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牙科放射線學 (2)

牙科放射線學 (2). Imaging of Salivary Gland. 唾 液 腺 影 像 攝 影 術. 陳玉昆教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw. 學 習 目 標. 1. 唾液腺攝影的 方法. 2. 唾液腺攝影的 適應症. 3. 唾液腺攝影方法之 優缺點. 4. 判讀 唾液腺攝影 影像. References.

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牙科放射線學 (2)

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  1. 牙科放射線學(2) Imaging of Salivary Gland 唾 液 腺 影 像 攝 影 術 陳玉昆教授: 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw

  2. 學 習 目 標 1.唾液腺攝影的方法 2.唾液腺攝影的適應症 3.唾液腺攝影方法之優缺點 4. 判讀唾液腺攝影影像 References 1. Eric Whaites: Essentials of dental radiography & radiology 3rd ed, Chapter 31, p. 403-14. 2. Kaohsiung Medical University Oral Pathology 3. Nahlieli et al. Endoscopic mechanical retrieval of sialoliths. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:396-402. 4. What you need to know about cancer. Sci Am 1996;289:28-119. 5. http://health.allrefer.compictures-imagessialography.html 6. https://medicine.uiowa.edu/iowaprotocols/sialogram-technique 7. www.pirogov-center.ru/english/news/detail.php?ID=33379 8. Georges Aoun, et al. Evaluation of the oral component of Sjögren's syndrome: An overview. J Int Soc Prevent & Community Dent 2016;6(4):278-84. 9. Oscar Hasson. Modern sialography for screening of salivary gland obstruction. J Oral Maxillofac Surg J Oral Maxillofac Surg 2010;68:276-80. 10. Nagla’a Abdel-Wahed, et al. Assessment of the role of cone beam computed sialography in diagnosing salivary gland lesions. Imag Sci Dent 2013;43:17-23. 11. Evaluation of salivary glands by imaging methods: correlated with SIALO-MR. DOI:10.26044/ecr2019/ C-1585 12. 口腔影像的臨床診斷, 2nd edition, Chapter 12, p.283 13. https://cancernz.org.nz/cancer-information/treatment/chemotherapy/what-is-chemotherapy/ 14. https://www.shutterstock.com/zh-Hant/search/infusion+pump

  3. Embryology Major glands: Parotid Submandibular Sublingual Histology Anatomy 本 課 程 目 標 : Physiology Pathology 1.唾液腺攝影的方法 2.唾液腺攝影的適應症 3.唾液腺攝影方法之優缺點 4. 判讀唾液腺攝影影像 Surgery

  4. Imaging methods Plain radiographic examination Sialography- conventional; CT (CBCT); MRI Computed tomography (CT) (Positron Emission Tomography) Radioisotope imaging including PET Flow rate studies Ultrasound Magnetic resonance imaging (MRI) Sialoendoscopy

  5. Plain radiographic examinations Panoramic radiography Oblique lateral radiography Rotated PA or AP Parotid gland Stensen duct Stensen duct Gland enlargement showing sialectasis Ref. 9

  6. Plain radiographic examinations Submandibular gland Panoramic radiography Oblique lateral radiography Lower 90o occlusal radiography Sialolith Wharton’ s duct Sialolith Refs. 1,9

  7. 片 子 橫 放 突 點 朝 下 Plain radiographic examinations giant sialolith: >15mm in any one dimension Refs. 1, 2

  8. Sialography (1) – Orifice of main salivary gland Stensen duct Wharton’s duct Wharton’s duct Sublingual gland Stensen duct orifice Parotid gland Submandibular gland Mylohyoid muscle Wharton’s duct orifice Refs. 1,2,5,6 Contrast medium is injected into the Stensen duct

  9. Sialography (1) – Parotid gland_procedure The cheek is retracted & inspected to identify the optimal position for cannulation The guide wire is then used to bluntly probe for the lumen of the duct Patient is oriented laying supine Stensen duct orifice guide wire (probe) Cannulate the duct with insertion of 22 or 24 gaugeangiocatheter Injection of the contrast medium through the tube contrast medium within syringe 24 gauge angiocatheter (blue) Ref. 6

  10. Sialography (1) – Submandibular gland procedure https://www.youtube.com/watch?v=kQzkXQNbk3k The patient is oriented laying supine Sialography- Procedure (patient) Cannulation of the left Wharton’s duct after topical lidocaine is placed in the mouth floor employing a 0.015" guidewire (dipped in viscous lidocaine) inserted into the duct orifice with microscopic guidance Dilation with probe guidewire (probe) Wharton’s duct orifice 24 gauge 22 gauge Duct dilation by serially placing initially a 24 gauge (plastic tapered yellow angiocatheter) followed by a 22 gauge (blue) Cannulation of duct with intravenous catheter (22 gauge) Ref. 6,9

  11. Sialography (2) – Three phases To note the position and/or presence of any radiopaque obstruction To assess the position of shadows cast by normal anatomical structures that may overlie the gland, such as hyoid bone To assess the exposure factors Preoperative phase Filling phase Ionic aqueous solutions -Diatizoate (Urografin) - Metrizoate (Triosil) Oil-based solutions - Iodized oil, e.g. Lipidolol(iodized poppy seed oil) - Water-soluble organic iodine compounds, e.g. Pantopaque Emptying phase A. Preoperative phase; B. Emptying phase; C. Filling phase The correct sequence of sialography is (1) A, B, C (2) B, A, C (3)A, C, B (4) B, C, A

  12. Sialography (3) – Contrast medium (oil-based) https://www.youtube.com/watch?v=BYiT5_i3N8w Sialography - parotid gland (animation) Contrast medium Advantages Disadvantages Oil-based Densely radiopaque, thus show good contrast Extravasated contrast may remain in the soft tissues for many months, and may produce a foreign body reaction High viscosity, thus slow excretion from the gland High viscosity means considerable pressure needed to introduce the contrast. Calculi may be forced down the main duct Wharton’s duct orifice Sublingual gland Calculi may Parotid gland be forced down the Submandibular gland main duct Mylohyoid muscle Ref. 1

  13. Sialography (3) – Contrast medium (aqueous) Contrast medium Advantages Disadvantages Low viscosity, thus easily introduced Aqueous Less radiopaque, thus show reduced contrast Easily and rapidly removed from the gland Excretion from the gland is very rapid unless used in a closed system Easily absorbed & excreted if extravasated

  14. Sialography (4) – Main indications Mainindications To determine the presence and/or position of calculi or other blockages, whatever their radiodensity To assess the extent of ductal and glandular destruction secondary to an obstruction To determine the extent or glandular breakdown and as a crude assessment of function in cases of dry mouth

  15. Sialography (5) – Contraindications Contraindications Allergy to compounds containing iodine Periods of acute infection/inflammation, when there is discharge of pus from the duct opening When clinical examination or routine radiographs have shown a calculus close to the duct opening, as injection of contrast medium may push the calculus back down the main duct where it may be inaccessible pus Ref. 2

  16. Sialography (6) – Techniques Sialographic techniques 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, (~ 0.7ml for parotid gland, 0.5ml for 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 https://wellcomelibrary.org/item/b24743938#?c=0&m=0&s=0&cv=0 Sialography-technique (good but old) Ref. 6

  17. Sialography (6) – Techniques Sialographic techniques 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 Reliance on patient’s responses Patients have to lie down during the procedure, so they need to be positioned in advance for the filling-phase radiographs Ref. 14

  18. Sialography (6) – Techniques Sialographic techniques Continuous infusion pressure-monitored technique Using aqueous contrast medium a constant flow rate is adopted & ductal pressure monitored throughout the procedure Advantages The controlled introduction of contrast media at known pressures is not likely to cause discomfort Does not cause overfilling of the gland Does not rely on the patient’s responses Disadvantages Complex equipment is required Time consuming Ref. 13

  19. Sialography (7) – Interpretation Sialographic interpretation A systematic approach A detailed knowledge of the radiographic appearances of normal salivary gland A detailed knowledge of the pathological conditions affecting the salivary glands Systematic approach Assess the duct structure within the gland, noting The branching & gradual tapering of the minor ducts towards the periphery of the gland The overall pattern and shape of the ducts The degree of overall glandular filling The presence and position of any filling defects Assess the degree of emptying Assess the degree of filling of duct structure Assess the main duct, noting The diameter of the duct The course & direction of the duct The presence & position of any filling defects

  20. Sialography (7) – Normal appearance Normal sialographic appearance- Parotid gland The main duct is of even diameter 1-2 mm wide) & should be filled completely & uniformly The duct structure within the gland branches regularly and tapers gradually towards the periphery of the gland, the so-called tree in winter appearance Ref. 1

  21. Sialography (7) – Normal appearance Normal sialographic appearance- Submandibular gland The main duct is of even diameter 3-4 mm wide) and should be filled completely & uniformly This gland is smaller than the parotid, but the overall appearances is similar with the branching duct structure tapering gradually towards the periphery – so-called bush in winterappearance Ref. 1

  22. Sialography (8) – Pathological appearance Pathological appearance - calculi Filling defect in the main duct Ductal dilatationcaused by associated sialodochitis The emptying film shows contrast medium retained behind the stone Ref. 1

  23. Sialography (8) – Pathological appearance Pathological appearance- sialodochitis Segmented sacculation or dilatation and stricture of the main duct, the so-called sausage link appearance Ref. 1

  24. Sialography (8) – Pathological appearance Pathological appearance - sialadenitis Dots or blobs (斑點) of contrast medium within the gland, an appearance known as sialectasis caused by the inflammation of the glandular tissue producing saccular dilation The main duct is normal Ref. 1

  25. Sialography (8) – Pathological appearance Pathological appearance - Sjögren’s syndrome Widespread dots or blobs of contrast medium within the gland, an appearance known as punctate sialectasisor snowstorm Considerable retention of contrast medium during emptying phase The main duct is normal Ref. 1

  26. Sialography (8) – Pathological appearance Normal acinus Sjögren’s syndrome Sialadenitis Ref. 1

  27. Sialography (8) – Pathological appearance Pathological appearance - Sjögren’s syndrome Rubin & Holt classification Stage 0 Normal image (without contrast media collection) Stage 1 Punctuate image (contrast media collection  1mm in diameter) Stage 2 Globular image (contrast media collection between 1 and 2mm in diameter) Stage 3 Cavitary image (contrast media collection  2mm in diameter) Stage 4 Destructive image (complete destruction of gland parenchyma) Normal sialogram of submandibular gland Normal sialogram of parotid gland Ref. 8

  28. Sialography (8) – Pathological appearance Pathological appearance - Sjögren’s syndrome Sialogram of Sjögren's syndrome-affected (a) parotid gland & (b) submandibular gland showing a stage 4 according to Rubin & Holt classification Ref. 8

  29. Pathological appearance - Sjögren’s syndrome Hematoxylin & eosin colored sections of minor salivary gland biopsy specimens showing lymphocytes infiltration Minor salivary glands biopsy through an incision in the lower lip Ref. 8

  30. Sialography (8) – Pathological appearance Pathological appearance - Intrinsic tumor An area of underfilling within the gland, due to ductal compression by the tumor Ductal displacement – the ducts adjacent to the tumor are stretched around it, an appearance known as ball in hand Retention of contrast medium in the displaced ducts during the emptying phase Ref. 1,12

  31. Sialography (9) – CT-sialography Computed tomography (CT-sialography) This technique consists in the introduction of a contrast agent into the duct of the salivary gland and subsequent scanning The images have a high spatial resolution & assess using 3-D reconstructions, the presence of outflow from the ducts of salivary glands Ref. 7

  32. Sialography (9) – CBCT-sialography Cone beam computed tomography-sialography A B C D Panoramic (A), 3D reconstruction (B), sagittal (C), and coronal (D) images of CBCT with large and small stones in submandibular gland (arrows) Ref. 10

  33. Sialography (9) – CBCT-sialography Cone beam computed tomography-sialography A B A. Panoramic sialogram shows stenosis of the right Stensen’s duct. B. CBCT sialography axial cut of the same patient and the relevant 3D reconstruction show stenosis with areas of strictures through the glandular ductules (arrows) Ref. 10

  34. Sialography (10) – MRI-sialography Magnetic resonance imaging (MRI)- sialography B C A Sialo-MRI. 3D-MIP reconstructions in the coronal (A and B) and sagittal (C) planes demonstrate dilatation of the right parotid duct and discreet ectasia of the submandibular ducts (yellow arrows) Ref. 11

  35. Computed tomography Computed tomography (CT) Axial view Indication Discrete swellings both intrinsic and extrinsic to the salivary glands Advantages Provides accurate localization of masses, especially in the deep lobe of the parotid The nature of the lesion can often be determined Disadvantages Provides no indication of salivary gland function Small calculi may not be detected Risks associated with intravenous contrast media Coronal view Ref. 2

  36. Radioisotope imaging Radioisotope imaging Indications Dry mouth due to salivary gland diseases such as Sjögren’s syndrome To assess salivary gland function PET for salivary gland tumors Advantages Provides an indication of salivary gland function Allows bilateral comparison & images all four major salivary glands at the same time Compute analysis of results is possible Can be performed in cases of acute infection Co-localization of PET with CT or MRI scans Disadvantages Provides no indication of salivary gland anatomy or ductal architecture Relatively high radiation dose to the whole body The final images are not disease-specific Refs. 1, 2

  37. Flow-rate studies Schimer’s test L R Flow-rate studies These are used to investigate salivary gland function Comparative flow rates of saliva from the major salivary glands are measured over a time period Indications Dry mouth Poor salivary flow Excess salivation Advantages Ionization radiation is not used Simple to perform Provides information on salivary gland function Disadvantages Provides only limited information- no indication of the nature of underlying diseases Time consuming Ref. 2

  38. Ultrasound https://www.youtube.com/watch?v=Bc4-61hUypU Sialography-a short guide (P’t) Ultrasound (US) Indications Discrete swellings both intrinsic & extrinsic to the salivary glands Salivary calculi Advantages Ionization radiation is not used Provides good imaging of superficial masses Excellent for differentiating between solid & cystic masses Different echo signals are obtained from different tumors Identification of radiolucent stones Lithotripsy of salivary stones now possible Disadvantages The sound waves used are blocked by bone, so limiting the areas available for investigation Provides no information on ductal architecture Ref. 1

  39. Magnetic resonance imaging Magnetic resonance imaging (MRI) Indications Discrete swellings both intrinsic & extrinsic to the salivary glands Advantages Ionization radiation is not used Provides excellent soft tissue detail, readily enables differentiation between normal and abnormal Provides accurate localization of masses The facial nerve is usually identifiable Images in all planes are available Co-localization possible with PET scans Disadvantages Provides no information on salivary gland function Limited information on surrounding hard tissues Ref. 1

  40. Sialoendoscopy Sialoendoscopy – Instruments Endoscopic mechanical retrieval of sialoliths https://www.youtube.com/watch?v=p6B_1h_jJWk Sialoendocopy-a short guide (animation) Exploration unit Surgical unit Ref. 3

  41. Sialoendoscopy Sialoendoscopy - Applications Retrieval of a sialolith using a basket Removal of a sialolith using a grasp https://www.youtube.com/watch?v=f2pLxsumjic Sialoendocopy- procedure (basket) Ref. 3

  42. Sialoendoscopy Sialoendoscopy - Applications https://www.youtube.com/watch?v=3j6fJxgb1fM Sialendoscopic salivary gland stone lithotripsy (ultrasound shock waves)& removal with forceps Grasp Opengrasp Ref. 3

  43. Summaries Knowing and understand 1. 唾液腺攝影的方法 2. 唾液腺攝影的適應症 3. 唾液腺攝影方法之優缺點 4. 如何判讀唾液腺攝影影像 https://prezi.com/qmc8oufve7-s/sialography/

  44. Your constructive comments are appreciated 謝 謝

  45. Sialography (1) Parotid Submandibular Duct orifice Duct orifice Dilation Dilation Cannulation Cannulation Ref. 1

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