of 37

37 Crispian Scully, JoseBagan et al- Oral squamous cell carcinoma overview Oral Oncology 45 ( 2009 ) # YingM, Ahuja A, Metreweli C. Diagnostic accuracy of sonographic criteria for evaluation of cervical lymphadenopathy. J Ultrasound Med1998; 17: YingM, Ahuja A. Sonography of neck lymph nodes. I. Normal lymph nodes. Clin Radiol2003; 58: HowlettDC, Kesse KW, Hughes DV, Sallomi DF. The role of imaging in the evaluation of parotid disease. Clin Radiol2002; 57: GritzmannN, Rettenbacher T, Hollerweger A, Macheiner P, Hubner E. Sonography of the salivary glands. Eur Radiol2003; 13: BusselsB, Maes A, Flamen P, et al. Dose-response relationships within the parotid gland after radiotherapy for head and neck cancer.radiother Oncol2004; 73: RoesinkJM, Moerland MA, Hoekstra A, Van Rijk PP, Terhaard CH. Scintigraphic assessment of early and late parotid gland function after radiotherapy for head-and-neck cancer: a prospective study of dose-volume response relationships. Int J Radiat Oncol Biol Phys2004; 58: KoischwitzD, Gritzmann N. Ultrasound of the neck. Radiol Clin North Am2000; 38: CandianiF, Martinoli C. Salivary glands. In: Solbiati L, Rizzatto G, eds. Ultrasound of superficial structures. Edinburgh, Scotland: Churchill Livingstone, 1995; US of the Major Salivary Glands: Anatomy and Spatial Relationships, Pathologic Conditions, and PitfallsEwa J. Bialek, MD, PhD, Wieslaw Jakubowski, MD, PhD, Piotr Zajkowski, MD, PhD, Kazimierz T. Szopinski, MD, PhD andantoni Osmolski, MD, PhD /rg May 2006 RadioGraphics, 26, Personal Information DR BHARAT M P - FIRST AUTHOR, DEPARTMENT OF RADIODIAGNOSIS, SDM MEDICAL COLLEGE, SATTUR, DHARWAD, KARNATAKA, INDIA PROF DR SK JOSHI - HEAD OF DEPARTMENT, RADIODIAGNOSIS AND IMAGING, SDM MEDICAL COLLEGE, SATTUR, DHARWAD, KARNATAKA, INDIA. DR SANTOSH PATIL - ASSISTANT PROFESSOR, RADIODIAGNOSIS, JNM MEDICAL COLLEGE AND KLE HOSPITAL, NEHRU NAGAR, BELGAUM, KARNATAKA, INDIA Page 37 of 37