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Application of magnetic resonance virtual endoscopy as a presurgical procedure before sialoendoscopy.

OBJECTIVES: The objectives of this study were to investigate the feasibility of clinical application of magnetic resonance (MR) virtual endoscopy as a presurgical procedure before sialoendoscopy and to evaluate its value in the diagnosis of obstructive salivary gland diseases and preoperative visualization of endoluminal views. STUDY DESIGN: This study presents our initial experience to use MR virtual endoscopy for the presurgical visualization of salivary duct lumen and ductal pathologies in comparison to the sialoendoscopy findings in a feasibility study. METHODS: Six consecutive patients with suspected obstructive salivary gland diseases underwent MR sialography with a three-dimensional fast imaging using steady-state acquisition. The three-dimensional MR data were transferred to an independent workstation and were postprocessed with navigator software to generate three-dimensional reconstruction and virtual endoscopic images. The fly-through mode was used to imitate the sialoendoscopic exploratory procedure. Then the patients underwent sialoendoscopy and the endoscopic findings were compared with the preoperative virtual endoscopic images. RESULTS: The MR data acquisition and postprocessing protocol were feasible. The virtual endoscopy created clear endoluminal views of salivary duct and the ductal pathologies. The diagnoses were all confirmed by surgical sialoendoscopy. The virtual endoscopic images showed close resemblance to the sialoendoscopic findings. CONCLUSIONS: MR virtual endoscopy is an effective and noninvasive diagnostic method for evaluating the endoluminal anatomy and pathologies of the salivary duct. The clinical application of MR virtual endoscopy as a presurgical procedure before sialoendoscopy is a valuable and promising approach, which can provide surgeons useful morphologic and pathologic information.

Adult↗

A case of multicentric reticulohistiocytosis, systemic sclerosis and Sjögren syndrome.

We report the case of a 42-year-old Japanese woman who developed multicentric reticulohistiocytosis (MR) complicated by systemic sclerosis (SSc) and Sjögren syndrome (SS). The patient complained of tender nodules on the left hand, polyarthralgia in the finger joints and knees, and xerostomia. The skin nodules were distributed mainly on her hands and fingers with skin sclerosis. The serum anti-nuclear test revealed anti-centromere antibody and the discrete speckled pattern of anti-nuclear antibody. The biopsy specimens from the finger nodule and the sclerotic finger skin showed a perivascular infiltration of multinucleated giant cells with ground-glass cytoplasm and dermal thick collagen proliferation, respectively. The lip biopsy and sialography specimens showed periductal lymphocyte infiltration and apple tree-like changes. Systemic corticosteroid treatment improved the polyarthritis, xerostomia, and skin sclerosis rapidly but suppressed the nodular lesions only gradually. This is the first report of a combined case of MR, SSc and SS. This multiple autoimmune complication suggests the involvement of an immunological disturbance in the pathogenesis of MR.

Adrenal Cortex Hormones↗

The clinical picture of benign lympho-epithelial lesion.

The histopathological diagnosis 'benign lympho-epithelial lesion' characterizes the major salivary gland disease in Sjögren's syndrome. It is not known if all cases with microscopically diagnosed benign lympho-epithelial lesion are variants of Sjögren's syndrome. The present clinical investigation showed that in 19 patients with the microscopical diagnosis of lympho-epithelial lesion, 84% fulfilled all criteria of Sjögren's syndrome. The rheumatoid factor and/or antinuclear factor was found in 84% and M-component was present in 16%. Sialography revealed sialectasis in all parotid glands. Salivary gland enlargement was found in 79%, and keratoconjunctivitis sicca in 89% of the patients. Systemic disease was found in 32%. The disease in the 2 patients with M-component took a malignant course, culminating in immunoblastic sarcoma and myelomatosis. The clinical diagnosis 'autoimmune sialadenitis' is proposed for the oral and salivary gland component is Sjögren's syndrome.

Adult↗

Senile dry skin type Sjögren's syndrome.

BACKGROUND: Elderly patients may show asteatotic dermatitis complicating Sjögren's syndrome (sjs) that we have named "senile dry skin type sjs." To define the condition further, we have examined a group of patients with sjs and have recorded clinical and laboratory findings in these patients. PATIENTS AND MATERIALS: Of the 36 patients, 11 were men and 25 were women, with a mean age of 72 years. In addition to the subjective sensation of dryness of the eyes and oral cavity and objective signs of dryness revealed by the Schirmer test, the rose bengal test, minor labial gland biopsy, and sialography were carried out, as well as other hematologic and immunologic tests. RESULTS: The following abnormal laboratory tests were found: elevated erythrocyte sedimentation rate (85%), mild hepatic dysfunction (50%), and anemia (45%), leukopenia (42%), and thrombocytopenia (16%). Immunologic abnormalities were also observed, such as: positive antinuclear antibody (55%), an increase in gamma globulin (28%), and a positive rheumatoid factor (20%). In 11 of the 36 patients (30%), the subjective sensation of dryness was absent and only objective signs of dryness were present. CONCLUSIONS: The present study suggests that dry-skin-dermatitis associated with sjs is rather common in the elderly.

Aged↗

Significance of oral examination in chronic graft-versus-host disease.

Fourteen patients who received allogeneic bone marrow transplantation (BMT) were examined 100 to 220 days after BMT. Ten out of 14 patients were diagnosed as having chronic graft-versus-host disease (cGVHD) in skin, liver, eyes and other organs. These cGVHD patients also had objective evidence of oral involvement. Subjective xerostomia was experienced by 7 cGVHD patients and decreased whole saliva flow was observed in 4 cGVHD patients. However, no patient had a history of parotid swelling or notable abnormality in parotid sialography. Labial salivary glands (LSG) or 9 cGVHD patients showed atrophy and/or destruction in association with diffusely infiltrating lymphocytes. The infiltrating lymphocytes were mainly CD3+ T cells with a predominance of CD8+ cells over CD4+ cells. Lichenoid lesions on the oral mucosa were also observed in 5 cGVHD patients. Thus, thus study indicated that oral examination, including LSG biopsy, is useful in the diagnosis of cGVHD.

Adolescent↗

Utility of three dimension fast asymmetric spin-echo (3D-FASE) sequences in MR sialographic sequences: model and volunteer studies.

OBJECTIVES: To evaluate the utility of 3D-FASE for the visualization of salivary gland ducts for use in MR sialographic sequences. METHODS: We compared MR sialographic images and virtual endoscopic views from 3D-FASE with those from three kinds of sequences described by previous reports in a 3D parotid gland duct model and volunteer. The four sequences were two-dimension fast spin-echo (2D-FSE), three-dimension fast spin-echo (3D-FSE), two-dimension fast asymmetric spin-echo (2D-FASE), and three-dimension fast asymmetric spin-echo (3D-FASE). RESULTS: In the 3D parotid gland duct model, image visibility on visual score was clearest with 3D-FSE, followed by 3D-FASE (P = 0.028). In the volunteers, the visualization of images improved in the following order: 3D-FASE > 3D-FSE > 2D-FSE > 2D-FASE. CONCLUSIONS: The technique of 3D-FASE sequencing is more suitable and useful for MR sialography with an appropriate acquisition time.

Adolescent↗

Permeability of canine submandibular glands to blood-borne horseradish peroxidase: effects of transient ductal obstruction during secretion.

Outflow obstruction of the submandibular duct, for a short period during parasympathetic secretion, caused an increase in glandular permeability to horseradish peroxidase. Higher frequencies of parasympathetic nerve stimulation during the obstructive period induced greater increases in the permeability. It is likely that the intraluminal distensions had disrupted some tight junctions and so permitted a greater paracellular leakiness. The damage tended to induce ballooning between striated ductal cells, similar to the appearances observed by Emmelin, Garrett & Gjörstrup (1977 a) when sympathetic secretion was accompanied by myoepithelial contraction against a raised outflow pressure. The present results have been compared with experimental data from other workers and give support to the idea that tight junctions can behave in a sieve-like manner towards the back-diffusion of molecules across them. This work indicates that there is a great need for care in permeability studies. It is possible that some permeability changes observed by other workers may have been the consequences of physical damage between cells. Our findings reinforce the need for morphological assessment of the glands after permeability experiments. In man it is likely that naturally occurring or artificially induced obstructive events may at times create similar permeability changes and these may enable protective substances to pass from the blood to the saliva. This affords possible explanation for such phenomena as the therapeutic value that often accrues from sialography and the efficacy of many different antibiotics in obstructive sialadenitis, despite the fact that most antibiotics do not normally permeate to the saliva.

Animals↗

Urinary monoclonal free light chains in primary Sjögren's syndrome: an aid to the diagnosis of malignant lymphoma.

Three patients, two with typical primary Sjögren's syndrome (SS) and the third with several features of SS, including abnormal sialography and reduced tear secretion, developed B cell non-Hodgkin's lymphoma (NHL) of parotid or lung, or both. Isoelectric focusing of concentrated urine specimens in agarose, followed by immunofixation, demonstrated the presence in each patient's urine of monoclonal free light chains of the same class as that shown on the tumour cells. In one patient the level of urinary free light chains was monitored and found to correlate with disease activity. Similar techniques showed no monoclonal light chains in the urine from a further 26 cases of SS with no clinical evidence of lymphoma. The detection of monoclonal urinary free light chains may provide an early diagnostic clue to the development of lymphoma in patients with SS and be a means of tumour monitoring.

Aged↗

The European Community Study Group on diagnostic criteria for Sjögren's syndrome. Sensitivity and specificity of tests for ocular and oral involvement in Sjögren's syndrome.

AIM: To establish a definitive set of diagnostic criteria in a multicentre European study a selected number of oral and ocular tests were performed on a large number of patients with Sjögrens Syndrome (SS) and controls. The diagnostic accuracy of each test for patients with primary and secondary SS and for controls at different ages, was studied. METHODS: Each centre received a clinical chart describing the series of tests to be conducted. The tests included: questionnaires for dry eye and dry mouth symptoms, Schirmer's-I-test (ScT), tear fluid lactoferrin level (TFLL), break-up time (BUT) and rose Bengal score (RBS) for the eye evaluation; unstimulated and stimulated whole saliva collection (UWSC and SWSC), salivary gland scintigraphy (SGS), parotid sialography (PS) and minor salivary gland biopsy (MSGB) for oral involvement. RESULTS: Data from 22 centres and 11 countries was collected on a total of 447 patients with SS (246 with primary SS and 201 with secondary SS) and 246 controls (of whom 113 had a connective tissue disease without SS). Among the ocular symptoms, the feeling of dry eye and 'sand in the eye' were the ones most commonly recorded in patients with SS. Similarly, the feeling of dry mouth, appearing either spontaneously or when the patient was eating or breathing, was the most frequent subjective oral symptom. Among the ocular tests, ScT showed the best balance between sensitivity and specificity (76.9% and 72.4% respectively), while RBS was the most specific test (81.7%). ScT and RBS gave also sufficiently concordant results. TFLL and BUT gave considerably less reliable results, which were not concordant with each other or with the other ocular tests. The quantitative lacrimal tests ScT and TFLL produced significantly different results in elderly controls, while RBS did not. Abnormal results for all of the ocular tests were less marked and less frequent in patients with secondary SS than in those with primary SS. The oral tests (except SWSC) were generally more reliable than the ocular tests in diagnosing SS. In particular, PS was the most specific diagnostic tools (100%), while MSGB (where the presence of at least one inflammatory focus was considered as indicative for the diagnosis) showed a good balance between sensitivity and specificity (82.4% and 86.2%, respectively). The tests showed a good degree of agreement, and, with the exception of UWSC, were not influenced by age. In the oral, as in the ocular tests, abnormal results were less frequent and less marked in patients with secondary SS. CONCLUSIONS: The results clearly show that ScT and RBS (for the eye evaluation), and SGS, PS, MSGB and UWSC (for salivary gland involvement) are the most reliable tests for the diagnosis of SS. The clinician should be aware, however, that the test results may vary depending on the age of the patient and the type of SS (primary or secondary).

Adult↗

Parotid gland: US findings in Sjögren syndrome. Work in progress.

To determine the value of sonography of the parotid gland in patients with Sjögren syndrome, six consecutive cases were retrospectively reviewed in which clinical findings indicated Sjögren syndrome. All patients were women. Two patients were found at sonography to have normal parotid glands. Four patients had multiple cystic changes in the parotid glands bilaterally. Each of these four patients had a clinical diagnosis of Sjögren syndrome. One of the four underwent sialography, which demonstrated characteristic sialectasia. Pathologic examination of an excised gland in one of the patients with Sjögren syndrome demonstrated typical benign lymphoepithelial aggregates, which cause obstruction and progressive ductal dilatation. While parotid enlargement in these patients may be due to salivary tumor, lymphoma, or sarcoidosis--all of which appear as solid lesions at sonography--this study suggests that bilateral cystic changes may be the rule in uncomplicated cases of Sjögren syndrome.

Adult↗

Ultrasound in salivary gland disease.

This text reviews the normal ultrasound (US) anatomy of the salivary glands along with tumoral, lithiasic, and inflammatory pathologies. For salivary gland tumors, US does have limitations (failure to visualize the entire parotid gland, relations with the nerve plexus, in-depth spread of large tumors, false-negative errors of malignancy for small encapsulated tumors). However, US is a simple technique allowing correct identification of the benign nature of a lesion in over 80% of the cases. For lesions under 3 cm in diameter, US is generally the only imaging technique used; for larger lesions, CT or MR is required. Sialolithiasis and inflammatory diseases are being documented by US more and more and the indications for sialography have strongly decreased.

Adenolymphoma↗

Sialolithiasis of an accessory parotid gland.

We report a case of sialolithiasis of an accessory parotid gland in the cheek demonstrated by computed tomography and sialography. The accessory parotid gland was located anterolateral to the masseter muscle and was isolated from the main parotid gland. The calculus developed from this accessory parotid gland, and the main parotid gland was free of sialolithiasis and inflammation. To our knowledge, this is the first report concerning sialolithiasis in an accessory parotid gland. The calculus was removed without facial nerve injury or salivary fistula via a peroral approach.

Adult↗

Saliva secretion from the rat submandibular gland after retrograde infusion of radiographic contrast media.

Rat submandibular saliva was collected at various times after retrograde infusion of water-soluble (Renografin 60%) or lipid-soluble (Lipiodol UF) radiographic contrast medium. Significant alterations in flow rate occurred following heavy parenchymal filling with both types of contrast media. Occasional changes in protein concentration, lactoperoxidase activity, and K+ levels were also noted. These changes were relatively mild and transient, and gland function had generally returned to normal by one wk after infusion. No alterations in glandular function were detected after infusion of contrast medium to a degree (ductal filling) comparable to that usually employed in clinical sialography.

Animals↗

Inflammatory and obstructive disorders of salivary glands.

Obstructive and inflammatory diseases of the salivary glands can have a congenital, traumatic, metabolic, or infectious-inflammatory cause. The acute inflammatory conditions include bacterial and viral infections, and the chronic conditions include sialoliths, strictures, chronic sialadenitis, sialectasis, and lymphoepithelial disease. The neoplastic disease can cause obstruction and/or infection and often make the diagnosis elusive. In addition to a working knowledge of possible etiology, one needs experience with clinical examination, salivary analysis, sialography, CT scans, MRI, and fine-needle aspiration and cytology in order successfully to evaluate and manage patients with these conditions.

Acute Disease↗

Sonographic evaluation of the parotid ducts: its use in tumour localization.

The previously unreported sonographic anatomy of the intraglandular parotid ducts is described, and how this aids tumour localization is illustrated. Forty patients underwent ultrasonography and computed tomography (CT) sialography for the evaluation of parotid tumours. Ultrasound identified two extra unsuspected 5 mm tumours in the superficial lobe, which could not be seen at CT. Both techniques produced similar results for deep and mixed lobe lesions. Ultrasound had one false positive mixed lesion, which surgery subsequently found to be confined to the deep lobe. The full extent of invasion in three deep lobe tumours was revealed only by CT to be parotid invasion by nasopharyngeal carcinomas. We conclude that parotid sonography with reference to the intraglandular ducts is highly accurate in localizing parotid tumours and should probably be the first-line imaging technique. Computed tomography should only be necessary for visualization of deep lobe tumour extent and in those cases where the complete tumour boundary cannot be seen by ultrasound alone.

Humans↗

Diagnostic value of computed tomography in parotid tumours.

In 18 cases of parotid tumours, CT demonstrated their primary site, extent and invasion of surrounding tissue precisely. It was valuable in the majority of cases in differentiating benign from malignant tumours and could distinguish accurately intrinsic from extrinsic. CT sialography was superior in equivocal cases when it made the tumour easier to identify and the diagnosis more accurate.

Diagnosis, Differential↗

Two cases of schwannoma with marked cystic changes.

We report two cases of schwannoma displaying marked cystic changes; one in the temporalis muscle and one in the submandibular space. The first patient, a 44-year-old male, presented after complaining of a swelling rapidly increasing in size in the left temporal region. Computed tomography (CT) indicated a low-density area surrounded by soft tissue. Magnetic resonance imaging (MRI) revealed signal hypointensity on T1 weighted imaging and strong signal hyperintensity on T2 weighted imaging. The extirpated tumour specimen measured 58 mm x 58 mm x 30 mm. Histopathological examination identified schwannoma, comprising spindle cell proliferation in a palisading pattern with obvious cystic changes. The second case involved a 46-year-old female who presented with swelling of the right submandibular region. Panoramic radiography and lateral oblique mandible projection, which were used together with conventional sialography of the submandibular gland, revealed the so-called "ball in hand" appearance of the submandibular gland, and contrast-enhanced CT identified a lesion of 30 mm diameter with a well-defined annular margin and homogeneous low-density near the tumour centre. Benign pleomorphic adenoma was suspected, but histopathological examination identified schwannoma, predominantly comprising Antoni B type tissue.

Adult↗

Symposium: management of tumors of the parotid gland. II. Diagnosis of parotid gland swelling.

Diagnosis of parotid gland swellings can be approached by attempting to answer the following questions: 1. Is it parotid? 2. Is it inflammatory or neoplastic? 3. If it is neoplastic, is it benign or malignant? Diagnosis is made by following the classical physical diagnostic procedures of inspection, palpation, and auscultation. These are followed by radiographic procedures, such as plain films, sialography and technetium scanning. Since approximately one in four parotid neoplasms is malignant, a definitive step should be biopsy. Excisional biopsy is recommended.

Biopsy↗