Ultrasound in Medical Therapy

Ultrasound, like any wave, carries energy that can be absorbed by the medium carrying it, producing effects that vary with intensity. When focused to intensities of [latex]{\text{10}}^{\text{3}}[/latex] to [latex]{\text{10}}^{\text{5}}[/latex] [latex]{\text{W/m}}^{\text{2}}[/latex], ultrasound can be used to shatter gallstones or pulverize cancerous tissue in surgical procedures. (See (Figure).) Intensities this great can damage individual cells, variously causing their protoplasm to stream inside them, altering their permeability, or rupturing their walls through cavitation. Cavitation is the creation of vapor cavities in a fluid—the longitudinal vibrations in ultrasound alternatively compress and expand the medium, and at sufficient amplitudes the expansion separates molecules. Most cavitation damage is done when the cavities collapse, producing even greater shock pressures.

Most of the energy carried by high-intensity ultrasound in tissue is converted to thermal energy. In fact, intensities of [latex]{\text{10}}^{3}[/latex] to [latex]{\text{10}}^{4}\phantom{\rule{0.25em}{0ex}}{\text{W/m}}^{2}[/latex] are commonly used for deep-heat treatments called ultrasound diathermy. Frequencies of 0.8 to 1 MHz are typical. In both athletics and physical therapy, ultrasound diathermy is most often applied to injured or overworked muscles to relieve pain and improve flexibility. Skill is needed by the therapist to avoid “bone burns” and other tissue damage caused by overheating and cavitation, sometimes made worse by reflection and focusing of the ultrasound by joint and bone tissue.

In some instances, you may encounter a different decibel scale, called the sound pressure level, when ultrasound travels in water or in human and other biological tissues. We shall not use the scale here, but it is notable that numbers for sound pressure levels range 60 to 70 dB higher than you would quote for [latex]\beta[/latex], the sound intensity level used in this text. Should you encounter a sound pressure level of 220 decibels, then, it is not an astronomically high intensity, but equivalent to about 155 dB—high enough to destroy tissue, but not as unreasonably high as it might seem at first.

Ultrasound in Medical Diagnostics

When used for imaging, ultrasonic waves are emitted from a transducer, a crystal exhibiting the piezoelectric effect (the expansion and contraction of a substance when a voltage is applied across it, causing a vibration of the crystal). These high-frequency vibrations are transmitted into any tissue in contact with the transducer. Similarly, if a pressure is applied to the crystal (in the form of a wave reflected off tissue layers), a voltage is produced which can be recorded. The crystal therefore acts as both a transmitter and a receiver of sound. Ultrasound is also partially absorbed by tissue on its path, both on its journey away from the transducer and on its return journey. From the time between when the original signal is sent and when the reflections from various boundaries between media are received, (as well as a measure of the intensity loss of the signal), the nature and position of each boundary between tissues and organs may be deduced.

Reflections at boundaries between two different media occur because of differences in a characteristic known as the acoustic impedance [latex]Z[/latex] of each substance. Impedance is defined as

where [latex]\rho[/latex] is the density of the medium (in [latex]{kg/m}^{3}[/latex]) and [latex]v[/latex] is the speed of sound through the medium (in m/s). The units for [latex]Z[/latex] are therefore [latex]{kg/\left(m}^{2}·\text{s)}[/latex].

(Figure) shows the density and speed of sound through various media (including various soft tissues) and the associated acoustic impedances. Note that the acoustic impedances for soft tissue do not vary much but that there is a big difference between the acoustic impedance of soft tissue and air and also between soft tissue and bone.

At the boundary between media of different acoustic impedances, some of the wave energy is reflected and some is transmitted. The greater the difference in acoustic impedance between the two media, the greater the reflection and the smaller the transmission.

The intensity reflection coefficient [latex]a[/latex] is defined as the ratio of the intensity of the reflected wave relative to the incident (transmitted) wave. This statement can be written mathematically as

where [latex]{Z}_{1}[/latex] and [latex]{Z}_{2}[/latex] are the acoustic impedances of the two media making up the boundary. A reflection coefficient of zero (corresponding to total transmission and no reflection) occurs when the acoustic impedances of the two media are the same. An impedance “match” (no reflection) provides an efficient coupling of sound energy from one medium to another. The image formed in an ultrasound is made by tracking reflections (as shown in (Figure)) and mapping the intensity of the reflected sound waves in a two-dimensional plane.

The applications of ultrasound in medical diagnostics have produced untold benefits with no known risks. Diagnostic intensities are too low (about [latex]{\text{10}}^{-2}\phantom{\rule{0.25em}{0ex}}{\text{W/m}}^{2}[/latex]) to cause thermal damage. More significantly, ultrasound has been in use for several decades and detailed follow-up studies do not show evidence of ill effects, quite unlike the case for x-rays.

The most common ultrasound applications produce an image like that shown in (Figure). The speaker-microphone broadcasts a directional beam, sweeping the beam across the area of interest. This is accomplished by having multiple ultrasound sources in the probe’s head, which are phased to interfere constructively in a given, adjustable direction. Echoes are measured as a function of position as well as depth. A computer constructs an image that reveals the shape and density of internal structures.

How much detail can ultrasound reveal? The image in (Figure) is typical of low-cost systems, but that in (Figure) shows the remarkable detail possible with more advanced systems, including 3D imaging. Ultrasound today is commonly used in prenatal care. Such imaging can be used to see if the fetus is developing at a normal rate, and help in the determination of serious problems early in the pregnancy. Ultrasound is also in wide use to image the chambers of the heart and the flow of blood within the beating heart, using the Doppler effect (echocardiology).

Whenever a wave is used as a probe, it is very difficult to detect details smaller than its wavelength [latex]\lambda[/latex]. Indeed, current technology cannot do quite this well. Abdominal scans may use a 7-MHz frequency, and the speed of sound in tissue is about 1540 m/s—so the wavelength limit to detail would be [latex]\lambda =\frac{{v}_{w}}{f}=\frac{\text{1540 m/s}}{7×{\text{10}}^{6}\phantom{\rule{0.25em}{0ex}}\text{Hz}}=0\text{.}\text{22 mm}[/latex]. In practice, 1-mm detail is attainable, which is sufficient for many purposes. Higher-frequency ultrasound would allow greater detail, but it does not penetrate as well as lower frequencies do. The accepted rule of thumb is that you can effectively scan to a depth of about [latex]500\lambda[/latex] into tissue. For 7 MHz, this penetration limit is [latex]500×0.22 mm[/latex], which is 0.11 m. Higher frequencies may be employed in smaller organs, such as the eye, but are not practical for looking deep into the body.

In addition to shape information, ultrasonic scans can produce density information superior to that found in X-rays, because the intensity of a reflected sound is related to changes in density. Sound is most strongly reflected at places where density changes are greatest.

Another major use of ultrasound in medical diagnostics is to detect motion and determine velocity through the Doppler shift of an echo, known as Doppler-shifted ultrasound. This technique is used to monitor fetal heartbeat, measure blood velocity, and detect occlusions in blood vessels, for example. (See (Figure).) The magnitude of the Doppler shift in an echo is directly proportional to the velocity of whatever reflects the sound. Because an echo is involved, there is actually a double shift. The first occurs because the reflector (say a fetal heart) is a moving observer and receives a Doppler-shifted frequency. The reflector then acts as a moving source, producing a second Doppler shift.

A clever technique is used to measure the Doppler shift in an echo. The frequency of the echoed sound is superimposed on the broadcast frequency, producing beats. The beat frequency is [latex]{F}_{B}=\mid {f}_{1}-{f}_{2}\mid[/latex], and so it is directly proportional to the Doppler shift ([latex]{f}_{1}-{f}_{2}[/latex]) and hence, the reflector’s velocity. The advantage in this technique is that the Doppler shift is small (because the reflector’s velocity is small), so that great accuracy would be needed to measure the shift directly. But measuring the beat frequency is easy, and it is not affected if the broadcast frequency varies somewhat. Furthermore, the beat frequency is in the audible range and can be amplified for audio feedback to the medical observer.