Sialography simplified

Section

of the

Federal dental services Sialographysimplified William M. Park, M. B.,” Salop, England, and Xaul L. Bahn, D.M.D., M.Sc.D.,*# West Haven, Corn. DEPARTMENT

OF RADIOLOGY AND SECTION OF ORAL SURGERY, DEPARTMENT

OF SURGERY, YALE UNIVERSITY HAVEN,

SCHOOL OF MEDICINE,

CONN., AND VETERANS ADMINISTRATION

WEST HAVEN,

YALR-NEW

HOSPITAL,

CONN.

T

he technique of injecting radiopaque media into salivary glands, introduced by Barsonyl in 1925, is now recognized as a valuable adjunct to a careful history and physical examination for the definitive diagnosis o’f a wide variety of salivary gland disorders. The superficial position of these glands makes this radiographic examination particularly suitable for the delineation of anatomic changes. Many different and ingenious methods of sialography have been described.2-s In recent years, sialography has been used not only to evaluate duct architecture but also to assess salivary gland function.g Hydrostatic (gravity-fed) sialography was first devised by Gullmo and B%k-HenderstrGmlO in 1957. The present technique is a modification of that described by Drevattne and Stirisll and by Park and Mason.12 Improved catheter design, elimination of the nylon leader in catheterization, and better control of administration of the contrast medium have led us to believe that hydrostatic sialography is superior to’ hand injection methods. MATERJALS Equipment

AND

METHODS

For the method to be described in this article, the following equipment required : 1. Syringe barrel (20 cc.). 2. Clear polyethylene catheters: sizes P.E. 160, 25 cm. long, and P.E. 205,100 cm. long (Intramedic Clay-Adams, Inc., New York, N. Y.) . *Consultant Radiologist, try, Salop, England.

The Robert

Jones and Agnes Hunt

Orthopsedic

Hospital,

**Clinical Instructor in Oral Surgery, Yale University School of Medicine, Conn. ; Oral Surgeon, Veterans Administration Hospital, West Haven, Conn.

728

is

Oswes-

New Haven,

Sialography simplified

Volume 26 Number 5

3. 4. 5. 6. 7. Preparafion

729

Luer-LOK two-way tap with end adapter for P.E. 205 tubing. Assorted lacrimal probes and dilators. Contrast agent (Hypaque, 50 per cent,). Straight-toothed gauge forceps. Intravenous pole. of catheters

When a polyethylene catheter is heated over an alcohol flame, it softens and can be dra.wn out by application of gentle traction.13 When this is done, an eccentric blister usuaJIy forms, as shown in Fig. 1, A. If traction is maintained and the catheter is removed from the heat, it will harden and retain its new shape. It can then be cut to the desired length through its narrowest portion. The other end of the catheter requires different preparation. As shown in Fig. 1, B, the end of the catheter will flare into a Y shape when brought close to a flame. Several P.E. 160 catheters should be prepared in this way, so that a variety of fine tips are available. Extremely fine-ended catheters are preferable for children, but for adults it is better to have a. catheter with a small blister near the tip. Once the catheter is inserted into the duct opening, the periductal tissues contract around the bulb in an almost sphincter% a.ction that prevents the catheter from becoming dislodged. Careful preparation of the P.E. 205 catheter is advisable. One end should be finely tapered to fit snugly into the flared end of the P.E. 160 tubing. The

A

Fig. 1. Preparation of the catheter. 8, Fine tip; different diameters of tip are obtained by va.rying tension on catheter as it is held over flame; increased tension is required for very fine tips. B, Flared end; catheter should not be held too close to flame; otherwise, it will ignite.

730

O.H., 0.x &.O.P. Novcmbcr, 1068

Park and Bahn

r----- - ____--------I I I I I ; I54 L----2---

t

# B

--_--_------_

II , c

Fig. 8. Assembly of apparatus. 8, Catheter, size P.E. 160. B, Catheter, size P.E. 205. C, End cap adapter fitting for P.E. 205 catheter. D, Luer-Lok two-may tap, E, Syringe barrel.

opposite end of the P.E. 205 catheter is flared, as described, so that it fits into the end adapter of the two-way tap without leaking (Fig. 2). The apparatus is assembled by connecting the two-way Luer-Lok tap (to which the P.E. 205 catheter has been attached) to a syringe barrel. The height at which the syringe barrel may be held is arbitrary. We have found that taping the barrel to an intravenous pole, 70 cm. above the patient’s head, gives an adequate flow rate. The smaller catheter (P.E. 160) is then pushed firmly onto the drawn end of the larger catheter (P.E. 205) until a. leakproof fit is obtained. The syringe barrel is filled with Hypaque and the tap is opened, expelling all the air. When the system is free of bubbles, the tap is switched off and the level of contrast medium in the syringe barrel is noted. Introduction

of the catheter

The patient is placed on a skull table in t,he supine position, under good illumination, and the duct is located with a lacrimal probe. For the parotid gland, it is best to stand behind the patient’s head and gently evert his cheek with the thumb inside the mouth. This stretches the mucosa and dilates the duct opening, making the duct easier to locate. The site of the duct orifice is usually on the apex of a small papilla. Difficulty may be experienced when the duct is eccentrically located or very small, or when the opening is concealed by a small flap of redundant mucosa. It is difficult to cannulate any salivary duct if the opening is insufficiently dilated. Dilators of increasing diameter should be gently introduced until the opening is adequate for acceptance of the catheter. Occasionally, particularly in young persons, the periductal tissues are so elastic that they snap the duct shut before the tubing can be introduced. In these cases, the dilator should be left in the duct and removed by an assistant just before the P.E. 160 catheter is inserted. The catheter should be inserted for a distance of 0.5 to 1 cm., until it is gripped firmly by the periductal soft tissues. For the submandibular gland, it is easier to face the patient, who raises

Volume 26 Number 5

Siahgraphy

simplified

73 1

the tip of his tongue and tries to touch the roof of the mouth as far back as possible, thereby stretching the sublingual structures. The duct will be more easily dilated if it is located with a fine lacrimal probe. Again, adequate dilation of the duct by the gentle introduction of increasingly larger dilators is necessary. The patient closes his lips on the tubing and the catheter loop is taped to the forehead for stability. Radiographic

technique

Standard radiographic projections are used and preliminary films should always be taken to demonstrate intragland calcification or duct calculi. Gland enlargement or local bone destruction may also be assessed. Parotid gland. Anteroposterior and lateral oblique projections are usually adequate. In the former, the patient’s chin should be well tucked in to avoid superimposition of the ear cartilage. For the lateral oblique projection, the neck should be well extended; otherwise, the pharynx and cervical spine will obscure the posterior part of the gland. Submandibular gland. The best projections are the true lateral and submentovertex views. Additional views are occasionally required, and these will be dictated by pa,rticular circumstances. We have found intraoral dental radiographs to be helpful in demonstrating duct calculi near the orifices of both the parotid and submandibula,r ducts.12 We find that film quality is improved by the use of high kilovoltage and short exposure, with an end cone on the x-ray tube such as that used for mastoid radiography. Overexposure should be avoided, and detail of the soft tissues should be visible on conventional viewing without the use of a bright light. Criteria

for gland

filling

Contrast medium is introduced slowly into the gland by intermittently opening the tap on the syringe barrel. The patient should be warned to expect a feeling of distention and discomfort. Because the pain threshold varies considerably in different persons, the subjective sensat,ion is an unreliable indicator of gland filling. Therefore, we use the following criteria : 1. Gland swelling. Unless the gland is grossly distended before the examination starts, the degree of swelling is good evidence of gland filling and will be visible and palpable. 2. Amount of contrast. Gland capacity varies widely, not only in different pathologic conditions but also in adults and children. It is unwise, therefore, to introduce a constant amount of contrast in all cases. For example, in obstruction with duct dilation the gland may hold 2.5 to 3 C.C.In atrophic glands, on the other hand, the duct system may be filled by 0.5 C.C. The normal pa.rotid gland will be filled adequately by about 1.5 C.C.of contrast medium and the submandibular gland by slightly lessl* The amount used in each case, of course, should be the minimum sufficient to produce a diagnosis. 3. Sialo-aciner reflux. This phenomenon appears as a hazy or cloudy opacity over the entire gland.14 It is usually homogenous (Fig. 3), but

o.s., ox. 8r0.~.

Park and Rah?a

732

Sovrmbr~,

1968

E

Pig. 3. Normal sialogram. Sialo-acinar reflux. Diffuse increase in density over gland is usually uniform, but may be patchy if filling is not quitr complrtc, In normal patient, all contrast medium is expelled immediately after removal of catheter. Fig. 4. Mixed parotid tumor. Note absence of sialo-acinar reflux and spreading of ducts At opwatiou a mixed parotid tumor was removed in lower pole of parotid gland (arrows). from this region.

Table

I Dingmsis

Congenital ductal hypertrophy Inflammatory strictures Calculi Intrinsic tumors Extrinsic tumors Mikulicz’s syndrome Sjiigren’s syndrome Atrophic Sialangiectasis Parotid fistula Normal (controls) Normal after disease completely

Yumber

of cases 2 16 12 11 2 5

treated

:;t 1 74 47

occssionally it has a patchy mottled appearance. It occurs when all duct branches have been filled and contrast medium has refluxed into the acini. The presence or absence of this reflux is critical to interpretation of sialograms. When it is persistently absent although adequate amounts of contrast have been introduced, the gland is diseased. Space-occupying lesions are indicated by “bare areas” (Fig. 4).

Volume 26 Number 5

Sialography simplified

Fig. 5. Overfilling of submandibular gland by hand injection of of opaque medium remain and outline acini several days after sialogram.

oi

733

contrast.

Once the gland has been filled and the radiographs taken, the catheter is removed and the patient is given a lemon to suck in order to stimulate emptying of the medium. Radiographs are taken in 5 minutes, concluding the examination. RESULTS A total of 202 sialograms (166 parotid and 36 submandibular) have been made (Table I). The ages of the patients ranged from 9 to 86 years. There was a slight preponderance of females, since many of the patients examined had rheumatoid arthritis. DISCUSSION With the hydrostatic technique described, we have been able to produce consistently satisfactory diagnostic sialograms, with few exceptions (for example, when the patient was unable to lie still or cooperate). Advantages Hydrostatic sialography has the following methods : 1. Controlled introduction of contrast

advantages over hand injection medium.

This eliminates

the

734

Park and Bah?a

Fdg. 6. SjSgren’s syndrome, Note water-soluble contrast sialectasis; this phenomenon is characteristic of disease.

O.S., O.M. & 02. November. 1968

medium

retained

within

punctate

likelihood of damage to gland architect.ure that can result from overfilling (Fig. 5) and is of paramount importance in conditions, such as Sjiigren’s syndrome, where atrophy predominates. It is also advantageous to distend the gland slowly in nervous patients. 2. Leakproof closed system. This is achieved by the elasticity of the periductal soft tissues which contract down around the catheter tip when it is advanced 0.5 to 1 cm. into the duct orifice. The presence of the previously mentioned small blister on the tubing makes dislodgment more difficult. Since interpretation of salivary gland pathosis by sialography ultimately depends on adequate uniform filling of the gland, a leakproof system is essential. 3. Water-soluble contrast medium. Because the medium is water soluble, it is rapidly eliminated by the salivary gland as soon as the catheter tubing is removed. It is abnormal for any contrast medium to remain in the ductal system or gland 5 minutes after secretion is stimulated by a lemon (Fig. 6). This rapid elimination of the medium speeds the examination, since postsecretion films can be taken promptly. 4. Suitable for examining groups of patients. Although in many hospitals and in ofice practice, sialography is not frequently required, it is advantageous to perform sialographic examinations in groups of two

Sidography simplified

Volume 26 Number 5

735

or three, when possible. In this situation we have found that the radiologist, the oral surgeon, and the x-ray technician can more rapidly develop expertise in producing diagnostic sialograms. 5. More tolerable for the patient. Several patients in our study had been examined previously by conventional hand injection sialography. Without exception, they found the hydrostatic method less painful. Disadvantages

The main disadvantage of the hydrostatic technique is the low iodine content of the contrast medium. This may give low-density images of the ducts, particularly in atrophic conditions. Attention to exposure factors, proper placement of the patient’s head, and particularly the use of a small cone on the x-ray tube overcome much of this difficulty. Higher-density contrast can be used, but the increase in cost and viscosity is not justified by significantly improved radiographs. Side effects

Most patients have slight residual gland edema for 24 hours after sialography.15f I6 If the edema is painful, especially at mealtime, mild analgesics can be prescribed 24 hours after the sialogram has been made. One patient developed a parotitis that lasted 36 hours. If glands are not examined during the acute inflammatory stage, side effects will be minimal.

A simple method of hydrostatic practice has been described.

sialography

suitable

for hospital

or office

REFERENCES

1. Barsony, T.: Idiopathische Stenongang-dilatation, Klin. Wchnschr. 4: 2500-2501, 1925. 2. Castigliano, 5. G. : Sialography of the Submaxillary Salivary Gland: A New Technique, Am. J. Roentgenol. 87: 385-386,1962. 3. Garusi, G. F.: The Salivary Glands in Radiological Diagnosis, Basel, 1964, S. Karger, p. 11. The Role of Sialography in the Diagnosis and 4. Isenburd, Leon, and Cranin, Norman: Treatment of Chronic Obstructive Sialadenitis, ORAL SURG.,ORAL MED. & ORAL PATH. 16: 1181-1191, 1963. 5. Liverud, K.: Sialographic Technique With a Polyethylene Catheter, Brit. J. Radiol. 32: 627-628, 1959. 6. Thomas, A. R.: The Technique of Sialography, Brit. J. Radiol. 29: 209-212, 1956. 7. Seward, G. R.: A Technique of Sialography, ORAL SURG., ORAL MED. & ORAL PATH. 14:

154-163, 1961.

8. Nitsche, H., and Val . E. : Methylglucamine Iodipamide: Contrast Material for Sialography, J. Oral Surg., P nesth. & Hosp. D. Serv. 20: 221-222, 1962. 9. Rubin, R., and Holt, J. P.: Secretory Sialography in Disease of the Major Salivary Glands, Am. J. Roentgenol. 77: 575-598, 1957. 10. Gullmo, A., and Book-Henderstriim, G.: A Method of Sialography, Acta radiol. 49: 17-24, 1958. 11. Drevattne, T., and Stiris, G.: Sialography by Means of a Polyethylene Catheter and Water Soluble Contrast Medium (Isopaque 75%), Brit. J. Radiol. 37: 317-321, 1964. 12. Park, W. M., and Mason, D. K.: Hydrostatic Sialography, Radiology 86: 116-122, 1966. 13. Saxton, H. M., and Strickland, B.: Practical Procedures in Diagnostic Radiology, London, 1964, H. K. Lewis & Co. Ltd., p. 204. 14. Samuel, E. : Sialo-acinar Reflux in Sialography, Brit. J. RadioI. 23: 167-161, 1950. 15. Mandel, L., and Baurmash, II.: Pathologic Changes From Sialographic b&&a, J. Oral Surg., Anesth. & Hosp. D. Serv. 20: 341-344, 1962. 16. McCallum, A.: A Suction Catheter for Sialography and Small Sinuses, Brit. J. &diol. 38: 703-706, 1965.