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Sialography: Pathologic-radiologic correlation
Oral SURGERY Oral MEDICINE
VOLUME
oral PATH 0 10 GY
MAY,
21
NUMBER AND
5 1966
Operative oral surgery Sialography: Pathologic-radiologic correlation Thomas J. Cook, D.D.X.,* and Joel Pollack, D.D.S.,“* DEPARTMENT AND
JACKSON
OF SURGERY, MEMORIAL
UNIVERSITY
OF MIAMI
SCHOOL
Miami,
Pin.
OF MEDICINE,
HOSPITAL
A
roentgenogram is a permanent record of the relat.ive opacities of tissues to roentgen rays. Sialography provides a radiographic demonstration of t,he ductal system of the parotid and submaxillary glands after a radiopaque liquid has been injected into the excretory duets. In 1941 Thornal described the use of radiopaque diagnostic media in the roentgen diagnosis of oral conditions. He included sialography in his article and presented an excellent anatomic description. The present study was motivated by the desire to develop a procedure that the oral surgeon could use as a diagnostic aid in his office. REVIEW
OF THE LITERATURE
Sialography had its beginning in 1904, when Charpy? demonsbrated the parotid duct system by injecting mercury into an isolated parotid gla,nd. The first clinical application of this procedure in a living person was made by Arcelin3 who, in 1913, published his report of a case of calculus in Wharton’s duct which had been injected with bismuth prior to radiography. Iodized oil has been used extensively to outline certain body cavities, both *Associate Professor **Former
Resident
and Chief, Division in Oral Surgery.
of Oral Surgery.
559
560
Cook and Pollack
P1:g. 1. Armamentarium.
normal and abnormal, since 1921 ~11~~1Sicard an11 Ii’orCsti(‘r introduced this substance as a rncdium that is opayuc to roentgen rays. CarMen was the first to use Lipiodol; he injccttd a parotid gland in April, reported a 1925, and reported the case in 1926. In I_)eccrnlw~, I$)%, Barsoq+ ease in which he injected 20 per cent potassium ioditle to demonstrate the dilation of Stensen’s duct. Uslenghi’ claimed that the procedure was originated by him and described a case in Rucnos Aires in Jul3-, 19%. In 1926 Jacobovici, Poplitza, and Albu” described the IW of sialogrn.ph\- in three casts to dernonstrate, respectively, a salivary calculus, a tumor of the parotid gland, and a tumor of the submaxillary gland. In 1927 Keith,!’ using I.5 C.C. of iodized oil and a 10 C.C. syringe with a long l&gauge blunt,ed nerdle, injected the parotid gland and concluded : “The anatomic relations of the parot,id gland can be demonstrated in a roentgenogram by this mca.ns and abnormalities in the size and sha.pe of the ducts can readily bc rnade out..” PLAN OF STUDY The anatomic, histologic, and physiologic features of the parotid and submaxillary glands were reviewed. A study was carried out to standardize a technique, select a contrast medium, and become familiar with the radiographic appearance of a normal gland. After rnaking 125 sialograms, WC believe that sialography, when used properly, is comparable to contrast studies of other excretory organs as an aid to diagnosis. TECHNIQUE The technique that we used is sirnilar to tha.t described by earlier investigators,g-12 with some modifications. The equipment includes a set of lacrimal probes (Nos. 1 to 4)) a polyethylene probe, a 22-gauge needle (the tip of which has been blunted, with solder added to a,ct as a stop), a, 10 C.C.syringe, adhesive tape, and Ethiodol’ (Fig. 1). “Ethiodol, the ethyl ester of iodized fatty acids of poppy seed oil containing 37 per cent iodine, is a product of E. Fougera & Co., Inc., Hicksville, IT. Y.
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Sialography
561
The procedure is carried out with the patient sitting upright in the dental chair (Fig. 2). A scout film is taken and developed immediately to rule out the presence of calculi or bone disease (Fig. 3). The duct of the gland to be studied is probed with a fine polyethylene probe. The location of the orifice to Stensen’s duct is located in the papilla of the buccal mucous membrane adjacent to the upper second molar. If the orifice is not visible, gentle massa,ge of the glaad or the patient’s sucking of a lemon will express saliva and aid in its location. The duct is then gently dilated by progressive dilation with lacrimal probes, care being taken not to perforate it. The 22’-gauge blunt-edged needle is then inserted and Ethiodol is slowly injected from a 10 cc. syringe. We found that the best results were achieved when between 0.8 and 1.2 CC. was injected. After the injection is completed, a piece of tape is placed over the handle of the syringe so that the full amount of contrast medium is kept within the system, and the patient is positioned for roentgenograms without moving from the dental chair. The patient is instructed to hold the film with one hand and the syringe with the other when lateral views are made (Fig. 4, A). The syringe is then removed, a piece of sterile gauze is placed over the orifice, and a posteroanterior view is taken. The entire procedure takes approximately 10 minutes. Lateral views are taken again in 30 minutes. If there is any contrast medium in the gland after 30 minutes, the patient is instructed to return in 24 hours for a follow-up film. The technique of submaxillary sialography is essentially the same (Fig. 4, B). The orifice to Wharton’s duct is located in the papilla salivaris on the floor of the mouth on either side of the midline at the base of the frenulum of the tongue. The amount of contrast medium used for submaxillary sialography va.ries between 0.8 CC. and 1.2 cc. We have found that, when properly injected, the normal gland will empty completely in 30 minutes. The course of the parotid duct varies as it passes the masseter muscle (Fig. 5). COMPLICATIONS
During our study, we encountered the following complications : (1) injection of medium into the floor of the mouth, cheek, or adjacent tissues, (2) overinjection, and (3) allergic reaction. The contrast medium may be injected outside the ductal system when the duct has been perforated (Fig. 6, A). Mandel and Baurmash,lG reporting a case of accidental injection of a contrast medium into the cheek, stated that a severe granulomatous reaction developed. It was shown that overinjection of the medium under pressure may perforate the capsule (Fig. 6, B) . The best results were obtained when not more than 1.2 cc. was injected into the parotid and not more than 1 cc. was injected into the submaxillary gland. Allergic reactions are rare. One case was seen in which a severe reaction occurred.
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Pifi I. 2
1. 3
Fig. 2. A, The inj ected aI Id film 0th er ha rnd as film Fig. 3. SCtout E, carci IlO1 na; P,
stage is set. B, Scout film exposed. C, Probing the duct. II, Co ttrast medi ium positioned; patient supports film with one hand and holds syringe q with is exposed. II, calcul US; films. A, Normal mandible; B, edentulous mandihlc; C, cyst unerupted tooth.
563
Volume 21 Number 5
4. Sinlograms
If’@/. 5. Contrast
of normal
parotid
medium demonstrates
(8)
and submaxillary
variations
in entrance
(8)
glands.
to Stensen’s duct.
564
Cook atid Yollack
Pig. 6. A, Perforation of Wharton’s duct upon probing, resulting in injection of contrast medium into floor of mouth. B, Contrast medium present 9 months later. C, Overinjection into submaxillary gland, forcing medium into pterygomandibular space.
FURTHER PLAN OF STUDY When the technique had proved satisfactory and a sufficient number of “no symptoms, no signs” cases had been studied, the different services of Jackson Memorial Hospital were asked to refer patients with swelling in the parotidsubmaxillary area to the Oral Surgery Clinic before biopsy or treatment. This report is based on the analysis of 100 cases in which sialography was used as an adjunct to diagnosis (Table I). INFLAMMATORY
DISEASES
Sialography should not be undertaken in the acute phase of inflammatory disease. Chronic nonneoplastie swellings of the salivary glands are due to a variety of etiologic factors, among which are (I) calculi and foreign bodies in the ducts, (2) Mikulicz’s disease, (3) SjSgren’s syndrome, (4) strictures in the orifice, (5) traumatic injury to duct and gland, (6) parotid swelling associated with masseter muscle hypertrophy, (7) congenital sialoangiectasis, and (8) specific injections associated with tuberculosis and actinomycosis. We have chosen to use the term chronic obstructive sinlodochiectasis in dc-
Volume Kumber
Table
21 5
Sialography
565
I Gland
Parotid
Submaxillary
Condition
1. Normal 2. Inflammatory A. Chronic obstructive sialodochiectasis Strictures 151 Calculus (i) ’ B. Nonobstructive sialoangiectasis (15) 3. Benign tumors 4. Malignant tumors 1. 2. 3. 4. 5. 6.
Normal Calculi Benign tumors Malignant tumors Tuberculosis Strictures
( Number
of patients 30 21
9 6 10 13 i 2 1 1 100
scribing nonneoplastic obstructions of the salivary glands, and we have used the term sialoangiectasis to describe nonobstructive sialodochiectasis. The term sialoangiectasis was first suggested by Swinburnezl to describe a condition of the salivary glands in which the ducts and terminal ductules and even the terminal alveoli are dilated, resembling the dilatation of the bronchi and terminal bronchioles in bronchiectasis. The term sialectasis, which had been used to describe the condition, is not correct etymologically since it translates as a stretching-out or dilatation of the saliva. Under chronic obstructive sialodochiectasis we list swellings of the gland due mainly to strictures and stones. In cases of chronic obstruction the abnormalities are seen mainly in the main duct. The duet is dilated with multiple strictures, giving a sausage-string appearance to Stensen’s duct. The remainder of the gland may appear normal. In cases of sialoangiectasis the abnormalities are seen mainly in the peripheral ducts, and the gland shows a “mulberry” pattern. Among the causes of sialoangiectasis are Sjiigren’s syndrome, Mikulicz’s disease, recurrent sialoadenitis in children, congenital sialogenectasis, and recurrent pyogenic parotitis. SWELLINGS
DUE TO NEOPLASTIC
DISEASES
A normal sialogram may serve to indicate that the mass is external to the gland. The abnormal sialographic patterns produced by tumors will depend on whether the tumor is extrinsic or intrinsic in relation to the gland. In cases of extrinsic encapsulated tumor, the general architecture of the gland is preserved and there is only a slight deviation of the intraglandular ducts, resulting usually in a peripheral filling defect. In the case of intrinsic encapsulated tumor, the glandular architecture remains intact but there is an impingement of the ductal system, resulting in a displacement of the ducts. The sialogram of an encapsulated or circumscribed intrinsic lesion will show a filling defect outlined by a displaced duct system. When there is massive involvement of the gland, the entire glandular structure may be destroyed and the sialogram will resemble that of an invasive neoplasm.
CASE REPORTS CASE
1
A 14.year-old white boy was seen in consultation with the Otolaryngology Service because of a i by i cm. submandilmlar swelling which had been present for 3 weeks (E’ig. 7, .4 ). ‘IIe scout film revealed calcified bodies in the submaxillary gland area (Fig. 7, II). A sialogram demonstrated a normal submaxillary gland and showed that the calcifirations WPI’C not in the gland (Fig. 7, c’). Surgical exploration disclosed a mass of hard, caseous nodes adjacent anal somewhat atlherent to, but not involving, the submaxillary gland. The pathologist’s report revealed “lvmphadcnitis y with tubrrculoitl granulomatcl,Ws inflammation.” A diagnosis of tuberrulosis ~xs made by the (Ihcst Service. CASE 2
*In 1 I-year-oltl Cuban hoy lvas scaen in the c’mergclncy room with a complaint of swelling (6 by 7 cm.) and pain in the right infra-auricular region. A tentative diagnosis of pnrotitis was made, and antibiotic therapy was instituted. An appointment was made for a sialogmm. When the patient returned 4 days later for the sialogram, he \vas asymptomatic. He informed us that he had had a similar swelling on tlvo prcxvious occasions. 1 c.c., was introduced into the parotid duct, ant1 a The scout film was negat,ivcx. Ethiodol, rornt,genogram revealed the typical “mull~c~rry” pattern sc~cn in sialoangicctt~asis (Fig. 8). The final diagnosis was sialoangiectasis. CASE 3
A 52.year-old white moman was first seen in the Oral Surgery Clinic wit,h a rccurrcnt parotid swelling which, accsortling to the paticlnt, had it,s onset when she was eating. area (Fig. 9, A ) . The Physical examination revealetl a swelling in the right parotid scout film was negative (Fig. 9, H). A right parotid sialogram showed that the main duct appearance indiwas greatly enlarged, with multiple strictures present. The sausage-string cated an abnormality along the entire main duct (Fig. 9, C). TOP 30 minutcx emptying film revealed the presence of contrast medium (Fig. 9, 1)): sialodocshiectasis associated with stricture of the The diagnosis was chronit obstructive thWt. right
CASE 4
The Tumor Clinic referred a 46.year-old white woman for a sinlogram because of a swelling of 4 months’ duration in the left parotid area. On physical examination, the patient was found to have a blood pressure of 160/80, a pulse rate of 80, and a respiration rate of 20. A 2 119 3 cm. round, firm, nontender mass was palpable at the right angle of the mandible (Fig. 10, A). This mass was fixed to the deep tissue, but the skin over it was freely movable. Laboratory findings were within normal limits. A sialogram revealed a filling defect in the lower left portion of the parotid gland (Fig. 10, II). On May 16, 1962, the patient was taken to the operating room where, under general anesthesia, a left superficial parotid lohectomy was performed. A well-encapsulated tumor arising from the deep portion of the superficial lobe of the left parotid, with a small amount of inflammatory response about it, was found. The surgeon traced the tumor’s location on the roentgenogram (Fig. 10, C). Microscopic examination of multiple sections of the parotid gland revealed a mediumsized cyst lined with many papillary projections which were covered with stratified columnar
Volume 21 Number 3
Xirr1ograph.y
567
Fin. 7’. Case 1. A, Submandibular swelling. B, Scout film reveals multiple calcificat~ions which appear to be intraglandulnr. C, Hialogram shows calcifications to be extraglandular. Fig,. 8. Cast 2. Sialoangiectasis of parotid gland.
cells. The connective tissue stalks were densely infiltrated ljy many lymphocytes, and lymphoid follicles were present in some areas. In other areas the ducts mere cystically dilated, and one was filled with debris, neutrophils, and foamy macrophages. Some of these ducts displayed squamous metaplasia. The adjacent parenchyma was infiltrated by many plasma cells and lymphocytes. A small abscess was noted. Some relatively normal parotid gland tissue was present in the periphery of the mass.
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Cook and Yollack
Pig. 9. Case 3. A, Swelling of parotid gland after eating. gram reveals strictures of duet. D, Thirty-minute postinjection
The diagnosis tumor).
was right
parotid
gland
papillary
R, Normal scout film. C, Sialofilm shows delayed emptying.
cystadenoma
lymphomatosum
(Warthin’s
CASE 5
a %-year-old Negro woman was first seen in the Tumor Clinic on Feb. 10, 1962, with a small nodule which began in the left cheek one year previously. The past medical history revealed that a mass diagnosed as fibroadenoma was removed from the breast on Jan. 23, 1962. Physical examination revealed a nodular, firm, nontender, movable mass over the left cheek at the angle of the mandible (Fig. 11, A). The blood pressure was 120/70, and the pulse rate was 72. Laboratory findings were within normal limits. A sialogram showed a normal main duct (Fig. 11, R). The ducts surrounding the tumor were displaced and the filling defect was outlined. The duct system showed no destructive changes, but a marked degree of displacement was evident. On Feb. 14, 1962, the patient was taken to the operating room where, under general anesthesia, a superficial and partial deep parotidectomy was performed. There was a 3 by 5 cm. firm, irregular mass in the left parotid gland, primarily occupying the superficial lobe with some extension to the deep lobe. The surgical specimen consisted of a large, lobulated, light tan, firm mass with associated adipose tissue aggregating 51by 5 by 3 cm. and weighing 40 grams. Multiple sections showed a well-encapsulated, lobulated mass of closely packed, spindle-shaped cells with uniform oval nuclei. The cytoplasm of these cells was scant and gray. In some areas the cells formed ducts
Volume Number
21 5
Xialography
E
co1
in sya
569
11
‘ig. 10. Case 4. A, Swelling in parotid area. B, Sialogram demonstratt :s fill ing def elct of ast metGum att lower portion of gland. C, Duplicate of B; exact locatic ,n of tu1mor d ra\$-n surgec m. Die zglzosis : Warthin’s tumor. swelling. B, Sialogram reveals diq 31:LCCI nentt of duct lg. 11. Case 5. A, Left parotid Mixed salivary gland tumc;r. El; tt in ferior margins by tumor. Diagnosis:
CASE
6
Ak 45.year-old Srgro man was first swu in tllc, Tumor (‘liuic: on May Xl, 1961, witIt :t hist,ory of a progressively enlarging mass on the left side of tlic nwk. The ](3ion was now twidrr and painless. Physical examination disclowtl a 10 11,v 5 cm. firm, movable mass ilt tllc sn])fIlitlldil)uIa1. arca. Intraoral examination was negative. Laboratory studies rwealed t,lre following: htwloglobin, 11 ; hcxmatocrit, 3X; uhitc blood couIlt, 5,400 with 45 wgmented nc~utrophils, 46 lymphocytes, 7 cosinophils, 2 basophils. h sialogram sho\wd the wntrast mcclium within the length of \Vharton’s duct. Tht: wmaind~~r of the duatal systc,ru IVES diffiwlt to visualize ; it appparcd to haw ]wn rrplawd I)y the tumor (Fig. 12, A ). \Vh~u the surgicdal spwimen IVXS plawd ou :I film ant] rsposwl, (Fig. 12, H ). contrast medium was wwalwl throughout On .Junc 7, 196 I, the pati(,nt was takw 1o tlrcb operating room wlrc~w, untlrr gc~rreral RIIPSthwia, the submaxillary glantl ant1 atljxwnt nodes \VCW rcw~oved through a suhmandibula~ incision. The operation was p~rformc~l by the JIcatl and Swk Service of .lackson 31Lemorial Hospital. A rather large [ 3 ])y 4 in?h) sulm~awillary gland surroundetl by an abundant of nodrs was rcnioved. E’rozeu swtions of tllcs noclw and gland intliwtcd a Iwnign wndition. Histologic 6xaIllillation showvc~tl that thck nodal awhitwture \~as prtwwwl. Thrw I\ cw numerous follicles, exhibiting diflcrwt shapw and Azw. Prominent germinal c,cwters wcrc found. The stromal awhitwture was unrc,l,larkabl(,. ‘1‘111~rapsul~ wwc thick. Swtions of the‘ salivary gland rewalrtl a neoplasm formcY1 l)y solid sheets of isolated strands and coords of rtpithelial cells, togrth~~r with amorpIIour mwinous material. Th(b stroma consisted of foci of mutinous material intt~rspc~rwd with strllatck wlls. The ~xpsulo was thic*k and was COW posed chiefly of collagrnous fibers sprinkled \vitll lymphoc$es. The diagnosis was (1 ) hppcrplasia of lymph nodw of t,hch prwaswlar area, submaxillary and subnwnt~al, and rxtwnal jugular wgions ant] (2) a histologic~ally benign mixed tumor of tllcx submaxillary glan~l. CASE
7
A4 64.year-old N(agro niwl \vas rcfnretl to the Oral Hurgwy Yrpartment f ram snothcar hospital hwauw of a right facial swelling which he had first not,iced 8 years before. The mass had been gradually incrrasing in size until 2 months previously, when the patiwt noticed a rapid increase in size with the onset of pain. Physical examination revealed a blood pressure of 200/130; a pulse rate of X0; and a trntlcr mass JWP respiration rate of 16. There was a 4 b.v 1 cm. hard, immovable, slightly truding from just und(,r the angle of the right mandihlr. 13.X ; hematocrit, 43 ; white: blood Laboratory data included tho following: hrmoglohin, count, 9,200, with 70 segmented neutrophils, 6 stabs, 19 lgmphoaytrs, 1 nionwyte, and 1 phosphataw, 5.3 ; VI)R.T,, non3.7 ; alkaline eosinophils ; strum calcium, 10.1; phospllorus, rrac t ive. A sialogram showctl irregular dcfwts in the substanw of the glautl. ‘I’hc~ normal duct alignment was distorted as a result of displacement by turtlor invasion. The preoperative diagnosis was tumor of the parotid gland. On May 25, 1962, the patient ~vas taken to the operating room !vhero, under general anw thesia, a right radical neck dissection and a total parotidertomy were performed. Scations of parotid tissue showed a neoplasm arising within thr substance of the gland This neoplasm consisted largely of sheets of and infiltrating the surrounding parenchyma. markedly pleomorphic nuclei cells with scanty amounts of cytoplasm and hyperchromatic, Tvith many giant forms. Both typical and atypical mitoses were frequent. Tn some areas the
\‘olurnc 21 Nurnbc~r 5
Fig.
13
Fig 1.2. Case 6. A, Sialogram demonstrates destruction of glandular ductal q-s tern by tur nor. B, Roentgenogram of specimen removed at operation reveals contrast mrtlium 1qsent. Ihi agno&:is: Mixed tumor, histologically benign. duct. H, Sialogram shows exact location of (aalculus Pig . 13. 3, C’alculus in parotid of c,ontrast in awe! ssory gland duct. C, Large calculus found with scout film. D, Injection me,dium reveals calculus in submaxillary gland.
572
cook mad Pollack
neoplsstic cells had more abundant, eosinoph ilic I’$ oplasu~ an,1 ~\-crc :~l’r:lIl~I~‘l l,, 1i:LIN’vIlI:Ll” and as abortive glandlike structures. Sections of lymph nodes showed small nests of tumor, identical lo that. I'cnmcl in Ilria parotid gland, in one out of five preauricular, one out of five subrnandil.rular~. arrd thr’t~ auf of sixteen upper cervical lymph nodes. Many of the lymph nodes contained melanin-latlcn histiocytes, and some showed lymphoid and sinus cell hyperplasia. The final diagnosis was anaplastic carcinoma of the parotid gland, \vith metsstases IO five of forty-eight lymph nodes.
CONCLUSION
Sialography is of value in demonstrating calculi, especialI)- in tho parotid duct where they are less frequent. The case represented in Fig. X3 is of particular interest. After a metal probe was passed into the duct to locate the calculus (Fig. 13, A), an unsuccessful attempt was made to remove the stone. Ethiodol was injected into the parotid duct after a 10 day waiting period, and the calculus was found to be in the duct of an accessory gla.nd (Fig. 13, R) , from which it was removed intraorally. A large calculus was demonstrated on a scout film (Fig. 13, C), and injection of contrast medium into the submaxillary duct revealed its presence in the gland. Sialography, a roentgenographic visualization of the salivary duck and their glands following injection of a radiopaque substance, is a valua.ble diagnostic aid in cases of tumefaction in the parotid-submaxillary area. A sialographic method which can be used by the oral surgeon at the de&al chair has been presented. The method is expedient, requires no special preparation of the patient, and can be carried out with a minimum of assistance. REFERENCES 1. Thoma, 2.
3. 4. 5. 6. 7. 8. 9. 10. 11 II.
12. 13. 14. 15. 16. 17.
K. H.: The Use of Radiopaque Diagnostic Media in Roentgen Diagonsis of Oral Surgical Conditions, Am. J. Orthodontics & Oral Surg. 27: 64, 1941. humaine, Paris, 1904 and 1914, Masson Poirier, P., and Charpy, A.: Traite d’anatomie & Cie! p. 89. Arcelm: Quoted by Berraud, A.: Revue prat. electrol. et radiol. Mod., May 3, 1913. radiologique par l’huile iodee Sicard, J., and Forestier, J.: Methode generale d’exploration (lipiodol), Bull. et mem. Sot. Chir. Paris 46: 463-469, 1922. in dem Ansfuhrungsgang der Speicheldrusen, Acta Carl&en, D. B.: Lipiodolinjektion radiol. 6: 221-223, 1926. Barsony, T. : Idiopathische Stenongang-dilatation, Klin. Wchnschr. 4: 2500-2501, 1925. Uslenghi, J. P.: New Technique for Radiologic Investigation of the Salivary Glands, Semana m6d. 27: 41, 1925,. Jacobovici, J., Poplitzka, W., and Albu, L.: La Sialographia, Presse med. 34: 1188, 1926. Keith. H. M.: Iniection of the Parotid Gland With Iodized Oil. J. A. M. A. 90: 1270. 1271,, ‘1928. ” Sialography in Diseases of the Major Salivary Rubm, P., and Holt, J. F.: Secretory Glands, Am. J. Roentgenol. 77: 575-598, 1957. Technique and Application in RoentBlady, J. V., and Hacker, A. F.: Sialography-Tts gen Study of Neoplasm5 of Parotid Gland, Surg. Gynec. & Obst. 67: 777-787, 1938. Valuable Diagnostic Method, D. Radiog. Ollerenshaw, R., and Rose, 8.: Sialography-A 29: 37, 1956. With Recurrent Subacute 1+:xLonde, S., and Pelz, M. D.: Chronic Sialodocho-parotitis acerbations, J. Pediat. 2: 594-602, 1933. Barsky, A. J.: Diagnosis and Treatment of Diseases of the Salivary Glands, .T. Am. Pent. A. 29: 2026-2046, 1942. Schroff, Joseph: Diseases of the Salivary Glands ; Sialography : Its Application in the Study and Treatment of Salivary Gland Conditions, J. Am. Dent. A. 26: 861-870, 1939. Changes From Sialographic Media, J. Oral Mandel, L., and Baurmash, II.: Pathologic Burg., Anesth. & Hosp. D. Serv. 20: 341-344, 1962. of Sialography in Nonncoplastic DisBlady, J. V., and Hacker, A. F.: The Application eases of the Parotid Gland, Radiology 32: 131-141, 1939.
Volume Numhw
Sinlopvphy
21 5
573
Brit,. J. Surg. 19: 142-148, 18. Payne, R. T. : Sialography : Its Technique ant1 Application, 1931. 19. Schulz, AI. u., and Weisberger, T). : The Sialogram in the Diagnosis of Swelling Alrout the Salivary Glands, Hurg. Clin. North America 27: 1156-1161, 1947. 20. Ollerenshaw, R,. CT., and Rose, S.: Radiological Diagnosis of Salivary Gland Biseasr, Brit. J. Radial. 24: 538-548, 1951. Brit. J. Surg. 27: 713-716, 1940. 21. Hwinhurne, G. : Sialoangiectasis, VVith Particular Reference to 22. Kimm, II. T., Spies, J. W., and Wolfe, J. J.: Sialography Seoplastic Diseases, Am. J. Roentgenol. 34: 289.296! 1935. 23. New, 0. B., and Harper, F. R. : Chronic Inflammatton of the Salivary Glands With or Without Calculi, Hurg. (fyncc. & Obst. 53: 456460, 1931. 24. Reward, G. R.: h Techmquc for Sinlography, ORAL STRG., ORAT, MED. & ORAL PATH. 14: 154-l 63,
1961.
Study of Sialograph and Tts Correlation With Histological 25. Ranger, 1.: An Experimental Appearance in Parotid and Submandibular Glands, Brit. .J. Surg. 44: 415-418, 195i. Koentgenologico-Surgical Corrr26. Einstein, R. J., and Perzik, 8. L.: Parotid Sialography: lation in a Series of 70 Cases, California Med. 88: 98-102, 1958. Pyogenic Parotitis-Its Pathology, Ijiagnosis and Treatment, 27. Payne, R. T.: Recurrent Lancet 1: 358-353, 1933. 28. Gerry, R. G., and Seigman, E. L.: Chronic Sialadenitis and Sialography, ORAL SURG., ORAL Mm. & ORAL PATH. 8: 453-478, 1955. 29. Schulz, 11. I)., and Weisberg, D.: Sialography: Its Value in the Diagnosis of Swellings Alrout the Salivary Glands, ORAL SURG., ORAI, lien. h ORAL PATH. 1: 233-249, 194X.
VOLUME
oral PATH 0 10 GY
MAY,
21
NUMBER AND
5 1966
Operative oral surgery Sialography: Pathologic-radiologic correlation Thomas J. Cook, D.D.X.,* and Joel Pollack, D.D.S.,“* DEPARTMENT AND
JACKSON
OF SURGERY, MEMORIAL
UNIVERSITY
OF MIAMI
SCHOOL
Miami,
Pin.
OF MEDICINE,
HOSPITAL
A
roentgenogram is a permanent record of the relat.ive opacities of tissues to roentgen rays. Sialography provides a radiographic demonstration of t,he ductal system of the parotid and submaxillary glands after a radiopaque liquid has been injected into the excretory duets. In 1941 Thornal described the use of radiopaque diagnostic media in the roentgen diagnosis of oral conditions. He included sialography in his article and presented an excellent anatomic description. The present study was motivated by the desire to develop a procedure that the oral surgeon could use as a diagnostic aid in his office. REVIEW
OF THE LITERATURE
Sialography had its beginning in 1904, when Charpy? demonsbrated the parotid duct system by injecting mercury into an isolated parotid gla,nd. The first clinical application of this procedure in a living person was made by Arcelin3 who, in 1913, published his report of a case of calculus in Wharton’s duct which had been injected with bismuth prior to radiography. Iodized oil has been used extensively to outline certain body cavities, both *Associate Professor **Former
Resident
and Chief, Division in Oral Surgery.
of Oral Surgery.
559
560
Cook and Pollack
P1:g. 1. Armamentarium.
normal and abnormal, since 1921 ~11~~1Sicard an11 Ii’orCsti(‘r introduced this substance as a rncdium that is opayuc to roentgen rays. CarMen was the first to use Lipiodol; he injccttd a parotid gland in April, reported a 1925, and reported the case in 1926. In I_)eccrnlw~, I$)%, Barsoq+ ease in which he injected 20 per cent potassium ioditle to demonstrate the dilation of Stensen’s duct. Uslenghi’ claimed that the procedure was originated by him and described a case in Rucnos Aires in Jul3-, 19%. In 1926 Jacobovici, Poplitza, and Albu” described the IW of sialogrn.ph\- in three casts to dernonstrate, respectively, a salivary calculus, a tumor of the parotid gland, and a tumor of the submaxillary gland. In 1927 Keith,!’ using I.5 C.C. of iodized oil and a 10 C.C. syringe with a long l&gauge blunt,ed nerdle, injected the parotid gland and concluded : “The anatomic relations of the parot,id gland can be demonstrated in a roentgenogram by this mca.ns and abnormalities in the size and sha.pe of the ducts can readily bc rnade out..” PLAN OF STUDY The anatomic, histologic, and physiologic features of the parotid and submaxillary glands were reviewed. A study was carried out to standardize a technique, select a contrast medium, and become familiar with the radiographic appearance of a normal gland. After rnaking 125 sialograms, WC believe that sialography, when used properly, is comparable to contrast studies of other excretory organs as an aid to diagnosis. TECHNIQUE The technique that we used is sirnilar to tha.t described by earlier investigators,g-12 with some modifications. The equipment includes a set of lacrimal probes (Nos. 1 to 4)) a polyethylene probe, a 22-gauge needle (the tip of which has been blunted, with solder added to a,ct as a stop), a, 10 C.C.syringe, adhesive tape, and Ethiodol’ (Fig. 1). “Ethiodol, the ethyl ester of iodized fatty acids of poppy seed oil containing 37 per cent iodine, is a product of E. Fougera & Co., Inc., Hicksville, IT. Y.
Volume 21 Number 5
Sialography
561
The procedure is carried out with the patient sitting upright in the dental chair (Fig. 2). A scout film is taken and developed immediately to rule out the presence of calculi or bone disease (Fig. 3). The duct of the gland to be studied is probed with a fine polyethylene probe. The location of the orifice to Stensen’s duct is located in the papilla of the buccal mucous membrane adjacent to the upper second molar. If the orifice is not visible, gentle massa,ge of the glaad or the patient’s sucking of a lemon will express saliva and aid in its location. The duct is then gently dilated by progressive dilation with lacrimal probes, care being taken not to perforate it. The 22’-gauge blunt-edged needle is then inserted and Ethiodol is slowly injected from a 10 cc. syringe. We found that the best results were achieved when between 0.8 and 1.2 CC. was injected. After the injection is completed, a piece of tape is placed over the handle of the syringe so that the full amount of contrast medium is kept within the system, and the patient is positioned for roentgenograms without moving from the dental chair. The patient is instructed to hold the film with one hand and the syringe with the other when lateral views are made (Fig. 4, A). The syringe is then removed, a piece of sterile gauze is placed over the orifice, and a posteroanterior view is taken. The entire procedure takes approximately 10 minutes. Lateral views are taken again in 30 minutes. If there is any contrast medium in the gland after 30 minutes, the patient is instructed to return in 24 hours for a follow-up film. The technique of submaxillary sialography is essentially the same (Fig. 4, B). The orifice to Wharton’s duct is located in the papilla salivaris on the floor of the mouth on either side of the midline at the base of the frenulum of the tongue. The amount of contrast medium used for submaxillary sialography va.ries between 0.8 CC. and 1.2 cc. We have found that, when properly injected, the normal gland will empty completely in 30 minutes. The course of the parotid duct varies as it passes the masseter muscle (Fig. 5). COMPLICATIONS
During our study, we encountered the following complications : (1) injection of medium into the floor of the mouth, cheek, or adjacent tissues, (2) overinjection, and (3) allergic reaction. The contrast medium may be injected outside the ductal system when the duct has been perforated (Fig. 6, A). Mandel and Baurmash,lG reporting a case of accidental injection of a contrast medium into the cheek, stated that a severe granulomatous reaction developed. It was shown that overinjection of the medium under pressure may perforate the capsule (Fig. 6, B) . The best results were obtained when not more than 1.2 cc. was injected into the parotid and not more than 1 cc. was injected into the submaxillary gland. Allergic reactions are rare. One case was seen in which a severe reaction occurred.
562
Cook and Pollack
Pifi I. 2
1. 3
Fig. 2. A, The inj ected aI Id film 0th er ha rnd as film Fig. 3. SCtout E, carci IlO1 na; P,
stage is set. B, Scout film exposed. C, Probing the duct. II, Co ttrast medi ium positioned; patient supports film with one hand and holds syringe q with is exposed. II, calcul US; films. A, Normal mandible; B, edentulous mandihlc; C, cyst unerupted tooth.
563
Volume 21 Number 5
4. Sinlograms
If’@/. 5. Contrast
of normal
parotid
medium demonstrates
(8)
and submaxillary
variations
in entrance
(8)
glands.
to Stensen’s duct.
564
Cook atid Yollack
Pig. 6. A, Perforation of Wharton’s duct upon probing, resulting in injection of contrast medium into floor of mouth. B, Contrast medium present 9 months later. C, Overinjection into submaxillary gland, forcing medium into pterygomandibular space.
FURTHER PLAN OF STUDY When the technique had proved satisfactory and a sufficient number of “no symptoms, no signs” cases had been studied, the different services of Jackson Memorial Hospital were asked to refer patients with swelling in the parotidsubmaxillary area to the Oral Surgery Clinic before biopsy or treatment. This report is based on the analysis of 100 cases in which sialography was used as an adjunct to diagnosis (Table I). INFLAMMATORY
DISEASES
Sialography should not be undertaken in the acute phase of inflammatory disease. Chronic nonneoplastie swellings of the salivary glands are due to a variety of etiologic factors, among which are (I) calculi and foreign bodies in the ducts, (2) Mikulicz’s disease, (3) SjSgren’s syndrome, (4) strictures in the orifice, (5) traumatic injury to duct and gland, (6) parotid swelling associated with masseter muscle hypertrophy, (7) congenital sialoangiectasis, and (8) specific injections associated with tuberculosis and actinomycosis. We have chosen to use the term chronic obstructive sinlodochiectasis in dc-
Volume Kumber
Table
21 5
Sialography
565
I Gland
Parotid
Submaxillary
Condition
1. Normal 2. Inflammatory A. Chronic obstructive sialodochiectasis Strictures 151 Calculus (i) ’ B. Nonobstructive sialoangiectasis (15) 3. Benign tumors 4. Malignant tumors 1. 2. 3. 4. 5. 6.
Normal Calculi Benign tumors Malignant tumors Tuberculosis Strictures
( Number
of patients 30 21
9 6 10 13 i 2 1 1 100
scribing nonneoplastic obstructions of the salivary glands, and we have used the term sialoangiectasis to describe nonobstructive sialodochiectasis. The term sialoangiectasis was first suggested by Swinburnezl to describe a condition of the salivary glands in which the ducts and terminal ductules and even the terminal alveoli are dilated, resembling the dilatation of the bronchi and terminal bronchioles in bronchiectasis. The term sialectasis, which had been used to describe the condition, is not correct etymologically since it translates as a stretching-out or dilatation of the saliva. Under chronic obstructive sialodochiectasis we list swellings of the gland due mainly to strictures and stones. In cases of chronic obstruction the abnormalities are seen mainly in the main duct. The duet is dilated with multiple strictures, giving a sausage-string appearance to Stensen’s duct. The remainder of the gland may appear normal. In cases of sialoangiectasis the abnormalities are seen mainly in the peripheral ducts, and the gland shows a “mulberry” pattern. Among the causes of sialoangiectasis are Sjiigren’s syndrome, Mikulicz’s disease, recurrent sialoadenitis in children, congenital sialogenectasis, and recurrent pyogenic parotitis. SWELLINGS
DUE TO NEOPLASTIC
DISEASES
A normal sialogram may serve to indicate that the mass is external to the gland. The abnormal sialographic patterns produced by tumors will depend on whether the tumor is extrinsic or intrinsic in relation to the gland. In cases of extrinsic encapsulated tumor, the general architecture of the gland is preserved and there is only a slight deviation of the intraglandular ducts, resulting usually in a peripheral filling defect. In the case of intrinsic encapsulated tumor, the glandular architecture remains intact but there is an impingement of the ductal system, resulting in a displacement of the ducts. The sialogram of an encapsulated or circumscribed intrinsic lesion will show a filling defect outlined by a displaced duct system. When there is massive involvement of the gland, the entire glandular structure may be destroyed and the sialogram will resemble that of an invasive neoplasm.
CASE REPORTS CASE
1
A 14.year-old white boy was seen in consultation with the Otolaryngology Service because of a i by i cm. submandilmlar swelling which had been present for 3 weeks (E’ig. 7, .4 ). ‘IIe scout film revealed calcified bodies in the submaxillary gland area (Fig. 7, II). A sialogram demonstrated a normal submaxillary gland and showed that the calcifirations WPI’C not in the gland (Fig. 7, c’). Surgical exploration disclosed a mass of hard, caseous nodes adjacent anal somewhat atlherent to, but not involving, the submaxillary gland. The pathologist’s report revealed “lvmphadcnitis y with tubrrculoitl granulomatcl,Ws inflammation.” A diagnosis of tuberrulosis ~xs made by the (Ihcst Service. CASE 2
*In 1 I-year-oltl Cuban hoy lvas scaen in the c’mergclncy room with a complaint of swelling (6 by 7 cm.) and pain in the right infra-auricular region. A tentative diagnosis of pnrotitis was made, and antibiotic therapy was instituted. An appointment was made for a sialogmm. When the patient returned 4 days later for the sialogram, he \vas asymptomatic. He informed us that he had had a similar swelling on tlvo prcxvious occasions. 1 c.c., was introduced into the parotid duct, ant1 a The scout film was negat,ivcx. Ethiodol, rornt,genogram revealed the typical “mull~c~rry” pattern sc~cn in sialoangicctt~asis (Fig. 8). The final diagnosis was sialoangiectasis. CASE 3
A 52.year-old white moman was first seen in the Oral Surgery Clinic wit,h a rccurrcnt parotid swelling which, accsortling to the paticlnt, had it,s onset when she was eating. area (Fig. 9, A ) . The Physical examination revealetl a swelling in the right parotid scout film was negative (Fig. 9, H). A right parotid sialogram showed that the main duct appearance indiwas greatly enlarged, with multiple strictures present. The sausage-string cated an abnormality along the entire main duct (Fig. 9, C). TOP 30 minutcx emptying film revealed the presence of contrast medium (Fig. 9, 1)): sialodocshiectasis associated with stricture of the The diagnosis was chronit obstructive thWt. right
CASE 4
The Tumor Clinic referred a 46.year-old white woman for a sinlogram because of a swelling of 4 months’ duration in the left parotid area. On physical examination, the patient was found to have a blood pressure of 160/80, a pulse rate of 80, and a respiration rate of 20. A 2 119 3 cm. round, firm, nontender mass was palpable at the right angle of the mandible (Fig. 10, A). This mass was fixed to the deep tissue, but the skin over it was freely movable. Laboratory findings were within normal limits. A sialogram revealed a filling defect in the lower left portion of the parotid gland (Fig. 10, II). On May 16, 1962, the patient was taken to the operating room where, under general anesthesia, a left superficial parotid lohectomy was performed. A well-encapsulated tumor arising from the deep portion of the superficial lobe of the left parotid, with a small amount of inflammatory response about it, was found. The surgeon traced the tumor’s location on the roentgenogram (Fig. 10, C). Microscopic examination of multiple sections of the parotid gland revealed a mediumsized cyst lined with many papillary projections which were covered with stratified columnar
Volume 21 Number 3
Xirr1ograph.y
567
Fin. 7’. Case 1. A, Submandibular swelling. B, Scout film reveals multiple calcificat~ions which appear to be intraglandulnr. C, Hialogram shows calcifications to be extraglandular. Fig,. 8. Cast 2. Sialoangiectasis of parotid gland.
cells. The connective tissue stalks were densely infiltrated ljy many lymphocytes, and lymphoid follicles were present in some areas. In other areas the ducts mere cystically dilated, and one was filled with debris, neutrophils, and foamy macrophages. Some of these ducts displayed squamous metaplasia. The adjacent parenchyma was infiltrated by many plasma cells and lymphocytes. A small abscess was noted. Some relatively normal parotid gland tissue was present in the periphery of the mass.
568
Cook and Yollack
Pig. 9. Case 3. A, Swelling of parotid gland after eating. gram reveals strictures of duet. D, Thirty-minute postinjection
The diagnosis tumor).
was right
parotid
gland
papillary
R, Normal scout film. C, Sialofilm shows delayed emptying.
cystadenoma
lymphomatosum
(Warthin’s
CASE 5
a %-year-old Negro woman was first seen in the Tumor Clinic on Feb. 10, 1962, with a small nodule which began in the left cheek one year previously. The past medical history revealed that a mass diagnosed as fibroadenoma was removed from the breast on Jan. 23, 1962. Physical examination revealed a nodular, firm, nontender, movable mass over the left cheek at the angle of the mandible (Fig. 11, A). The blood pressure was 120/70, and the pulse rate was 72. Laboratory findings were within normal limits. A sialogram showed a normal main duct (Fig. 11, R). The ducts surrounding the tumor were displaced and the filling defect was outlined. The duct system showed no destructive changes, but a marked degree of displacement was evident. On Feb. 14, 1962, the patient was taken to the operating room where, under general anesthesia, a superficial and partial deep parotidectomy was performed. There was a 3 by 5 cm. firm, irregular mass in the left parotid gland, primarily occupying the superficial lobe with some extension to the deep lobe. The surgical specimen consisted of a large, lobulated, light tan, firm mass with associated adipose tissue aggregating 51by 5 by 3 cm. and weighing 40 grams. Multiple sections showed a well-encapsulated, lobulated mass of closely packed, spindle-shaped cells with uniform oval nuclei. The cytoplasm of these cells was scant and gray. In some areas the cells formed ducts
Volume Number
21 5
Xialography
E
co1
in sya
569
11
‘ig. 10. Case 4. A, Swelling in parotid area. B, Sialogram demonstratt :s fill ing def elct of ast metGum att lower portion of gland. C, Duplicate of B; exact locatic ,n of tu1mor d ra\$-n surgec m. Die zglzosis : Warthin’s tumor. swelling. B, Sialogram reveals diq 31:LCCI nentt of duct lg. 11. Case 5. A, Left parotid Mixed salivary gland tumc;r. El; tt in ferior margins by tumor. Diagnosis:
CASE
6
Ak 45.year-old Srgro man was first swu in tllc, Tumor (‘liuic: on May Xl, 1961, witIt :t hist,ory of a progressively enlarging mass on the left side of tlic nwk. The ](3ion was now twidrr and painless. Physical examination disclowtl a 10 11,v 5 cm. firm, movable mass ilt tllc sn])fIlitlldil)uIa1. arca. Intraoral examination was negative. Laboratory studies rwealed t,lre following: htwloglobin, 11 ; hcxmatocrit, 3X; uhitc blood couIlt, 5,400 with 45 wgmented nc~utrophils, 46 lymphocytes, 7 cosinophils, 2 basophils. h sialogram sho\wd the wntrast mcclium within the length of \Vharton’s duct. Tht: wmaind~~r of the duatal systc,ru IVES diffiwlt to visualize ; it appparcd to haw ]wn rrplawd I)y the tumor (Fig. 12, A ). \Vh~u the surgicdal spwimen IVXS plawd ou :I film ant] rsposwl, (Fig. 12, H ). contrast medium was wwalwl throughout On .Junc 7, 196 I, the pati(,nt was takw 1o tlrcb operating room wlrc~w, untlrr gc~rreral RIIPSthwia, the submaxillary glantl ant1 atljxwnt nodes \VCW rcw~oved through a suhmandibula~ incision. The operation was p~rformc~l by the JIcatl and Swk Service of .lackson 31Lemorial Hospital. A rather large [ 3 ])y 4 in?h) sulm~awillary gland surroundetl by an abundant of nodrs was rcnioved. E’rozeu swtions of tllcs noclw and gland intliwtcd a Iwnign wndition. Histologic 6xaIllillation showvc~tl that thck nodal awhitwture \~as prtwwwl. Thrw I\ cw numerous follicles, exhibiting diflcrwt shapw and Azw. Prominent germinal c,cwters wcrc found. The stromal awhitwture was unrc,l,larkabl(,. ‘1‘111~rapsul~ wwc thick. Swtions of the‘ salivary gland rewalrtl a neoplasm formcY1 l)y solid sheets of isolated strands and coords of rtpithelial cells, togrth~~r with amorpIIour mwinous material. Th(b stroma consisted of foci of mutinous material intt~rspc~rwd with strllatck wlls. The ~xpsulo was thic*k and was COW posed chiefly of collagrnous fibers sprinkled \vitll lymphoc$es. The diagnosis was (1 ) hppcrplasia of lymph nodw of t,hch prwaswlar area, submaxillary and subnwnt~al, and rxtwnal jugular wgions ant] (2) a histologic~ally benign mixed tumor of tllcx submaxillary glan~l. CASE
7
A4 64.year-old N(agro niwl \vas rcfnretl to the Oral Hurgwy Yrpartment f ram snothcar hospital hwauw of a right facial swelling which he had first not,iced 8 years before. The mass had been gradually incrrasing in size until 2 months previously, when the patiwt noticed a rapid increase in size with the onset of pain. Physical examination revealed a blood pressure of 200/130; a pulse rate of X0; and a trntlcr mass JWP respiration rate of 16. There was a 4 b.v 1 cm. hard, immovable, slightly truding from just und(,r the angle of the right mandihlr. 13.X ; hematocrit, 43 ; white: blood Laboratory data included tho following: hrmoglohin, count, 9,200, with 70 segmented neutrophils, 6 stabs, 19 lgmphoaytrs, 1 nionwyte, and 1 phosphataw, 5.3 ; VI)R.T,, non3.7 ; alkaline eosinophils ; strum calcium, 10.1; phospllorus, rrac t ive. A sialogram showctl irregular dcfwts in the substanw of the glautl. ‘I’hc~ normal duct alignment was distorted as a result of displacement by turtlor invasion. The preoperative diagnosis was tumor of the parotid gland. On May 25, 1962, the patient ~vas taken to the operating room !vhero, under general anw thesia, a right radical neck dissection and a total parotidertomy were performed. Scations of parotid tissue showed a neoplasm arising within thr substance of the gland This neoplasm consisted largely of sheets of and infiltrating the surrounding parenchyma. markedly pleomorphic nuclei cells with scanty amounts of cytoplasm and hyperchromatic, Tvith many giant forms. Both typical and atypical mitoses were frequent. Tn some areas the
\‘olurnc 21 Nurnbc~r 5
Fig.
13
Fig 1.2. Case 6. A, Sialogram demonstrates destruction of glandular ductal q-s tern by tur nor. B, Roentgenogram of specimen removed at operation reveals contrast mrtlium 1qsent. Ihi agno&:is: Mixed tumor, histologically benign. duct. H, Sialogram shows exact location of (aalculus Pig . 13. 3, C’alculus in parotid of c,ontrast in awe! ssory gland duct. C, Large calculus found with scout film. D, Injection me,dium reveals calculus in submaxillary gland.
572
cook mad Pollack
neoplsstic cells had more abundant, eosinoph ilic I’$ oplasu~ an,1 ~\-crc :~l’r:lIl~I~‘l l,, 1i:LIN’vIlI:Ll” and as abortive glandlike structures. Sections of lymph nodes showed small nests of tumor, identical lo that. I'cnmcl in Ilria parotid gland, in one out of five preauricular, one out of five subrnandil.rular~. arrd thr’t~ auf of sixteen upper cervical lymph nodes. Many of the lymph nodes contained melanin-latlcn histiocytes, and some showed lymphoid and sinus cell hyperplasia. The final diagnosis was anaplastic carcinoma of the parotid gland, \vith metsstases IO five of forty-eight lymph nodes.
CONCLUSION
Sialography is of value in demonstrating calculi, especialI)- in tho parotid duct where they are less frequent. The case represented in Fig. X3 is of particular interest. After a metal probe was passed into the duct to locate the calculus (Fig. 13, A), an unsuccessful attempt was made to remove the stone. Ethiodol was injected into the parotid duct after a 10 day waiting period, and the calculus was found to be in the duct of an accessory gla.nd (Fig. 13, R) , from which it was removed intraorally. A large calculus was demonstrated on a scout film (Fig. 13, C), and injection of contrast medium into the submaxillary duct revealed its presence in the gland. Sialography, a roentgenographic visualization of the salivary duck and their glands following injection of a radiopaque substance, is a valua.ble diagnostic aid in cases of tumefaction in the parotid-submaxillary area. A sialographic method which can be used by the oral surgeon at the de&al chair has been presented. The method is expedient, requires no special preparation of the patient, and can be carried out with a minimum of assistance. REFERENCES 1. Thoma, 2.
3. 4. 5. 6. 7. 8. 9. 10. 11 II.
12. 13. 14. 15. 16. 17.
K. H.: The Use of Radiopaque Diagnostic Media in Roentgen Diagonsis of Oral Surgical Conditions, Am. J. Orthodontics & Oral Surg. 27: 64, 1941. humaine, Paris, 1904 and 1914, Masson Poirier, P., and Charpy, A.: Traite d’anatomie & Cie! p. 89. Arcelm: Quoted by Berraud, A.: Revue prat. electrol. et radiol. Mod., May 3, 1913. radiologique par l’huile iodee Sicard, J., and Forestier, J.: Methode generale d’exploration (lipiodol), Bull. et mem. Sot. Chir. Paris 46: 463-469, 1922. in dem Ansfuhrungsgang der Speicheldrusen, Acta Carl&en, D. B.: Lipiodolinjektion radiol. 6: 221-223, 1926. Barsony, T. : Idiopathische Stenongang-dilatation, Klin. Wchnschr. 4: 2500-2501, 1925. Uslenghi, J. P.: New Technique for Radiologic Investigation of the Salivary Glands, Semana m6d. 27: 41, 1925,. Jacobovici, J., Poplitzka, W., and Albu, L.: La Sialographia, Presse med. 34: 1188, 1926. Keith. H. M.: Iniection of the Parotid Gland With Iodized Oil. J. A. M. A. 90: 1270. 1271,, ‘1928. ” Sialography in Diseases of the Major Salivary Rubm, P., and Holt, J. F.: Secretory Glands, Am. J. Roentgenol. 77: 575-598, 1957. Technique and Application in RoentBlady, J. V., and Hacker, A. F.: Sialography-Tts gen Study of Neoplasm5 of Parotid Gland, Surg. Gynec. & Obst. 67: 777-787, 1938. Valuable Diagnostic Method, D. Radiog. Ollerenshaw, R., and Rose, 8.: Sialography-A 29: 37, 1956. With Recurrent Subacute 1+:xLonde, S., and Pelz, M. D.: Chronic Sialodocho-parotitis acerbations, J. Pediat. 2: 594-602, 1933. Barsky, A. J.: Diagnosis and Treatment of Diseases of the Salivary Glands, .T. Am. Pent. A. 29: 2026-2046, 1942. Schroff, Joseph: Diseases of the Salivary Glands ; Sialography : Its Application in the Study and Treatment of Salivary Gland Conditions, J. Am. Dent. A. 26: 861-870, 1939. Changes From Sialographic Media, J. Oral Mandel, L., and Baurmash, II.: Pathologic Burg., Anesth. & Hosp. D. Serv. 20: 341-344, 1962. of Sialography in Nonncoplastic DisBlady, J. V., and Hacker, A. F.: The Application eases of the Parotid Gland, Radiology 32: 131-141, 1939.
Volume Numhw
Sinlopvphy
21 5
573
Brit,. J. Surg. 19: 142-148, 18. Payne, R. T. : Sialography : Its Technique ant1 Application, 1931. 19. Schulz, AI. u., and Weisberger, T). : The Sialogram in the Diagnosis of Swelling Alrout the Salivary Glands, Hurg. Clin. North America 27: 1156-1161, 1947. 20. Ollerenshaw, R,. CT., and Rose, S.: Radiological Diagnosis of Salivary Gland Biseasr, Brit. J. Radial. 24: 538-548, 1951. Brit. J. Surg. 27: 713-716, 1940. 21. Hwinhurne, G. : Sialoangiectasis, VVith Particular Reference to 22. Kimm, II. T., Spies, J. W., and Wolfe, J. J.: Sialography Seoplastic Diseases, Am. J. Roentgenol. 34: 289.296! 1935. 23. New, 0. B., and Harper, F. R. : Chronic Inflammatton of the Salivary Glands With or Without Calculi, Hurg. (fyncc. & Obst. 53: 456460, 1931. 24. Reward, G. R.: h Techmquc for Sinlography, ORAL STRG., ORAT, MED. & ORAL PATH. 14: 154-l 63,
1961.
Study of Sialograph and Tts Correlation With Histological 25. Ranger, 1.: An Experimental Appearance in Parotid and Submandibular Glands, Brit. .J. Surg. 44: 415-418, 195i. Koentgenologico-Surgical Corrr26. Einstein, R. J., and Perzik, 8. L.: Parotid Sialography: lation in a Series of 70 Cases, California Med. 88: 98-102, 1958. Pyogenic Parotitis-Its Pathology, Ijiagnosis and Treatment, 27. Payne, R. T.: Recurrent Lancet 1: 358-353, 1933. 28. Gerry, R. G., and Seigman, E. L.: Chronic Sialadenitis and Sialography, ORAL SURG., ORAL Mm. & ORAL PATH. 8: 453-478, 1955. 29. Schulz, 11. I)., and Weisberg, D.: Sialography: Its Value in the Diagnosis of Swellings Alrout the Salivary Glands, ORAL SURG., ORAI, lien. h ORAL PATH. 1: 233-249, 194X.