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Ultrasound Sialography (Ultrasound With Salivary Duct Infusion)

see also: Sialograms and SialographyParotid duct dilation and steroid insufflation in clinic

Definitions

Sialography: 'the method of making visible by injection of radiopaque material these [salivary] duct systems and the subsequent securing of appropriate roentgenograms" (Schulz and Weisbereger 1948). Affirmed by these authors: "The greatest value of this examination lies in the recognition and diagnosis of nonneoplastic swellings". First report attributed to Arcelin (Arcelin 1921) by Lomas (Lomas 1996). Also first report of sialograpny attributed to Carlsten (Carlsten 1926) by Shulz and Weisberger (1948)

Radiocontrast media: "agents used to increase the contrast of an image, to enhance the visibiity of internal structures in imaging technology." (Mahajan 2019)

MR Sialography: Employs saliva as intrinsic contrast material for visulization of salivary ducts with a high signal intensity on fat suppressed, fast spin echo T2-weighted images on MRI (Dillon 1998. Lomas 1996. Thibalt 1993). Also as per Dillon (1998): " 'MR sialography', however, is somewhat of a misnomer..." and "MR does not demonstrate delayed filling or emptying without an injection of contrast material, and the occasional therapuetic success of stone release during plain film sialography will not occur"

Ultrasound Contrast Agents: 'typically comprised of gas bubbles encapsulated by a shell" (Vollert 2022). The shell is a phosopholipid layer surrounding the gas - which in Sonovue (Bracco, Milan Italy) is sulfur hexafluoride (SF6) (Quaia 2007)

Contrast-Enhanced Ultrasound (CEUS): as per Bhatia et al (Bhatia 2018) "Most salivary CEUS has usually been performed ... by injecting intravenously a small volume (4.8 mL) of microbubbles (Sonovue, Bracco, Milan, Italy) into a peripheral vein, with continuous evaluation of the passage of microbubbles through the region of interest for at least 120 seconds". These authors related that "at present the clinical utility of this obsevation is unclear' and go on to relate that 'intraductal injection of microbubbles has also been anecdotally reported..."

Intraductal Applied Contrast-Enhanced Ultrasound (IA-CEUS): Term used in the study (Zengel 2010) of SonoVue® infusion to the salivary gland with imaging via 'high-end ultrasound machine' (Siemens, ACUSON,S200, Germany) to conclude that, compared to conventional ultrasound, this technique 'not only improved the visulaization of the glandular duct system as a whole, but was less time-consuming as well as more reproducible'   

Experience with Intraductal Applied Contrast Enhanced Ultrasound (IA-CEUS) (Zengel 2010, 2011, 2013) 

also termed Endocavitary Contrast-Enhanced Ultrasound (Vollert 2022)

and Ultrasound Guided Sialo-Irrigation (Oh 2018)

Zengel et al 2011 relate "To the best of our knowledege, our team represents the first to combine ultrasound with an intraductal ultrasound contrast agent application"

- Intraductal infusion of SonVue® [0.3 ml mixed with 9.5 ml of 0.9% NaCl]; SonVue® is "a second-generation blood pool contrast agent" consisting of stabilized microbubbles of sulfur hexafluoride; administered into duct via 20 G needle with concurrent imaging via 9 MHz probe (Siemens, ACUSON S 2000TM with a "9 MHz probe, in the contrast puse sequencing (PCS) imaging mode"

- Conclude: "In comparison to MR-Sialography, the IA-CEUS examination is considerabley less expensive and less time consuming" and "the information obtained is roughly comparable but provides a higher resolution of the smallest duct system"

Vollert et al 2022 relate that intraductal administration of contrast agent during ultrasonography 'makes it possible to simultaneously evaluate the gland parenchyma as well as the intraglandular and extraglandular duct system"

- contrast agent (Sonovue (Bracco, Milan, Italy) diluated wtih a ratio of 1:10 then administerd via catheter (Vollert, citing Zengel's previous work) - Vollert et al comment that dilution of the contrast agent with NaCl is required 'since the space in which the contrast agent is dispersed is significantly smaller compared to the total blood volume in intravenous administration". Vollert et al indicate that with some exceptions (pediatric voiding urosonography) - ultrasound contrast agents are approved for intravascular use and "endocavitary use, is considered off-label". They identify that with intravenous application of ultrasound contrast agents 'the risk of serious adverse event is very low (less than 0.008%)' and further identify that 'in the case of diluted endocavitary application, the frequency of undesired side effects is significantly lower' and then conclude 'Therefore, it is a safe procedure"

- with surveillance employing the ultrasound - 'the contrast agent is administered slowly' with attention for findings of duct obstructions, filling defects' - and delays in the 'contrast wash-in in the gland'

Oh et al 2018 employed a saline-air mixture to perform 'ultrasound-guided sialo-irrigation'

- initial ultrasound scn (GE LOGIQ% Expert® device - GE Medical Systems, Milwaukee, WI) with a 12 MHz linear scanner with 45 x 10 mm footpring. 

- the duct is cannulated then saline solution 'injected until the patient felt uncomfortable or expansion of the salivary gland was observed"

- saline then mixed with air introduced via a device connected to the cannula as developed by Oh et al: two syringes - one containing saline, the other syringe containing air  

- imaging with the air bubbles in place presented an echogenic focus that assisted in real-time ominitoring of the injected saline solution.

Case Example - Ultrasound with Infusion of Kenalog 10

References

Vollert K, Clevert DA, Kleffel T. Endocavitary Contrast-Enhanced Ultrasound. Rofo. 2022 Aug 17. English, German. doi: 10.1055/a-1826-0325. Epub ahead of print. PMID: 35977555.

Yusuf GT, Fang C, Huang DY, Sellars ME, Deganello A, Sidhu PS. Endocavitary contrast enhanced ultrasound (CEUS): a novel problem solving technique. Insights Imaging. 2018 Jun;9(3):303-311. doi: 10.1007/s13244-018-0601-x. Epub 2018 Mar 28. PMID: 29594851; PMCID: PMC5991005.

Oh SH, Kang JH, Choi YJ, Kim BY, Lee SR, Lee SH, Choi YS, Hwang EH. Ultrasound-guided sialo-irrigation with a saline-air mixture as the contrast medium. Oral Radiol. 2019 Jan;35(1):84-89. doi: 10.1007/s11282-018-0331-2. Epub 2018 Apr 27. PMID: 30484189.

Kim EM, Lee SH, Oh SH, Kim GT, Choi YS, Hwang EH. Ultrasound-guided sialo-irrigation for the treatment of chronic sialodochitis with sialolithiasis. Oral Radiol. 2021 Apr;37(2):345-351. doi: 10.1007/s11282-020-00495-2. Epub 2021 Jan 4. PMID: 33394278.

Wang Y, Cong H, Wang S, Yu B, Shen Y. Development and application of ultrasound contrast agents in biomedicine. J Mater Chem B. 2021 Sep 29;9(37):7633-7661. doi: 10.1039/d1tb00850a. PMID: 34586124.

Thorpe RK, Foggia MJ, Marcus KS, Policeni B, Maley JE, Hoffman HT. Sialographic Analysis of Radioiodine-Associated Chronic Sialadenitis. Laryngoscope. 2021 May;131(5):E1450-E1456. doi: 10.1002/lary.29279. Epub 2020 Nov 17. PMID: 33200832.

Morimoto Y, Tanaka T, Yoshioka I, Masumi S, Yamashita M, Ohba T. Virtual endoscopic view of salivary gland ducts using MR sialography data from three dimension fast asymmetric spin-echo (3D-FASE) sequences: a preliminary study. Oral Dis. 2002 Sep;8(5):268-74. doi: 10.1034/j.1601-0825.2002.01819.x. PMID: 12363112.

Wang Z, Zourelias L, Wu C, Edwards PC, Trombetta M, Passineau MJ. Ultrasound-assisted nonviral gene transfer of AQP1 to the irradiated minipig parotid gland restores fluid secretion. Gene Ther. 2015 Sep;22(9):739-49. doi: 10.1038/gt.2015.36. Epub 2015 Apr 14. PMID: 25871828; PMCID: PMC4560616.

SCHULZ MD, WEISBERGER D. Sialography; its value in the diagnosis of swellings about the salivary glands. Oral Surg Oral Med Oral Pathol. 1948 Mar;1(3):233-48. doi: 10.1016/0030-4220(48)90208-4. PMID: 18904969.

Barsky AJ, Silberman H. Röntgen Visualization of the Parotid Gland by Means of Lipiodol Injection. Ann Surg. 1932 Jan;95(1):46-51. doi: 10.1097/00000658-193201000-00004. PMID: 17866716; PMCID: PMC1391546.

Mahajan R, Singh P. Radiocontrast media: Applications and concerns. Int J App Basic Med Res 2019;9:191-2.

Dillon WP. MR sialography? AJNR Am J Neuroradiol. 1998 Aug;19(7):1183. PMID: 9726447; PMCID: PMC8332203.

Tonami H, Ogawa Y, Matoba M, Kuginuki Y, Yokota H, Higashi K, Okimura T, Yamamoto I, Sugai S. MR sialography in patients with Sjögren syndrome. AJNR Am J Neuroradiol. 1998 Aug;19(7):1199-203. PMID: 9726453; PMCID: PMC8332227.

Lomas DJ, Carroll NR, Johnson G, Antoun NM, Freer CE. MR sialography. Work in progress. Radiology. 1996 Jul;200(1):129-33. doi: 10.1148/radiology.200.1.8657900. PMID: 8657900.

Arcelin L. Radiographie dun calcul salivaire de le gland sublinguale. Lyon Med 1921:118: 769-773

Thibault F, Halimi P, Bely N, Chevallier JM, Bonfils P, Lellouch-Tubiana A, Frija G. Internal architecture of the parotid gland at MR imaging: facial nerve or ductal system? Radiology. 1993 Sep;188(3):701-4; discussion 705. doi: 10.1148/radiology.188.3.8351336. PMID: 8351336. "In conclusion, T1-weighted axial MR images of the parotid gland routinely depict low-signal--intensity linear structures coursing through the parenchyma. Many of these structures were shown to repressnt branches of the ductal system and could, therefore, explain part of what was previously called intraparotid facial nerve branches"

Zengel P, Siedek V, Berghaus A, Clevert DA. Intraductally applied contrast-enhanced ultrasound (IA-CEUS) for improved visualization of obstructive diseases of the salivary glands, primary results. Clin Hemorheol Microcirc. 2010;45(2-4):193-205. doi: 10.3233/CH-2010-1298. PMID: 20675900.

Zengel P, Schrötzlmair F, Kramer M, Paprottka P, Clevert DA. Management von Speichel-drüsenerkrankungen mittels Kontrastmittelapplikation [Management of salivary gland diseases with contrast-enhanced ultrasound]. Radiologe. 2011 Jun;51(6):490-6. German. doi: 10.1007/s00117-010-2104-8. PMID: 21614648. [German]

Zengel P, Berghaus A, Weiler C, Reiser M, Clevert DA. Intraductally applied contrast-enhanced ultrasound (IA-CEUS) for evaluating obstructive disease and secretory dysfunction of the salivary glands. Eur Radiol. 2011 Jun;21(6):1339-48. doi: 10.1007/s00330-010-2038-6. Epub 2010 Dec 31. PMID: 21193911.

Fischer T, Paschen CF, Slowinski T et al (2010) Differentiation of parotid gland tumors with contrast-enhanced ultrasound. Rofo 182:155–162

Thomas R, Burke C, Howlett D (2009) CT “invisible” lesion of the major salivary glands-a diagnostic pitfall of contrast-enhanced CT. Clin Radiol 64:1137

Bhatia KSS, Dai YL. Routine and Advanced Ultrasound of Major Salivary Glands. Neuroimaging Clin N Am. 2018 May;28(2):273-293. doi: 10.1016/j.nic.2018.01.007. PMID: 29622119.

Quaia E: Microbubble ultrasound contrast agents: an update. Eur Radiol 2007;17(8):1995-2008. 

Zengel P, Schrötzlmair F, Reichel C, Paprottka P, Clevert DA. Sonography: the leading diagnostic tool for diseases of the salivary glands. Semin Ultrasound CT MR. 2013 Jun;34(3):196-203. doi: 10.1053/j.sult.2012.11.012. PMID: 23768886.

Wang Z, Zourelias L, Wu C, Edwards PC, Trombetta M, Passineau MJ. Ultrasound-assisted nonviral gene transfer of AQP1 to the irradiated minipig parotid gland restores fluid secretion. Gene Ther. 2015 Sep;22(9):739-49. doi: 10.1038/gt.2015.36. Epub 2015 Apr 14. PMID: 25871828; PMCID: PMC4560616.
 
Passineau MJ, Zourelias L, Machen L, Edwards PC, Benza RL. Ultrasound-assisted non-viral gene transfer to the salivary glands. Gene Therapy 2010; 17: 1318–1324