Investigations pertaining to salivary glands
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Presented in PG symposiumin SMC in 2018
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Investigations pertaining to salivary glands
- 1. Investigations pertaining to Salivary Glands Dr.R.Malarvizhi Post graduate student MS (ENT )
- 2. Techniques available Non-Invasive Invasive • Ultrasonogram ▫ Conventional ▫ Doppler • Plain radiographs • Laboratory • CT • MRI ▫ Contrast ▫ Fat suppression ▫ Proton Spectroscopy • FNAB • Sialogram ▫ Conventional ▫ MR ▫ Digital subtraction • Scintigraphy • Cutting needle biopsy • Frozen section (intra operative) • Endoscopic sialoendoscopy • Histopathology ▫ Histochemistry ▫ Immunohistochemistry ▫ Cytophotometry ▫ Molecular and cytogenetic studies ▫ Electron microscopy
- 3. Non neoplastic • Calculous disease ▫ Of submandibular and Parotid ▫ Ultrasound ▫ Sialography ▫ Non invasive MR ▫ Conventional subtraction sialography • Non – calculous disease ▫ Ultrasound ▫ CECT ▫ FNAB
- 4. Neoplastic • Benign • MRI • Ultrasound (as MR is costlier) • US guided FNAC • CECT – less suited • Parotid (MC) ▫ Pleomorphic ▫ Adenolymphoma ▫ Hemangiomas (pediatric) • Malignant ▫ Mucoepidermoid Ca ▫ Adenoid cystic ca ▫ Acinic cell ca ▫ Adenocarcinoma ▫ Squamous ca ▫ Submandibular ▫ Sublingual ▫ FNAB ▫ Cutting needle biopsy ▫ MRI > CT
- 5. Pediatric Salivary Gland • Commonly inflammatory- viral • Sialolithiasis and ranula • Benign ▫ Hemangiomas, lymphomas ▫ Pleomorphic adenoma • Malignant ▫ Mucoepidermoid ca
- 6. Pediatric salivary gland • Ultrasound • Doppler enhanced US • MRI
- 7. • Chest x ray • Laboratory evaluation REF:SATALOFF
- 8. Plain radiographs • Calculi • Gross erosion- mandible • Open mouth lateral images with extended chin, posteroanterior images and bilateral oblique images
- 10. Orthopantomogram
- 11. Ultrasound • Are 2D gray- scale • Reflection of ultrasound waves (5-7 MHz) • Hyperechoic –tissue reflects most of the ultrasound (calcifications, bone) • Hypoechoic- reflects less amount when compared to adjacent • Anechoic- no reflection (cystic)
- 12. • Location • Dimension • Shape • Margins • Echogenicity • Vascularization • Intra parotid lymph nodes, retromandibular vein and ECA, facial nerve
- 13. Vascularization • Grade 1 : no vessels visible, low flow • Grade 2: few vessel segments ( no more than 3 blood vessels visible in whole mass) • Grade 3 : upto 5 visible vessels in the mass • Grade 4: more than 5 visible vessels in the mass
- 14. Ultrasound Benign Malignant • Round/ovoid • Circumscribed margin • Homogenous echotexture • Vascularization grades 1-2 • Stones – ▫ 20 % radiolucent ▫ Precise location ▫ Sensitive ▫ 90% accuracy • Cysts ▫ Size • Irregular • Spiculated or ill-defined • Heterogenous echotexture • Punctate calcification • Vascularization grade 3-4 • Accuracy 20% • Nodal involvement
- 15. • Vascularization in conventional USG to differentiate benign from malignant – not reliable in all cases • Increased fat in parotid more attenuated than submandibular gland • Abscess- frank- fluid, gas microbubbles • Inflammatory- hypoechoiec, ill defined, ducts within lesion
- 16. Anterior calculi in submandibular duct
- 18. USG Parotid Parotid gland with multiple calcifications
- 19. Reactive Lymph node Malignant lymph node
- 20. Ultrasound Advantages Disadvantages • Non-invasive & Non- ionizing radiation used • Inexpensive (relatively) • Pediatric • Solid vs. cystic • Echo signal from different tumors • Lithotripsy of salivary stones • Salivary obstruction • Guided for FNAC • Differentiate intra & extra glandular mass • Intra oral- probes • Deeper structures (behind ramus, parapharyngeal/retropharynge al extension) • Beyond bony concretions or bone or air filled • Lack of identifiable anatomical landmarks • Minimum 30 min • No info on fine architecture
- 21. Color Doppler Ultrasound • Distribution of vessels in and around salivary glands and nodes • Reactive and neoplastic lymph nodes
- 22. MRI • Soft tissue contrast resolution • Iv contrast – Gadolinium • Multiplanar reconstruction software • Differentiate cystic from solid (contrast) • Images at 5 s interval for 370 s • Rate of contrast- 3 ml/s followed by 20 ml saline flush • Sialodochitis- ductal sialadenitis ▫ Sausage string appearance (interstitial fibrosis) in MRI
- 23. MRI Benign Malignant • Distinct border /capsule • Gradual enhancement – pleomorphic • Low signal T1 • High signal T2enhance heterogeneously • Warthin’s – increased Tech Pertechenate uptake, early enhancement & high washout • Early enhancement and low washout • Low signal T1 & T2 • Post contrast ill defined margins • Low grade- pseudocapsule
- 26. MRI Advantages Disadvantages • Non invasive • Non ionizing • Excellent soft tissue details • Benign vs. malignant • Facial nerve • MR spectroscopy- differentiate tissues by chemical constituents • MR sialography – no contrast • Function cannot be assessed • Limited adjacent hard tissue information • Pacemakers/implants • Cost • Time • Claustrophobia
- 27. CT • Computed tomography • Contrast enhancement • Bony & Morphological detail • Salivary gland pathology, adjacent structures & proximity to facial nerve • Calcifications, abscess, cyst walls , osseous erosions and sclerosis
- 28. CT Benign Malignant • Cystic • Calcifications • More attenuating & homogenous • Erosions of adjacent bony structures
- 31. CT Advantages Disadvantages • Osseous vs. soft tissue • Less affected by motion artifacts • Faster compared to MRI • Calcification and bony detail • Ionizing radiation • IV contrast • Artifacts with dense bone and metallic objects • Multiplanar images difficult to reconstruct (compared to MRI)
- 32. PET CT • Non invasive – identify based on altered tissue metabolism • Fasting state • 18 F- Flurodeoxyglucose
- 33. • Primary malignancy • Synchronous malignancy • Recurrence / residual • Metastatic lymph nodes • Lymphoma • Limitations ▫ Tumor less than 1 cm dia ▫ Affected by hyperglycemia and muscular activity ▫ Cannot differentiate between squamous cell carcinoma from others ▫ Uptake in malignant and inflammatory cells
- 34. PET
- 35. Sialography • 1902 • Radiographic demonstration of major salivary glands by introducing a radio-opaque contrast medium into their ductal system ▫ Pre operative phase ▫ Filling phase ▫ Emptying phase Parenchymal – water soluble Evacuation – fat soluble
- 36. Techniques Techniques Contrasts • Simple injection • Hydrostatic • Continuous infusion monitored • Normal is a “leafless tree” appearance • Iodine based ▫ Ionic aqueous solution Diatrizoate (urograffin) Metrizoate (triosil) ▫ Non ionic aqueous solution Iohexol (omniopaque) • Oil based ▫ Iodized oil (lipiodol) ▫ Water insoluble organic iodine compounds (pantopaque)
- 37. • Cysts and carcinomas – replacing normal glandular tissue – areas of non – opacity • Benign mixed and Warthin’s – varying degrees of radioactivity • Sjogren’s – atrophy and punctate sialectasia • Combination with pneumoradiography & tomography- CO2 – periglandular space by intraoral/mylohyoid/ transcutaneous puncture
- 40. Disadvantages • Iodine sensitivity • Acute inflammation contraindicated • Thyroid function interference
- 41. Scintigraphy • Functional study • Morphology of glands and any SOL • Iv injection of contrast • Trapping should occur within 1 min of IV injection in normal glands • Peak activity 10-21 min within the glands • Appearance in ducts max 30-45 min • Sialagogue administered to evaluate secretory capacity
- 42. • Symmetric gland accumulation drainage, increased or decreased function (increased/decreased /no uptake) • Salivary gland function , dry mouth, Sjogren’s syndrome, parotid tumor , NPC, post radiation therapy ▫ Technetium -99m Pertechenate ▫ Gallium-67 citrate ▫ Thallium -201 chloride
- 44. • FNAC ▫ based on cytology, op , 22 gauge , safe, reliable, economically effective, convenient, accurate • Frozen section (intraoperative) ▫ Benign or malignant ▫ Margin – extent of surgery • Arteriography • Permanent section pathology ▫ - conventional HPE , MAINSTAY
- 45. Endoscopic sialendoscopy • Relatively new • Endoscopic trans luminal visualization of major salivary gland ductal system and aids in diagnosis and treatment of inflammatory and obstructive pathology related to ductal system
- 46. SALIVARY GLAND SWELLING Suspected inflammatory process Suspected solid mass or neoplasm USG Calculi /steno sis Normal Solid mass Conventional sialography or MR sialography If involvement of deep lobe parotid suspected go for CT MRI/CT If indicated image guided FNA
- 48. References • Scott Brown • Sataloff • Cummings • Stell and Maran • Bluestone • Batsakis