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Vol. 120 No.

6 December 2015

Cone beam computed tomography (CBCT) sialographydan

adjunct to salivary gland ultrasonography in the evaluation
of recurrent salivary gland swelling
Tobias Kroll, MD,a Andreas May, DDS,b Claus Wittekindt, MD, PhD,a Christopher Kähling, MD,b
Shachi Jenny Sharma, MD,a Hans-Peter Howaldt, MD, DDS, PhD,b Jens Peter Klussmann, MD, PhD,a and
Philipp Streckbein, MD, DDSb

Objective. Cone beam computed tomography (CBCT) sialography could help improve the visualization of the ductal system
of salivary glands. The aim of this retrospective investigation was to monitor the use of CBCT sialography for the diagnosis of
pathologies within the intraglandular ductal system when ultrasonography was inconclusive.
Study Design. Fourteen consecutive patients suffering from recurrent swelling of a major salivary gland were evaluated. In 12
patients (8 female; 4 male; average age 46 years), a radiopaque contrast agent could be injected into the ductal system,
followed by a routine CBCT. Four blinded examiners evaluated the acquired data sets retrospectively.
Results. CBCT revealed seven stenosis, two salivary stones, one complete duct atresia, one intraglandular duct ectasia, and
one regular duct system. Three of the detected pathologies were strictly intraglandular.
Conclusions. CBCT sialography shows promise as a supplementary noninvasive diagnostic tool for the visualization of the
intraglandular ductal system of the major human salivary glands. Controlled studies to further validate this method should be
undertaken. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;120:771-775)

Various radiologic and nonradiologic methods are computed tomography (CBCT) in otorhinolaryngology
available for the imaging diagnostics of salivary gland and cranio-maxillo-facial surgery, a new radiologic
parenchyma and salivary ducts. Currently, because of imaging method appears to have become available for
its known advantages, ultrasonography is the key the visualization of salivary glands, particularly sali-
nonradiologic modality used for imaging the paren- vary gland ducts, after injection of a radiopaque
chyma of major salivary glands.1 However, salivary contrast agent into the ductal system. This approach,
ducts can only be demonstrated when they are filled. called CBCT sialography, is, however, still in an early
This occurs either when they are obstructed through a stage of development.7,8
salivary stone or a stenosis, or when a salivation- The aim of this retrospective review is to demonstrate
inducing substance, such as ascorbic acid, has been that CBCT sialography is a suitable imaging modality
orally administered.2 Injection of an ultrasound contrast for the diagnosis of salivary duct pathologies, in
agent into the ductal system can improve visualization particular, when sonography has failed to demonstrate
of the gland parenchyma and the ductal system during pathology in patients suffering from recurrent swelling
examination.3,4 of a salivary gland.
A further, established, nonradiologic imaging
method for the visualization of salivary ducts is mini-
mally invasive sialendoscopy, which, since 2006, is MATERIAL AND METHODS
increasingly being performed as a routine procedure in Indication for CBCT sialography remained uncertain
Otorhinolaryngology in Germany.5 because of recurrent gland swellings after the initial
Radiologic imaging modalities available to visualize clinical examination. Contraindications were detected
salivary gland parenchyma and salivary gland ducts are due to recurrent gland swellings, such as stones, duct
conventional sialography, computed tomography (CT), lesions, or intraglandular lesions. All of the patients
and magnetic resonance imaging (MRI) sialography.6 (n ¼ 92) who presented from February 2013 to
With the introduction and increasing use of cone beam February 2014 at our institution with recurrent swelling

Department of Otorhinolaryngology, University Hospital Gießen,
Justus Liebig University, Klinikstraße 33, Giessen, 35392, Germany.
Statement of Clinical Relevance
Department of Cranio-Maxillo-Facial Surgery, University Hospital
Gießen, Justus Liebig University, Klinikstraße 33, Giessen, 35392,
Cone beam computed tomography sialography al-
Received for publication May 13, 2014; returned for revision Feb 14, lows for visualization of ductal anomalies even in
2015; accepted for publication Sep 2, 2015. peripheral locations. It shows promise as a supple-
Ó 2015 Elsevier Inc. All rights reserved. mentary noninvasive diagnostic tool for the visuali-
2212-4403/$ - see front matter zation of the intraglandular ductal system.

772 Kroll et al. December 2015

of a parotid or submandibular gland were scanned for male. The average patient age was 46 years. The parotid
this retrospective evaluation. After a comprehensive gland was examined in eight (66.7%) and the sub-
anamnesis and clinical examination, diagnostic ultra- mandibular gland in four (33.3%) cases. Five (41.7%)
sonography of the swollen salivary gland was per- patients underwent sialendoscopy before CBCT sia-
formed routinely in all cases. In 14 patients, the cause lography. In these cases, the indication for CBCT sia-
of the recurrent salivary gland swelling could not be lography was unsolved pathology within the
established in the initial examination or sialendoscopy. sialendoscopy.
CBCT sialography was indicated for further imaging of Evaluation of the acquired CBCT images (Table I)
the salivary duct system. Each patient signed an revealed seven (58.3%) salivary duct stenoses, of
informed consent form before routine CBCT which three (42.9%) were found close behind the
sialography. papilla, even though the papilla had showed no signs
In preparation for the CBCT sialography, the efferent of obstruction in prior clinical examinations or
duct of the swollen gland was dilated to 22 gauges with ultrasonography; three (42.9%) were in the main
salivary duct probes (Marchal Salivary Duct Probes, efferent duct, and one (14.3%) was in an
Karl Storz, Tuttlingen, Germany). Then, depending on intraglandular duct (Figure 1). In addition, in two
the gland, the caruncle or papilla was cannulated with (16.7%) submandibular glands, salivary stones that
an indwelling venous cannula (Vasofix Braunüle, had remained undetected during ultrasonography
Braun, Melsungen, Germany), through which a radi- could be demonstrated as the cause of the recurrent
opaque contrast agent (Ultravist-370, Bayer Vital, swelling of the gland. One stone was found in an
Leverkusen, Germany) was injected into the ductal intraglandular duct (50%), and the other was found in
system of the swollen gland until the patient reported the main efferent duct (50%). Complete atresia of the
fullness of the gland or the contrast agent flowed past Stensen duct was found in one (8.3%) parotid gland,
the probe into the oral cavity. Before scanning, patients and intraglandular duct ectasia was found in one
were positioned such that they did not have to be (8.3%) other parotid gland (Figure 2). For one (8.3%)
repositioned after injection of the contrast agent. A gland, no correlating pathology could be found with
radiologic image was then acquired with a CBCT CBCT sialography (Figure 3).
scanner (ProMax 3-D Max, Planmeca, Helsinki, On the basis of the results of CBCT sialography,
Finland). The following operational parameters were three (25.0%) patients were indicated for a subsequent
used to acquire the scan: For the parotid gland, a field of sialendoscopy, or revision sialendoscopy. One (8.3%)
view with a width of 230 mm, a height of 160 mm, and patient was treated with a combined approach. On the
a resolution of 0.4 mm was chosen. The resultant tube basis of an individual concept, a wait-and-watch strat-
voltage was 96 kV, with a tube current of 12 mA. The egy was chosen for eight (66.7%) patients.
data acquisition time for this scan was 9 seconds. For
the submandibular gland, a field of view with a width of DISCUSSION
130 mm, a height of 55 mm, and a resolution of 0.2 mm Visualizing the ductal system of the major salivary
was chosen. The tube voltage for this scan was 96 kV, glands has always been a challenge for clinicians,
with a tube current of 12 mA, and a data acquisition although various imaging modalities are available.
time of 12 seconds. Currently, the four most frequently used imaging mo-
The acquired CBCT data sets were visualized as dalities in everyday clinical routine are ultrasonogra-
multiplanar and three-dimensional reconstructions (3-D phy, sialography, CT, and MRI. Compared with the
recons) and analyzed by four independent blinded ex- first two methods, the two latter methods play a sub-
aminers qualified to perform radiologic evaluations. ordinate role due to cost, possible radiation exposure,
Data analysis was performed with DICOM viewer and availability issues.9 As an additional imaging
software (OsiriX MD, v2.8.5 64 bit, Pixmeo SARL, method, minimally invasive sialendoscopy is being
Bern, Switzerland). For every patient’s images, visual- increasingly used.5
ization of the ductal system was individually optimized, Currently, ultrasonography is the method of choice
followed by an evaluation for certain pathologies, such for imaging salivary glands because it can be performed
as stones, duct stenosis, duct ectasia, or duct atresia. by the attending physician, does not incur a radiation
burden, and provides an adequate imaging accuracy for
RESULTS diagnosis in many cases.1 However, to be adequately
Fourteen consecutive patients with indication for sia- visible during ultrasonography, the salivary ductal
lography were included in the retrospective review. Due system has to be filled. Salivary ducts can either be
to impenetrable salivary ducts, CBCT could not be intentionally filled by orally administering ascorbic
performed in two cases. Of the remaining 12 patients, acid to induce flow of saliva or may already be filled
eight (66.7%) were female, and four (33.3%) were as the result of obstructive pathologies, such as
Volume 120, Number 6 Kroll et al. 773

Table I. Patient list with patient history, diagnosis, and procedure after cone beam computed tomography (CBCT)
Duration Diagnosis Procedure
of symptoms after CBCT after CBCT
Gland Side Symptoms (anamnesis) Comorbidities sialography sialography
1 Parotid gland Right Recurrent swellings 36 months None Duct stenoses Combined approach
with acute parotits (sialendoscopy and
2 Parotid gland Left Recurrent swellings 15 months Metabolic Duct atresia Sialendoscopy
3 Parotid gland Right Recurrent swellings 18 months Arterial Duct stenoses Wait-and-watch
hypertension at papilla
4 Parotid gland Right Recurrent swellings 3 months None Duct stenoses Sialendoscopy
at papilla
5 Parotid gland Left Recurrent swellings 1 month Adiposity Intraglandular Wait-and-watch
with acute parotits duct ectasia
6 Parotid gland Right Recurrent swellings 4 months Arterial Regular salivary Wait-and-watch
hypertension duct
7 Parotid gland Left Recurrent swellings 60 months None Intraglandular Wait-and-watch
duct stenoses
8 Submandibular left Recurrent swellings 30 months None Sialolithiasis Sialendoscopy
9 Submandibular Left Recurrent swellings 5 months None Intraglandular Wait-and-watch
gland sialolithiasis
10 Submandibular Left Recurrent swellings 6 months None Duct stenoses Wait-and-watch
11 Submandibular Right Recurrent swellings 18 months None Duct stenoses Wait-and-watch
12 Parotid gland Right Recurrent swellings 2 months Arterial Duct stenoses Wait-and-watch
hypertension at papilla

salivary stones or duct stenosis.2 The retrograde Sialendoscopy has been established as an additional
administration of a contrast agent, similar to the procedure for the diagnosis and therapy of salivary
procedure for sialography, can aid in the visualization gland disease. Koch et al. preserved over 97% of sali-
of the ductal system during ultrasonography.3,4 A lim- vary glands with stenoses of the Wharton ducts or
itation of ultrasonography in demonstrating the cause of Stensen ducts by using this method along with a com-
recurrent salivary gland swelling is that pathologies bined approach.11,12 However, the method can only be
other than obstruction by stones can be difficult to di- used for extraglandular duct pathologies or those
agnose with this method.10 located close to the hilum.

Fig. 1. A, Three-dimensional reconstruction of the efferent duct system of the parotid gland. B, Axial section in a planar
reconstruction. The images show a stenosis located behind the junction to the tertiary division branch of the duct system. The
stenosis is indicated by a red arrow.
774 Kroll et al. December 2015

Fig. 2. Intraglandular ectasia of the efferent parotid gland duct system. Ectasia can be seen to begin at the junction point between
the primary and secondary duct branches and to continue into the secondary branch. A, Three-dimensional reconstruction of the
efferent duct system. B, Axial section in a planar reconstruction. In both images, the red arrows indicate the ectatic portion of the

Although sialography, which was initially described stones.8 Our findings support the results reported by
in 1902, still holds a place in salivary gland diagnostics, Varoquaux et al. that the salivary gland duct system
this method is increasingly being replaced by modern can be visualized up to the sixth branch with CBCT
methods, such as CBCT.13-15 CBCT has become an sialography after a contrast agent has been injected.10
established diagnostic tool in cranio-maxillo-facial This high imaging accuracy is due to the isotropic
surgery and is rapidly gaining entry into otorhinolar- voxel resolution afforded by the CBCT unit.8 In a
yngology. This imaging method is being used for the first comparative study on radiation dose, Jadu et al.
diagnostics of the bony structures of the paranasal si- found that by choosing appropriate parameters, the
nuses and petrous bone. effective radiation dose from CBCT sialography
Early studies have shown that CBCT is also a suit- equaled that of conventional sialography.9
able modality for the visualization of salivary ducts that In the present retrospective review, the three-
have been enhanced with a radiopaque contrast agent.7-10 dimensional visualization of the salivary duct system
In a study that directly compared conventional two- through CBCT allowed us to diagnose a total of three
dimensional sialography with three-dimensional sia- previously undetected intraglandular pathologies. Our
lography, Jadu et al. postulated that CBCT sialography findings thus support Varoquaux et al.’s suggestion that
outperformed conventional sialography for the visuali- the underlying causes for recurrent swelling of a sali-
zation of salivary gland parenchyma and salivary vary gland, not due to obstruction through a stone, can

Fig. 3. No correlating pathology could be found, and the reasons for recurrent swellings remain uncertain. A normal parotid gland
duct system is shown as a three-dimensional reconstruction (A), and as a planar reconstruction (B).
Volume 120, Number 6 Kroll et al. 775

elude ultrasonographic diagnosis. It remains to be 3. Kroll T, Helbig M, Klussmann JP, Wittekindt C. Intraductal
clarified if ultrasonography can accurately image application of Levovist(R) in salivary glands of animals. Lar-
yngorhinootologie. 2012;91:229-232 [in German].
intraglandular duct pathologies after contrast medium 4. Zengel P, Berghaus A, Weiler C, Reiser M, Clevert DA. Intra-
has been injected into the salivary duct system. ductally applied contrast-enhanced ultrasound (IA-CEUS) for
Comparative studies need to be undertaken to shed light evaluating obstructive disease and secretory dysfunction of the
on this question. salivary glands. Eur Radiol. 2011;21:1339-1348.
Although it must be stressed that CBCT sialography 5. Kroll T, Finkensieper M, Hauk H, Guntinas-Lichius O,
Wittekindt C. Sialendoscopydlearning curve and nation-wide
cannot be a substitute for sialendoscopy, the targeted survey in German ENT-departments. Laryngorhinootologie.
use of CBCT sialography could, however, reduce the 2012;91:561-565 [in German].
indication for sialendoscopy for pathologies of the 6. Kraff O, Theysohn JM, Maderwald S, et al. High-resolution MRI
extraglandular duct system or the area around the hi- of the human parotid gland and duct at 7 Tesla. Invest Radiol.
lum. In these cases, CBCT sialography could be helpful 2009;44:518-524.
7. Abdel-Wahed N, Amer ME, Abo-Taleb NS. Assessment of the
in accurately identifying patients who could profit from role of cone beam computed sialography in diagnosing salivary
further gland-preserving interventions. gland lesions. Imaging Sci Dent. 2013;43:17-23.
8. Jadu FM, Lam EW. A comparative study of the diagnostic ca-
CONCLUSIONS pabilities of 2 D plain radiograph and 3 D cone beam CT sia-
In this retrospective review, CBCT sialography was lography. Dentomaxillofac Radiol. 2013;42:20110319.
9. Jadu F, Yaffe MJ, Lam EW. A comparative study of the effective
helpful in diagnosing unexplained cases of swelling of radiation doses from cone beam computed tomography and plain
one of the major salivary glands with intraglandular radiography for sialography. Dentomaxillofac Radiol. 2010;39:
pathologies when ultrasound was inconclusive. We 257-263.
could thus demonstrate that CBCT sialography shows 10. Varoquaux A, Larribe M, Chossegros C, Cassagneau P, Salles F,
promise as a supplementary noninvasive diagnostic tool Moulin G. Cone beam 3 D sialography: preliminary study. Rev
Stomatol Chir Maxillofac. 2011;112:293-299 [in French].
for the visualization of the intraglandular duct system. 11. Koch M, Iro H, Kunzel J, Psychogios G, Bozzato A, Zenk J.
Our encouraging findings suggest that performing a Diagnosis and gland-preserving minimally invasive therapy for
CBCT sialography before sialendoscopy may be justi- Wharton’s duct stenoses. Laryngoscope. 2012;122:552-558.
fied in cases of unexplained, recurrent swelling of a 12. Koch M, Kunzel J, Iro H, Psychogios G, Zenk J. Long-term re-
salivary gland to rule out pathologies that are intra- sults and subjective outcome after gland-preserving treatment in
parotid duct stenosis. Laryngoscope. 2014;124:1813-1818.
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scope. Patients could, thus, be spared the unpleasantness eds. Oral Radiology: Priciples and Interpretation. 6th ed. St.
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An advantage of CBCT over other radiologic imag- 14. Rzymska-Grala I, Stopa Z, Grala B, et al. Salivary gland calcu-
ing, such as CT and MRI, is its lower cost. The amount lidcontemporary methods of imaging. Polish J Radiol. 2010;75:
of exposure to radiation is less than with CT and is 15. Shahidi S, Hamedani S. The feasibility of cone beam computed
comparable with conventional sialography. tomographic sialography in the diagnosis of space-occupying
Controlled studies with higher case numbers and lesions: report of 3 cases. Oral Surg Oral Med Oral Pathol
follow-up examinations are planned to further verify the Oral Radiol. 2014;117:e452-e457.
value of CBCT examinations for the diagnosis of sali-
vary gland pathologies. Reprint requests:
Tobias Kroll, MD
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