SIALOGRAPHY

DACROCYSTOGRAPHY

SIALOGRAPHYINTRODUCTION A radiographic examination of the

salivary glands(PAROTID & Submandibular GLAND) and ducts using contrast media

Cannulation of Sublingual gland ducts is almost impossible

INDICATIONS FOR EXAM

Stones (Calculi) sialolithiasis Obstruction / Strictures Pain & Swelling (esp when recurrent) Infection Masses / Tumors Changes secondary to trauma When plain radiography is inconclusive

CONTRAINDICATIONS FOR EXAM

History of contrast media allergies

Severe inflammation of the salivary ducts

ANATOMY OF THE SALIVARY GLANDS

3 pairs---Parotid

SM

SL

Situated adjacent to OC, aid in initial digestion

ANATOMY OF THE SALIVARY GLANDS

PAROTID GLANDLargest salivary gland

Lies just below the ZYG arch in front & below the ear

Parotid duct(Stensons duct) is 5cm long, runs

over the messeter & opens into oral vestibule

opposite 2nd upper molar

SUBMANDIBULAR GLANDS

Extends posteriorly from below

1st lower molar to angle of mandible

Forms part of soft tissues on the medial margin of the mandible & the hyoid bone

Submandibular duct(whartsons duct ) is 5 cm long, runs forward ,medially and upward & opens into mouth on side of frenulum

SUB LINGUAL GLANDSSmallest pair

Located in floor of mouth on the surface of mylohyoid muscle.

Numerous, small sublingual ducts(ducts of Rivinus) open into floor of mouth

Ducts may join to form a single(duct of Bartholin) which empties into the submandibular duct.

SALIVARY GLAND IMAGING PLAIN RADIOGRAPHS

SIALOGRAPHY

CT(Glandular enlargement , tumors)

RADIONUCLIDE IMAGING(to provide additional physiological info in cases of over or under secretion )

MRI

SIALOGRAPHY

Radiologic exam of salivary glands and ducts using contrast media

CT and MRI have largely replaced this exam

PROCEDURE Preliminary radiographs

Detect conditions that do not require contrast

Give pt secretory stimulant 2 to 3 minutes before contrast administration

Pt asked to suck on lemon wedge-Opens duct for easy identification

Duct orifice is sprayed with topical anaesthetic

Duct is cannulated, (dialator may be required), contrast introduced with fluoroscopic guidance

Contrast (oil based or water soluble iodinated)

(conc = 240mg/ml)

Should be injected manually until pt feels discomfort

Quantity needed may vary btw 1-2 ml

Images taken immediately after contrast is complete

After taking req. images ,pt sucks on a lemon wedge again to evacuate contrast

Take post-procedure(delayed) radiographs after 5 minutes to confirm evacuation of contrast/ demonstrate any residual contrast

Dilation with probe of Wharton’s duct of the submandibular gland.

Cannulation of duct with intravenous catheter (22 gauge).

FILMS Parotid----Control Films

- PA - LAT - LAT OBLIQUE

Parotid -----Sialography Film

- PA - LAT - LAT OBLIQUE

FILMS SM----Control Films

- INFEROSUPERIOR/OCCLUSAL 1 - INFEROSUPERIOR/OCCLUSAL 2 - LAT

SM -----Sialography Film

- LAT - LAT OBLIQUE

Normal salivary gland visualized by sialography.

Lateral Submandibular radiographs

Sialogram of the right parotid gland showing multiple punctate glandular collections, 1 mm in diameter, suggestive of punctate sialectasis

SialoectasisSialogram of the parotid gland; lat. projection. In the glandular parenchyma pools of contrast can be seen. The accessory parotid gland is also affected (arrow).

Salivary Gland Swelling with Ductal Narrowing

DACROCYSTOGRAPHYIntroduction

A Radiographic examination of the

Naso lacrimal duct(s) following

administration of a contrast medium to define the Lacrimal gland & NLD system anatomically in search of stenosis or obstruction

Indications

Lacrimal duct obstruction/stricture

Contra-indications

Non-consent by patient to procedure

Contrast media or iodine allergy

Pregnancy (risk is minimal but patient may wish to delay procedure)

Anatomy

Tears (lacrimal fluid) are produced by the lacrimal gland which is located at the supero-lateral aspect of the orbit.

Drainage of the lacrimal fluid is achieved by the lacrimal canaliculi, lacrimal sac, and nasolacrimal duct.

The lacrimal fluid drains from the nasolacrimal duct into the nasal cavity via the inferior meatus

Preparation Patient identification (3 'C's- correct

patient, correct side, correct procedure)

Completed consent form

No diet restrictions

Collect/review relevant previous imaging for ease of access prior to procedure

TECHNIQUE

The patient lies supine on the fluoroscopy table with the head in a reverse occipito-mental position.

Support either side of the patient's head by immobilization device, particularly if a subtraction technique is employed.

Select a small field of view and fine focus

Control images taken

TECHNIQUE(cont)

Anaesthetic eye drops are used for patient comfort

A fine cannula is inserted into the puncta of each eye, then the eye is closed and the catheter taped to the patient's cheek

It may be necessary to dilate the puncta

to facilitate insertion of the cannula

TECHNIQUE(cont)

After the mask is acquired, commence injection

Images are taken immediately after injection

A drainage image can be taken after 15 minutes if considered necessary

Unilateral dacrocystogram demonstrating a normal lacrimal ductSubtraction has been utilizedminimal reflux into superior lacrimal canal

Bilateral dacrocystogram with subtractionNormal lacrimal duct on the leftSlower flow of contrast on the right (this may not be pathological- may reflect note the amount of extravisated contrast medium on the right)Demonstrated right duct appears normalReflux into superior lacrimal canal on rightPerfect X-ray beam collimationadequate subtraction

Bilateral dacrocystogram with subtractionExcellent X-ray beam collimationeffective subtractionReflux into superior lacrimal canal on right

Bilateral dacrocystogram without subtractionDelayed drainage imageAbnormal accumulation of contrast on the left

Unilateral injectionAbnormal pooling of contrast proximally

Unilateral injectionSubtraction techniqueMinimal contrast filling of right lacrimal sacContrast reflux into superior lacrimal canal

Contrast or Subtraction Artifact?It will not always be clear whether you have demonstrated contrast filling or subtraction artifactThe consistency of the arrowed structure and its similarity to the other subtraction artifacts suggests that it is not contrast medium(Experience Required!!!)

Technique Notes

It is normal practice to image both sides (comparison/increased incidence of bil. abns)

It is preferable to inject both sides at the same time

Collimate the X-ray beam to include the orbits superiorly and laterally and the maxillary PNS inferiorly

A sialogram needle (metal or plastic tip) can be used for cannulation of the puncta (16 gauge or similar)

A focused spotlight can be a useful aid for the radiologist in locating the lacrimal punctum

Inferior punctum is often easier to canulate

Catheter should not be inserted too far into the canaliculus

Dacrocystogram protocol may include adjunct nuclear medicine study

Thank you