sialography & dacrocystography
DESCRIPTION
radiologyTRANSCRIPT
SIALOGRAPHY
DACROCYSTOGRAPHY
SIALOGRAPHYINTRODUCTION A radiographic examination of the
salivary glands(PAROTID & Submandibular GLAND) and ducts using contrast media
Cannulation of Sublingual gland ducts is almost impossible
INDICATIONS FOR EXAM
Stones (Calculi) sialolithiasis Obstruction / Strictures Pain & Swelling (esp when recurrent) Infection Masses / Tumors Changes secondary to trauma When plain radiography is inconclusive
CONTRAINDICATIONS FOR EXAM
History of contrast media allergies
Severe inflammation of the salivary ducts
ANATOMY OF THE SALIVARY GLANDS
3 pairs---Parotid
SM
SL
Situated adjacent to OC, aid in initial digestion
ANATOMY OF THE SALIVARY GLANDS
PAROTID GLANDLargest salivary gland
Lies just below the ZYG arch in front & below the ear
Parotid duct(Stensons duct) is 5cm long, runs
over the messeter & opens into oral vestibule
opposite 2nd upper molar
SUBMANDIBULAR GLANDS
Extends posteriorly from below
1st lower molar to angle of mandible
Forms part of soft tissues on the medial margin of the mandible & the hyoid bone
Submandibular duct(whartsons duct ) is 5 cm long, runs forward ,medially and upward & opens into mouth on side of frenulum
SUB LINGUAL GLANDSSmallest pair
Located in floor of mouth on the surface of mylohyoid muscle.
Numerous, small sublingual ducts(ducts of Rivinus) open into floor of mouth
Ducts may join to form a single(duct of Bartholin) which empties into the submandibular duct.
SALIVARY GLAND IMAGING PLAIN RADIOGRAPHS
SIALOGRAPHY
CT(Glandular enlargement , tumors)
RADIONUCLIDE IMAGING(to provide additional physiological info in cases of over or under secretion )
MRI
SIALOGRAPHY
Radiologic exam of salivary glands and ducts using contrast media
CT and MRI have largely replaced this exam
PROCEDURE Preliminary radiographs
Detect conditions that do not require contrast
Give pt secretory stimulant 2 to 3 minutes before contrast administration
Pt asked to suck on lemon wedge-Opens duct for easy identification
Duct orifice is sprayed with topical anaesthetic
Duct is cannulated, (dialator may be required), contrast introduced with fluoroscopic guidance
Contrast (oil based or water soluble iodinated)
(conc = 240mg/ml)
Should be injected manually until pt feels discomfort
Quantity needed may vary btw 1-2 ml
Images taken immediately after contrast is complete
After taking req. images ,pt sucks on a lemon wedge again to evacuate contrast
Take post-procedure(delayed) radiographs after 5 minutes to confirm evacuation of contrast/ demonstrate any residual contrast
Dilation with probe of Wharton’s duct of the submandibular gland.
Cannulation of duct with intravenous catheter (22 gauge).
FILMS Parotid----Control Films
- PA - LAT - LAT OBLIQUE
Parotid -----Sialography Film
- PA - LAT - LAT OBLIQUE
FILMS SM----Control Films
- INFEROSUPERIOR/OCCLUSAL 1 - INFEROSUPERIOR/OCCLUSAL 2 - LAT
SM -----Sialography Film
- LAT - LAT OBLIQUE
Normal salivary gland visualized by sialography.
Lateral Submandibular radiographs
Sialogram of the right parotid gland showing multiple punctate glandular collections, 1 mm in diameter, suggestive of punctate sialectasis
SialoectasisSialogram of the parotid gland; lat. projection. In the glandular parenchyma pools of contrast can be seen. The accessory parotid gland is also affected (arrow).
Salivary Gland Swelling with Ductal Narrowing
DACROCYSTOGRAPHYIntroduction
A Radiographic examination of the
Naso lacrimal duct(s) following
administration of a contrast medium to define the Lacrimal gland & NLD system anatomically in search of stenosis or obstruction
Indications
Lacrimal duct obstruction/stricture
Contra-indications
Non-consent by patient to procedure
Contrast media or iodine allergy
Pregnancy (risk is minimal but patient may wish to delay procedure)
Anatomy
Tears (lacrimal fluid) are produced by the lacrimal gland which is located at the supero-lateral aspect of the orbit.
Drainage of the lacrimal fluid is achieved by the lacrimal canaliculi, lacrimal sac, and nasolacrimal duct.
The lacrimal fluid drains from the nasolacrimal duct into the nasal cavity via the inferior meatus
Preparation Patient identification (3 'C's- correct
patient, correct side, correct procedure)
Completed consent form
No diet restrictions
Collect/review relevant previous imaging for ease of access prior to procedure
TECHNIQUE
The patient lies supine on the fluoroscopy table with the head in a reverse occipito-mental position.
Support either side of the patient's head by immobilization device, particularly if a subtraction technique is employed.
Select a small field of view and fine focus
Control images taken
TECHNIQUE(cont)
Anaesthetic eye drops are used for patient comfort
A fine cannula is inserted into the puncta of each eye, then the eye is closed and the catheter taped to the patient's cheek
It may be necessary to dilate the puncta
to facilitate insertion of the cannula
TECHNIQUE(cont)
After the mask is acquired, commence injection
Images are taken immediately after injection
A drainage image can be taken after 15 minutes if considered necessary
Unilateral dacrocystogram demonstrating a normal lacrimal ductSubtraction has been utilizedminimal reflux into superior lacrimal canal
Bilateral dacrocystogram with subtractionNormal lacrimal duct on the leftSlower flow of contrast on the right (this may not be pathological- may reflect note the amount of extravisated contrast medium on the right)Demonstrated right duct appears normalReflux into superior lacrimal canal on rightPerfect X-ray beam collimationadequate subtraction
Bilateral dacrocystogram with subtractionExcellent X-ray beam collimationeffective subtractionReflux into superior lacrimal canal on right
Bilateral dacrocystogram without subtractionDelayed drainage imageAbnormal accumulation of contrast on the left
Unilateral injectionAbnormal pooling of contrast proximally
Unilateral injectionSubtraction techniqueMinimal contrast filling of right lacrimal sacContrast reflux into superior lacrimal canal
Contrast or Subtraction Artifact?It will not always be clear whether you have demonstrated contrast filling or subtraction artifactThe consistency of the arrowed structure and its similarity to the other subtraction artifacts suggests that it is not contrast medium(Experience Required!!!)
Technique Notes
It is normal practice to image both sides (comparison/increased incidence of bil. abns)
It is preferable to inject both sides at the same time
Collimate the X-ray beam to include the orbits superiorly and laterally and the maxillary PNS inferiorly
A sialogram needle (metal or plastic tip) can be used for cannulation of the puncta (16 gauge or similar)
A focused spotlight can be a useful aid for the radiologist in locating the lacrimal punctum
Inferior punctum is often easier to canulate
Catheter should not be inserted too far into the canaliculus
Dacrocystogram protocol may include adjunct nuclear medicine study
Thank you