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RESEARCH

An evaluation of efficacy of ultrasonography in the diagnosis of head and neck swellings

R Chandak* ,1 , S Degwekar 1 , RR Bhowte 1 , M Motwani 1 , P Banode 2 , M Chandak 3 and S Rawlani 1

1 Department of Oral Medicine and Radiology, Sharad Pawar Dental College and Hospital, Sawangi (M) Wardha, India; 2 Department Of Radiodiagnosis, Jawaharlal Nehru Medical College, DMIMS, Sawangi (M) Wardha, Maharashtra, India;3 Department of Conservative Dentistry, Sharad Pawar Dental College, DMIMS, Sawangi (M) Wardha, Maharashtra, India

Objective : The aim of this study was to evaluate the efficacy of ultrasonography in thediagnosis of swellings in the head and neck regions.Methods : For this study, 70 cases with clinically obvious swellings in head and neck regionswere selected randomly. The ultrasonographic features considered were shape, boundary,echo intensity, ultrasound architecture of lesion, posterior echoes and ultrasoundcharacteristic of tissues. Intergroup comparisons were made between four different typesof swellings: inflammatory; cystic; benign; and malignant.Results: A comparison was made between benign and malignant neoplasms, and the criteriaof boundary, echo intensity and ultrasound architecture of lesions are statistically significantas the P -value is , 0.05. The comparison of inflammatory swellings and malignant neoplasmsshows that criteria of boundary and ultrasound architecture of lesions are statisticallysignificant. The comparison of cystic swellings and benign neoplasms concluded that only thecriterion of ultrasound characteristics of tissues is statistically significant. The comparison of inflammatory swellings and benign neoplasms shows that the criteria of boundary and echointensity are statistically significant. The comparison of inflammatory swellings and cysticswellings concluded that the criteria of boundary, shape, echo intensity, posterior echoes and

ultrasound characteristics of tissues are statistically significant. The comparison of cysticswellings and malignant neoplasms concluded that the criteria of ultrasonography,boundary, shape, echo intensity, ultrasound architecture of lesion, posterior echoes andultrasound characteristics of tissues are statistically significant as the P -value is , 0.05.Conclusion: It can be concluded that clinical diagnosis had a sensitivity and accuracy of 85.7 % and ultrasonographic diagnosis had a sensitivity and accuracy of 98.5 % .Dentomaxillofacial Radiology (2011) 40, 213221. doi: 10.1259/dmfr/68658286

Keywords: ultrasonography; swelling; echo intensity; posterior echoes

Introduction

Sonography means imaging with ultrasound; ultrameans beyond or in excess; sound means audiblesound energy. The term ultrasound means the form of sound energy beyond audible range. Ultrasound usedfor diagnostic purposes has a frequency of 2 MHz 20 MHz while ultrasound used for ophthalmology hasa range of 2 MHz50 MHz. 1,2

Ultrasound wave is a form of longitudinal mechan-ical wave that needs a medium to transmit from oneplace to another. Ultrasound is produced by vibratingpiezoelectric crystals using a high-frequency electricalpulse which causes mechanical oscillation and pro-duces ultrasound waves. Therefore, electrical energy isconverted into mechanical energy. Diagnostic ultra-sound utilizes a transducer which generates a narrowfocus beam. This beam is reflected from the tissue andsent back to the same transducer, which assembles theseechoes into an image that can be visualized andrecorded. 1,2

*Correspondence to: Dr Rakhi Chandak, Lecturer, Sharad Pawar DentalCollege and Hospital, Sawangi (M) Wardha, Maharashtra, India; E-mail:[email protected] 30 June 2009; revised 28 January 2010; accepted 19 February 2010

Dentomaxillofacial Radiology (2011) 40, 213221 2011 The British Institute of Radiology

http://dmfr.birjournals.org


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Ultrasonography has several advantages over othermodalities as it is harmless, uses no ionizing radiation,is widely available, easy-to-use, non-invasive, inexpen-sive and unaffected by metal artefacts such as dentalrestorations. It can be performed without heavy se-dation. Ultrasound causes no health problems and maybe repeated as often as necessary.

In ultrasonography, there is the facility of on-screennodal measurement. 3 Ultrasound is capable of differ-entiating cystic from solid lesions and is also helpfulin diagnosing malignant vs benign masses. It is helpfulin delineating the presence of multiple lymph nodesand the course of resolution of infectious diseases. It isused to visualize the presence and extent of facialabscesses. It can be used in cases of oral carcinoma toobserve the presence of regional lymph node metastasis.Ultrasound is helpful in detecting sialoliths and inthe diagnosis of conditions involving the salivary gland.CT is used for parapharyngeal space. 4

Various disease processes may affect head and neckregions, which present clinically as swellings. Thedisease processes which lead to such types of swellingscan be broadly classified as inflammatory, cystic,benign or malignant in nature.

In evaluation of such swellings, detailed case historyand clinical examination are the most important andmandatory steps. But in some cases, such as chronic in-flammation, abscess formation, deep-seated or infectedcystic lesion and neoplasms, clinical examination andpalpation do not provide complete assessment of theexact origin and nature of swellings; such cases requireradiological imaging. Therefore, to get a final diag-

nosis, clinical examination must be joined with variousinvestigative procedures.In the present study, an attempt has been made to

evaluate the efficacy of ultrasonography in the processof arriving at the diagnosis of swelling in the head andneck region. In this research study, sensitivity, specifi-city, positive predictive value, negative predictive valueand accuracy of the test were calculated in inflamma-tory, cystic, benign and malignant swellings.

The aim of this study was to compare the ultrasono-graphic differentiation of inflammatory swellings, cysticswellings, benign neoplasms and malignant neoplasmswith each other in head and neck regions. Intergroupcomparison was also carried out in the study.

Material and methods

The protocol of this study was approved by the insti-tutional ethical committee. The study was conductedduring 20062008.

Inclusion criteria: for this single blind cross-sectionalstudy, 70 cases with clinically obvious swellings in headand neck regions were selected randomly, with the agerange of 870 years. Age limitation was not consideredand male-to-female ratio was 3:2.

Exclusion criteria: swellings owing to trauma orfracture were not included because clinical diagnosis of haematoma is not a problem as there is historyof trauma and changes in skin colour and mucousmembrane.

Swellings obscured by an overlying jaw bone werenot included, e.g. any pathology present in the deeplobe of the parotid gland not seen on the ultrasound asit is obscured by the ramus of the mandible.

Patients were informed about the procedures andwritten consent forms were obtained.

The patients detailed case history was recorded andclinical examinations were carried out on the basis of criteria given by Das. 5 Criteria include inspection of swellings and palpation of swellings. In inspection,situation, colour, shape, size, border, surface and over-lying skin over the swelling were noted; in palpation,consistency, tenderness, temperature, fluctuance, com-pressibility and fixity of skin over the swelling were

recorded.The data obtained were recorded in the structuredproforma for recording clinical findings and a provi-sional diagnosis was made.

Based on clinical diagnosis, swellings were dividedinto four groups:

1. inflammatory swelling;2. cystic swellings;3. benign neoplasms; and4. malignant neoplasms.

After provisional diagnosis, patients were subjected to

radiological imaging. An ultrasonographic investigationof each swelling was carried out in the Departmentof Radiodiagnosis using Philips Envisors C Series(Sarrone, Italy) of ultrasonogram. When the lesion wasless than 3.5 cm in diameter, a linear transducer probewith a frequency of 15 MHz and a depth of 3 cm wasused. A transcavitary probe with a frequency of 7.5 MHz and a depth of 8 cm was used when the lesionwas larger than 3.5 cm in diameter. In this study,different values of frequency were used because asfrequency of ultrasound increases, depth of penetrationof ultrasound decreases (thereby reducing the visibilityrange of ultrasounds). At the same time as frequencyincreases, resolution increases. For better resolution,15 MHz was used.

The following features were considered in describingthe ultrasonographic images of swelling in the head andneck in accordance with Shimizu et al: 6

N shape: oval, lobular, round, polygonal, irregular;N boundary: very clear, relatively clear, partially

unclear, ill defined;N echo intensity: anechoic, isoechoic, hypoechoic,

hyperechoic, mixed;N ultrasound architecture of lesion: homogeneous,

heterogeneous;N presence of necrosis: eccentric, central;

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N presence of calcification: macrocalcification, micro-calcification;

N posterior echoes: enhanced, unchanged, attenuated; andN ultrasound characteristic of tissues: cystic, solid, mixed.

All the sonographic images obtained were interpretedby three qualified sonologists in the Department of Radiodiagnosis. After unanimous agreement, a reportwas given by the senior sonologist.

Following clinical and ultrasonographic diagnosis,surgical intervention was carried out by incision anddrainage or excision/incisional biopsy/fine-needle aspira-tion cytology as indicated. The obtained biopsy speci-mens were submitted for histopathological examinationand a final diagnosis was made. In cases of inflamma-tory swellings, a blood picture was carried out and finaldiagnosis was established on the basis of response of either surgical intervention, i.e. incision and drainage, orsuccessful non-surgical treatment.

The obtained results were tabulated and statisticallyanalysed. Sensitivity, specificity, positive predictive value,negative predictive value and accuracy of the test werecalculated to evaluate the reliability and diagnosticefficacy of ultrasonography as an investigative tool.

Results

A total of 70 patients with clinically obvious swellingsin head and neck regions were included in the study(Table 1).

Out of 35 cases, 30 swellings were finally diagnosed asinflammatory swellings by carrying out ultrasonographyand surgical intervention investigations.

Inflammatory swellingsInflammatory swellings that showed signs of inflammationfrom odontogenic origin (18 out of 30) were diagnosed ascellulites or abscesses. The remaining inflammatory swel-lings were from non-odontogenic origin (12 out of 30). Outof these 12 inflammatory swellings of non-odontogenicorigin, 5 were diagnosed as sialadenitis as they originatedfrom salivary glands and the remaining 7 were diagnosed aslymphadenitis as they originated from lymph nodes. In fivepatients, clinical diagnosis did not match with finaldiagnosis, and in one case sonographic diagnosis did notmatch with final diagnosis.

By considering ultrasonographic features given byShimizu et al, 6 in this study most of the inflammatory

swellings had relatively clear boundaries, irregular shapes,hypoechoic echo intensity and homogeneous ultrasoundarchitecture of lesion. The posterior echoes appearedenhanced and ultrasound characteristics of tissues werecystic or solid in nature (Table 2, Figures 1 and 2).

Cystic swelling Out of the total eight cases of cystic swellings, six swel-lings were diagnosed as odontogenic cysts and two asnon-odontogenic cysts by carrying out ultrasonographyand surgical intervention investigations.

In two out of eight cases, clinical diagnosis did notmatch with final diagnosis, whereas all the sonographicdiagnoses matched with final diagnosis.

In the present study, most of cystic swellings had veryclear boundaries, round shapes and anechoic echointensity. The ultrasound architecture of lesions of cysticswellings was homogeneous, posterior echoes appearedenhanced and ultrasound characteristic of tissues of cystic swellings were cystic in nature. Fine-needleaspiration was done in cystic cases (Table 3, Figure 3).

Benign neoplasmOut of the total nine cases of benign neoplasms, sevenswellings were finally diagnosed as benign neoplasmsby carrying out ultrasonography and surgical interven-tion investigations.

Out of these seven cases of benign neoplasms, onecase was of cavernous haemangioma, two cases were of capillary haemangioma, two cases were of lymphan-gioma, one case was of lipoma and one case was of fibroma. In two out of nine patients, clinical diagnoses

Table 1 Distribution of types of swellings (70 patients) in head andneck regions

Diseases No. of patients Percentage

Inflammatory swelling 35 50Cystic swelling 8 11.4Benign neoplasms 9 12.8Malignant neoplasms 18 25.7Total 70 100

Table 2 Ultrasonographic features of inflammatory swellingstotal(35)

Greyscale sonographic features

Inflammatoryswellings No. Percentage

Boundary Very clear 12 34.2Relatively clear 18 51.4Partially unclear Ill defined 5 14.2

Shape Oval 13 37.1Lobular 3 8.5Polygonal Irregular 15 42.8

Round 4 11.4Echo intensity Anechoic 11 31.4Isoechoic 6 17.1Hypoechoic 15 42.8Hyperechoic Mixed (hypo +hyper)

3 8.5

Ultrasound architectureof lesion

Homogeneous 23 65.7Heterogeneous 12 34.2

Posterior echoes Enhanced 17 48.5Unchanged 12 34.2Attenuated 5 14.2Unenhancement 1 2.8

Ultrasound characteristicof tissues

Cystic 15 42.8Solid 16 45.7Mixed 4 11.4

Ultrasonography in head and neck swellingsR Chandak et al 215



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did not match with final diagnosis, whereas all thesonographic diagnoses matched with final diagnosis.

Most benign neoplasms had very clear boundaries,irregular shapes and hypoechoic echo intensity. The

ultrasound architecture of lesions of benign neoplasmswas homogeneous, posterior echoes appeared enhancedand ultrasound characteristics of tissues were solid innature (Table 4, Figure 4).

a b

c

Figure 2 (a) Inflammatory swellingcysticercosis cellulosae (clinical photograph). (b) Inflammatory swellingcysticercosis cellulosae(ultrasonographic image). (c) Flow chart of inflammatory swelling

a b

Figure 1 (a) Inflammatory swellingsubmandibular lymphadenitis (clinical photograph). (b) Inflammatory swellingsubmandibularlymphadenitis (ultrasonographic image)




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Malignant neoplasmOut of the total 18 cases of malignant neoplasms, 17swellings were finally diagnosed as malignant neoplasmsby performing ultrasonography and surgical interven-tion investigations.

Out of 17 cases of malignant neoplasms, 7 cases wereof moderately differentiated squamous cell carcinomas,5 cases were of well-differentiated squamous cellcarcinomas, 2 cases were of poorly differentiated squa-mous cell carcinomas, 1 case was of malignant mela-noma, 1 case was of fibrosarcoma and 1 case was of pleo-morphic adenoma undergoing carcinomatous changes.In 1 out of 18 patients, clinical diagnosis did not matchwith final diagnosis, whereas all the sonographicdiagnoses matched with final diagnosis.

From this study, it can be concluded that mostmalignant neoplasms had ill-defined boundaries, irregu-lar shapes and hypoechoic echo intensity. The ultra-sound architecture of lesions of malignant neoplasmswas heterogeneous, posterior echoes appeared un-changed and ultrasound characteristic of tissues of malignant neoplasms were solid in nature. If there wasno enhancement or attenuation posterior to the lesion,posterior echoes were considered to be unchanged(Table 5, Figure 5).

For the intergroup comparison amongst the fourgroups of swellings, six groups for the comparisonswere made, including benign neoplasms from malignantneoplasms; inflammatory swellings from malignantneoplasms; benign neoplasms from cystic swellings;inflammatory swellings from benign neoplasms; inflam-matory swellings from cystic swellings; and cysticswellings from malignant neoplasms.

Table 3 Ultrasonographic features of cystic swellingstotal (8)

Greyscale sonographic features Cystic swellings No. Percentage

Boundary Very clear 8 100Relatively clearPartially unclearIll defined

Shape Oval 3 37.5LobularPolygonalIrregularRound 4 50Tubular 1 12.5

Echo intensity Anechoic 7 87.5IsoechoicHypo + anechoic 1 12.5Hyperechoic

Ultrasound architectureof lesions


Posterior echoes Enhanced 8 100UnchangedAttenuated

Ultrasound characteristicof tissues Cystic 8 100SolidMixed

a b

Figure 3 (a) Cystic swellinginfected dental cyst (clinical photograph). (b) Cystic swellinginfected dental cyst (ultrasonographic image)




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A comparison was made between benign and malig-nant neoplasms in head and neck swellings according togreyscale sonographic features. In these comparisons,the x 2 value and P-value were calculated. From thesevalues, it can be concluded that in greyscale ultrasono-graphy, criteria of boundary, echo intensity and ultra-sound architecture of lesions are statistically significantto differentiate benign from malignant neoplasms in thehead and neck as the P -value is , 0.05.

A comparison was made between inflammatoryswellings and malignant neoplasms in head and neckswellings according to greyscale sonographic features.In these comparisons, the x 2 value and P -value werecalculated. From these values it can be concluded thatin greyscale ultrasonography, the criteria of boundaryand ultrasound architecture of lesion are statisticallysignificant to differentiate inflammatory swellings from

malignant neoplasms in the head and neck as theP -value is , 0.05.

A comparison was made between cystic swellings andbenign neoplasms in head and neck swellings accordingto greyscale sonographic features. In these compar-isons, the x 2 value and P -value were calculated. Fromthese values, it can be concluded that in greyscaleultrasonography, only the criteria of ultrasound char-acteristics of tissues is statistically significant todifferentiate cystic swellings from benign neoplasms inthe head and neck as the P -value is , 0.05.

A comparison was made between inflammatoryswellings and benign neoplasms in head and neckswellings according to greyscale sonographic features.In these comparisons, the x 2 value and P -value werecalculated. From these values, it can be concluded thatin greyscale ultrasonography, the criteria of boundaryand echo intensity are statistically significant todifferentiate inflammatory swellings from benign neo-plasms in the head and neck as the P -value is , 0.05.

A comparison was made between inflammatoryswellings and cystic swellings in head and neckswellings according to greyscale sonographic features.In these comparisons, the x 2 value and P- value werecalculated. From these values, it can be concluded thatin greyscale ultrasonography, the criteria of boundary,shape, echo intensity, posterior echoes and ultrasoundcharacteristics of tissues are statistically significant todifferentiate inflammatory swellings from cystic swel-lings in the head and neck as the P -value is , 0.05.

A comparison was made between cystic swellings andmalignant neoplasms in the head and neck according to

greyscale sonographic features. In these comparisons,the x 2 value and P -value were calculated. From thesevalues it can be concluded that all the criteria of ultrasonography, such as boundary, shape, echointensity, ultrasound architecture of lesion, posteriorechoes and ultrasound characteristic of tissues, arestatistically significant to differentiate cystic swellingsfrom malignant neoplasms in the head and neck as the

Table 4 Ultrasonographic features of benign neoplasmstotal (9)

Greyscale sonographic features Benign neoplasms No. Percentage

Boundary Very clear 7 77.7Relatively clearPartially unclearIll defined 2 22.2

Shape Oval 2 22.2Lobular 1 11.1PolygonalIrregular 5 55.5Round 1 11.1

Echo intensity Anechoic 2 22.2IsoechoicHypoechoic 3 33.3Hypo + anechoic 1 11.1Hyperechoic 3 33.3



Posterior echoes Enhanced 7 77.7Unchanged 1 11.1Attenuated 1 11.1

Ultrasound characteristicof tissues Cystic 2 22.2Solid 6 66.6Mixed 1 11.1

a b1 b2

Figure 4 (a) Benign neoplasmcystic hygroma (clinical photograph). (b1) Benign neoplasmcystic hygroma (ultrasonographic image). (b2)Benign neoplasmcystic hygroma (ultrasonographic image)




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P -value is , 0.05 and the criteria of boundary, echointensity and ultrasound characteristics of tissues arealso statistically highly significant.

After considering the results of all 70 cases of thepresent study (Tables 69), it can be concluded thatclinical diagnosis had a sensitivity and accuracy of 85.7 % whereas ultrasonographic diagnosis had asensitivity and accuracy of 98.5 % .

Discussion

The differential diagnosis of swelling in the head andneck is broad and extensive and includes both seriousand benign aetiologies. Accurate diagnosis of a headand neck swelling is of paramount importance.

In this study, most of the inflammatory swellings hadrelatively clear boundaries, irregular shapes, hypoechoicecho intensity and homogeneous ultrasound architectureof lesion. The posterior echoes appeared enhanced andultrasound characteristics of tissues were cystic or solidin nature. Our findings were consistent with findingsgiven by Sivarajasingam et al 7 and Baurmash et al 8 whostated that in cases of abscesses, ultrasonographyshowed reduction of echo intensity and deep underlyingcystic change. In this study, there were five cases of inflammatory swellings from non-odontogenic origin,such as sialadenitis, which included three cases of parotitis and two cases of submandibular sialadenitis.Three cases had coarsening of glandular parenchyma,hypoechoic areas and heterogeneous echo texture of thegland as seen in parotitis and submandibular sialadeni-tis. Our findings were consistent with findings given byHowlett 9,11 and Alyas et al. 10

In this study, in one case which was diagnosed

clinically as submandibular lymphadenopathy but theultrasound showed hyperechoic foci casting posterioracoustic shadowing and enlargement of the gland, ductdilation proximal to obstruction was seen. It was diag-nosed as obstructive submandibular sialadenitis. 1214

In this study, in the group of inflammatory swellings,clinical diagnosis had a sensitivity and specificity of 85.7 % whereas sonographic diagnosis had a sensitivityof 97.1 % and specificity of 100 % (Table 6).

Cysts on the sonogram appear as anechoic with avery clear boundary and homogeneous echo texture.If the cysts become infected then the content of thelesion can produce some echoes, producing hypoechoicstructures. 15,16

In this study, four cases of periapical cyst werestudied. All four cases showed very clear boundaries,posterior echoes appeared enhanced and homogeneousinternal echoes were suggestive of periapical cyst. Inthese four cases, sonography had been performedintraorally with a transcavitary probe. 17

In this study, in the group of cystic swellings, clinicaldiagnosis had a sensitivity of 75 % and a specificity of

a b1 b2

Figure 5 (a) Malignant neoplasmhigh-grade mucoepidermoid carcinoma (clinical photograph). (b1) Malignant neoplasmhigh-grademucoepidermoid carcinoma (ultrasonographic image). (b2) Malignant neoplasmhigh-grade mucoepidermoid carcinoma (ultrasonographicimage)

Table 5 Ultrasonographic features of malignant neoplasmstotal(18)

Greyscale sonographic features

Malignantneoplasms No. Percentage

Boundary Very clear 1 5.5Relatively clearPartial ly unclear 6 33.3Ill defined 11 61.1

Shape OvalLobular 4 22.2PolygonalIrregular 10 55.5Round 4 22.2

Echo intensity AnechoicIsoechoic 4 22.2Hypoechoic 14 77.7Iso + hypoechoic 1 5.5Hyperechoic



Posterior echoes Enhanced 6 33.3Unchanged 7 38.8

Attenuated 5 27.7Ultrasound characteristicof tissues

CysticSolid 14 77.7Mixed 4 22.2




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87.1 % , whereas sonographic diagnosis had a sensitivityof 100 % and a specificity 98.3 % (Table 7).

In this study, one pleomorphic adenoma had a veryclear boundary, was rounded in shape and hadhypoechoic echo intensity associated with heterogeneousinternal architecture. Our findings were comparable withfindings given by Howlett 9,11 and Alyas et al. 10

In the present study, there were four cases of haemangioma, of which two cases had hypoechoicecho intensity with heterogeneous internal architectureand a posterior echo that appeared enhanced. In onecase there was an anechoic area and the heterogeneousinternal architecture with posterior echo was enhanced,whereas in another case there were hyperechoic areaswith homogeneous internal architecture and enhancedposterior echo. Two cases of cavernous haemangiomahad compressible vascular spaces on colour Dopplerexamination. Our findings were consistent with findingsgiven by Kalinowska et al, 18 Turkington et al 19 andHowlett et al. 11

Lipoma appeared on ultrasound as a solid homo-

geneous mass of similar echogenicity to that of sub-cutaneous fat. 19

In this study, clinical diagnosis of benign neoplasmshad a sensitivity of 77.7 % and specificity of 86.8 % ,whereas sonographic diagnosis had a sensitivity of 100% and a specificity 98.3 % , and the accuracy of thetest was 98.5 % (Table 8). Our findings were consistentwith findings given by Ahuja et al, 20 Turkingtonet al 19 and Howlett et al. 11

Ultrasound can predict malignancy in 89 % of cases butvarious forms of malignancy cannot be differentiated. Onultrasounds of lower grade tumours, smaller lesions mayappear as well defined and similar to a benign tumour.

Larger lesions developed more overtly with malignantfeatures, including irregular and poorly defined marginswith heterogeneous internal architecture. 911

In the present study, in the group of malignantneoplasms, clinical diagnosis had a sensitivity of 94.4 %and specificity of 82.6 % , whereas sonographic diag-nosis had a sensitivity of 100.0 % and specificity of 98.0 % (Table 9).

Conclusion

The intergroup comparison amongst the four groups of swellings was made and from this it can be concludedthat:

(1) There are six criteria of ultrasonography of whichthree criteria (boundaries, echo intensity andultrasound architecture of lesions) are statisticallysignificant to differentiate benign neoplasms frommalignant neoplasms in the head and neck as theP -value is , 0.05.

(2) To differentiate inflammatory swellings frommalignant neoplasms in the head and neck, twocriteria (boundaries and ultrasound architecture of lesion) are statistically significant as the P -value is, 0.05.

(3) Only one criterion of ultrasonography (ultra-sound characteristics of tissues) is statisticallysignificant to differentiate benign neoplasms fromcystic swellings as the P -value is , 0.05.

(4) Two criteria of ultrasonography (boundaries andecho intensity) are statistically significant to differ-entiate inflammatory swellings from benign neo-plasms in the head and neck as the P -value is , 0.05.

(5) Five criteria of ultrasonography (boundaries,shape, echo intensity, posterior echos and ultra-

sound characteristic of tissue) are statisticallysignificant and differentiate inflammatory swellingsfrom cystic swellings as the P -value is , 0.05.

Table 6 Comparison of clinical and ultrasonographic diagnosis of inflammatory swellings

Sensitivity analysisClinical diagnosis( % )

Ultrasonographicdiagnosis ( % )

Sensitivity 85.7 97.1Specificity 85.7 100Positive predictive value 85.7 100Negative predictive value 85.7 97.2Likelihood ratio 6.0 Accuracy of the test 85.7 98.5

Table 7 Comparison of clinical and ultrasonographic diagnosis of cystic swellings



Sensitivity 75 100Specificity 87.1 98.3Positive predictive value 42.8 88.8Negative predictive value 96.4 100Likelihood ratio 5.8 62Accuracy 85.7 98.5

Table 8 Comparison of clinical and ultrasonographic diagnosis of benign neoplasms



Sensitivity 77.7 100Specificity 86.8 98.3Positive predictive value 46.6 90Negative predictive value 96.3 100Likelihood ratio 5.9 61Accuracy 85.7 98.5

Table 9 Comparison of clinical and ultrasonographic diagnosis of malignant neoplasms



Sensitivity 94.4 100Specificity 82.6 98.0Positive predictive value 65.3 94.7Negative predictive value 97.7 100Likelihood ratio 5.4 52accuracy 85.7 98.5




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