|Year : 2014 | Volume
| Issue : 4 | Page : 425-427
Resourcefulness of cone beam computed sialography in detection of multiple radiolucent sialoliths: A case report
Tatu Joy Elenjickal1, Indu Krishna1, Raghupathy Lakshmana Perumal1, Saumya Verma2
1 Department of Oral Medicine and Radiology, Sree Mookambika Institute of Dental Sciences, Kulasekaram, Tamil Nadu, India
2 Hazaribag College of Dental Sciences, Hazaribag, Jharkhand, India
|Date of Submission||05-Nov-2014|
|Date of Acceptance||07-Apr-2015|
|Date of Web Publication||22-Apr-2015|
Indeevaram, TC 10/693, Edayilakonam, Mannanthala, Trivandrum - 695 015, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Obstructive conditions of the salivary glands are common and may necessitate imaging of the gland for the purpose of diagnosis and management. Sialography is considered the gold standard for examining obstructive conditions of the parotid and submandibular glands but is largely influenced by the imaging technique to which it is coupled. The aim of this paper is to discuss the importance of cone beam computed sialography imaging which is a relatively new and very promising imaging modality in the detection of radiolucent sialoliths and to report a case of detection of radiolucent parotid sialoliths using cone beam computed sialography.
Keywords: Cone beam computed tomography, radiolucent sialolith, salivary gland, sialogram
|How to cite this article:|
Elenjickal TJ, Krishna I, Perumal RL, Verma S. Resourcefulness of cone beam computed sialography in detection of multiple radiolucent sialoliths: A case report. J Indian Acad Oral Med Radiol 2014;26:425-7
|How to cite this URL:|
Elenjickal TJ, Krishna I, Perumal RL, Verma S. Resourcefulness of cone beam computed sialography in detection of multiple radiolucent sialoliths: A case report. J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2020 May 26];26:425-7. Available from: http://www.jiaomr.in/text.asp?2014/26/4/425/155635
| Introduction|| |
Sialography is a radiographic demonstration of major salivary glands by introducing a radiopaque contrast medium into the ductal system which is an excellent modality for demonstrating ductal anatomy, presence of obstructions, strictures and also suitability of the ductal system for interventional sialographic procedures. The success of sialography is largely dependent on the imaging modality to which it is coupled.  Cone beam computed tomography (CBCT) is one of the recent imaging modalities used for head and neck, and dento-maxillofacial diagnosis which provides relatively high isotropic spatial resolution of osseous structures at a low radiation dose. , The CBCT scanner collects volume data with a single rotation in 9-40 seconds with the help of a cone-shaped X-ray beam and two-dimensional detectors. 
This case report is rare because CBCT sialography is hardly conducted and there are only very few case reports in literature. This technique has proved to be highly reliable and superior to other imaging modalities in identifying non-calcified sialoliths (as in our case) which are usually difficult to detect and diagnose using even the most sophisticated imaging techniques. Combined with the advent of sialoendoscopes, previously morbid surgeries of the salivary glands can now be avoided which demonstrates the therapeutic efficacy of the technique too.
| Case Report|| |
A 60-year-old female reported with a complaint of pain in the left parotid region. Patient gave a history of chronic pain since 2 years and prolonged history of occasional discomfort since early forties. She consulted a host of specialities and was diagnosed with chronic bacterial sialadenitis of left parotid. She reported with no other relevant medical history. Plain film orthopantomograph (OPG) showed no abnormality [Figure 1].
|Figure 1: Cropped OPG showing restored 15, 36 and 46, missing 24, 25, 26, 27 and 28, and root stumps of 38|
Click here to view
An ultrasound imaging was also performed which gave no additional value to the existing diagnosis. Sialography of the left parotid gland was performed. A conventional sialogram performed using 3 ml of Urografin 760 contrast media, which was injected by hand, did not reveal any obstruction except for a filling defect and pooling of contrast medium in one region in the OPG [Figure 2]. This prompted us to perform a 8 × 8 volume CBCT scan, which was done in the early emptying phase using a Sirona Orthophos XG-3D CBCT unit [Figure 3]. Two small filling defects were seen, one located distal to the isthmus of the Stenson's duct and the other defect was noticed in the deeper part of inferior lobe of the gland which we suspected to be two radiolucent sialoliths. Cone beam computed tomography data was displayed in Galaxis Galileos software and the sialoliths were easily demonstrable [Figure 4] and [Figure 5].
|Figure 2: OPG showing filling defect and pooling of contrast medium in one region|
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The patient was referred to a head and neck surgical unit where she was posted for a guided balloon dilatation and Dormia basket retrieval of stones, which was performed under local anesthesia and fluoroscopic radiological guidance. Two small sialoliths of size 1 × 1 mm were retrieved by the basket.
| Discussion|| |
Sialolithiasis is the most common salivary gland disorders in adults. It has a slight male predilection. Sialoliths usually appear in the third to sixth decade of life. The most common gland affected is submandibular gland (80%) followed by the parotid (19%) and sublingual gland (1%). They appear unilateral and are usually radiopaque (they will show up on conventional radiographs), or they can be radiolucent (where they are not visible on radiographs, although some of their effects on the gland may still be visible). Twenty percent of submandibular calculi and 40% of parotid calculi fall into the latter category. Sialolithiasis causes pain and swelling of the involved salivary gland due to the obstruction of salivary secretion. It may remain asymptomatic too. Imaging plays a very crucial role in the diagnosis of cause, extent and effects of obstruction. Salivary gland calculi can usually be detected by various methods like projection radiography, ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI). Sialography is not indicated once a radiopaque sialolith is located, to prevent deeper displacement of the sialoliths from its current favorable position.
Sialography is the radiographic demonstration of major salivary glands by introducing a radiopaque contrast medium into their ductal system. It is useful for demonstrating ductal anatomy, presence of obstructions and strictures. The additional advantage is that the interventional sialographic procedure is in itself therapeutic as infusion of the sialographic dye causes strictural dilatation and release of occluding mucous plugs.
Cone beam computed tomography is the latest imaging modality used widely in maxillofacial radiology due to the high resolution, low radiation dose, fast scanning time and geometrically accurate images. , The advantage of CBCT sialography is that 3D reconstruction can be performed and the ductal architecture viewed in all possible dimensions. CBCT provides useful information about measurements and location of sialoliths. Combining the benefits of the CBCT with the versatility of the sialography is then only logical and both would complement each other.
Cone beam computed tomography sialography is hardly conducted and there are only few case reports in literature. ,,,, Drage and Brown reported two cases in females in their sixth decade of life with classical symptoms of salivary obstruction. Their results indicated that the primary duct, secondary duct and obstruction were easily identified in both cases.  They also concluded that CBCT sialography delivered a radiation dose equal to fluoroscopic sialography but higher than plain image sialography.  Another study regarding the effective doses from CBCT examinations centered on parotid and submandibular salivary gland by Jadu et al. where 15 cm FOV was chosen in combination with exposure conditions of 80 kVp and 10 mA, concluded that they were comparable to those calculated for plain sialography. 
Cone beam computed tomography sialography has now emerged as a highly reliable technique for identifying both radiopaque as well as radiolucent sialoliths (as in our case) and ductal strictures, two of the most common causes of obstruction as well as differentiating normal salivary glands with secondary inflammatory changes.  In fact CBCT sialography has proved to be superior to other imaging modalities in identifying non-calcified sialoliths which were usually difficult to detect and diagnose using even the most sophisticated imaging techniques.  It is also encouraging that there is a high correlation among observers interpreting the salivary gland lesions in terms of presence of stenosis, dilatation and evagination. ,
| Conclusion|| |
In obstructive salivary gland diseases, CBCT sialography is superior to conventional sialography in demonstrating the ductal system of the gland, identifying sialoliths and strictures. CBCT sialography is a very interesting field and opens up a lot of exciting possibilities in the years ahead. It is a novel technique for imaging the major salivary glands by combining the benefits of the CBCT with the versatility of the sialography. Combined with the advent of sialoendoscopes, previously morbid surgeries of the salivary glands can now be avoided.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]