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Oral Maxillofac Surg8:276-280, 2010

Modern Sialography for Screening ofSalivary Gland Obstruction

Oscar Hasson, DDS*

Purpose: To revisit and reintroduce sialography as an important tool for the assessment and diagnosisof salivary gland obstruction.

Patients and Methods: A sample of 30 consecutive patients undergoing sialography was selected.Parotid sialography was performed in 22 patients (12 females and 10 males). The patients undergoingparotid sialography presented with bilateral or unilateral enlargement or swelling. Submandibularsialography was performed in 8 patients (all males) who had presented with swelling and pain in theaffected gland.

Results: Parotid sialography revealed 6 cases of sialolithiasis without significant duct narrowing, 3 ofnarrowing and strictures of Stensen’s duct without a sialolith, 3 glands with gland sialectasis, 1 parotidgland with intraglandular cyst-like duct degeneration, 1 of a parotid mass displacing Stensen’s duct, and1 gross dilation of duct. The findings of 7 parotid gland sialograms were normal. Submandibular glandsialography revealed the presence of sialolithiasis (single and multiple) in 4 patients, narrowing of theduct in 2, and normal findings in 2.

Conclusions: Sialography is a simple technique and an important tool for the assessment of salivarygland obstruction in patients presenting with sialadenitis.© 2010 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 68:276-280, 2010

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bstruction of salivary glands is a common pathologicnding that affects a large number of patients. Oralnd maxillofacial surgeons have been increasingly in-olved in the diagnosis and treatment of differentypes of salivary gland obstructions, making necessarynderstanding and familiarity with the diagnosticools available for these pathologic features of utmostmportance.

New techniques, such as endoscopy of the salivarylands (sialoendoscopy),1-4 have been introduced asn important strategy for assessing and treating sali-ary gland obstruction. Endoscopic techniques havepgraded the available arsenal of therapeutic ap-roaches for treating salivary gland pathologic fea-ures. Nevertheless, after many years as a neglectedechnique, technological advances have brought backialography as an important diagnostic x-ray study foratients with recurrent sialadenitis, who are candi-ates for sialoendoscopy. Up to the late 1970s andarly 1980s, patients with salivary gland obstructions

*Oral and Maxillofacial Surgeon, Assuta Hospital, Tel Aviv, Israel;

rivate Practice, Ramat Gan, Israel.

Address correspondence and reprint requests to Dr Hasson: Nahal

amla Street, 3/21, Kiriat Ono 55450 Israel; e-mail: oshasson@yahoo.

om

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/10/6802-0007$36.00/0

doi:10.1016/j.joms.2009.09.044

276

nderwent sialography, which revealed pathologicndings in different areas of the salivary gland system.lthough surgical techniques have enabled the re-oval of the obstructions and the opening of stric-

ures in deeper areas of the gland, injury to vitaltructures, such as the lingual nerve, which passeselow the submandibular gland duct, is still a risk.With the introduction of sialoendoscopy, sialogra-

hy gained an important role in the assessment ofalivary gland status, reviving this radiographic tech-ique.The purpose of the present study was to report mod-

rn day sialography, discuss different sialographic pic-ures, and indicate the importance of this radiographictudy in mapping salivary gland obstructions before per-orming interventional sialoendoscopy.

atients and Methods

A total of 30 consecutive patients undergoing sia-ography of the affected salivary gland were includedn the present study. Sialography was performed afterhe acute phase in patients with sialadenitis. All sialo-raphic studies were performed without the need forocal anesthesia. The use of delicate catheters andentle techniques made the procedure painless. Afterisual identification of the duct orifice of the affectedland, lacrimal probes were introduced to dilate the

uct entrance (Fig 1). When the orifice was suffi-

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OSCAR HASSON 277

iently dilated, an adult intravenous catheter (22-auge) was introduced (Fig 2). It was not necessary touture the catheter in place. Next, 1.5 to 2 mL ofontrast material was injected. Ultravist (Bayer Health-are Pharmaceuticals, Wayne, NJ), an iodinated water-oluble agent, was used. Patients usually reportedome discomfort and pressure sensation during theye injection. Alternatively, salivary duct lavage with.5 mL bupivacaine hydrochloride (Marcaine) can beerformed before the procedure to reduce the sensa-ion of pressure. The contrast material was injectednder fluoroscopic guidance, reducing risk of perfo-ations and gland extravasation. Panoramic or pos-eroanterior and lateral views of the mandible werebtained. The presence of acute salivary gland infec-ion and allergy to contrast material are contraindica-ions for sialography. Patients with a sialolith blockinghe opening of the duct also cannot undergo sialog-aphy. Such patients should undergo surgical sialoli-hiasis removal and exploratory sialoendoscopy as thereatment of choice.

esults

All 30 sialograms were successful. Parotid sialogra-hy revealed 6 cases of sialolithiasis (Fig 3), 3 ofarrowing and strictures on the Stensen’s duct (Fig 4),of gland sialectasis (a diffuse spherical collection of

ontrast material distributed through the gland) (Fig), 1 gland with cyst-like degeneration of intraglandu-

ar duct (Fig 6), 1 parotid mass displacing the Stens-n’s duct (Fig 7), and an oversized dilated duct in 1

IGURE 1. Dilation with probe of Wharton’s duct of the subman-ibular gland.

scar Hasson. Modern Sialography for Screening. J Oral Maxil-ofac Surg 2010.

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atient with intermittent swelling in the anterior pa-otid gland (Fig 8). The findings of 7 parotid glandialograms were normal.

Submandibular gland sialography revealed the pres-nce of sialolithiasis (single and multiple) in 4 patientsFig 9), narrowing of the duct in 2, and normal find-ngs in 2. All patients underwent sialography usinguoroscopic guidance. None of the patients under-

IGURE 2. Cannulation of duct with intravenous catheter (22auge).

scar Hasson. Modern Sialography for Screening. J Oral Maxil-ofac Surg 2010.

IGURE 3. Sialogram of the parotid gland demonstrating pres-nce of sialolithiasis (arrows).

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278 MODERN SIALOGRAPHY FOR SCREENING

ent a second radiographic study to check for void-ng of contrast material. No complications occurreduring any of the procedures. The postoperative in-tructions to the patients included consuming a nor-al diet after sialography.

IGURE 4. Sialogram of parotid gland demonstrating narrowingf strictures of Stensen’s duct. Note presence of accessory glandarrows).

scar Hasson. Modern Sialography for Screening. J Oral Maxil-ofac Surg 2010.

IGURE 5. Sialogram of parotid gland showing sialectasis inemale patient presenting with bilateral gland enlargement.

scar Hasson. Modern Sialography for Screening. J Oral Maxil-ofac Surg 2010.

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iscussion

The initial screening for patients with suspectedbstruction of the salivary glands consists of a clinicalxamination and radiograph studies, such as Panorex,cclusal radiography, ultrasonography, and computedomography, when indicated. With the advance in

IGURE 6. Sialogram of the parotid gland showing intraglandularyst-like duct degeneration.

scar Hasson. Modern Sialography for Screening. J Oral Maxil-ofac Surg 2010.

IGURE 7. Parotid sialogram of patient with intragland tumorisplacing Stensen’s duct (arrow). Note, also, gross lateral dis-lacement of ducts by medially placed tumor.

scar Hasson. Modern Sialography for Screening. J Oral Maxil-ofac Surg 2010.

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OSCAR HASSON 279

echnology and the development of endoscopic tech-iques for the diagnosis and treatment of obstructionsf the salivary glands, sialography has regained an

mportant place as one of the tools available for thevaluation of salivary gland obstructions.1,4,5

In most cases, modern sialography is not time-con-uming, and the refinement of intravenous cathetersas made the procedure painless and easy to perform.he contraindications for the procedure includehen the duct is blocked by sialolithiasis and theresence of an internal stricture. In both situations,uct dilation with probes and sialography is not pos-ible. Instead, surgical removal of the sialolith andurgical opening of the duct should be done andialoendoscopy performed without previous sialogra-hy. An allergy to the contrast material (usually io-ine) is also a contraindication. With the introductionf minimally invasive endoscopic procedures for sal-

vary gland obstructions, sialography has re-emergeds an important gland examination, disclosing impor-ant anatomic and pathologic information about theland before sialoendoscopy.Reviewing the published data, we found that sia-

ography is an accepted tool for the assessment ofalivary gland obstructions; however, some have indi-ated their abstention from performing the proce-ure. Marchal and Dulguerov6 reported a preferenceor using sialoendoscopy, rather than sialography, as arimary tool for the diagnosis of salivary gland ob-truction. They reported that the injection of contrast

IGURE 8. Gross dilation of Stensen’s duct. Note presence ofntraduct strictures (arrows).

scar Hasson. Modern Sialography for Screening. J Oral Maxil-ofac Surg 2010.

aterial could push sialoliths further back into theOl

uct, complicating endoscopic removal of the sialo-ith. Varghese et al7 also claimed that the invasivenessf sialography is a drawback of the procedure. Theyompared the use of magnetic resonance sialographyith that of conventional sialography in 49 patients

nd concluded that magnetic resonance sialography isufficiently sensitive in cases of tight strictures but notensitive enough when salivary stones are present.atz,8 Hasson and Nahlieli,3 and Hasson4 have, how-ver, indicated the use of sialography as their tool ofhoice for salivary gland assessment.Sialography is also a minimally invasive and painless

echnique if performed carefully. Kalk et al9 reportedn the morbidity of the procedure. Of the 24 patients

ncluded in their study, 19 experienced no pain, andreported little pain during infusion of the contrastaterial. During sialography, 16 reported no discom-

ort, 7 found it slightly unpleasant, and only 1 re-orted that it was very unpleasant.Sialographic studies can demonstrate important

nd interesting pathologic features of the involvedalivary glands. The anatomy of the duct can be dis-layed, revealing its form as narrow or large, theresence of secondary branches leaving the mainuct, and the presence of accessory glands or sialoli-hiasis, including their dimensions, number, and po-itions. Another advantage of this technique is itsbility to reveal the presence of internal duct stric-ures, especially in the parotid gland, which alwaysscape detection with radiography and sometimesith ultrasonography. Without doubt, all this infor-ation, readily obtained from sialography, is neces-

ary for a better understanding of salivary gland statusefore sialoendoscopy.The sialographic techniques for the parotid and

ubmandibular glands are similar. In most cases,

IGURE 9. Sialogram of the submandibular gland showing pres-nce of multiple sialolithiasis (arrows).

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280 MODERN SIALOGRAPHY FOR SCREENING

tensen’s duct opening is easily seen, dilated, andannulated compared with Wharton’s duct opening.hen performing the study in the parotid gland,

owever, care must be taken to avoid iatrogenic per-oration of the duct owing to its curvature whenending around the anterior border of the masseteruscle. Wharton’s duct is straighter and runs in a

ownward direction within the floor of the mouth,endering it is less prone to perforation.

eferences. Nahlieli O, Baruchin A: Three years’ experience as a diagnostic

and treatment modality. J Oral Maxillofac Surg 55:912, 1997

. Hasson O: Endoscopy of salivary glands, what have we learned?

J Oral Maxillofac Surg 63:137, 2005 (suppl)

. Hasson O, Nahlieli O: Endoscopy of salivary glands (sialoendos-copy): A new technique for the removal of the sialolithiasis. RevAssoc Paul Dent 52:277, 1998

. Hasson O: Sialoendoscopy and sialography: Strategies for assess-ment and treatment of salivary gland obstruction. J Oral Maxil-lofac Surg 65:300, 2007

. Tighe JVP, Bailey BMW, Khan MZ, et al: Relation of preoperativesialographic findings with histopathological diagnosis in case ofobstructive sialadenitis of the parotid and submandibular glands:Retrospective study. Br J Oral Maxillofac Surg 37:290, 1999

. Marchal F, Dulguerov P: Sialolithiasis management: The state ofthe art. Arch Otolaryngol Head Neck Surg 129:951, 2003

. Varghese JC, Thorton F, Lucey BC, et al: A prospective compar-ative study of MR sialography and conventional sialography ofsalivary duct disease. AJR Am J Roentgeol 173:1497, 1999

. Katz P: Endoscopy of salivary glands. Ann Radiol (Paris) 34:110,1991

. Kalk WWI, Vissink A, Spijkervet FKL, et al: Morbidity from

parotid sialography. J Oral Surg 92:572, 2001