Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 8
Ultrasonographic evaluation of fascial space
infections of odontogenic origin Mohit Sharma, Kathikeya Patil, Mahima V Guledgud Department of Oral Medicine and Radiology, JSS Dental College and Hospital, Mysore, Karnataka, India INTRODUCTION Dental infection has plagued the human kind for as long as our species has existed. When dental infection spreads deeply into the soft tissue rather than exiting supercially through oral or cutaneous routes, fascial spaces may be affected. Following the path of least resistance through connective tissue and along fascial planes, infections may spread quite distantly from its dental source, causing considerable morbidity and mortality. It is often difcult to diagnose the stage of infection and to dene its exact anatomic location based on clinical and conventional radiographic examination alone. [1] In patients with acute odontogenic infections, it is often difcult to clinically determine, whether there is an abscess which requires surgical intervention or cellulitis that can be managed satisfactorily with antimicrobial therapy and supportive care alone. [2] Finding of uctuance is often difcult on clinical examination, especially in spaces such as the submasseteric, where purulent material is deep within the soft tissues and muscle. The relative blind surgical incision and drainage performed in such situations usually results in excessive harm through unnecessary extensive incisions, and failure to locate and evacuate the abscess cavity completely. [2] Radiographs and other imaging studies can be used to diagnose the spreading infections in the head and neck. However, plain radiographs do not often provide good denition of soft tissue. Both A B S T R A C T Introduction: Dental infection has plagued the human kind for as long as our species has existed. It is often difcult to diagnose the stage of infection. The relative blind surgical incision and drainage performed in such situations usually results in excessive harm through unnecessary extensive incisions, and failure to locate and evacuate the abscess cavity completely. The potential use of ultrasonography (USG) in fascial space infections of odontogenic origin has not been explored completely and deserves much more intensive, high quality research. Objectives: (1) To elucidate the role of USG as an adjunctive diagnostic aid for fascial space infections of odontogenic origin. (2) To aid in appropriate treatment planning and management of fascial space infections of odontogenic origin. Materials and Methods: The study group comprised of 30 patients of either genders, irrespective of age and presented with unilateral fascial space infection of odontogenic origin. After the clinical and radiographic examinations, patients underwent USG evaluation. USG-guided intraoperative aspiration was done to conrm the diagnosis. All the ndings were tabulated and subjected to statistical analysis. Results: USG was as accurate as USG-guided intraoral aspiration (Gold standard) in diagnosing fascial space infections of odontogenic origin with sensitivity and specicity of 100%. In cases of abscess USG showed a well-dened homogenous anechoic pattern, cellulitis cases showed an ill-dened heterogeneous hyperechoic pattern while edema showed an ill-dened isoechoic pattern. Conclusion: The different stages of fascial space infections of odontogenic origin can be clearly depicted on the USG. USG can be used as a reliable adjunctive imaging technique in the diagnosis of fascial space infection of odontogenic origin and thus aids in appropriate treatment planning and management of such cases. Key words: Fascial space infections, USG, USG guided intra operative aspiration Address for correspondence: Dr. Mohit Sharma, Department of Oral Medicine and Radiology, JSS Dental College and Hospital, Mysore, Karnataka, India. E-mail: msmohitcop@gmail.com Access this article online Quick Response Code: Website: www.joomr.org DOI: 10.4103/2321-3841.133553 Original Article [Downloadedfreefromhttp://www.joomr.orgonThursday,August28,2014,IP:118.96.200.204]||ClickheretodownloadfreeAndroidapplicationforthisjournal Mohit, et al.: Ultrasonography of odontogenic fascial space infections Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 9 CT and MRI are expensive, time consuming and not easily available. [3] Hence, we need adjunctive diagnostic aids to correctly identify the stage of infections and to provide appropriate management. Ultrasonography (USG) has played a major role as a diagnostic tool in various medical conditions. The sonographic images are identied in terms of echoes as hypoechoic, hyperechoic and anechoic images. The potential use of ultrasonography in fascial space infections of odontogenic origin has not been explored completely and deserves much more intensive, high-quality research. MATERIALS AND METHODS The study sample comprised of 30 subjects, presenting to the Department of Oral Medicine and Radiology, J.S.S. Dental College and Hospital, JSS University, Mysore, with fascial space infections of odontogenic origin, satisfying the following inclusion and exclusion criteria and those willing to participate in the study were selected by purposive sampling. Inclusion criteria 1. Subjects of either gender, irrespective of age, presenting with unilateral fascial space infections of odontogenic origin. Exclusion criteria 1. Individuals who required immediate emergency management. 2. Individuals who were non-ambulatory. 3. Individuals with bilateral involvement of fascial spaces. Ethical clearance was obtained from the Institutional Ethical review board prior to conducting the study. The selected subjects were explained in detail about the procedures involved and a written informed consent was obtained from them. The selected patients were made to sit comfortably on the physiological dental chair with articial illumination. Relevant history was noted down on a specially designed proforma. A detailed extraoral and intraoral clinical examination was carried out by adopting the methods of Kerr, Ash and Millard [4] and relevant ndings ascertaining the nature of fascial space infection, and its origin, were noted on the individual proforma. The subjects were then transferred to the radiology section for radiographic examinations either intraoral periapical (IOPA) or panoramic radiographs as deemed necessary on a case to case basis to conrm the clinical ndings. Both IOPA and panoramic radiographic examinations were carried out adopting the methods of White and Pharoah. [5] After evaluating the clinical and radiographic ndings, a working diagnosis was made and noted down in the individual proforma. The patients were then subjected to USG examination using a linear array transducer with a frequency of 6-10 MHz in both transverse and axial sections to determine the nature of fascial space infection. Bilateral images from both infected and non-infected sides were taken for comparison. The gray scale images were described as follows: [6] Hyperechoic (brighter) Isoechoic (darker) Anechoic (no internal echoes) Mixed signals This information was used to stage the infection from acute edematous phase to complete abscess formation as follows: [6] Edematous changes: The echogenicities of the tissues were isoechoic, similar to the normal or uninfected side but with an increase in the uid contents. Cellulitis: The echogenicities of the tissues were higher (hyperechoic) than normal because of massive inammatory inltration to the infected region. Preabscess stage: The echogenicities of the tissues were mixed (hypoechoic and hyperechoic) at the end of cellulitis stage and the beginning of abscess formation stage. Abscess stage: The echogenicities of the tissues were absent (anechoic) because of the abscess cavity, which can be solitary or multiple well-dened foci of pus. The USG images were interpreted by the operator (Sonologist) on the monitor and the USG diagnosis was obtained. After the USG examination, the USG-guided intraoperative aspiration was undertaken in all cases under aseptic conditions. A high-resolution ultrasound scan was performed using a 5.7 linear array probe in direct contact with skin surface using sterile ultrasound gel as the coupling agent. The patient was in the supine position with the head tilted toward the unaffected side. After visualizing the abscess cavity under the guidance of the ultrasound, the probe position was adjusted so that the intended puncture point of the abscess was aligned with the imaginary midline of the probe and distance from skin surface to the required depth of the needle insertion was measured accurately. A 20-gauge needle mounted on sterile 10 ml disposable plastic syringe was inserted freehand at an angle perpendicular to the scanning plane. During the procedure the patient was instructed not to move, breathe deeply, or [Downloadedfreefromhttp://www.joomr.orgonThursday,August28,2014,IP:118.96.200.204]||ClickheretodownloadfreeAndroidapplicationforthisjournal Mohit, et al.: Ultrasonography of odontogenic fascial space infections Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 10 swallow during the needle insertion to avoid the shifting of the image. The needle was withdrawn and the site was covered with a temporary dressing. The aspirate collected was sent for microbiological culture sensitivity tests. The USG-guided intraoperative aspiration ndings served as the gold standard for the denitive diagnosis. Statistical analysis The data thus obtained was subjected to statistical analysis using SPSS version 16.0 for Windows. The statistical methods used in this study were as follow. 1. Descriptive statistics 2. Crosstabs 3. Chi-square test 4. Fishers test RESULTS Among the 30 study subjects included in the study, 12 (40%) were males and 18 (60%) were females. The males ranged in age from 9 to 58 years with a mean age of 31.5 years. The females ranged in age from 6 to 59 years with a mean age of 29.9 years. Of the 43 involved spaces, submandibular space was the most commonly involved space (15, spaces 34.8%). The second most commonly involved space was the buccal space (10, 23.2%) and the third was the canine space (8, 18.6%), they were followed by submental (7, 16.2%) and submasseteric space (3, 6.9%) [Table 1]. Single space involvement was noted in 17 (56.7%) cases and multiple spaces were involved in 13 (43.3%) cases. According to the ndings of ultrasonography, out of the 30 cases 6 (20%) were in edema stage, 10 (33.3%) in cellulitis and 14 (46.7%) cases were noted to be in abscess stage. In all the abscess cases USG showed well-dened edge denition expect in 2 (14.3%) cases where the edge was not clearly dened. The internal echo pattern was homogenous and anechoic in all of the abscess cases [Table 2, Figure 1]. USG ndings in cases of cellulitis showed an ill-dened edge denition with a heterogeneous hyperechoic internal echo pattern. In six edema cases USG showed an ill-dened edge denition and heterogeneous and isoechoic internal echo pattern [Tables 3 and 4, Figures 2 and 3]. Out of the 30 cases of fascial space infections, 7 (23.3%) cases were involving the deciduous dentition. Lower second deciduous molar was the most commonly involved tooth. In the permanent dentition lower second and third molars were the most commonly involved teeth. Comparison of clinical working diagnosis and USG guided intra operative aspiration Of the 30 subjects, a clinical working diagnosis of abscess and cellulitis was rendered in 17 (56.7%) and 13 (43.3%) cases, respectively. Table 1: Ultrasonography results of fascial space involvements Fascial space involved Clinical ndings (%) USG ndings(%) Types of fascial spaces Submandibular space 15 (34.8) 15 (34.8) Supercial Submental space 7 (16.2) 7 (16.2) Supercial Buccal space 10 (23.2) 10 (23.2) Supercial Canine space 8 (18.6) 8 (18.6) Supercial Submasseteric space 3 (6.9) 3 (6.9) Supercial Table 2: USG ndings in abscess cases Patient no. Space involved Edge denition Internal echo Pattern Intensity Case no 2 Left submasseteric Well dened Homogenous Anechoic Case no 3 Right canine Well dened Homogenous Anechoic Case no 5 Right submandibular, buccal Well dened Homogenous Anechoic Case no 7 Left buccal Ill dened Homogenous Anechoic Case no 8 Right submandibular, buccal Well dened Homogenous Anechoic Case no 11 Left submandibular, buccal Well dened Homogenous Anechoic Case no 13 Left submandibular, buccal Ill dened Homogenous Anechoic Case no 14 Right buccal, submandibular Well dened Homogenous Anechoic Case no 17 Left buccal Well dened Homogenous Anechoic Case no 18 Right submandibular, buccal Well dened Homogenous Anechoic Case no 19 Left canine Well dened Homogenous Anechoic Case no 25 Left submasseteric Well dened Homogenous Anechoic Case no 26 Left submandibular, buccal Well dened Homogenous Anechoic Case no 29 Left submasseteric Well dened Homogenous Anechoic Figure 1: USG changes with edema [Downloadedfreefromhttp://www.joomr.orgonThursday,August28,2014,IP:118.96.200.204]||ClickheretodownloadfreeAndroidapplicationforthisjournal Mohit, et al.: Ultrasonography of odontogenic fascial space infections Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 11 On USG-guided intra operative aspiration of the fascial space infections of all 30 subjects, 14 (46.7) cases were found to be abscess and 16 (53.3%) were found to be cellulitis. On comparing the results of clinical working diagnosis with USG-guided intra operative aspiration, a positive correlation was found in 11 (64.7%) of the 17 cases with a clinical working diagnosis of abscess. Six (35.5%) cases with a clinical working diagnosis of abscess were diagnosed as cellulitis on USG-guided intraoperative aspiration. On comparing the results of clinical working diagnosis with USG-guided intraoperative aspiration, a positive correlation was found in 10 (76.9%) of the 13 cellulitis cases. Three (23.1%) cases with clinical working diagnosis of cellulitis were found to be abscess on USG-guided intra operative aspiration. The overall co-relation of results between clinical working diagnosis and USG-guided intraoperative aspiration was found to be signicant, with a P value of 0.03. The overall sensitivity of diagnosing abscess and cellulitis cases by clinical and radiographic examination alone (i.e. clinical working diagnosis) was found to be 78.5% with a specicity of 62.5%. A positive predictive value of 64.7% and negative predictive value of 76.9% was obtained [Table 5]. Compari son of the Ul trasonographi c diagnosis and USG-guided intraoperative aspiration Of the 30 subjects, an USG diagnosis of abscess and cellulitis was rendered in 14 (46.7%) cases and 16 (53.3%) cases, respectively. On comparing the results of USG diagnosis with USG- guided intraoperative aspiration, a positive correlation was found in all 14 abscess cases and all 16 cellulitis cases. The overall co-relation of results between USG diagnosis and USG-guided intra operative aspiration was found to be very highly signicant, with a P value of 0.0001. USG showed a sensitivity and specificity of 100% for diagnosing the cases of fascial space infection of odontogenic origin [Table 6]. Figure 2: USG changes with cellulitis Figure 3: USG changes with abscess Table 3: USG ndings in cellulitis cases Patient no. Space involved Edge denition Internal echo Pattern Intensity Case no 1 Right canine Ill dened Heterogeneous Hyperechoic Case no 6 Left canine Ill dened Heterogeneous Hyperechoic Case no 10 Right canine Ill dened Heterogeneous Hyperechoic Case no 15 Left canine Ill dened Heterogeneous Hyperechoic Case no 21 Right submandibular, submental Ill dened Heterogeneous Hyperechoic Case no 22 Right submandibular Ill dened Heterogeneous Hyperechoic Case no 23 Right submandibular Ill dened Heterogeneous Hyperechoic Case no 24 Left submandibular, submental Ill dened Heterogeneous Hyperechoic Case no 27 Left buccal Ill dened Heterogeneous Hyperechoic Case no 28 Right canine Ill dened Heterogeneous Hyperechoic Table 4: USG ndings in edema cases Patient no. Space involved Edge denition Internal echo Pattern Intensity Case no 4 Left submandibular, submental Ill dened Heterogeneous Isoechoic Case no 9 Right buccal, Ill dened Heterogeneous Isoechoic Case no 12 Left submandibular, submental Ill dened Heterogeneous Isoechoic Case no 16 Left submandibular Ill dened Heterogeneous Isoechoic Case no 20 Left submandibular, Ill dened Heterogeneous Isoechoic Case no 30 Left submandibular, buccal Ill dened Heterogeneous Isoechoic [Downloadedfreefromhttp://www.joomr.orgonThursday,August28,2014,IP:118.96.200.204]||ClickheretodownloadfreeAndroidapplicationforthisjournal Mohit, et al.: Ultrasonography of odontogenic fascial space infections Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 12 Comparison of clinical working diagnosis and the Ultrasonographic diagnosis On comparing the results of clinical working diagnosis with USG diagnosis, a positive correlation was found in 11 (64.7%) of the 17 abscess cases. Six (35.5%) cases with a clinical working diagnosis of abscess were diagnosed as cellulitis on ultrasonography. On comparing the results of clinical working diagnosis with USG, a positive correlation was found in 10 (76.9%) of the 13 cellulitis cases. Three (23.1%) cases with clinical working diagnosis of cellulitis were found to be abscess on USG. The overall co-relation of results between clinical working diagnosis and USG diagnosis was found to be signicant, with a P value of 0.03 [Table 7]. DISCUSSION The mean age of the distribution of patients was 31.5 15.6 years. There are no studies that show if age has an impact on diagnosing fascial space infections. A study by Cachovan et al. found the mean age of patients presenting to the emergency department with odontogenic infections in an 8-year epidemiologic analysis to be 34.8 16.8 years and showed that patients in the 20-29 range age group utilized emergency care more frequently. Similar ndings were noted in our study also. [7] In the present study the most common primary space involved was the submandibular space (34.8%) followed by the buccal space (23.2%). The lower molars, primarily second and third molars have roots which are below the attachment of mylohyoid muscle, and the lingual cortical plate is thinner as compared to the buccal cortical plate. Odontogenic infections from these teeth will perforate the lingual cortical plate in most cases, resulting in submandibular facial space infection. Infections from maxillary molar teeth and mandibular rst molar will result in buccal facial space infection. The roots of permanent maxillary molars are above the attachment of buccinator muscle while the roots of mandibular permanent rst molar are below the attachment of buccinator muscle. In the maxilla the buccal cortical plate is thinner than the palatal plate and fenestration in the buccal cortical plate favors the spread of infection to the buccal space. Rega et al. in their study reported that submandibular space was involved in 30% cases followed by buccal space which was involved in 27.5% cases. A different pattern was Table 5: Comparison of Clinical working diagnosis and USG guided Intra operative aspiration by Crosstabs Evaluation Condition % Count USG-guided Intra operative aspiration Total Signicance Abscess Cellulitis Clinical Abscess Count % of CWD* 11 6 17 working diagnosis 64.7% 35.3% 100.0% Cellulitis Count % of CWD 3 10 13 0.03 23.1% 76.9% 100.0% Total Count % of CWD 14 16 30 46.7% 53.3% 100.0% Table 7: Comparison of clinical working diagnosis and ultrasonographic diagnosis by Crosstabs Evaluation Condition % Count USG diagnosis Total Signicance Abscess Cellulitis Clinical Abscess Count % of CWD 11 6 17 working diagnosis 64.7% 35.3% 100.0% Cellulitis Count % of CWD 3 10 13 0.03 23.1% 76.9% 100.0% Total Count % of CWD 14 16 30 46.7% 53.3% 100.0% Table 6: Comparison of the ultrasonographic diagnosis and USG-guided intra operative aspiration by Crosstabs Evaluation Condition % Count USG-guided Intra operative aspiration Total Signicance Abscess Cellulitis Ultrasonographic diagnosis (USGD)* Abscess Count % of USGD 14 0 17 100.0% 0.0% 100.0% Cellulitis Count % of USGD 0 16 13 0.001 0.0% 100.0% 100.0% Total Count % of CWD 14 16 30 46.7% 53.3% 100.0% [Downloadedfreefromhttp://www.joomr.orgonThursday,August28,2014,IP:118.96.200.204]||ClickheretodownloadfreeAndroidapplicationforthisjournal Mohit, et al.: Ultrasonography of odontogenic fascial space infections Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 13 observed by Bridgeman et al., where buccal space (52.6%) was the most common space followed by submandibular space (24%). Labriola et al. reported 24% of their patients presented with submandibular space infections and 20% with buccal space infections. [8-10] Out of the 30 cases, 17 (56.7%) had single space involvement while in 13 (43.3%) multiple space involvement was noted. Since many of fascial spaces of head and neck communicate either directly or indirectly with each other, spread of infection from one region to another can occur when the balance between patient resistance and bacterial virulence is unfavorable. [6] Various other studies have also shown the involvement of multiple spaces in patients with fascial space infection of odontogenic origin. [6,11,12] In the present study out of the 30 study subjects, a clinical working diagnosis of abscess and cellulitis was rendered in 17 (56.7%) cases and 13 (43.3%) cases, respectively. On USG-guided intraoperative aspiration abscess cases were found to be 14 (46.7%) and cellulitis cases were 16 (53.3%) in number. Similar higher incidence of cellulitis cases was found by Pelgel et al. [2] On comparing the results of clinical working diagnosis with intraoperative aspiration procedure, a positive correlation was found in 11 (64.7%) of the 17 abscess cases. Six (35.5%) cases with a working diagnosis of abscess were diagnosed as cellulitis on aspiration. A higher incidence of diagnosing abscess clinically in comparison with diagnosing cellulitis is also in accordance with study conducted by Aarthi et al. [12] In addition, on comparing the results of clinical working diagnosis with USG-guided intraoperative aspiration, a positive correlation was found in 10 (76.9%) of the 13 cellulitis cases. Further, 3 (23.1%) cases with a clinical working diagnosis of cellulitis turned out to be abscess on intra operative aspiration. The overall comparison of the clinical working diagnosis with USG-guided intra operative aspiration diagnosis resulted in a highly signicant with a P value of 0.03. This shows that with clinical and radiographic examination alone a correct diagnosis was made in 21cases out of 30 cases. The overall sensitivity of diagnosing abscess and cellulitis cases by clinical and radiographic examination alone (i.e. clinical working diagnosis) was found to be 78.5% with a specicity of 62.5%. A positive predictive value of 64.7% and negative predictive value of 76.9% was obtained. Similar results were noted with various other studies. [11-13] Such results emphasize the role of good clinical and radiographic acumen in the diagnosis of fascial space infections of odontogenic origin. In the present study, USG was correctly able to diagnose all the cases of abscess, i.e. 14 (46.7%) cases as were diagnosed with USG-guided intraoperative aspiration. Similarly, all 16 (53.3%) cases of cellulitis were correctly diagnosed with USG. This shows sensitivity and specicity of 100% for diagnosing both abscess and cellulitis cases by ultrasonography. Similar results were found by Bassiony et al. In their study USG had accurately revealed 76% of all involved fascial spaces and 100% of involved supercial spaces. This indicated that USG is reliable and has potential to replace MRI in detection of buccal, canine, infraorbital, submandibular, submental, and submasseteric spaces. The authors concluded that USG was a valuable addition in diagnosis of supercial fascial space infections and in demonstrating the stages of infections. However, MRI was superior to USG in assessment of deep fascial space involvements, such as the parapharyngeal and masticator spaces. [6] Since, in the present study all study subjects had supercial fascial space infections; all were accurately diagnosed when correlated with the USG-guided intraoperative aspiration which was considered as the gold standard. During the USG evaluation of the subjects the fascial space infections were graded according to the description given by Bassiony et al., [6] and it was found that out of 30 cases 6(20%) were in the edema stage, 10 (33.3%) were in the cellulitis stage and 14 (46.7%) were in the abscess stage. Ultrasonographic staging was not included during the statistical analysis because it is not clear in the literature what is expected to be found in the other stages upon surgical intervention. For example, is pus expected to be found in the preabscess stage since it is considered to be between the cellulitis and abscess stages? The diagnoses were made based upon whether the operator and expert believed the swellings were mainly in the cellulitis or abscess stage (i.e. whether the purulence was expressed upon intra operative aspiration or not). Making a clear cut diagnosis or knowing the stage of the swelling is important if the treatment of the swellings is different. But for cases with either cellulitis or edema the treatment rendered will be the same. [Downloadedfreefromhttp://www.joomr.orgonThursday,August28,2014,IP:118.96.200.204]||ClickheretodownloadfreeAndroidapplicationforthisjournal Mohit, et al.: Ultrasonography of odontogenic fascial space infections Journal of Oral and Maxillofacial Radiology / January-April 2014 / Vol 2 | Issue 1 14 Ultrasonographic images in the present study in the cases of cellulitis showed ill-defined edges with the heterogeneous pattern and hyperechoic intensity; also, there was an increase in the thickness of involved muscle and subcutaneous tissue [Figure 2]. While in the cases of abscess, the edges were well dened with the homogenous pattern and hypoechoic/anechoic intensity, with posterior acoustic enhancement suggestive of some collection [Figure 1]. The same ndings were conrmed in studies conducted by various investigators. [6,11-15] The echogenicities of the tissues in the edematous phase were isoechoic, similar to the normal or uninfected side but with an increase in the uid content and with increased thickness of skin and subcutaneous tissues [Figure 3]. On comparing the results of clinical working diagnosis with USG diagnosis, a positive correlation was found in 11 (64.7%) of the 17 abscess cases. Six (35.5%) cases with a working diagnosis of abscess were diagnosed as cellulitis on ultrasonography. In addition, on comparing the results of working diagnosis with USG diagnosis, a positive correlation was found in 10(76.9%) of the 13 cellulitis cases. Further, 3 (23.1%) cases with a clinical working diagnosis of cellulitis turned out to be abscess on USG evaluation. The overall comparison of the clinical working diagnosis with USG diagnosis was highly signicant with a P value of 0.03. Aarthi et al. and various other investigators also rendered similar results in their studies when a comparison was made between clinical working diagnosis and USG diagnosis. [11-13] CONCLUSION The conclusions drawn from the study are as follows. The different stages of fascial space infections of odontogenic origin can be clearly depicted on the USG USG displays utmost accuracy in the diagnosis of fascial space infections of odontogenic origin. USG can be used as a reliable adjunctive imaging technique in the diagnosis of fascial space infection of odontogenic origin and thus aids in appropriate treatment planning and management of such cases. REFERENCES 1. Topazian R, Moton H, Goldberg M, Hupp JR. Oral and Maxillofacial infections. 4 th ed. USA: W.B Saunders company; 2002. p.168-84. 2. 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. 3. Baurmash HD. 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Ultrasonography of inflammatory soft tissue swellings of head and neck. J Oral Maxillofac Surg 1987;45:842-6. Cite this article as: Sharma M, Patil K, Guledgud MV. Ultrasonographic evaluation of fascial space infections of odontogenic origin. J Oral Maxillofac Radiol 2014;2:8-14. Source of Support: Nil. Conict of Interest: None declared. [Downloadedfreefromhttp://www.joomr.orgonThursday,August28,2014,IP:118.96.200.204]||ClickheretodownloadfreeAndroidapplicationforthisjournal