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see: Checklist Steroid Insufflation to Salivary Glands in Clinic

return to: Sialograms and Sialography or Salivary Swelling

currently (April 2024) use: glydo® lidocaine 2% HCL jelly, USP 6 ml (120mg per 6 mL) (20 mg per mL)

glydo® lidocaine 2% HCL jelly, USP 6 ml (120mg per 6 mL) (20 mg per mL)

GENERAL CONSIDERATIONS

1. Sialography is performed in the Radiology fluoroscopy suite
2. Difficulty in cannulating the ducts and performing the dilations has warranted Otolaryngology involvement
   1. We employ a microscope to help with visualization most commonly
   2. Cannulation at other sites in the hospital (clinic/CRU = clinical research unit) are done with loup magnification
3. An oral rinse with dilute betadine or chlorhexidine is usually performed, followed by application of 2% viscous lidocaine on a 4x4 gauze sponge to the floor of mouth (SMG) or buccal region (parotid)
4. We most commonly employ the 0.015 inch Cook guide wire, although 000 and 0000 lacrimal probes can also be used (see: Parotid duct dilation and steroid insufflation in clinic)
   1. The cheek is retracted and inspected to identify the optimal position for cannulation
   2. The guide wire is then used to insert into the orifice - may also use to bluntly probe for the lumen of the duct if it is difficulty visualize
   3. Pressure on the gland may permit egress of saliva to help identify the duct; manipulation of the cheek (variable traction) may open (or close) the duct orifice
   4. The guidewire is used to cannulate the duct 
   5. Permits placement of a 22 or 24 gauge angiocatheter over it via the Seldinger technique.
5. Contraindications
   1. Anticipated failure in cannulating duct orifice
   2. Active inflammation/infection
6. Patients with acute or chronic inflammation within their salivary gland may be found to have a "panda sign" on exam, in which there is increased symmetric uptake in the parotid and lacrimal glands superimposed over normal nasopharyngeal uptake, creating an image that shows a striking similarity to the mottled coloring of a panda. While this is classically associated with sarcoidosis, it may also be found in post-radiation changes to the head and neck, lymphoma (post irradiation), Sjogren's syndrome, AIDS, and lymphoma.
7. Anatomy
   1. See anatomy of submandibular gland and duct
   2. see also: Salivary Ductoplasty

PREOPERATIVE PREPARATIONS

1. Appropriate patient selection:
   1. Ensure the need for a sialogram
      1. Alternatives: sialendoscopy w/o sialogram; MR sialography, other imaging
      2. Currently all adult patients with planned parotid sialendoscopy under general anesthesia undergo either sialography (as described in this protocol) or MRI sialography in order to:
         1. Identify ductal anatomy (unexpected strictures, abnormal anatomy)
         2. Ensure the capacity to enter the ductal system through a transoral route
2. Usually:
   1. Ensure patients is well hydrated (easiest way to identify duct is through expression of saliva)
      1. While the sialogram is a procedure, NPO status is not indicated as the patient will not be under general anesthesia.
   2. Pre-medicate with antibiotics - commonly: Augmentin/Levaquin or clindamycin: 10 day course to begin 7 days before procedure and continued for 3 days afterward.
3. Consent for Surgery
   1. Identify the indications/technique/alternatives and risks:
      1. Bleeding, infection, reaction to the anesthetic,
      2. Damage to adjacent structures
         1. Conceivable to cause scarring of duct orifice or perforation of duct
         2. Conceivable to exacerbate infection
   2. Ideally: show the patient this protocol in process of getting consent 

NURSING CONSIDERATIONS

1. Equipment (including microscope) is brought to the Radiology suite by Otolaryngology nursing
2. see: Parotid duct dilation and steroid insufflation in clinic

RESIDENT CONSIDERATIONS

1. View previous procedure notes prior to case and ensure any special/additional equipment that may have been utilized at last visit are available for the procedure.
2. Arrive in radiology suite prior to scheduled procedure time to fill out consent and ensure physical exam has been performed.
3. Ensure the patient swishes and spits betadine solution at least twice before the procedure
4. Ensure microscope, guidewire, Rosen needle, Ziegler dilators (in addition to other necessary equipment) are available in the room prior to start.

ANESTHESIA CONSIDERATIONS

1. A 4x4 piece of gauze is soaked in Topical 2% viscous lidocaine and applied to the duct region for 5 min.

OPERATIVE PROCEDURE

1. IsoVue should be prepared in a 5 cc syringe. A small length of IV tubing should be secured to the luer end and air purged from the line.
2. Visualize duct with microscope -
   1. Stensen's duct (Parotid) empties onto the parotid papilla, on the buccal mucosa adjacent to the maxillary first/second molar
   2. Wharton's duct (Submandibular) is located on the floor of mouth, exiting on the sublingual caruncle on the anterior floor of mouth, adjacent to the lingual frenulum 
3. Pre-load 22 gauge angiocath onto 0.018 inch guidewire
4. Pick up 0.015 inch (or 0.018) guidewire with DeBakey forceps and dip tip of guidewire in KY jelly
5. Place guidewire into duct and advance the angiocatheter over guide wire into duct
6. Grab the angiocatheter with Hemostats, and subsequently remove guidewire. Attach the IV tubing connecting to syringe filled with contrast.
7. Wrap a small piece of gauze around the hub of the angiocath and place the wrapped hub in between the patients teeth. Have the patient gently bite down to hold the catheter in place during the injection of the dye.
8. Once the angiocath is secure, step out of the room while radiology performs the examination. Be immediately available as the angiocath occasionally does fall out and needs to be replaced into the duct.
9. Lemon juice may be administered to help the patient salivate and purge the duct of contrast, instruct nursing to have the patient spit this out.

POSTOPERATIVE CARE

1. Encourage patient to gently massage salivary gland in order to express dye.

REFERENCES

Mosier, K., Diagnostic Radiographic Imaging for Salivary Endoscopy, Otolaryngol Clin N Am 42 (2009) 949--972.

McGahan JP, Walter JP, Bernstein L. Evaluation of the parotid gland. Comparison of sialography, non contrast computed tomography and CT sialography. Radiology
1984;152:453--8. 

Varghese JC, Thornton F, Lucey BC, et al. A prospective comparative study of MR sialography and conventional sialography of salivary duct disease. AJR 1999;173:1497–503.

Abdullah A, Rivas FF, Srinivasan A. Imaging of the salivary glands. Semin Roentgenol 2013 Jan;48(1):65-74.