SIALOGRAPHY-CONVENTIONAL, CT, MRI

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 Wharton’s or Stensen’s
duct.
• Sublingual glands unlikely to be
imaged due to difficulty in the
cannulation
Ductal anatomy
• Parotid duct’s 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
• Wharton’s 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.
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
• 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 t e ra l Su b m a n d ib u la r
Se t -Up
Pa ro t id Ra d io g 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
Parotid sialogram
Both parotid &
submandibular sialograms
Calculus
Stenosis
Sialodochitis
Sialosis
Sjogren’s syndrome
Neoplasms
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 operator’s 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 active filling
of the ductal system
SIALOLITHIASIS
SJOGREN’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
• 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.
THANK YOU