Sialography Sialography Sialography Sialography

Sialography

1. Sialography & Sialolithiasis

2. Sialography First performed by Carpy in 1902, using Mercury as contrast medium. Performed for detection of disorders of major salivary glands (parotid / submandibular gland) The procedure involves cannulation and filling with a radio-opaque agent to make the acini and canals / ducts of the gland visible on a radiograph.

3. Indications: Detection of calculi or foreign bodies Determination of the extent of destruction of salivary gland tissue secondary to obstruction such as calculi or foreign bodies Detection of fistulas, diverticuli and strictures Detection and diagnosis of recurrent swelling and inflammatory processes Demonstration of tumour size, location and origin Selection of site for biopsy Outline of plans of facial nerve as a guide in planning a biopsy or dissection Detection of residual stones, residual tumour fistulas and stenosis or a retention cyst following lithotomy or other surgical procedures

4. Contraindications: Patient’s with known allergy or hypersensitivity to iodine compounds. During acute sialoadenitis because: The contrast media cause irritation There is increased chance of rupture of duct There is potential for retrograde dissemination of pyogenic organisms throughout the gland Patient’s scheduled for thyroid function tests

5. Technique: Identify duct opening Explore duct with a lacrimal probe Cannulation with a polyethylene tube with a special blunt metallic tip with side holes Introduction of dye with a 5-10 ml syringe 0.76 – 1.00 ml of dye is injected for parotid 0.50 – 0.75 ml of submandibular gland After taking X-rays, cannula is removed and salivary flow is stimulated using lesions

6. Contrast Sialography Can be performed by Lipid soluble or Water soluble agents. Lipid soluble agents Contains 37% iodine e.g. ethiadol .

7. Advantages: Not diluted by saliva Not absorbed across glandular mucosa Disadvantages: More viscous therefore increase injection pressure required The injection is accompanied by more pain and discomfort Calculus will get displaced backward When extravasated it is not readily absorbed Can cause foreign body reactions

8. Water soluble agents: These agents contain 28-38% iodine e.g. hypaque . Advantages: They have low viscosity, low surface tension and more miscible with salivary secretions The residual medium is absorbed and excreted through kidney It coats and outlines calculi better than oil based agents Disadvantages: Opacification is not as good as oil based media It is diluted by saliva

9. Phases of silography Ductal phase Starts with the retrograde injection of contrast media & ends when glandular parenchyma starts to become “hazy”, onset of acinar opacification . The normal opacified parotid ductal system is described as “ leafless tree ”. X rays taken are -A-P, -puffed A-P views of the cheek -Lateral view

10. Acinar phase Starts with the completion of ductal opacification and ends when there is a generalized increased density to the gland reflecting filling of glandular acini . Radiographs A-P, Lateral view for parotid gland and A-P & oblique lateral for submandibular gland Post evacuation phase Useful in assessing the secretory function of the gland & detecting ductal pathology. - I subphase : unstimulated (60 sec.) - II subphase : stimulated with sialogogue e.g. lemon juice

11. Non-clearing or incomplete clearing of a gland during phase can be due to: Sialolith and/or stricture Extraductal or extravasated contrast medium Collection of contrast medium in abscess cavities Underlying physiological abnormality

12. Observations The salivary calculi, stricture and other obstructions appear radiolucent In Sjogren’s syndrome – large dye filled space giving “ cherry blossom ” or “ branchless fruit laden tree ” Tumours – displacement of glandular structure gives rise to “ ball in hand ” appearance

13. Sialolithiasis Also known as salivary gland calculus or salivary gland stone It is the formation of a SIALOLITH (calculus or stone) in the salivary gland duct or gland resulting in obstruction of salivary flow. It can form in the parenchyme or duct of major or minor salivary gland

14. Sialolithiasis The presence of one or more oval or round calcified structures in a duct of a major or minor salivary gland Sialolithiasis results in a mechanical obstruction of the salivary duct Is the major cause of unilateral diffuse parotid or submandibular gland swelling

15. Pathogenesis The exact pathogenesis of sialolithiasis remains unknown. It is assumed that a congealed mucin, protein, and desquamated ductal epithelial cells form a small nidus on which calcium salts precipitate Acute ductal obstruction may occur at meal time when saliva producing is at its maximum, the resultant swelling is sudden and can be painful

16. Factors like local irritation, inflammation or drug Can cause stagnation of saliva leading to formation of a organic nidus which eventually calcify

17. Most common in the submandibular gland (83%) Long curved path of Wharton’s duct Has increase chances of entrapment of organic debris. Higher concentration of calcium and phosphate in the secretion of gland. Thick consistency High mucous content

18. Sialolith It is a calcified mass with laminated layers of inorganic material Its results from crystallization of salivary solute. Yellowish in color Single or multiple Ovoid or elongated of 2cm or more in diameter

19. Sialolith Composition Organic; often predominate in the center Glycoproteins Mucopolysaccarides Bacterial Cellular debris Inorganic; often in the periphery Calcium carbonates & calcium phosphates in the form of hydroxyapatite

20. Clinical features Common in middle age person Pain Swelling Transient swellign during meal which resolves after meal. Calculus rarely blocks the duct completely, so saliva sweeps. When salivary demand diminishes swelling subsides. Fever and malaise Pus may exudate from gland

21. Investigations Radiaograph AP view Lateral Lateral Oblique Occlusal view Sialography Calculi can be approximately located.

22. Complications Bacterial infection of the gland may result in the obstruction of long duration Dilatation of the gland and the duct. The retention of saliva may result in the formation of mucoceles . May result in atrophy of the gland

23. Management The smaller sialoliths , which are located near the ductal opening may be removed by manipulation (milking of the gland) Larger are surgically removed The stones which are not impacted, may be extracted through the intubation of the duct with fine soft plastic catheter and application of suction to the tube Multiple stones in the gland require removal of the gland Lithotripsy can be used.

24. Transoral sialolithotomy of the submandibular duct Procedure is carried out under LA Exact site of the stone is located by radiographs and palpation Suture is placed behind the stone to prevent its backward movement. Tongue is lifted and held Incision is made in the mucosa parallel to the duct. Blunt dissection is carried out Tissue is displaced to locate the duct Longitudinal incision is made over the stone Stone is held with forceps and removed Suture are placed at the mucosa

25. Treatment Stone excision: Simple removal (20% recurrence) Lithotripsy Interventional sialendoscopy Gland excision

26. Gland excision Very posterior stones Intra-glandular stones Failed transoral approach

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