Iodinated contrast media allergy is rare in patients undergoing sialography

BACKGROUND

Iodinated contrast media allergy is considered as a strong contra-indication for performing sialography. There is little evidence to support this approach.

OBJECTIVE

To evaluate the rate of iodinated contrast media (ICM) allergy in subjects undergoing sialography and to assess the risk for allergic responses in patients with a previous diagnosis of allergy.

METHODS

We retrospectively reviewed sialo-CBCT studies performed from 2014 to 2019. During the study period we implemented a protocol for performing sialo-CBCT in patients with a prior diagnosis of allergy: 1) Clinical data were collected from a questionnaire and medical records. 2) No premedication was administered but, instead, oxygen, epinephrine and a resuscitation cart were accessible. 3) Following the procedure, each patient was observed for one hour and contacted by telephone 24 hrs later.

RESULTS

No allergic responses were documented in the medical records of 1515 subjects following sialo-CBCT studies, including 13 individuals previously diagnosed with ICM allergy. Investigation of the subgroup with prior allergy disclosed that the range of injected volume was between 2 ml to 6.2 ml per patient and that complete secretion of ICM was detected in 7 of 13 patients. In the remainder of subjects, retention rates of 5-50% were observed.

CONCLUSIONS

Allergic reactions are exceedingly rare following sialo-CBCT studies regardless of a previous diagnosis of allergy. Pre-medication with corticosteroids and antihistamines is usually not warranted.

Standardization of terminology, imaging features, and interpretation of CBCT sialography of major salivary glands: a clinical review

Sialography combined with cone beam computerized tomography (sialo-CBCT) is an imaging technique that demonstrates the ductal system of the major salivary glands and allows evaluation of gland function. This review describes the sialo-CBCT technique, terminology, common pitfalls and limitations, as well as radiographic features and suggested pathogenicity of various salivary gland disorders, based on 1,758 sialo-CBCT examinations conducted over the last decade in one institution, and the current literature. The adoption of standardized terminology is proposed to prevent miscommunication, facilitate formulation of differential diagnoses, and thereby promote patient management: (1) Sialo-CBCT requires specific training, and operator experience is required for adequate glandular filling with minimal extravasation; (2) Limit injection-to-scan time to avoid pre-mature emptying; (3) The sialo-CBCT report should include a description of the morphology of the primary duct as well as the secondary, tertiary, and descending branches, the maximal branching level, the presence of sialectasis, overall glandular size, and parenchymal findings; (4) Functional evaluation is based on assessment of iodine clearance in the post evacuation image; (5) Sialectasis and ductopenia are the main findings in Sjogren syndrome and recurrent juvenile parotitis; (6) Sialodochitis with or without fillings defects or hyperdense calcifications characterize obstructive sialadenitis and sialolithiasis; (7) The findings following radioactive-iodine-induced damage are similar to obstructive sialadenitis, with atrophy in late stages; (8) In chronic graft-versus-host disease (cGVHD), variable presentations of ductopenia, sialectasis, and sialodochitis may be evident; (9) The red flags indicating a space-occupying lesion include areas of no filling, splaying of ducts, and primary duct deviation.

[DIAGNOSTIC, CLINIC AND TREATMENT OF DISEASES OF SUBMANDIBULAR SALIVARY GLAND]

The purpose of the research was to study the structure of diseases of the submandibular salivary gland, to improve the diagnosis and effectiveness of the surgical treatment of patients with diseases of the submandibular salivary glands. A survey and treatment of 1094 patients with diseases of the submandibular salivary glands was performed. It was revealed that the most common disease of the submandibular salivary gland is calculous submaxillitis in the exacerbated and chronic stages of the inflammatory process (82.1%). Tumors and tumor-like formations of the submandibular glands account for 15.3% (167 patients), among which tumor-like formations were detected in 6.0%, and benign and malignant tumors of the submandibular glands were found in 94.0% of cases. Postoperative tumor relapses were detected in 2.1% of cases. The reason for them was a violation of the technique of surgical intervention. According to our observations, only the joint use of different diagnostic methods for examining patients with pathology of the submandibular glands (sialography, orthopantomosialography, computed tomosialography, CT, MRI, ultrasound) can significantly increase the diagnostic value of the methods used. The operation must be carried out by simultaneously removing the detected neoplasm with extirpation of the submandibular gland.

Treatment strategy of hilar and intraglandular stones in wharton's duct: A 12-year experience

OBJECTIVES/HYPOTHESIS

To suggest a strategy for transoral removal of hilar and intraparenchymal submandibular stones.

STUDY DESIGN

Retrospective case series.

METHODS

Retrospective evaluation was performed for 514 consecutive patients with hilar and intraparenchymal submandibular stones treated via endoscopy-assisted surgery from January 2006 to June 2018. Three patients had bilateral stones. The stones were classified as: hilar (type I), posthilar (type II), intraparenchymal (type III), and multiple stones (type IV).

RESULTS

The affected glands included 311 with type I, 84 with type II, 65 with type III, and 57 with type IV stones. Stones were successfully removed in 478 glands (92.5%, 478/517). Main treatment techniques included hilum ductotomy in 311 glands, intraparenchymal ductotomy in 68, submandibulotomy in 14, intraductal retrieval in 74, and hilum ductotomy accompanied by intraductal retrieval in 11. At a mean 40-months follow-up of 478 successful cases, clinical outcomes were good in 425, fair in 27, and poor in 26 glands. Postoperative sialograms in 75 stone-free patients were categorized as: type I, normal (n = 6); type II, ectasia or stenosis in the main duct and no persistent contrast on functional films (n = 44); type III, ectasia or stenosis in the main duct and mild contrast retention (n = 15); and type IV, poor shape of the main duct and evident contrast retention (n = 10). Postoperative sialometry of 32 patients revealed no significant differences of the gland function between the two sides.

CONCLUSIONS

Appropriate use of various endoscopy-assisted approaches helps preserve the gland and facilitates recovery of gland function in patients with different depths of hilo-parenchymal submandibular stones.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2360-2365, 2020.

Ameloblastoma incidentally detected in cone-beam computed tomography sialography: A case report and review of the literature

BACKGROUND AND OVERVIEW

Cone-beam computerized tomographic (CBCT) imaging is increasingly used in the maxillofacial region for various purposes. The volumetric dataset created by means of CBCT increases the possibility of detecting incidental findings.

CASE DESCRIPTION

In this case report, the authors describe an otherwise healthy 45-year-old man who was referred from the Sjogren's Syndrome Center in Jerusalem, Israel, for bilateral parotid CBCT sialographic imaging owing to xerostomia lasting for 4 months. CBCT sialographic imaging using iodine contrast material showed normal glandular structure and activity according to the postcannulation panoramic imaging. CBCT sialographic imaging routine volume interpretation revealed a lesion in the mandibular area causing destruction and perforation of the cortical plates, partial disappearance of adjacent lamina dura, and resorption of adjacent teeth, suggesting an aggressive benign tumor. Histopathologic examination confirmed mural cystic ameloblastoma, which was resected with preservation of the mental nerve and the lower mandibular border. The patient received bone graft and implants, with regular follow-ups and no recurrence after 4 years.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

This case strengthens the need for thorough examination of the whole CBCT imaging volume within and outside the region of interest to detect incidental findings with clinical importance.

Evaluation of Parotid Gland Function Before and After Endoscopy-Assisted Stone Removal

PURPOSE

To quantify gland function before and after endoscopy-assisted lithectomy for patients with parotid stones and to analyze correlations among different evaluation modalities.

MATERIALS AND METHODS

This study investigated 58 patients (27 men and 31 women) with a stone larger than 5 mm or multiple parotid stones who underwent successful endoscopy-assisted surgery at the authors' center from August 2007 through September 2017. Meticulous postoperative manipulations were administered routinely for 3 to 6 months to promote functional recovery of the affected gland. Gland function was evaluated preoperatively and 6 to 36 months (mean, 12 months) postoperatively by sialography, scintigraphy, and sialometry. Statistical analyses were conducted to quantify gland function recovery and to distinguish correlations among the 3 objective tests.

RESULTS

Preoperative sialograms exhibited ductal ectasia at the stone site with ductal stenosis anterior to the stone (n = 53) or duct interruption at the stone site (n = 5). Postoperative sialograms of 45 patients without stones were categorized as approximately normal (type I; n = 17); showing ectasia or stenosis of the main duct without persistent contrast on the functional film (type II; n = 16); showing ectasia or stenosis of the main duct with mild contrast retention (type III; n = 6); or showing poor ductal shape with evident contrast retention (type IV; n = 6). Scintigraphy of 23 preoperative and 12 postoperative patients and sialometry of 24 preoperative and 12 postoperative patients indicated severe preoperative impairment and postoperative improvement of gland function. Postoperatively, although no relevant differences in saliva flow rate were found between the 2 sides, scintigraphy showed lower function of the affected gland compared with the control side. Statistical data showed positive correlations among the 3 methods. Sialography intuitively reflected the ductal shape, whereas sialometry and scintigraphy were more sensitive for evaluating gland function.

CONCLUSION

For patients with parotid stones, minimally invasive endoscopic surgery and meticulous postoperative manipulations help preserve the glands and facilitate recovery of gland function. The 3 evaluating modalities have certain positive correlations.

Magnetic Resonance Sialography and Salivary Gland Scintigraphy of Parotid Glands in Sjögren's Syndrome

OBJECTIVE

To assess the correlation between conventional magnetic resonance (MR) imaging and MR sialography of parotid glands with salivary gland scintigraphy in patients with Sjögren's syndrome.

METHODS

A retrospective study was conducted on eight patients with Sjögren's syndrome who underwent MR imaging and salivary gland scintigraphy. Conventional MR imaging techniques, such as T1-weighted images (T1WI), T2-weighted images (T2WI), and short TI inversion recovery images (STIR) were used for changes of fat signal in the parotid gland, while the MR sialography were used for ducts dilation of the parotid gland. Regarding scintigraphy, time-activity curves of each parotid gland were analysed. The salivary gland excretion fraction was defined as A (before stimulation test (counts/20 s)) and B (after stimulation test (counts/20 s)).

RESULTS

Regarding characteristic appearances of fat signal, the A/B of parotid gland with homogeneous intensity distribution (3.51 ± 0.75) was higher than that with heterogeneous intensity distribution (1.56 ± 0.66, P = 0.001). Regarding MR sialographic stages, the A/B of parotid gland with stage 0 (3.51 ± 0.75) was higher than that with stage 1 (2.03 ± 0.86, P = 0.009) and with stage 2 (1.26 ± 0.25, P = 0.000).

CONCLUSION

The results suggest that MR sialography of the parotid glands is a useful noninvasive tool for evaluating the decrease of salivary gland excretion in patients with Sjögren's syndrome.

Imaging in primary Sjögren's syndrome: the 'obsolete and the new'

Primary Sjögren's syndrome (pSS) is a complex systemic autoimmune disease primarily characterised by a focal chronic inflammation of glandular parenchyma, with chronic and persistent involvement of major salivary gland remaining a key element of the disease. Indeed, classification criteria proposed for pSS have always included items for histological and/or imaging salivary gland assessment. Over time, the approach to the definition of glandular involvement in pSS is constantly evolving. In this review we will therefore illustrate the state of the art of imaging techniques in pSS, focusing on conventional and novel modalities and discussing their advantages, drawbacks and possible future developments.

[Endoscopy-assisted sialodochoplasty for the treatment of severe sialoduct stenosis]

OBJECTIVE

To evaluate the effects of endoscopy-assisted sialodochoplasty for the treatment of severe sialoduct stenosis with concurrent megaducts.

METHODS

From Jul.2010 to Dec. 2016, 8 patients presenting with severe parotid duct stenosis and 3 patients with occlusion of the Wharton's duct underwent endoscopy-assisted sialodochoplasty.All these patients had concurrent severe ductal ectasiaand manifested a painful swelling of the involved salivary glands.The diameter of ectasia and length of stenosis of the sialoducts were measured preoperatively by sialography, computed tomography, or ultrasonography. The megaducts were opened transorally and sutured to the buccal or oral floor mucosa, therefore creating a neo-ostium. All the patients were followed up periodically after operation. The treatment effects were evaluated by clinical signs, sialogram and sialometry.

RESULTS

The length of the Stensen's duct stenosis was 5-12 mm, and the diameter of the concurrent ectasia was 8-16 mm. The length of the Wharton's duct stenosis was 10-20 mm, and the diameter of the concurrent ectasia was 6-8 mm.The neo-ostiums healed uneventfully 2 weeks after operation. The duration of the follow-up varied from 6 to 78 months (median: 24 months). Among the 8 patients with Stensen's duct stenosis, two experienced re-obliteration of the neo-ostium, but the buccal bulge and clinical symptoms disappeared; one reported recurrent clinical symptoms after initial alleviation, which could be controlled with self-massaging; the remaining 5 patients had satisfactory clinical results, i.e., disappearance of the obstruction symptoms and buccal bulge, patent ostium,clean saliva and improvement of the ductal ectasia on sialogram. Three patients with Wharton's duct occlusion were asymptomatic with clear saliva and patent ostium;two exhibited approximately normal appearance and one showed improvement of the sialogram.Sialometry was performed in 9 patients with patent neo-ostium of the involved glands,the resting saliva flow rate of the affected glands showed no differences compared with the normal side, and stimulated flow rate showed a significant increase, though less than the control side.The clinical results included good in 5 patients, fair in 4 patients, and poor in 2 patients, with a total effective rate of 82% (9/11).

CONCLUSION

Endoscopy-assisted sialodochoplasty appears to be effective and can be a viable option for patients presenting with severe sialoducts tenosis and concurrent ectasia.

[Fortuitous discovery of a Stafne bone cavity in the Cone Beam CT sialography]

The Stafne defect is a benign, asymptomatic, non-progressive and rare bone depression, mainly discovered by chance in the posterior mandibular region. It is described radiographically as an oval radiolucency located below the mandibular canal, in the molar region, close to the submandibular gland. Sialography is a traditional technique in the radiographic examination of salivary glands that involves the injection of an iodine-based contrast medium into the main salivary duct. The Cone Beam Computed Tomography (CBCT) is a 3D imaging technique that has modernized the dental and maxillofacial practice with its advantages such as high speed, good spatial resolution and low radiation exposure. The CBCT Sialography that consists in a 3D Sialography with cone beam offers the same benefits as traditional sialography and allows three-dimensional viewing. It is a new imaging test for an accurate anatomical study of the major salivary glands and their relationships with their environments. The aim of this report is to present a case of Stafne bone cavity containing right submandibular gland tissue, occurring in a 58-year-old man and diagnosed by using CBCT sialography.

Sialodochitis fibrinosa (kussmaul disease) report of 3 cases and literature review

BACKGROUND

Sialodochitis fibrinosa is a rare disease which is characterized by recurring episodes of pain and swelling of the salivary glands due to the formation of mucofibrinous plugs. Analytic studies ascertain elevated levels of eosinophils and immunoglobulin E (IgE). Imaging studies such as magnetic resonance imaging (MRI) and sialography reveal dilation of the main salivary duct (duct ectasia). Treatment is initially supportive, consisting of compressive massages, and use of antihistamines and/or corticosteroids.

MATERIAL AND METHODS

In the following, 3 cases of sialodochitis fibrinosa are presented which were diagnosed in a third level hospital during the period of 2008 and 2016, as well as a literature review of all cases reported to our knowledge.

RESULTS

Of the 41 cases found, including the 3 of this article, 66% were women with an average age of 45 years old. However, 75% of reported cases were of Japanese heritage. Involvement of the parotid glands was more frequent than the submandibular glands. In more than half of all cases treatment with compressive massages, antihistamines and/or corticosteroids was effective.

CONCLUSION

Clinicians should consider sialodochitis fibrinosa as a diagnostic possibility when presented with cases of recurring parotid and submandibular gland tumescence.

Role of the Accessory Parotid Gland in the Etiology of Parotitis: Statistical Analysis of Sialographic Features

This retrospective study aimed to identify if the existence of the accessory parotid gland correlated with the etiology of parotitis. This may aid the development of better treatment strategies in the future. Sialographic features of cases with parotitis and healthy subjects were reviewed. The chi-square test was used to compare the incidence of accessory parotid gland between the groups. The Student's t test was used to compare the length of Stensen's duct, the length from the orifice to the confluence of the accessory duct, and the angle between the accessory duct and Stensen's duct between the groups. The incidence of accessory parotid gland in patients with parotitis was 71.8% (28/39), which was significantly higher than that in healthy subjects (P = 0.005). Patients with parotitis had a longer Stensen's duct than healthy subjects (P = 0.003). There was no significant difference in the length from the orifice to the confluence of the accessory duct or the angle between the accessory duct and Stensen's duct (P = 0.136 and 0.511, respectively) between the groups. The accessory parotid gland might play a role in the pathogenesis of parotitis. The existence of an accessory parotid gland is likely to interfere with salivary flow. Computational fluid dynamics analysis of salivary flow in the ductal system would be useful in future etiologic studies on parotitis.

Congenital salivary gland anlage tumor - in utero and postnatal imaging

We present a case of an infant with congenital salivary gland anlage tumor, with fetal and postnatal imaging. To the best of our knowledge, this is the first case describing the in utero imaging findings of salivary gland anlage tumor. A fetal MRI was performed secondary to the clinical finding of polyhydramnios, which identified a nasopharyngeal mass. Because findings were concerning for airway obstruction, the fetus was delivered by ex utero intrapartum treatment (EXIT) to airway procedure. A postnatal CT confirmed the findings of the fetal MRI. The lesion was resected when the baby was 4 days old and recovery was uneventful.

Computational fluid dynamics analysis of salivary flow and its effect on sialolithogenesis

OBJECTIVE

Sialolithiasis is a common disease caused by intraductal stones, formed by reduction in salivary flow, salivary stagnation, and metabolic events. We used computational fluid dynamics to investigate changes in salivary flow field around parotid stones of different shapes.

MATERIALS AND METHODS

Three-dimensional configurations of the Stensen's duct were reconstructed from computed tomography sialographic images. Fluid dynamics modeling was used to analyze the salivary flow field around stones under unstimulated and stimulated conditions.

RESULTS

The majority of sialoliths were oval-shaped (59/98), followed by irregular (24/98) and round (15/98). Salivary velocity was significantly higher around streamlined stones, compared with round (P = 0.013) and oval (P = 0.025) types. Changes in salivary flow field around sialoliths were found to affect the pattern of mineral deposition in saliva. The area of low velocity around the round stone was double the size observed around the streamlined stone during the unstimulated state, whereas in the stimulated state, local vortexes were formed on the downstream side of round and oval stones.

CONCLUSIONS

Salivary flow field around sialoliths plays an important role in the progression of multicentric stones, and analysis of the salivary dynamics during sialolithiasis may provide deeper understandings of the condition and aid in developing successful treatment strategies.

Diagnostic accuracies of sialography and salivary ultrasonography in Sjögren's syndrome patients: a meta-analysis

OBJECTIVES

The purpose of this study was to compare the diagnostic performance of sialography and salivary ultrasonography (US) for Sjögren's syndrome (SS) patients.

METHODS

We searched Medline, Embase, and the Cochran library, and performed two meta-analyses on the diagnostic accuracy of sialography and salivary US in SS patients.

RESULTS

A total of six studies including 488 patients and 447 controls from two European and four Asian studies were available for the meta-analysis. The pooled sensitivity and specificity of sialography were 80.0% (95% confidence interval [CI] 76.4-83.2) and 89.0% (85.8-91.8), respectively, and 77.4 (73.7-80.9) and 81.5 (77.6-85.0) for US, respectively. For sialography, the PLR, NLR, and DOR were 9.296 (4.200-20.57), 0.228 (0.170-0.305), and 46.51 (16.14-134.0), respectively, and for US were 4.631 (2.707-7.864), 0.302 (0.226-0.403), and 17.48 (10.03-30.45), respectively. The area under the curve (AUC) of sialography was 0.824, and the Q* index was 0.757, while the AUC of US was 0.864, and its Q* index was 0.794, indicating that the diagnostic accuracy of US is comparable with sialography in SS patients. A subgroup meta-analysis according to the diagnostic criteria did not change the overall diagnostic accuracy.

CONCLUSIONS

Our meta-analysis of published studies demonstrates that the diagnostic accuracy of salivary US is comparable with sialography in SS patients.

Sjögren's syndrome: An underdiagnosed condition in mixed connective tissue disease

OBJECTIVE

To determine the prevalence of sicca symptoms, dry eye, and secondary Sjögren's syndrome and to evaluate the severity of dry eye in patients with mixed connective tissue disease.

METHODS

In total, 44 consecutive patients with mixed connective tissue disease (Kasukawa's criteria) and 41 healthy controls underwent Schirmer's test, a tear film breakup time test, and ocular surface staining to investigate dry eye. In addition, the dry eye severity was graded. Ocular and oral symptoms were assessed using a structured questionnaire. Salivary gland scintigraphy was performed in all patients. Classification of secondary Sjögren's syndrome was assessed according to the American-European Consensus Group criteria.

RESULTS

The patients and controls had comparable ages (44.7±12.4 vs. 47.2±12.2 years) and frequencies of female gender (93 vs. 95%) and Caucasian ethnicity (71.4 vs. 85%). Ocular symptoms (47.7 vs. 24.4%) and oral symptoms (52.3 vs. 9.7%) were significantly more frequent in patients than in controls. Fourteen (31.8%) patients fulfilled Sjögren's syndrome criteria, seven of whom (50%) did not have this diagnosis prior to study inclusion. A further comparison of patients with mixed connective tissue disease with or without Sjögren's syndrome revealed that the former presented significantly lower frequencies of polyarthritis and cutaneous involvement than did the patients without Sjögren's syndrome. Moderate to severe dry eye was found in 13 of 14 patients with mixed connective tissue disease and Sjögren's syndrome (92.8%).

CONCLUSIONS

Sjögren's syndrome, particularly with moderate to severe dry eye, is frequent in patients with mixed connective tissue disease. These findings alert the physician regarding the importance of the appropriate diagnosis of this syndrome in such patients.

Advances in imaging of obstructed salivary glands can improve diagnostic outcomes

INTRODUCTION

Obstruction of the major salivary glands is a relatively common condition defined as the blockage of the salivary outflow in the glandular ductal system. It can however mimic more aggressive pathology.

METHODS

The most common cause of salivary obstruction is sialolithiasis, followed by ductal strictures. Salivary obstruction is clinically characterized by a food-related painful swelling of the affected gland, known as 'mealtime syndrome'.

RESULTS

When obstruction is clinically suspected, the role of imaging consists of confirming the obstruction, identifying its cause, evaluating the position and extent of the obstruction and evaluating for associated complications. However, if imaging shows up signs of a tumour or other pathology which can mimic an obstructed gland clinically instead, the radiologist can alert the clinician accordingly to change the course and plan of treatment. Several imaging techniques are available for investigating the obstructed salivary glands.

CONCLUSIONS

This review looks at the causes of obstruction and the use, diagnostic performance and practicality of the various imaging modalities. Importantly, an imaging approach algorithm for the evaluation of the obstructed salivary gland is also proposed.

Anterior lingual mandibular bone depression in an 11-year-old child

This report describes physical and imaging findings in a case of anterior lingual mandibular bone depression in a child. This entity is very rarely diagnosed and even more extremely rarely seen in children. We present some characteristic findings depicted on images provided by different sources and briefly address current hypotheses on its pathogenesis.

Unusual presentation of Sjögren syndrome: multiple parotid cysts

Sjögren syndrome is a chronic autoimmune exocrinopathy that destroys salivary and lacrimal gland tissue. We report an unusual case of this disease in a 40-year-old woman who presented with bilateral parotid cystic masses. As this case illustrates, Sjögren syndrome should be included in the differential diagnosis of bilateral cystic parotid lesions.

[Clinical assessment of oral diagnostic items in 2002 classification criteria for primary Sjogren's syndrome]

OBJECTIVE

To evaluate the diagnostic value of each item in 2002 international classification criteria for primary Sjogren's syndrome (pSS) in clinically diagnosed cases.

METHODS

All patients were from the Department of Oral Medicine of Peking University School of Stomatology from 2005 to 2010. Their clinical manifestations and lab testing results met the standard criteria and the diagnosis was established according to international classification criteria (2002). We retrospectively collected all of the clinical and information and did the data analysis.

RESULTS

A total of 148 pSS patients were included in the study. When the oral evaluations were performed, 98.0% of the patients complained dry mouth, 96.6% of them had decreased non-stimulated salivary flow rate, and 60.1% had positive parotid sialography results, which was consistent with diagnosis. It was found out in the lab testing that 79.7% of the patients had positive anti-SSA antibody, and 75.0% of them had elevated globulin level. 20.3% of the patients were finally diagnosed by performing the lower lip biopsy.

CONCLUSION

When applying 2002 international classification criteria for the diagnosis of pSS patients, oral symptoms and unstimulated salivary flow rate are feasible and sensitive, which play an important and indicative role in the diagnosis of pSS.

Salivary gland imaging

Dry mouth, facial swelling, and pain are common signs of salivary gland disorders that may be encountered in the dental practice. Diagnostic imaging can facilitate assessment of patients with these problems. The purpose of this review paper is to discuss the imaging modalities available for assessment of the major salivary glands, their indications, and limitations to assist the dentist managing patients with salivary gland disorders.

Sialoendoscopy for diagnosis and treatment of non-neoplastic obstruction in the salivary glands

INTRODUCTION

The objective of this study was to evaluate our experience with sialoendoscopies for diagnosis and treatment of obstructive disease in the large salivary glands in Eastern Denmark and to broaden awareness of the procedure.

MATERIAL AND METHODS

A retrospective study was designed including the first 100 consecutive sialoendoscopies in 91 patients performed at Hillerød Hospital and Rigshospitalet, in the 2004-2009 period.

RESULTS

The median age of the 91 patients was 45 years (range 9-74 years) with a female-to-male ratio of 1.68. A total of 53 parotid and 47 submandibular endoscopies were performed. The indications for sialoendoscopy were sialolithiasis, stenosis, recurrent swelling and recurrent infections. We found an overall success rate of 91% in 100 diagnostic endoscopies and 62% in 65 interventional endoscopies. We observed an improvement in success rates over the course of the study period. Symptom relief was obtained in 69% of the patients with pathology following intervention. No serious complications occurred.

CONCLUSION

Sialoendoscopy is a safe, effective and minimally invasive method for diagnosis and treatment of obstructive salivary gland disease.

The use of the "puffed-cheek" computed tomography technique to confirm the diagnosis of pneumoparotitis

Pneumoparotitis is a rare etiology of symptomatic parotid gland enlargement that is often misdiagnosed clinically. Pneumoparotitis results from air refluxing into the parotid ductal system via an incompetent Stensen duct orifice. We report a protracted case of pneumoparotitis evaluated with the "puffed-cheek" computed tomography technique to help confirm the diagnosis.

Distal parotid duct pseudocyst as a result of blunt facial trauma

The sequelae of sharp trauma to the parotid duct, such as sialocele and salivary fistula, are well known. In contrast, complications of blunt trauma to the parotid duct are not as common. A search of the English-language literature revealed 2 cases of parotid pseudocysts caused by blunt trauma. Although no well-known management protocol exists for complications of blunt trauma to the parotid duct, the treatment modalities for sharp trauma complications potentially could be applied. We describe a case of a blunt-trauma-induced distal parotid duct pseudocyst that remained refractory to conservative management, including repeated aspiration and cannulation of the duct. After characterizing and localizing the pseudocyst with sialography and cross-sectional imaging, we performed a surgical repair. This repair involved marsupialization of the parotid duct to the level of the pseudocyst. The edges of the opening of the proximal duct and the pseudocyst were sutured to the oral mucosa, and a small intraoral drain was left in the pseudocyst to prevent collapse and abscess formation. The drain was removed after 5 days, and the patient experienced no further problems during 14 months of follow-up.

Salivary simulation with ascorbic acid enhances sonographic diagnosis of obstructive sialadenitis

PURPOSE

High-frequency ultrasound (US) is routinely used to evaluate various diseases of the salivary glands. Normally, the duct network of the submandibular and parotid glands is not visible during US assessment. In obstructive sialadenitis of the parotid and submandibular glands, localization of the obstacle is often difficult.

METHODS

In a case-control study, the sonographic visibility of the duct before and after stimulation with oral ascorbic acid (vitamin C) was compared with sialendoscopy as the gold standard. Twenty male and 23 female patients suffering from salivary gland diseases were included in this study and compared with 25 healthy volunteers. US examination of the parotid and submandibular glands was performed before and after oral ascorbic acid stimulation. Changes in visibility of the main excretory duct were recorded and US diagnoses were compared with results of sialendoscopy.

RESULTS

In 7 of 25 controls, the main duct became partially visible after stimulation. In the group of 43 patients, the main duct was depicted before stimulation in 27 patients (63%). After ascorbic acid stimulation, the main duct became visible in 41 patients (95%). Grading the stimulated duct dilation by measuring diameters at different points revealed no correlation with the underlying type of pathology.

CONCLUSIONS

Application of ascorbic acid prior to diagnostic US examination facilitates the sonographic evaluation of obstructive salivary gland diseases.

Traumatic diseases of parotid gland and sequalae. Review of literature and case reports

Parotid gland injuries are accompanied by a large number of sequelae. The aim of this paper is to highlight the importance of thorough management of these parotid glandinjuries especially at initial presentation in order to minimize the complications that accompany these injuries. A review of the aetiology and management of the existing cases of parotid gland injuries obtained from published journals and internet search as well as a report of two cases managed in our centre is presented in this paper. A total of about 70 cases in the previous literatures were reviewed of which assault was responsible for almost 90% of the cases. Sialoceles and fistulae were the main sequelae of these injuries. More than half of the cases (54%) were managed by conservative methods. Surgical drainage was done in about 44% cases; where the Stenson's ducts were accessible, primary repair was done. Excision of the gland was done in very few cases. The two cases managed in our centre were due to assault from broken bottles and road traffic accident respectively and both were managed by conservative methods. The first patient was a case of sialocele following the injury, which resolved within 3 weeks after the cyst formation with reduction in food intake, aspirations and external surgical drainage; while the second patient was a case of persistent fistula which healed after about 5 weeks following the trauma. Follow-up of both patients for about 3 months revealed no further leakage or accumulation of saliva. Management of these injuries involves a thorough understanding of the structure and function of the parotid gland and closely related tissues.

[Diagnostic value of magnetic resonance sialography for submandibular sialolithiasis]

PURPOSE

To evaluate the role of MR Sialography(MRS) in diagnosis of submandibular sialolithiasis.

METHODS

Twenty-one patients with submandibular sialolithiasis were scanned by MRS, the results of MRS were compared with those after proper treatment.

RESULTS

The results of MRS were consistent with those after proper treatment.

CONCLUSION

MRS has high diagnostic accuracy in diagnosis of sialolithiasis including submandibular sialadenitis.

[Developmental anomaly of parotid and submandibular glands ducts]

Authors based upon multispiral computer tomography with building up multiplanar 3D-reconstructions disclosed earlier not described developmental anomaly of salivary glands: rudimentary ducts running beyond capsule of parotid and submandibular glands.

[Sialoendoscopy possibilities in diagnostics and comprehensive treatment of chronic sialoadenitis]

Checkup and treatment of 187 patients with different forms of chronic sialoadenitis was done, 38 from them parotid gland sialoendoscopy was performed. Sialoendoscopic criteria of chronic sialoadenitis forms and clinical results of the fulfilled sialoendoscopic procedures in the immediate postoperation period were described. The direct visual assessment of parotid duct system let with high degree of exactness to determine the sialoadenitis form and simultaneously to make surgical intervention that made sialoendoscopy the choosing method in diagnostic and treatment of chronic inflammatory pathology of major salivary glands.

HTLV-I infection results in resistance toward salivary gland destruction of Sjögren's syndrome

OBJECTIVE

The role of HTLV-I infection in Sjögren's syndrome (SS) remains unclear. In this study, we clinically compared radiographic imaging with histological cellular infiltration between HTLV-I-seropositive and HTLV-I-sero-negative SS.

METHODS

Sixty primary SS patients were divided into two age-matched groups based on the seropositivity of the anti-HTLV-I antibody. We evaluated the two groups through labial salivary gland biopsy-proven cellular infiltration and sialography-proven radiographic gland destruction.

RESULTS

In these 60 pSS patients, the incidence of abnormalities as determined by salivary gland biopsy and sialography was 51.7% (31/60) and 76.7% (46/60), respectively. Although there was no difference in the prevalence of abnormal findings between salivary gland biopsy and sialography in the whole 60 patients, there were significantly fewer abnormalities determined by sialography in HTLV-I-seropositive SS patients in comparison with HTLV-I-seronegative SS patients. Also, these findings were strengthened by the results that none of HTLV-I-seropositive SS patients with focus score 0 had abnormal sialography findings.

CONCLUSION

Our results suggest that HTLV-I infection results in resistance toward salivary gland destruction of Sjögren's syndrome.

Morbidity of salivary gland digital sialography using a non-ionic dimeric contrast medium

AIM

Sialography is considered a low invasive procedure, due to cannulation of salivary duct orifice. The aim of this study was to evaluate the morbidity of sialography using a nonionic dimeric contrast medium.

METHODS

A questionnaire was proposed to 90 patients who underwent parotid and submandibular sialography to reveal related symptoms as: pain, swelling, impairment to daily activities and taste alteration. Pain and swelling intensity was assessed using a visual analogue scale (VAS).

RESULTS

Fifty-two out of ninety questionnaires were returned. Sialography was performed in 30/52 patients in the submandibular gland, 22/52 in the parotid gland. Pain during sialography was complained by 28/52 patients with a 2.4 mean VAS score. Pain after sialography, was reported by 17/52 patients with a 1.3 mean VAS score. Swelling was reported by 25/52 patients with a 2.4 mean VAS score; 48/52 patients returned immediately to daily activities; 8/52 complained different taste alterations.

CONCLUSION

Main related symptoms for submandibular and parotid sialography are pain and swelling, spontaneously resolving after 24-48 hours in most of cases. The statistical analysis also demonstrated in patients who underwent submandibular sialography the onset of pain during the procedure is significantly related to an increase of pain after the examination. Thus in patients, who referred severe pain during sialography, antiinflammatory drugs are recommended to control the onset of pain after sialography.

Status of the remaining parotid duct and gland following superficial parotidectomy

The changes in Stensen's duct and remaining parotid tissue following superficial parotidectomy have not been studied previously. The aim of this clinical case control study is to describe these changes using sialography and CT-sialography techniques. Fourteen superficial parotidectomy cases underwent parotid sialography bilaterally. CT sialography was also done. Stensen's duct was patent in 11 cases (79%), and non-patent in three cases (21%). Its angle in relation to our reference line was 20 degrees in operated cases versus 37 degrees for the non-operated cases. Following superficial parotidectomy, the remaining parotid tissues usually remain functional and retain drainage through Stensen's duct. Furthermore, superficial parotidectomy changes the direction of this duct. Parotid sialography and CT sialography can still be used to study the status of remaining parotid tissue following superficial parotidectomy. The post-surgical changes should be reviewed with care before interpreting these studies.

Pediatric Salivary Gland Obstructive Swelling: Sialendoscopic Approach

OBJECTIVE

To assess the efficacy of sialendoscopy as a diagnostic and interventional procedure for salivary ductal pathologies of children.

DESIGN

Prospective case series study.

SETTING

Tertiary care teaching hospitals.

PATIENTS

Eight children were investigated under general anesthesia by sialendoscopy for recurring salivary gland swellings between 2003 to 2004 in two university centers.

INTERVENTION

Diagnostic sialendoscopy was used for classifying ductal lesions as sialolithiasis or stenosis. Interventional sialendoscopy was used to treat these disorders. Different variables were analyzed: type of endoscope used, intraoperative findings, type of device used for sialoliths fragmentation or extraction, total number of procedures, and size and number of sialoliths removed.

RESULTS

Five cases of parotid and three cases of submandibular gland recurring swellings were included in the present study. Diagnostic sialendoscopy was possible in all cases. Salivary stones were found in six patients and parotid ductal stenosis in the remaining two. Multiple stones were seen in two cases. Interventional sialendoscopy was also possible in all cases, allowing an intraductal retrieval of the stones in three cases, and a marsupialization of the duct in two cases. Two cases required laser fragmentation of the stone. No major complications occurred intraoperatively or during follow-up (mean 18 months).

CONCLUSION

Diagnostic sialendoscopy is a new technique allowing a reliable evaluation of salivary ductal disorders in children, with low morbidity. Interventional sialendoscopy allows early treatment of pediatric sialoliths and stenosis in most cases, avoiding classical open surgery.

The ductal stretching technique: an endoscopic-assisted technique for removal of submandibular stones

OBJECTIVE

The purpose of this study was to describe an innovative surgical technique for the removal of posterior and hilar stones of the submandibular salivary duct.

METHODS

Between 1999 and 2005, 172 patients who had sialolithiasis of the submandibular duct were treated primarily by transoral incision and marsupialization of the duct and salivary gland. The ductal stretching technique involved endoscopic location of the stone, incision of the oral mucosa above the duct, isolation of the duct from the surrounding tissues, stretching of the duct, ductal incision above the calculus, sialolithotomy, and insertion of a drain.

RESULTS

Forty-one patients with stones located in the posterior aspect of the duct were symptom-free and stone free after the procedure. One hundred and five patients with stones located in the hilum were treated with a success rate of 98%. Twenty-six patients with multiple stones in the hilar region were treated with a success rate of 81%. The overall success rate of the procedure was 96%. In 48 patients (28%), an additional undetected stone was diagnosed by endoscopy after the removal of the stone in the hilum. In 62 patients (36%), strictures were diagnosed endoscopically posterior to the stone. Lingual nerve paresthesia occurred in one patient, who recovered completely.

CONCLUSION

The ductal stretching technique is recommended as the procedure of choice in cases with posterior and hilar stones more than 5 mm in diameter to avoid surgical removal of the salivary gland.

[The value of MRS in diagnosis of Sjoigren's syndrome in parotid gland]

PURPOSE

The purpose of this study is to evaluate the value of MR sialography in diagnosis of Sjoigren's syndrome in parotid gland.

METHODS

MRI and MRS were used to diagnose Sjoigren's symdrome and differentiate with other disease combined with clinical, serologic and histopathologic result. Meanwhile, the result of MRS was compared with sialograph.

RESULTS

25 cases were ultimately diagnosed as Sjoigren's syndrome among 32 cases by clinical, serologic, histopathologic and sialography or MRS method. 23 cases were presented typical image in MRS, and sensitivity was 92%; specificity 71.4% and accuracy 87.5%. Other different manifestations were found in 25 cases, such as: autoantibody 68%, focui lymphocytic infiltration 72%. 18 cases have the positive results between MRS and sialography and 15 cases (83.3%) have the same manifestations by degree classification.

CONCLUSION

The Sjoigren's syndrome can be confirmed by clinical, serologic, histopathologic, and MRS or sialography. MRS is a reliable method to diagnosis and differentiated diagnose Sjoigren's syndrome with other disease.

Salivary duct strictures: nature and incidence in benign salivary obstruction

OBJECTIVES

The aim of this study was to establish the incidence and character of salivary duct strictures by carrying out a 10 year retrospective review. Salivary gland obstruction is most commonly caused either by salivary calculi or duct strictures. These strictures or stenoses develop secondarily to inflammation in the duct wall and may be single or multiple.

METHODS

All reports of sialographic examinations performed on patients referred to the Dental Radiology Department in a London Dental Hospital between 1995 and 2004 were reviewed and those patients with symptoms of salivary obstruction identified. In total, 1362 sialograms using the conventional hand injection technique with water-soluble contrast media were performed on 1349 patients with obstructive symptoms during the 10-year period.

RESULTS

Of the 1362 sialograms performed, the reports revealed that 877 (64.4%) showed evidence of benign intraductal obstruction. The remaining 485 (35.6%) were normal. 642 of the cases (73.2%) revealing obstruction were reported to be due to salivary calculi, 198 due to duct strictures (22.6%) and the remaining 37 (4.2%) were considered to be due to mucous plugs. Detailed analysis of the patients with strictures showed they were more common in women with a mean age of 52 years. Single strictures were evident in 66.7% of cases while 33.3% showed multiple stenoses. Strictures were more common in the parotid duct (75.3%). 7% of patients presented with bilateral stenoses.

CONCLUSION

This is the largest review of duct strictures to be reported. It has shown that ductal stricture formation accounts for almost 25% of cases of benign salivary obstruction and appears to have been an under-recognized condition. Strictures more commonly affect parotid ducts and are typically found in the fourth, fifth or sixth decades, particularly in women.

Salivary gland parameters and clinical data related to the underlying disorder in patients with persisting xerostomia

This study assessed salivary gland parameters and clinical data in patients referred to our clinic because of persisting xerostomia of unknown origin, in order to facilitate early diagnosis and recognition of the underlying disorder. Most patients were referred for diagnostic analysis of a possible Sjögren's syndrome (SS). A complete diagnostic work-up was available in all patients (n = 176), including data on salivary gland function, saliva composition, sialography, salivary gland swelling, pattern of complaints, general health, and medication. Patients were diagnosed with SS (n = 62), sialosis (n = 45), sodium retention syndrome (n = 30), or medication-induced xerostomia (n = 9). In 30 patients no disease related to salivary gland pathology was found. Unstimulated whole salivary flow was decreased in all patients, except in patients with sodium retention syndrome and in patients without salivary gland pathology. Submandibular/sublingual salivary flow was lowest in SS patients. SS and sialosis patients had increased salivary potassium concentrations, whereas only SS patients had increased sodium concentrations. About half of the sialosis patients mainly complained of persistent parotid gland swelling. Xerostomia-inducing medication was used by most patients. It was concluded that gland-specific sialometry and sialochemistry is useful in discriminating between the various disorders causing persisting xerostomia.

Sialodochoplasty in the treatment of salivary-duct stricture in chronic sialoadenitis: technique and results

PURPOSE

This study was undertaken to investigate peroral balloon angioplasty of salivary-duct strictures (sialodochoplasty) in chronic sialadenitis, analysing the technique, results and limitations.

MATERIALS AND METHODS

Nine patients underwent sialodochoplasty: seven for Stensen's-duct strictures and two for Wharton's-duct strictures. One patient had a double stricture of Stensen's duct and another a salivary stone associated with a Wharton's-duct stricture. All patients were subjected to preliminary sialography to evaluate stricture site, length and grade. Sialodochoplasty was performed after local anaesthesia and progressive dilation of the salivary-duct orifice.

RESULTS

The stricture was successfully dilated in 7/9 patients. The stricture was unchanged after dilatation in one patient, and in another, it recurred after 13 months. In the patient with a double stricture of Stensen's duct, one was resolved and the other was only partially dilated, with significant symptom improvement. One patient developed a new episode of sialadenitis after 3 months, which resolved with medical therapy. Five out of seven patients were asymptomatic at follow-up.

CONCLUSIONS

Sialodochoplasty is an effective procedure in the treatment of salivary-duct strictures, improving symptoms in the majority of patients. The procedure is repeatable and can be proposed as a first-line treatment for symptomatic salivary-duct stricture.

Efficacy prediction of cevimeline in patients with Sjögren's syndrome

The objective of this study was to examine the clinical and immunological factors influencing the efficacy of cevimeline hydrochloride hydrate (cevimeline) for the treatment of xerostomia in patients with Sjögren's syndrome (SS). Thirty primary SS patients who were medicated with cevimeline were enrolled in this study. Whole stimulated sialometry (WSS) was compared between pre- and posttreatment points (4 weeks after oral cevimeline administration) and the increment rate of WSS was calculated. Multiple regression was employed to examine the relative contributions of the clinical and immunological factors, including age, pretreatment WSS, duration of disease, sialography, minor salivary gland biopsy, anti-Ro/SS-A antibodies, anti-La/SS-B antibodies, and antibodies to muscarinic type 3 receptors to the posttreatment WSS. Patients with normal sialography findings, negative minor salivary gland biopsy, and absence of anti-La/SS-B antibodies had significantly higher increment rates of WSS compared with those with positive findings (p=0.042, 0.002, and 0.018, respectively). Results of the multiple regression analysis showed that sialography (coefficient=-0.867, p=0.004) and minor salivary gland biopsy (coefficient=-0.869, p=0.003) had significant associations with the posttreatment WSS. Our preliminary results demonstrated the relationship between the effect of cevimeline on saliva secretion and the degree of salivary gland destruction evaluated by sialography and histopathological findings in the labial minor salivary glands. These diagnostic approaches could provide useful prognostic information on the efficacy of cevimeline in SS patients.

Surgical treatment of chronic parotid sialadenitis

OBJECTIVE

To review the results of surgical management of chronic parotid sialadenitis refractory to medical therapy, with particular respect to long-term symptom resolution and development of post-operative complications.

METHODS

A retrospective review of parotidectomies performed for chronic intractable parotid sialadenitis. Information was collected about presentation, pre-operative investigations, surgical treatment, post-operative complications and outcome.

RESULTS

36 parotidectomies were performed for chronic sialadenitis between 1991 and 2002. Age at presentation was 56+/-9.6 years, with median symptom duration of 2.3 years. For patients with non-specific presentations, magnetic resonance imaging (MRI) was the most useful pre-operative investigation. Superficial parotidectomy with duct preservation was the main treatment with a 94 per cent success rate, and near-total parotidectomy was reserved for patients with extensive deep-lobe involvement. Duct ligation significantly increased the risk of transient facial palsy. There was a 56 per cent and 22 per cent incidence of temporary facial paresis and Frey's syndrome, respectively.

CONCLUSIONS

Controversies exist regarding the optimal pre-operative investigation and surgical treatment of chronic parotid sialadenitis. We advocate magnetic resonance image (MRI) scanning for patients with non-specific symptoms of sialadenitis, and sialography in the presence of reasonable clinical suspicion. We propose superficial parotidectomy without parotid duct ligation as the standard of care, with near-total parotidectomy reserved for extensive deep-lobe disease.