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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5770_Библиотеки_им_академика_М_И_Перельмана.pdf
Sonography oftheParanasal Sinuses,
Soft Tissues oftheFace, Orbit, andBony
Structures oftheFace
HansJ.Welkoborsky
14
Ultrasonography of the soft tissues in the face, of the paranasal
sinuses, and of the orbit is not as common as examinations of
the neck, thyroid glands, or salivary glands. One reason for
this lies in the anatomy that makes ultrasonographic imaging
sometimes impossible. The rst part of this chapter focusses
on anatomical and technical remarks for ultrasonography of
the face and paranasal sinuses. Both common techniques,
A-mode and B-mode sonography, are described with their
diagnostic accuracy and their advantages and limitations. The
second part of the chapter describes typical sonographic characteristics of particular diseases, e.g., acute and chronic sinusitis, inammatory diseases of facial soft tissues, and masses of
the soft tissues. The third part of the chapter details sonography of the orbit and its adnexa.
14.1 Introduction
Ultrasonographic examinations of the soft tissues in the face,
of the paranasal sinuses, and of the orbits are not as common
as examinations of the neck or salivary glands. One reason lies
in the anatomy: the soft tissue layers in the face are usually
relatively thin. Underneath these soft tissues, the bony structures that mainly form the face are predominant and reect
more than 90% of all ultrasound energy. The bony structures
surround the paranasal sinuses, and in healthy conditions, they
are lled with air, which does not reect sufcient sound
energy to create interpretable images [1]. Pathologic conditions in the soft tissues of the face and in the paranasal sinuses
and orbits, however, sometimes create fairly typical ultrasound
characteristics that make this technique suitable to be applied
in this area, rather than other imaging techniques.
Of the paranasal sinuses, only the maxillary sinuses and
the frontal sinuses are accessible for ultrasound. Studies pub-
lished on this issue are rare, and some date from 20years ago
or even earlier, but many of these studies have shown good
correlations between plain x-ray, CT scans, and ultrasound
ndings in a population of patients with acute and chronic
sinus disease [2–6]. The sphenoid sinus and the anterior ethmoid sinuses are usually withdrawn from ultrasound examinations because of the very thick bony structures that lie
between the ultrasound transducer and the sinus. On the
other hand, the posterior ethmoid cells can be assessed by
using the eyeball as a water path for ultrasound imaging of
these structures, which lie deep in the head. Ultrasound of
the middle and inner ear is not possible with the currently
available technology and equipment, because the thickness
of the temporal bone prevents most ear structures from being
visualized by ultrasonography [1].
The soft tissues of the face are relatively supercial, so
they are easily accessible for ultrasonography. Ultrasound
also provides some important information about pathologic
conditions of the bones, such as bony fractures of the
zygoma, the infraorbital or supraorbital rim, or the nasal
skeleton, and it can therefore contribute to differential diagnosis. With its easy accessibility in institutions equipped for
ultrasonography, it can serve as a rst-line assessment for
screening of trauma and infectious or tumorous conditions
and pathologies, rather than more complex imaging techniques such as CT scans. This advantage is especially important in the ofce setting or for patients for whom radiation
exposure should be avoided, such as children and pregnant
women. This chapter focuses on the indications, technique,
and typical ndings of ultrasonography in the soft tissues of
the face, the paranasal sinuses, and the orbit.
14.2 Anatomical Remarks
H. J. Welkoborsky (*)
Department of Otorhinolaryngology, Head and Neck Surgery,
KRH Nordstadt Clinic–Academic Hospital, Hanover, Germany
e-mail: hans-juergen.welkoborsky@krh.eu
© Springer Nature Switzerland AG 2019
H. J. Welkoborsky, P. Jecker (eds.), Ultrasonography of the Head and Neck, https://doi.org/10.1007/978-3-030-12641-4_14
The soft tissue layers in the face consist of the skin, the subcutaneous adipose tissue, and at muscles. Underneath these
relatively thin, soft tissues are located the bony structures,
which create a more signicant acoustic mismatch. The soft
291
292
H. J. Welkoborsky
tissues, which are located supercially, are easily accessible
for ultrasound imaging, but only the supercially located
bony structures can be examined by sonography. Therefore
only fractures and other bony discontinuities of the nasal
skeleton, the mandible, or the orbital walls can be visualized,
along with bony swellings such as those due to a bony tumor.
The frontal sinuses are slightly curved; their expansion
underlies signicant interindividual variations. The anterior bony wall of the frontal sinuses can easily be examined
by ultrasonography, along with parts of the sinus oor.
Secretions, mucosal swellings, or cystic lesions create typical ultrasound ndings in both A-mode and B-mode ultrasonography and can therefore be diagnosed with high
accuracy. The maxillary sinuses are shaped like a pyramid
with its base directed to the cheek. The roof of the sinus is
the orbital oor with the infraorbital rim. As in the frontal
sinuses, the anterior maxillary sinus wall and the sinus contents can be easily examined. The anterior and posterior
ethmoid sinuses are located between the orbits. They can be
visualized only in part, using the eyeball as a water path so
that the sound can pass [3].
Of the midface bony structures, the infraorbital, supraorbital, and lateral orbital rims can be visualized, along with
parts of the mandible and the bones of the nose.
sonography, but A-mode sonography is historically
anchored in Europe as part of the diagnostics of paranasal
sinus diseases, especially in an ofce setting. A-mode
sonography can detect mucosal swellings, cysts, and uid
retention in both the maxillary and frontal sinuses. The
technique is reliable and simple, which is the reason for its
wide application, mainly in Europe [7, 8].
In healthy patients, the echo of the anterior wall of the
maxillary and frontal sinuses normally can be detected. It is
usually not possible to visualize the posterior wall or to
examine the sinus lumen in an air-lled sinus (Fig.14.2).
During acute and chronic sinusitis, with swollen mucosa or
retention of uid, which conducts the ultrasound waves, a
second echo from the posterior wall can be visualized.
14.4 Ultrasonography oftheParanasal
Sinuses
The main indications for ultrasonography of the paranasal
sinuses are detailed in Table14.1.
14.4.1 Acute Sinusitis
14.3 Technical Remarks
For ultrasound examination of the soft tissue of the face,
high-frequency array transducers of 7.5MHz or above are
appropriate. Alternatively, multiband transducers of 7.5–
12MHz might be used. For dermatologic purposes such as
estimation of skin inltration by a tumor, transducers of even
higher frequencies (15–20MHz) should be used. One should
keep in mind that the depth of sound penetration decreases
with the increase of the transducer’s frequency, so the resolution of a high-frequency transducer is excellent in the supercial parts but worse in the deeper tissue layers, as discussed
in Chap. 2. For examination of the paranasal sinuses, ultrasound transducers of lower frequencies (3.5 or 5MHz) are
appropriate.
Imaging of the facial bones and soft tissue is performed
with the patient lying in a supine position, but ultrasonography of the paranasal sinuses ideally should be performed
with the patient sitting upright with anteexion of the head
(Fig.14.1). This position ensures that if the patient has uid
in the sinus lumen, this uid has some contact with the anterior bony sinus wall, which is essential for its detection.
Basically, ultrasonography of the paranasal sinuses can
be performed in two different technical ways: A-mode
sonography (amplitude-mode) or B-mode sonography
(brightness or grayscale mode). Ultrasonography of the
paranasal sinuses is usually performed using B-mode
Acute sinusitis is a usually clinical diagnosis, based on the
combination of the symptoms: history of rhinitis or acute
upper respiratory tract infection, frontal headache that is
intensied when the head is bent forward or downward, and
sometimes some pus visible in the nasal cavity.
Ultrasonography can support this diagnosis. Both A-mode
and B-mode sonography are suitable. A-mode sonography
shows a broadening of the anterior wall echo in cases without
uid retention and an echo of the posterior wall in cases with
uid retention (pus) (Fig.14.3). It is important to note that the
examination should be performed with the patient in an
upright position with the chin directed to the sternum, so that
retained uid is in contact with the anterior sinus wall and
thus with the ultrasound transducer. If the patient is supine,
uid retention could be overlooked.
B-mode sonography also shows the anterior bony wall
with a broadening of the swollen mucosa behind it. If there is
no uid retention, the posterior wall cannot be visualized
(Fig.14.4). In cases with pus, the posterior wall can be seen.
Some investigations have compared the diagnostic accuracy of ultrasound with that of other imaging techniques in
the diagnosis of acute sinusitis. Early studies were performed
using A-mode ultrasonography. Zagolski and Strek [8] found
a concordance between CT scans and A-mode ultrasound in
58.8% of cases with acute sinusitis and in 85% of cases with
chronic sinusitis. The limitation of the technique is that only
uid retention, mucosal swelling, and some cysts can be
detected by A-mode sonography without a direct anatomical
ab
cd
ef
14 Sonography oftheParanasal Sinuses, Soft Tissues oftheFace, Orbit, andBony Structures oftheFace
293
Fig. 14.1 (a–d) Ultrasound examination of the paranasal sinuses with
A-mode sonography: The patient is sitting in an upright position with a
slightly anteexion of the head. The ultrasound transducer is placed on
the maxillary sinuses and frontal sinuses on both sides. The transducer
is moved around the sinus silhouette to detect even minor uid retentions, cysts, or mucosal swellings in the sinus lumen. The patient’s head
can be moved in a more anterior position when uid retention is sus-
pected, so that the uid comes in contact with the anterior sinus wall,
which creates an echo. (e–l) B-mode ultrasonography of the paranasal
sinuses. This patient is also sitting in an upright position with a slightly
anteexion of the head. The anatomical structures can easily be examined by the ultrasound transducer. The examination is performed in two
planes, usually in axial and longitudinal planes
294
gh
ij
kl
H. J. Welkoborsky
Fig. 14.1 (continued)
context. Others have applied A-mode ultrasonography in
patients with asthma to estimate a probable sinus disease.
They found at least minimal mucosal thickening in the paranasal sinuses in 74% of the patients. A-mode sonography
demonstrated a sensitivity of 70% but a specicity of only
22% for detecting mucosal hyperplasia [9]. For B-mode
sonography, rates of concordance between ultrasound, x-ray,
and CT scans of 62.5% to 92% were reported [2]. In the setting of an ICU, ultrasound can be used as a bedside diagnostic tool to detect sinusitis [10, 11]; the sensitivity and
specicity of 100% are in accordance with other publications [2, 8, 10–14].
A pretty good correlation between ultrasound results and
CT scans has also been described for diagnosing acute sinusitis in the maxillary sinus in the pediatric population [15–17].
Some authors described evidence that the loss of a posterior
wall echo during therapy of an acute sinusitis correlates well
with a decrease of clinical symptoms [17]. Benninger etal.
[18] developed an animal model for ultrasound visualization
of uid in the maxillary sinus during microgravity and
rechte Kieferhöhle
09.07.2018 18:15
14 Sonography oftheParanasal Sinuses, Soft Tissues oftheFace, Orbit, andBony Structures oftheFace
Table 14.1 Main indications for A-mode and B-mode sonography of the paranasal sinuses
A-Mode sonography B-Mode sonography
Conrmation of uid retention (i.e., acute sinusitis) Conrmation of uid retention (i.e., acute sinusitis)
Cysts; mucoceles Cysts; mucoceles
Conrmation of mucosal swelling (i.e., chronic sinusitis) Conrmation of mucosal swelling (i.e., chronic sinusitis)
Polyps; tumors Paranasal sinus tumors
Therapy monitoring (i.e., during antibiotic therapy of an
Tumors of the soft tissues of the face and the bony sinus borders
acute sinusitis)
Postoperative care following functional endoscopic sinus
surgery
Therapy monitoring (i.e., during antibiotic therapy of an acute sinusitis or
chemotherapy of a malignant tumor)
Suspected bony fractures if x-ray exposure must be avoided
Postoperative care following functional endoscopic sinus surgery
Localization of foreign bodies in the maxillary sinus
Intraoperative application during endonasal endoscopic skull base surgery
medial
295
cranial
eye ball
sinus lumen
a
0.0 1.0 2.0 3.0 4.0 5.0 [cm]
Verstärkung: 75 %
linke Stirnrhöhle
09.07.2018 18:16
c
0.0 0.5 1.0
Verstärkung: 80 %
1.5 2.0 2.5 3.0 3.5 [cm]
b
d
e
Fig. 14.2 A-mode and B-mode ultrasound of the maxillary sinus in
axial and longitudinal section (a–c) and of the frontal sinus in axial section (d, e) in a healthy person. The anterior bony wall creates an echo.
If there is no uid retention and no cyst (as in this case), the posterior
wall is not visible. The anterior wall of the frontal sinus is slightly
curved
296
ab
anterior sinus wall anterior sinus wallposterior sinus wall
0.0
Verstärkung: 80 %Verstärkung: 80 %
H. J. Welkoborsky
rechte Kieferhöhle rechte Stirnrhöhle
1.0 2.0 3.0 4.0 5.0 [cm] 0.0 0.5 1.0
Fig. 14.3 (a) A-mode sonography in a patient with acute maxillary
sinusitis and uid retention. A broadening of the anterior wall echo is
visible, along with the echo of the posterior wall. (b) This patient with
30.04.2018 14:32
frontal sinusitis has no uid retention, so only the broadening of the
anterior wall is visible, not the echo of the posterior wall
09.04.2018 15:56
1.5 2.0 2.5 3.0 3.5
[cm]
ab
Fig. 14.4 (a) B-mode sonography of the maxillary sinus in a patient
with acute sinusitis and uid retention. The swollen mucosa inside the
sinus creates a broadening of the anterior wall and the uid inside the
postulated diagnostic criteria for acute bacterial rhinosinusitis in the microgravity environment. Ultrasound has also
been applied to help in the localization of foreign bodies in
the maxillary sinuses [19].
Thus one can conclude that ultrasound of the paranasal
sinuses is a rapid, painless, nonionizing, reproducible, and
low-cost imaging technique to conrm a clinical diagnosis of
an acute sinusitis [20, 21], which can be applied when
ionizing exposure is contraindicated. Further applications
for this technique include clinical follow-up and monitoring
sinus lumen is visible. (b) In cases with no uid retention, only the
broadening of the anterior wall due to the swollen mucosa can be displayed, not an echo of the posterior wall
of antibiotic therapy. In such cases, ultrasound might reduce
the need for further radiological imaging and may help to
reduce unnecessary antibiotic treatment [21].
14.4.2 Chronic Sinusitis
Chronic sinusitis is also basically a clinical diagnosis [7],
suggested by a combination of some of the following
symptoms: nasal obstruction, postnasal drip, rhinorrhea,
0.0
Sondenfrequenz 4, 25 MHz
linke Kieferhöhle
01.06.2018 14:09
Sondenfrequenz 4, 25 MHz
linke Kieferhöhle
30.04.2018 14:33
14 Sonography oftheParanasal Sinuses, Soft Tissues oftheFace, Orbit, andBony Structures oftheFace
297
Verstärkung: 80 %
Fig. 14.5 A-mode sonography in a patient with a cyst in the maxillary
sinus. In this case, the anterior wall echo is visible. The cystic uid also
creates an echo of the posterior wall of the cyst. According to the depth
of the posterior wall, the diameter of the cyst can be determined; it is
about 3cm in this case
frontal headache or oppression feeling, and recurrent episodes of acute sinusitis. In some cases, patients also suffer
from an allergy. The ndings in A-mode and B-mode ultrasonography are unspecic. In cases with mucosal swellings, the echo of the anterior sinus wall appears broadened.
In cases of uid retention, the posterior wall is seen. In
patients with nonpolypoid chronic rhinosinusitis, A-mode
sonography was proven to be helpful in identifying intrasinusoidal liquid contents rather than hypertrophic mucous
membranes [7]. Cystic lesions lead to a quite characteristic
sonographic appearance in both A-mode (Fig.14.5) and
B-mode sonography: rst the anterior wall echo appears,
then the echo of the posterior wall of the cyst, and nally
the echo of the posterior sinus wall can appear [12]. In
cases of polyps, some irregular structures with higher
echogenicity appear inside the sinus lumen in B-mode
ultrasonography. A-mode sonography sometimes only
reveals some single echoes behind the anterior wall echo
(Fig.14.6). Different investigators have had difculty
reproducing results, however, especially for A-mode ultrasonography, so some authors conclude that A-mode sonography should not be recommended to diagnose uid
retention or mucosal swelling in patients with chronic
mucosal changes [9]. The results for B-mode sonography
in chronic nonpolypoid sinusitis are better at detecting
mucosal swelling or uid retention.
precise imaging of the paranasal sinuses to investigate anat-
1.0 2.0 3.0 4.0 5.0
[cm]
The sustained increase in demand for more detailed and
0.0 1.0 2.0 3.0 4.0 5.0
Verstärkung: 80 %
Fig. 14.6 A-mode sonography in polypoid sinusitis. The polyps create
some single echoes behind the anterior wall echo
[cm]
omy and the skull base has led to a wide application of CT or
cone beam scans in the diagnosis of chronic sinusitis. When
operative therapy is planned, CT or cone beam scans of the
paranasal sinuses and skull base is mandatory to estimate the
olfactory gap and to exclude some anatomical abnormalities
of the skull base. In such cases, sonography is only an additive to conrm the suspected diagnosis of a chronic sinusitis,
and it has some justication in monitoring of therapy or in the
postoperative care of patients following functional endonasal
sinus surgery for early detection of uid retention [8, 12].
14.4.3 Cysts andMucoceles
Cysts in the paranasal sinuses have a quite characteristic
sonographic nding. In B-mode sonography, they appear as
a hypoechoic mass only when the cyst is attached to the anterior sinus wall and therefore gets contact to the ultrasound
transducer [1, 22, 23]. Some hyperechoic inclusions can
occur, representing debris or large protein molecules in the
cystic uid. If the anterior sinus wall is missing, the lesion
appears as a round or roundish, well-demarcated mass, the
contents of which frequently have a higher echogenicity
(Fig.14.7). In A-mode sonography, the anterior sinus wall
echo is followed by an anechoic area. The posterior wall of
the cyst causes a second or third echo.
Mucoceles are large, cystic lesions that show some inltrating growth pattern. They are usually of sinugenic origin;
spontaneous mucoceles are extremely rare. In most cases, a
history of head injury, paranasal sinus surgery, or recurrent
severe sinus inammations can be determined. Mucoceles
298
H. J. Welkoborsky
a
b
c
Fig. 14.7 (a) B-mode sonography (axial image) in a patient with a cyst in the maxillary sinus. (b) Longitudinal image of the same patient. The
anterior sinus wall is visible, and the cyst is seen as a roundish, hypoechoic mass. (c) CT scan (coronal scan) of the same patient
display as hypoechoic or anechoic masses with clear borders. In most cases, additional nely granulated echoes can
be seen inside the lesion, which are due to protein molecules
and cell debris in the mucocele content. The echogenicity is
often more homogeneous than that of abscesses. A posterior
enhancement is apparent in most mucoceles [4, 24].
Dehiscence of the bony walls, enabling the mucocele to
tral nervous system like a shell. They also contain cerebrospinal uid. Lesions with extension into the paranasal sinuses
and orbit can be visualized by B-mode sonography. Here the
bony gap is visible, and the lesion is seen as a hypoechoic
mass with some areas of higher echogenicity surrounded by
a more hyperechoic, band-like structure, which corresponds
to the meninges (Fig.14.9).
grow into neighboring structures, can be detected in many
cases (Fig.14.8).
Color-coded duplex sonography does not reveal any intra-
14.4.4 Postoperative Care
lesional vessels in either cysts or mucoceles. In contrast to
abscesses, usually no hypervascularity is also seen in the
vicinity of the mucocele or cyst.
Meningoceles or meningoencephaloceles are intracranial
lesions that protrude through the skull base through a bony
gap. They consist of meninges that surround parts of the cen-
Repeated use of ultrasonography takes advantage of its
dynamic character and lack of patient inconvenience and
radiation exposure. Thus it is suitable for application in
postoperative care following paranasal sinus surgery, to
exclude uid retention and to monitor healing. It is also
14 Sonography oftheParanasal Sinuses, Soft Tissues oftheFace, Orbit, andBony Structures oftheFace
299
a
c
b
Fig. 14.8 Mucocele of the right frontal sinus. (a) Clinical picture
shows protrusion of the anterior wall of the sinus. (b) In the CT scan,
the erosion of the bone is visible. (c) B-mode sonography reveals a gap
better than other imaging techniques for monitoring of
therapy with topical corticoids. Both A-mode and B-mode
sonography can be used for monitoring of therapy and
healing, to estimate signs of uid retention and mucosal
swelling [8].
14.4.5 Paranasal Sinus Tumors
Both benign and malignant tumors can occur in paranasal
sinuses. Frequent tumors of the paranasal sinuses are inverted
papillomas, squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, and malignant lymphoma. Malignant
melanoma and sarcomas are less frequent.
There is no typical ultrasound nding for particular
tumors. A-mode sonography is limited in the diagnosis of a
paranasal sinus tumor. In many cases it reveals only some
in the bony sinus wall (arrow) and the extension of the mucocele into
the orbit. The mucocele itself presents as a hypoechoic mass with some
complex echogenicity inside the lesion
echoes appearing inside the sinus (when the tumor is limited
to the particular sinus), and A-mode sonography cannot
detect inltration into the surrounding tissues; nor does it
show other important sonographic features, such as echogenicity or vascularization. Therefore A-mode ultrasonography cannot be recommended as a diagnostic technique if a
tumor is suspected.
The diagnostic accuracy of B-mode sonography in patients
with paranasal sinus tumors is higher than that of A-mode
sonography. Liu etal. [25] found that ultrasound detected 78.1%
of tumors, compared with a detectability rate of 96.9% for CT
scans. However, sonography showed a higher detectability of
tumors in the nasal vestibule and on the wings of the nose, compared with CT [25]. These authors concluded that sonography
should be applied especially in these indications (Fig.14.10).
In many tumorous lesions of the paranasal sinuses,
B-mode sonography reveals a hypoechoic mass with
300
a b
c
H. J. Welkoborsky
Fig. 14.9 Patient with a meningoencephalocele of the left skull
base with involvement of the paranasal sinuses and the orbit. (a) The
eye bulb is displaced and deviated to the left side. (b) The CT scan
shows the bony gap in the frontal skull base, with prolapse of the
meninges and some intracranial structures into the ethmoid sinuses
frequent areas of higher or complex echogenicity inside
the sinus lumen. Hypoechoic or echo-complex masses
with inhomogeneous echogenicity are common, depending on histology. Other sonographic features, including
shape, internal echogenicity, calcification, bone infiltration, or borders can be estimated, and an examination of
the neck in patients with malignant tumors can be used
to exclude cervical lymphadenopathy. If the tumor has
infiltrated the surrounding tissue, B-mode sonography
shows an infiltrative growth pattern, and the stage of the
infiltration can be estimated. Even T-staging of a maxillary tumor is possible by sonography in some cases [26].
A cytologic or histologic examination is required when
sinus tumors or metastasis is suspected. Color-coded
and into the orbit. (c) B-mode sonography reveals a hypoechoic or
anechoic mass that is surrounded by a capsule-like structure, which
represents the meninges. Blood vessels are visible only in this
region
duplex sonography is advantageous for estimating tumor
vascularization and for differential diagnostic purposes
[22, 25]. A higher vascularization can be detected for
some tumors, such as metastases of renal cancer.
14.5 Ultrasonography oftheBony
Structures intheMidface
Because of the high acoustic mismatch of bony structures,
ultrasound waves are reected almost completely.
Therefore the intact bone appears as a hyperechoic, bandlike structure. Fractures lead to a disruption of continuity
at the surface of the bone. With modern ultrasound