ADVANCED IMAGING TECHNIQUES

1-ULTRASONOGRAPHY
Diagnostic ultrasound is now established as the first choice imaging modality for soft tissue
investigations of the face and neck, particularly of the salivary glands. It is a non-invasive
investigation that uses a very high frequency(7.5–20 MHz) pulsed ultrasound beam, rather
than ionizing radiation, to produce high resolution images of more superficial structures. The
use of color power Doppler allows blood flow to be detected.
Equipment and theory
Several machines are available , the high frequency ultrasound beam is directed into the body
from a transducer placed in contact with the skin. Jelly is placed between the transducer and
the skin to avoid an air interface. As the ultrasound travels through the body, some of it is
reflected back by tissue interfaces to produce echoes, which are picked up by the same
transducer and converted into an electrical signal and then into a real-time black, white and
grey visual echo picture, which is displaced on a computer screen.
The ultrasound image is also sectional image or tomograph, but it represents a topographical
map of the depth of tissue interfaces.
-The thickness of the section is determined by the width of the ultrasound beam.
- Areas of different density in the black/white echo picture are described as hypoechoic
(dark) or hyperechoic (light).
- Utilization of the Doppler effect – a change in the frequency of sound reflected from a
moving source – allows the detection of arterial and/or venous blood flow.
- The computer adds the appropriate color, red or blue, to the vascular structures in the
visual echo picture image, making differentiation between structures straightforward.
-The ultrasound wave must be able to travel through the tissue to return to the transducer. If
it is blocked by the tissue, no image will result. Since air, bone and other calcified materials
block nearly all the low frequency ultrasound beam its diagnostic use is limited. However, the
newer high frequency machines enable penetration of more superficial structures to provide
high resolution images.
Main indications for ultrasound in the head and neck
1- Evaluation of swellings of the neck, particularly those involving the major salivary
glands – ultrasound is now regarded as the investigation of choice for detecting solid
and cystic soft tissue masses.
2- Detection of salivary gland and duct calculi.
3- Determination of the relationship of vascular structures and vascularity of masses
with the addition of color flow Doppler imaging.
4- Therapeutically can help to break up salivary calculi into approximately 2-mm
fragments which can then pass out of the ductal system so avoiding major surgery.
Advantages over conventional X-ray imaging
1- Sound waves are NOT ionizing radiation.
2- There are no known harmful effects on any tissues at the energies and doses currently
used in diagnostic ultrasound.
3- Images show good differentiation between different soft tissues and are very sensitive for
detecting focal disease in the salivary glands.
4- The technique is widely available and relatively inexpensive.
Disadvantages
1- Ultrasound has limited use in the head and neck region because sound waves are blocked
by bone. Its use is therefore restricted to the superficial structures.
2- The technique is operator-dependent.
3- Images can be difficult to interpret for inexperienced operators.
4- Real-time imaging means that the radiologist must be present during the investigation.
2-Magnetic Resonance Imaging )MRI)
Magnetic Resonance Imaging (MRI), nuclear magnetic resonance imaging
(NMRI), or magnetic resonance tomography (MRT) is one of the most powerful
diagnostic tools, highly sensitive and specific imaging modality that is being used
in radiology and diagnostic science. Magnetic resonance imaging is used to
visualize internal structures of the body in detail.
Unlike conventional x-ray examinations and computed tomography (CT) scans,
MRI does not depend on ionizing radiation. Instead, it depends on the magnet
and radio frequency waves (RF). MRI uses the property of nuclear magnetic
resonance (NMR) to image nuclei of atoms inside the body.
Types of MRI
1. Closed MRI
2. Open MRI
3. Extremity MRI
4. Dynamic MRI
Mechanism of MRI
To make an MR image, the patient is first placed inside a large magnet.
-This magnetic field causes the nuclei of many atoms in the body especially hydrogen, to align
with the magnetic field.
-Then RF pulse has been emitted, causing some hydrogen nuclei to absorb energy and
resonate.
-When the RF pulse is turned off, the stored energy is released from the body and the signals
detected by coils in the scanner.
-The magnetic field in MRI scanner is provided by external powerful permanent magnet with
strength range from (0.1- 4 Tesla), the 1.5 Tesla is the most commonly used and it's about
30000 times the strength of the earth's magnetic field.
- As a strong magnet is used, all metallic devices MUST be removed before entering the MRI
room. This includes clothes with metal zips and jewelry.
Magnetic Resonance Signal
-The MR signal received by a coil after RF pulse turning off, the magnitude of this signal is
proportional to the overall concentration of hydrogen nuclei (proton density) in the tissue.
-The strength of the signal also depends on the degree to which hydrogen is bound within a
molecule. Tightly bound hydrogen atoms as those present in bone, don't align themselves
with the external magnetic field and produce only weak signal. While loosely bound or mobile
hydrogen atoms as those present in soft tissues and liquids, react to the RF pulse and produce
a detectible strong signal.
-The higher concentration of loosely bound hydrogen atoms, the stronger magnetization, the
more intense recovered signal, and the brighter corresponding part of MR image.
T1 and T2 relaxation time
-T1 relaxation time represents the time required for 63% of the net magnetization to return to
equilibrium, so it reflects the ability of hydrogen atoms to transfer their excess energy to
surrounding molecules.
-T2 relaxation time is the time constant that describe the exponential rate of loss of
transverse magnetization.
Tissue contrast
It depends on proton density, T1 and T2 times of the tissue being imaged.
-T1- Weighted image: are most commonly used to demonstrate anatomy of the part being
imaged depending on the differences in T1 values of tissues.
-Tissues with short T1 times, such as fat, appear bright. While tissue with long T1 times, such
as CSF (water or fluid), appear dark.
-T2- Weighted image: are most commonly used for identifying pathology because
pathological tissue usually contain more water than surrounding tissues due to inflammation,
depending on the differences in T2 values of tissues. Tissues with long T2 times, such as CSF
or TMJ fluid, appear bright. While tissue with short T2 times, such as fat, appear dark.
MRI contrast agents
-MRI provides good contrast between the different soft tissues of the body, which makes it
especially useful in imaging the brain, muscles, the heart, and cancers compared with other
medical imaging techniques such as computed tomography (CT) or X-rays.
-Unlike CT scans or traditional X-rays, MRI does not use ionizing radiation.
-contrast agents most commonly Gadolinium, may be injected intravenously to enhance the
appearance of blood vessels, tumors or inflammation.
-Contrast agents may also be directly injected into a joint in the case of arthrograms (MRI
images of joints).
-Gadolinium is not imaged itself, but it shortens the T1 relaxation times of the enhancing
tissues making them appear brighter.
MRI versus CT
1. A computed tomography (CT) scanner uses X-rays (ionizing radiation) to acquire images,
making it a good tool for examining tissue composed of elements of a higher atomic number
than the tissue surrounding them, such as bone and calcifications (calcium based) within the
body (carbon based flesh), or of structures (vessels, bowel). MRI, on the other hand, uses
non-ionizing radio frequency (RF) signals to acquire its images and is best suited for soft tissue
(although MRI can also be used to acquire images of bones & teeth) .
2. A contrast in CT images is generated purely by X-ray attenuation, while a variety of
properties may be used to generate contrast in MR images. Contrast agents for CT contain
elements of a high atomic number, relative to tissue, such as iodine or barium, while contrast
agents for MRI have paramagnetic properties, such as gadolinium and manganese, used to
alter tissue relaxation times.
3. For purposes of tumor detection and identification in the brain, MRI is generally superior.
However, in the case of solid tumors of the abdomen and chest, CT is often preferred as it
suffers less from motion artifacts. Furthermore, CT usually is more widely available, faster,
and less expensive. However, CT has the disadvantage of exposing the patient to harmful
ionizing radiation
Advantages of MRI
1. It offers best contrast resolution of soft tissues
2. No ionizing radiation is involved with MRI
3. Direct multi planar imaging is possible without patient re-orientation
Disadvantages of MRI
1. Long imaging time sometimes reaching 30 min.
2. Hazard associated with metal objects (ferromagnetic metals) present in patient's body such
as cardiac pacemaker, cerebral aneurysm clips, shrapnel, vagus nerve stimulators, insulin
pumps, cochlear implants. The strong magnetic field may harm the patient by moving this
metal object, cause excessive heating, or induce strong electrical currents.
3. Some patients have claustrophobia and discomfort when positioned in MRI machine as a
result of narrow area or acoustic noise , this can be managed by using open MRI, chemical
sedation , general anesthesia, or listening to music on headphones.
4. Gadolinium contrast agent is known to cross the placenta and enter the fetal blood stream,
so it is recommended that their use should be avoided in pregnancy.
5. High imaging cost.
- Gold and stainless steel are considered to be ferromagnetic, whereas titanium, nickel,
amalgam restorations and silver palladium are not.
- There is medical evidence that a tattoo can cause a reaction during magnetic resonance
imaging . The tattoo inks expected to cause a reaction are those containing iron oxide
(some black, brown, red, flesh, yellow, orange). Not all dyes of these colors contain iron
oxide. Also, some dyes of other colors may contain lesser quantities of magnetic metal.
Magnetic metals can convert the radio-frequency pulses of an MRI machine into electricity.
-The burning sensation that would be felt at the site of the tattoo may be a result of
electricity running through the tattoo or from the 'pull' exerted on the magnetic material in
the tattoo.
Applications of MRI in head and neck
Because of its excellent soft tissue contrast resolution, MRI is used in evaluating soft tissue
conditions such as:
1. Position and integrity of the disk in the TMJ.
2. Evaluating soft tissue diseases especially neoplasia of tongue, cheek, neck and salivary
gland.
3. Determining malignant involvement of lymph nodes.
4. MR angiography used to visualize the blood flowing in vessels for arteries imaging to
diagnose occlusion, aneurysm or malformation.
5. Evaluate suspected early osteomyelitis of the jaws to determine edematous changes in the
fatty marrow and the surrounding soft tissue
Fig 1: randomly oriented atoms fig 2: atoms with applied magnetic field
FIG. 3
A, T1 -weighted MR image of the TMJ..
B, T2-weighted MR image
C, the disk is anteriorly displaced (arrow),
with the posterior band in the 9 o'clock position relative to the condylar head.
COMPUTED TOMOGRAPHY
Computed tomography (CT) CT scanners use X-rays to produce computer generated
tomographs – sectional or slice images. In CT the radiographic film is replaced by very
sensitive crystal or gas detectors.
The detectors measure the intensity of the X-ray beam emerging from the patient and
convert this into digital data which are converted, stored and can be manipulated by a
computer. This numerical information is converted into a grey scale representing different
tissue densities thus allowing a visual image to be generated.
Equipment and theory
The CT scanner is essentially a large square piece of equipment (the gantry) with a central
circular hole. The patient lies down with the part of the body to be examined within this
circular hole. The gantry houses the X-ray tube head and the detectors. The mechanical
geometry of scanners varies.
-In third generation scanners , both the X-ray tube head and the detector array revolve
around the patient.
-In fourth-generation scanners, there is a fixed circular array of detectors (as many as 1000)
and only the X-ray tubehead rotates.
This stop–start movement means the investigation takes several minutes to complete and the
radiation dose to the patient is high .
-As a result, spiral CT has been developed in recent years. Acquiring spiral CT data requires a
continuously rotating X-ray tubehead and detector system.
-In the case of third-generation scanners or, for fourth-generation systems, a continuously
rotating X-ray tubehead. This movement is achieved by slip-ring technology. The patient is
now advanced continuously into the gantry while the equipment rotates, in a spiral
movement, around the patient.
The investigation time has been shortened to only a few seconds with a radiation dose
reduction of up to 75% and the slices to be imaged are selected and the X-ray tubehead
rotates around the patient scanning the desired part of the body and producing the required
number of slices. These are usually in the axial plane.
Diagrams showing the principles of A a third-generation CT scanner – both the X-ray
tubehead and the detector array rotate around the patient,
B a fourth-generation CT scanner – the X-ray tubehead rotates within a stationary ring of
detectors, and
C spiral CT – the tubehead and detectors move in a continuous spiral motion around the
patient as the patient moves continuously into the gantry in the direction of the solid arrows.
D The Philips MX 8000 multislice spiral CT scanner
The sequence of events in image generation can be summarized as follows:
● As the tubehead rotates around the patient, the detectors produce the attenuation or
penetration profile of the slice of the body being examined.
● The computer calculates the absorption at points on a grid or matrix formed by the
intersection of all the generation profiles for that slice.
● Each point on the matrix is called a pixel and typical matrix sizes comprise either 512 × 512
or typical matrix sizes comprise either 512 × 512 or1024 × 1024 pixels. The smaller the
individual pixel the greater the resolution of the final image .
● The area being imaged by each pixel has a definite volume, depending on the thickness of
the tomographic slice, and is referred to as a voxel .
● Each voxel is given a CT number or Hounsfield unit between, for example, +1000 (dense
bone (white) and −1000 (air(black)), depending on the amount of absorption within that
block of tissue.
● Each CT number is assigned a different degree of greyness, allowing a visual image to be
constructed and displayed on the monitor. The patient moves through the gantry and
sequential adjacent sections are imaged.
● The selected images are photographed subsequently to produce the hard copy pictures,
with the rest of the images remaining on disc.
Image manipulation
The major benefits of computer-generated images are the facilities to manipulate or alter the
image and to reconstruct new ones, without the patient having to be re-exposed to ionizing
radiation
Reconstructed images
The information obtained from the original axial scan can be manipulated by the computer to
reconstruct tomographic sections in the coronal, sagittal or any other plane that is required,
or to produce three-dimensional images
Main indications for CT in the head and neck
1-Assessment of the site, size and extent of cysts, giant cell and other bone lesions
2- Assessment of disease within the paranasal air sinuses
3- Tumour staging – assessment of the site, size and extent of tumours, both benign and
malignant, affecting the maxillary antra
4- Investigation of tumours and tumour-like discrete swellings both intrinsic and extrinsic to
the salivary glands
5- Investigation of osteomyelitis
6- Investigation of the TMJ
7- Preoperative assessment of maxillary and mandibular alveolar bone height and thickness
before inserting implants.
Part of an axial CT scan showing an expansive cystic lesion in the anterior palate (black
arrows). Mucosal thickening within the antrum is also evident(white arrows).
Advantages over conventional film-based tomography
1- Very small amounts, and differences, in X-ray absorption can be detected. This in turn
enables:
– Imaging of hard and soft tissues
– Excellent differentiation between different types of tissues, both normal and diseased.
2-Images can be manipulated.
3- Axial tomographic sections are obtainable.
4-Reconstructed images can be obtained from information obtained in the axial plane.
Disadvantages
1-The equipment is very expensive.
2-Very thin contiguous or overlapping slices result in a generally high dose investigation.
3-Metallic objects, such as fillings, may produce marked streak or star artefacts across the CT
image
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