Chronic sialadenitis and sialography

ROGER G. GERRY, COMMANDER (DC) USN, AND EDWIN LIEUTENANT COMMANDER (MC) USNR

L. SEIQMAN,

HRONIC sialadenitis is a recurrent and frequently painful swelling of one or more of the major salivary glands, which may be characterized by episodes of acute infection. The process presents difficult diagnostic problems. The literature is not always clear on all aspects of this disease, either clinically or roentgenographically, and diagnostic criteria have not been well established. There is also no unanimity of opinion on the form of treatment of sialadenitis except during acute exacerbations. In this article we will review the literature and summarize the various data covering a series of twenty-five patients followed at the United States Naval Hospital, St. Albans, New York. Consideration of these cases indicates that there are actually two different types of chronic sialadenitis, although hitherto this fact has not been adequately stressed. One type involves the submaxillary gland and is characterized by the presence, or former presence, of a calculus in the duct; it is shown radjographically by demonstration of tortuous dilatation of the principal ducts and the presence of strictnres. The second type of chronic sia.ladenitis involves the parotid gland. This is not preceded by sialolitlniasis, and radiographically shows shotlike dilatations of the ductules and moderate dilatation of both the major and minor ducts, sometimes with stricture formation. This condition, because 01 its radiographic similarity to bronchiectasis, has been locally termed “sialeetasis. “I It is int,eresting to note that in none of our ca,ses was parotid sialolithiasis demonstrable; nor were we able to discover a.ny proved examples of this condition in the literature. Conversely, sialectasis was not observed in submaxillary sialadenitis. No chronic inflammation 01 the sublingual glands was observed, either in the lit,erature or in our own cases, although occasio:nally sublingua,l glands drained into the submaxillary ducts and this variation could bc demonstrated when submaxillary sialographs were taken. From the Dental and Radiology Services, United States Naval Hospital, St. Albans, New York, and the School of Dental and Oral Surgery, Columbia University. The opinions expressed in this article arc those of the writers alone and do not necessarily reflect the official attitude of the United States Navy Department.

453

Review of Literature In reviewing the etiology of chronic parotitis, Hobbs and Sneierson,2 Schroff,” and Thorna.” thought that it was the result, of oral infection ascending along the parotid duet and was cha.ra.cterized by inflammation of the duet and especially of its orifice. Thorna thought that general debilitation and certain occupational hazards, such as glassblowing, predisposed to the disease. These could be obtained by aspirawriters were also of the opinion that positive cultures tion from the ducts of the involved glands and that the principal organisms involved were, in order of frequency, Staphylococcus aureus, Xkeptococcus vi& The theory of ascending oral infection &zns, and S%reptococcus hemolyticus. along Xtenson’s duct was also elaborated on by hnspach and GriEeth,5 who showed that in the oral application of certain met,allic drugs enough radiopaque fluid was drawn up into the parotid gland to demonstrate the major ducts radiographically. These writers were also generally of the opinion that in ascending infection the saliva was thickened and this factor, along with. organic bacterial debris, caused blockage of the smaller ducts with the production of multiple small Schroff 3 abscesses which increased in size with time and repeated recurrences. believed tha,t infection of this type is more likely to occur in the parotid tissue because of the absence of bactericidal mucus in the parotid secretions. This in.vest,igator also thought that allergies may be a factor in the production of Rlady and HockerG have reported that they were chronic parotid sialadenitis. not able to produce sialectasis, experimentally, in dogs. In the treatment of chronic sialectasis, Schroff3 recommended a diet of acid fruits and dry cereals, and the slitting of the orifice of the duct. Lane’ has with the use of five to fifteen drops of a saturated reported excellent results solution of potassium iodide three times a day. He has kept some patients on i;his routine for months and has had no recurrences. He thinks his good results are due to the expectorant action of potassium iodide. On this basis, although 110 one has used them, pilocarpine or arecoline may be effective. Goodman and Gilmans state that minute doses of pilocarpine stimulate copious salivation of a charact,er similar in composition to the ultrafiltrate of the salivary fluid. Areeoline is similar, pharmacologically, to pilocarpine, and parotitis is unknown among Chamorros who take it daily in betel nut. Use of vitamin A to inhibit epithelial proliferation in the ducts has not been reported. No writers have reported death secondary to an acute exacerbation of chronic parotitis. Sialography is the most important diagnostic procedure at the elinicia.n’s disposal for the evalua,tion of abnormalities of the salivary glands. Actually, sialography is the radiographic study of the salivary glands and their duct systems by the injection of the contrast medium retrogradely into the orifices of the ducts. Lipiodol, Iodochlorol, or similar substances may be used. Recently, reports have appeared in the literature on the use of water-soluble emulsions. Apparently these have given satisfactory resultIs. A great deal of variation has been encountered in the literature in the methods of doing sialography and in the amounts of material which have been injected. The amounts that have been -used vary from 0.5 to 6.0 C.C. Most

CMEONIC

SIALADENITIS

AND

SIALOGRAEHY

455

Good filling may be guaranteed writers agree that 1.0 to 4.0 C.C. is optimum. the first time by doing the injection under fluoroscopic control, as suggested by Writers are in general agreement that a diseased gland Payne9 and others. will hold more contrast material than a normal gland. It is the consensus of opinion that the fluid should be injected until the patient feels pain or until. the gland starts to swell. Obviously, however, from the great range of the dosage quoted, evaluation of pain and swelling is subject to considerable variation. While it is recognized that these injection symptoms arc strongly influenced by the rcla.tivc character of the sialadenitis at the time of injection, there is some possibility that the contrast media themselves may be irritating in spite of the fact that some writers use weekly injections of Lipiodol therapeutically. Sicard and Forestiei? reported that 10 to 12 cc. of Lipiodol could be injected intramuscularly with no reaction and that these injections could be repeated daily to a total of 80 to 100 cc. without damage.’ In this connection, Epsteen and BendixI have recently shown in dogs that a marked foreign body reaction in the submaxillary glands resulted from the injection of materials containing poppyseed oil (such as Lipiodol) , as well as sesame oil, peanut oil, emulsions of mineral oil, and oil of theobromine. They noted a minimal reaction in use of This foreign body reolive oil, plain mineral oil, cottonseed oil, and glycerine. action, they thought, should bc taken into account in evaluating the pathology of glands removed after sialography. Although no work of this type has been reported in human beings, it would seem logical, in view of the findings, to use as an oily vehicle one of the materials noted previously, which produces minimum foreign body reaction. In a recent paper, Putney and Shapiro12 recommend a double injection method of sialography. They give 0.5 cc. and take films to visualize the duct and its main branches and then give 1.0 cc. more for visualization of the parenchyma. In 1951 Dechaume and Bonnea.u13 recommended a delayed film technique. They made films fifteen minutes and one, two, six, and eight hours after injection, or even one to two days afterward, in order to check for delay in emptying. They also suggested that films be made thirty minutes after injection and that the mouths of the ducts be clamped for visualization of the pattern of diffusion of the oil in the acini of the gland. Description of the sialography of children is rarely encountered in the literature, but .Wicdemann14 recently has written a paper which describes normal and abnormal sialograms in children of various ages. The various diseases occurring in the salivary glands of adults also can be demonstrated in children. Wicdemann finds it a relatively easy procedure and usually does not even use a local anesthetic. Wis paper gives a table of the amount of oil necessary to fill the parotid gland in children of various ages. The following conditions can be diagnosed by sialography, although in several of these conditions there is considerable dispute in the literature as to the characteristic finding in the particular disease under discussion : 1. Recurrent parotitis 2. Stenosis of salivary

or sialadenitis. gland duct.

3. DifEerentiation between benign and malignant tumors and also between intrinsic and extrinsic tumors OS t,he salivary glands. 4. Calculi in the gland or ducts. 5~ Fist&a. 6. Mikulicx’s disease. 7. Sarcoid. 8. Xerostomia. 9. Tubereulous and inflammatory adenitis. 10. Trauma to the ducts and glands. 11. Reflex dilatation of the ducts due to spasm of the sphincters at the mouth of the ducts. 12. SjSgren’s syndrome. 13. Atrophy of the parotid gland or submaxillary gland after radiotherapy, particularly in children. There is considerable disagreement in the literature as to whether it is normal or abnormal for the parenchyma of the gland to be filled after injection. HareI and Himm and his associate,+” think that the parenchyma of the gland is not demonstrable’ in the normal gland. SamuelI also thinks that reflux into the acini is due mainly to technical error of overfilling. Csillag and Czunftl’ Peel that the gland is not normal unless there is absorption of the contrast fluid into the parenchyma. Ollerenshaw and RoseI also say that acinar filling is normal and should be visualized on the films for completeness of the examination. They use 2.0 to 2.5 CC. of oil for parotid visualization under pressure up to 400 mm. of water to fill the a,cini of the normal gland. They state that submaxillary acini are easier to fill. Blady and HockerG state that the diffusion of the medium through the parenchyma is diagnostic of xerostomia 01’ Mikulicz’s disease. These authors routinely inject 1.0 to 2.0 cc. In 1947, Schulz and WeisbergerZO reported 1.25 sialograms with only fifteen unsuccessful attempts due to the inability to cannulatc the duct or to the loss of dye in the soft tissues. They found the highest percentage of positive findings abin obstructive and inflammatory processes. They found no significant normality of the pattern in Mikulicz’s disease or in sarcoid. The absence of significant findings in sarcoid or Mikulicz’s disease is agreed to by Payne, who finds no radiographic abnormalities in these diseases but clinically notes a painless enlargement. The paper by Dechaume and Bonn.eau,13 quoted previously, also agrees with this concept. They consider the sialographic findings not characteristic in Mikulicz’s disease, xerostomia, and SjGgrcn’s syndrome. They diagnose these conditions mainly by clinical means. They also diagnose malignant tumors of the salivary glands without too much dependence on the sialograms. However, Duclos, Parret, and DumasZ1 do not agree with the authors just referred to at least in so far as SjSgren’s syndrome is concerned. They consider this syndrome a type of “sclerosis” and describe characteristic findings in this disease. However, the consensus is that most o-f the diseases just discussed do not have typical roentgenographic findings.

CHRONIC

SIALAUENITIS

AND

SIALOGRAPHY

457

Rose”” states that parotid stones are much less common than submaxillary stones. He finds recurrent swelling, especially of the parotid gland, usually due to the following: (1) R ecurrent pyogenic infection, which is seen most frequently in women in the fourth and fifth decades. The early and late cases show characteristic sialographic changes, (2) Simple duct obstruction, which is more common than pyogenic parotitis, He differentiates two types, papillary and buccal, with the main changes in the ducts. Infection may complicate the process and tidings. (3) Duct obstruction with secondary infection. This type is similar in findings to the pyogenic. In a later paper, Ollerenshaw and RoseI This is rare and considered a remission add a fourth type: chronic parotitis. stage of recurrent infections. They also list causes of chronically enlarged glands, snch as (1) congenital, (2) due to calculus, (3) caused by tumor, (4) uveoparotitic polyneuritis (another name for this is Hecrfordt’s syndrome, a manifestation of sarcoidosis) , and uveoparotitic polyarthritis ( SjFgren’s syndrome) . Mikulicz’s disease is considered to include the last two entities. Tuberculous adenitis is rare.

Sialographic

Technique

Scout films of the gland are taken routinely before sialography to observe the presence of possible calculi. The duct of the gland to be studied is then probed with a small “abscess” probe. In those instances in which it is difficult to pass this probe, an aspirator with a Frazier brain tip is used, with the least amount of suction necessary, to immobilize the orifice while the probe is passed. When the orifice cannot be located readily, the patient is given a slice of lemon to suck for one minute to stimulate salivary flow and indicate the location of the orifice. After the abscess probe has been removed from the duct, a punctum The dilator is indilator can be inserted easily into the orifice for dilatation. troduced as far as possible with the assistance of the aspirator tip, and is a.llowcd to remain for about one minute. Immediately after its removal a blunt Luer This should be at least twenty-two gauge Tlok needle, with stilette, is introduced. and preferably should be larger. The x-ray plate then is placed in position, In this hospital the stilette is withdrawn, and the contrast medium is injected. we use a solution of two and one-half parts Lipiodol or Iodochlorol to one part olive oil. In practice this is prepared by injecting 8 C.C. of sterile olive oil into a 20 KC, vial of contrast medium, and withdrawing from this stock solution as occasion demands. The diluted contrast medium is warmed in a hot bath to slightly more than body temperature and should not be allowed to cool before Injection injection. The solution is injected while the x-ray plate is in position. should be slow a,nd intermittent, as rapid injection under pressure will cause postinjection symptoms and will also cause the contrast medium to be a,bsorbed into the parenchyma and thus obscure the arboreal pattern of the duct system. The pa.tient is instructed to keep his left hand on his knee and to raise it whenever the gland feels full and replace it when the feeling of fullness subsides. Contrast medium should not be injected during the period of fullness, and when this sensation does not disappear in fifteen to twenty seconds the injection should

be discontinued and. the syringe detached from the needle. The st;ilette Should be replaced immediately into the needle, which is not removed from the duct, X-rap exposure should hn made at once. -Posferoanterior, lafeml, 181~1~~1olnliq~~~

Fig. i.-Roentgenogram of injected duct system of normal submaxillary gland removed Note fine arborization of ducts and progressive diminution of size. Slight at post mortem. parenchymal filling is present. Jdarge OPB~UP ares. at 10 o’clock is due to tearing of gland by forceps at time of remova.1.

Fig. Z.-Lateral view of sialogram system. Several of the larger ducts but still not of pathologic significance.

of a submaxillary appear to be of The parenchyma

gland with essentially normal duct slightly greater than normal caliber, is faintly visualized due to reflux.

and (in the case of submaxillary gland) ocelusal exposures are usually made. In general, we never inject more than 1.5 CC. in the submaxillary gland or 2 C.C. in the parotid gland on the first injection. Diseased glands usually will

CHRONIC

SIALADENITIS

AND

SlALOGRAPHP

459

take more contrast medium than will healthy glands. Using the technique just described, only the arboreal pattern will be visualized (Figs, 1 and 2). The parenchyma will be visualized if desired, as in tumors, by injecting 0.5 to 1 C.C. additional contrast medium. Ordinarily, this should be done in a separate, later procedure. During our early experience in sialography, patier& frequently had considerable pain and glandular swelling during the injection and up to twenty-four hours afterward. Since this technique has been mastered, however, our patients have not had any discomfort and have required neither anesthesia nor sedation. When pain occurs during or after sialography, it, is because of the injection of too much contrast medium or because the medium has been injected too rapidly or under too much pressure. It should be mentioned, however, that diseased glands will respond more easily to these stimuli than will normal. glands. In the procedure of sialography it is important that all probes and needles be blunt and rounded. It is quite easy to perforate the duct wall, especially in the case of the submaxillary gland, and unwittingly to inject the contrast medium into the surrounding soft tissues. In this event, the medium will be absorbed very slowly and may require a year or more for complete resolution, as in the instance of our own mishap of this type. During this period, of course, further sialography may not bc performed, as the arboreal pattern will be obscured by the presence of contrast medium in the surrounding tissues. In the event this accident does occur, there is no great cause for concern, as the contrast medium ultimately will bc absorbed and apparently will cause no pain or discomfort to the patient. Radiographic

Aspects of Chronic

Xialadenitis

I. Submaxillary Xialadenitis.--Frequently the preliminary films of the area will show a calculus in the duct or in one of its main branches. Even after the stone has been passed or removed, residual changes are demonstrated on the sialogram for varying periods, of time. The most important, 01 these is a stricture at the point where the stone was located. This may be due to chronic infection and fibrosis, and possibly may be complicated by scarring from an operative procedure. Bacterial infection, when present, may be the primary cause in producing the changes demonstrated, but infection is usually secondary to calculus. Regardless of whether the ba.cterial infection is primary or secondary to a stone, the main duct shows the same changes in both conditions. Figs. 1 and 2 show normal submaxillary sialograms. Characteristically, the main duct is dilated and tortuous proximal to the or stricture. It may be slightly irregular, but it does not show a “beaded” appearance. Smaller ducts and their branches show a similar but less marked dilatation. The parenchyma does not show any typical changes when it can be filled. The duct changes usually can be identified if technique is good, although early or borderline cases may present difficulties in interpretation. It has been found that, in spite of these changes in. the duct system, the gland often funcstone

2-i

27

M

M

M

Y

M

S-2

S-3

S-4

s-5

S-6

25

67

34

24

M

S-l

/ AGE

SEX

;:ERj

Lingual cancer treated by liemiglossectomy. Since surgery recurrent swelling of left gland, especially after meals. Pain, right side.

Swelling on right side which went away. Two months later had ( Lsticking ” sensation in area without swelling but with tenderness.

Tender swelling in right submaxillary area for 3 years. Difficulty in mastication and swallowing. Swelling subsided spontaneously with discharge of yellowish white exudate in mouth. Six episodes since. Last episode 1Ys weeks before admission, at which time was asymptomatic.

Several calculi removed from right duct 6 months prior to admission. Swelling 2 to 3 months prior to admission, with frequent recurrence. Pain and swelling, left gland, 3 weeks before admission. Suppuration through duct.

1 - HISToR1t%%S-lcAL

1.

Early sialadenitis, right and left. Tortuous dilatation of principal ducts, right and left.

Entire structure of gland well outlined. 9t junction of intraglandular radicles and main trunk there is a stone in glandular substance near duet. Left: Stricture of proximal portion of duet with considerable dilatation behind this.

Slight itiammation only.

EmSTOLOGIC FmDINGS

Inflammation.

I /

--

sialadenitis.

___--

Early None.

tion.

.-._..-_---

------

-

Sialogram of left submax
-_----

_-____

RESULT

Salivary retention after meals continued for 6 months, but kept diminishing.

of eland.

of cal-

’

I 1

None.

Excision

Excision culus.

Gland excised.

Calculus in gland. Tortuous dilatation of main ducts. Small constricted tree. Marked dilatation of duct. Large calculus 10 mm. distal to intraglandular radicles. Gland is not well demonstrated.

excised.

TREATMENT

‘Gland

j

BItl~a~mTIi3

Tortuous dilatation of principal ducts, with strictures. Otherwise tree is restricted.

FINDINGS

SUB~IAXILLARY

1 SIALOGRAPHIC

TABLE

Swelling and pain, right submaxillary area; subsided spontaneously. Similar episode 2 years previous, at which time was operated on. Surgeon states presence of 2 deep calculi in the gland, which he could not remove. Trauma (toothbrush)? left submaxillary gland m May, 1953. Four recurrent episodes in 3 months following. Intermittent pain and swelling of left submaxillary gland for 2% months, which was worse at mealtime and on eating some foods. Passed several small calculi spontaneously,

25

29

22

&I

F

M

I?

F

s-9

S-10

s-11

s-12

S-13

31

29

Kervous, pain in jaws on menstruating. Earaches. Had mass, left submaxillary gland, after searlatina and measles at the age of 4.

24

M

S-8

Soft swelling, left submaxillary area. Not tender. Probe inserted 5 cm. without obstruction. Swelling, left submaxillary area. Small, hard nodule palpable.

--

Swelling, right submaxillary area, Large palpable mass on right: small one on left.

S’i

ntr

S-7

None.

No interference indicated at time. To return in 6 months. Did not return. Swelling subsided taneously.

__----

spon-

Excision

None. Will follow.

Sialogram-normal gland. Taken after calculi were passed. Slight diffuse dilatation of Wharton’s duct. Possible small calculus within glandular portion of duct.

of gland.

Excision

Slight narrowing of duct as it enters gland. Large superior branch of duet was not filled.

New

patient,

Six months, progressive diminution in diameter of both submaxillary ducts with decreased salivary flow. No diagnosis established. -_---of gland.

Normal. Slight pain and None. swelling after injection of 0.9 cc. of medium. Possibly acute inflammation. Unsatisfactory sialoPotassium iodide for 6 weeks, imgram. Could not pass probe in left. Right, proved slightly. constricted sialogram.

Right: good outline of gland. One inch from tip of needle is 2 mm. oGa1 semicircular caleulus. Minimal dilatation beyond these. Left gland normal. Normal.

sialadeni-

Chronic nonspecific sialadenitis and hyperplastie lymphadenitis. -_-__-

Chronic tis.

------

--- _. -

5 w

4

‘d 2

E L

SEX

M

M

M

51

M

M

N%%81

P-14

P-15

P-16

P-17

P-18

P-19

/

21

24

45

25

24

25

AGE

/

AND CLINICAL

FINDINGS

vi&fans.

PAROTID

probably

for 14

Not followed since November, 1953. Par&id status not clear.

No recurrence months.

No significant progress. Repeated abscesses, which may have originated in parotid or ear

at

Parotid gland not involved.

Ssymptomatic None. time of sialograms.

Apparent stricture in duct. Poorly outlined tree. Enlarged left parotid of normal structure.

2

Parotitis slowly subsided after 3 months. TWO years later there was still bilateral swelling, but patient had no pain since discharge.

for

None.

None to parotitis. Developed lymphadenopathy while hospitalized. Positive Kveim.

peni-

No recurrence months.

with

Full recovery cillin.

BESULT

No follow-up.

I

Radiation therapy to arrest gland function.

TREATMEIiT

-____

Tree small and almost invisible. Apparent strieture, main duct.

Advanced sialectasis of terminal duct system without evidence of obstruction.

Dilatation of principal duct. ( ( Shotlike ’ ’ acini, “ shotlike ’ ’ appearance of duetules.

FINDINGS

Q~ALADEWITIS

I 1 SIALOGRAPHIC

II.

Unilateral swelling, left face, 3 times in 2 years. Exploration in May, 1950, with no significant findings. Asymptomatic except for asymmetry. Sialograms show obliteraParotitis and mastoidectomy, right, tion of tree in lateral at 6 years. Swelling or abscess in aspect of gland and right parotid 16 times in 3 years. Fourteen incisions and drainages. presence of possible cyst History of having abscessed teeth in upper medial aspect. removed, but several parotid episodes since. Incision and drainage in .Tanuary, 1953 ; 15 cc. of pus removed.

Swelling, right parotid, four years before admission. Subsided spontaneously. Two days before admission noted headache, pain in left parotid and testicles. On admission bilateral parotid swelling noted. Right papilla inflammed. Other findings resolved, but parotitis persisted for about 6 weeks and then slowly subsided. Recurrent painless swelling right parotid for several years.

coccus

Recurrent painful swellings of right parotid every 3 months for 6 to 8 years. Concurrent purulent exudate from duct. Mumps at 15 years. Numerous allergies. Always subsided under antibiotic therapy. Sialadenitis not acute on admission. Pain and swelling, right parotid. Similar episodes twice before at &month intervals. Acutely ill, temperature 101” F. Purulent exudate from duct, cultured Strepto-

HISTORY

TABLE

M

M

M

M

M

M

P-20

P-21

P-22

P-23

P-24

P-25

46

54

21

28

25

24

Recurrent painful swelling beneath left ear which recurred several times between 1950 and 1953. Childhood mumps. On admission swelling and dull ache, left parotid, during mealtimes. Duct orifice normal. Recurrent painful swelling in region of left cheek starting 3 years before admission, which is occurring with increased frequency. Episode about once monthly but 3 or 4 times per year is quite large. Left papilla inflamed. History of compound fracture, left mandibular angle, 2 years before onset of symptoms, but x-rays of mandible negative. 1Mumns at 8 years. Swelling. left parotid, with pain on eat&g some foods since that time. Increased swelling and pain on salivation. Mass about 6 cm.; A-P x 3.5 cm. Childhood mumps. Otherwise asymp. tomatic in region except pharyngitis 2 months before admission. Two weeks before admission, small nodule over angle of jaw; increased in size and became painful and indurated and involved entire left face. Mass red and hot. Duct orifiee inflamed. Posterior cervical ’ lymphadenopathy. Mumps 15 years before admission. Patient feels that he has had enlarged left parotid since. Two years prior to admission, first of many recurrent episodes of pain and swelling in left parotid occurred. Stricture 1 cm. from orifice. Mumps 25 years before admission. Painless swelling of right parotid. No previous episodes. Occurred at mealtime night before. Asymptomatic at disLoeal heat to area. Incharge. Sialogram reduration resolved. Antipeated 2 months later. biotics. Abscess aspiNo change in sialorated three days after admission and twice sub- graphic appearance. sequently. Bloody purulent fluid.

Ductile structures essentially normal. Few small areas of limited sialectasis. Lower anterior region not well visualized. Probably abscessed area.

Stricture with early dilatation, main duct. Stricture about 2r/ cm. from orifice.

Duct elongated and beady in appearance. Dilated throughout most of length. Stricture 1 cm. from orifice.

No treatment.

No sialectasis. Normal gland. Gland may be smaller than normal.

Sialography

only.

Stricture stretched at time of sialography. Duct dilated again about 1 month later.

Much improved after sialography. More eomfortable than in 2 years. No significant recurrence for 6 months. Feels right gland may be involved to lesser extent. Swelling subsided 4 days after onset. No recurrenee during past year.

No follow-up.

No follow-up.

Symptomatic Resolved.

Dilatation of glandular portion of duet. drborization of gland is normal.

therapy.

No recurrence for 4 months after last sialogram. Probably represents therapeutic effect of contrast medium.

Sialeetasis, left parotid. Impacted left mandibular Sialogram, right parotid, third molar removed. also shows sialectasis, even though there have never been any symptoms.

4.64

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L.

REI:IOMAS

tions adequa,tely. Conversely, since a. good sialogram shows only the duct system in sfaladenitis, the arboreal pa.tt,ern ma,y bo demonstrated as normal in the presence of a diseased parenehyma (Fig. 5). aX0tid. ~~aIa~e~i~~s~----I~i contrast to submaxillary infections, parotid reactions (includin, Q strictures of the ducts) are almost never caused by calculi. Rowever, we have found a history of mumps occurring after puberty in several of our cases showing strictures of the main duct. The part played by mumps as a causative agent of parotid disease has not yet been clarified. Ordinary pyogenic infections also may be important factors in parotid disease, but in general the etiology of chronic parotitis is obscure and has not yet been we31 evaluated. On the sialogram, when a stricture is demonstrated it is usually near the distal end of the main duct. Proximal to this the duct shows dilatation and elongation in varying degrees, depending on how long the stricture has been present. The margins of the duct may show small serrations. The primary and secondary branches of the main duct show irregularities in filling, with localized areas of dilatation and narrowing. They may or may not show small shotlike areas of dilatation or “beading. ” These are the findings in early pa.rotid sialadenitis. More advan.ced disease shows definite pooling of contrast material in small pockets along the course of the intraglandular duct system. This is similar to the appearance of saccular bronchiectasis in the bronchial tree, so we have referred to it as “sialectasis. ” We think that sialectasis is limited to the duct system, but possibly the disease may extend into the parenchyma. Evaluation of the parenchyma of parotid glands in chronic parotitis is unsatisfactory with the use of present sialographic techniques. For this reason, a gland may appear to bc sialographically normal in the presence of symptoms based on changes in the parenchyma. This qna.lification also applies in the ca.se of snhma,xillary glands. inflammatory

Clinical Findings Since it has already been demonstrated that there is little or no relation ship between the submaxillary and parotid types of chronic sialadenitis, these two entities will be considered separately and on a general basis, rather than by describing the management of each individual case. The individual cases are all briefly summarized in Tables I and II. In considering our cases it should be recall.ed that the majority of patients in the naval service are young adult men, and that on this basis any opinions based on age or sex distribution, It also should be mentioned at this time in this report, would be unreliable. that the series of patients presented were not all treated by us, nor were they all even treated on the same service. For this reason, there is considerable variation in the types of treatment used. It seems quite certain that at least some of the patients presented would have been mana.ged differently had they been treated on other services. Tn fact, one of our original aims i.n compiling this material was to try to stimulate a program of group planning for the management of patients with chronic sialaden.itis in much the same manner as

CHRONIC

HIAI,ADENITIH

AND

465

SIAI>OGRAPHV

Programs already in existence for deciding upon the disposition of oncologic In such a group representaproblems and temporomandibular joint disorders. tives of the general surgery, medical, ENT, dental,’ and radiology services should be included. To further this aim, we have sponsored symposia in sialographg and chronic sialadenitis during the years of 1953 and 1954 and, since Oct. 1, 1954, all patients with chronic disease of the salivary glands have been presented for evaluation to the Head and Neck Surgical Policy Board. All the sialography in this series of patients, and in fact all sialography done in th.is hospital for any reason, has been performed by us or under our direction. Submaxillary Xialadenitis.-The group of patients with chronic submaxillary sialadenitis will be considered first, primarily because it is a simple problem to evaluate and treat. In this series there were thirteen patients who, for one reason or another, had sialograms of their submaxillary glands (Table I).

a.

B.

Fig.

3.--Case S-4. A, fosteroanterior view or sialogram of right submaxillary gland. Chronic sialadenitis due to calculus. Note semicircular filling defect due to calculus near proximal end of main duct. The principal intraglandular ducts show dilatation and tortuosity, but no “pooling” OC contrast media. 6, Lateral view showing dilated intra&mdular ducts proximal to the stone at the beginning

of

the

main

duct.

There were ten men and three women in. the group, and their ages varied from 21 to 67 years. Seven patients (S-l, S-2, S-3, S-4, S-7, S-Xl, a~nd S-13) had histories of calculus in either a submaxillary gland or a duct. These had histories of recurrent episodes of pain and swelling and exfoliation or excretion of one or more calculi from three years prior to admission to three weeks prior to admission. In one case (S-4, Fig. 3)) in which there was large calculus in

the substance of the gland and in which t,here had been oniy one proved episode of three weeks’ duration, the gland was excised in order to remove the calculus. In four cases (S-f, S-2, S-3, a,nd S-l I ), in. which there had been at least two oy more pa.iuful recnrrenres of aei.rte Sii~ladCnitiS, the affected gland mas a.lso excised. However, in one of these eases (S-2) there was also a calculus the gland should not bo excised within the substance of the gland. Ordinarily, unless there arc recurrent episodes of sialadenitis after the removal of calculi within t)le whstanee a-f the gland itself. from the duct or there are large calculi

Fig. 4.-C&e S-5. maxillary sialadenitis the main duct is well to moderate dilatation ing” of iodized oil along WX~SSOPY lobe anterior

Chronic subLateral view of sialogram of left submaxillary gland. due to stricture. The postoperative stricture near the distal end of Slight visualized. Proximal to this, the duct is dilated and tortuous. of the intraglandular duct system is also present. There is no "poolthe duct system. The parenchyma, is only faintly outlined. Note thn to the rr~xin duct.

Small calculi in the gland frequently are passed into the duct without sign&ant sialadenitis. At present we are following two patients of this type, one of whom One patient (S-3)) (S-7) has gone more than one year without recurrence. with seven episodes of acute, suppurative, submaxillary sialadenitis of three years’ duration, has been free from symptoms for more than eighteen months following the removal of calculus from the duct. Another patient, who had only one acute episode with considerable pain, swelling, elevation of temperature, regional lymphadenopathy, and suppuration from the duct, has remained free of symptoms for six months following spontaneous exfoliation of a large calculus through the wall of the duct. This patient’s findings have not been entered in Table I, as he did not have chronic sialadenitis. One of the remaining patients (S-5, Fig. 4) had recurrent submaxillary sialadenitis following surgery. In this case strictures of the duct, with dilatation, could be demonstrated sialographically. This case also tended to improve following sialography, probably because of stretching of the adhesions. No other treatment was given in this instance,

CIIBONIC

SIALADENITIS

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467

ln one instance (S-12) there was history only of injury to the gland with a toothbrush bristle followed by four episodes of acute sialadcnitis in. three months. The sialogram in this instance was within normal limits, and the A.

B.

Fig, 5.--Case S-12. Photomicr’ographs of atrophied submaxillary gland. This g$%in~ was acutely infected, apparently as the result of trauma. The sialogram was normal. preservation of intralobular ducts and interlobular se&a. Most of the acini have been destroyed, and there is extensive 1yrnphOCytiC infiltratiOrL ( MagniJkation : A, X75 and 6, X300; reduced lk. )

gland was excised by the service which was treating the patient. Histologically, there was considerable inflammation with atrophy of the acini. However, the duct system itself appeared to have remained intact (F’ig. 5).

presented somewha,t less definite findings- One patient (S-6) complained of recurrent pain i.n the right submaxillary gland, hut gave no history of sia.lolithiasis. Sialograrns during hospitalization prcucnted Lhe arboreal tortuosities and di.latations usually associated with submaxilThe patient was discharged without therapy. Another pa.tienL la ry sinlsdenitis. (H-8) presented with an enlarged left submaxil.lary gland and a -normal sialoThe swelling receded during hospitalization without specific therapy. gram. Another patient with the same findings (S-9) presented wit.11 increase of pain Acute sialadenitis may amd tenderness on t,hc day after an 0.9 cc. sialogram. ha.ve been stimulated by the irritan.t contrast medium. The most interesting patient in this group was a 29-year-old pregnant woman (S-10), who gave a history o-F a. left submaxillary mass at 4 years of age following sca.rlatina and measles. She reported recurrent, painful swelling of this gland, and to a lesser cstent the right gland, since that age. Several unsuccessful attempts to probe Lhe left submaxillary duct, preparatory to sialography, were made over a period of three months, during which time pain and swelling continued. At the beginning of this period the right duct could be probed but sialography was not performed because of greater interest in the left gland. Gy the end of three months the right duct could not be entered either. The patient had a decrease in symptoms during a six weeks’ course of potassium iodide. The patient was Lhen presented to the Head and Neck Surgical Policy Board which eoncurred that she should continue under observation, without treatment, for approxiNear the end of this period the patient mately six months, until she delivered. still had swelling of both submaxillary glands and almost constant low-grade pain, but to a lesser degree than when first seen. At this time, also, both duct orifices could be probed quite easily, but, both ducts were perforated as contrast medium passed into the tissues of the Boor of the mouth. A very rcccnt follow-up on this woman showed the persistent bilateral submaxillary swelling to be still present. She complained of frcguent low-grade pain, especially on the left. Attempts to probe the duet were unsuccessful on both sides. The left submaxillary triangle was explored in December, 1.954, and no submaxillary salivary gland could be found. However, a hypertrophic, hemorrhagic lymph node was removed, and the patient has had no subsequent symptoms in this arca. Tlzc four remaining

patients

Parotid Sialadenitis.-There were twelve patients in the group who were a.dmitted with diagnosis of chronic parotid siala.denitis (Table II). These were all men who varied in a,ges from 21 to 54 years. Nine of these patients averaged 24.1 years of age. The other three, all of whom had duct strictures which probably were secondary to acute endemic parotitis as young adult,s many years before admission, varied in ages from 45 to 54 years. The three patients with strictures (P-17, P-24, and P-25) all responded well to sialography alone, followed by periods of stretching of the strictures, as indicated (Pig. 6). No other treatment was required to alleviate their symptoms. In these cases, when sialectasis was present, it was early in type. Four patients (P-14, P-15, P-20, and P-23) showed more or less advanced sialectasis. These all gave histories

CElltONIC

SIALADXNITIS

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469

of multiple recurrences of acute parotitis from six months to eight years prior to admission. The patient with the radiographically most advanced. sialectasis (P-15) reported symptoms of only six months’ duration with two episodes of sialadenitis (Fig. 7). One patient with bilateral sialadenitis (.P-20) showed

Fig. B.-Case P-24. Chronic parotitis with Posteroanterior view of parotid sialogram. early sialectasis. Note stricture near distal end of main duct, probably due to previous attack of mumps in adulthood of patient. Main duct proximal to stricture is slightly dilated and elongated. Principal intraglandular ducts show irregularities of filling and of size, with slight “pooling” of contrast oil.

Fig. Il.-~-Case P-15. sialectasis. Note essentially along intraglandular duct Oil.

Lateral normal system.

Adval~ed view of sialogram of right parotid gland. main duct, but with marked “pooling” of contrast materiai The parenchyma contains only a small amount of iodized

IWax

470

G. Gl?:RRY fwm li:DWlN I,. SETGMAN

a greater degree of sialectasis of the asymptomatic gland (Fig. 8). Two (P-14 and P-75) ihad purulent, exudate from the duet, from which was cultured RLraptococcl&s vi,ridans. The duct orifices were inflamed in some instances (P-14 and P-X?), bat it ifi not aswmed that siaicetasis is always the result of a,scending oral infections, especially in recurrent episodes. One patient (p-14) was treated with radiation therapy to arrest salivary sccrction, but this is not, recommended except as a last resort, because of inevitable damage to the submucous glands and resultant regional xerostomia. Acute episodes responded well to a.ntihiot.ic therapy, but tile long-ra.nge management of these patients is

li‘ig,

R.-Case

Note “Pooling” in nc )t remarkable

P-20. Lateral view of sialopram of right parotid gland. of contrast material along course of sn~aller intraglandular Parenchyma is partially except for slight tortuosity.

Parotid ducts. filled.

s4&3

still a problem. The five remaining patients (P-16, P-18, P-19, P-21, and P-23) are difficult to classify. One of these (P-21 ) showed normal arborization of gland with dilatation of the glandular portion of the duct following recurrent parotitis every three to four months for three years. The cause, in this case, is unknown and also may have been mumps. The patient had no recurrence for several months after sialography and, if sialectasis does not, develop, this may represent a case in which the patient might have devclopcd sialectasis if adequate salivary drainage had not been provided. Of the remaining patients, one (P-16) reported with a first episode of left pirotitis of two days’ duration aeeompanicd by pain in both test,icles. The patient had a positive Kveim test and parotitis subsided slowly in about six weeks. The Kveim area was to have been biopsied after discharge to confirm the tentative diagnosis of sarcoidosis, but the patient did not return. However, contact with him was reestablished two years after discharge. At that time he had been free of pain since discharge and had no other symptoms except slight, unchanging enlargement of both parotid glands. His x-ray pictures

CHRONIC

SIALADENITIS

AND

SIALOGRAI’HY

471

during hospitalization showed poorly visualized arborization without siaiectasis. His actual diagnosis must bc considered undetermined at present. Another patient (P-23) presented with a first episode of abscess of the parotid gland.

Wig. Y.---Case P-3 8. A, Posteroanterior view of sialogram of nornx+J parotid gland, using “ow?rAlling” technique to msua.lize pawnchyma of gland. R, Lateral view showing normal principal duct system and filling of the parenchyna Note lobulation of gland, and obscuring of minor ducts by oil in the parenchyma.

After adequate incision and drainage, the patient had no recurrence for three months, although the abscessed area in the gland showed no evidence of restituThe most interesting patient tion of the duct system in a subsequent sialogram.

$72

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of the group

(P-19) gave a. history of acute parotitis, mastoiditis, and mastoidectomy at 6 years of .age. From 1.8 to 21 years of age he had episodes of right Repeated aialograms showed pfirotitis, with fourteen incisions and drainages. nhliteration of the duet. pattern in the la,te~a,l aspect, with a filling defect which may have represented a small oyst. No diagnosis in this ease has been established, although aetinomyoosis, a logical suspect, was ruled out. One patient (P-18) presented with unilatera,l swelling of the face which had been explored three years previously with no significant tidings. In the three postoperative years he had no recurrences, but the affected side of the face remained larger. Sialograms showed a normal parotid gland which was described a,s “Iarge~ than normal” (Fig. 9). It is likely that the facial asymmetry had no relation to the parotid gland and that the diagnosis quoted was given on a purely subjective basis. It is entirely probable that the original deformity was masseteric hypcrtropby has&/ on unilateral mastication.

Discussion Chronic sialadenitis is a recurrent swelling of the submaxillary or parotid salivary glands, which may or may not be aeeompanied by pain, tenderness, and eleva,tion of temperature. While the most a.pparent clinical characteristics, that is, recurrent enlargement and pain, are similar in chronic sialadenitis of both the submaxillary and parotid glands, actually chronic submaxillary sialadenitis and chronic parotid sialadenitis have little in common and may be considered almost as two separate disease processes. The etiological factor in chronic submaxillary sialadenitis is almost invariably a calculus, or recurrent calculi, although any cicatricial obstruction to salivary flow may periodically produce the symptomatology of the disease and may become complicated by acute secondary infection ~ Radiographically, as previously described in detail, sialograms of typically diseased submaxillary glands show dilatation of the principal duct between the obstruction and the gland, and tortuosities and dilatations of the secondary ducts, with loss of filling of the minor ducts. Microscopically, the acini apparently atrophy quite early in the affected lobules and may or may not be replaced by fat cells (Figs. 5 and 10). In these cases the intralobular duct system may be intact, and thus a normal sialogram may be obtained in the presence of considerable parenchymal disease. Attempts at fil1in.g of the parenchyma in sialadenitis are not of diagnostic value, as the greater part of the glandular tissue is composed of secretory units, or acini, and even partial filling of these would produce a general cloudiness which would obscure the radiographic characteristics of the glandular duct system (Fig. 11). Chronic submaxillary sialadenitis, as mentioned previously, is easy to treat. When acute infection is present it, should be controlled with antibiotics, incision and drainage, and the usual symptomatic therapy. Duct calculi, when present, should bc removed as early as is possible. Stricture of -the principal duct frequently may be corrected with repeated dila,tation. However, presence of large calculi within the substance o-’ the gland, or history of

CHRONIC!

SIAEADENITIS

AND

SIhT&GRAPllY

473

repeated episodes of sialadcnitis, -usually indicates excision of the gland invol ved. Careful sialographic study of submaxillary glands before excision and (:omparison of the radiographic findings with the microscopic characteristics of the excised tissue will aid considerably in the development of a more eompreher lsive lrnowlcdge of the disease.

Thrs patient ret :eived Fig. 10.-Photornicrographs of atrophied submaxillary &~nd. carirradiation (aprmmimately 5,000 r) through this gland in treating a pharyngeal Most of the acini have been destroyed and replaced by fibrosis. (MagnificE &ion A, X75 and B, X330; reduced 16)

heavy

CinOlTla.

4.74

ROGER

Cl, GERRY

ANI)

EDWTN

L.

SEIGYAN

The etiology the subma.xillary important

of chronic parotid sialadenitis is more obscure than that of gland, but it ia likely that primary bacteria.1 Section is an FRCI.OT. Whrt,hrr !:his in-Fcntion is rctrogr::dP through the ;irwt From A.

B. Note presence of very little 11.-Photomicrographs of normal submaxillary gland. stroma. Fields are filled with serous mini and intralobular ducts. In high-power view (13) (Magnification : A, X75 ;lnd part of a mucous acinus may be seen at about 1 o’clock. R, 330 ; reduced I/&.) Fig.

the mouth, or hematogenous through the circulation, Probably both routes play varying roles in different

is difficult to establish. patients. Patients who

CEIBONIC

SIALADENITIS

AND

SIALOGRWHY

475

have had acute endemic parotitis, or mumps, as adults, seem to be especially prone to the disease, but in these cases it usually does not occur until some years after the acute episode. The precise m.echanism of the increased susceptibility to chronic parotitis of persons who have had mumps as adults is not well un.derstood, but it may be based on the presence of increased scarring in the adult type of mumps. Radiographically, early cases of parotid sialadenitis show dilatation and elongation of the main duct and its branches. They may have a Advanced cases show sialectasix, “beaded” appearance and filling irregularities. which is a shotlikc pooling of the media along the course of the intraglandular duct system, especially in the smaller branches. In parotid, as in submaxillary, As the volume of sialography parenchymal changes a,re difficult to evaluate. the parenchyma, or secretory tissue, is large in comparison with that of the duct system, the gland is homogenously opacified when the “overfilling” technique The smaller ductules are blotted out, and is used to visualize the parenchyma. the arboreal pattern of the duct system is poorly demonstrated. For this reason, it is our impression that the shotlike dilatations of sialectasis are located in the intralobular duct system rather than in the parenchyma. So far as we are able to tell to date, the “overfilling” technique to demonstrate parenchymal tissue is of value only in the evalua.tion of salivary gland tumors. Unfortunately, since parotid tissue probably is never excised in the treatment of chronic parotid sialadenitis, we are unable to correlate sialographic characteristics with microscopic findings. WC have observed parenchymal atrophy with fat deposition in parotid tissue surrounding excised tumors, as mucoepidermoid carcinoma, mixed tumor, and Warthin’s tumor, but feel that these findings probably were secondary to the presence of the neoplasm. Unfortunately, none of the glands so examined demonstrated sialectasis before excision. On this basis, however, sialography of parotid glands should be performed meticulously when parotid tumor is suspected, as eventually some of these glands inevitably must show the characteristics of concurrent sialectasis. Careful microscopic study of the excised tissue and comparison of the histologic findings with the sialographic findings should certainly be enlightening. The treatment of chronic parotitis is far less satisfactory at present than that of chronic submaxillary sialadenitis, as in general excision of the parotid gland is not surgically feasible in the mana,gement, of chronic parotid sialadenitis. When duct st,rictures are present, as sequellae of mumps, trauma, etc., the gland seems to respond well to stretching of the strictures whenever indicated. This usually is accomplished with a punctum dilator, as discussed in the technique for sialography. Siaiography itself seems to be of value in some non purulent cases, probably because it is mildly baeteriostatic and mildly irritating in the pres.. and stirnulatcs a flow of saliva from the a&eted gland. Obviously, ence of an acute nM3ammatory episode sialography usually is not indicated until These conditions respond well to the use of the acute phase has resolved. properly selected antibiotics, local heat, etc. When suppuration is present, the choice of antibiotics should be influenced by the nature of the pyogenic organism.

,118

mm

67. GRRRY

nm

mmm

1,. smwm~

Systemic potassium iodide was used only once in our se&s of cases and we cannot fairly praise or condemn it. In the one case in which it .wa~ used li- did not appear to be verp effcct,ive, althotlgh Lane,‘l who has had more c.~perionce with its ‘use, praises i.t highly. As already stated, our own patients i’esponded best to dilatation of st,rietures, when these were present, and to the therapeutic effect of sialography, although the latt,er cannot be regarded as At present the entire system a. truly cffcctive, dependable method of therapy. of treatment of chronic parotitis must bc considered as only partially effective, ;rlthough the (‘clinic” system of therapeutic planning, as diseussed, should prove very useful in the management of future problems. In closing, it seems appropriate to include a word of caution concerning the misuse of radiation therapy in the treatment of chronic parotitis. Some clinicians feel that when chronic parotitis is present the symptoms will disa,ppear if t,he gland is irradiated until the parenehyma at,rophies and the gland becomes nonsecretory. This opinion is undoubtedly correct, but it fails to consider that the gland is often a very difficult one to “knock out,” and may Inquire a large radiation dose. Whether or not the parotid is rendered nonsecretory, the mucous glands of the soft palate and the buccal and pharyngeal mucosa beneath it will certainly atrophy as a result of excessive irradiation. The residual drying of these tissues usua,lly is more uncomfortable to the patient than the chronic, recurrent parotitis and this loss of adequate mucosal moistening may be an important factor in the carcinogenesis of this area. On this basis, it is our thought that the use of radiation therapy for the treatment of chronic parotitis is indicated only rarely, and tha.t any consideration of its use should be based on careful evaluation of its hazards. We have had little experience with the rare syndromes involving the At least two salivary glands which have been menGoned in the literature. of OUT patients may have had systemic components in their diseases> but longer followups than we have completed will be necessary before a definite diagnosis can be established in either case. However, the role of systemic disease in the incidence of chronic sialadenitis is not well classified in the literature, and considerable confusion still exists. It is to be hoped that careful study will eliminate some of these difficulties in the near future. Very recent research has demonstrated the important role of the salivary glands in extrathyroid iodine metabolism by use of iodine 131 isotope tags.23 Apparently there is an enzyme system in the salivary glands which breaks down iodine in diiodotyr0sin.c from the thyr0i.d gland into a degraded protein and free iodide ions. This opens an entire new field for investigation of salivary gland diseases and function. Small tracer doses of iodine 131 may be given and counts made over the normal and diseased glands for comparison of iodine uptake for functional activity. In addition, the salivary ducts may be catheterized and saliva. counted for activity in the normal glands and glands suspected of disease for determina,tion of amount of dysfunction.

CHRONIC

SIALADENITIS

ANL) SIALOGRAPHY

477

These studies may lead to a better correlation of the relationship between salivary gland disease and general body diseases, which, as we have indicated metabolic diseases may have previously, is in a confused state. Particularly, a very strong influence on the salivary gland-general body relationship.24 Of course, these studies would presume a previous determination of normal thyroid and renal functions. urnmary

and Conclusioms

1. A review of the literature pertaining to sialadenitis and siaiography has been presented. 2. A series of twenty-five patients with the symptoms of chronic submaxillary or parotid sialadenitis has been reviewed. Sialograms were obtained on each of these patients. 3. Technique of sialography has been described. The importance of the use of warmed, diluted oil-base contrast medium and rapid exposure of x-ray film after injection has been emphasized. 4. Chronic submaxillary sialadenitis and chronic parotitis have different sialographic characteristics, and probably are not the same disease. 5. The principal cause of chronic submaxillary sialadenitis is calculus formation. The main cause of chronic parotitis is not well understood, but it is -probably on an infectious basis. 6. The treatment of chronic submaxillary and parotid sialadenitis has been discussed briefly. 7. Demonstration of the parenchyma is not of value in the diagnosis of chronic sialadcnitis, but it is an important consideration in the evaluation of salivary gland tumors. 8. In spite of the lack of a definitive treatment for chronic parotitis, the use of excessive radiation therapy to destroy the secretory function of the gla.~~d is contraindicated. We are deeply indebted to Lieutenant John W. Pickrcn (MC) USNR, for the photo micrographs, and to Mr. Morton Russin for the remainder of the photographs used in &is

article.

IReferences 1. Williams, S. E’. : Personal commiinication. 2. rCobbs, W. II., and Sneierson, H.: Infections of Parotid Gland: Farther Studies 011 Etiology and Treatment; Sialograms o-f Normal and Abnormal Glands and Ducts, Including Tumors, Am. J. Burg. 32: 258-271, 1936. Diseases of Salivary Glands; Sialography; Its Application in Study and 3. Schroff, J.: Treatment of Salivary Gland Conditions, J. Am. Dent. A. 26: 861-870, 1939. Use of Radiopaque Diagnostic Media in Roentgen Diagnosis of Oral 4. Thoma, IX. EI.: Surgical Conditiions, Am. J. Orthodontics and Oral Surg. 27: 64-82, 1941. Visualization of Salivary Glands Following Use 5. Anspa&, W. E., and Griffeth, I?. W.: of Opaque Material in the Mouth, Am. J. Roentgenol. 37: 469-471, 3937. A.pplication of Sialography in Non-Neoplastic Diseases 6. Blady, J. V., and I-Iocker, A. F.: of Parotid Gland, Radiology 32: 1X-141, 1939. Personal communication. 7. Lane, 8. L.: The Pharmacological I&is of Therapeutics, New York, 8. Goodman, L., and Gilman, A.: 1941, The Macmillan Company. Its Technique and Applications, Brit. S. Surg. 19: 142-148, 9. Payne, R. T.: Sialography: 1931.

10, Sicard, J, A., and Forestier, J.: Iodized Oil as Contrast Medium in Radioscopy, Bull. et m&n. Sot. med. d. h6n. de Par. 46: 46346S. 1922. il ~Fpsteen, c. .M.,and Renaix,LR.: Effect of Non-Volatile Substances on Salivary Glands in Sialography, Plast. & Roconstruet. Surg. 13: 299306, 1954. 12. Putney, F. J., and Shapiro, M. J.: Sialography, Arch. Otolaryog. 51: 526-534, 1950. 1.7. Dechaume, J*, and Bonneau, M.: La Sialograpbie; Methodc de Diagnostic Dan-s les A.ffoctions des Glandes Salivaires,.Presse m&l. 59: 561-564, 1951. 14. Wiedemann, H. R. : Sialografie im Kmdesalter, Ztschr. Kinderh. 69: 133-160, 1951. 15, Hare, H. F.: Sialography or Lipiodol Injection of the Salivary Ducts, S. Clin, North America 15: 1567-1573, 1935. I6 Xim.m, If. T., Spies, J. W., and Wolfe, J. J.: Sialography, With Particular Reference to Neoplastic Diseases, Am. J. Roentgenol. 34: 289-296, 1935. 17. Samuel, E.: Sialo-Acinar Reflux in Sialography, Brit. J. Radial. 23: 157-161, 1950. 18. Csillag, S. L., and Czunft, V.: Roentgenoscopy of Salivary Glanas by Injectmy Lipiodol, Orvosi hetil. 77: 1023-1025. 1933. 19. OUeremhaw, R. G. W., and Rose, S. S.: Radiological Diagnosis of Salivary Glaud Disease, Brit. J. Radial. 24: 538-548. 1.951. 20. Schulz, M. D., and Weisbergcr, I).: The Sialogram in the Diagnosis of Swelling About the Salivarv Glands. S. Clin. North America 27: 3356-1161. 1947. 21, Duclos, J., Parr&, J., and Dumas, 1). : La Sialographie, Lyon cl&. 47: 689-757, 1952. Sizzlography in Diagnosis, Postgrad. Med. 26: 521-531, 1950. 22. Rose, 8. S.: 2X. Famcett, D. M., and Kirkwood, S.: Role of the Salivary Glands in Extrathyroidal Iodine Metabolism,~Science 120: 547-548, 1954. 24, Thode, H. G., Jalmet, C. H., and Kirkwood, S.: Stuaics and Diagnostic Tests of Salivary Gland and Thyroid C1a.d Function With. Radioiodine, Now England J, Med. 251: 129-l 34,

1954.