radiology

1. SIALOGRAPHY
DACROCYSTOGRAPHY

2. SIALOGRAPHY
INTRODUCTION
 A radiographic examination of the
salivary glands(PAROTID &
Submandibular GLAND) and ducts
using contrast media
 Cannulation of Sublingual gland ducts is
almost impossible

3. INDICATIONS FOR EXAM
 Stones (Calculi) sialolithiasis
 Obstruction / Strictures
 Pain & Swelling (esp when recurrent)
 Infection
 Masses / Tumors
 Changes secondary to trauma
 When plain radiography is inconclusive

4. CONTRAINDICATIONS FOR EXAM
 History of contrast media allergies
 Severe inflammation of the salivary
ducts

5. ANATOMY OF THE SALIVARY
GLANDS
 3 pairs---Parotid
SM
SL
 Situated adjacent to OC, aid in initial
digestion

6. ANATOMY OF THE SALIVARY
GLANDS

9. PAROTID GLAND
Largest salivary gland
 Lies just below the ZYG arch in front & below
the ear
Parotid duct(Stensons duct) is 5cm long, runs
over the messeter & opens into oral vestibule
opposite 2nd upper molar

11. SUBMANDIBULAR
GLANDS
Extends posteriorly from below
1st lower molar to angle of mandible
Forms part of soft tissues on the medial margin
of the mandible & the hyoid bone
Submandibular duct(whartsons duct ) is 5 cm
long, runs forward ,medially and upward &
opens into mouth on side of frenulum

12. SUB LINGUAL GLANDS
Smallest pair
Located in floor of mouth on the surface of
mylohyoid muscle.
Numerous, small sublingual ducts(ducts of
Rivinus) open into floor of mouth
Ducts may join to form a single(duct of
Bartholin) which empties into the submandibular
duct.

13. SALIVARY GLAND IMAGING
 PLAIN RADIOGRAPHS
 SIALOGRAPHY
 CT(Glandular enlargement , tumors)
 RADIONUCLIDE IMAGING(to provide
additional physiological info in cases of
over or under secretion )
 MRI

14. SIALOGRAPHY
 Radiologic exam of salivary glands and
ducts using contrast media
 CT and MRI have largely replaced this
exam

15. PROCEDURE
 Preliminary radiographs
Detect conditions that do not require contrast
 Give pt secretory stimulant 2 to 3 minutes before
contrast administration
Pt asked to suck on lemon wedge
-Opens duct for easy identification

16.  Duct orifice is sprayed with topical anaesthetic
 Duct is cannulated, (dialator may be required),
contrast introduced with fluoroscopic guidance
 Contrast (oil based or water soluble iodinated)
(conc = 240mg/ml)
 Should be injected manually until pt feels
discomfort
 Quantity needed may vary btw 1-2 ml

17.  Images taken immediately after contrast is
complete
 After taking req. images ,pt sucks on a
lemon wedge again to evacuate contrast
 Take post-procedure(delayed) radiographs
after 5 minutes to confirm evacuation of
contrast/ demonstrate any residual contrast

18. Dilation with probe of Wharton’s duct of
the submandibular gland.
Cannulation of duct with intravenous
catheter (22 gauge).

19. FILMS
 Parotid----Control Films
- PA
- LAT
- LAT OBLIQUE
 Parotid -----Sialography Film
- PA
- LAT
- LAT OBLIQUE

20. FILMS
 SM----Control Films
- INFEROSUPERIOR/OCCLUSAL 1
- INFEROSUPERIOR/OCCLUSAL 2
- LAT
 SM -----Sialography Film
- LAT
- LAT OBLIQUE

21. Normal salivary gland visualized by sialography.

22. Lateral Submandibular radiographs

24. Sialogram of the right parotid gland showing multiple
punctate glandular collections, 1 mm in diameter,
suggestive of punctate sialectasis

25. Sialoectasis
Sialogram of the parotid gland; lat. projection. In the glandular
parenchyma pools of contrast can be seen. The accessory parotid
gland is also affected (arrow).

26. Salivary Gland Swelling with Ductal Narrowing

27. DACROCYSTOGRAPHY
Introduction
 A Radiographic examination of the
Naso lacrimal duct(s) following
administration of a contrast medium to
define the Lacrimal gland & NLD
system anatomically in search of
stenosis or obstruction

28. Indications
 Lacrimal duct obstruction/stricture

29. Contra-indications
Non-consent by patient to procedure
Contrast media or iodine allergy
Pregnancy (risk is minimal but patient may
wish to delay procedure)

30. Anatomy
Tears (lacrimal fluid) are produced by
the lacrimal gland which is located at the
supero-lateral aspect of the orbit.

31.  Drainage of the lacrimal fluid is achieved
by the lacrimal canaliculi, lacrimal sac,
and nasolacrimal duct.
 The lacrimal fluid drains from the
nasolacrimal duct into the nasal cavity
via the inferior meatus

36. Preparation
 Patient identification (3 'C's- correct
patient, correct side, correct procedure)
 Completed consent form
 No diet restrictions
 Collect/review relevant previous imaging
for ease of access prior to procedure

37. TECHNIQUE
 The patient lies supine on the
fluoroscopy table with the head in a
reverse occipito-mental position.
 Support either side of the patient's head
by immobilization device, particularly if a
subtraction technique is employed.
 Select a small field of view and fine
focus
 Control images taken

38. TECHNIQUE(cont)
 Anaesthetic eye drops are used for
patient comfort
 A fine cannula is inserted into the puncta
of each eye, then the eye is closed and
the catheter taped to the patient's cheek
 It may be necessary to dilate the puncta
to facilitate insertion of the cannula

39. TECHNIQUE(cont)
 After the mask is acquired, commence
injection
 Images are taken immediately after
injection
 A drainage image can be taken after 15
minutes if considered necessary

40. Unilateral dacrocystogram demonstrating a normal lacrimal duct
Subtraction has been utilized
minimal reflux into superior lacrimal canal

41. Bilateral dacrocystogram with subtraction
Normal lacrimal duct on the left
Slower flow of contrast on the right (this may not be pathological- may reflect
note the amount of extravisated contrast medium on the right)
Demonstrated right duct appears normal
Reflux into superior lacrimal canal on right
Perfect X-ray beam collimation
adequate subtraction

42. Bilateral dacrocystogram with subtraction
Excellent X-ray beam collimation
effective subtraction
Reflux into superior lacrimal canal on right

43. Bilateral dacrocystogram without subtraction
Delayed drainage image
Abnormal accumulation of contrast on the left

44. Unilateral injection
Abnormal pooling of contrast proximally

45. Unilateral injection
Subtraction technique
Minimal contrast filling of right lacrimal sac
Contrast reflux into superior lacrimal canal

46. Contrast or Subtraction Artifact?
It will not always be clear whether you have demonstrated contrast filling or
subtraction artifact
The consistency of the arrowed structure and its similarity to the other
subtraction artifacts suggests that it is not contrast medium
(Experience Required!!!)

47. Technique Notes
It is normal practice to image both sides
(comparison/increased incidence of bil. abns)
It is preferable to inject both sides at the same time
Collimate the X-ray beam to include the orbits
superiorly and laterally and the maxillary PNS
inferiorly
A sialogram needle (metal or plastic tip) can be
used for cannulation of the puncta (16 gauge or
similar)

48. A focused spotlight can be a useful aid for the
radiologist in locating the lacrimal punctum
Inferior punctum is often easier to canulate
Catheter should not be inserted too far into the
canaliculus
Dacrocystogram protocol may include adjunct
nuclear medicine study

49. Thank you