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Ultrasound uses high-frequency sound waves emitted from a probe, which is applied to the skin and a sensor senses the reflection of the sound waves back. Since soft tissue and hard tissue have different reflective characteristics an image is constructed. Ultrasound has long since been used for the diagnosis of salivary gland pathologies and only recently with our state of art imaging software have we been able to really identify the anatomy of the ducts and the problems in them. This procedure is safe, painless, non-invasive and takes only fifteen minutes.
We have formulated and perfected our own protocols to image particular ductal pathologies in the salivary system where we not only get excellent visualizations of the gland involved but also get details about stones, narrowed segment of ducts and other problems leading to sialadenitis.
Ultrasound is a relatively inexpensive first-line tool for infective and inflammatory conditions of the salivary glands, which gives us excellent information about the gland involved, whether the texture of gland is normal or changed due to repeated episodes or acutely infected. It also gives us views of the ducts where we can measure the ductal diameter, which aids us in planning Sialendoscopy since that is the road to dealing with our pathology. It can also tell us about the narrowed segments of the duct, their length, something that even a CT scan cannot predict.
In stones greater than 3mm in size, ultrasound gives us details about the location of the stone, its size, shape and orientation in the duct. It also tells us the ductal diameter surrounding the duct and can give us pointers whether the duct walls are free from the stone or not. In stones smaller than 3mm ultrasound may not be able to distinguish them from the surrounding tissue so our sensitivity as of now stands at about 60-70%, which is comparable to world standards.
In cases of stone in the salivary gland duct, CT scan is an indispensable tool for accurate diagnosis and planning. CT scan is painless and fast so that patient discomfort is minimized.
CT scan helps in differentiating between single large stones and multiple stones, which may be stuck together giving the appearance of a single stone on the ultrasound. This changes our preoperative planning and strategy to tackle problems, which may be faced during a sialendoscopic procedure.
CT scan also has the advantage of estimating the density of the stone in the duct. This density then helps us to determine whether using laser can break down the stone or not. This is an ongoing study in our department where stones of diameter larger than 8mm have been broken down into multiple pieces using laser and the debris cleared using baskets leading to a purely endoscopic management of these stones without even a millimetre of an incision. The CT scan also gives us invaluable information about the gland and whether there is an abscess or not during an acute infection.
Cone beam CT scan is rapidly emerging s an alternative for conventional CT scan where we get excellent reconstructed images with the advantage of lower radiation. However, due to limited centres having this facility and relatively higher cost it is not used as a first choice at present.
Magnetic Resonance Imaging (MRI) is a state of the art line of investigation for soft tissue differentiation in the human body. Traditionally dye was injected into the salivary gland duct and multiple Xray or Ct scanning was done to see the ductal branching patterns, ductal diameter and other problems in the duct. This procedure is now abandoned since we have a newer modality of MR Sialography.
In this investigation, higher weighted images are taken and saliva present in the ducts act like contrast and show up as white in an otherwise dark background. This helps us in assessing the duct of salivary glands in a completely non-invasive way. All pathologies related to the duct and the glands themselves are shown excellently by this technique. It is, however, inferior to the CT scan in showing the details of the stone in cases of salivary gland and ductal stones. This, however, remains the method of choice to detect and diagnose stenosis and acute bends of the salivary ducts which can sometimes lead to similar symptoms.
The MRI scan is completely safe and has no risk of radiation exposure. The only drawbacks are lack of detail in cases of salivary gland stones and the relatively higher cost and the need for the patient to remain absolutely still in the machine for MRI for a long time. We, at our centre, have a state of the art 3T MRI machine where we get excellent high-resolution images of the salivary ducts which help us in diagnosing and managing patients with salivary gland problems in the best
After an accurate diagnosis of stones in the salivary gland ducts, we deal with stones in an as minimal way as possible. Stones which are less than 4 mm in size are removed through the endoscope using baskets without any cut in the body. Larger stones are also removed via combined approach without a scar and usually, there is no need to remove the gland affected. We have been removing stones as large as 2.8cm in size present almost at the end of the duct without any major cuts and preserving the gland and its function.
In cases of intraglandular stones, complete stenosis of the duct and chronic sialadenitis unresponsive to stone removal and medicines gland removal is to be considered. Gland removal is done in our centre with minimum complications and a small scar. We try our best to preserve the gland and all its function in all cases.
