Chronic Obstructive Sialadenitis due to an Abnormal Wharton's Duct Draining to the Tonsillar Fossa.

INTRODUCTION: Chronic obstructive sialadenitis (COS) is an entity that causes a marked loss in patient quality of life, including changes in eating habits and a progressive loss of gland function. It is characterized by repeated episodes of painful glandular swelling often requiring emergency care. There are multiple causes of COS, including lithiasis, strictures, anatomical variants, and others. The development of specific imaging tests such as magnetic resonance (MR) sialography or sialendoscopy have increased knowledge of these obstructions and how to specifically treat them. CASE SUMMARY: We present an unusual case of a woman with a years-long history of chronic obstructive sialadenitis in which an abnormal path of Wharton's duct was in evidence. This duct, which was atrophic and smaller in diameter, opened in the tonsillar fossa rather than lateral to the lingual frenulum. This case, the first in vivo description of its kind, was confirmed by MR sialography and sialendoscopy. DISCUSSION: Congenital anomalies of the submandibular duct are a rare finding, but may cause COS. Therefore, COS requires a detailed diagnostic study, usually by ultrasound, MR sialography and sialendoscopy, to rule out complex anatomical variants.

Radiocontrast Dye Extravasation During Sialography.

OBJECTIVE: Evaluate the pathophysiology of contrast extravasation. METHODS: Two hundred fifty-five sialograms at the University of Iowa from 2008 to 2016 were reviewed. RESULTS: Twelve sialograms (4.7% of total) were identified with main ductal extravasation. In each case, ductal stenosis as a diagnosis was supported by clinical history and the finding of difficulty in advancing the cannula into the duct during sialography. In all but 1 case, extravasation occurred at the distal duct with no further imaging of the ductal system. Each of the 5 cases treated with sialendoscopy with or without gland resection confirmed stenosis. Ultrasound evaluation of 5 of the cases detected ductal dilation in 4 (80%). Six of 11 computed tomography scans done before the sialogram were interpreted as normal with indirect evidence for ductal stenosis (duct dilation) reported in only 1. All extravasations were associated with either stricture alone or stricture with stone (1 case). CONCLUSION: Radiocontrast extravasation from the main duct during sialography is highly associated with the presence of ductal stricture. In our experience, the inability to fill the ductal system with radiocontrast is a useful sialographic finding that correlated closely with anatomic abnormality rather than technical error. The frequent finding of extravasation of radiocontrast supports the use of water soluble contrast.

Does sialography require antibiotic prophylaxis?

The objective of this study was to identify if bacteraemias occur during sialography, which could predispose to endocarditis in susceptible patients. Patients requiring sialography who gave informed consent were included in the trial. Patients taking antibiotics, or who were predisposed to infective endocarditis, were excluded. Sialography was performed using a standard hand injection technique with a water-soluble non-ionic contrast agent (Niopam, Bracco, UK). An indwelling cannula was inserted into the forearm prior to the procedure and then three blood samples of at least 10 ml were taken: sample one before sialography; sample two was taken as a continuous withdrawal during the sialographic procedure; and sample three over a further 10 min period after sialography. The blood samples were cultured for bacteria using the BacT/ALERT system (BioMerieux, UK). 32 patients were included in the study. No samples showed evidence of bacteraemia. Three patients had bacterial contamination from skin commensals. Using the rule of three, we have shown a 95% confidence interval of 3/32 = 0.09. In conclusion, the results of this study suggest that sialography is not associated with bacteraemia.

Lipiodol ultra-fluid - foreign body in the cheek.

We report a case in which iodinated oil (lipiodol ultra-fluid (UF)) leaked from an iatrogenic perforation of Stensen's duct and constituted a foreign body in the cheek. The distribution of contrast medium near the lower border of the mandible seems unusual. 2 years following sialography, the UF was still not being resorbed. No radiological signs of reactive inflammatory changes to the soft tissue were observed. We believe the contrast agent arrived beneath the skin, but external to the platysma, through a simple perforation in either the duct and/or the mucosa.

Lipiodol UF retention in dental sialography.

Lipiodol is a lipid based contrast medium and is very useful in sialography. It gives very fine images and clearly shows the details of the gland. It is viscous and has a relatively high iodine content. However, lipiodol UF drops sometimes remain in the salivary gland and in the adjacent tissues for a long time and may cause irritation. We report a case where lipiodol UF leaked from Stensen's duct and was not resorbed after a period of 70 months.

Morbidity from parotid sialography.

OBJECTIVE: Sialography is commonly used for the diagnosis of Sjögren's syndrome, although its invasive nature is often regarded as a serious drawback for routine usage. The aim of this study was to evaluate the morbidity and acceptability of parotid sialography using oil-based contrast fluid. STUDY DESIGN: Twenty-four consecutive sialographic procedures were evaluated in terms of morbidity and the patient's acceptance of the procedure, assessed with a standardized questionnaire. Information was also obtained by recording relevant physical parameters during the procedure. RESULTS: There was good acceptance of the sialographic procedure, and the morbidity was low. No signs of overfilling or false route were observed in any of the sialograms. On average, 0.74 mL of contrast fluid was infused with a velocity of 0.01 mL/s. The whole procedure was completed within 12 minutes. CONCLUSIONS: Parotid sialography appears less invasive than is often thought. It had a low morbidity rate and was well accepted by the patients.

Pain and swelling after sialography: is it a significant problem?

OBJECTIVES: This study investigated the incidence of pain and swelling after sialography and quantified the duration and severity of these symptoms. STUDY DESIGN: Sialography was performed on 92 patients who were then given a questionnaire to complete. Seventy-two questionnaires were returned and completed in a satisfactory manner. The patients were asked to assess pain and swelling before and after the sialogram was performed by using a Visual Analogue Scale (VAS). Comparisons between postsialographic measurements and baseline measures were carried out by using Friedman repeated measures analysis of variance on ranks. RESULTS: VAS scores increased significantly for both pain and swelling 1 hour after the sialogram (T1). The scores for swelling returned to baseline levels after 1 day (T2). The VAS for pain showed a similar pattern, but 2 days after the sialogram (T3), the scores were significantly lower, compared with those before the sialogram (P <. 05). CONCLUSIONS: Sialography is a safe procedure. Patients should be advised that minor effects may last approximately 1 day. A reduction in pain to below baseline levels was noted 2 days after sialography, which may suggest an unexpected benefit of sialography.

Radiation-induced cancer risk in radiographic cephalometry.

The carcinogenic risks associated with the cephalometric x-ray techniques customarily used in orthodontics and oral surgery have been estimated. Lateral, posteroanterior, 45 degrees oblique, lateral temporomandibular joint tomography, basilar techniques, and commonly-used combinations were examined. Data reported in a previous article on doses absorbed by pituitary (brain), salivary, and thyroid glands were used to calculate increased risk over normal incidence using the BEIR V model. The findings are expressed in a number of graphs. Tables list the estimated percentage increase in carcinomas for several of the most often used cephalometric procedures, and compare these with the more common complete mouth (periapical) and panoramic surveys. The overall conclusion is that responsible use of cephalometric radiology adds very little to the person's carcinogenic burden.

An adverse reaction following sialography.

Reactions following the administration of iodine are well documented in general radiography, but are unusual following sialography. A patient who experienced an adverse reaction following sialography with an iodine-based, low osmolar, contrast medium, Hexabrix 320, is presented. The reaction consisted of severe shoulder and back pain 24 h after the procedure. A skin rash was identified involving the right axilla, groin and elbow, with swelling visible around the right elbow joint. It was not possible to distinguish, on the basis of the available evidence, between an anaphylactoid and idiosyncratic allergic reaction.

Bacterial colonization of the parotid duct in xerostomia.

Salivary flow rate and bacterial colonization of the parotid main duct were investigated in 17 patients referred for sialography and in 10 healthy controls. Cultures in the controls were negative whilst the patient group revealed bacterial colonization of the main duct, especially in those with the lowest flow rates. The implications of this finding in patients at high risk of endocarditis who will be undergoing sialography are discussed.

Salivary gland uptake of gallium-67 citrate after sialography.

Sialography may cause greatly increased Ga-67 activity within otherwise normal salivary glands. Five patients are presented in whom sialography with oily contrast material injected 8-26 days before Ga-67 imaging produced strongly positive examinations. In each patient it appears that sialography rather than pre-existing pathologic conditions accounted for the increased activity. Sialography-induced subclinical sialadenitis may be the mechanism for the phenomenon.

Sialographic damage in rat submandibular gland.

The damage caused to rat submandibular glands by intraductal injection was examined. When a small volume of isotonic saline was injected, even if salivation was not influenced, salivary composition was greatly affected because the intercellular junctions of the duct cells were damaged. Intraductal injections of hyperosmotic solutions or highly viscous liquids were more effective in damaging intercellular junctions. When interpreting the significance of a salivary composition in clinical diagnosis, it is necessary to consider the sialographic damage which might influence the salivary composition.