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Sialadenitis / SialolithiasisImaging

Ultrasound, CT, and Others

William Ryan, MDAssistant Professor

Head and Neck Oncologic/Endocrine/Salivary SurgeryDepartment of Otolaryngology-Head and Neck Surgery

Disclosures

Consultant for Medtronic

PURPOSES OF IMAGING

Establishing Diagnosis – Etiology- Sialolith- Stenosis

- Inflammation / Fibrosis- Tumor, Cyst

- Single Gland / Generalized

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Establishing Diagnosis – Etiology- Sialolith- Stenosis

- Size (Number) of Sialolith(s) >4-7mm – OPEN (combination)

- Location of Sialolith(s) / Stenosis(es)Parotid, Submandibular

Distal, Proximal, Parenchymal

Establishing Diagnosis – Etiology- Sialolith- Stenosis

- Size (Number) of Sialolith(s) >4-7mm – OPEN (combination)

- Location of Sialolith(s) / Stenosis(es)Parotid, Submandibular

Distal, Proximal, Parenchymal

Determine Indication for:

Observation / Conservative Measures

Referral (oral medicine, rheumatology, neurology, etc)

Sialendoscopy

Transoral Open

Transcervical/Transfacial Open Combination

Sialadenectomy

Location of Sialolith (Stenosis)-> Treatment

Distal: Transoral or Sialendoscopy

Proximal: Sialendoscopy or Transoral

Transcervical / Transfacial Combined Approach

Parenchymal: Transcervical / Transfacial Combined Approach or

Sialedenectomy

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Modalities

Ultrasound(Ultrasound Guided Sialendoscopy / Sialithotomy)

CT neck

Others:Head / Dental X-ray

MRISialogram

MR Sialogram

Modalities

Ultrasound(Ultrasound Guided Sialendoscopy / Sialithotomy)

CT neck

Others:Head / Dental X-ray

MRISialogram

MR Sialogram

Ultrasound and CTCommon place / available

InterpretableEstablishing Diagnosis - Etiology

Location (Number) Determining Treatment

Ultrasound Advantages7.5-13 MHz linear probe

High Resolution has improved sensitivityCheaperEfficient Non-invasiveNo radiation

Surgeon-performed / In-clinicDynamic (real time / intraoperative)Dynamic dilation (with sialagogues)Better lymph node definitionEasy repeat follow up (extension of physical exam)

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Ultrasound Disadvantages

Sensitivity: 77-81%Specificity: 94-95%PPV: 94%NPV: 78%Accuracy 85-86%

Can’t totally rule out sialolithiasisNo deep parotid lobe evaluation

Operator dependent

Ultrasound Disadvantages

Sensitivity: 77-81%Specificity: 94-95%PPV: 94%NPV: 78%Accuracy 85-86%

Can’t totally rule out sialolithiasisNo deep parotid lobe evaluation

Operator dependent

CT Neck Advantages

Need 1 mm slicesNON-CONTRAST BETTER

Less Operator DependentMore Sensitive

Precise location of sialolithsBetter floor of mouth definitionBetter tumor / infiltrative process delineation

CT Neck Disadvantages

False positivesLess ductal definition

Radiation (more with contrast)ExpensiveAnother visit

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Submandibular Ultrasound

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Parotid Ultrasound

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Intraoperative Ultrasound Guided Sialendoscopy/Sialolithotomy

Intraoperative Ultrasound Guided Sialendoscopy/Sialolithotomy

- Updated Imaging At Time of the Procedure

- Intraoperative Sialolith / Stenosis Location

- Intraoperative Sialolith Removal Confirmation

- Sialendoscope / Forceps Guidance(Retrieval / Fragmentation)

- Needle Catheter Insertion

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Dynamic Assessment

Finger Floor of Mouth Manipulation Finger Floor of Mouth Manipulation

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Intraoperative Sialolith Confirmation (of Removal)

Forceps Guidance (Retrieval / Fragmentation)

Sialendoscope Guidance

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Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

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Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

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Submandibular CT

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Tonsilith

Parotid CT

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• Screen Shot 2014-10-29 at 10.01.34 AM

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Others MRI

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MRISometimes an incidental finding

Better Soft Tissue Definition

Better Parotid (Deep) EvaulationTumor Type Prediction

No Radiation

ExpensiveTime-ConsumingClaustraphobiaContraindications: Pacemakers, etc

Less PPV / NPV

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Sjogren’s Sjogren’s

Carcinoma

X-rays

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Sialography

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SialographyOld Gold StandardBetter / Comprehensive- Sialolith size/ location- Duct morphologic structureSjogren’s - Diagnostic Sometimes therapeutic

Drawbacks:InvasiveIrradiationCAN PUSH STONE UP FURTHERPerforation / Infection / PainAnaphylactic shock

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MR Sialography

MR SialographyT2 pulse sequenceNon-invasiveNo contrastNo irradiationNo pain

Time-consuming (45 mins)ExpensiveClaustrophobiaDental artifactsMisses very small stones (CT better)

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112 patients with chronic parotitis

CT, MR, U/S, Sialography scansPositive and negative for sialoloths

63% PPV for endoscopic visualization100% NPV for sialoliths

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CONCLUSIONS

CONCLUSIONS

Ultrasound – Adequate- Inexpensive / In clinic

CT Scan – Highly sensitive / thorough- Expensive / Radiation

MRI / Sialography / MR Sialography- Interpretable

- Possibly More Accurate- Expensive

– May Not Change Management

CONCLUSIONS

Location of Sialolith (Stenosis)Dictates Treatment / Expectations

- Distal: Transoral or Sialendoscopy

- Proximal: Sialendoscopy or Transoral or Transcervical / Transfacial Combined Approach

- Parenchymal: Transcervical / Transfacial Combined Approach or Sialedenectomy

THANK YOU