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Imaging of salivary gland

Salivary gland Parotid

Radiographic projections used OPG Oblique lateral Rotated PA or AP Intraoral view of the cheek OPG Oblique lateral Lower 90 occlusal (to show the duct) Lower oblique occlusal (to show the gland) True lateral skull with the tongue depressed

Submandibular

Imaging techniques
Plain films Contrast radiography- sialography Ultrasound CT scan Scintigraphy Flow rate studies Magnetic resonance imaging (MRI).

Plain films
Occlusal radiographs- anterior 2/3rd duct OPG- overlapping Lateral oblique- 150 view , post 1/3rd duct Intra buccal Postero anterior view Lateral ceph

Ultrasonography

CT scan

Sialography is a radiographic procedure that is useful diagnostic aid in the detection of masses and pathological processes in the salivary glands by injection of radio-opaque die through major salivary gland ductal system.

 Detection of a calculus / calculi / foreign body Determination of the extent of destruction of gland secondary to obstructing calculi / foreign body Detection of fistulae , diverticuli or strictures Detection / diagnosis of recurrent swelling and inflammatory processes Tumor location / size Selection of a site for biopsy Outline the plane of facial nerve Residual stone / tumor, fistula or stenosis

 Known sensitivity to Iodine compounds Acute inflammation of salivary system

Interfere with thyroid function tests

DEFINITION: Radiopaque substances that have been

developed to alter artificially the density of different parts of the patient

IDEAL REQUISITES: Physiologic properties similar to saliva Miscibility with saliva Absence of systemic / local toxicity Low surface tension and low viscosity Easy elimination

Absorption and detoxification

Iodine-based aqueous solutions:

Ionic monomers: * iothalmate (e.g. Conray) * metrizoate (e.g. Isopaque) diatrizoate (e.g. Urografin) Ionic dimers: ioxaglate (e.g. Hexabrix) Non-ionic monomers: * iopamidol (e.g. Niopam) * iohexol (e.g. Omnipaque) * iopromide (e.g. Ultravist)

-Iodine-based oil solutions such as Lipiodol (iodized poppy seed oil) used for lymphography and sialography
-Water insoluble organic iodine compounds eg Pentopaque

Contrast medium Oil-based

Advantages Densely radiopaque, thus show good contrast High viscosity, thus slow excretion from the gland

Disadvantages Extravasated contrast may remain in the soft tissues for many months, and may produce a foreign body reaction High viscosity means Considerable pressure needed to introduce the contrast, calculi may be forced down the main duct
Less radiopaque, thus show reduced contrast Excretion from the gland is very rapid unless used in a closed system

Aqueous

Low viscosity, thus easily introduced Easily and rapidly removed from the gland Easily absorbed and excreted if extravasated

EQUIPMENTS
Polyethylene tubing with blunt end metallic tip 5 to 10cc syringe Lacrimal dilators Contrast medium Lemon extract /Lemon slices

PROCEDURE 3 Phases 1) Preliminary plain film

evaluation 2) Injection / Filling phase

3) Parenchymal / Evacuation
phase

PROCEDURE

Location of orifice of the duct Duct exploration with Lacrimal probe Insertion of sialographic canula into the duct Injection(slow) of contrast medium into the duct 3 to 4 sets of radiographs are taken during procedure -Preliminary plain films -Filling phase films -Post evacuation phase films Instruction to the patient

3 methods of injecting dye

Simple injection technique

Oil-based or aqueous contrast medium is introduced using gentle hand pressure until the patient experiences tightness or discomfort in the gland, (about 0.7 ml for the parotid gland, 0.5 ml for the submandibular gland).

Advantages

Simple Inexpensive.

Disadvantages

The arbitrary pressure which is applied may cause damage to the gland Reliance on patient's responses may lead to underfilling or overfilling of the gland.

Hydrostatic technique

Aqueous contrast media is allowed to flow freely into the gland under the force of gravity until the patient experiences discomfort.

Advantages

The controlled introduction of contrast medium is less likely to cause damage or give an artefactual picture Simple Inexpensive.

Disadvantages

Reliant on the patient's responses Patients have to lie down during the procedure, so they need to be positioned in advance for the filling-phase radiographs.

Continuous infusion pressure-monitored technique

Using aqueous contrast medium, a constant flow rate is adopted and the ductal pressure monitored throughout the procedure.

Advantages

The controlled introduction of contrast media at known pressures is not likely to cause damage Does not cause overfilling of the gland Does not rely on the patient's responses.

Disadvantages Complex equipment is required Time consuming.

COMPLICATIONS Over Distension

Foreign body Reaction Chronic Inflammatory Process

Parotid gland
The duct structure within the gland branches regularly and tapers gradually towards the periphery of the gland, the so-called tree in winter appearance

Submandibular gland
This gland is smaller than the parotid, but the overall appearance is similar the so-called bush in winter appearance

Ductal changes associated with:

Calculi Sialodochitis (ductal inflammation/infection) Glandular changes associated with: Sialadenitis (glandular inflammation/infection) Sjogren's syndrome Intrinsic tumours.

Calculus: Filling defects in main duct distal to calculus, lobules are overfilled. Ductal dilatation caused by associated Sialodochitis Emptying film shows retained contrast media

Sialodochitis: Segmental strictures & dilation of larger ducts. sausage string appearance Acini & ductules are not dilated

Glandular changes:
Sialadenitis: - Dots or blobs of contrast medium within the gland, an appearance known as sialectasis caused by the inflammation of the glandular tissue producing saccular dilatation of the acini - Main duct & inter lobular ducts appear normal in caliber.

Sjogren`s syndrome: Wide spread dots / blobs of contrast media within the gland. Snow storm appearance, Punctate Sialectasis. Due to the wearing of epithelial lining the intercalated ducts allow escape of contrast media.

Intrinsic tumors: An area of underfilling within the gland, due to ductal compression by the tumour Ductal displacement the ducts adjacent to the tumour are usually stretched around it, known as BALL IN HAND APPEARANCE. Retention of contrast medium in the displaced ducts during the emptying phase.

PARA NASAL SINUS AND IMAGING

Normal appearance
Radiolucent cavity in the maxilla Well-defined, dense, corticated radiopaque margins Internal bony septa and blood vessel canals in the walls all produce their own shadows. Thin lining epithelium is not normally seen.

Investigation Periapical (paralleling or bisected angle technique)

Area of antrum shown

Floor Base of antral cavity Relationship with upper posterior teeth

Dental panoramic

Floor Posterior wall Base of antral cavity Relationship with upper posterior teeth Medial wall Allows comparison of both sides

0 occipitomental (0 OM)

Main antral cavity Lateral wall Roof or upper border Medial wall Allows comparison of both sides

Upper oblique occlusal

Floor Lower half of antral cavity Relationship with upper posterior teeth

True lateral skull

Main antral cavity Posterior wall Anterior wall Note: Superimposition of one antral shadow on the other
Main antral cavity Floor Anterior wall Lateral wall Posterior wall Medial wall Roof or upper border Allows comparison of both sides (coronal only) Main antral cavity Floor All walls Roof or upper border Surrounding structures Allows comparison of both sides Images hard and soft tissue

Linear or spiral tomography in coronal or sagittal plane

Computed tomography (CT) or MRI

Radiological signs for antral disease

Opacity within the antrum total or partial - the shape, site and extent of the opacity often determining the differential diagnosis, e.g. a fluid level Alteration in the integrity of the antral walls, including discontinuity owing to a fracture or destruction by an intrinsic or extrinsic tumour Alteration in the antral outline, including expansion or compression owing to an intrinsic or extrinsic lesion Presence of a foreign body within the antrum.

Common pathologies affecting antra

Infection/inflammation Acute / Chronic sinusitis Trauma Oro-antral communication Fractures Foreign bodies Cysts Intrinsic Extrinsic Tumors Intrinsic Extrinsic Other bone abnormalities Fibrous dysplasia Paget's disease Osteopetrosis.

ACUTE SINUSITIS
Causes
Upper respiratory tract infection, particularly the common cold Trauma, including roots or teeth displaced into the antrum or the formation of an oroantral communication Apical infection associated with the upper posterior teeth

CHRONIC SINUSITIS Causes

Prolonged antral infection Continued presence of a foreign body or oroantral communication.

Radiographic features of acute sinusitis

Total opacity within the antral cavity Opaque zone confined to base of antrum, with initial collection of fluid, before the combination of mucosal thickening and fluid totally opacifies the antrum Features of apical inflammatory changes, if infected teeth are involved resorption and remodelling of the antral floor producing

antral halo

Evidence of a foreign body

Chronic sinusitis

Mucoperiosteal thickening of the maxillary sinus Localized at the base of the sinus. Generalized around the entire wall of the sinus. Complete filling of the sinus except about the ostium on the medial wall. Complete filling of the sinus.

Causes of Oroantral communication

Extraction of closely related upper posterior teeth can remove part of the antral floor or fracture the tuberosity Inappropriate or incorrect use of elevators during root or tooth removal may also cause the root, or rarely the tooth, to be displaced into the antrum.

Radiographic features
Break in the continuity of the floor may be evident Characteristic features of acute or chronic sinusitis owing to the ingress of bacteria Evidence of the displaced root or tooth a second view of the antrum with the head in a different position may be required to ascertain the exact location of the displaced object

MUCOCELES AND MUCOUS RETENTION CYSTS

Pathogenesis is obstruction due to inflammation or allergy.

Main radiographic features

Incidental finding Well-defined, round, dome-shaped opacity within the antrum Usually no evidence of thickening of the remainder of the epithelial lining Usually no alteration of the antral outline Occasionally bilateral

Radiographic features of Odontogenic cysts

Small cyst
Round, dome-shaped opacity in the base of the antrum with a well-defined, radiopaque corticated margin to the edge of the meniscus, i.e. the odontogenic cyst has a bony margin and so can be differentiated from the soft tissue mucosal retention cyst or antral polyp Lateral expansion of the alveolar bone Sometimes displacement of the associated tooth.

Large cyst

Total opacity of the antral region owing to complete compression of the antral cavity Loss of antral outline Sometimes displacement of the associated tooth

Foreign bodies
Causes
Displaced root fragments or teeth Excess root canal filling material forced through the apex of an upper posterior tooth during endodontics Antrolith calcification within the antrum Foreign material pushed into the antrum through an existing oro-antral communication.

Main radiographic features

The presence, position and often the nature of the foreign body Occasionally associated sinusitis.

POLYPS

Thickened mucous membrane of a chronically inflamed sinus frequently forms into irregular folds called polyps.

Malignant neoplasm affecting antra

Air sinus Frontal

Investigation 0 occipitomental (0 OM) PA skull True lateral skull Tomography CT/ MRI 0 occipitomental (with the patient's mouth open) True lateral skull Submento-vertex (SMV) Tomography CT/ MRI 0 occipitomental 30 occipitomental True lateral skull PA skull Tomography CT /MRI

Sphenoidal

Ethmoidal

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