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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