Ultra sound for dentist

Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241

Ultrasonographic imaging of head and neck pathology
Ralf Schon, DDS, MD*, Jurgen Duker, DDS, MD,
¨ ¨ ¨
Rainer Schmelzeisen, DDS, MD
Department of Oral and Maxillofacial Surgery, Albert-Ludwigs-University, Klinik und Poliklinik fur
¨
Mund-Kiefer-Gesichts Chirurgie, Hugstetter Straße 55, D-79106 Freiburg im Breisgan, Germany

This article demonstrates the properties of sonographic images for the diagnosis of soft tissue
pathologies in the head and neck. Ultrasonography in medicine has been used as an imaging
technology since 1950. Developments in computer technology have allowed modern ultrasound
machines to produce real-time high-quality images of soft tissues; however, limitations must be
considered. A total reflection of sonographic waves on bone and a complete extinction behind
air-filled cavities, such as the oral cavity and the paranasal sinus, limit the sonographic investi-
gation to soft tissues. Ultrasonography is recommended as the first imaging technique of choice
for suspected soft tissue pathology in the head and neck. It is noninvasive, inexpensive, quick to
perform, and can easily be performed in children and pregnant women. Unlike with computed
tomography (CT) and magnetic resonance imaging (MRI), injectable contrast media or sedation
in infants (both requiring intravenous tube placement) is not needed for sonography. Typical
indications for sonographic evaluation in the head and neck include infection, cysts, salivary
gland diseases, neck masses, and neoplasms.
In the head and neck, a 7.5-MHz scanner is routinely used for sonography. Sonographic
images in B-mode (brightness mode) show the texture and borders between tissues as a black-
and-white picture. Color duplex sonography allows the visualization of moving tissues, such as
blood cells. Relative movement toward the scanner is color-coded red and relative movement
away from the scanner, blue. The visualization of tissue perfusion, such as in hyperemia in in-
flammatory changes, vascularization of tumors, and for the evaluation of the location of blood
vessels relative to pathologic findings, adds valuable diagnostic information to the B-mode
picture. Dynamic sonographic evaluation techniques demonstrate in real time mobility and
compressibility of the investigated tissues. Color Doppler mode allows for the quantitative eval-
uation of the perfusion in larger vessels.
The interpretation of sonographic images for head and neck surgeons not used to sono-
graphic images may be initially difficult because the sonographic images are not produced in de-
fined axial and coronal planes, such as those known for CT and MRI. A basic knowledge of the
sonographic anatomy of the head and neck is required for the understanding of sonographic
findings. Typical effects in sonographic imaging such as echo enhancement behind tissues, which
causes lower attenuation compared with the surrounding tissues (such as in pleomorphic adeno-
mas of salivary glands or cystic lesions) or total reflection of the sonographic waves with a shad-
owing effect behind strong reflectors, eg, bone or stones of the salivary glands, may be evident.
These effects can be used to interpretate the ultrasonographic image.
This article presents sonographic images of typical pathologic findings in the head and neck
and correlates these pathologies with the clinical picture.

* Corresponding author.
E-mail address: schoen@zmk2.ukl.uni-freiburg.de (R. Schon).
¨

1061-3315/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved.
PII: S 1 0 6 1 - 3 3 1 5 ( 0 2 ) 0 0 0 0 9 - 4

214 R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241
¨

Sialolithiasis of salivary glands

Frequency/incidence

The most common cause of salivary obstruction is the formation of intraductal sialolith.
Sialoliths are most frequently found in the submandibular gland (Fig. 1A) [1].

Signs and symptoms

Patients present with recurrent swelling, which usually occurs during eating and drinking.
Typical chronic changes of the gland may occur after some years (Fig. 2D).

Etiology/pathophysiology

Formation of viscous mucous plaques can occur in the ducts and may result in the obstruc-
tive changes [1]. Mineralization of plaques causes firm stone-like sialoliths (Fig. 1A, B).

Image of choice for diagnosis

Because it is noninvasive, easy to apply, and inexpensive, sonography is the first imaging
method of choice for diagnosis of suspected salivary gland disease. Depending on the degree
of mineralization, sialoliths may show in X rays (Fig. 1A) [2]. Sialography gives indirect infor-
mation on the presence of a stone in the ductal system, and obstructive changes within the gland
may be obvious. Stones of the submandibular glands are often located at the posterior border of
the mylohyoid muscle (Fig. 1A).

Fig. 1. Intraductal sialolith of the submandibular gland is demonstrated in sialography. (A) Contrast media in the
intraglandular ductal system shows the obstruction within the gland caused by the stone located posterior to the
mylohoid muscle. (B) In B-mode sonography, the stone is obvious as a strong reflector with a posterior shadowing effect.
(C) Inflammatory reaction in sialolithiasis with hyperemia of the submandibular gland is evident in color duplex
sonography.

R. Schon et al / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 213–241
¨ 215

Fig. 1 (continued )

Image hallmarks

The sialolith shows a strong echo caused by the complete reﬂection of the ultrasonic wave.
Posterior to the sialolith, the echo is extinguished, and a shadow posterior to the stone is present
(Fig. 1B). Hyperemia as inﬂammatory reaction of the gland tissue is demonstrated by color du-
plex sonography (Fig. 1C).

Management

The preferred therapy is the surgical removal of the stone. Removal from an intraoral root is
possible when the stone is located in the anterior part of the submandibular or parotid duct. If a
stone is located below the mylohyoid muscle, the submandibular gland has to be removed to-
gether with the stone by a submandibular approach. Care has to be taken not to harm the lin-
gual nerve, which crosses over the duct.

¨

Sialadenitis

Frequency/incidence

Acute sialadenitis most often affects the submandibular gland rather than the parotid and mi-
nor salivary glands. The frequency of acute exacerbation of a chronic infection of the salivary
gland increases with the degree of obstructive changes of the gland tissue.

Signs and symptoms

Acute sialadenitis leads to a massive swelling of the affected gland (Fig. 2A). Pus may be found
on palpation of the salivary gland at the exit of the duct. The skin overlying the affected gland is
usually swollen and red. Patients complain of massive pain, and mouth opening can be limited.


Sialadenitis can be caused by radiation and viral or bacterial infection. Acute streptococcus
staphylococcus sialadenitis arises by retrograde infection in an obstructed gland. Degeneration
of acina is seen along with interstitial inflammatory cell infiltrates [1]. Multiple or single
abscesses may form in acute glands (Fig. 2E). Changes in the immune system or electrolytes
may also cause inflammation of the salivary glands.


Color duplex sonography is the imaging method of choice for the diagnosis of sialadenitis.

Image hallmark

In the sonographic image, the gland is massively enlarged in side comparison. Hyperemia of
the acute gland is seen in color duplex sonography (Fig. 2B). A chronic recurrent infection

Fig. 2. (A) Acute sialadenitis with swelling of the left parotid gland. (B) Color duplex sonography shows hyperemia of the
massively enlarged gland. In chronic sialadenitis, hyperemia is less obvious compared with findings in acute sialadenitis. (C) A
swelling of the right parotid gland is less obvious in a patient with chronic parotitis. (D) Pathological changes of the salivary
gland tissue with multiple microabscesses caused by recurrent sialadenitis is evident in sonography and (E) sialography.

¨ 217

Fig. 2 (continued )

with less massive enlargement of the parotid gland presents with irregular echogenic structures
within the gland (Fig. 2C). Microabscesses and sclerotic changes of the gland appear as multiple
hypoechoic or inhomogeneous lesions (Fig. 2D). Further information on pathologic changes
within the gland may be gained by sialography (Fig. 2E).

Management

The management of acute infection is antibiotic therapy. After recurrent infections with per-
manent changes of the salivary gland, tissue removal of the gland becomes necessary.

¨

Fig. 2 (continued )

Salivary retention cyst

Frequency/incidence

After injury or abscess of the parotid gland, saliva may be retained within the gland.

¨ 219

Signs and symptoms

Symptoms of a salivary retention cyst is nonpainful swelling with ﬂuctuation (Fig. 3A).


Sonography, using B-mode for the demonstration of cystic lesions, is the imaging method of
choice.

Image hallmarks

The salivary retention cyst has a regular border and an hypoechoic echo. The lesion is com-
pressible with the transducer (Fig. 3B). Enhancement of the sonographic echo posterior to the
cyst is seen.

Management

The management of a salivary retention cyst is surgical, with removal or drainage. Drainage
of the cyst into the duct system or the oral cavity can be performed under intraoperative sono-
graphic guidance.

Pleomorphic adenoma

Frequency/incidence

Pleomorphic adenoma is the most common benign salivary gland tumor, with the highest in-
cidence in the parotid gland. Most pleomorphic adenomas arise in women in their 30s and 40s.

Fig. 3. (A,B) A patient with a ﬂuctuating swelling of the left parotid gland without signs of acute infection shows a cystic
lesion in the sonographic picture. The space occupying the hypoechoic lesion shows a regular border and is compressible.
(B) Enhancement of the sonographic echo posterior to the cyst is evident.

¨

Fig. 3 (continued )

The second most common salivary gland tumor is the Whartin tumor (papillary cyst adenoma
lymphomatosum), which occurs more frequently in men. Whartin tumor is often present in both
parotid glands [1].

Signs and symptoms

The tumor presents as a ﬁrm mobile swelling of the gland. The adenoma is usually painless
and does not aﬀect the facial nerve. The growth of the tumor over a period of several months is
often reported by patients.


The pleomorphic adenoma derives primarily from myoepithelia—sometimes adipose, chon-
droid, and osseous elements may be present in these tumors. The pleomorphic adenoma shows a
slow growth with a minor risk for malignant transformation [1].


With typical patient history, tumor location, and palpation of the tumor, B-mode sonogra-
phy is the imaging method of choice.

Image hallmarks

The lesion presents as a hypoechoic mass with a regular border and cannot be compressed.
The echo enhancement posterior to the lesion is typical (Fig. 4). In Whartin tumor, a polycystic
appearance of the lesion may be seen sonographically.

¨ 221

Fig. 4. The noncompressible hypoechoic intraparotid mass is preauricularly located and presents a regular border.
Posterior echo enhancement, a typical sign in pleomorphic adenoma, is less obvious compared with fluid-filled cystic
lesions.

Management

The management of suspected pleomorphic adenoma is surgical. Histological findings such as
malignancies may define further treatment.

Malignant neoplasm of the parotid gland

Frequency/incidence

The more common malignancies of the salivary glands are mucoepidermoid carcinoma
(28%), acinus cell carcinoma (23%), adenocarcinoma (16%), and adenocystic carcinoma (9%)
[3]. Epithelial malignancies of the salivary glands are less common and the most common site
is the parotid gland.

Signs and symptoms

Patients present with an induration or swelling of the gland, which is often painful (Fig. 5A).
In contrast to benign lesions, malignancies of the parotid gland may present with facial nerve
palsy.

Etiology/Pathophysiology

Malignant tumors of the major glands are typically invasive. Some low-grade malignancies
may derive from surrounding tissues. Most often, the malignancies arise de novo. The malignant
transformation of benign neoplasms is rare [1].

¨

Fig. 5. (A) A patient presented with a painful swelling of the left parotid gland. A beginning weakness of the orbicular
branch of the facial nerve was noted. (B) MRI in axial and coronal view demonstrated the invasive growth of an
adenocystic carcinoma of the parotid gland. (C) In sonography, the neoplasm of the salivary gland shows an irregular
border and an inhomogeneous echo pattern with unechoic, hypoechoic, and echodense structures. Micronerve
reconstruction of the facial nerve using a sural nerve graft was performed immediately after surgical removal of the
tumor. Secondarily, a deepithelialized parascapular flap was used for tissue augmentation. Monitoring of the buried flap
was performed by color duplex sonography. (D) The postoperative appearance of the patient 24 months after tumor
resection, postoperative radiation, and 6 months after soft tissue augmentation.


The imaging method of choice for primary evaluation of a swelling in the area of the parotid
gland is sonography (Fig. 5C). Further information on the extent of a tumor or the infiltration
of the neighboring anatomic structures may be gained by CT and/or MRI (Fig. 5B).

Image hallmarks

Malignant tumors of the salivary glands show an irregular border and an inhomogeneous
echo pattern with unechoic, hypoechoic, and echodense structures. There may be dorsal shad-
owing and dorsal signal enhancement behind the lesions (Fig. 5C). The infiltration of adjacent
anatomic structures with invasion of muscles or destruction of the ascending ramus of the man-
dible is visible by sonography (Fig. 5C).

Management

Surgical management is the therapy of choice. Depending on the extent of the tumor and the
pathohistologic findings after tumor resection, radiation and/or chemotherapy may be indicated
(Fig. 5D).

¨

Fig. 5 (continued )

¨
Intraparotid lymph nodes in Sjogren syndrome

Frequency/incidence

Intraparotid lymph nodes may be present in Sjogren syndrome. Benign lymphoid epithelial
¨
lesions of Sjo
¨gren syndrome are less common than Whartin tumor. The disease predominately
aﬀects middle-aged women. Lymphomas may develop in the setting of Sjogren syndrome.
¨

¨ 225

Signs and symptoms

Visible swelling in the parotid gland area may be present (Fig. 6A). Xerostomia is usually the
main oral symptom; dry eyes is the main ocular symptom.


Sjogren syndrome, also known as sicca syndrome, is a chronic, progressive autoimmune dis-
¨
ease characterized by lymphocyte infiltration of the salivary and lacrimal gland with loss of the
secretory epithelium. Parotitis can be caused by periductal and acinal infiltration. Sjo ¨gren
syndrome may present as primary or secondary disease with other autoimmune disorders, such
as rheumatoid arthritis [4].


Sonography is the imaging method of choice for the diagnosis of swelling in the area of the
salivary glands. The diagnosis of Sjogren syndrome is verified by Schirmer test to evaluate the
¨
lacrimal secretion and pathohistologic evaluation of the mucosal specimen.

Image hallmarks

Intraparotid groups of lymph node tissues with hyperemia are visualized by color duplex
sonography (Fig. 6B).

Fig. 6. (A) A patient with Sjogren syndrome presented with a swelling in the area of the parotid gland. (B) Color duplex
¨
sonography demonstrates multiple intraparotid lymph nodes with hyperemia.

¨

Management

The treatment of this autoimmune disease is based on the patient’s symptoms. Replacement
of saliva and tears may limit mucosal injury caused by reduced secretion. In severe cases, ste-
roids and immunosuppressive agents are indicated [2].

Malignant lymphoma

Frequency/incidence

Neoplasms originating in lymphatic tissue can occur at any age, although the highest inci-
dence occurs in patients aged 60 to 70 years. Manifestation of malignant lymphomas in the
cervical and inguinal lymph nodes is common.

Signs and symptoms

Patients may present with reduced general condition, with fever, loss of weight, and anemia;
however, patients are often asymptomatic. Swelling of lymph nodes in single or multiple loca-
tions may be present (Fig. 7A).


Malignant lymphomas comprise histologically different diseases of the lymphatic tissues,
such as Hodgkin and non-Hodgkin lymphomas. The cause of malignant lymphomas is not
clearly understood, although it may be related to a viral factor. An increase of incidence in
HIV-positive patients has been reported.


For the evaluation of cervical lymph node enlargement, sonography is the imaging method of
choice. Other imaging techniques, such as CT and MRI, are indicated for staging purposes and
for the evaluation of extended neoplasms, which can infiltrate bone. The diagnosis is verified by
pathohistologic evaluation.

Image hallmarks

An enlargement of one of multiple lymph nodes may be present. Lymphatic tissue or groups
of lymph nodes may show hyperemia. Margins in-between the lymph nodes and to the sur-
rounding tissues may not be defined (Fig. 7B).

Management

The histologic finding defines the treatment of choice and the prognosis. The oncologic ther-
apy with chemotherapy and/or radiotherapy, depending on the histopathologic finding, is the
first line of treatment. Surgical intervention may be indicated in rare cases.

Thyroglossal duct cyst

Frequency/incidence

Thyroglossal duct cysts (TDCs) are usually not apparent at birth. The majority of lesions are
diagnosed in the first 20 years of life.

¨ 227

Fig. 7. (A) A patient presented with an asymptomatic swelling in the left canine fossa. The swelling was treated as a
suspected odontogenous infection by a dental practitioner with repeated incisions for 6 months. (B) In color duplex
sonography, a well-vascularized neoplasm without clear margins was evident. A highly malignant B-cell lymphoma was
diagnosed after biopsy. (C) The extend of the tumor with inﬁltration of the maxillary sinus is demonstrated in CT.

¨

Signs and symptoms

TDCs are typically located in the midline between the hyoid bone and the thyroid cartilage.
A swelling of the anterior floor of the mouth may be present (Fig. 8A).


The thyroglossal duct connects the foramen cecum and the developing thyroid. The duct usu-
ally atrophies after the thyroid descends to its final position. Parts of the duct may be persistent
and become cystic in nature. Malignancies may develop in TDCs [5].


The cystic formation in the midline can be investigated by noninvasive sonography. The
lesion can also be demonstrated by CT with contrast media (Fig. 8B).

Image hallmarks

A hypoechoic cystic mass in the midline of the anterior floor of the mouth is demonstrated pre-
and postoperatively (Fig. 8C,D). The lingual artery is seen next to the cystic lesion (Fig. 8E).

Management

Surgical removal of the cyst is recommended.

Sublingual infection formation

Frequency/incidence

Abscess formation in the submandibular space with perimandibular abscess formation is
more common than sublingual abscess formation.

Signs and symptoms

Firm painful swelling of the floor of the mouth and in the sublingual area is found in sublin-
gual infection (Fig. 9A). The mouth opening may be limited. The clinical diagnosis of an early
sublingual abscess or infiltration of the floor of the mouth may be difficult to make because fluc-
tuation is not always present.


The most common cause for sublingual and perimandibular abscess formation is odonto-
genic infection. Nonodontogenic causes include cystic lesions, sialadenitis, lymphadenitis, or
soft tissue injuries. The infection may spread from the submandiblar space into the sublingual
space because of the connection at the posterior aspect of the diaphragm oris.


After diagnosis of the underlying odontogenic cause using X ray, such as panoramic views,
the presence of an abscess can be investigated by sonography.

¨ 229

Fig. 8. (A) A patient presented with a nonpainful swelling in the midline of the anterior ﬂoor of the mouth. (B) CT
performed with contrast prior to referral of the patient demonstrates the lesion located in the midline. (C) The
sonographic images in two planes with the transducer placed in a vertical and horizontal position in the submental area
demonstrate the cystic lesion preoperatively and (D) after surgical removal. (E) The lingual artery is seen postoperatively
in power mode.

¨

Fig. 8 (continued )

Image hallmarks

Hyperemia of the left sublingual area without signs of abscess formation is demon-
strated in an acute inﬂammatory reaction. The transducer is placed in a vertical and horizontal
position to produce images in two planes (Fig. 9B).

Management

The treatment of choice may diﬀer concerning the degree of the infection. When there is no
sign of abscess formation, treatment of the underlying dental cause and antibiotic treatment are
indicated. Drainage of an abscess by intraoral or extraoral incision is needed when an abscess
has already formed.

¨ 231

Fig. 8 (continued )

Second branchial cleft cyst

Frequency/incidence

The second branchial cleft cyst (BCC) represents approximately 95% of all BCCs. The first
BCC represents approximately 1% of these cysts [6].

Signs and symptoms

The swelling in the midportion of the anterior aspect of this sternocleidomastoid muscle can
be palpable and visible (Fig. 10A). Recurrent swelling in this area may be present because of
inflammation.


Anomalies may develop in the development of the first, second, and fourth branchial arches.


Soft tissue anomalies can be seen using sonography.

Image hallmark

A fluid-filled, unechoic, compressible cystic process is demonstrated next to the carotid ar-
teries using color duplex sonography (Fig. 10B).

Management

Second branchial and brachial cleft cysts are structural abnormalities and do not resolve
spontaneously. Therefore, complete surgical excision is the treatment of choice [5].

¨

Fig. 9. (A) Firm, painful swelling of the ﬂoor of the mouth and in the sublingual area is found in sublingual infection.
Noninvasive sonographic investigation can be easily performed in infants and children. (B) Using color duplex
sonography with the transducer placed in the submental area, hyperemia as a sign of the inﬂammatory reaction without
abscess formation was evident.

Cervical lymph node metastasis

Frequency/incidence

Most lymph node metastasis in the head and neck region originate from squamous cell car-
cinomas. Metastatic disease of other neoplasms, such as malignant melanoma, prostate and
breast adenocarcinoma, or tumors of unknown primary origin, are less common.

¨ 233

Fig. 10. (A) A patient presented with a swelling of the midportion of the sternocleidomastoid muscle. (B) A fluid-filled
unechoic cystic process is demonstrated next to the carotid arteries by color duplex sonography. The compressibility of
the cystic lesion was seen when compression was applied with the transducer.

Signs and symptoms

Cervical swelling, which can be painful, may be present (Fig. 11A, Fig. 11D).


Cervical lymph node metastasis is frequently found in patients with squamous cell carcinoma
of the oropharyngeal cavity. Carcinomas of other origin may cause also nodal metastasis
(Fig. 11D, E).


Sonography has a high accuracy for the demonstration of pathologic findings of cervical
lymph nodes compared with CT and MRI.

Image hallmarks

The echo-free central aspect of a lymph node metastasis is a typical sign for central necrosis
in the tumor mass (Fig. 11B). Compression or infiltration of the internal jugular vein or infiltra-

Fig. 11. (A) A patient presented with cervical swelling on the right side. (B) Color duplex sonography demonstrates a
lymph node metastasis with central necrosis and compression of the internal jugular vein. (C) Cervical metastasis in
another patient with inﬁltration of the internal jugular vein is evident in color duplex sonography. (D) A patient
presented with a swelling with a similar clinical appearance as that in (A). (E) Color duplex sonography shows a well-
vascularized tissue, a metastatic disease of a thyroid carcinoma.

¨ 235

Fig. 11 (continued )

tive growth of lymph node metastasis may be an important prognostic ﬁndings (Color Fig. 11B,
C). A high degree of vascularization is not typical for metastasis of squamous cell carcinomas
but can be present in other neoplasms, such as thyroid malignancies (Fig. 11D, E).

Management

Tumor resection is the treatment of choice. Pathohistologic ﬁndings after ablative tumor sur-
gery and neck dissection may indicate radiotherapy and/or chemotherapy.

Glomus vagale tumor

Frequency/incidence

Approximately 3% to 5% of all paragangliomas originate from the vagus nerve. The female
to male ratio is approximately 3 to 1, and the mean age of patients is 48 years [7].

¨

Signs and symptoms

Patients with glomus tumours present with a slow-growing painless neck mass; pulsation
of the mass may be palpable. When the tumor is located in the pharyngeal area, bulging of
the lateral pharyngeal wall may be present. In extensive cases where the recurrent laryngeal
nerve and hypoglossal nerve are involved, paralysis of the soft palate and a back-drop phenom-
enon of the posterior pharyngeal wall may be evident. Vagal nerve paralysis with hoarseness and
aspiration may develop [7].


Paragangliomas show a unique anatomic feature. The cervical tumor forms finger-like pro-
jections, which may invade fissures and foramens of the skull base. Bone as well as dura may
be infiltrated and destroyed.


The cervical tumor can be detected using sonography (Fig. 12A); however, for the diagnosis
and further evaluation of the tumor when located next to the skull base, medial to the mandible,
and near the pharyngeal, MRI and MR angiography are recommended to demonstrate the ex-
tend of the tumour and the degree of its vascularization (Fig. 12B, C).

Image hallmarks

A highly vascularized tumor next to the carotid artery is demonstrated using color duplex
sonography (Fig. 12A). The extend of the tumour with bulging of the lateral pharyngeal wall
and the vascularization are demonstrated in MRI, MR angiography, and conventional catheter
angiography for preoperative immobilization (Fig. 12B–D).

Management

The surgical removal of the tumor is indicated because tumor growth causes further
destruction of bone as well as dura. The tumor can be approached by submandibular
incision. Temporary osteotomy of the mandible to access the superior pharyngeal space
may be necessary. When an intracranial extension of the tumor is present, a craniotomy
for the complete removal of the lesion and the involved dura is indicated. After complete
resection, recurrence is rare [8]. Embolization prior to tumor resection is recommended be-
cause bleeding of the tumor is a possible complication. There is a risk of damage to cranial
nerves, the hypoglossal, and the facial nerve when the tumor is located next to the jugular
foramen [8].

Hemangioma

Frequency/incidence

With an incidence of 3% in newborns and a development in the first 3 months of infancy,
hemangioma is the most common congenital lesion. Almost 12% of 1-year-olds present with
a hemangioma. The head and neck are the most common sites for the development of heman-
gioma [5].

¨ 237

Fig. 12. A patient presented with an asymptomatic right cervical swelling. (A) Using color duplex sonography, a well-
vascularized tissue was obvious next to the carotid arteries. (B,C) MR angiography and conventional catheter
angiography during preoperative embolization show the vascularization of the tumor.(D) MRI demonstrates the extend
of the inﬁltrative growing tumor with bulging of the lateral pharyngeal wall.

¨


Signs and symptoms

Hemangioma can appear as cutaneous skin lesions, subcutaneous masses, or both, as com-
pound lesions. Cutaneous lesions appear as erythematous masses. Subcutaneous lesions can
present as soft, cystic, and compressible lesions with bluish discoloration of the overlying skin
(Fig. 13A). The high degree of perfusion may be palpable and audible.


Hemangiomas may develop from arrested mesenchymal vascular primordial and are there-
fore true congenital malformations rather than neoplastic processes. They usually grow rapidly
until the age of 6 to 8 months. They then slowly and spontaneously resolve over the next years.
Fifty percent of hemangiomas are resolved by the age of 5 years, 70% by the age of 7 years, and
almost all will spontaneously resolve by the age of 12 years [9,10].


Sonography is the imaging technique of choice because it is noninvasive and easy to perform
in infants without sedation or the use of contrast media.

¨ 239


¨

Image hallmarks

Color duplex and color Doppler sonography allow for the qualitative and quantitative anal-
ysis of the vascularization within the lesion (Fig. 13B, C). The depth of soft tissue infiltration of
the lesion can be measured. The results can be used for close follow-up and monitoring of the
growth, especially during the first 8 months.

Management

Hemangiomas tend to involute spontaneously. Therefore, observation and sonographic fol-
low-up of the lesion is indicated. Approximately 10% to 30% of hemangiomas require treatment

Fig. 13. (A) Subcutaneous hemangioma of the left cheek presents in a 5-month-old patient as soft, cystic, compressible
lesions with bluish discoloration of the overlying skin. (B) The high degree of perfusion, which may be palpable and
audible, and the depth of infiltration of the lesion is demonstrated by color duplex sonography. (C) Color Doppler
sonography allows for the qualitative and quantitative analysis of the vascularization pattern in the lesion.

¨ 241


because of threatening function, or potential disfiguration or obstruction. Extensive surgery
with or without preoperative embolization may be indicated. Because of surgical removal of
the infiltrative growing hemangioma, there may be disturbance of normal growth or damage
of vital structures. To avoid damage, control of the lesions by systemic or intralesional steroids
are the first line of therapy. Laser treatment has also been used [5,11]. Radiotherapy can cause
malignancies and is therefore obsolete.

References

[1] Ellis GL, Auclair PL, Gnepp DR. Surgical pathology of the salivary glands. Philadelphia: WB Saunders; 1992.
[2] Langlais RP, Kasle MJ. Sialadenitis: the radiolucent ones. Oral Surg Oral Med Oral Pathol 1975;40:686–90.
[3] Eversole L. Salivary gland pathology. In: Fu Y-S, et al, editors. Head and neck pathology with clinical correlation.
New York: Churchill Livingstone; 2001. p. 242–90.
[4] Campbell SM, Montanaro A, Bardana EJ. Head and neck manifestations of autoimmune disease. Am J
Otolaryngol 1983;4:187–216.
[5] Kellman RM, Freije JE. Clincal considerations for non-neoplastic lesions of the neck. In: Fu Y-S, et al, editors.
Head and neck pathology with clinical correlations. New York: Churchill Livingstone; 2001. p. 665–9.
[6] Cote DN, Gianoli GJ. Fourth branchial cleft cysts. Otolaryngol Head Neck Surg 1996;114:95.
[7] Uruquhart AC, et al. Glomus vagale: paraganglioma of the vagus nerve. Laryngocope 1994;104:440.
[8] Samii M, Draf W. Surgery of the skull base. An interdisciplinary approach. Berlin: Springer; 1989. p. 414–25.
[9] Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in infants and children: a classification based
on endothelial characteristics. Plast Reconstr Surg 1982;69:412.
[10] Philipps SE, Constantino PD, Houston GD. Clinical considerations for neoplasms of the oral cavity and
oropharynx. In: Fu Y-S, et al, editors. Head and neck pathology with clinical correlations. New York: Churchill
Livingstone; 2001. p. 472–3.
[11] Waner M, Suen JY, Dinehart S. Treatment of hemangiomas of the head and neck. Laryngoscope 1992;102:1123.

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