Radiographic Examination Of

Salivary Glands.

MaxilloFacial Surgery &Diagnostic

Sciences.

Oral & MaxilloFacial Radiology.

5Th Academic Year.

1-Describe the gross anatomy of major salivary

glands (Parotid, Submandibular, and sublingual

glands).

2-List the main salivary complaints and their

causes.

3-Discuss the most appropriate investigation can

be used on salivary gland.

4- Discuss when and the different techniques to

use a plain radiographs

5- Describe the sialography and the types of

contrast media used in investigating the

salivary gland disorders.

6-Identify the advantages and disadvantages of

using sialography.

7- Discuss the use of Ultrasound in salivary gland

disorders.

8- Discuss the use of Magnetic Resonance Images

(MRI) in generalized (e.g. Sjogren’ Syndrome)

or discrete swelling or lump both intrinsic and

extrinsic to the salivary glands

9- Identify the advantages and disadvantages of

using the MRI in salivary glands investigation.

10- Discuss the advantages and disadvantages of

using the Radioisotope imaging in cases of dry

mouth and to assess salivary gland function and

tumors.

11- Discuss the use of Computed tomography in

localizing of masses occurred in the deep lobe

of the parotid gland.

Introduction.

The Major Salivary Glands

Parotid

Submandibular

Sublingual

The Minor Salivary Glands:

These are many tiny glands

glands located in the lips, inner

cheek area (buccal mucosa) &

floor of the mouth

8

Salivary Gland Disorders.

Classification according to signs and symptoms:

Acute intermittent generalized swelling of an entire gland,

often related to meals Caused by obstructive disorders

including:-

Sialolithiasis - salivary stones or Stricture,

fibrosis and/or stenosis of the duct usually secondary to

surgery,

stones or infection.

9

Salivary gland disorders- cont.

Acute generalized swelling of one or more glands.

Caused by infection either:

viral e.g. mumps,

bacterial ascending sialadenitis.

Chronic generalized swelling, often involving

more than one gland. Caused by:

Sjogren's syndrome, either primary or

secondary,

Sialosis, or

cystic Fibrosis.

10

Salivary gland disorders - cont.

Discrete swelling within or adjacent to a

gland, Caused by:

Intrinsic tumor, benign or malignant.

Extrinsic tumor, cysts, or

Overlying lymph nodes.

11

Dry mouth(Xerostomia) Caused by:

Sjögren's syndrome,

Post-radiation damage,

Mouth breathing,

Dehydration,

Functional disorders including: drugs as

antidepressants,

Neuroses particularly chronic anxiety

states.

Salivary gland disorders - cont.

12

Excess salivation(Ptyalism) Caused by:

psychological (false ptyalism ).

Reflex e.g. due to local stimulation,

heavy metal poisoning .

Salivary gland disorders – cont.

13

Sialadenitis (sialoadenitis):

is inflammation of a salivary gland. It may be subdivided into

acute, chronic and recurrent forms.

Sialosis :

is an uncommon non neoplastic and non inflammatory

disorder causing bilateral non painful enlargement

of the major salivary glands.(1. Diabetes mellitus 2. Hypothyroidism

3. Malnutrition 4. Alcoholic)

Ptyalism:

An excessive flow of saliva.

Sialolithiasis:

refers to the formation of stones in the salivary

glands

Sialodochitis:

Inflammation of the duct of a salivary gland

Plain radiographic examination .

Sialography.

Ultrsonography

Magnetic Resonance Imaging(MRI.)

Computed tomography ( CT ).

Radioisotope imaging including PET.

Flow rate studies.

Diagnostic imaging of the

salivary glands.

18

Diagnostic imaging of the

salivary glands- cont. Plain radiographic examination:

A large proportion of salivary calculi (40 – 80%)

are radio-opaque, so patients presenting with

obstructive symptoms of acute intermittent

swelling require routine radiographs to

determine the presence and position of stones

19

Lower 90° occlusal showing a

large radiopaque calculus

(arrowed) in the right

submandibular duct.

Part of a panoramic

radiograph showing another

calculus (arrowed) in the left

submandibular gland.

Diagnostic imaging of the

salivary glands- cont.

20

Diagnostic imaging of the

salivary glands.cont. A summary of the commonly used radiographic projections for

the parotid and submandibular glands.

Salivary gland Radiographic projection used

Parotid Panoramic radiograph

Oblique Lateral

Rotated PA or AP

Intra-oral View of the Cheek

Submandibular Panoramic radiograph

Oblique Lateral

Lower 90º occlusal (to show the duct)

Lower oblique occlusal (to show the gland)

True lateral skull, with the tongue depressed

Rotated AP (below mandible)

21

Diagnostic imaging of the

salivary glands.cont.

A Diagram showing the

normal anatomy of the

parotid and

submandibular salivary

glands, ducts and duct

orifices.

22

Sialography

Radiographic demonstration of major salivary

glands by introducing a radioopaque Contrast

medium into the ductal system

Mainly for parotid & submandibular glands

While sublingual glands are not examined by by

this method due to diffculty of canulation.

23

Sialography. Cont.

Typs of contrast media:

Aqueous solution

Oil based solution e.g. Lipidol

A- Ionic aqueous solution e.g.Urographin

B- Ionic aqueous solution e.g. Omnipaque

Siaiography. Cont.

AQEOUS OIL BASED

Low viscosity & easily

introduced into canal.

High viscosity , needs pressure

on injection.

Easily removed from the gland. Foreign body reaction.

Easily absorbed & Excreted.

Slow excretion due to high

viscosity.

Decreased contrast due to low

radiopacity.

Rapid excretion from gland.

Increased contrast with high

radiopacity.

Sialography. Cont.

Ideal ? Contrast ؟

Media

Sialography. Cont.

1-Radioaque Good delineation of duct

2-Chemically inert No foreign body reaction

3-Low surface tension, pH physiologic to saliva

4-Proper viscosity Easy injection

5-Rapid absorption Rapid excretion

6-Non Toxic

7-Available

Sialography. Cont.

TECHNIQUE. ???

Sialography.Cont.

Pre-operative phase:

Scout Radiographs:

Rinsing with antiseptic M.W.

Identification of duct orifice

Topical anesthesia of duct orifice

1-To detect any stones

2-To assess exposure parameters

Sialography.Cont.

Filling phase:

Dilatation of duct with lacrimal probe

Duct Canulation

Injection of contrast media

Lat. oblique & AP. radiographs.

•0.5 ml for Submandibular

gland

•0.7ml for Parotid gland

Sialography.Cont.

Emptying phase:

Removal of canula

Rinse with lemon juice to aid evacuation(N=30 m.)

Sialographs are taken (1-5 m. later)

Assessment of salivary glands function

Sialography. Cont.

Parotid submandibular

Clinical

photographs

showing these

duct orifices

(arrowed),

being dilated

and

cannulated.

32

Sialography. cont.

Sialograph showing

a normal left parotid

gland, the tree in

winter

appearance.(The

duct of even

diameter 1-2 mm

with regular

branching & tapering

toward the prephary) 33

Sialography. cont.

Sialograph showing a

normal left

submandibular gland,

the bush in winter

appearance.As the

gland is smaller than

parotid

34

Sialography.Cont.

(A)Sialograph of a left parotid

gland showing a filling defect at

the posterior end of the main

duct (arrowed), caused by a

stone in the duct. Ductal

dilatation is evident beyond the

stone.

(B) Emptying film of the same

gland showing the contrast

medium retained behind the

filling defect (arrowed),

confirming the diagnosis of

salivary calculus in the main

duct.

35

Sialography.Cont.

Sialograph of a left

submandibular gland, showing

a normal main duct, a large

calculus (solid arrow) at the

posterior end of the main duct

and associated segmental

sacculation or dilatation and

stricture of the ducts beyond

the stone. Within the gland

(open arrow) the sausage-link

appearance is caused by

sialodochitis.

36

Sialography. Cont

Sialograph of a left

parotid showing

gross dilatation of

the main duct caused

by sialodochitis

secondary to

stenosis at the

orifice (arrowed).

Sialodochitis

Sausage Link

appearance

37

Sialograph of a right parotid

gland showing the dots or

blobs of contrast medium

within the gland — the

appearance known as

sialectasis (Sac like acini)

caused by sialadenitis. Note

the main duct is normal.

Sialography. Cont.

38

Sialograph of a right parotid

gland of a patient with

Sjobgren's syndrome. The

main duct is normal and there

are widespread dots or blobs

of contrast medium

throughout the gland, the

snowstorm appearance of

punctate sialectasis. due to

escape of CM. as the

epithelium of IC.duct is weak.

Sialography. Cont.

39

Diagrams showing an intercalated ductule and acinus. A In a normal

gland. B In SjOgren's syndrome, the epithelium lining the

intercalated ductule becomes weakened allowing escape of the

contrast medium out of the duct so producing the dots or blobs. C In

sialadenitis, the acinus becomes dilated allowing the collection of

contrast into a dot or blob.

Sialography. Cont.

40

Sialograph of a right parotid showing a

large area of underfilling in the lower lobe

(arrowed) caused by an intrinsic tumour

(biopsy confirmed a pleomorphic

adenoma). A(ii) Rotated AP view showing

the lateral bowing and displacement of the

ducts (arrowed) around the tumour. B

Rotated AP view of a normal parotid gland

for comparison.

A Sialograph of a right parotid gland

showing a large area of underfilling in

the lower lobe (arrowed) caused by an

intrinsic tumour (pleomorphic

adenoma). B Rotated AP view

showing extensive ductal

displacement, the appearance

described as ball in hand (arrowed).

Sialography. Cont.

41

(i) Fluoroscopic sialograph showing an open

Dormia basket in the left submandbular duct.

The stone has been captured and is inside the

basket (white arrows). Contract media is

evident in the dilated main duct within the

gland. (ii) The Meditech (Boston Scientific)

Dormia basket — A closed for insertion beyond

the stone; B open ready to draw back; C open

with the stone inside and D closed around the

stone ready for withdrawal.

Sialography. Cont.

42

Diagnostic imaging of the

salivary glands.(Ultrasound )

Patient undergoing

ultrasound investigation

of the left

submandibular gland.

43

Ultrasound image of a pleomorphic

adenoma in the parotid gland. The

benign tumour shows well defined

margins and is generally hypoechoic

(dark) with through transmission

suggesting low density and a high water

content.

Ultrasound image of a submandibular

gland (the margin of the gland is marked

by the black arrow heads) containing a

small calculus (white arrow) within the

hilum of the main duct. The stone

measured 2.2 mm in diameter and was

radiolucent on plain radiography. The

dilated duct to the right of the stone is also

evident.

Ultrsound. Cont.

44

Ultrasound image showing the changes typically seen within

the parotid gland in Sjogren's syndrome. The multiple small

hypoechoic (dark) areas represent lymphoepithelial

infiltration of the gland parenchyma.

Ultrsound. Cont.

45

Diagnostic imaging of the

salivary glands.(MRI)

Axial MR scan, showing a well-

circumscribed benign mass in the

right parotid gland (arrowed).

Histopathology revealed a

pleomorphic adenoma.

No duct canulation or CM.

Used in acute condition

No ionizing radiation

Evaluate duct structure in

inflammatory & auto-immune

dis.

46

(A) MR sialographic image showing a normal

parotid gland and (B) MR sialographic image of

a patient with Sjogren's syndrome.

MRI. Cont.

47

Two radioisotope scans showing the thyroid (large arrow) and salivary

glands (small arrows). A 2 minutes after the injection of technetium. B 15

minutes after the injection of technetium. In the 2-minute image, note the

large amount of background activity owing to the technetium still in the

bloodstream and in both scans the lack of uptake by the non- functioning

RIGHT parotid (open arrow).

Diagnostic imaging of the

salivary glands.(PET)

48

Summary.

Oral Radiology Principles And Interpretation

Stuart C. White

Michael J. Pharoah

6th Edition