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Imaging of salivary gland
Salivary gland Parotid
Radiographic projections used OPG Oblique lateral Rotated PA or AP Intraoral view of the cheek OPG Oblique lateral Lower 90° occlusal (to show the duct) Lower oblique occlusal (to show the gland) True lateral skull with the tongue depressed
Plain films Contrast radiography- sialography Ultrasound CT scan Scintigraphy Flow rate studies Magnetic resonance imaging (MRI).
Occlusal radiographs- anterior 2/3rd duct OPG- overlapping Lateral oblique- 150 view , post 1/3rd duct Intra buccal Postero anterior view Lateral ceph
Ultrasonography CT scan .
.Sialography is a radiographic procedure that is useful diagnostic aid in the detection of masses and pathological processes in the salivary glands by injection of radio-opaque die through major salivary gland ductal system.
Detection of a calculus / calculi / foreign body Determination of the extent of destruction of gland secondary to obstructing calculi / foreign body Detection of fistulae . diverticuli or strictures Detection / diagnosis of recurrent swelling and inflammatory processes Tumor – location / size Selection of a site for biopsy Outline the plane of facial nerve Residual stone / tumor. fistula or stenosis .
Known sensitivity to Iodine compounds Acute inflammation of salivary system Interfere with thyroid function tests .
DEFINITION: Radiopaque substances that have been developed to alter artificially the density of different parts of the patient IDEAL REQUISITES: Physiologic properties similar to saliva Miscibility with saliva Absence of systemic / local toxicity Low surface tension and low viscosity Easy elimination Absorption and detoxification .
g. Urografin®) — Ionic dimers: • ioxaglate (e.g. Hexabrix®) — Non-ionic monomers: * iopamidol (e.g. Iodine-based aqueous solutions: — Ionic monomers: * iothalmate (e.g. Omnipaque®) * iopromide (e. Isopaque®) • diatrizoate (e. Niopam®) * iohexol (e.g.g. Conray®) * metrizoate (e.g. Ultravist®) .
-Iodine-based oil solutions such as Lipiodol® (iodized poppy seed oil) used for lymphography and sialography -Water insoluble organic iodine compounds eg Pentopaque .
Contrast medium Oil-based Advantages Densely radiopaque. thus easily introduced Easily and rapidly removed from the gland Easily absorbed and excreted if extravasated . thus show good contrast High viscosity. thus show reduced contrast Excretion from the gland is very rapid unless used in a closed system Aqueous Low viscosity. and may produce a foreign body reaction High viscosity means Considerable pressure needed to introduce the contrast. calculi may be forced down the main duct Less radiopaque. thus slow excretion from the gland Disadvantages Extravasated contrast may remain in the soft tissues for many months.
EQUIPMENTS •Polyethylene tubing with blunt end metallic tip •5 to 10cc syringe •Lacrimal dilators •Contrast medium •Lemon extract /Lemon slices .
PROCEDURE 3 Phases 1) Preliminary plain film evaluation 2) Injection / Filling phase 3) Parenchymal / Evacuation phase .
PROCEDURE •Location of orifice of the duct •Duct exploration with Lacrimal probe •Insertion of sialographic canula into the duct •Injection(slow) of contrast medium into the duct •3 to 4 sets of radiographs are taken during procedure -Preliminary plain films -Filling phase films -Post evacuation phase films •Instruction to the patient .
. Disadvantages The arbitrary pressure which is applied may cause damage to the gland Reliance on patient's responses may lead to underfilling or overfilling of the gland.5 ml for the submandibular gland). (about 0. Advantages Simple Inexpensive. 0.3 methods of injecting dye Simple injection technique Oil-based or aqueous contrast medium is introduced using gentle hand pressure until the patient experiences tightness or discomfort in the gland.7 ml for the parotid gland.
. Hydrostatic technique Aqueous contrast media is allowed to flow freely into the gland under the force of gravity until the patient experiences discomfort. so they need to be positioned in advance for the filling-phase radiographs. Advantages The controlled introduction of contrast medium is less likely to cause damage or give an artefactual picture Simple Inexpensive. Disadvantages Reliant on the patient's responses Patients have to lie down during the procedure.
Disadvantages Complex equipment is required Time consuming. Advantages The controlled introduction of contrast media at known pressures is not likely to cause damage Does not cause overfilling of the gland Does not rely on the patient's responses. Continuous infusion pressure-monitored technique Using aqueous contrast medium. . a constant flow rate is adopted and the ductal pressure monitored throughout the procedure.
COMPLICATIONS •Over Distension •Foreign body Reaction •Chronic Inflammatory Process .
but the overall appearance is similar— the so-called bush in winter appearance .Parotid gland • The duct structure within the gland branches regularly and tapers gradually towards the periphery of the gland. the so-called tree in winter appearance Submandibular gland • This gland is smaller than the parotid.
.Ductal changes associated with: — Calculi — Sialodochitis (ductal inflammation/infection) • Glandular changes associated with: — Sialadenitis (glandular inflammation/infection) — Sjogren's syndrome — Intrinsic tumours.
Ductal dilatation caused by associated Sialodochitis Emptying film shows retained contrast media . lobules are overfilled.Calculus: Filling defects in main duct distal to calculus.
“sausage – string ” appearance Acini & ductules are not dilated .Sialodochitis: Segmental strictures & dilation of larger ducts.
an appearance known as sialectasis caused by the inflammation of the glandular tissue producing saccular dilatation of the acini . .Dots or blobs of contrast medium within the gland.Glandular changes: Sialadenitis: .Main duct & inter lobular ducts appear normal in caliber.
Due to the wearing of epithelial lining the intercalated ducts allow escape of contrast media. “ Snow – storm ” appearance.Sjogren`s syndrome: Wide spread dots / blobs of contrast media within the gland. Punctate Sialectasis. .
due to ductal compression by the tumour • Ductal displacement — the ducts adjacent to the tumour are usually stretched around it. known as BALL IN HAND APPEARANCE. . • Retention of contrast medium in the displaced ducts during the emptying phase.Intrinsic tumors: • An area of underfilling within the gland.
PARA NASAL SINUS AND IMAGING .
corticated radiopaque margins Internal bony septa and blood vessel canals in the walls all produce their own shadows. dense. Thin lining epithelium is not normally seen. .Normal appearance Radiolucent cavity in the maxilla Well-defined.
Investigation Periapical (paralleling or bisected angle technique) Area of antrum shown Floor Base of antral cavity Relationship with upper posterior teeth Dental panoramic Floor Posterior wall Base of antral cavity Relationship with upper posterior teeth Medial wall Allows comparison of both sides 0° occipitomental (0° OM) Main antral cavity Lateral wall Roof or upper border Medial wall Allows comparison of both sides Upper oblique occlusal Floor Lower half of antral cavity Relationship with upper posterior teeth .
True lateral skull Main antral cavity Posterior wall Anterior wall Note: Superimposition of one antral shadow on the other Main antral cavity Floor Anterior wall Lateral wall Posterior wall Medial wall Roof or upper border Allows comparison of both sides (coronal only) Main antral cavity Floor All walls Roof or upper border Surrounding structures Allows comparison of both sides Images hard and soft tissue Linear or spiral tomography in coronal or sagittal plane Computed tomography (CT) or MRI .
the shape. site and extent of the opacity often determining the differential diagnosis.Radiological signs for antral disease Opacity within the antrum — total or partial . e. . including discontinuity owing to a fracture or destruction by an intrinsic or extrinsic tumour Alteration in the antral outline. including expansion or compression owing to an intrinsic or extrinsic lesion Presence of a foreign body within the antrum.g. a fluid level Alteration in the integrity of the antral walls.
.Common pathologies affecting antra • Infection/inflammation — Acute / Chronic sinusitis • Trauma — Oro-antral communication — Fractures — Foreign bodies • Cysts — Intrinsic — Extrinsic • Tumors — Intrinsic — Extrinsic • Other bone abnormalities — Fibrous dysplasia — Paget's disease — Osteopetrosis.
including roots or teeth displaced into the antrum or the formation of an oroantral communication • Apical infection associated with the upper posterior teeth CHRONIC SINUSITIS Causes • Prolonged antral infection • Continued presence of a foreign body or oroantral communication. .ACUTE SINUSITIS Causes • Upper respiratory tract infection. particularly the common cold Trauma.
before the combination of mucosal thickening and fluid totally opacifies the antrum Features of apical inflammatory changes.Radiographic features of acute sinusitis Total opacity within the antral cavity Opaque zone confined to base of antrum. if infected teeth are involved — resorption and remodelling of the antral floor producing antral halo Evidence of a foreign body . with initial collection of fluid.
Complete filling of the sinus except about the ostium on the medial wall. . Generalized around the entire wall of the sinus.Chronic sinusitis Mucoperiosteal thickening of the maxillary sinus Localized at the base of the sinus. Complete filling of the sinus.
to be displaced into the antrum.Causes of Oroantral communication Extraction of closely related upper posterior teeth can remove part of the antral floor or fracture the tuberosity Inappropriate or incorrect use of elevators during root or tooth removal — may also cause the root. . or rarely the tooth.
Radiographic features Break in the continuity of the floor may be evident Characteristic features of acute or chronic sinusitis owing to the ingress of bacteria Evidence of the displaced root or tooth — a second view of the antrum with the head in a different position may be required to ascertain the exact location of the displaced object .
MUCOCELES AND MUCOUS RETENTION CYSTS Pathogenesis is obstruction due to inflammation or allergy. round. dome-shaped opacity within the antrum Usually no evidence of thickening of the remainder of the epithelial lining Usually no alteration of the antral outline Occasionally bilateral . Main radiographic features Incidental finding Well-defined.
radiopaque corticated margin to the edge of the meniscus.e. dome-shaped opacity in the base of the antrum with a well-defined. Large cyst • Total opacity of the antral region owing to complete compression of the antral cavity • Loss of antral outline • Sometimes displacement of the associated tooth . the odontogenic cyst has a bony margin and so can be differentiated from the soft tissue mucosal retention cyst or antral polyp • Lateral expansion of the alveolar bone • Sometimes displacement of the associated tooth.Radiographic features of Odontogenic cysts Small cyst • Round. i.
Main radiographic features The presence. position and often the nature of the foreign body Occasionally associated sinusitis. .Foreign bodies Causes Displaced root fragments or teeth Excess root canal filling material forced through the apex of an upper posterior tooth during endodontics Antrolith — calcification within the antrum Foreign material pushed into the antrum through an existing oro-antral communication.
POLYPS Thickened mucous membrane of a chronically inflamed sinus frequently forms into irregular folds called polyps. .
Malignant neoplasm affecting antra .
Air sinus Frontal Investigation 0° occipitomental (0° OM) PA skull True lateral skull Tomography CT/ MRI 0° occipitomental (with the patient's mouth open) True lateral skull Submento-vertex (SMV) Tomography CT/ MRI 0° occipitomental 30° occipitomental True lateral skull PA skull Tomography CT /MRI Sphenoidal Ethmoidal .
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