Dacrocystography and sialography

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20 Jun 2019

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Dacrocystography and sialography

  1. Dacrocystography and Sialography Yashawant ku. Yadav Bsc. MIT 2nd year NAMS (Bir Hospital )
  2. Contents • Introduction • Anatomy • Indication and contraindications • Contrast media • Technique • Filming's • Complications • Aftercare • References
  3. Dacryocystography (DCG) •A Radiographic examination of the Nasolacrimal ducts following administration of a contrast medium to define the Lacrimal gland & NLD system anatomically in search of stenosis or obstruction.
  4. Anatomy glance • The structure concerned with secretion & drainage of lacrimal or tear fluid. • Made up of following parts; i. Lacrimal gland & duct. ii. Conjunctival sac. iii. Lacrimal puncta & lacrimal canaliculi iv. Lacrimal sac. v. Nasolacrimal duct.
  5. Anatomy glance
  6. Indications Epiphora to demonstrate the presence and extent of obstruction Obstruction may be due to: congenital obstructions supernumerary canaliculi lacrimal fistula or diverticula concretions (dacryoliths) neoplastic or inflammatory processes  post treatment changes
  7. Contraindications  Hypersensitivity to contrast  Local sepsis at the punctum  Pregnancy( risk is minimal but evaluate risk vs benefit)
  8. Equipment • Under couch image intensifier with digital imaging equipment to facilitate production of subtracted image. • Dedicated skull unit with focal spot size 0.3 mm to facilitate macro radiography.  Silver dilator and cannula lacrimal cannula or blunt needle with polythene catheter  A 22 G/18G polyvinylchloride tubing catheter  The catheter technique has the advantage that the examination can be performed on both sides simultaneously, and films can be taken during the injection.  Disposable syringe (3-5)ml
  9. Contrast media Oil based contrast media ,Lipiodol produces higher quality images of the lacrimal sac than water-soluble dye Low Osmolar CM [LOCM], 300mgI/ml Dose: 0.5– 2 ml  Oil-soluble contrast media should not be utilized in the suspicion of tumors, traumatism or fistulae, considering the risk of leakage and permanence in the subcutaneous tissue for many years, inducing the formation of granulomas. water-soluble contrast agents (iohexol , iopamidol , and 52.7% diatrizoate meglumine and 26.9% iodipamide meglumine compared with the iodized oil- based contrast agent Lipiodol.
  10. Patients preparation • Patient identification (3 'C's- correct patient, correct side, correct procedure) • Completed consent form • No diet restrictions • Collect/review relevant previous imaging for ease of access prior to procedure • A small quantity of local anesthesia is dropped into the inner canthus of eye prior to cannulation of the punctum. • Usually no premedication is given but children may require sedation.
  11. PRELIMINARY FILM • Occipito-mental • Lateral (centering to inferior orbital margin) • Oblique
  12. Technique • The patient lies supine on the fluoroscopy table with the head in a reverse occipito-mental position. • Support either side of the patient's head by immobilization device, particularly if a subtraction technique is employed. • Select a small field of view and fine focus • Control images taken
  13. Contd.. • Anesthetic eye drops are used for patient comfort • A fine cannula is inserted into the puncta of each eye, then the eye is closed and the catheter taped to the patient's cheek • It may be necessary to dilate the puncta to facilitate insertion of the cannula. • After the mask is acquired, commence injection • Images are taken immediately after injection • A drainage image can be taken after 15 minutes if considered necessary
  14. FILMS Occipito mental –immediately following the injection to show filling and emptying of the nasolacrimal duct Lateral When catheter is used 1st film-as plain film for subtraction 2nd film-when 1 ml of CM has been injected 3rd film-injection completed The radiographs are then processed and subtracted
  15. DCG
  16. Technique Note • It is normal practice to image both sides (comparison) • It is preferable to inject both sides at the same time • Collimate the X-ray beam to include the orbits superiorly and laterally and the maxillary PNS inferiorly • A focused spotlight can be a useful aid for the radiologist in locating the lacrimal punctum • Inferior punctum is often easier to cannulate • Catheter should not be inserted too far into the canaliculus • Dacrocystogram protocol may include adjunct nuclear medicine study
  17. AFTER CARE The eye is covered for approx. 1 hr after the examination to prevent ingress of foreign material Pt is usually kept in the department for about half an hour after the examination until the effects of the LA is worn out.
  18. COMPLICATIONS • Contrast extravasation. • Granuloma formation (with lipidol) • Perforation to the canaliculus. • Infection
  19. SIALOGRAPHY • A radiographic examination of the salivary glands(PAROTID & Submandibular GLAND) and respectives ducts using contrast media. • Cannulation of Sublingual gland ducts is almost impossible.
  20. Anatomy •3 pairs 1 . Parotid 2 . Submandibular 3 . Sublingual • Situated adjacent to OC, aid in initial digestion
  21. Anatomy contd… Parotid Submandibular Sublingual Largest salivary gland Extends posteriorly from below 1st lower molar to angle of mandible Smallest pair Lies just below the ZYG arch in front & below the ear Forms part of soft tissues on the medial margin of the mandible & the hyoid bone Located in floor of mouth on the surface of mylohyoid muscle Parotid duct(Stenson’s duct) is 5cm long, Submandibular duct(whartsons duct ) is 5 cm long, runs forward ,medially and upward & opens into mouth on side of frenulum Numerous, small sublingual ducts(ducts of Rivinus) open into floor of mouth runs over the messeter & opens into oral vestibule opposite 2nd upper molar Ducts may join to form a single(duct of Bartholin) which empties into the submandibular
  22. Indications • Stones (Calculi) sialolithiasis • Obstruction / Strictures • Sicca syndrome • Pain & Swelling (esp when recurrent) • Infection • Masses / Tumors • Changes secondary to trauma • When plain radiography is inconclusive
  23. CONTRAINDICATIONS FOR EXAM • History of contrast media allergies . • Severe inflammation of the salivary ducts . PATIENT PREPARATION:- • Any radio opaque artefacts are removed • Premedication usually not required but children may require sedation
  24. Contrast media • Oil based or water soluble contrast medium • Dose:1 to 2 ml • Either a compound with low viscosity or an ethiodized oil may be used after the medium has been warmed to body temperature to further reduce its viscosity. • HOCM or LOCM 240 to 300 mgI/ml
  25. Equipment • Skull unit using macro radiography technique • Fluoroscopic unit with spot film device • lebrich’s double ended lacrimal probe • Cannula 18G blunt needle and polythene catheter • Disposable syringe 3-5ml • Adhesive tape , cotton swabs , gauze piece, sterile gloves • Lemon or ascorbic acid tablets to produce reflux stimulation of saliva before taking clear radiograph Overhead light
  26. PRELIMINARY FILMS Parotid gland Submandibular gland AP view with head rotated 50 away from the side under examination, Centre to the midline of the lower lip Inferosuperior using an occlusal film. This is a useful view to show calculi. Lateral, centered to the angle of the mandible Lateral, with the floor of the mouth depressed by a wooden spatula. Lateral oblique, centered to the angle of the mandible, and with the tube angled 200 cephalad. Lateral oblique, centred 1 cm anterior to the angle of the mandible, and with the tube angled 200 cephalad
  27. TECHNIQUE • Preliminary radiographs • Detect conditions that do not require contrast • Give pt. secretory stimulant 2 to 3 minutes before contrast administration • Pt. asked to suck on lemon wedge -Opens duct for easy identification • Duct orifice is sprayed with topical anesthetic • Duct is cannulated, (dilator may be required), contrast introduced with fluoroscopic guidance • Contrast (oil based or water soluble iodinated) (conc = 240mg/ml) • Should be injected manually until pt. feels discomfort
  28. Contd.. • Quantity needed may vary between 1-2 ml • Images taken immediately after contrast is complete • After taking required images, pt. sucks on a lemon wedge again to evacuate contrast • Take post-procedure(delayed) radiographs after 5 minutes to confirm evacuation of contrast/ demonstrate any residual contrast
  29. FILMS Parotid----Control Films • - AP - LAT - LAT OBLIQUE Parotid -----Sialography Film • - AP - LAT - LAT OBLIQU SM----Control Films • - INFEROSUPERIOR/OCCLUSAL • - LAT SM -----Sialography Film • INFEROSUPERIOR/OCCLUSAL • - LAT - LAT OBLIQUE
  30. Flemings AP
  31. Lateral
  32. Filming of SM Inferior superior -Elevate the patient's thorax on several firm pillows. - Place the film in the mouth with the long axis directed transversely. - Central ray perpendicular to the plane of the film
  33. Contd.. • submandibular and sublingual glands. Calcification (arrow) is seen in the sublingual region.
  34. Contd.. • Center the IR to the inferior margin of the angle of the mandible. • Adjust the patient's head in a true lateral position • depressing the floor of the mouth to displace the submandibular gland below the mandible • Neck should be hyper extended so that the submandibular gland is projected below the mandible
  35. Complications •Pain • Infection • Damage to the duct orifice •Rupture to the ducts •No aftercare is needed for the patient.
  36. Contd.. • Sialography has also been recognized as a therapeutic procedure because the dilation of the ductal system produced during study may aid in the drainage of ductal debris • Also, iodine which is used as a contrast media has beneficial antiseptic properties
  37. Advancements •Ultrasonography •CT sialography •MR sialography • Radionuclide imaging
  38. Ultrasonography •Non invasive and cost effective imaging modality that can be used in evaluation of masses occurring in the submandibular gland and the superficial lobe of parotid gland • best at differentiating between intra and extra glandular masses and as well as between cystic and solid lesions • Can demonstrate the presence of abscess in the acutely inflamed gland also sialolithiasis • The deep portion of the parotid gland is difficult to visualize
  39. CT sialography • CT is now well recognized and is of particular value in distinguishing between lesions within two deep pole of the parotid and with extrinsic pharyngeal masses which compress and displace the gland • Ultrafast CT and three dimensional –image CT sialography have been effective for visualization of masses • The disadvantage of CT includes radiation exposure, administration of the contrast media for enhancement, and potential scatter from dental restorations.
  40. MR sialography • MR is used to diagnosis of lesions of the salivary glands • Now contrast studies are useful in differentiating benign or low grade malignant from the high grade malignant tumors • Contrast enhancement is useful in differential diagnosis of cystic from solid lesions, and when determining the degree of perineural spread of malignant disease
  41. Sequences used in MR sialography •T1- weighted and T2-weighted images are taken with a slice thickness of 3mm and interslice gap of 1mm. •FSE T2-weighted image may require fat suppression • Gadolinium enhanced scans with T1 weighting and fat suppression are obtained in axial plane. •Sagittal and coronal images may be obtained as required
  42. References • • Guide to radiological procedure, Chapman • A handbook of radiological procedures , Abinash Jha , Pooja Shah • web
  43. Questions ? • In sialography What are the filming sequences for parotid and submandibular gland ? • What are the time for delay radiograph in both DCG and SCG ? • List out the anatomic structure of lacrimal apparatus ? • Basic Sequence used in MRI for sialography • What is the advantage of catheter technique in DCG? And what is the volume of contrast used in DCG?

Notes de l'éditeur

  1. -paired, almond-shaped, serous gland. -situated in lacrimal fossa on the anterolateral -Small accessory lacrimal glands are also found around it -About 10-12 of its duct pierce conjunctiva of upper lid & open into conjunctival sac near the superior fornix -Potential space between palpebral & bulbar part. (Conjunctival sac) -small aperture, in medial portion of each eyelid. Collect tears produced by lacrimal glands. Canaliculus begins at the lacrimal puncta, about 10mm long. Has vertical part, 2mm long & horizontal part, 8mm long. -Membranous sac 12mm long & 5mm wide -Inflammation of sac called dacrocystitis. -Membranous passage 18mm long. Runs downward, backward & laterally and opens into inferior meatus of nose
  2. Anesthetic eye drops(0.4% benoxinate hydrochloride) can be used for patient comfort.
  3. Local anesthesia
  4. Other modalities Ct Mri
  5. Sicca syndrome: An autoimmune disease, also known as Sjogren syndrome, that classically combines dry eyes, dry mouth, and another disease of connective tissue such as rheumatoid arthritis (most common), lupus, scleroderma or polymyositis. Lupus is a systemic autoimmune disease that occurs when your body's immune system attacks your own tissues and organs.  Polymyositis: a rare inflammatory disease that causes muscle weakness affecting both sides of your body.
  6. Center the horizontal ray to the parotid area
  7. Center to a point approximately 1 inch (2.5 cm) superior to the mandibular angle. Adjust the head so that the midsagittal plane is rotated approximately 15 degrees toward the IR from a true lateral -An oblique projection is often necessary to obtain an image of the deeper portions of the parotid gland -20 to 25 degree cranial angulation is given
  8. Post secretory films Same views are taken 5 min after the cannula is taken out to see the emptying of the duct with the same views
  9. Also its been beneficial for the patient who are unable to lie for a long time (pediatric, claustrophobic, physically or mentally challenged patients) and for the patients for whom MRI is contraindicated
  10. Ap/ lat / oblique inferosuperior occlusal 15min/5 min Lacrimal gland in lacrimal fossa . Lacrimal ducts . Conjunctival sac , puncta 10 mm . Nasolacrimal sac and duct in inferior nasal meatus T1W/T2W/ FSE T2W for fat suppression or STIR 0.5-2 ml (300mgI/ml)