| Abstract|| |
Salivary gland examination is an important part of oral examination, especially because of it's involvement in most of the systemic diseases. Patients most commonly seek medical attention when the major salivary glands like parotid and submandibular gland become enlarged or painful. The various imaging modalities practiced to check the salivary gland disorders include conventional radiography, sialography, ultrasonography, computerized tomography, radionuclide imaging and magnetic resonance imaging. Sialography is one of the oldest imaging procedures and still most commonly practiced, as it is a chair side procedure, simple to perform, and cost effective. We report the role of sialography as an adjuvant in the diagnosis of bacterial sialadenitis and sialadenosis and as a diagnostic and therapeutic aid in a case of juvenile recurrent parotitis.
Keywords: Radiosialography, sialadenitis, sialadenosis, recurrent parotitis
|How to cite this article:|
Reddy SS, Rakesh N, Raghav N, Devaraju D, Bijjal SG. Sialography: Report of 3 cases. Indian J Dent Res 2009;20:499-502
Sialography or radiosialography is the radiographic visualization of the salivary gland following retrograde instillation of contrast material into the ducts.  Sialography is one of the oldest imaging procedures and was first mentioned by Carpy in 1902 using mercury as a contrast agent. ,
|How to cite this URL:|
Reddy SS, Rakesh N, Raghav N, Devaraju D, Bijjal SG. Sialography: Report of 3 cases. Indian J Dent Res [serial online] 2009 [cited 2019 Sep 18];20:499-502. Available from: http://www.ijdr.in/text.asp?2009/20/4/499/59449
Salivary gland disorders range from developmental, inflammatory and immune-related to neoplastic. Treatment primarily depends on diagnosis, which is complemented by the investigations. Conventional sialography remains a useful technique for the investigation of patients presenting with obstructive symptoms of parotid and submandibular gland evaluating intrinsic and acquired abnormalities of the ductal system because it provides clear visualization of the branching ducts and acinar ends. , Sialography can also be used as a therapeutic aid in obstructive salivary gland disorders as it helps in the dislodgement of the small calculi and mucous plugs within the salivary gland ducts which cannot be identified on routine radiographs. Further, sialography can be used in cases of recurrent infections as it helps in salivary gland lavage.
| Case Reports|| |
A 14-year-old boy reported with a complaint of swelling associated with pain on the right side of the face since two days. The swelling was associated with pain, discomfort and salty taste in mouth. The patient gave a history of recurrent swellings on the right and left side of face alternatively since one year of age and had at least two episodes a year. The swelling and pain used to subside with antibiotics and analgesics. A hypertrophic scar was seen in front of the tragus on the left side of face corresponding to the incision and drainage of the parotid gland performed a year ago following chronic infection. On inspection, the parotid swelling on the right side was roughly oval in shape measuring 3 × 4 cm in diameter, and skin over the swelling was stretched. It was firm in consistency, tender and febrile. The submandibular lymph nodes were palpable and tender. Intraoral findings include thick ropy saliva and no inflammation over the ductal orifice of the parotid gland was found.
Provisional diagnosis of recurrent parotitis was considered and differential diagnosis included bacterial sialadenitis, Sjogren's syndrome, mumps and tubercular sialadenitis. The complete blood picture was normal and the peripheral smear was normocytic and normochromic with a few macrocytes. Serum IgE and IgM levels were within the normal range. Montoux test was negative and no abnormality was detected in chest radiograph. Culture of saliva from parotid duct was positive for coagulase negative streptococci and sensitive to cloxacillin, erythromycin and amikacin. Ultrasonogram of the right and left parotid glands revealed multiple hypoechoic areas and heterogeneous distribution of internal echoes suggestive of inflammatory changes and dilation of acini in both glands. Salivary flow rate of unstimulated and stimulated saliva was 0.26 ml/min and 0.45 ml/min respectively suggestive of salivary gland hypofunction. Sialography was performed using Iopromide (ultravist-300) as a contrast media for both right and left parotid gland after the clinical symptoms subsided. Sialography revealed dots or blobs of contrast media distributed throughout the gland, an appearance known as "sialectasis" suggestive of sialadenitis [Figure 1].
Based on the history given by the patient, clinical picture, investigations and sialographic appearance, the final diagnosis of juvenile recurrent parotitis was arrived. Antibiotics and analgesics were prescribed for 10 days. Sialography was performed twice at an interval of six months for the glandular lavage which helps to clear the mucous plugs that form in the acute phase. The treatment seems to be effective as there is no recurrence of swelling since 18 months.
A 56-year-old female patient reported with a complaint of swelling on the left side of face since one year. The swelling was initially small in size and gradually increased to the present size. It was not associated with pain or discomfort during mealtime. There was no history of discharge or paraesthesia associated with the swelling. Medical history revealed that she was diabetic and on oral hypoglycemics since 15 years. The swelling was roughly oval in shape, measuring 2 × 3 cm in diameter in the left submandibular region, and skin over the swelling was normal. It was firm in consistency, non tender and afebrile. The provisional diagnosis of sialadenosis was given and pleomorphic adenoma was considered for the differential diagnosis. Investigations included complete blood picture, urea and electrolytes, erythrocyte sedimentation rate, fasting blood glucose, liver function tests, rheumatoid factor and autoantibody screen. All the values, except for fasting glucose (160 mg/dL), were within normal range; fine needle aspiration cytology (FNAC) of the swelling revealed normal acini and sheets of ductal epithelium and stromal fragments.
Sialography was performed using Iopromide (ultravist-300) as a contrast media which showed "leafless-tree" appearance with compression of finer ducts [Figure 2] suggestive of sialadenosis. Based on the history given by the patient, clinical features, investigations and sialographic appearance a final diagnosis of diabetic sialadenosis was given. As the condition was asymptomatic, no treatment was indicated and periodic follow-up was advised.
An 89-year-old male patient reported with a painful swelling below the lower right jaw since 20 days. The swelling appeared for the first time five months back. It was initially smaller in size and slowly increased to the present size. The swelling was roughly oval in shape, measuring 3 × 4 cm in diameter in the right submandibular region. It was firm in consistency, tender and afebrile. Intraoral findings include increase in the size of right Wharton's ductal orifice with no signs of inflammation and pus expressed on milking the gland.
The provisional diagnosis of bacterial sialadenitis of the right submandibular salivary gland was given and the patient was prescribed antibiotics and analgesics for seven days. FNAC revealed normal acini and sheets of ductal epithelium with a few lymphocytes and stromal fragments. As sialography is contraindicated in acute infections, the patient was recalled after two weeks. Sialography was performed using Iopromide (ultravist-300) as a contrast media after the clinical symptoms subsided and it revealed "sausage-linked" appearance of the duct with normal acini suggestive of sialodocitis [Figure 3]. Based on the history given by the patient, clinical features, investigations and sialographic appearance a final diagnosis of sialodocitis was arrived and the patient has been under follow-up for the last one year with no recurrence reported.
| Discussion|| |
Detailed imaging of the diseased salivary glands is necessary to diagnose, stage the disease and plan the treatment. Conventional radiography of the salivary glands is a widely accepted technique to detect the calcification within the glands and know the presence of metastasis. But radiographs are not useful to know the extent of destructive and invasive lesions.  To overcome these pitfalls other imaging modalities such as sialography, ultrasonography, computerized tomography, radionuclide imaging and magnetic resonance imaging have been introduced.
Ultrasound allows assessment of lesions of the gland parenchyma and intra and extra-glandular duct ectasia, periglandular structures and salivary stones. , Radionucleotide imaging is a valuable diagnostic tool for salivary glands and is performed using an oxidized form of technetium 99 m ( 99m Tc) pertechnetate. It evaluates physiology as well as pathology. CT and MRI provide excellent soft tissue details but they are not economical. Hence, sialography remains an indispensable choice for detailed assessment of the salivary glands when compared to the above mentioned imaging modalities as it is simple to perform, quick and almost a pain free diagnostic procedure.
MR sialography is a recent advancement with non-invasive 3D imaging technique. It is performed using a heavily T2-weighted sequence that allows the imaging of the salivary ducts because the containing saliva appears hyperintense and the surrounding tissue appears hypointense (Becker et al., 2000). It does not require cannulation of the duct nor does it use a contrast media. It is neither painful nor does it require ionizing radiation. Thus it is useful and might be able to replace classical sialography when it fails to evaluate the salivary gland and the duct. 
Sialography is an important diagnostic procedure in the evaluation of salivary calculi, sialectasis, strictures, fistulae, and tumors. Based on the various sialographic appearances on the radiographs, the salivary gland disorders can be identified.  As in the case of juvenile recurrent parotitis the sialograph revealed dots or blobs of contrast media distributed throughout the gland, an appearance known as "sialectasis" suggestive of sialadenitis caused by the inflammation of glandular tissue producing dilation of terminal duct and sac like acini with normal main duct.
In case of sialadenosis, the sialography revealed "leafless-tree" appearance caused by the compression of finer ducts. In the case of sialodocitis the sialography revealed "sausage-linked" appearance because of ductal dilation with normal acini. In all our cases sialography played a key role and helped in the diagnosis. Although sialography is commonly used as a diagnostic aid it is contraindicated in active infections of the salivary gland, allergy to contrast media, blocked salivary gland duct orifice due to the presence of sialolith or stricture, and/or small orifice of salivary duct. ,
Sialography is used mainly for diagnostic purposes, but also plays an important role as a therapeutic aid in the treatment of patients suffering from obstructive sialadenitis.  In our case of juvenile recurrent parotitis, sialography was done twice at an interval of six months and proved beneficial. The treatment seems to be effective as it helps clear the mucous plugs and cells in case of recurrent infections. 
Nahlieli et al. (2004) diagnosed and treated 21 cases of juvenile recurrent parotitis with a combined endoscopic approach. The treatment composed of lavage with 60 ml of normal saline, ductal dilatation with saline pressure or balloon dilation followed by hydrocortisone (100 mg) injections via the endoscope into the gland. The treatment modality was directed to lavage the ductal system and the sialectases from plaques and to dilate strictures.  Mandel stated that steroids may reduce swelling, but will not prevent recurrences. , Bailey recommended duct cannulation and lavage with 1% mercurochrome for the glandular lavage. 
| Conclusion|| |
Sialography remains the most popular imaging procedure for assessment of ductal inflammatory and degenerative diseases despite the more sophisticated imaging techniques currently available. Sialography also proves to be a therapeutic aid in cases of obstructive sialadenitis and recurrent infections.
| Acknowledgment|| |
The authors would like to acknowledge Dr. H. N. Shama Rao, Professor and Principal, M. S. Ramaiah Dental College, Bangalore for his constant guidance and support.
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Sujatha S Reddy
Department of Oral Medicine and Radiology, M. S. Ramaiah Dental College & Hospital, MSRIT post, New Bel Road, Bangalore 560 054
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]