Teaching mat er ials Radiog aphy Te cnique 4

13 t h Meeting
SIALOGRAPHY

DEFINITION SIALOGRAPHY EXAMINATION

Sialography is the term applied to radiologic examination of the salivary

Glands and ducts with the use of a contrast material, usually one of the water-

soluble iodinated media. Because of improvements ii computed tomography

(CT) and magnetic resonance imaging (M R I) techniques, sialography is

performed Iess often than it once was. When the presence of a salivary stone

or lesion is suspected, CT or MRI is often the modality of choice. However,

sialography remains a viable tool when definitive diagnosis is needed for a

problem related to one of the salivary ducts. The procedure is used to

demonstrate such conditions as inflammatory lesions and tumors, to

determine the extent of salivary fistulae, and to localize diverticula, strictures,

and calculi. Because the glands are paired and the pairs are in such close

proximity, only one gland at a time can be examined by the sialographic

method.

ANATOMY

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The three pairs of salivary glands produce approximately 1 liter of saliva each

day. The glands are named the parotid, the submandibular, and the sublingual.

a) Parotid glands

The largest of the salivary glands, each consist of a flattened superficial

portion and a wedge-shaped deep portion. The superficial part lies

immediately anterior to the external ear and extends inferiorly to the

mandibular ramus and posteriorly to the mastoid process. The deep, or

retromandibular, portion extends medially toward the pharynx. The

parotid duct runs anteriorly and medially to open into the oral vestibule

opposite the second upper molar.

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b) Submandibular glands

The submandibular glands are fairly large, irregularly shaped glands. On

each side a submandibular gland extends posteriorly from a point below

the first molar almost to the angle of the mandible. Although the upper

part of the gland rests against the inner surface of the mandibular body,

its greater portion projects below the mandible. The submandibular

duct extends anteriorly and superiorly to open into the mouth on a

small papilla at the side of the frenulum of the tongue.

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c) Sublingual galnds

The sublingual glands, the smallest pair, are narrow and elongated in

form. These glands are located in the floor of the mouth beneath the

sublingual fold. Each is in contact with the mandible laterally and

extends posteriorly from the side of the frenulum of the tongue to the

submandibular gland. Numerous small sublingual ducts exist. Some of

these ducts open into the floor of the mouth along the crest of the

sublingual fold, and others open into the submandibular duct. The main

sublingual duct opens beside the orifice of the submandibular duct.

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A. PATHOLOGY

The procedure is used to demonstrate such conditions as inflammatory lesions

and tumors, to determine the extent of salivary fistulae, and to localize

diverticulae, strictures, and calculi. Because the glands are paired and the pairs

are in such close proximity, only one gland at a time can be examined by the

sialographic method.

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B. EUIPMENT

Tool used in sialography examination is:

a) Upper (sterile )shelf

 Salivary duct dilator

 Lacrimal duct cannula or polythene catheter and adaptor

 One 2 ml syringe

 One 5 ml syringe

 Drawing up cannula

 Towels

 Gauze swabs

b) Lower (unsterile) shelf

 Ampoules of contrast medium in bowl of warm water

 Slice of lemon

 Adhesive strapping

 Receiver

 Mouth wash

 Disposable cup

 Angle poise lamp

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C. PROCEDURE

Sialography involves the following steps:

a) Inject the radiopaque medium into the main duct. From there the

contrast flows into the intraglandular ductules, making it possible to

demonstrate the surrounding glandular parenchyma, as well as the duct

system.

b) Obtain preliminary radiographs to detect any condition demonstrable

without the use of a contrast medium and to establish the optimum

exposure technique.

c) About 2 or 3 minutes before the sialographic procedure, give the

patient a secretory stimulant to open the duct for ready identification

of its orifice and for easier passage of a cannula or catheter. For this

purpose, have the patient suck a wedge of fresh lemon. On completion

of the examination, have the patient suck on another lemon wedge to

stimulate rapid evacuation of the contrast medium.

d) Take a radiograph about 10 minutes after the procedure to verify

clearance of the contrast medium, if needed. Most physicians inject the

contrast medium by manual pressure (i.e., with a syringe attached to

the cannula or catheter). Other physicians advocate delivery of the

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medium by hydrostatic pressure only. The latter method requires the

use of a water soluble iodinated medium, with the contrast solution

container (usually a syringe barrel with the plunger removed) attached

to a drip stand and set at a distance of 28 inches (70 cm) above the level

of the patient's mouth. Some physicians perform the filling procedure

under fluoroscopic guidance and obtain spot radiographs. (Articles cited

in the bibliography provide detailed descriptions of the numerous

methods of performjng sialography.)

D. EXAMINATION TECHNIQUES

a. Parotid glands

Tangential projection

Image receptor: 8 x 1 0 inch (1 8 x 24 cm) lengthwise

Position of patient

a) Place the patient in either a recumbent or seated position.

b) Because the parotid gland lies midway between the anterior and

posterior surfaces of the skull, obtain the tangential projection of

the glandular region from either the posterior or the anterior

direction.

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Position of part

Supine body position

a) With the patient supine, rotate the head slightly toward the side

being examined so that the parotid area is perpendicular to the

plane of the IR.

b) Center the I R to the parotid area.

c) With the patient's head resting on the occiput, adjust the head so

that the mandjbular ramus is parallel with the longitudinal axis of

the IR.

Prone body position

a) With the patient prone, rotate the head so that the parotid area

being examined is perpendicular to the plane of the IR.

b) Center the IR to the parotid region.

c) With the patient's head resting on the chin, adjust the flexion of

the head so that the mandibular ramus is parallel with the

longitudinal axis of the IR.

d) When the parotid (Stensen's) duct does not have to be

demonstrated, rest the patient's head on the forehead and nose.

e) Shield gonads.

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f) Respiration: Improved radiographic quality can be obtained,

particularly for the demonstration of calculi, by having the patient

fill the mouth with air and then puff the cheeks out as much as

possible. When this cannot be done, ask the patient to suspend

respiration for the exposure.

Central ray

Perpendicular to the plane of the IR, directed along the lateral surface

of the mandibular ramus

Structures shown

A tangential projection demonstrates the region of the parotid gland

and duct. These structures are clearly outlined when an opaque

medium is used.

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Evaluation criteria

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The following should be clearly demonstrated:

a) Soft tissue density

b) Most of the parotid gland lateral to, and clear of, the mandibular

ramus

c) Mastoid overlapping only the upper portion of the parotid gland

b. Parotid and submandibular glands

Lateral projection (R or L position)

Image receptor: 8 x 1 0 inch ( l 8 X 24 cm) lengthwise

Position ot patient

Place the patient in a semi prone or seated and upright position.

Position of part

Parotid gland

a) With the affected side closest to the IR, extend the patient's neck so

that the space between the cervical area of the spine and the

mandibular rami is cleared.

b) Center the IR to a point approximately I inch (2.5 cm) superior to the

mandibular angle.

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c) Adjust the head so that the midsagittal plane is rotated approximately 1

5 degrees toward the IR from a true lateral position.

Submandibular gland

a) Center the I R to the inferior margin of the angle of the mandible.

b) Adjust the patient's head in a true lateral position.

c) Iglauer' suggested depressing the floor of the mouth to displace the

submandibular gland below the mandible. When the patient's throat is

not too sensitive, accomplish this by having the patient place an index

finger on the back of the tongue on the affected side.

Shield gonads.

Respiration: Suspend.

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Central ray

Perpendicular to the center of the IR and directed (I) at a point I inch (2.5

cm) superior to the mandibular angle to demonstrate the parotid gland or

(2) at the inferior margin of the mandibular angle to demonstrate the

submandibular gland.

Structures shown

A lateral image demonstrates the bony structures and any calcific deposit

or swelling in the unobscured areas of the parotid and submandibular

glands. The glands and their ducts are well outlined when an opaque

medium is used.

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Evaluation criteria

a) The following should be clearly demonstrated:

b) Mandibular rami free of overlap from the cervical vertebrae to best

show the parotid gland superimposed over the ramus

c) Superimposed mandibular rami and angles if no tube angulation or

head rotation is used for the submandibular gland

d) Oblique position for the parotid gland.

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c. Submandibular dan sublingual glands

Axial projection (Intraoral method)

Image receptor: Occlusal film 57 X76 mm

Position of patient

a) Elevate the patient's thorax on several firm pillows.

b) Flex the patient's knees to relax the abdominal muscles and thereby

allow full extension of the neck.

c) Adjust the shoulders to lie in the same transverse plane.

Placement of film

a) Tape a side marker (R or L) on one corner of the exposure surface of

the occlusal film packet.

b) Place the film in the mouth with the long axis directed transversely.

c) Center the packet to the mjdsagittal plane, and gently insert it far

enough so that it is in contact with the anterior borders of the

mandibular rami.

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d) Instruct the patient to gently close the mouth (to hold the packet in

position).

e) After placement of the occlusal film, fully extend the patient's neck

and rest it on the vertex with the midsagittal plane vertical.

Shield gonads.

Respiration: Suspend.

Central ray

Perpendicular to the plane of the film and directed to the intersection of

the midsagittal plane and a coronal plane passing through the second

molars.

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Structures shown

An axial image of the floor of the mouth is demonstrated, showing the

entire sublingual gland areas and the duct and anteromedial part of the

submandibular gland areas.

Evaluation criteria

The following should be clearly demonstrated:

a) Soft tissue density of the floor of the mouth

b) Both sides of the mandible and dental arches symmetric

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c) Sublingual glands in their entirety along with a portion of the

submandibular glands when the film includes the lower molars.

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REFERANCE

a. http://www.nurilahi.co.id/2008/05/usage-of-high-kilovoltagekv-
in-chest.html
b. Whitley, A. Stewart. Jeferson , Gail. and friends. 2016. “Clark’s
Positioning in Radiography Thirteenth Edition”. London. CRC
Press.
c. Steward C. Bushong. Radiologic Science for Technologists: Physics,
d. Biology, and Protection. Mosby Inc, St. Louis, 2001.
e. Bontrager, radiological Technique, 2014
f. Vinnita Merrils, Atlas Of Roentgenographic Position and Standart
Radioation Procedure, 2013
g. Meschan radiographic Positioning and Related Anatomy, WB
Saunders
h. KC Clark Positioning in radiography, Ilford Ltd William
Heineman, Medical Book, 2003
i. Eisenberg, Ronald R : Radiographic Positioning, Little Brown And
Co Boston

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