Ultrasonography and colour doppler sonography of salivary glands in primary Sjögren's syndrome

Reliability Exercise of Ultrasound Salivary Glands in Sjögren's Disease: An International Web Training Initiative

INTRODUCTION

Major salivary gland ultrasonography (SGUS) demonstrated its good metric properties as an outcome measure for diagnosing primary Sjögren's disease (SD). The objective was to assess SGUS reliability among sonographers with different levels of experience, using web training.

METHODS

Sonographers from expert centers participated in the reliability exercise. Before exercises, training was done by videoconferencing. Reliability of the two most experienced sonographers (MES) was assessed and then compared to other sonographers. Intra-reader and inter-reader reliability of SGUS items were assessed by computing Cohen's κ coefficients.

RESULTS

All sets were read twice by all 14 sonographers within a 4-month interval. Intra-reader reliability of MES was almost perfect for homogeneity, substantial for Outcome Measures in Rheumatology (OMERACT) scoring system (OMERACTss). Among LES (less experienced sonographers), reliability was moderate to almost perfect for homogeneity, fair to moderate for OMERACTss, and fair to almost perfect for binary OMERACTss. Inter-reader reliability between MES was almost perfect for homogeneity, substantial for diagnosis, moderate for OMERACTss, and substantial for binary OMERACTss. Compared to MES, reliabilities of LES were moderate to almost perfect for both homogeneity and diagnosis, only fair to moderate for OMERACTss, but increased in binary OMERACTss.

CONCLUSIONS

Videoconferencing training sessions in an international reliability exercise could be an excellent tool to train experienced and less-experienced sonographers. SGUS homogeneity items is useful to distinguish normal from abnormal salivary glands parenchyma independently of diagnosis. Structural damage evaluations by OMERACT scoring system is a new comprehensive score to diagnose patients with SD and could be easily used by sonographers in a binary method.

The Novel OMERACT Ultrasound Scoring System for Salivary Gland Changes in Patients With Sjögren Syndrome Is Associated With MRI and Salivary Flow Rates

OBJECTIVE

To assess the construct validity of the novel Outcome Measures in Rheumatology (OMERACT) ultrasound (US) semiquantitative scoring system for morphological lesions in major salivary glands by comparing it with magnetic resonance imaging (MRI) and unstimulated whole salivary flow rates (U-WSFRs) in patients with primary Sjögren syndrome (pSS).

METHODS

Nine sonographers applied the OMERACT 0-3 grayscale scoring system for parotid (PGs) and submandibular glands (SMGs) in 11 patients with pSS who also had MRIs performed. These were evaluated by 2 radiologists using a semiquantitative 0-3 scoring system for morphological lesions. The agreement between US and MRI and the association between U-WSFRs and imaging structural lesions was determined. A score ≥ 2 for both US and MRI was defined as gland pathology.

RESULTS

The prevalence of US morphological lesions in 11 patients with a score ≥ 2 was 58% for PGs and 76% for SMGs, and 46% and 41% for PGs and SMGs, respectively, for MRI. The agreement between OMERACT US scores and MRI scores was 73-91% (median 82%) in the right PG and 73-91% (median 91%) in the left PG, 55-91% (median 55%) in the right SMG and 55-82% (median 55%) in the left SMG. When relations between the presence of hyposalivation and an US score ≥ 2 were examined, agreement was 91-100% (median 83%) in both PGs and 55-91% (median 67%) in both SMGs.

CONCLUSION

There is moderate to strong agreement between the OMERACT US and MRI scores for major salivary glands in patients with pSS. Similar agreement ratios were observed between the higher OMERACT US scores and presence of hyposalivation.

UHFUS: A Valuable Tool in Evaluating Exocrine Gland Abnormalities in Sjögren's Disease

Sjögren's Disease (SjD) is a chronic autoimmune disorder that affects the salivary and lacrimal glands, leading to xerostomia and xerophthalmia. Ultrasonography of Major Salivary Glands (SGUS) is a well-established tool for the identification of the salivary glands' abnormalities in SjD. Recently, a growing interest has arisen in the assessment of the other exocrine glands with ultrasonography: lacrimal glands (LGUS) and labial salivary glands (LSGUS). The objective of this study is to explore the practical applications of ultra-high frequency ultrasound (UHFUS) in the assessment of lacrimal glands and labial salivary glands. Indeed, UHFUS, with its improved spatial resolution compared to conventional ultrasonography, allows for the evaluation of microscopic structures and has been successfully applied in various medical fields. In lacrimal glands, conventional high-frequency ultrasound (HFUS) can detect characteristic inflammatory changes, atrophic alterations, blood flow patterns, and neoplastic lesions associated with SjD. However, sometimes it is challenging to identify lacrimal glands characteristics, thus making UHFUS a promising tool. Regarding labial salivary glands, limited research is available with conventional HFUS, but UHFUS proves to be a good tool to evaluate glandular inhomogeneity and to guide labial salivary glands biopsy. The comprehensive understanding of organ involvement facilitated by UHFUS may significantly improve the management of SjD patients.

Sonographic Assessment of the Salivary Glands among Sudanese Snuff-dippers

Background

The parotid, submandibular, and sublingual glands, as well as the smaller subsidiary glands, are all the examples of the salivary glands. The likelihood of the salivary glands being impacted by snuff components increases due to this close proximity of the salivary glands to the mouth when snuff is used. The aim of this study was to evaluate the salivary glands of the Sudanese snuff-dippers.

Methods

Sixty-five adult snuff-dippers (research group) and 36 adult nonusers (control group) were enrolled in the study. Sonography of the submandibular and parotid glands was performed; size, blood flow, echogenicity, echotexture, and any other pathological changes were evaluated. The study was conducted in the ultrasound unit at our institution from June 2021 to June 2022.

Results

The result of the study showed that the average size of the left submandibular gland and left and right parotid glands of snuff-dippers was significantly greater than the average size of nonusers. Blood supply and tissue characteristics were normal.

Conclusion

The study concluded that the snuff use could affect the parotid and submandibular glands; ultrasonography is a modality of choice in the examination of the salivary glands of snuff users and other tobacco users.

Performance Evaluation of Multiple Ultrasonographical Methods for the Detection of Primary Sjögren's Syndrome

Major salivary gland ultrasonography (SGUS) is increasingly being recognized as having critical roles in differentiating primary Sjögren’s syndrome (pSS) from other connective tissue disorders. Contrast-enhanced ultrasonography (CEUS) has been reported to evaluate microvascularity of lesions in different tissues with objective angiographic index, eliminating the observer-dependent defect of ultrasonography. However, there are few relevant studies concentrating on the application of CEUS in the diagnosis and assessment for pSS, and their clinical utility prospect remains uncertain. In this study, a total of 227 eligible patients were enrolled, including 161 pSS and 66 non-pSS patients with comprehensive ultrasonographic evaluation of the parotid and submandibular glands, including grayscale ultrasonography, color Doppler sonography (CDS), and CEUS. Compared with non-pSS, pSS patients had significantly higher grayscale ultrasound (US) scores and CDS blood grades in the parotid gland and significantly higher grayscale US and CEUS scores in the submandibular glands. Diagnostic model combining ultrasonographic signatures, anti-SSA/Ro60, and keratoconjunctivitis sicca (KCS) tests showed a remarkable discrimination [mean area under the curve (AUC)0.963 in submandibular glands and 0.934 in parotid glands] for pSS, and the nomogram provided excellent prediction accuracy and good calibration in individualized prediction of pSS. A combination of multiple ultrasonographical examinations of the major salivary glands (SGs) is a promising technique that may be used as a practical alternative to minor SG biopsy in the detection of pSS.

Development of a new ultrasound scoring system to evaluate glandular inflammation in Sjögren's syndrome: an OMERACT reliability exercise

OBJECTIVE

The aim of this exercise from the OMERACT ultrasound subgroup on Sjögren's syndrome (pSS) was to develop and assess the reliability of a consensus-based semiquantitative colour Doppler (CD) ultrasound scoring system for pathologic salivary gland vascularization in patients with pSS.

METHODS

Using the Delphi method a CD semiquantitative scoring system for vascularization of bilateral parotid and submandibular glands was developed and tested in static images and on patients (9 pSS patients and 9 sonographers). Intra-reader and inter-reader reliability of grading the salivary glands were computed by weighted Cohen and Light's kappa (κ) analysis, respectively.

RESULTS

The consensus-based semiquantitative score was: Grade 0, no visible vascular signals; Grade 1, focal, dispersed vascular signals; Grade 2, diffuse vascular signals detected in < 50% of the gland; Grade 3, diffuse vascular signals in > 50% of the gland. In static images, the intra- and inter-reader reliability showed excellent κ values (95% confidence interval) = 0.90 (0.87-0.93) and 0.80 (0.74-0.84), respectively) for all four salivary glands together. In patients, the intra- and inter-reader reliability for all four salivary glands together was κ  = 0.84 (0.73-0.92) and 0.70 (0.64-0.76), respectively.

CONCLUSION

The consensus-based CD ultrasound scoring for the evaluation of salivary gland vascularization in pSS showed a good inter-reader reliability and excellent intra-reader reliability in static images and in patients. The clinical application of the developed scoring system should be tested in clinical settings.

Ultrasound in Inflammatory and Obstructive Salivary Gland Diseases: Own Experiences and a Review of the Literature

Background: Ultrasound is established as a diagnostic tool in salivary glands for obstructive diseases such as sialolithiasis and tumors. Concerning inflammatory diseases and in non-sialolithiasis-caused obstruction, much fewer data are available. In recent years, technical development has allowed a better assessment of the gland parenchyma, and knowledge about intraductal pathologies has increased considerably, which has provided new insights and a new interpretation of ultrasound findings. Objectives: To provide a comprehensive review of the literature that includes our own experiences and to point out the state of the art in ultrasound in the diagnostics of inflammatory and obstructive salivary gland diseases, taking adequate techniques and recent technical developments into consideration. Data sources and study eligibility criteria: A systematic literature search was performed in Pubmed using various specific key words. Results: According to the literature results, including our own experiences, ultrasound is of value in up to >90% of cases presenting with inflammatory and/or obstructive diseases. Technical developments (e.g., elastography) and the application of modified ultrasound techniques (e.g., transoral ultrasound) have contributed to these results. Today, ultrasound is considered a first-line diagnostic tool in these diseases. However, in some inflammatory diseases, the final diagnosis can be made only after inclusion of the anamnesis, clinical symptoms, serologic blood tests, or histopathologic investigation. Conclusions: Ultrasound can be considered as a first-line diagnostic tool in obstructive and inflammatory salivary gland diseases. In obstructive diseases, it may be sufficient for diagnostics in >90% of cases. In inflammatory diseases, ultrasound is at least an excellent screening method and can be used to establish the diagnosis in cases of an early suspicion. In all diseases ultrasound can contribute to better management and can be used for monitoring during follow-up.

Salivary Glands and Periodontal Changes in a Population of Sjögren's and Sicca Syndrome Treated by Pilocarpine: A Pilot Study

Introduction

Oral administration of pilocarpine enhances salivary flow in sicca patients but its effect upstream on ultrasound (US) of salivary glands (SG) and downstream on periodontium remain unknown.

Methods

Sicca patients were prospectively included. Echostructural and vascularization of SG were assessed using B mode and pulsed Doppler (USPD). Vascularization of SG was measured using resistive index (RI) before and after stimulation by lemon juice. Echostructure (measure of glandular length in cm², evaluation of parotid and submandibular glands parenchymal abnormalities) was assessed at baseline (M0) and after 3 months (M3) of treatment with pilocarpine. A dental consultation was performed at M0 and M3 to evaluate changes in unstimulated salivary flow (USSF), stimulated salivary flow (SSF), and periodontal parameters such as modified gingival index (Lobene), plaque index (Silness), bleeding index, pocket depth, and pH.

Results

Nineteen patients were included but only 11 received pilocarpine treatment for 3 months, as six stopped pilocarpine due to side effects and two were excluded for other causes. Among the 11 patients who completed the 3-month follow-up, five had primary Sjögren’s syndrome according to the American-European’s classification criteria. As expected, statistical differences were found concerning SSF (p = 0.018) and USSF (p = 0.027) between M0 and M3 while no statistical change in both SG echostructure and vascularization or periodontal evaluation was shown.

Conclusions

Pilocarpine improved SSF and USSF measurements in sicca syndrome but no ultrasonography of major salivary glands (SGUS) structural and vascular changes were detected as well as periodontal evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-020-00263-y.

Ultra-high frequency ultrasound (UHFUS) applications in Sjogren syndrome: narrative review and current concepts

Primary Sjogren's syndrome (SS) is a systemic autoimmune chronic inflammatory disease with predominant involvement of the exocrine glands, particularly the salivary glands (SGs). The role of salivary glands ultrasound (SGUS) in the work-up of patients with primary Sjogren syndrome (SS) is progressively increasing due to its useful support in diagnosis and follow-up as a widely available, repeatable, non-invasive and safe technique. Although SGUS is not yet included in the dominant primary SS classification, several studies supported its inclusion in the American College of Rheumatology/European League Against Rheumatism criteria. In this context, a novel imaging technique, ultra-high frequency ultrasound (UHFUS), is being explored. Compared to the frequencies used in conventional ultrasound (US) (up to 22 MHz), UHFUS operates with higher frequencies (30-100 MHz) allowing for outstanding image resolution, up to 30 µm. UHFUS permits the scan of both major and minor SGs, opening new avenues for the integration of tissue and imaging biomarkers. Although further studies are needed to confirm its role, this novel imaging technique might lead to several potential improvements, including earlier diagnosis, reduction of unnecessary and inadequate biopsies and better management and follow-up of patients with primary SS.

Diagnostic accuracy of salivary gland ultrasound in Sjögren's syndrome: A systematic review and meta-analysis

BACKGROUND

To systematically review the diagnostic accuracy of salivary gland ultrasound in primary Sjögren's syndrome (pSS).

METHODS

PubMed, Embase, CINAHL, Cochrane Central and Scopus and ClinicalTrials.gov were searched to identify diagnostic or validation studies in patients with pSS meeting the diagnostic criteria. A diagnostic test meta-analysis was performed using a bivariate model to calculate the pooled sensitivity, specificity, positive/negative likelihood ratios, and the diagnostic odds ratio. Meta-regression analyses were done for several pSS covariates.

RESULTS

Sixty-five studies met our criteria for the qualitative review. Fifty-four studies with a total of 6087 patients were included in the meta-analysis. Pooled sensitivity for salivary gland ultrasound was 80% [95% confidence interval (CI): 77-83%; I 2 = 78%], and specificity was 90% (95% CI: 87-92%; I 2 = 76%). The pooled positive and negative likelihood ratios were 8 (95% CI: 6.4-10) and 0.22 (95% CI: 0.19-0.25), respectively. The corresponding pooled diagnostic odds ratio (DOR) was 37 (95% CI: 28-48). Separate meta-regression models resulted in similar diagnostic estimates: (a) adjusted for mean age: sensitivity 81% (95% CI:77-84%; I 2 = 99%) and specificity 90% (95% CI: 87-93%; I2 = 99%); (b) adjusted for mean disease duration, sensitivity 79% (95% CI:72-84%; I 2 = 99%), and specificity 90% (89-94%; I 2 = 99%). The diagnostic estimates were robust to sensitivity analyses by quality criteria, pSS diagnostic criteria and ultrasound scoring systems.

CONCLUSION

Salivary gland ultrasound is a valuable modality for the diagnosis of Sjögren's syndrome. It is plausible that salivary gland ultrasound can be used as an important criterion for the diagnosis of pSS.

Current status of imaging of Sjogren's syndrome

Primary Sjögren's syndrome (pSS) is an autoimmune disease, which involves salivary glands (SG) and extra glandular organs. Today, Sjögren's patients' diagnosis is based on classification criteria taking into account five objective tests, including histology, immunology, two ophthalmological tests, and salivary flow evaluation. To date, the challenge is to find the right imaging tool for diagnosis, follow up, and prognosis of pSS. The objective of this review is to describe as to what are these imaging modalities and particularly the place and validity of salivary glands ultrasonography (SGUS) in the diagnosis and follow-up strategy of patients with suspected pSS. Moreover, new noninvasive tools are emerging, including elastography, a new ultrasonography technique that provides an estimate of tissue elasticity, MRI, MR sialography, and ¹⁸ fluorodeoxyglucose-positron emission tomography. Although new imaging opportunities are available, SGUS should be the first-line choice in pSS because of its accessibility, feasibility over time, and sensitivity to change.

Sonographic Features of Salivary Glands in Sjögren's Syndrome and its Mimics

PURPOSE OF REVIEW

For 30 years, ultrasound has been investigated as a means to evaluate salivary gland abnormalities in patients with autoimmune disease. We aim to review the test characteristics of ultrasound for diagnosing Sjögren's syndrome, the scoring systems used for this purpose, and the ultrasound similarities and differences between Sjögren's syndrome and some of its potential salivary gland mimics.

RECENT FINDINGS

Hypo/anechoic glandular lesions are the major ultrasound characteristic found in Sjögren's syndrome. Most studies have reported such ultrasound abnormalities to have a sensitivity and specificity in the range of 65-85% and 85-95%, respectively, as well as a positive likelihood ratio between 4 and 12. However, similar findings can also be seen in sarcoidosis, amyloidosis, IgG4-related disease, HIV, and lymphoma. A "nodal" pattern of involvement or the ultrasound artifact of "through transmission" can help distinguish some of these mimics from Sjogren's syndrome. Ultrasound can substantially influence the diagnosis of Sjögren's syndrome.

Weight of salivary gland ultrasonography compared to other items of the 2016 ACR/EULAR classification criteria for Primary Sjögren's syndrome

OBJECTIVE

Major salivary gland ultrasonography (SGUS) is widely used for the diagnosis of primary Sjögren's syndrome (pSS). Our objective was to assess the contribution of SGUS compared to other items of the 2016 ACR/EULAR pSS classification criteria, based on expert opinion.

METHODS

A secure web-based relational database was used by 24 experts from 14 countries to assess 512 realistic vignettes developed from data of patients with suspected pSS. Each vignette provided classification criteria items and information on history, clinical symptoms and SGUS findings. Each expert assessed 64 vignettes, and each vignette was assessed by 3 experts. A diagnosis of pSS was defined according to at least 2 of 3 experts. Validation was performed in the independent French DiapSS cohort of patients with suspected pSS.

RESULTS

A criteria-based pSS diagnosis and SGUS findings were independently associated with an expert diagnosis of pSS (P < 0.001). The derived diagnostic weights of individual items in the 2016 ACR/EULAR criteria including SGUS were as follows: anti-SSA, 3; focus score ≥ 1, 3; SGUS score ≥ 2, 1; positive Schirmer's test, 1; dry mouth, 1; and salivary flow rate < 0.1 mL/min, 1. The corrected C statistic area under the curve for the new weighted score was 0.96. Adding SGUS improves the sensitivity from 90.2 % to 95.6% with a quite similar specificity 84.1% versus 82.6%. Results were similar in the DiapSS cohort: adding SGUS improves the sensitivity from 87% to 93%.

CONCLUSION

SGUS had similar weight compared to minor items, and its addition improves the performance of the 2016 ACR/EULAR classification criteria.

Latest Advances in Ultrasound Assessment of Salivary Glands in Sjögren Syndrome

OBJECTIVE

There are different imaging techniques to assess the parotid glands (i.e., sialography, salivary gland scintigraphy) in patients with Sjögren syndrome (SS). However, their use is limited by the invasive character or high cost. Ultrasound (US) is gaining interest by rheumatologists as a complementary diagnostic tool for SS. To date, there is an increasing body of evidence supporting its sensitivity in the assessment of salivary glands in SS. The aim of our study was to analyze the potential role of US as a diagnostic and prognostic tool in SS and to discuss existing evidence to support its application use.

METHODS

A systematic search was performed in the electronic database PubMed, using the following search terms: (salivary glands OR parotid glands OR submandibular glands) AND Sjögren's syndrome AND (ultrasonography OR ultrasound OR sonography). Titles, abstracts, and full reports were systematically screened.

RESULTS

The results of the studies analyzed in this review show encouraging results in terms of accuracy, validity, and diagnostic value, which leads us to believe that in the future US could become the reference imaging tool to assess SS. The studies include a small cohort of patients, and there is no standardized approach in terms of US techniques for the assessment of salivary glands.

CONCLUSIONS

Ultrasound of major salivary glands is a useful tool for diagnosis, prognostic evaluation, and response to treatment in SS. The use of this imaging technology is still under development, and more multicentric studies are needed to validate this tool.

Diagnostic value of major salivary gland ultrasonography in primary Sjögren's syndrome: the role of grey-scale and colour/power Doppler sonography

Primary Sjögren's syndrome (pSS) is an autoimmune connective tissue disease characterized primarily by chronic inflammatory involvement of the exocrine glands, particularly the salivary glands. The use of ultrasound in the study of salivary glands (SGUS) has expanded considerably in recent years. The ultrasound can document structural alterations that can be visualized as hyperechogenic and hypoechogenic areas, or as areas with non-homogeneous echogenicity. To date, several systems of SGUS scoring systems of abnormalities during pSS are available. From the studies published in recent decades, it has been possible to document the high sensitivity and specificity of the pathological findings that can be documented by SGUS. SGUS can also provide added value in identifying patients at risk for developing disease complications such as lymphoma. The Doppler technique can also supply information about glandular tissue vascularization, which is very useful for diagnostic and differential purposes. In this review we will present the state of the art of SGUS, with a prevailing focus on diagnostic use and possible future developments.

Video clip assessment of a salivary gland ultrasound scoring system in Sjögren's syndrome using consensual definitions: an OMERACT ultrasound working group reliability exercise

OBJECTIVE

To develop ultrasound (US) definitions and a US novel scoring system for major salivary gland (SG) lesions in patients with primary Sjögren's syndrome (pSS) and to test their intrareader and inter-reader reliability using US video clips.

METHODS

Twenty-five rheumatologists were subjected to a three-round, web-based Delphi process in order to agree on (1) definitions and scanning procedure of salivary gland ultrasonography (SGUS): parotid, submandibular and sublingual glands (PG, SMG and SLG); (2) definitions for the elementary SGUS lesions in patients with Sjögren's syndrome; (3) scoring system for grading changes. The experts rated the statements on a 1-5 Likert scale. In the second step, SGUS video clips of patients with pSS and non-pSS sicca cases were collected containing various spectrums of disease severity followed by an intrareader and inter-reader reliability exercise. Each video clip was evaluated according to the agreed definitions.

RESULTS

Consensual definitions were developed after three Delphi rounds. Among the three selected SGs, US assessment of PGs and SMGs was agreed on. Agreement was reached to score only greyscale lesions and to focus on anechoic/hypoechoic foci in a semiquantitative matter or, if not possible on a qualitatively (present/absent) evaluation of fatty or fibrous lesions. Intrareader reliability for detecting and scoring these lesions was excellent (Cohen's kappa 0.81) and inter-reader reliability was good (Light's kappa 0.66).

CONCLUSION

New definitions for developing a novel semiquantitative US score in patients with pSS were developed and tested on video clips. Inter-reader and intrareader reliabilities were good and excellent, respectively.

Multiple microlithiasis in bilateral parotid glands as the initial clinical manifestation of primary Sjögren's syndrome

We report a rare case of Sjögren's syndrome (SS) with multiple microliths in the bilateral parotid glands. A 41-year-old man presented to our department with mild pain in the region of the right parotid gland. The dental examination was negative except for the parotid regions. The right region was moderately swollen and the left mildly swollen. Plain radiography revealed multiple calculi in the bilateral parotid glands. Ultrasonography showed heterogenic parenchyma, with microliths and cystic lesions in the parotid glands and heterogenic echotexture in the submandibular glands. Immunologic tests and the Schirmer test confirmed the diagnosis of SS. As the patient had no classic symptoms of SS, the bilateral multiple microliths were the first sign, facilitating the final diagnosis. Early diagnosis of SS is highly relevant because the proper therapy can be initiated. Adequate follow-up and, especially, control of the disease activity by identifying the predictive factors, are the primary objectives of SS management, enabling personalized treatment of this malignant disease. This case is a good example of how detection of calcifications in the bilateral parotid glands by plain radiography can help diagnose SS at an early stage.

Salivary gland ultrasound abnormalities in primary Sjögren's syndrome: consensual US-SG core items definition and reliability

Objectives

Ultrasonography (US) is sensitive for detecting echostructural abnormalities of the major salivary glands (SGs) in primary Sjögren’s syndrome (pSS). Our objectives were to define selected US-SG echostructural abnormalities in pSS, set up a preliminary atlas of these definitions and evaluate the consensual definitions reliability in both static and acquisition US-SG images.

Methods

International experts in SG US in pSS participated in consensus meetings to select and define echostructural abnormalities in pSS. The US reliability of detecting these abnormalities was assessed using a two-step method. First 12 experts used a web-based standardised form to evaluate 60 static US-SG images. Intra observer and interobserver reliabilities were expressed in κ values. Second, five experts, who participated all throughout the study, evaluated US-SG acquisition interobserver reliability in pSS patients.

Results

Parotid glands (PGs) and submandibular glands (SMGs) intra observer US reliability on static images was substantial (κ > 0.60) for the two main reliable items (echogenicity and homogeneity) and for the advised pSS diagnosis. PG inter observer reliability was substantial for homogeneity. SMGs interobserver reliability was moderate for homogeneity (κ = 0.46) and fair for echogenicity (κ = 0.38). On acquisition images, PGs interobserver reliability was substantial (κ = 0.62) for echogenicity and moderate (κ = 0.52) for homogeneity. The advised pSS diagnosis reliability was substantial (κ = 0.66). SMGs interobserver reliability was fair (0.20< κ ≤ 0.40) for echogenicity and homogeneity and either slight or poor for all other US core items.

Conclusion

This work identified two most reliable US-SG items (echogenicity and homogeneity) to be used by US-SG trained experts. US-PG interobserver reliability result for echogenicity is in line with diagnosis of pSS.

Sonoelastographic Modalities in the Evaluation of Salivary Gland Characteristics in Sjögren's Syndrome

The purpose of this study was to investigate salivary tissue assessment with various sonoelastographic modalities (real-time tissue elastography, Virtual Touch imaging and quantification) in patients with Sjögren's syndrome as compared with an appropriate control group. The sonoelastographic modalities were evaluated in 50 patients with primary Sjögren's syndrome (pSS). Patients underwent high-resolution ultrasonography of the submandibular and parotid glands. Results of B-mode, real-time tissue elastography, Virtual Touch imaging-each graded with the appropriate scoring system-and Virtual Touch quantification were compared with those for 50 patients with sicca symptoms who did not fulfill the American-European consensus group criteria. In B-mode, 34 of 50 parotid glands in patients with pSS and 8 of 50 in the control group had abnormal findings (p < 0.001). Compared with 9 of 50 control patients, 38 of 50 patients with pSS had abnormal findings in submandibular gland B-mode (p < 0.001). With real-time tissue elastography, there was a trend toward higher scores for parotid glands in the pSS group (p = 0.238), whereas scores for submandibular glands in the control group were higher (p = 0.107). Virtual Touch imaging did not indicate any difference (p = 0.647 and p = 0.658). In Virtual Touch quantification, values for parotid (mean: 2.99 m/s) and submandibular glands (mean: 2.54 m/s) in the pSS group were higher than those for parotid (mean: 2.16 m/s) and submandibular (mean: 2.04 m/s) glands in the control group (p < 0.001 and p = 0.008). Glandular stiffness, measured by Virtual Touch quantification, was significantly higher in patients with Sjögreńs syndrome than in patients with sicca symptoms.

Multiobserver Reliability of Ultrasound Assessment of Salivary Glands in Patients with Established Primary Sjögren Syndrome

Objective.

To evaluate the multiobserver reliability of salivary gland ultrasonography (SGUS) for scoring greyscale (GS) parenchymal inhomogeneity and parenchymal color Doppler (CD) signal in patients with established primary Sjögren syndrome (pSS).

Methods.

The study comprised 2 multiobserver reliability assessments in patients with pSS in 2 European centers. The first reliability exercise was performed on 24 patients with pSS and 8 controls who were independently evaluated with GS and CD US by 5 observers at the Institute of Rheumatology, Belgrade, Serbia. The second reliability exercise was carried out on 10 patients with pSS who were independently assessed with GS and CD US by 8 observers at the Hospital G.U. Gregorio Marañón, Madrid, Spain. SGUS parenchymal inhomogeneity and parenchymal CD signal were semiquantitatively scored using a 4-grade scoring system. The multiobserver agreement was calculated by the overall agreement and Light’s κ statistics.

Results.

A total of 640 SGUS examinations were performed in the first reliability exercise and a total of 320 examinations in the second reliability exercise. Multiobserver reliability was good (κ = 0.71–0.79) to excellent (κ = 0.81–0.82) for GS parenchymal inhomogeneity in both exercises. There was a moderate (κ = 0.53–0.58) to good (κ = 0.70) multiobserver reliability for parenchymal CD signal in the first exercise. However, there was no agreement or only a fair agreement (κ = 0.03–0.29) for parenchymal CD signal in the second exercise.

Conclusion.

US may be a reliable technique in the multiobserver scoring of GS parenchymal inhomogeneity of major SG in patients with established pSS. CD scoring of SG needs further standardization to be used in multicenter studies.

Standards for the assessment of salivary glands - an update

The paper is an update of 2011 Standards for Ultrasound Assessment of Salivary Glands, which were developed by the Polish Ultrasound Society. We have described current ultrasound technical requirements, assessment and measurement techniques as well as guidelines for ultrasound description. We have also discussed an ultrasound image of normal salivary glands as well as the most important pathologies, such as inflammation, sialosis, collagenosis, injuries and proliferative processes, with particular emphasis on lesions indicating high risk of malignancy. In acute bacterial inflammation, the salivary glands appear as hypoechoic, enlarged or normal-sized, with increased parenchymal flow. The echogenicity is significantly increased in viral infections. Degenerative lesions may be seen in chronic inflammations. Hyperechoic deposits with acoustic shadowing can be visualized in lithiasis. Parenchymal fibrosis is a dominant feature of sialosis. Sjögren syndrome produces different pictures of salivary gland parenchymal lesions at different stages of the disease. Pleomorphic adenomas are usually hypoechoic, well-defined and polycyclic in most cases. Warthin tumor usually presents as a hypoechoic, oval-shaped lesion with anechoic cystic spaces. Malignancies are characterized by blurred outlines, irregular shape, usually heterogeneous echogenicity and pathological neovascularization. The accompanying metastatic lesions are another indicator of malignancy, however, final diagnosis should be based on biopsy findings.

Vascular mapping of the face: B-mode and doppler ultrasonography study

BACKGROUND

To analyze the face vascularization pattern using B-mode and Doppler ultrasonography, and also propose an arterial vessel mapping.

MATERIAL AND METHODS

The investigation was performed on 20 ultrasonography exams of facial vessels through linear and endocavitary transducers. We analyzed and determined the average values for diameters, peak systolic velocity and resistive index of the following arteries: external carotid, lingual, deep lingual, sublingual, facial, submental, inferior labial, superior labial, angular, maxillary inferior alveolar, mental, buccal, greater palatine, infraorbital, superficial temporal, transverse facial and frontal.

RESULTS

Data was obtained allowing the analysis of the tissue hemodynamics. We were able to map the vascularization of the face and it was possible to access three arteries of small diameter (0,60mm angular artery; 0,55mm greater palatine artery; 0,45mm infraorbital artery).

CONCLUSIONS

The results presented in this article are valid tool supporting the non-invasive mapping of facial vascularization.

[Clinical usefulness of salivary gland ultrasonography in Sjögren's syndrome: Where are we now?]

Salivary gland ultrasonography is a simple, noninvasive and inexpensive procedure, which provides valuable information for the diagnosis of primary Sjögren's syndrome (pSS). The main sonographic characteristic of the major salivary glands (parotid and submandibular) in pSS patients is the heterogeneity of the parenchyma, with the appearance of hypoechoic areas. Numerous studies published over the past 20 years report a sensitivity of 70% and a specificity of more than 90% for the diagnosis of pSS. Before the widespread use of this procedure in daily practice and its integration into classification criteria of the disease, it has yet to be validated in terms of reproducibility and a consensus score should be established. This work is being conducted by an international group of experts. Other ultrasound techniques such as elastography could also be of interest to objectively quantify changes in the glandular tissue that occur during the disease.

Ultrasound analysis of mental artery flow in elderly patients: a case-control study

OBJECTIVES

Mental artery flow decreases with age and may have an aetiological role in alveolar ridge atrophy. The aim of this study was to identify factors associated with alterations of mental artery flow, assessed by ultrasonography.

METHODS

This case-control study was conducted on elderly patients (aged above 60 years) at the beginning of dental treatment. Intraoral B-mode Doppler ultrasonography was used to assess mental artery flow. The cases were defined as patients with a weak/absent ultrasound signal, whereas the controls presented a strong ultrasound signal. Demographics and radiographic findings (low bone mineral density on dual-energy X-ray absorptiometry and mandibular cortical index on panoramic radiographs) were analysed as risk factors for weak/absent ultrasound signal and were calculated as adjusted odds ratios (AORs) with 95% confidence intervals (CIs) using conditional logistic regression. In addition, the Student's t-test was used to compare the mean alveolar bone height of the analysed groups. A p-value <0.05 was considered statistically significant.

RESULTS

A total of 30 ultrasound examinations (12 cases and 18 controls) were analysed. A weak/absent mental artery pulse strength was significantly associated with edentulism (AOR = 3.67; 95% CI = 0.86-15.63; p = 0.046). In addition, there was a significant difference in alveolar bone height between edentulous cases and controls (p = 0.036).

CONCLUSIONS

Within the limitations of this study, the present results indicate that edentulism is associated with diminished mental artery flow, which, in turn, affects alveolar bone height.

Salivary gland ultrasonography: a highly specific tool for the early diagnosis of primary Sjögren's syndrome

Introduction

Recently, a great interest has arisen for salivary gland ultrasonography (SGUS) as a valuable tool for the assessment of major salivary gland involvement in primary Sjögren’s syndrome (pSS. The aims of this study were to test the accuracy of SGUS for the early detection of pSSand to compare the diagnostic performance of SGUS with minor salivary gland biopsy (MSGB) and unstimulated salivary flow (USFR) in this context.

Method

Patients with suspected pSS and symptoms duration of ≤5 years were consecutively enrolled in this study. The diagnosis of pSS was made according to the AECG criteria. SGUS was performed by two radiologists blinded to the diagnosis and a previously reported ultrasound scoring system (De Vita et al. 1992, cut-off ≥ 1) was used to grade the echostructure alterations of the salivary glands. Statistical analysis was performed using SPSS v16.

Results

This study included 50 pSS patients and 57 controls with no-SS sicca symptoms. The mean(SD) age of the pSS group was lower than non-SS group (47(13) vs 53(12)yrs, p = 0.006). No further differences between the two groups were observed. Patients with pSS showed a significantly higher SGUS score in comparison with controls (mean(SD) = 2.1(1.8) vs 0.0(0.4), p = 0.000). The SGUS cut-off ≥ 1 showed a sensitivity (SE) of 66 %, a specificity (SP) of 98 %, a positive predictive value (PPV) of 97 % and a negative predictive value (NPV) of 73 % for pSS diagnosis. The SGUS score correlated also with patients’ MSGB/FS and USFR.

Conclusions

This study confirmed the good performance of SGUS for the early non-invasive diagnosis of pSS. Further research in larger international cohort of patients is mandatory in order to assess the role of SGUS in the diagnostic algorithm of pSS.

Metabolic syndrome and prostate abnormalities in male subjects of infertile couples

No previous study has evaluated systematically the relationship between metabolic syndrome (MetS) and prostate-related symptoms and signs in young infertile men. We studied 171 (36.5 ± 8.3-years-old) males of infertile couples. MetS was defined based on the National Cholesterol Education Program Third Adult Treatment Panel. All men underwent hormonal (including total testosterone (TT) and insulin), seminal (including interleukin-8 (IL-8), seminal plasma IL-8 (sIL-8)), scrotal and transrectal ultrasound evaluations. Because we have previously assessed correlations between MetS and scrotal parameters in a larger cohort of infertile men, here, we focused on transrectal features. Prostate-related symptoms were assessed using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and the International Prostate Symptom Score (IPSS). Twenty-two subjects fulfilled MetS criteria. In an age-adjusted logistic ordinal model, insulin levels increased as a function of MetS components (Wald = 29.5, P < 0.0001) and showed an inverse correlation with TT (adjusted r = -0.359, P< 0.0001). No association between MetS and NIH-CPSI or IPSS scores was observed. In an age-, TT-, insulin-adjusted logistic ordinal model, an increase in number of MetS components correlated negatively with normal sperm morphology (Wald = 5.59, P< 0.02) and positively with sIL-8 levels (Wald = 4.32, P < 0.05), which is a marker of prostate inflammation, with prostate total and transitional zone volume assessed using ultrasound (Wald = 17.6 and 12.5, both P < 0.0001), with arterial peak systolic velocity (Wald = 9.57, P = 0.002), with texture nonhomogeneity (hazard ratio (HR) = 1.87 (1.05-3.33), P < 0.05), with calcification size (Wald = 3.11, P< 0.05), but not with parameters of seminal vesicle size or function. In conclusion, in males of infertile couples, MetS is positively associated with prostate enlargement, biochemical (sIL8) and ultrasound-derived signs of prostate inflammation but not with prostate-related symptoms, which suggests that MetS is a trigger for a subclinical, early-onset form of benign prostatic hyperplasia.

Radioprotective agents for the prevention of side effects induced by radioiodine-131 therapy

Radioiodine 131 (131I) has been used worldwide for the ablation of remnant thyroidal tissue after surgery or as the first-line treatment for Graves’ disease. Although the use of 131I is becoming increasingly prevalent, there is evidence suggesting that this treatment is associated with side effects such as salivary gland dysfunction and an increased risk of leukemia. This article aims to review the potential use of radioprotective agents and the side effects induced by 131I therapy. Several synthetic and natural compounds have been investigated in preclinical and clinical studies. The protective agents reduced the toxicity of 131I, mainly in the salivary glands, and mitigated the genetic damage through different mechanisms. There are limited clinical studies evaluating the use of radioprotective agents in patients undergoing radioiodine therapy. However, lemon candies, lemon juice and sugarless chewing gum have been proposed to be beneficial for minimizing the side effects of radioiodine within the salivary glands.

The usefulness of ultrasound in the diagnostics of Sjögren's syndrome

Sjögren's syndrome is an autoimmune exocrinopathy which manifests itself with dryness of the eyes and the oral cavity. These symptoms comprise a so-called sicca syndrome (xerostomia and xerophthalmia). Two forms of this disease may be distinguished: primary Sjögren's syndrome which affects salivary glands and secondary Sjögren's syndrome with other autoimmune diseases present such as rheumatoid arthritis, systemic lupus erythematosus or systemic scleroderma. The diagnosis is based on the classification criteria established in 2002 by a group of American and European scientists (American-European Consensus Group), which involve the interview and physical examination as well as serological, histopathological and radiological tests. Most of these examinations show some limitations such as invasiveness, expensiveness or limited accessibility. The latest research suggests that ultrasound examination may appear promising in the diagnostics of the main salivary glands: submandibular and parotid glands. It is an accessible and relatively cheap examination with high sensitivity and specificity values which are comparable to those obtained via conventional means used in the diagnostics of this disease, i.e. biopsy of the minor salivary glands, sialography and scintigraphy, as well as superior to those obtained in sialometry and Schirmer's test. Additionally, ultrasonography correlates with the results of magnetic resonance imaging. Therefore, a number of authors claim that US examination should be included in the classification criteria of Sjögren's syndrome. The aim of this article is to present the diagnostic capacity of the US examination in Sjögren's syndrome using the current ultrasound classification systems based on the grey-scale, Doppler and contrast-enhanced examinations. The latest research confirms that the most valuable diagnostic criterion in Sjögren's syndrome is the heterogeneity of the glandular parenchyma. The outcome of the examination greatly depends on the examiner's experience.

Ultrasound applications for the practicing rheumatologist

Musculoskeletal ultrasound is an increasingly used tool for the evaluation and management of rheumatologic diseases. Its utilisation by rheumatologists is varied around the world and is dependent upon training and local expertise. Its applications can be broadly categorised into three main areas; for the education of patients, to aid the rheumatologist in the diagnosis and monitoring of disease, and therapeutically for joint aspiration and injection. Ultrasound is a safe, portable, easily repeatable, dynamic images in multiple planes and cheap form of imaging. Ultrasound however, is operator dependent and has a number of artefacts that can result in misinterpretation. Musculoskeletal Ultrasound uses a number of modes to characterise joint pathology, including grey scale, colour and power Doppler, spectral Doppler, 3D imaging, elastography. Musculoskeletal ultrasound can detect and monitor multiple joint pathologies including synovitis, tenosynovitis, and tendon pathologies, entheseal processes, bone erosions and osteophytes, cartilage changes and bursal pathologies.

Contribution of salivary gland ultrasonography to the diagnosis of Sjögren's syndrome: toward new diagnostic criteria?

OBJECTIVE

To determine the accuracy of salivary gland ultrasonography (SGUS) for diagnosing primary Sjögren's syndrome (SS) and to suggest modifications of the American-European Consensus Group (AECG) classification criteria.

METHODS

We conducted a cross-sectional study in a prospective cohort of patients with suspected primary SS that was established between 2006 and 2011. The echostructure of the bilateral parotid and submandibular glands was graded from 0 to 4, and the gland size was measured; blood flow to the parotid gland was assessed using Doppler waveform analysis. The reference standard was a clinical diagnosis of primary SS as determined by a group of experts blinded to the results of SGUS. Receiver operating characteristic (ROC) curve analysis was performed to compare the diagnostic value of the 0-4-point echostructure grade for each of the 4 major salivary glands, the sum of the grades for the 4 glands, and the highest grade among the 4 glands.

RESULTS

Of the 158 patients in the study, 78 had a diagnosis of primary SS according to the experts, including 61 patients (78.2%) who met the AECG criteria. Doppler waveform analysis and gland size measurement showed poor diagnostic performance. The results of ROC curve analysis showed that the highest grade among the 4 glands provided the best diagnostic value. The optimal grade cutoff was 2 (62.8% sensitivity and 95.0% specificity). A weighted score was constructed using scores for the 5 variables selected by logistic regression analysis, as follows: (salivary flow×1.5)+(Schirmer's test×1.5)+(salivary gland biopsy×3)+(SSA/SSB×4.5)+(SGUS×2). According to ROC curve analysis, a score of ≥5 of 12.5 had 85.7% sensitivity and 94.9% specificity, compared with 77.9% sensitivity and 98.7% specificity for the AECG criteria. The addition of SGUS to the AECG criteria increased sensitivity to 87.0% but did not change specificity.

CONCLUSION

Modifications of the AECG criteria, including the addition of a SGUS score, notably improved diagnostic performance.

Ultrasonography of major salivary glands could be an alternative tool to sialoscintigraphy in the American-European classification criteria for primary Sjogren's syndrome

OBJECTIVE

To test the diagnostic accuracy of modified American-European classification criteria (AEC) for primary SS (pSS) by replacing sialoscintigraphy (sSC) with ultrasonography of the major salivary glands.

METHODS

One hundred and ninety subjects were evaluated for the diagnosis of pSS, including US of the salivary glands. We tested the diagnostic accuracy of the three different sets of five diagnostic criteria for pSS. Each set combined these four criteria (ocular symptoms, oral symptoms, Schirmer-I test and auto-SS-A antibody) and one of the following: US (US set), sSC (sSC set) or biopsy (Biopsy set). The area under the receiver operating characteristics curve (AUC-ROC) was used to evaluate the diagnostic accuracy of each set of criteria.

RESULTS

Out of 190 subjects examined, 140 subjects fulfilled the AEC for the diagnosis of pSS, whereas 50 subjects were classified as non-pSS subjects. US score was positive in 129 (92%), sSC in 123 (88%) and biopsy in 93 (66%) of 140 pSS patients. Among 140 patients with pSS, 88 (63%) patients fulfilled the criteria of the US set, 85 (61%) patients of the sSC set and 71 (51%) patients of the Biopsy set. None of the subjects from the non-pSS group fulfilled any of the sets of criteria. Diagnostic accuracy of each of the three sets of criteria was high and similar [AUC-ROC (s.e.) for the US set was 0.99 (0.00), followed by the sSC set at 0.98 (0.00) and the Biopsy set at 0.97 (0.00)].

CONCLUSION

US finding of major salivary gland involvement could replace sSC in AEC for the diagnosis of pSS.

Elevated body mass index correlates with higher seminal plasma interleukin 8 levels and ultrasonographic abnormalities of the prostate in men attending an andrology clinic for infertility

BACKGROUND

Obesity is associated with a systemic, low-grade inflammatory state. Although the relationship between obesity and semen parameters or prostate diseases has been previously investigated, the association between body mass index (BMI), prostate inflammatory diseases and color- Doppler ultrasound (CDU) of the male genital tract (MGT) has been poorly studied.

AIM

To evaluate the association between BMI and CDU features of the MGT, signs and symptoms of prostate inflammation, semen parameters.

MATERIALS/SUBJECTS AND METHODS

We studied 222 men seeking medical care for couple infertility. According to the World Health Organization classification, subjects were divided into 3 groups: normal weight (no.=131, BMI=18.5-24.9 kg/m2), overweight (no.=71, BMI=25.0-29.9 kg/m2), obese (no.=20, BMI≥30.0 kg/m2). All patients underwent simultaneous testosterone evaluation and seminal analysis, including interleukin 8 (sIL-8), along with scrotal and transrectal CDU, before and after ejaculation. Prostatitis symptoms were evaluated by National Institutes of Health- Chronic Prostatitis Symptom Index questionnaire.

RESULTS

After adjusting for age and testosterone levels, higher BMI was significantly related to higher prostate volume and several CDU features of the prostate, including macro-calcifications, inhomogeneity, higher arterial peak systolic velocity (the latter adjusted also for blood pressure), but not with abnormalities of testis, epididymis, seminal vesicles. Furthermore, higher BMI and BMI class were significantly related to higher sIL-8, a reliable surrogate marker of prostate inflammatory diseases, even after adjustment for age. Conversely, no associations among BMI, clinical symptoms of prostatitis or semen parameters were observed.

CONCLUSIONS

Subjects with higher BMI might develop CDU and biochemical signs suggestive of prostate inflammation, although not clinically overt.

A comparison of diagnostic tools for Sjögren syndrome, with emphasis on sialography, histopathology, and ultrasonography

OBJECTIVE

The present study examined the reliability and correlation of sialography, salivary gland biopsy, and ultrasonography for Sjögren syndrome (SS) and evaluated the usefulness of ultrasonography as a diagnostic tool for SS compared with sialography and histopathology.

STUDY DESIGN

Seventy-three patients who underwent sialography, ultrasonography, and salivary gland biopsy were included in this study. The study evaluated the diagnostic reliability and correlation of each kind of examination with SS.

RESULTS

There was a statistically significant difference in the sensitivities of sialography and histopathology, in the specificities of sialography and ultrasonography, and in the accuracies of sialography and both ultrasonography and histopathology. The correlation coefficient (r) between sialography and ultrasonography was significantly higher than the others and indicated a good correlation.

CONCLUSIONS

Ultrasonography can be used as a diagnostic tool for SS, with its advantage of noninvasiveness and ease of use.

Diagnostic Value of Salivary Gland Ultrasonographic Scoring System in Primary Sjögren’s Syndrome: A Comparison with Scintigraphy and Biopsy

Objective.

To compare an ultrasonographic (US) scoring system of salivary glands with scintigraphy and salivary gland biopsy, in order to evaluate its diagnostic value in primary Sjögren’s syndrome (SS).

Methods.

In 135 patients with suspected SS, the grades of 5 US measures of both parotid and submandibular salivary glands were scored (0–48 scale). Diagnosis of primary SS was established following the American-European Consensus Group criteria of 2002. The patients’ total scintigraphic score (0–12 scale) was determined and the histopathological changes of minor salivary glands graded. Area under the receiver-operating characteristic (ROC) curve was employed to evaluate the diagnostic value of the US scoring system.

Results.

Primary SS was diagnosed in 107 (79.2%) patients and the remaining 28 subjects (20.8%) constituted the control group. US changes of salivary glands were established in 98/107 patients with SS and in 14/28 controls. Mean US score was 26 in SS patients and 6 in controls. Through ROC curves, US arose as the best performer (0.95 ± 0.01), followed by scintigraphy (0.86 ± 0.31). Setting the cutoff score for US at 19 resulted in the best ratio of specificity (90.8%) to sensitivity (87.1%), while setting the cutoff scintigraphic score at 6 resulted in specificity of 86.1% and sensitivity of 67.1%. Among 70 patients with US score ≥ 19, a scintigraphic score > 6 was recorded in 54/70 (77.1%) and positive biopsy findings in 62/70 (88.5%) patients.

Conclusion.

We show high diagnostic accuracy of a novel US scoring system of salivary glands (0–48) in patients with primary SS comparable to invasive methods, i.e., scintigraphy and salivary gland biopsy.

Sonographic diagnostic criteria for screening Sjögren’s syndrome

OBJECTIVE

The objective of this study is to establish readily applied sonographic diagnostic criteria for Sjögren's syndrome.

STUDY DESIGN

Sonographic images of 79 cases of previously suspected Sjögren's syndrome (including 43 actual cases) were analyzed retrospectively for the following characteristic features: (1) multiple hypoechoic areas, (2) multiple hyperechoic lines or spots, (3) multiple hypoechoic areas surrounded with hyperechoic lines or spots, and (4) obscuration of the gland configuration. Logistic regression analysis was used to extract valuable sonographic findings. Sonographic images of 80 prospective patients (of whom 48 proved to have Sjögren's syndrome) were scored prospectively using selected features to verify the usefulness of the established criteria.

RESULTS

Three sonographic findings in parotid and submandibular glands were selected by logistic regression analysis and retrospective and prospective patients compared. Experienced observers could differentiate positive cases of Sjögren's syndrome from negative controls to a highly significant degree. Findings correlated very well with sialographic grading.

CONCLUSION

Sonography can be substituted for sialography when applying the selected criteria in screening for Sjögren's syndrome.

Ultrasonographic contrast-enhanced study of sicca syndrome

OBJECTIVE

To assess the ability of US contrast-enhanced time-intensity curves to depict the changes connected with sicca syndrome, a fairly common condition that is often associated with autoimmune disorders such as Sjogren's syndrome or other diseases. Diagnostic criteria are complex and controversial and although no single test can be considered the gold standard, salivary gland scintigraphy and biopsy are reliable diagnostic methods.

MATERIALS AND METHODS

Sixty consecutive patients with sicca syndrome, 40 of whom had primary (n = 23) or secondary (n = 17) Sjogren's syndrome and 20 had non-Sjogren's sicca syndrome, selected according to European Community Study Group diagnostic criteria for Sjogren's syndrome and subjected to contrast-enhanced US imaging of the parotids using a second-generation contrast agent with analysis of time-intensity curves at rest and during salivary stimulation, Tc99m salivary gland scintigraphy and labial gland biopsy.

RESULTS

In the 40 Sjogren's patients, US enhancement values were significantly lower (P < 0.0001 and P < 0.00003, respectively) than in the 20 non-Sjogren's patients both at rest and during stimulation. In the 23 subjects with the primary syndrome, values during stimulation were significantly lower than in the 17 subjects with the secondary syndrome (P < 0.0006), whereas at rest differences were not significant. Contrast-enhanced US imaging allowed to discriminate Sjogren's from non-Sjogren's sicca patients with 87.5% sensitivity, 85% specificity and 86.7% accuracy and the primary from the secondary syndrome with 78.2% sensitivity, 70.5% specificity and 75% accuracy. Interestingly, in eight patients with the primary syndrome, i.e. those with the more severe gland involvement, enhancement values were lower during stimulation than at rest.

CONCLUSION

Preliminary results indicate that contrast-enhanced US imaging can provide useful information on sicca characterisation and severity.

Multiple sialolithiasis in the parotid gland with Sjögren's syndrome and its sonographic findings--report of 3 cases

We present 3 cases of Sjögren's syndrome in which multiple sialolithiasis were observed in the parenchyma of the parotid gland. The sonographic examinations showed microliths that were observed as hyperechoic spots. Some of the microliths were accompanied with comet sign, however most of them showed no particular posterior echoes. None of them showed acoustic shadows, which are normally observed in cases with sialolithiasis. We were able to prove that some of the hyperechoic spots observed sonographically in patients with severe Sjögren's syndrome were microliths. Although these multiple microliths are rarely detected, they may exist potentially in higher frequency in patients with severe Sjögren's syndrome.