Dacrocystography and Sialography
Yashawant ku. Yadav
Bsc. MIT 2nd year
NAMS (Bir Hospital )

Contents
• Introduction
• Anatomy
• Indication and contraindications
• Contrast media
• Technique
• Filming's
• Complications
• Aftercare
• References

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.

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.

Anatomy glance

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

Contraindications
 Hypersensitivity to contrast
 Local sepsis at the punctum
 Pregnancy( risk is minimal but evaluate risk vs benefit)

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

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.

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.

PRELIMINARY FILM
• Occipito-mental
• Lateral (centering to inferior orbital
margin)
• Oblique

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

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

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

DCG

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

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.

COMPLICATIONS
• Contrast extravasation.
• Granuloma formation (with lipidol)
• Perforation to the canaliculus.
• Infection

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.

Anatomy
•3 pairs
1 . Parotid
2 . Submandibular
3 . Sublingual
• Situated adjacent to OC, aid in initial
digestion

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

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

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

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

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

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

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

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

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

Flemings AP

Lateral

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

Contd..
• submandibular and sublingual
glands. Calcification (arrow) is
seen in the sublingual region.

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

Complications
•Pain
• Infection
• Damage to the duct orifice
•Rupture to the ducts
•No aftercare is needed for the patient.

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

Advancements
•Ultrasonography
•CT sialography
•MR sialography
• Radionuclide imaging

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

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.

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

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

References
• http://eknygos.lsmuni.lt/springer/531/143-154.pdf
• Guide to radiological procedure, Chapman
• A handbook of radiological procedures , Abinash Jha , Pooja Shah
• web

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?