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SIALOGRAPHY-CONVENTIONAL, CT, MRI

Shivaprakash.B.H PG-BIR
Shivaprakash.B.H
PG-BIR

SIALOGRAPHY

Sialography is an invasive procedure in which radiopaque contrast material is injected retrograde into ductal system via the intraoral opening of either Whartons or Stensens duct.

Sublingual glands unlikely to be imaged due to difficulty in the cannulation

Ductal anatomy

Ductal anatomy

Parotid ducts normal luminal caliber is only 1 to 2 mm, and on a direct conventional posteroanterior film, the duct should lie within 15 to 18 mm of the lateral mandibular cortex

Normally, the ducts do not lie parallel to one another in any plane

Whartons duct is seen to run downward and laterally at about a 45° angle to both the

sagittal and horizontal planes.

Indications

Sialolithiasis Infectious diseases

Neoplastic or tumour like conditions

Auto immune disorders Trauma and its complications

As a dilatation procedure rarely in mild ductal stenosis

Contraindications

Acute suppurative or inflammatory conditions of salivary gland

Previous reaction to contrast in sialography

Anticipated thyroid investigations

Pre-procedure

Procedure is to be explained

Consent to be taken for the procedure

No pre-procedure stipulations

Equipments

Fluoroscopic unit w/spot film capabilities

Cannula for introducing contrast Connecting tubing Lemons Dilators for duct 5 mL syringe Overhead light Gauze Contrast

Catheters usually used.

Catheters usually used.

Contrast agents

Fat soluble-Pantopaque,Ethoidol (39% bound iodine,ethiodised poppy seed oil)

Water soluble contrast with high iodine is preferred when available.Sinograffin(38% bound iodine,diatrizoate meglumine)

Water soluble contrast materials donot produce adequate visualisation of the ductal system due to rapid diffusion and dilution by saliva,absorption of contrast into the blood stream.

Conventional sialography (technique)

Identify the orifice of ductal system to be studied.

Dilatation can be done by lacrimal probes.

Curved blunt needle with olive 1cm from the tip is preferred prevents over penetration & backflow of contrast media

Catheter introduced co-axially introduced into the salivary duct

Catheter introduced co - axially introduced into the salivary duct
• Connecting tubing is attached to the needle & is anchored to the corner of the

Connecting tubing is attached to the needle & is anchored to the corner

of

the mouth.

1 to 1.5 ml of contrast is injected (parotid) n 0.2 to 0.5 ml (submandibular).

Examination is performed under flouroscopic guidance, multiple well coned spot sialograms in multiple projections at various stages of filling of ductal system.

Upon opacification of the gland parenchyma with fluffy,cloudy contrast stain conventional overhead roentgenograms in anteroposterior,lateral and oblique projections are taken.

Films are checked for technical adequacy and the tube is removed.

Sialogogue(lemon juice) to stimulate salivary secretion is used.

Overhead roentgenograms are taken in conventional position after 10 to 15 minutes,to evaluate the degree of evacuation of injected contrast.

La te ra l Su bm a n d ib u la r Se t-Up

La te ra l Su bm a n d ib u la r Se t-Up

Pa rotid Ra d iog ra p h s Se t- Up

Pa rotid Ra d iog ra p h s Se t- Up
Pa rotid Ra d iog ra p h s Se t- Up

Phases of sialography

Filling phase

absence of normal ductal filling can be due to,

a. complete obstruction of the main duct by an impacted stone or cicatricial obstruction;

b.invasion of the main duct by neoplasm;

c.catheter positioning with the catheter tip beyond the wall of the main duct or an acutely kinked segment of the main duct.

Parenchymal opacification phase

Injection of contrast material under fluoroscopic control is carried to the stage where filling of the acini can be recognized.

This phase of examination is mainly useful for two conditions

a.Subacute autoimmune sialosis

there is diffuse parenchymal edema with consequent elevation of the pressure in the acini.Acinar filling may be impossible by the retrograde sialographic technique.

b.peripheral intraglandular space occupying lesion

Lesions of this type can be easily missed by duct system opacification only

Post evacuation phase

complete evacuation on sialogogue stimulation is noted in normal salivary glands with active salivary secretion.

If contrast remains in the portion of the gland even after 24 hrs its distinctly abnormal.

If contrast material is noted out of the confines of the ductal system or the acini it may be due traumatisation secondary to faulty technique,or disease such as invasive neoplasm or inflammatory process.

Complete evacuation may be delayed in the presence of stricture in the ductal system

Contrast may also remain in duct & acini due to absence of secretion by the salivary gland.

Normal sialograms

Normal sialograms

Parotid sialogram

Parotid sialogram

Both parotid & submandibular sialograms

Both parotid & submandibular sialograms

Calculus

Calculus

Stenosis

Stenosis

Sialodochitis

Sialodochitis

Sialosis

Sialosis

Sjogrens syndrome

Sjogren ’ s syndrome
Neoplasms
Neoplasms

Trauma

Trauma

CT sialography

CT is better than conventional for delineation of calculi and various calcifications.

Cannulation of the duct is same as in conventional sialography

Axial sections are obtained in chin elevated position In case of dental fillings,semi- axial projections with gantry tilted to 15-20 degree CT parameters o 3 mm spiral acquisitions reconstructed at continuous 3 mm intervals o Pitch of 1 o 170 to 280 mA & 120 kV o

o Axial sections are obtained from skull base at the level of external auditory canal to the level of mid-thyroid cartilage.

o Imaging prior to contrast injection is necessary for the baseline image.

MR sialography

ionizing radiation,dependence on the operators technical skills for successful ductal cannulation, and the need for retrograde injection of contrast material are relative drawbacks of conventional sialography. Potential complications include rupture of the ductal system,

activation of a clinically quiescent infection, and adverse reactions to contrast material. Catheter manipulation or the pressure of injection of contrast material may also result in the displacement of

an anteriorly placed ductal stone into a position in which

its retrieval by

means of

endoscopy or intraoral surgery becomes more difficult or even impossible.

MR sialography is based on the principle that stationary fluids are hyperintense on heavily T2-weighted images.

No specific preparation

Need to breathe quietly and refrain from coughing or vigorous swallowing during image acquisition.

Rapid sagittal, coronal, and axial localizers were obtained to facilitate section positioning.

MR sialographic images were obtained in a axial plane parallel to the hard palate and in a sagittal-oblique plane parallel to either the Wharton or Stensen duct.

Available MR sequences

RARE (Rapid acquisition with relaxation enhancement) • GRASE (Gradient and spin echo sequence) • HASTE (Single shot turbo spin echo) • 2D-FSE (2D fast spin echo) • 3D-FSE (3D fast spin echo)

sialolithiasis and shows the distal displacement of the calculus ( long straight arrow ) caused by

sialolithiasis and shows the distal displacement of the calculus (long straight arrow) caused by active filling of the ductal system

SIALOLITHIASIS

SIALOLITHIASIS

SJOGREN’S

SJOGREN’S
Sagittal oblique- WARTHIN’S

Sagittal oblique- WARTHIN’S

To summarise

Sialography is a valuable diagnostic procedure in the work-up of disease conditions of the major salivary glands

A complete sialographic examination should include 3 stages:

a. Filling stage performed under fluoroscopic control and spot filmed during the initial visualization of the duct s stem

b. Parenchymal opacification stage for the study of the gland parenchyma beyond the duct system

c. Postevacuation stage for the study of secretory activity of the gland and to detect any destruction of the walls of the duct system or the acini.

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