MR sialographic assessment of the masseter muscle and the ductal kinking in patients with recurrent parotitis

Dysfunction of the masseter muscle may cause pathological kinking of the parotid duct leading to parotitis; MR sialography is a non-invasive radiological examination that allows to evaluate dynamically the ductal system of the parotid glands. In the present study we aimed to assess the relationships between Stensen's duct and masseter muscle and their implications in the aetiopathogenesis of recurrent parotitis secondary to masseter muscle dysfunction. Forty-one patients with recurrent unilateral parotitis and nine with bilateral recurrent parotitis, all with a clinical suspicious of masseter muscle hypertrophy due to bruxism were enrolled. They underwent ultrasonography as a first line examination and then MR sialography and sialendoscopy. Different anatomical features were studied. Involved parotid glands had a wider duct compared to contralateral unaffected parotid glands of patients with recurrent parotitis (p = 0.00134); male subjects with parotitis had a longer duct compared to the salivary glands of healthy patients (p = 0.00943 for affected glands and p = 0.00629 for the contralateral). A concordance between the evidence of an acute duct angle during sialendoscopy and a wider duct in patients with parotitis was observed although not statistically significant. These initial findings suggest that the masticatory muscle dysfunction related to bruxism seems to condition alteration of parotid duct course and anatomy thus favouring the occurrence of recurrent parotitis. A specific diagnostic iter based on clinical evaluation, dynamic ultrasonography and MR sialography, is therefore, mandatory to confirm the relationship between masseter muscle anatomy and parotid duct anomalies; this is the premise for an adequate therapeutic approach to underlying masticatory muscle disorder.

Ultrasound and Sialogram Correlates to Parotid Immunoglobulin G4-Related Disease

Immunoglobulin G4 (IgG4)-related disease is an immune-mediated disorder that commonly manifests in the salivary glands. As a recently described disorder, the description and classification of IgG4-related disease is an ongoing process. Diagnosis of IgG4-related disease requires integration of clinical history, histopathology, and radiographic findings, including ultrasonography and sialography. In this case report, we correlate parotid ultrasonographic and sialographic findings in a patient with proven IgG4-related disorder confirmed from analysis of previous submandibular gland resections. We aim to highlight the utility of multimodality imaging in the diagnosis of IgG4-related disease.

A comparative study of three-dimensional cone-beam CT sialography and MR sialography for the detection of non-tumorous salivary pathologies

BACKGROUND

Imaging of the salivary ductal system is relevant prior to an endoscopic or a surgical procedure. Various imaging modalities can be used for this purpose. The aim of this study was to compare the diagnostic capability of three-dimensional (3D)-cone-beam computed tomography (CBCT) sialography versus magnetic resonance (MR) sialography in non-tumorous salivary pathologies.

METHODS

This prospective, monocenter, pilot study compared both imaging modalities in 46 patients (mean age 50.1 ± 14.9 years) referred for salivary symptoms. The analyses were performed by two independent radiologists and referred to identification of a salivary disease including sialolithiasis, stenosis, or dilatation (primary endpoint). The location and size of an abnormality, the last branch of division of the salivary duct that can be visualized, potential complications, and exposure parameters were also collected (secondary endpoints).

RESULTS

Salivary symptoms involved both the submandibular (60.9%) and parotid (39.1%) glands. Sialolithiasis, dilatations, and stenosis were observed in 24, 25, and 9 patients, respectively, with no statistical differences observed between the two imaging modalities in terms of lesion identification (p1 = 0.66, p2 = 0.63, and p3 = 0.24, respectively). The inter-observer agreement was perfect (> 0.90) for lesion identification. MR sialography outperformed 3D-CBCT sialography for visualization of salivary stones and dilatations, as evidenced by higher positive percent agreement (sensitivity) of 0.90 [95% CI 0.70-0.98] vs. 0.82 [95% CI 0.61-0.93], and 0.84 [95% CI 0.62-0.94] vs. 0.70 [95% CI 0.49-0.84], respectively. For the identification of stenosis, the same low positive percent agreement was obtained with both procedures (0.20 [95% CI 0.01-0.62]). There was a good concordance for the location of a stone (Kappa coefficient of 0.62). Catheterization failure was observed in two patients by 3D-CBCT sialography.

CONCLUSIONS

Both imaging procedures warrant being part of the diagnostic arsenal of non-tumorous salivary pathologies. However, MR sialography may be more effective than 3D-CBCT sialography for the identification of sialolithiasis and ductal dilatations.

TRIAL REGISTRATION

NCT02883140.

Radiographic findings of space-occupying lesions in sialo-CBCT of the major salivary glands

OBJECTIVES

When performing CBCT sialography (sialo-CBCT), space-occupying lesions may be identified incidentally. The objective was to describe their radiologic-clinical-histopathologic correlations.

METHOD AND MATERIALS

The archive of sialo-CBCT scans was retrospectively searched for suspected space-occupying lesions. Based on the scan and clinical-histopathologic data, the cases were divided into "pathologic" vs "normal," "intra-parenchymal" vs "extra-parenchymal," and "benign" vs "malignant." Two precalibrated, blinded radiologists performed a survey of the radiographic features of each scan. Cohen kappa, chi-square, Kruskal-Wallis, and Mann-Whitney tests assessed inter-observer agreement and radiologic-clinical-histopathologic correlations.

RESULTS

In total, 27 (1.5%) suspected space-occupying lesions were found in 1,758 reports. Full follow-up data were available for 15 cases: four were "malignant," six were "benign," and the remaining five were "normal." Kappa showed substantial inter-observer agreement (0.8 to 1.0). Constant swelling correlated with "pathologic" cases (P = .003). Lesion diameter was greater in "pathologic" than "normal" (P < .001) cases, with a cut-off of 12.6 mm. Clinical and radiographic features were similar in "benign" and "malignant" lesions. "Intra-parenchymal" and "extra-parenchymal" space-occupying lesions correlated with "no-fill-region" (P = .01) and "main-duct-displacement" (P = .002), respectively.

CONCLUSIONS

Suspected space-occupying lesions in sialo-CBCT with a diameter greater than 12.6 mm are likely to be "pathologic." No radiographic features were able to differentiate between "malignant" and "benign" space-occupying lesions.

Diagnosing Juvenile Recurrent Parotitis. Case Reports

Diagnosis of juvenile recurrent parotitis is based upon clinical symptomatology, because no positive serologic signs have been identified. Objective confirmation is best obtained from sialographic or ultrasound studies.

Cone beam computed tomography (CBCT) sialography--an adjunct to salivary gland ultrasonography in the evaluation of recurrent salivary gland swelling

OBJECTIVE

Cone beam computed tomography (CBCT) sialography could help improve the visualization of the ductal system of salivary glands. The aim of this retrospective investigation was to monitor the use of CBCT sialography for the diagnosis of pathologies within the intraglandular ductal system when ultrasonography was inconclusive.

STUDY DESIGN

Fourteen consecutive patients suffering from recurrent swelling of a major salivary gland were evaluated. In 12 patients (8 female; 4 male; average age 46 years), a radiopaque contrast agent could be injected into the ductal system, followed by a routine CBCT. Four blinded examiners evaluated the acquired data sets retrospectively.

RESULTS

CBCT revealed seven stenosis, two salivary stones, one complete duct atresia, one intraglandular duct ectasia, and one regular duct system. Three of the detected pathologies were strictly intraglandular.

CONCLUSIONS

CBCT sialography shows promise as a supplementary noninvasive diagnostic tool for the visualization of the intraglandular ductal system of the major human salivary glands. Controlled studies to further validate this method should be undertaken.

Ultrasound and CT imaging features in a patient with salivary duct carcinoma of the parotid gland: a case report with literature review

The aim of this paper was to present the ultrasound (US) and computed tomography (CT) appearance of a patient with salivary duct carcinoma of the parotid gland. US showed a voluminous mass of the parotid gland, with multiple calcifications. Furthermore, it revealed regional multiple lymph nodes with malignant characters. Sonoelastography of the lesion and lymph nodes detected increased rigidity. Contrast enhanced CT scan of the neck completed the data description regarding the mass expansion and invasion of surrounding tissues. US and CT imaging features played a key role in establishing the malignant character of the mass and lymph nodes.

SPECT/CT characterization of oral activity on radioiodine scintigraphy

CONTEXT

Oral activity on radioiodine scintigraphy is commonly seen and may cause diagnostic dilemma. Determining the precise mechanism of oral uptake on radioiodine scintigraphy will increase the accuracy and confidence of interpretation and avoid possible misinterpretation.

OBJECTIVE

To determine the etiology of focal persistent radioiodine oral uptake seen on radioiodine scans.

DESIGN

Retrospective sequential series at a university clinic and a phantom study experiment.

METHODS

Preablation iodine-131 planar and single photon emission computed tomography/computed tomography (SPECT/CT) scans of 216 patients after total thyroidectomy were reviewed. Planar images were inspected for the presence of oral activity above the salivary gland background and SPECT/CT was reviewed to determine the location and nature of oral activity. A post-hoc phantom study was designed using typodont stone models fitted with various dental materials, immersed in a diluted iodine-131 solution, and imaged with SPECT/CT to characterize radioiodine uptake by high-attenuation dental materials.

RESULTS

Oral activity was seen on planar images in 123 of 216 (57%) patients; 12 patients were excluded from analysis because the SPECT/CT field of view did not cover the entire oral cavity. In the remainding 111 patients SPECT/CT images demonstrated focal uptake localizing to high-attenuation dental material on the CT in 95 of 111 (86%) patients. All cases of oral activity on planar imaging were interpreted as benign etiology on SPECT/CT. The phantom study confirmed focal in vitro uptake within high-attenuation dental materials representing a range of commonly used metal alloys.

CONCLUSION

Focal oral activity on diagnostic radioiodine scans frequently localizes to high-attenuation dental material on SPECT/CT. We postulate that an affinity between negatively charged iodide ions (I(-)) in saliva and positively charged metal ions (eg, Ag(+), Hg(+), Au(2+), Pd(2+)) within the dental materials is at the basis of persistent focal radioiodine uptake in the oral cavity. This represents a new mechanism underlying benign radioiodine activity not previously described in the medical literature.

IgG4-related Mikulicz's disease is a multiorgan lymphoproliferative disease distinct from Sjögren's syndrome: a Caucasian patient and literature review

OBJECTIVES

This paper aims to report a case of IgG4-related Mikulicz's disease with a systematic review.

METHODS

The relevant English literature was searched using the keywords 'Mikulicz's disease' and 'IgG4'. Original and review articles were reviewed, and the clinical scenarios were exemplified with a case report.

RESULTS

A 49-year-old Caucasian man presented with axillary lymphadenopathy and bilateral parotid/submandibular enlargement. A chest computerized tomography showed mediastinal lymphadenopathy, with low metabolic activity on the position emission tomography. A histopathological study showed an IgG4/IgG ratio of 75% in the plasma cells of the submandibular glands, associated with high levels of total serum IgG and IgG4. He had dry mouth, but minor salivary gland biopsy was negative without xerophthalmia. He had nasal obstruction and dyspnea, notably with supine position/cervical rotation, which substantially improved with glucocorticoid treatment. He had newly diagnosed diabetes mellitus with hyperlipasaemia and diffuse pancreatic swelling supportive of autoimmune pancreatitis.

CONCLUSIONS

Our case report supports the literature that there are similarities between IgG4-related Mikulicz's disease and Sjögren's syndrome, but the differences are significant. IgG4-related Mikulicz's disease is a multi-organ lymphoproliferative disease distinct from Sjögren's syndrome.

Combined CBCT and sialogram: report of three cases

Cone beam computed tomography (CBCT) has been applied to an array of clinical scenarios. Its application within the oral and maxillofacial region continues to impress those involved with its use. Salivary gland imaging has been accomplished by standard radiographs, computed tomography, and more recently, CBCT. This article reviews the application of sialograms with CBCT and discusses three patients who received this procedure during their evaluations. The importance of the oral and maxillofacial radiologist is highlighted as a fundamental part of the health care team.

Salivary duct carcinomas: clinical and CT and MR imaging features in 20 patients

INTRODUCTION

Salivary duct carcinoma (SDC) is an uncommon high grade adenocarcinoma of the salivary gland with a grave prognosis. The aim of this study was to investigate the clinical and CT and MR imaging features of SDC.

METHODS

We retrospectively evaluated the clinical and CT and MR imaging findings in 20 patients (14 men and six women; mean age, 59 years) with histologically proved SDC. We also tried to correlate clinicoradiological tumor staging with pathologic tumor staging in 17 patients who underwent surgery.

RESULTS

The tumor originated in the parotid gland (n = 11; 55%), the submandibular gland (n = 7; 35%) and the buccal space along the distal Stensen's duct (n = 2; 10%). Locoregional recurrence occurred in 41% and distant metastasis in 47%. Fifty-eight percent died of the disease with a mean survival period of 32 months after diagnosis. On CT and MR images, SDC was mostly seen as an ill-defined (85%) and infiltrative (60%) mass with frequent calcification (50%) and necrosis (80%). Although various signal intensities were seen on MR images, six of nine tumors contained the areas of marked hypointensity on T2-weighted images. Clinicoradiological tumor staging correlated well with pathologic tumor staging in 82% of the patients.

CONCLUSION

Ill-defined, infiltrative mass with calcification on CT scans and the areas of marked hypointensity on T2-weighted MR images may be useful radiologic features to suggest the diagnosis of SDC. CT and MR imaging are useful for staging of SDC.

[Cone beam 3D sialography: preliminary study]

INTRODUCTION

Stones, stenosis and inflammatory lesions are the main causes of mealtime syndrome. The aim of paraclinical exam is to find the cause of these obstructive symptoms. Ultrasound is often sufficient to confirm the lithiasic origin of salivary gland swelling. Non-lithiasic salivary obstructions are more difficult to diagnose. We studied the feasibility and quality of a new medical imaging device: three-dimensional (3D) sialography using the technique of cone beam with flat panel (CPCT).

PATIENTS AND METHODS

Five patients were included, referred for diagnostic management of non-lithiasic salivary gland parotid colic. It was performed for each patient in the angiography room, conventional sialography and 3D CPCT. Images were compared to conventional sialography.

RESULTS

None of catheterization failure or side effects were observed in five patients. 3D CPCT sialography enabled to view gland ducts until their fifth or sixth division. Compared to conventional sialography, 3D CPCT improves signal and contrast to noise ratio.

DISCUSSION

This technique allows an anatomic resolution and signal/noise ratio unmatched. It also allows to reduce metallics artefacts. Its main drawback is those associated with ductal catheterization, exposure to ionizing radiation and potential allergy to iodinated contrast agents.

Pediatric sialolithiasis distinctive characteristic in radiological imaging

AIM

Aim of the present paper was to investigate the imaging and related clinical characteristics of sialolithiasis in Italian pediatric population trying to determine the difference between pediatric and adult.

METHODS

Twenty-nine pediatric patients (age range 1-17 years) with pain and postprandial swelling and/or purulent discharge in the salivary gland areas were referred to radiology department after pediatric ear, nose and throat (ENT) evaluation. They all were submitted to ultrasound examination of the main salivary glands. Multidetector computed tomography (MDCT) only was performed in 2/6 patients, in 2/6 patients both sialography and MDCT were performed due to inconclusive MDCT features, 2/6 only sialography was performed. Sialoliths were classified on their location and size.

RESULTS

In 6 out of 29 patients (4 males, 2 females, age range 1-17 years) salivary stones were detected. Sialoliths were detected in 5/6 patients in the submandibular gland and 1/6 in the parotid gland. All sialoliths, excepted for a case of multiple sialoliths, were located in the distal part of the main salivary ducts.

CONCLUSION

Imaging characteristics of sialolith in pediatric group are similar than in adult population in few aspects. In fact sialoliths are smaller in size and located more frequently in the distal part of the main salivary duct, than in adult, making sialography cannulation more complex and requiring short thickness in MDCT.

[New digital method of small salivary glands sialometry]

The authors suggested new digital method of small salivary glands (SSG) sialometry. The proposed method foresee SSG functional activity determination by SSG smears making upon transparent celluloid film painted on one side by water soluble dye and further transfer (scanning) of the print into digital picture with the possibility of its further processing and storage upon digital carrier.

Primary Sjögren's syndrome or multiple sclerosis? Our experience concerning the dilemma of clinically isolated syndrome

The authors present the case of a 50 years old woman who during 3 years had a transient right limbs palsy, and numerous episodes of unilateral/bilateral optic neuropathy. The CSF and MRI examinations did not sustain the diagnosis of multiple sclerosis (MS). After 2 years from the onset, she presented bilateral trigeminal neuropathy, and after 9 months the anti-SS-A and anti SS-B antibodies were positive. The sialography and the minor salivary ducts biopsy (in the absence of xerostomia and xerophthalmia) have established the diagnosis of primary Sjögren's syndrome (pSS). Subsequently, the patient presented spastic paraparesis, the clinical and imagistical features have suggested the diagnosis of acute transverse myelitis C4-T4. The treatment administered (corticosteroids and IGIV) improved the clinical state. The authors analyse then cases with SLE and cases with pSS, whose initial diagnosis was MS possibly with no evidence of collagen tissue disorders (CD) for many years. In conclusion, screening for biomarkers of SLE or pSS should be systematically performed in a case of acute or chronic myelopathy. Some laboratory tests as CSF examination, the antibodies type, cranial and spinal MRI, are useful for the differential diagnosis with MS. In a neurological clinically isolated syndrome (CIS) the diagnosis of MS should be precautiously established; the close follow-up of patients is always necessary, those with atypical neurological symptoms for MS, relapsing-remitting form, or lack of response to the common treatment for MS, should be examined for CD.

[Application of 3D FIESTA sequence in magnetic resonance sialography for obstructive salivary diseases]

OBJECTIVE

To investigate the value of 3D FIESTA sequence in magnetic resonance sialography (MRS) in the diagnosis of obstructive salivary diseases.

METHODS

Eleven patients with obstructive salivary diseases underwent MRS, and three-dimensional (3D) reconstruction and virtual endoscopic images of the salivary gland ducts were obtained after MRS data post-processing for comparison with those of sialoendoscopy.

RESULTS

The diagnostic accuracy of MRS was 72.7% for obstructive salivary diseases. The virtual endoscopy provided a visual field highly consistent with that by sialoendoscopy.

CONCLUSION

MRS is capable of visualizing the tracts of salivary glands. MR virtual endoscopy can provide sufficient morphological and pathological data for preoperative assessment of salivary operations with sialoendoscopy.

A quantitative analysis of sonographic images of the salivary gland: a comparison between sonographic and sialographic findings

We performed three quantitative analyses (particle analysis, fractional Brownian motion [fBM] model analysis, two-dimensional [2-D] fractal analysis) of the ultrasonographic (US) images of the salivary gland and evaluated whether the obtained indices correlated with the sialographic stage of Rubin-Holt. Our study included 192 patients suspected of having Sjögren's syndrome (SS). In 89 patients, sialography demonstrated abnormal findings. Based on a particle analysis, we calculated both the average size of the particles (avg-area) and the area ratio to evaluate the presence of hypoechoic areas and echogenic lines, which are characteristic of SS. According to the fBM model, we calculated the Hurst index of the original image (Hurst-ori) and the background-subtracted image (Hurst-bs) to evaluate the complexity of the pixel value distribution. We also obtained the 2-D fractal dimension (2-D-FD) to evaluate the complexity of the contour lines. We entered these indices of the parotid glands (PG) into a logistic regression analysis and evaluated which indices were useful predictors for detecting an abnormal sialographic stage. Significant differences were observed between the normal and abnormal groups in all five indices of the PG (Mann-Whitney U test) and all five indices were correlated with the Rubin-Holt stage (Spearman's Rank Correlation Test). As the Rubin-Holt stage became more severe, both the Hurst-ori and 2-D-FD became smaller. Alternatively, the Hurst-bs, avg-area, and area ratio became higher. Three indices (avg-area, area ratio and Hurst-ori) were selected as useful predictors for detecting abnormal sialographic stages. This quantitative analysis system is therefore considered to have potentially useful clinical applications for the detection of abnormal sialographic findings.

Magnetic resonance identification of an accessory submandibular duct and gland: an unusual variant

We report a case of an accessory submandibular gland and duct which is extremely rare.

MATERIAL AND METHODS

A 20-year-old male presented with complaints of painful swelling in the right submandibular region. As a part of the radiological investigation, a radiograph occlusal view was taken digital sialography, magnetic resonance imaging and magnetic resonance sialography were performed.

RESULTS

Digital sialography revealed a small calculus distal to the punctum with diffuse dilatation of the main duct and intraglandular branches, which passed out spontaneously prior to magnetic resonance examination. The presence of an accessory submandibular duct was well delineated on both digital as well as magnetic resonance sialography.

CONCLUSIONS

Magnetic resonance sialography is helpful in delineating the anatomy of the submandibular duct non-invasively and without associated radiation exposure. To the best of our knowledge this is the first report of magnetic resonance identifying an accessory submandibular duct and gland.

Imaging of salivary gland tumours

Imaging of salivary gland tumours is a major challenge for radiologists due to the great variety of differential diagnoses. This article gives a short overview on the anatomy of the salivary glands, the epidemiology of salivary gland tumours as well as the clinical presentation and the different imaging modalities including new magnetic resonance techniques such as diffusion-weighted magnetic resonance imaging, dynamic contrast-enhanced magnetic resonance imaging and magnetic resonance spectroscopy applied in the work-up of salivary gland masses. The imaging features of different tumour types and their differential diagnoses are also discussed. Finally, staging classification and treatment options are presented.

[Diagnostic value of radiographic and ultrasonic examinations in patients with sialoadenitis and sialolithiasis]

PURPOSE

The aim of this study was to evaluate diagnostic role of the native x-ray and ultrasonography (US) in sialoadenitis and sialolithiasis.

MATERIALS AND METHODS

During a period of 30 months 52 patients were selected in a study group with lithiasis and adenitis of the major salivary glands. Panoramic and either occlusal plain radiographs (sublingual and submandibular cases) or anteroposterior "blowed out" bucca and intraoral bucca radiographs (parotid cases), and US were taken of all patients. Further investigations, such as CT, MRI or FNAB were performed to discover probable differential diagnostic problems.

RESULTS

The sensitivity of US for salivary stones was 75.0%, for inflammation was 77.4%. The sensitivity of x-ray for salivary stones was 60.7%. The cumulative effectiveness of x-ray and US for sialolithiasis was 91.3%. In the remaining two cases of sialolithiasis, CT supported the earlier diagnosis. In sialoadenitis, twice FNAB, four times MRI verified the supposed diagnosis.

CONCLUSIONS

Despite the advantages of CT and MR evaluations, sonography and native x-ray seems to keep their priorities as diagnostic methods, because they are cost-effective and easily available in dento-alveolar surgical practice. The lack of intraductal imaging ability might be considered as one of the major disadvantages in evaluation of possible diagnostic alternatives.

3D MR sialography protocol for postradiotherapy follow-up of the salivary duct system

PURPOSE

To develop and evaluate an MR sialography protocol that reproducibly images the parotid and submandibular ducts over time, in 3D. Such a protocol is needed in order to investigate the possible radiation-induced changes to the salivary ducts in patients receiving radiotherapy to the head-and-neck.

MATERIALS AND METHODS

MR sialography was performed on a 1.5-T MR scanner. Sequence parameters were optimized on 11 healthy volunteers. A 3D water-selective turbo spin echo (TSE) pulse sequence (TR/TE = 6000 msec/190 msec), using a two-element circular surface coil was applied twice in one MR session. In order to assess the reproducibility, the same procedure was repeated four to six months later. The quality of the MR sialograms was measured subjectively by developing a visibility scoring system and objectively by the means of contrast-to-noise ratio (CNR) of the ducts vs. fat (CNR(duct-fat)).

RESULTS

High-quality, 3D MR sialographic images were obtained. The quality of the MR sialograms and the subjective visibility score of the salivary ducts were constant over time. The CNR(duct-fat) varied between volunteers (standard deviation, SD 26%) but it was relatively constant per volunteer (SD 5%).

CONCLUSION

The MR sialography protocol presented in this study provides good quality 3D imaging of the major salivary ducts, submandibular duct, and the parotid duct and it can be used for the comparison of the salivary duct system of an individual over time.

MR-Sialographie: Prospektive Evaluation ultraschneller Sequenzen mit paralleler Bildgebung und oraler Stimulation bei Patienten

PURPOSE

To evaluate an ultra-fast sequence for MR sialography requiring no post-processing and to compare the acquisition technique regarding the effect of oral stimulation with a parallel acquisition technique in patients with salivary gland diseases.

MATERIALS AND METHODS

128 patients with salivary gland disease were prospectively examined using a 1.5-T superconducting system with a 30 mT/m maximum gradient capability and a maximum slew rate of 125 mT/m/sec. A single-shot turbo-spin-echo sequence (ss-TSE) with an acquisition time of 2.8 sec was used in transverse and oblique sagittal orientation. All images were obtained with and without a parallel imaging technique. The evaluation of the ductal system of the parotid and submandibular gland was performed using a visual scale of 1-5 for each side. The images were assessed by two independent experienced radiologists. An ANOVA with post-hoc comparisons and an overall two tailed significance level of p = 0.05 was used for the statistical evaluation. An intraclass correlation was computed to evaluate interobserver variability and a correlation of > 0.8 was determined, thereby indicating a high correlation.

RESULTS

Depending on the diagnosed diseases and the absence of abruption of the ducts, all parts of excretory ducts were able to be visualized in all patients using the developed technique with an overall rating for all ducts of 2.70 (SD +/- 0.89). A high correlation was achieved between the two observers with an intraclass correlation of 0.73. Oral application of a sialogogum improved the visibility of excretory ducts significantly (p < 0.001). In contrast, the use of a parallel imaging technique led to a significant decrease in image quality (p = 0,011).

CONCLUSION

The applied ss-TSE for MR sialography allows fast and sufficient visualization of the excretory ducts of the main salivary glands in patients, and no elaborate post-processing is required. Use of an oral sialogogum is suggested to improve the results of MR sialography.

Interventional Sialography and Minimally Invasive Techniques in Benign Salivary Gland Obstruction

Salivary gland obstruction is the commonest complaint affecting this organ and is usually due to the development of salivary calculi, ductal strictures, or both. Imaging has a role in the diagnosis of the cause, extent, and effects of obstruction. In recent years, the role of radiology has evolved; techniques, such as salivary stone lithotripsy, and salivary stone extraction and balloon ductoplasty are carried out under imaging guidance. This article reviews the current status of minimally invasive salivary interventions.

The functional evaluation of salivary glands using dynamic MR sialography following citric acid stimulation: a preliminary study

OBJECTIVE

We introduce a new technique for the functional evaluation of the salivary glands using continuous magnetic resonance (MR) sialography before and after citric acid stimulation.

METHODS

In 10 volunteers, the time-dependent changes in the maximum area of the detectable parotid gland ducts on MR sialographic images taken every 30 seconds before and after citric acid stimulation were analyzed. The time period to the occurrence of the maximum duct area poststimulation was noted, and then the time for the area to return to its 50% value pre-citric acid stimulation was also observed. This new technique was clinically applied in 1 patient with an excessive supply impression of saliva and in 1 patient with a short supply impression with saliva.

RESULTS

In all volunteers after citric acid stimulation, the maximum area of the detectable salivary gland ducts first increased and then decreased. A strong relationship was found between the maximum area of the detectable salivary gland ducts before citric acid stimulation and total saliva volume (Pearson r = 0.672, P = .031). Compared with all the volunteers, the ratio of change in the detectable ducts was the highest in the patient with an excessive supply impression of saliva, but lowest in the patient with a short supply impression with saliva.

CONCLUSIONS

This initial study suggests that dynamic MR sialography allows for functional and morphological evaluation of the salivary glands. This technique appears to have many possible applications and further investigation in this field is necessary.

Fast and high-resolution MR sialography using a small surface coil

PURPOSE

To establish a fast and high-resolution MR sialographic technique that provides fast and high-resolution imaging.

MATERIALS AND METHODS

MR sialography was performed on a 1.5-T MR imager using a small (47-mm) surface coil. We determined appropriate sequence parameters, and then applied the technique to the salivary glands of 143 patients with xerostomia (including those with Sjögren's syndrome or hyperlipidemia) or salivary gland inflammation. We compared the high-resolution MR sialography with conventional x-ray sialography in the patients with xerostomia to evaluate the effectiveness of the MR sialography technique.

RESULTS

We found that a single-shot, single-slice MR sialography (TR/TR/number of signal acquisitions [NSA] = 8000 msec/1000 msec/6) using a small surface coil provides excellent duct images that are clinically feasible with fast (imaging time of 56 seconds) and high-resolution images. An alternative three-dimensional MR sialography technique provided better details of the branches at the expense of imaging time. The MR sialography technique using a small surface coil depicted effectively the ductal changes in the salivary glands in patients with or without Sjögren's syndrome, reflecting the severity of the diseases.

CONCLUSION

We conclude that MR sialography can be performed using a fast and high-resolution sequence.

Usefulness of magnetic resonance sialography in patients with juvenile Sjögren's syndrome

OBJECTIVE

Sialography is an important means for evaluating parotid gland damage in patients with Sjögren's syndrome (SS). However, 'conventional' X-ray sialography is invasive and sometimes difficult to perform and repeat, especially for young patients. Recently, magnetic resonance (MR) sialography has been used in adult SS patients. In this study, we investigated the usefulness of MR sialography for evaluating parotid gland damage in juvenile SS.

METHODS

Eight young patients suffering from SS were studied. MR sialography and X-ray sialography were performed simultaneously in the same patients. The images obtained by both methods were assessed with Rubin-Holt staging.

RESULTS

MR sialography detected ductal dilatation in 5 of 8 patients, while it was detected in 7 of 8 patients by X-ray sialography. The stages were the same in 4 patients by both methods. In 3 patients, the stages on X-ray sialography were higher than those on MR sialography; in 1 patient, the stage on MR sialography was higher. The correlation between the stages determined by the 2 methods was 0.85. There were no side effects in MR sialography, whereas 3 patients complained of pain during X-ray sialography.

CONCLUSION

MR sialography can evaluate Stage II approximately III parotid gland damage in juvenile SS. Although MR sialography cannot detect subtle changes in the duct, it has no side effects and can be performed repeatedly in young patients. We propose that MR sialography be chosen as the first tool for diagnosing and during follow-up of the status of the glands in juvenile SS.

Chemical shift MR images of the parotid gland in Sjögren's syndrome utilizing low-field MR system comparison with MR sialography and salivary secretion function

PURPOSE

To compare chemical shift imaging and MR sialography in patients with Sjögren's syndrome utilizing a low (0.3 Tesla) magnetic field.

METHODS

We retrospectively evaluated 8 controls (16 glands) and 30 patients (60 glands) with parotitis of Sjögren's syndrome. MR images were obtained with a 0.3 Tesla system (HITACHI MRP-7000, Hitachi, Ltd., Tokyo, Japan) with a coil for the temporomandibular joint. MR sialography was graded according to the grading system established for conventional sialography. The signal decrease rate between in- and opposed-phase images, and the standard deviation (S.D.) of the parotid parenchymal signal in opposed-phase images were measured.

RESULTS

MR sialography and chemical shift images were obtained in 38 and 46 glands, respectively. MR sialography was graded as 0 in 15, 1 in 12, 2 in 4, and 3 in 5 glands. The mean signal decrease rate in in/opposed phase was 37.6%, and the mean S.D. of the parotid parenchymal signal in the opposed-phase images was 655.9. The salivary secretion function was related to heterogeneity on opposed phase (r=-0.3) but not to MR sialography grading.

CONCLUSION

Heterogeneity on opposed-phase images assessable with a low-field magnet system may be a useful parameter to add in the evaluation of Sjögren's parotitis.

[MR-sialography: optimisation and evaluation of an ultra-fast sequence in parallel acquisition technique and different functional conditions of salivary glands]

PURPOSE

To optimise a fast sequence for MR-sialography and to compare a parallel and non-parallel acquisition technique. Additionally, the effect of oral stimulation regarding the image quality was evaluated.

MATERIAL AND METHODS

All examinations were performed by using a 1.5-T superconducting system. After developing a sufficient sequence for MR-sialography, a single-shot turbo-spin-echo sequence (ss-TSE) with an acquisition time of 2.8 sec was used in transverse and oblique sagittal orientation in 27 healthy volunteers. All images were performed with and without parallel imaging technique. The assessment of the ductal system of the submandibular and parotid gland was performed using a 1 to 5 visual scale for each side separately. Images were evaluated by four independent experienced radiologists. For statistical evaluation, an ANOVA with post-hoc comparisons was used with an overall two-tailed significance level of P =.05. For evaluation of interobserver variability, an intraclass correlation was computed and correlation >.08 was determined to indicate a high correlation.

RESULTS

All parts of salivary excretal ducts could be visualised in all volunteers, with an overall rating for all ducts of 2.26 (SD +/- 1.09). Between the four observers a high correlation could be obtained with an intraclass correlation of 0.9475. A significant influence regarding the slice angulations could not be obtained (p = 0.74). In all healthy volunteers the visibility of excretory ducts improved significantly after oral application of a Sialogogum (p < 0.001; eta (2) = 0.049). The use of a parallel imaging technique did not lead to an improvement of visualisation, showing a significant loss of image quality compared to an acquisition technique without parallel imaging (p < 0.001; eta (2) = 0.013).

CONCLUSION

The optimised ss-TSE MR-sialography seems to be a fast and sufficient technique for visualisation of excretory ducts of the main salivary glands, with no elaborate post-processing needed. To improve results of MR-sialography, it is reasonable to use an oral Sialogogum.

Lipiodol UF retention in dental sialography

Lipiodol is a lipid based contrast medium and is very useful in sialography. It gives very fine images and clearly shows the details of the gland. It is viscous and has a relatively high iodine content. However, lipiodol UF drops sometimes remain in the salivary gland and in the adjacent tissues for a long time and may cause irritation. We report a case where lipiodol UF leaked from Stensen's duct and was not resorbed after a period of 70 months.

[The study of magnetic resonance sialography in diagnosing parotid diseases]

OBJECTIVE

To study the feasibility of diagnosing parotid disease with magnetic resonance sialography (MRS) and to select the optimal scanning sequence.

METHODS

Twenty-three patients with parotid gland disease and 5 normal adults received sialography using magnetic resonance imaging technique and several sequences (including IR-FSE, FSE, SS-IR-FSE, SS-FSE) were used. After first scanning, the patients were scanned respectively 3 and 10 minutes after buccal application of vitamin C. And MR images of duct obtained. The images of parotid duct system were analysed and evaluated according to their displaying effects. Qualitative diagnosis was made based on MRI and those diagnosis were compared with pathological diagnosis after operation.

RESULTS

Images of MR sialography clearly displayed the main duct and its branches of parotid gland and the pathological changes of duct, such as narrow, expanded, stoppage. Of the scanning sequences, IR-FSE was superior to others in manifesting the parotid gland duct (P < 0.05). The performance of images after being given vitamin C did not significantly improve the displaying effect. The accurate rate of qualitative diagnosis was 95.6%.

CONCLUSIONS

MR sialography can clearly display the parotid ducts and their pathological changes. The accurate rate of qualitative diagnosis of parotid disease was higher than that X-ray sialography.

Clinical application of magnetic resonance sialographic 3-dimensional reconstruction imaging and magnetic resonance virtual endoscopy for salivary gland duct analysis

PURPOSE

In a previous study, we showed that the new and fast sequence 3-dimensional (3D)-fast asymmetric spin-echo sequencing could be applied in magnetic resonance (MR) sialographic 3D reconstruction imaging of the parotid gland ducts and in producing virtual endoscopic views of the parotid gland with MR data.

MATERIALS AND METHODS

In the present study, we examined the clinical application of these MR sialographic 3D reconstruction imaging and virtual endoscopy of the salivary gland ducts using MR data sets with 3D-fast asymmetric spin-echo sequencing.

RESULTS

The MR sialographic 3D reconstruction images showed a complete view in the branch paths from all angles, and the MR virtual endoscopic views showed conditions in the endoluminal tracts of the large branches in 20 patients with salivary gland duct abnormalities, including Sjögren syndrome, cyst, tumor, sialadenitis, and salivary calculi.

CONCLUSION

The clinical use of MR sialographic 3D reconstruction imaging and MR virtual endoscopy for salivary gland ducts may enhance understanding of the 3D relationship between the ducts and the surrounding tissue, as well as the endoluminal circumstance within ducts. Possible future applications abound, and further investigation in this field is expected.

[The diagnostic value of magnetic resonance sialography for chronic obstructive parotitis]

PURPOSE

To evaluate the diagnostic value of magnetic resonance sialography (MRS) for chronic obstructive parotitis (COP).

METHODS

18 patients with COP underwent both conventional sialography and MRI sialography. A new magnetic resonance technique was applied. In addition to the usually performed T1 and T2 cross-sectional sequence, a heavy T2-weighted sequence (TR=4000 msec,TE=250 msec)was performed that allowed depiction of the fluid-filled parotid duct system. The MRI sialographic findings were compared with that of conventional sialography. The overall accuracy of diagnosis and ductal stenosis were assessed.

RESULTS

The main duct of the parotid gland as well as primary branching ducts could be reliably depicted. Compared with the conventional sialography, the diagnostic accuracy of MRS was 94.4%(17/18) and stenosis diagnosis reached 100%(17/17).

CONCLUSIONS

Initial experience indicates that magnetic resonance sialography can be applied successfully to investigate the duct system of the parotid gland. It is completely noninvasive and a promising alternative to radiographic sialography.

Gadolinium an alternative contrast agent for sialography in patients with iodine sensitivity

The use of iodinated contrast material in radiography is contraindicated in patients with known iodine sensitivity and such patients may present a management dilemma. The successful use of gadolinium in contrast sialography is described.

Pilot study using technetium-99m pertechnetate sequential radionuclide-sialography to assess salivary gland function in nasopharyngeal cancer patients on radiation therapy

INTRODUCTION

Nasopharyngeal carcinoma (NPC) is mainly treated by radiation therapy. A common complication of radiotherapy is xerostomia. Direct measurements of the amount of saliva produced using suction cups and volumetric assessments are cumbersome and time-consuming. Sequential radionuclide sialography is a reproducible and convenient method of measuring salivary function.

MATERIALS AND METHODS

Patients with newly diagnosed NPC underwent a pilot study using technetium-99m pertechnetate sequential radionuclide sialography to assess their salivary function before and at 3 months post radiation therapy. From the sialography, time activity curves were obtained for analysis of salivary function. The shape of the time activity curve with citric acid stimulation was classified into 4 types according to the degree of radiation-induced dysfunction.

RESULTS

All 14 patients had worse (P < 0.005) time activity curves for both parotids and submandibular glands after radiation therapy. All patients with abnormal curves before radiation therapy presented type IV (non-functioning) curve after radiation therapy. A ratio of pre- and post-stimulation counts allowed for quantification of the degree of stimulatory response. We found a significant decrease in Rc before and after radiation therapy for all salivary glands (P < 0.001). The salivary gland to background ratio, which is a reflection of the degree of salivary gland functional uptake, also had a significant reduction after radiation.

CONCLUSION

It is feasible to use technetium-99m pertechnetate in the measurement of salivary gland function in nasopharyngeal cancer patients treated with radiation therapy.

Management of chronic parotitis: a review

Chronic parotitis is an insidious inflammatory disorder, which is characterized by a recurrent, often painful, swelling of the gland or glands. Sialography remains the investigation of choice. Diagnostic siladenoscopy may complement or supersede sialography as the diagnostic procedure of choice, as more experience is gained in this technique and its use becomes more widespread. The management options are conservative or surgical, but controversy exists regarding the timing and method of surgical intervention. The surgical methods that have been described include injection of methyl violet - a sclerosing agent, ductal ligation, ductoplasty, tympanic neurectomy, and parotidectomy. Parotidectomy is considered the ultimate surgical option but because of its significant morbidity the exact technique and procedure that should be used remains contentious.

[MR Sialography]

Indications for sialography have became rare and radiologists are less and less experienced for salivary gland cannulation. MR Sialography allows opacification of salivary ducts without any cannulation and could replace residual indications for sialography. The purpose of this paper is to review the principle of the technique, the normal and pathologic aspects of MR Sialography and to emphasize advantages and limitations compared to other techniques.

Magnetic resonance imaging and magnetic resonance sialography of parotid glands in primary Sjogren's syndrome

OBJECTIVE

To look for structural parotid gland changes on magnetic resonance (MR) imaging and MR sialography of primary Sjögren's syndrome (SS) patients and healthy control subjects and to compare these methods with each other.

METHODS

MR imaging and MR sialography of both parotid glands were performed on 26 patients and 7 healthy controls. Bilateral surface coils were used to obtain high spatial resolution.

RESULTS

Twenty-two of the 26 patients had abnormalities on MR imaging. Twenty-one had a nodular or dendritic parenchymal pattern, 5 had cavities, and 6 had duct dilatations. On MR sialography, 25 of the 26 patients had abnormalities of the ducts, and 16 of them also had cavities. One patient and all 7 controls had normal results with both methods. The structural appearance of the parotid glands on MR images had marginal linear association with the duct system changes but no correlation with the cavitary changes seen on MR sialography. Furthermore, duct system abnormalities did not correlate with cavitary changes. Both parenchymal and sialographic abnormalities were associated with the presence of Ro/SSA antibodies but not with age of the patient, disease duration, salivary flow rate, or the presence of hypergammaglobulinemia or extraglandular manifestations.

CONCLUSION

MR imaging and MR sialography are noninvasive methods that provide definitive information of morphologic changes in parotid glands and can be used as diagnostic indicators of primary SS. Because these methods give information on different aspects of glandular pathology, both should be performed when evaluating parotid glands of SS patients. MR sialography is more sensitive, but conventional MR imaging gives complementary information on the progressive pathologic changes of glandular parenchyma.

Morbidity from parotid sialography

OBJECTIVE

Sialography is commonly used for the diagnosis of Sjögren's syndrome, although its invasive nature is often regarded as a serious drawback for routine usage. The aim of this study was to evaluate the morbidity and acceptability of parotid sialography using oil-based contrast fluid.

STUDY DESIGN

Twenty-four consecutive sialographic procedures were evaluated in terms of morbidity and the patient's acceptance of the procedure, assessed with a standardized questionnaire. Information was also obtained by recording relevant physical parameters during the procedure.

RESULTS

There was good acceptance of the sialographic procedure, and the morbidity was low. No signs of overfilling or false route were observed in any of the sialograms. On average, 0.74 mL of contrast fluid was infused with a velocity of 0.01 mL/s. The whole procedure was completed within 12 minutes.

CONCLUSIONS

Parotid sialography appears less invasive than is often thought. It had a low morbidity rate and was well accepted by the patients.

Sjögren's syndrome as seen by an oral physician

This article provides a brief overview of the various orofacial presentations of Sjögren's syndrome. The paper summarises the clinical features of patients with xerostomia, and alludes to differential diagnosis, investigative procedures and therapeutic modalities for the oral component of Sjögren's syndrome.

New criteria for diagnosing Sjögren's syndrome: a step forward?--or

Primary Sjögren's syndrome seems to be the most common of the chronic systemic inflammatory connective tissue diseases, according to epidemiological investigations. Basic and clinical research, including treatment within this group, is increasing while simultaneously there is increasing confusion and uncertainty about the classification criteria for Sjögren's syndrome. Within the last three decades nine different classification criteria sets have been introduced including the recent US-European classification criteria set. The diagnostic criteria used in daily practice seem to differ even more and many forget that the function of both the lachrymal glands and the salivary glands should be diminished. Consequently many rheumatologists prefer to diagnose patients according to classification criteria. The advantages and disadvantages of the various classification criteria for primary Sjögren's syndrome are dealt with but it is stressed that the majority of these will exclude former/present smokers (from the diagnoses)--more than half of the population!

Diagnostic value of sialography with both the conventional and digital subtraction techniques in children with primary and secondary Sjögren's syndrome

OBJECTIVE

The application of anamnestic data on siccative symptoms required for classifying adult Sjögren's syndrome is limited in childhood. Instrumental test procedures are therefore necessary for objectively recording the oral and ophthalmologic manifestations of the disease. The aim of this study was to clarify the sialographic changes that occur in Sjögren's syndrome in children.

STUDY DESIGN

A total of 23 sialograms were obtained with both conventional and digital subtraction techniques in 21 children with primary (10 girls and 1 boy) or secondary Sjögren's syndrome (10 girls). The films were assessed by 3 physicians and submitted for a consensus analysis if necessary.

RESULTS

The pathologic features observed in the children varied from a slightly narrowed ductal system to multiple peripheral ductal ectasias and completely destroyed parenchyma. Sialographic examinations demonstrate that, with progressing disease, regression of acinar dilatations and rarification of the ductal system occur.

CONCLUSION

The results show that the spectrum of sialographically recordable lesions in Sjögren's syndrome in children is greater than is described thus far in the literature.

[Comparative sonographic, x-ray and morphological studies of the salivary glands in Sjögren's syndrome]

AIM

To define diagnostic value of parotid gland (PG) sonography in Sjogren's syndrome (SS) as compared to sialography and morphological changes of labial salivary glands (LSG).

MATERIALS AND METHODS

Examination of 50 females with primary (20 patients) and secondary (30 patients) SS consisted of clinical, ultrasonic, x-ray and morphological investigations.

RESULTS

Sonographically, PG in SS is characterized by nonhomogeneity of parenchymal picture detected in 75% of patients with primary and 50% of patients with secondary SS. Moderate and severe nonhomogeneity of PG parenchyma was seen in the stage of marked manifestations of chronic parenchymatous parotitis.

CONCLUSION

Relationship between PG sonographic image in SS and morphological changes in LSG need further study. PG sonography may help in combined examination of SS patients.