* Presented at the Seventy-second Annual Meeting of the American Roentgen Ray Society, Boston, Massachusetts, September 28- October 1, 1971.
From the Department of Radiology, Indiana University Medical Center, Indianapolis, Indiana.
JUNE, 1972
420
CURRENT STATUS OF SIALOGRAPHY*
By HEUN Y. YUNE, M.D., and EUGENE C. KLATTE, M.D.
INDIANAPOLIS, INDIANA
I
N THE half century since the introduc-tion of sialography by B#{225}rsony, this
diagnostic technique has been of proven
value. Minor modifications of technique
were made by subsequent authons,3’4’68
with resultant technical improvement and
diagnostic accuracy. Sialognaphy is not
widely utilized, because of the accepted
misconception that it offers more penalty
than reward both to the patient and the
examiner.
The purpose of the authors is to review
certain technical aspects of the method and
evaluate established diagnostic criteria in
various abnormalities of the major salivary
glands.
MATERIAL
At Vanderbilt University Medical Center,
sialography has been routinely performed
in those patients with recurrent swelling,
pain, mass on any combination of these
signs and symptoms in the area of major
salivary glands.
This report is based on the result of our experience in performing 158 sialognaphies on 126 patients.
TECHNIQUE
The technique utilized is similar to that
described by Rubin and Holt.8 The orifice
of the duct of the gland to be studied is
identified and dilated utilizing graded silver lacnimal probes. A 14-18 gauge soft plastic
intravenous catheter, approximately 25
cm. in length, is introduced approximately
2 cm. beyond the orifice of the duct. To
facilitate the introduction of the catheter,
the tip is beveled. More recently we have
utilized a Fr 4 to 5 radiolucent thin-walled
teflon tube,* the end of which is markedly
tapered so that the outer diameter of the
tip is approximately o.#{231}to I.o mm. Utiliz-
ing this catheter, prior dilatation of the
duct is rarely necessary. A stop-cock is
placed between the catheter and a 2 cc.
syringe containing ethiodol.t It is im-
pontant that the catheter be flushed with
the ethiodol prior to introduction into the
duct so that air bubbles are avoided. After
insertion, the catheter is anchored to the
corner of the mouth by a strip of adhesive
tape. This anchoring is important in that
the patient’s head may be moved during
the examination without fear of catheter
dislodgement and the examiner’s fingers
are removed from the radiation field. The
examination is performed under fluoro-
scopic control. Multiple well coned spot
sialograms are obtained in multiple projec- tions at various stages of filling of the duct
system. Roentgenographic detail is of
great importance and therefore it is im-
perative that a small focal spot and re-
ciprocating grid be utilized. Approximately
i to i cc. ethiodol is injected. Upon
opacifi cation of the gland panenchyma with
fluffy, cloudy contrast stain, fluoroscopy is
terminated and conventional overhead
roentgenograms in the anteropostenior, lat-
eral and oblique projections are taken.
During the filming the stop-cock is closed,
so that contrast material does not pass
from the duct system into the syringe.
Films are checked for technical adequacy
and the tube is removed. The patient is
then given a slice of lemon or a few drops
of lemon extract to stimulate salivary
* Cook Incorporated, Bloomington, Indiana, Box 1272, 47401.
t E. Fougera & Co., Inc., Hicksville, Long Island, New York ii 802.
VOL. 115, No. Current Status of Sialography 421
secretion
.
Overhead noentgenognams inconventional positions are nepeated ap-
proximately 30 minutes later, to evaluate
the degree of evacuation of the injected
contrast material.
The examination may be divided into
three parts:
I. Filling Phase (Fig. i, A-H). Fluoroscopi-
cally controlled fractionated filling with mul-
tiple spot sialograms assures better opportuni- ties for the study ofthe total duct system. If an
ordinary branching of the duct system is ab-
sent, one must consider the following possibili- ties: (a) complete obstruction of the main duct by an impacted stone or cicatnicial obstruction;
(b) invasion ofthe main duct by neoplasm; and
(c) improper catheter positioning with the
catheter tip beyond the wall of the main duct
or an acutely kinked segment of the main duct.
Slight readjustment of the catheter tip will
eliminate the last condition. Examination dun-
ing the filling phase eliminates the objection by
some authors, who advocate termination of the
examination before the contrast opacification of
the acini which tends to obscure the duct
4,7
2. Parenchymal Opac:fication Phase (Fig. 2,
A-E). Injection of contrast material under
fluoroscopic control is carried to the stage
where filling of the acini can be recognized. At
this stage the syringe is disconnected and the
stop-cock is closed to prevent spillage of the
contrast material through the catheter. Three
conventional views as described will provide the
picture of the total gland parenchyma. This
phase of the examination is especially useful in the diagnosis of 2 major clinical conditions: (a) subacute autoimmune sialosis. In this condition
there is diffuse parenchymal edema with conse-
quent elevation of the pressure in the acini.
Acinar filling may be impossible by the retro- grade sialographic technique. Further con firma- tion of this situation is possible by re-injecting
the duct with aqueous contrast material such
as meglumine diatrizoate. If nonfilling of the
acini continues, diffuse parenchymal edema is
very likely; and (b) peripheral intraglandular space occupying lesion. Lesions of this type can be easily missed by duct system opacification
only6 (Fig. 3, il-F). We do not advocate over-
distention of the gland parenchyma to the de-
gree advocated by Osmer and Pleasants.6 These
authors use a minimum of 3 cc. in the parotid
gland and 2.5 cc. in the submaxillary gland.
Faint diffuse and uniform opacification of the
parenchyma is felt more desirable than a dis-
torted overdistended gland.
3. Postevacuation Phase. In all normally
functioning salivary glands that have active
salivary secretion, the contrast material will be
virtually completely evacuated upon stimula-
tion by a strong sialogogue. If a portion of the injected contrast material remains in the gland
beyond 24 hours, this is distinctly abnormal.”8
It may represent contrast material in the tissue out ofthe confines ofthe wall ofthe duct system or acini, which may be secondary to faulty tech-
nique with traumatization or disease such as
invasive neoplasm or inflammatory processes.
Complete evacuation may be delayed by the
presence of stricture of the duct system. The
contrast material may also remain within the
duct and acini due to absence ofsecretion of the salivary gland (Fig. , zl-E).
RESULTS
In all patients the sialograms, clinical
records, laboratory data, and surgical and
pathologic reports were reviewed. In many
cases, pathologic material was available;
however, in some the final diagnosis was
based on clinical, laboratory, and radio-
graphic criteria.
The cases were divided into those with:
I. calculi; II. inflammatory disease; III.
neoplasms; IV. trauma and its complica-
tions; V. normal gland; and VI. undiag-
nosed (Table I).
I. Thirty-two cases had salivary calculi.
Seventeen were within the duct system of
the parotid gland, and 15 were in the duct
system of the submaxillary gland. It was
of interest that only 7 of 17 panotid calculi were opaque, while 10 of 15 submaxillary
calculi were opaque. Multiple parotid
stones were more frequently seen in the
dilated acini and in intralobular ductules.
These stones were usually quite small. The
submaxillary stones were usually in the re-
gion of the gland hilus. The submaxillary
stones were in general larger and in some
cases up to I cm. in diameter. In many
JUNE, 1972
422 1-leun Y. Yune and Eugene C. Kiatte
Fic. I. (4-D) Selected spot sialograms of the filling stage of the submaxillary gland. Fractionated filling
and spot filming in various projections during fluoroscopy assures opportunities for the study of the total
duct system. (E-H) Small, radiolucent, nonobstructing stones in thispatient’s night Stensen’s duct could
have been missed if the fractionated filling and spot filming steps were not taken. Many cases of clinically
unsuspected stones were demonstrated by this method.
Voi.. 115, No. Current Status of Sialographv 4-i#{149}1)
cases, the preradiographic diagnosis of
salivary calculi was confirmed. In 7 cases
with calculi in the main duct requiring
surgical removal, the initial clinical diag-
nosis was nonspecific swelling or bacterial
infection. All of these were in the sub-
maxillary glands.
II. In 6o cases the final diagnosis was
inflammatory disease. The vast majority
of these were thought to represent auto-
immune sialosis (52 cases). Fifty-seven of
the 6o cases with inflammatory disease of
the salivary gland had positive radio-
graphic findings. The earliest manifesta-
tion of inflammatory disease is radio-
graphically manifest by a “pruned-tree”
appearance of the duct system with lack
of acinar filling, which is felt to be secon-
dary to acinar edema. If a consciencious
effort is made to fill the acini and this is
TABLE I
BREAK-DOWN OF PATI ENT MATERIAL
AND DIAGNOSIS (126 Patients-i8 Examinations)
I. Stone (s) 32
II. Infectious Disease 6o
Autoimmune sialosis 52
Abscess 5
Other inflammatory conditions . . . 3
III. Neoplastic on Tumor-Like Conditions. . . . 24
Benign mixed tumor 13
Wanthin’s tumor 2
Cyst (hemorrhagic)
Malignant mixed tumor 2
Acinic cell adenocarcinoma Adenocystic adenocarcinoma....
Lymphoma 2
Metastatic tumor 2
IV. Trauma and Its Complication 8
V. Normal Gland
VI. Undiagnosed 5
I’IG. 2. (A) Normal panotid gland, (B and C) normal
submaxillary gland when their acinan spaces are of the right panotid gland in an early autoimmune filled (parenchymal opacification stage). Note sialosis. The acinan filling could not be obtained diffuse, homogeneous, slightly mottled staining of even with an aqueous contrast material. The ex-
the gland parenchyma beyond the duct system. amination is considered either incomplete or
(D and E) The so-called “pruned-tree” appearance abnormal when the acinan filling is absent.
424 Heun Y. Yune and Eugene C. Klatte JUNE, 1972
11G. 3. (A-D) Spot sialograms during filling stage. (E and F) Standard roentgenograms after the acinan filling stage of the left submaxillary gland. Note a peripheral, subcapsular filling defect of the supenolatenal aspect of the gland (arrows). Note also that Figure izl-D is the same as Figure i,11-D. If a conscientious
effort were not made to obtain the parenchymal stain, and the procedure terminated at the end of filling
of the duct system, this type of lesion would have been easily missed.
\OL. 115, No. 2 Current Status of Sialography 425
unsuccessful, this is an important radio-
graphic finding. With progression of the
inflammatory process, there is noted to be
punctate dilatations of the peripheral
ductules as described by Rubin and Holt.8
The intraglandular duct system is fre-
quently stretched and tapered secondary
to edema of the gland. Later there is ir-
regularity of the caliber of the duct and
local dilatations. When irregularity and
dilatation of the main ducts are present,
there is almost always associated sub-
alveolar dissection of the contrast material
on multiple small berry-like dilatations of
the peripheral intraglandular ductules and/
or acini. Two patients with pathologically proven multi focal chronic i nfl ammatory
disease had normal sialograms. It is felt
likely that in a small minority of patients
with inflammatory disease of the gland
parenchvma, there will not be sufficient
alteration of the normal physiologic and
anatomic features to be demonstrated by
the current method of sialography.
In i patient the surgical specimen was
noted to contain changes of acute infec-
tious process, but this was in fact due to
an acute suppurative process of a sub-
mandibular lymph node in juxtaposition
to the submaxillary gland. Sialography was
entirely normal.
III. Twenty-four patients with patho-
logically proven salivary gland neoplasms
were studied. In 21 additional patients the
presialognaphic clinical impression was
neoplasm of the major salivary gland; how-
ever, because of the sialographic findings
the diagnosis was changed and surgical in-
tervention was either cancelled or modified.
Fic. . (4) Saccular dilatations of intralohular duct-
ules and acini in a “dry-gland” of a very far ad-
vanced autoimmune sialosis (a case of Sj#{246}gren’s
syndrome). (B and C) Stricture of the duct Sys-
tem. In this case inflammation and scar were asso-
ciated with a radiolucent stone. (D and E) Sub-
alveolar contrast material dissection in an ad- vanced case of autoimmune sialosis. Note that there is no injury to the main duct system.
Normal, actively secreting gland should be able
to evacuate virtually all of the injected contrast material within several minutes after administra- tion of the sialogogue.
426 Heun Y. Yune and Eugene C. Klatte JINE, 1972
TABLE II
RADIOGRAPHIC SIGNS* IN INFLAMMATORY DISEASE
(6o Cases)
I. “ Pruned-tree” appearance (stretched i ntra-
glandular ducts, swollen gland and non- filling of the acini even with aqueous con- trast)
2. Dilatation of intnalobulan ductules and acini (punctate to sacculan)
3. Irregular caliber and shape of intraglandular
duct system (nonobstructive sialodochi tis)
4. Subalveolar contrast dissection (contrast dis-
section within gland panenchyma and not
from traumatic dissection from the main
duct)
5. Localized abscess (communicating with duct
system/with on without stone)
6. Obstructive sialodochiectasis (with or with-
out stone/stricture of the main duct-ex-
cept post-traumatic stricture)
i.Nonmal sialogram (false negative )
S These signs are seen usually in combination rather than alone, but for the sake of convenience cases are classified accord- ing to the main feature noted.
The final diagnosis, later proven either
surgically on clinically, includes lymph-
adenopathy in juxtaposition to the major
salivary glands, abscess in the adjacent soft
tissue, inflammatory disease of the salivary
gland, masseter muscle hypentrophy, and
salivary calculi. Eighteen of the 24 patients
with salivary neoplasms were correctly
diagnosed by sialognaphy preopenatively.
Of the 6 patients with tumors which were
missed, were benign mixed tumors. In 2
of these 5 patients the sialognaphic exami-
nation was incomplete with lack of acinar
opacification. In the remaining 3 patients the lesions were located either in the deep lobe of the panotid gland on in the subcap- sulan, peripheral portion, so that they were interpreted as the result of an extrinsic pressure. In the last case the changes were
misinterpreted as inflammatory disease.
This last patient was a case that was later proven as Hodgkin’s disease invading the
panotid gland. The duct system was noted
to be diffusely irregular and tortuous and
no acinar opacification was obtained. At-
tempts at differentiation between benign
and malignant intrinsic neoplasms of the
salivary gland were fraught with disap-
pointment. The majority of the neoplasms
were mixed tumors which were well local-
ized. It is extremely difficult to differentiate
the benign from malignant mixed tumors
even with gross and microscopic pathologic i8 examination. Patients with infiltrative neo-
plasms such as squamous cell carcinoma
13 and lymphosarcoma had more readily
recognizable destruction of the salivary
6 ducts.
The sialognaphic appearance of patients with inflammatory and neoplastic diseases
5 15 summarized in Tables II and III.
IV. We have encountered 8 cases of
5 post-traumatic salivary gland problems.
These include: 2 cases ofsalivary fistula; 2
10 cases of duct orifice stricture due to scan;
3 2 cases of duct stricture away from the
orifice secondary to facial laceration; and i case each ofsalivary cyst secondary to duct obstruction and gland laceration, and duct obstruction due to an ill-placed suture. We were able to pin-point the area of problem
by sialognaphy in all of these cases.
V. Of 29 proven normal salivary glands,
sialognaphy was performed in 9 cases for
the question of inflammatory disease of the salivary gland, 6 for the question of neo-
plastic disease, and for the question of
calculi. The other io cases are control
studies for the purpose of comparison with
the abnormal gland.
VI. In the undiagnosed group: i case was thought to have an intrinsic mass
lesion which was not confirmed surgically;
there was unsatisfactory examination in 2
cases, in one due to contrast material dis-
section from the main duct created by
faulty technique, and in the other due to
incomplete examination in an uncoopera- tive mental patient; the remaining 2 cases
had normal sialognaphy, but there were no
supporting clinical data.
DISCUSSION
Our experience with sialognaphy has
reinforced our enthusiasm for this diag-
nostic procedure. Recurrent swelling of a
major salivary gland with a varying degree
VoL. 115, No. Current Status of Sialography 427
TABLE III
RADIOGRAPHIC SIGNS IN NEOPLASTIC DISEASE (24 Cases)
I. Displacement of ducts (pressure effect from the mass)
2. Amputation on encasement of ductules (invasive neoplasm)
3. Nonopacified area in the gland panenchyma (space occupying lesion)
Appropriate Radio-
graphic Signs Comment on Misdiagnosis
A. Benign Mixed tumor (13) (8)* *(2)Technical miss due to premature
Tanthin’s tumor (2) (2) termination of examination
16 Cyst (,) (,) () In deep lobe or in subcapsulan
location thought to be due to
an extrinsic mass
B. Malignant Mixed tumor (2)
Acinic-cell adenocancinoma (i)
(o)t (o)t
t(4) An intrinsic mass lesion demon- stnated on all these, but with
(8) Cylindroma (i)
Lymphoma (2)
Metastatic malignant tumor (2)
()
(I) (i)t
benign characteristics; called
benign tumor
(i) Hodgkin’s disease that has no
localizing mass; called inflam- matory lesion
ofpain is a cardinal sign in stone, infection and neoplasm.
Not uncommonly salivary duct calculi
are radiolucent and therefore not visible on
routine roentgenograms of the salivary
gland. In order to devise proper therapy,
opacification of the duct system is neces-
sary.
An opaque stone may be visualized on
plain film roentgenograms, but its accurate localization and the presence of complica-
tion depend on sialognaphy. A calcified
lymph node is often mistaken as a salivary calculus. The previously accepted general
incidence of calculus disease of the major
salivary gland is 4 submaxillary to i par-
otid. With emphasis on total duct system
evaluation prior to panenchymal opacifica-
tion as described, we were able to demon-
strate many more clinically unsuspected
small radiolucent stones. This appears to
be the main reason for the similar incidence
of calculi in the 2 major salivary glands in
this series.
Accurate diagnostic criteria for inflam-
matory disease of the salivary gland are
noted. One can determine not only the
presence, but also the extent of the inflam-
matory disease process and therefore the
proper medical or surgical therapy for the
patient.
Sialography is accurate in the diagnosis
of salivary gland neoplasms. In oven one-
halfofthe cases referred to oun department with the clinical diagnosis of salivary gland neoplasm, the final diagnosis was inflamma-
tory or other non-neoplastic conditions. In
these cases proper management was facili-
tated. In a minority ofdiffusely infiltrating
neoplastic lesions, such as the case of Hodg-
kin’s disease in this series, no discretely
localized mass may be demonstrated. These
cases may be nadiographically indistin-
guishable from chronic inflammatory di-
sease. We were disappointed in our inabil-
ity to differentiate benign and malignant
mixed tumors of the salivary glands. In
certain cases this could be implied, but
absolute diagnostic criteria even in retro-
spect are not apparent.
SUMMARY
I. Sialography is a valuable diagnostic
procedure in the work-up of disease condi-
tions of the major salivary glands.
428 Heun Y. Yune and Eugene C. Klatte JUNE, 1972
2. A complete sialographic examination
should include 3 stages:
a. Filling stage performed under fluoro-
scopic control and spot filmed during
the initial visualization of the duct
system
b. Parenchvmal opacification stage for
the study of the gland parenchyma
beyond the duct system
c. Postevacuation stage for the stud of
secretory activity of the gland and to
detect any destruction of the walls of
the duct system or the acini.
3. The validity of currently accepted
diagnostic criteria is again confirmed. In
addition, the significance of lack of acinar
opacification is stressed.
Heun Y. Yune, M.I).
Department of Radiology
Indiana University Medical Center
ioo West Michigan Street Indianapolis, Indiana 46202
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