Proposal for standardized ultrasound analysis of the salivary glands: Part 1 submandibular gland

Objectives

The Salivary Gland Committee of the American Academy of Otolaryngology-Head and Neck Surgery seeks to standardize terminology and technique for ultrasonograpy used in the evaluation and treatment of salivary gland disorders.

Methods

Development of expert opinion obtained through interaction with international practitioners representing multiple specialties. This committee work includes a comprehensive literature review with presentation of case examples to propose a standardized protocol for the language used in ultrasound salivary gland assessment.

Results

A multiple segment proposal is initiated with this focus on the submandibular gland. We provide a concise rationale for recommended descriptive language highlighted by a more extensive supplement that includes an extensive literature review with additional case examples.

Conclusion

Recommendations are provided to improve consistency both in performing and reporting submandibular gland ultrasound.

Ultrasound-guided disc pain induction test for diagnosis of discogenic lumbar pain: a cross-sectional study

BACKGROUND

Several methods can be used to diagnose discogenic pain, but only discoblock can diagnose discogenic pain definitively. This study aimed to examine the usefulness of an ultrasound-guided disc pain induction test for a simple and accurate diagnosis of the culprit lesion.

METHODS

We included 41 patients with lumbar pain in whom pain was induced by an ultrasound-guided disc pain induction test. All patients had confirmed pain at L1/2 to L5/S1 based on an ultrasound-guided disc pain induction test and underwent X-ray photography and magnetic resonance imaging. Seventeen patients who required injection due to severe pain underwent discoblock procedures for discs with the most intense pain, and visual analogue scale (VAS) scores were obtained before and after the procedure for these patients. We analysed the association between painful discs and radiological findings.

RESULTS

Pain induction was noted in a total of 65 discs, and the pain was induced in 23 patients in only one disc. All patients had disc degeneration of Pfirrmann classification grade 1 or higher, with more significant disc degeneration in painful discs than in painless discs. There was no significant relationship between the presence or absence of pain and Modic type. The average VAS measurements improved significantly from 9.5 (pre-procedure) to 2.5 (post-procedure). These results suggest that the most painful discs were the causes of discogenic lumbar pain.

CONCLUSIONS

Our ultrasound-guided disc pain induction test may help diagnose disc degeneration and identify culprit lesions, even when multiple discs exhibit findings of degeneration.

Ultrasound-Guided Cervical Intervertebral Disc Injection Without Fluoroscopy

Cervical disc degeneration commonly results in referred neck pain, which is traditionally diagnosed via fluoroscopy-guided provocative discography. Herein, we discuss three cases of neck and shoulder pain treated with cervical intradiscal injections administered under ultrasound (US) guidance. The most painful intervertebral disc was identified using the sonopalpation technique, which involved palpation while visualizing anatomical structures using US. Injectant spread within the intervertebral disc was validated using superb microvascular imaging rather than fluoroscopy. Symptoms significantly improved following blocks at the identified sites, suggesting that US can be used to guide cervical intradiscal injections even in the examination room.

Diagnosis of Lumbar Transverse Process Fractures in Orthopedic Clinics Using Sonography

Sonography is conventionally used to diagnose fractures by identifying cortical discontinuity in the bone. However, its usefulness for diagnosing lumbar transverse process fractures (LTPFs) remains unknown. In this series, we describe static and stress sonography findings during manual application of compression stress on the lateral lumbar vertebrae in 17 patients with LTPFs. Features of LTPFs on static sonography included cortical discontinuity (89.3%), hematoma (71.4%), step-off deformity (67.9%), and focal reverberation echo (78.6%). All LTPFs were confirmed on stress sonography. Thus, stress sonography should be considered for the detection of LTPFs when there is at least one static sonographic fracture sign.

The applicability of ultrasound in the diagnosis of inflammatory and obstructive diseases of the major salivary glands: a scoping review

OBJECTIVES

The purpose of the present scoping review was to determine the contribution of ultrasound images in the diagnosis of inflammatory and obstructive diseases of the major salivary glands (MSGs).

METHODS

A search of studies of ultrasonographic assessments of human samples was performed in several electronic databases and grey literature up to July 2021. The extracted data were the examined MSG; the diagnostic value of ultrasound (sensibility, specificity, positive- and negative predictive value, accuracy); features of lesions, including number, echogenicity, echotexture, form, margins, size, posterior acoustic aspect, and location; and related clinical information, such as swelling, palpation, sensible to pain, salivation, lymph nodes, recurrence, duration, and causes.

RESULTS

After verifying the eligibility criteria, 90 articles focused on detecting inflammatory, and obstructive diseases of the MSG were gathered, with variable study designs and size samples. A wide variety of pathologies were assessed, including sialolitiasis (n = 45), acute sialadenitis (n = 30), chronic sialadenitis (n = 25), granulamatous diseases (n = 15), Kuttner's tumor (n = 11), juvenile recurrent parotitis (n = 9), abscess (n = 7), post-radiotherapy sialadenitis (n = 6), sialadenosis (n = 9), abscess (n = 7), IgG4-related disease sialadenitis (n = 5), HIV-sialadenitis (n = 4), obstructive sialadenitis (n = 3), iodinated contrast-induced sialadenitis (n = 2), and pneumoparotitis (n = 1). Most studies were case reports or series of cases. Few studies exhibited data about the accuracy of ultrasound in detecting MSG diseases.

CONCLUSIONS

The present scoping review concluded that ultrasound aspects of different MSG pathologies are similar but contribute to their differential diagnosis and can be considered as a valuable initial method for assessing the MSG of adults and children.

Randomised controlled trial for evaluation of an ultrasound-guided palpation intervention for palpation skill training

Although there are increasing reports on the usefulness of sonopalpation with ultrasound imaging, many previous studies have reported interventions without a control group. This single-blind, parallel-group randomised controlled trial aimed to determine whether educational instruction with sonopalpation for physical therapy students has a more superior effect on skill improvement than traditional instruction without ultrasonography. Twenty-nine physical therapy students participated in the study and were randomised using block randomisation into an ultrasound imaging group (n = 15) and a control group (n = 14). Subsequently, they underwent three training sessions focusing on the shoulder joint. Participants underwent a scoring assessment of their palpation skills at pre-intervention, post-intervention, and follow-up 3 months after training. The raters were blinded to the subjects’ group. The Friedman and Mann–Whitney U tests were used for data analysis. The intervention group showed a significant increase in scores at post-intervention and the 3-month follow-up; the effect sizes were large (0.849 and 0.849, respectively). A comparison of the scores at different time points after the intervention at the 3-month follow-up revealed no significant difference between the groups. Education using ultrasound imaging may be non-inferior to education without it; nevertheless, further studies are needed to demonstrate superiority.

Utility of Ultrasonography for Diagnosis of Salivary Gland Sialolithiasis: A Meta-Analysis

OBJECTIVES

We hypothesized that ultrasonography for salivary gland stone detection would have a diagnostic accuracy similar to that confirmed by sialendoscopy, sialography, or surgery. Therefore, we evaluated the diagnostic characteristics of ultrasonography in terms of submandibular and parotid stone detection compared to confirmatory methods.

METHODS

We searched PubMed, Embase, the Web of Science, SCOPUS, and the Cochrane database to October 31, 2021. The risk of bias was evaluated using the QADAS-2 tool.

RESULTS

Ten studies involving 1393 patients were included in the analysis. The diagnostic odds ratio of ultrasonography was 162.6013 (95% confidence interval [CI] [53.9883; 489.7208] and I² value 81.0%). The area under the summary receiver operating characteristic curve was 0.963. The sensitivity, specificity, negative predictive value, and positive predictive value were 0.8992 (95% CI [0.8534; 0.9318]; I²  = 79.9%), 0.9664 (95% CI [0.9290; 0.9844], I²  = 65.6%), 0.8076 (95% CI [0.7256; 0.8694]; I²  = 80.4%), and 0.9853 (95% CI [0.9629; 0.9943]; I²  = 77.4%), respectively. However, high-level among-study heterogeneity (I²  ≥ 50%) was evident, attributable to the inclusion of different glands. On subgroup analysis, significant differences in the negative predictive values (parotid gland only [0.9392], submandibular gland only [0.6718], and parotid and submandibular glands [0.8105]) were apparent. We found no significant among-study difference in the sensitivity, specificity, positive predictive value, or diagnostic odds ratio (P > .05).

CONCLUSION

Ultrasonography usefully detects submandibular and parotid gland stones. Ultrasonography of the parotid gland was associated with the highest diagnostic accuracy, but further clinical studies are needed.

LEVEL OF EVIDENCE

NA Laryngoscope, 2022.

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.

Incorporating Sialendoscopy into the Otolaryngology Clinic

Simple sialendoscopy procedures may be performed in the outpatient clinic with few complications. This process spares patients the risks, increased cost, and time burdens of sialendoscopy under general anesthesia. Sialendoscopy procedures may be incorporated into the outpatient practice after gaining experience with these procedures in the operating room. Diagnostic sialendoscopy, dilation of stenosis, and endoscopic sialolithotomies of small, freely mobile stones are appropriate for in-office sialendoscopy in many instances.

In Vivo Accuracy of Ultrasound for Sizing Salivary Ductal Calculi

OBJECTIVES

The present study was developed to evaluate the accuracy of in vivo ultrasound sizing for parotid and submandibular salivary gland calculi, as compared with ex vivo pathology sizing with a standard plastic ruler after extraction.

STUDY DESIGN

Retrospective chart review.

SETTING

Ultrasound is frequently used to size salivary calculi and make treatment decisions, but the accuracy of measurements from this modality has not been validated.

SUBJECTS AND METHODS

We evaluated and reviewed the charts and ultrasound examinations of 167 patients who underwent procedures for the treatment of sialolithiasis involving the parotid and submandibular glands. US examinations were performed between 2009 and 2016 in a tertiary-level hospital setting by the senior author. Measurements were collected from ultrasound evaluation before sialolithotomy, and pathology measurements were taken after removal. Ultrasound measurements in millimeters were compared with the measurements collected with a ruler. The differences were calculated and compared.

RESULTS

A total of 167 calculi measurements were compared. Good concurrent validity between pathology and ultrasound measurements was suggested by a Pearson correlation of 0.92 (95% CI, 0.887-0.937). On Bland-Altman plot, correlation of the difference between US and pathology measurements showed a mean difference of 0.095 mm (95% CI, -0.19 to 0.38 mm) with a limit of agreement ranging from -3.59 mm (95% CI, -3.84 to -3.34 mm) to +3.78 mm (95% CI, +3.53 to +4.03 mm).

CONCLUSIONS

Ultrasound is an accurate, relatively precise, and minimally invasive imaging tool for salivary gland sialolithiasis. Preoperative size of calculi can be used to guide management and clinical decision making.

LEVEL OF EVIDENCE

2C.

Transoral Ultrasound in the Diagnosis of Obstructive Salivary Gland Pathologies

Transcutaneous ultrasound (TCUS) is an accepted diagnostic method in salivary gland diseases. However, sparse data are available on the use of transoral ultrasound (TOUS) in sialadenopathies. One hundred five patients presenting with various obstructive sialadenopathies were examined using TOUS and TCUS. Ultrasound findings were validated by direct visualization in subsequent sialendoscopy examinations. By TOUS, but not by TCUS, all patients with sialolithiasis (70/105) could be identified and virtually all concrements, even very small ones, were detected and distinguished from artifacts. Ductal stenoses (16/105) could be correctly differentiated from sialoliths, and exceptional insights into the delicate anatomy of parotid duct stenoses were gained. TOUS provided detailed information on other space-occupying lesions (14/105) and circumvented the method-related diagnostic weaknesses of TCUS. As a valuable tool in the diagnosis of obstructive sialadenopathies, TOUS seems superior to TCUS in pathologies involving the distal parotid duct, the submandibular duct system and the floor of the mouth.

The value of the twinkling artefact for the diagnosis of sialolithiasis of the large salivary glands

Objective:

The imaging of stones in the salivary glands and ducts poses a challenge, even to experienced ultrasound examiners. This study investigated whether the ‘twinkling artefact’, which occurs at internal calcific foci during Doppler ultrasound examinations, is useful for detecting salivary gland stones.

Methods:

In a model test, 20 salivary stones were analysedin vitro, via Doppler ultrasound, with regard to their representability and the triggering of the twinkling artefact. In a follow-up study, 28 patients with sialolithiasis and food-related large salivary gland swellings were examined, using both power and colour Doppler modes, with regard to the twinkling artefact. All ultrasound examinations were performed by an experienced examiner and retrospectively graded by two experienced sonographers.

Results:

All stones could reliably be detected using the twinkling artefact in the model test. Twenty-seven of 28 salivary stones (96 per cent) also showed twinklingin vivo, during patient assessment. The power Doppler mode showed a significantly higher intensity level of twinkling than the colour Doppler mode (p< 0.0001).

Conclusion:

The twinkling artefact is a very reliable sign for the diagnosis of sialolithiasis. Power Doppler is superior to colour Doppler for detection of the twinkling artefact.

Surgeon-Performed Ultrasound for Chronic Obstructive Sialadenitis Helps Predict Sialendoscopic Findings and Outcomes

Objective

To determine the accuracy of surgeon-performed ultrasound (SP-US) features for predicting intraoperative sialendoscopic findings and to correlate ultrasound features with short-term symptomatic outcomes following sialendoscopy-assisted salivary duct surgery (SASDS).

Study Design

Case series with chart review.

Setting

The practices of 2 academic sialendoscopy surgeons.

Subjects and Methods

Between February 2014 and September 2015, 82 patients with 105 symptomatic glands underwent SASDS, of whom 56 patients (75 glands) met inclusion criteria. SP-US and sialendoscopic findings were reviewed for patients with chronic obstructive sialadenitis who underwent SASDS and who had been prospectively evaluated with the University of California–San Francisco Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire (scored 0-100) administered preoperatively and 3 months postoperatively.

Results

The positive predictive value (PPV) and negative predictive value (NPV) of SP-US for identifying sialoliths intraoperatively were 94% (33/35) and 91% (39/43), respectively. Of glands with sialoliths on SP-US, 97% (34/35) had complete symptom resolution (COSS ≤10) after SASDS. The PPV and NPV of salivary duct dilation on SP-US for finding a corresponding stenosis on sialendoscopy were 93% (14/15) and 50% (14/28), respectively. Nonsialolith SP-US features with the highest PPV for complete or partial symptom resolution (COSS ≤25) following SASDS included distal duct dilation of all glands (86%; 6/7) and dilation of both distal and proximal parotid ducts (75%; 6/8).

Conclusion

SP-US has high accuracy for ruling in and ruling out sialoliths, as well as for ruling in but not for necessarily ruling out stenosis presence and location. Ultrasound is helpful in estimating degree of short-term symptom response following SASDS.

Eliciting renal tenderness by sonopalpation in diagnosing acute pyelonephritis

Diagnosing acute pyelonephritis relies on the combination of historical, physical, and laboratory findings. Costovertebral angle tenderness is important, although its accuracy is unknown. Point-of-care ultrasound-guided palpation (sonopalpation) may aid clinicians in localizing pain to discrete anatomic structures in cases of suspected acute pyelonephritis lacking classic features. We describe three low-to-moderate pre-test probability cases wherein maximal tenderness was elicited by renal sonopalpation, aiding in the diagnosis of acute pyelonephritis. In a fourth case, absence of renal tenderness to sonopalpation in a patient exhibiting typical acute pyelonephritis features led to an alternate diagnosis. Therefore, renal sonopalpation may be useful in confirming or refuting suspected cases.