Radiologi Pemeriksaan Kelenjar Saliva

• SALIVARY GLAND DISORDERS

  • Acute intermittent generalized swelling of a gland, often related to meals
  • Acute generalized swelling of one or more glands
  • Chronic generalized swelling, often involving more than one gland
  • Discrete swelling within or adjacent to a gland
  • Dry mouth
  • Excess salivation.

• Salivary Gland Complaint

  • Acute intermittent generalized swelling

    obstructive disorders:

    • sialolithiasis- salivary stones
    • stricture or stenosis of the duct, usually secondary to surgery, stones or infection
    • recurrent parotitis of childhood

  • Acute generalized swelling

    Infection:

    • Viral, e.g. mumps (Mumps is most recognisable by the painful swellings in the side of the face under the ears (the parotid glands)
    • bacterial-ascending sialadenitis

  • chronic generalized swelling

    • Sjogren's syndrom, either primary or secondary
    • sialonisis
    • chronic infection
    • HIV disease
    • Cystic fibrosis
    • Sarcoidosis

  • Discrete swelling

    • Intrinsic tumour, benign or malignant
    • extrinsic tumour
    • cyst
    • overlying lymph nodes

  • Dry mouth

    • sjogren's syndrome
    • post-radiation damage
    • mouth breathing
    • dehydration
    • functional disorders, including
    • drugs, such as tricyclic antidepressants
    • neuroses, particularly chronic anxiety states

  • Excess salivation

    • physchological (false ptyalism)
    • reflex, e.g. due to local stimulation
    • heavy metal poisoning

  

  

• Salivary Gland Complaint Based on Area

  • Parotid Gland Area
    • Unilateral (one side)
      • bacterial sialodenitis
      • sialodochitis
      • cyst
      • benign neoplasm
      • malignant neoplasm
      • introglandular lymph node
      • masseter muscle hyperthrophy
      • lesions of adjacent osseous structures
    • Bilateral
      • bacterial sialodenitis
      • viral sialadenitis (mumps)
      • Sjogren's syndrome
      • Alcoholic hyperthrophy
      • Medication-induced hyperthrophy (iodine, heavy metals)
      • Human immunodeficiency virus- associated multicentric cysts
      • Masseter muscle hypertrophy
      • Accesory salivary glands
      • Temporomandibular joint-related lesions
  • Submandibular gland area
    • Unilateral
      • bacterial sialadenitis
      • sialodochitis
      • fibrosis
      • cyst
      • benign neoplasm
      • malignant neoplasm
    • Bilateral
      • bacterial sialadenitis
      • Sjogren's syndrome
      • Lymphadenitis
      • Branchial cledt cyst
      • Submandibular space infection

Investigations

• Plain radiograph

  • Pemeriksaan umum untuk salivary stones/calculi/sialolith

  • Salivary calculi (approximately 40–60% in the parotid and 80% in the submandibular glands)

  • pemetaan

    • phlebolit

      A phlebolith is a small local, usually rounded, calcification within a vein.

    • triticeous cartilage and thyroid cartilage

      Triticeous cartilage is a small ovoid cartilaginous structure located within the thyrohyoid ligament extending from the hyoid bone (distal aspect of the greater cornu) to the thyroid cartilage (tip of the superior cornu) at the level of C3 and C4 vertebrae

    • calcified lymph nodes

      result from prior granulomatous infections, especially tuberculosis and histoplasmosis.

    • tonsilloliths

      Tonsil stones, also called tonsilloliths, are small lumps that form in your tonsils. The main symptom of tonsil stones is bad breath.

    • calcified atheromatous plaque

      Aortic valve calcification is a condition in which calcium deposits form on the aortic valve in the heart. These deposits can cause narrowing at the opening of the aortic valve. This narrowing can become severe enough to reduce blood flow through the aortic valve — a condition called aortic valve stenosis.

    • antrolith

      An antrolith is a calcified mass within the maxillary sinus.

    • ossified stylohyoid ligament

      Calcification or ossification of the stylohyoid ligament is a frequent, often incidental finding on radiographs, however when the source of pain is from the styloid process or calcified stylohyoid ligaments it is referred to as Eagle's syndrome. The symptoms may be confused with other causes of head and neck pain.

    • sialoliths

      Sialolithiasis is a condition where a calcified mass or sialolith forms within a salivary gland, usually in the duct of the submandibular gland

    

  • Radiographic projection used

    • Kelenjar Parotid
      • panoramic radiograph
      • oblique lateral
      • rotated PA or AP with cheek blown out
      • intraoral view of the cheek
    • Kelenjar Submandibular
      • panoramic radiograph
      • oblique lateral
      • lower 90 derajat occlusal (to show the duct)
      • lower oblique occlusal (to show the gland)
      • True lateral skull with the tongue depressed
      • rotated AP (below mandible)

  • Jenis Plain radiograph

    • Occlusal RO

      underexposed mandibular occlusal radiograph demonstrates a radiopaque sialolith in Wharton's duct

      

    • Panoramic

      sialoliths (arrows) near the antegonial notch of the mandible and superior to hyoid bone

      

    • Periapical radiograph

      

    • AP Radiograph

      anteroposterior skull view with cheek blown out (kelihatan pipi) to provide air contrast to reveal a parotid sialolith (arrow)

      

  • Sialolithiasis

    • Definisi

      Adalah kalsifikasi deposisi kalsium pada duktus/ kelenjar saliva.

    • Kandungan

      sialoliths consist of hydroxyapatite, amorphous carbonated calcium phosphate, carbonated apatite, and whitlockite in combination with fi brous proteins such as mucins.

    • Klinis

      • Umumnya pada submandibular gland,
      • usia pertengahan,
      • 80% single (tidak bilateral,
      • asimptomatik,
      • Biasanya ada riwayat nyeri dan bengkak pada dasar mulut, atau pada pipi (sialolith kelenjar parotid),
      • rasa tidak nyaman ketika makan

    • Location.

      • submandibular gland (83% to 94% of cases) → a longer duct, higher mineral content → punya saluran sekresi namanya duktus Wharton
      • parotid gland (4% to 10%)/ duktus stensen
      • sublingual gland (1% to 7%)

    • Periphery and Shape

      batas jelas

      • located in the duct of the submandibular gland
      • cylindric and very smooth in their outlines

      

      

      

• Sialography

  Suatu pemeriksaan radiografi pada bagian kelenjar ludah beserta salurannya dengan menggunakan sinar-x dan bantuan media kontras untuk menegakkan diagnosa.

  • normal anatomy

    1. Kelenjar parotis : Ductus Stensen
    2. Kelenjar sub mandibula : Ductus Wharton
    3. Saluran sub lingual: Ductus bartholin

    

    

  • Langkah sialography

    • pre operatif/ pengambilan Ro pra operasi (scout)

      perkiraan dan coba2

      • Mengetahui posisi/ adanya obstruksi radioopak
      • Mengetahui Posisi jatuhnya bayangan struktur anatomi lain
      • Untuk menilai faktor eksposure

    • fase pengisian

      • scout film
      • menemukan duktus
      • dilebarkan dan canulasi (canulasi: dimasukkan zat kontras)
      • injeksi media contrast

      

    • fase pengosongan

      sisa cairan masuk yang tadi masuk agar keluar, lalu difoto ke 3x

      biasanya bila ada retensi zat kontras ada kelainan

      • pengangkatan canula
      • penggunaan jus lemon
      • Fo Ro fase pengosongan (1-5 menit)
      • Penilaian fungsi

  • Media Kontras

    • Ionic aqueous solutions:
      • Diatrizoate (Urografin®)
      • Metrizoate (Triosil®)
    • Non-ionic aqueous solutions, including:
      • Iohexol (Omnipaque®)
    • Oil-based solutions
      • Iodized oil, e.g. Lipiodol® (iodized poppy seed oil)
      • Water-insoluble organic iodine compounds, e.g. Pantopaque®.

  • Indikasi

    • To determine the presence and/or position of Calculi (stone consist of mineral stones)
    • To assess the extent of ductal and glandular destruction secondary to an obstruction

  • Kontraindikasi

    • Alergi pada iodine & Gadolinium
    • Inflamasi akut, pus pada ductus
    • When clinical examination or routine radiographs have shown a calculus close to the duct opening

  • Teknik

    • simple injection technique

      • Oil-based or aqueous contrast medium is introduced using gentle hand pressure until the patient experiencs tightness or discomfort in the gland

      • (+)

        ● Simple ● Inexpensive

      • (-)

        ● Tekanan dapat merusak kelenjar ● Respon pasien pasif

    • hydrostatic technique

      • Aqueous contrast medium is allowed to flow freely from an overhead reservoir into the gland under the force of gravity until the patient experiences discomfort.
      • Advantages
        • The controlled introduction of contrast medium is less likely to cause damage or give an artefactual picture
        • Simple
        • Inexpensive.
      • Disadvantages
        • Pasien harus berbaring selama prosedur berlangsung, harus diposisikan terlebih dahulu untuk prosedur radiograf
        • Respon pasien pasif

    • continuous infusion pressure monitored technique

      Continuous infusion pressure-monitored technique Using aqueous contrast medium, a constant flow rate is adopted and the ducal pressure monitored throughout the procedure.

      • Advantages

        • The controlled introduction of contrast media at known pressures is not likely to cause damage
        • Does not cause overfilling of the gland
        • May give information on the presence of obstruction.

      • Disadvantages

        ● Complex equipment is required

        ● Time consuming.

  • gambaran normal

    • tree in winter/ leafless tree

    

  • pathological change

    • ductal changes

      • calculi

        • retensi zat kontras
        • duktus membengkak
        • Filling defect(s) pada ductus utama
        • Ductal dilatation proximal to the calculus
        • The emptying film usually shows contrast medium retained behind the stone.

        

        

      • sialodochitis

        sausage link appearance (seperti sosis jerman)

        • Berhubungan dengan calculi atau penyempitan duktus.
        • dilatation and stricture of the main duct, the so-called sausage link appearance

        

        

    • glandular changes

      • sialadenitis

        • Gambaran Dots/ Blobs dari media kontras ( Sialectasis)
        • Disebabkan karena inflamasi yang menyebabkan dilatasi acini kelenjar
        • Ductus utama biasanya Normal

        

      • sjogren syndrome

        dot lebih banyak→ sialectasis

        • Widespread dots or blobs of contrast medium within the gland, an appearance known as punctate sialectasis or snowstorm
        • Disebabkan karena melemahnya epitel lining pada intercalacted duct
        • The main duct is usually normal.

        

        

    • intrinsic tumours

      • Terdapat area yang tidak terisi bahan contras, ductus tertekan tumor

      • Ductal displacement

      • Ball in hand

      • Retensi media kontras selama fase pengosongan

      • gambaran RO

        

        A(i) Sialograph of a right parotid showing a large area of underfilling in the lower lobe (arrowed) caused by an intrinsic tumour (biopsy confirmed a pleomorphic adenoma).

        • A(ii) Rotated AP view showing the lateral bowing and displacement of the ducts (arrowed) around the tumour.
        • B Rotated AP view of a normal parotid gland for comparison (arrowed).

        

        • A Sialograph of a right parotid gland showing a large area of underfilling in the lower lobe (arrowed) caused by an intrinsic tumour (pleomorphic adenoma).
        • B Rotated AP view showing extensive ductal displacement, the appearance described as ball in hand (arrowed).

• Ultrasound

  • Indications:

    • Pembengkakan pada kelenjar saliva

    • Obstruksi kelenjar saliva

      

  • Advantages

    • Ionizing radiation is not used
    • Provides good imaging of superficial masses
    • Useful for differentiating between solid and cystic masses and for identifying the nature and location of the margins of a lesion
    • Different echo signals from different tumours
    • Assessment of blood flow using colour Doppler
    • Identification of radiolucent stones
    • Lithotripsy of salivary stones
    • Ultrasound-guided fine-needle aspiration (FNA) biopsy possible
    • Intraoral ultrasound possible with small probes.

  • disadvantages

    ● The sound waves used are blocked by bone, so limiting the areas available for investigation ● Provides no information on fine ductal architecture.

  • Hasil Ultrasound

    • Hyperechoid

      hiperecoid: putih

      menyatakan adanya jaringan yang menciptakan glombang eko lebih terang dibanding jaringan sekitarnya. Contohnya: tulang, lemak perirenal, dinding vesica felea dan hepar yang sirosis.

    • Hypoechoid

      hipoecoid: hitam

      menyatakan adanya jaringan yang menciptakan gelombang eco lebih redup disbanding jaringan sekitarnya . contoh : kelenjar limfe, beberapa jenis tumor dan cairan tapi perlu diperhatikan lebih jelas krna cairan bukan bahan satu-satunya yang bersifat hypoechoid.

    

    Ultrasound image of a pleomorphic adenoma in the parotid gland. The benign tumour shows well-defined margins and is generally hypoechoic (dark) with through transmission suggesting low density and a high water content. (Kindly provided by Mrs J.E. Brown.)

    • Hyperechoic

      

      hiperecoid

      Ultrasound image of a submandibular gland (the margin of the gland is marked by the black arrow heads) containing a small calculus (white arrow) within the hilum of the main duct. The stone measured 2.2 mm in diameter and was radiolucent on plain radiography.

      The dilated duct to the right of the stone is also evident. (Kindly provided by Mrs J.E. Brown.)

    • Hyphoechoic

      

      hipoecoid

      Ultrasound image showing the changes typically seen within the parotid gland in Sjögren’s syndrome. The multiple small hypoechoic (dark) areas represent lymphoepithelial infiltration of the gland parenchyma. (Kindly provided by Mrs J.E. Brown.)

• MRI

  • Definisi

    Magnetic resonance imaging (MRI) atau pencitraan resonansi magnetik adalah pemeriksaan yang memanfaatkan medan magnet dan energi gelombang

  • Advantages

    • Tidak menggunakan radiasi
    • Excellent soft tissue detail
    • Provides accurate localization of masses
    • The facial nerve may be identifiable
    • Co-registration possible with PET scans
    • Water in the ducts and glands can be visualized to create MR sialographs without the use of contrast agents

  • Disadvantages

    • Provides no information on salivary gland function
    • Limited information on surrounding hard tissues
    • Tidak dapat mendeteksi antara tumor dan kista pada lesi tumor dengan kandungan air tinggi

  • Contoh hasil MRI

    

    Axial MR scan, showing a well-circumscribed mass in the right parotid gland (arrowed). (Kindly supplied by Dr M. Hourihan.)

• CT

  • Definisi

    CT Scan adalah suatu cara untuk melihat bagian dalam tubuh manusia secara detail dengan alat khusus. Prosedur CT Scan menggunakan teknologi sinar-X dan komputer untuk menghasilkan sejumlah gambar irisan dari organ dalam tubuh.

  • Indikasi

    Pembengkakan pada kelenjar saliva

  • Advantages

    • Provides accurate localization of masses
    • The nature of the lesion can often be determined
    • Images can be enhanced by using contrast media, either in the ductal system (CT sialography) or more commonly intravenously
    • Co-registration possible with PET scans.

  • Disadvantages

    • Provides no indication of salivary gland function
    • Risks associated with intravenous contrast media if used
    • Fine duct detail is not well imaged
    • High radiation dose
    • May be difficult to distinguish tumours in the submandibular gland from normal gland tissue (due to similar density).

  • Hasil

    • tepi well defined: benign
    • malignant: tidak ada kapsul, irregular

    

    Axial CT scan showing a clearly identifiable benign parotid tumour (arrowed). (Kindly provided by Dr M. Hourihan.)-

• CBCT (Cone beam computed tomographic imaging)

  • Untuk Evaluasi struktur terdekat kelenjar saliva
  • Tidak dapat menunjukkan densitas jaringan lunak
  • Kalsifikasi dapat digambarkan secara minimal pad CBCT , berguna sebagai modalitas
  • konvensional sialografi, memberikan gambaran 3D dari strutur ductus

  

  

  CBCT imaging of a submandibular sialolith. Coronal (A), axial (B), and three-dimensional

• Radioisotope imaging

  • Definisi

    A radionuclide or isotope scan is a way of imaging bones, organs and other parts of the body by using a small dose of a radioactive chemica

  • Scintigrafi, Nuclear medicine, Emission Tomography

  • Untuk melihat fungsi kelenjar

  • PET-scan untuk kelenjar Saliva

  • Menyuntikkan radiopharmaceuticals pada kelenjar

  • (echnetium 99m (99mTc)- pertechnetate) yang diinjeksikan intravena.

  • Di ekskresi oleh kelenjar saliva, tyroid, dan mamae

  → dilihat perubahan kelenjar

  • Advantages
    • Provides an indication of salivary gland function
    • Allows bilateral comparison and images all four major salivary glands at the same time
    • Computer analysis of results is possible
    • Can be performed in cases of acute infection
    • Co-registration of PET with CT or MR scans
  • Disadvantages
    • Provides no indication of salivary gland anatomy or ductal architecture
    • Relatively high radiation dose to the whole body
    • The final images are not disease-specific.

  

  melihat fungsi kelenjar