Value of High-Frequency Ultrasonography in the Qualitative and Semi-Quantitative Assessment of Immunoglobulin G4-Related Submandibular Sialadenitis.

OBJECTIVE: To assess the value of high-frequency ultrasonography in the evaluation of immunoglobulin G4-related submandibular sialadenitis (IgG4-SS). METHODS: Thirty-four submandibular glands in 17 patients with IgG4-SS were retrospectively enrolled, as well as 34 submandibular glands in 17 healthy control subjects. Qualitative ultrasonic features including submandibular gland size, border, echogenicity, and vascularity were reviewed. Two different scoring systems (0-16 and 0-48, respectively) were used for semi-quantitative analysis of imaging features. Comparison of both qualitative and semi-quantitative ultrasonic analysis were made between patients with IgG4-SS and healthy controls. Spearman correlation was used to explore relationships between variables. RESULTS: The submandibular glands with IgG4-SS presented with enlarged size, rough border, increased vascularity, and abnormal echogenicity (All P < .05). The most common echogenicity pattern for IgG-SS was diffuse hypoechoic foci pattern (44.1%), followed by superficial hypoechoic pattern (20.6%), tumor-like pattern (14.7%), and diffuse hypoechogenicity pattern (11.8%). Most IgG4-SS glands presented linear hyperechogenicity in parenchyma (91.2%). Based on both scoring system, scores of IgG4-SS were significantly higher than those of the controls (All P < .05). Association analysis of both scoring systems showed positive correlation of scores with vascularity in the gland parenchyma (All P < .05). CONCLUSION: The ultrasonic features of IgG4-SS comprise enlarged gland, rough border, increased vascularity, and abnormal echogenicity, which correlate with its pathological characteristics. The most common echogenicity pattern for IgG4-SS was diffuse hypoechoic foci pattern. Semi-quantitative analysis systems could be useful in the assessment of IgG4-SS. Ultrasound is a potential, valuable, and non-invasive tool for the diagnosis and evaluation of IgG4-SS.

Assessment of Dimensional Changes in Submandibular Glands in Head-Neck Radiotherapy Patients by Ultrasonography.

OBJECTIVES: The present study investigated the dimensional changes in the submandibular glands following radiotherapy using ultrasonography. METHODS: Twenty-three patients planned to receive head-neck radiotherapy were included in this study. The anteroposterior, superoinferior, mediolateral length, and volumes of 46 submandibular glands were measured by ultrasonography at 3 different time periods (before radiotherapy and in the second and sixth months after the radiotherapy onset) and evaluated in terms of dimensional changes and the effect of the radiation dose on these changes. The data were statistically analyzed using repeated measures analysis of variance (ANOVA) and 2-factor repeated measures ANOVA. RESULTS: Before radiotherapy and in the second and sixth months after the radiotherapy onset, mean anteroposterior length of the submandibular glands was 32.39 ± 4.55, 30.38 ± 4.80, and 31.50 ± 3.68 mm, respectively; mean superoinferior length was 9.96 ± 1.54, 8.76 ± 1.26, and 9.08 ± 1.01 mm, respectively; mean mediolateral length was 24.66 ± 3.77, 22.03 ± 3.73, and 21.76 ± 4.01 mm, respectively; and mean volume was 4.21 ± 1.01, 3.08 ± 0.77, and 3.32 ± 0.63 cm3 , respectively. Moreover, there were significant differences in the anteroposterior (P < .01), superoinferior (P < .001), and mediolateral lengths (P < .001), as well as the volumes (P < .001) of the submandibular glands measured at the 3 different time periods. CONCLUSION: In the second and sixth months after the radiotherapy onset, the sizes of the submandibular glands were markedly reduced, but it partially recovered to normal as more time elapsed after radiotherapy.

Viscosity Plane-wave UltraSound (ViPLUS) in the assessment of parotid and submandibular glands in healthy subjects - preliminary results.

AIMS: Viscosity is an important mechanical property directly linked to the shear wave dispersion within tissues. The purpose of this study was to establish the normal viscosity value of the parotid gland (PG) and submandibular gland (SMG) in a group of healthy subjects, using the novel Viscosity Plane-wave UltraSound (ViPLUS) technique, and to assess its potential dependence on gender and age. MATERIAL AND METHODS: The study group included a total of 49 healthy volunteers (median age 31, 65% females) prospectively examined between February 2021 and March 2021. The viscosity of both PG and SMG was measured using the new Aixplorer MACH 30 ultrasound system (SuperSonic Imagine, Aix-en-Provence, France) equipped with a curvilinear C6-1X transducer. The mean value of three valid measurements was considered (quantified in Pa.s). RESULTS: The mean viscosity value for the PG was 2.13±0.23 Pa.s, significantly lower than the mean viscosity value of the SMG 2.44±0.35 Pa.s (p<0.0001). A negative low correlation between SMG viscosity and age was found (rho=-0.38, p=0.006). Viscosity values of the SMG were significantly lower in the age group between 35-77 years (2.12±0.35 Pa.s) than in the age groups 25-34 years (2.52±0.36 Pa.s), and 20-24 years (2.53±0.24 Pa.s), respectively (p<0.05). Viscosity values of both salivary glands did not differ significantly between gender groups. CONCLUSIONS: Supersonic ViPLUS represents an innovative and useful non-invasive method to assess the viscosity of the parotid and submandibular glands. Age is a potential confounding factor in the evaluation of normal SMG viscosity.

Quantitative assessment of dry mouth in scrub typhus using salivary scintigraphy.

Scrub typhus is an acute febrile illness caused by the intracellular pathogen Orientia tsutsugamushi. The clinical features include fever, myalgia, lymphadenopathy, and dry mouth. However, no studies have assessed the symptom of dry mouth in patients with scrub typhus. We investigated the pattern of salivary scintigraphy during the acute febrile state and compared it with any changes after treatment. Fourteen patients underwent both pre- and post-treatment salivary scintigraphy. Imaging analysis was conducted using radioactivity in the oral cavity, parotid glands, and submandibular glands. During the acute phase, the radioactivity in the oral cavity markedly decreased, while that in the parotid and submandibular glands was preserved. After treatment, radioactivity in the oral cavity showed a significant increase at 20-min, 40-min, and after wash-out. The ejection fraction (%) of the parotid glands also increased after treatment. In contrast, the radioactivity levels of the parotid and submandibular glands were not statistically different after treatment. Salivary scintigraphy indicated that insufficient saliva excretion from the salivary glands into the oral cavity was one reason for the dry mouth reported by patients with scrub typhus. In the future, salivary scintigraphy imaging could contribute to the evaluation of dry mouth in patients with scrub typhus.

Patient-based reliability of the Outcome Measures in Rheumatology (OMERACT) ultrasound scoring system for salivary gland assessment in patients with Sjögren's syndrome.

BACKGROUND: To assess the reliability of the consensually agreed US definitions of major salivary gland lesions and the US scoring system for salivary gland assessment in patients with SS. METHODS: Nine experienced sonographers scanned and read the US images of both parotid glands (PGs) and submandibular glands (SMGs) in eight patients with primary and secondary SS in two rounds. A consensually agreed four-grade semi-quantitative scoring was applied in B-mode for morphological lesions: grade 0, normal; grade 1, mild inhomogeneity without anechoic or hypoechoic areas; grade 2, moderate inhomogeneity with focal anechoic or hypoechoic areas; grade 3, severe inhomogeneity with diffuse an- or hypoechoic areas occupying the entire gland or fibrous gland. The presence or absence of typical SS lesions, i.e. the Sjögren's signature, was scored binary. Intra- and interreader reliabilities were computed using weighted and unweighted Cohen's and Light's κ coefficients. RESULTS: The mean prevalence of grades 0-3 in PG were 43, 17, 23 and 31% and 28, 14, 33 and 32% for the SMGs, respectively. The weighted κ for intrareader reliability ranged from 0.44 to 1 for grading and 0.64 to 1 for the Sjögren's signature of PG and 0.59 to 1 and -0.09 to 0.6 for SMGs, respectively. The interreader reliability κ for grading in PG was 0.62 (95% CI 0.47, 0.74) and for Sjögren's signature it was 0.36 (95% CI 0, 0.43); in SMG it was 0.62 (95% CI 0.47, 0.72) and 0.03 (95% CI 0, 0.07) respectively. CONCLUSIONS: The consensually agreed novel US scoring system for major salivary gland lesions showed substantial intra- and interreader reliability in patients with SS. The reliability of the Sjögren's signature was moderate.

Quantitative assessment of normal submandibular glands and submandibular sialadenitis using CT texture analysis: A retrospective study.

OBJECTIVE: The purpose of this study was to quantitatively assess normal submandibular glands and submandibular sialadenitis (SS) using computed tomography (CT) texture analysis as part of radiomics quantitative analysis. STUDY DESIGN: In total, 31 patients with unilateral SS who underwent head and neck magnetic resonance imaging (MRI) and CT and were retrospectively reviewed. Submandibular glands with abnormal signals (STIR: high, T2-weighted image: high, T1-weighted image: low) on MRI were identified as SS. The radiomics features of the contralateral normal submandibular glands and SS were analyzed using an open-access software, MaZda Version 3.3. Sixteen radiomics features were selected with Fisher and probability of error and average correlation coefficient methods in MaZda from 279 original parameters calculated for each of the normal and SS glands. The results were statistically analyzed with the Wilcoxon rank sum test. RESULTS: One gray-level co-occurrence matrix feature and 9 gray-level run length matrix features displayed significant differences between normal submandibular glands and glands with SS (P < .05). CONCLUSIONS: CT texture analysis was able to quantitatively distinguish between normal and diseased submandibular glands. It therefore may have the potential to detect SS.

Assessment of major salivary gland size in primary Sjögren's syndrome: Comparison between clinical examination and ultrasonography.

OBJECTIVE: Parotidomegaly is a criterion of the EULAR Primary Sjögren Syndrome Disease Activity Index (ESSDAI). The cut-off value was set at 3 cm in length for the parotid gland, 2 cm for the submandibular glands. However, clinical appreciation of salivary glands size remains hazardous. The objective is to evaluate inter-observer reproducibility of parotid gland measurement by palpation, and to secondary evaluate its reliability compared to US assessment. METHODS: Outpatients with primary Sjögren Syndrome (pSS) or with a diagnostic suspicion, in a single reference centre, were included. They underwent clinical examination by two independent investigators (VDP and DC), evaluating: parotid gland swelling, parotid gland size (direct measurement with a decameter under the mandibular angle), and pain. Cohen's kappa coefficient was calculated to determine inter-observer concordance for parotid gland swelling, and intraclass correlation coefficient to determine inter-observer agreement of gland size measurement. RESULTS: Thirty-four patients (33 women, 1 man) were included. Clinical data were complete for 33 patients. Inter-observer concordance Kappa coefficient was 0.90 [0.76-1.00] for detection of parotidomegaly over 66 parotid glands. It was of 0.60 [0.42-0.73] for gland length measurement. For one observer, the median cut-off for defining parotidomegaly was 4.15 cm; for the second observer, it was of 4.92 cm. For submandibular glands palpation, no correlation was found between investigators. A significant association between clinical parotidomegaly and a larger echographic surface was found. CONCLUSION: Clinical measurement of parotidomegaly was concordant between two observers on a binary mode (presence/absence). However, concordance on direct measurement was weak. US could be a complementary examination.

Assessment of Parotid and Submandibular Glands With Shear Wave Elastography Following Radioactive Iodine Therapy for Papillary Thyroid Carcinoma.

OBJECTIVES: Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy. Radioactive iodine (RAI) therapy is used for remnant ablation following thyroidectomy. Side effects such as dysphagia, xerostomia, and sialoadenitis may occur. We aimed to determine the differences in the parotid and submandibulary glands between healthy patients and patients with PTC who had undergone RAI therapy and have dry mouth symptoms using both shear wave elastography and ultrasonography. METHODS: We enrolled 30 patients with PTC who had undergone RAI therapy following surgery and 30 healthy controls. Ultrasonography and shear wave elastography of submandibular and parotid glands were performed. The volume of the submandibular glands and the thickness of parotid glands were determined. Ten independent measurements were obtained from each gland, with the region of interest placed at different points on the glands. The mean shear wave velocities (SWVs) were calculated and compared between the patients and controls. RESULTS: In the PTC group, there was a significant reduction in the volume of the submandibular glands (P < .05) and in the thickness of the parotid glands (P < .05) compared with the control group. The mean SWVs of the parotid glands and submandibular glands were significantly higher in the PTC group compared with the control group (P < .0001). The SWVs of the parotid glands were higher than the SWVs of the submandibular glands (P < .0001). CONCLUSIONS: Shear wave elastography could be a noninvasive and easy assessment method of parotid and submandibular glands in patients who had undergone RAI therapy and experience dry mouth.

Assessment of Lingual Concavities in Submandibular Fossa Region in Patients requiring Dental Implants-A Cone Beam Computed Tomography Study.

AIM: The present study was aimed at assessing the lingual concavities in the submandibular fossa region in patients requiring dental implants with the help of cone beam computed tomography (CBCT). MATERIALS AND METHODS: The present study included 140 patients who visited the department with the missing mandibular posterior teeth. CBCT images were obtained using planmeca machine. Cross sections of 1 mm of submandibular fossa in the region of 1st and 2nd molar were studied and Type I to III lingual concavities were analyzed by a radiologist. RESULTS: Type I lingual concavity (< 2 mm) was seen in 23%, type II (2-3 mm) in 62% and Type III (> 3 mm) in 15% of patients. The difference was significant (p < 0.05). Males had slightly higher mean ± S.D value at 1st molar (2.6 mm ± 0.94) and 2nd molar (2.8 mm ± 0.90) on the left side and (2.7 mm ± 0.92) at 1st molar and (2.9 mm ± 0.93) at 2nd molar on the right side. The difference was nonsignificant (p > 0.05). Females had mean ± S.D value at 1st molar (2.3 mm ± 0.90) and (2.5 mm ± 0.92) at 2nd molar on the left side and (2.4 mm ± 0.91) at 1st molar and (2.8 mm ± 0.93) at 2nd molar. The difference was nonsignificant (p > 0.05. The difference between both genders was statistically nonsignificant (p > 0.05). CONCLUSION: Type I bone is the best for placing an implant. The chances of complications are more in type II and III bone. CBCT provides necessary information before planning implant in the edentulous area. CLINICAL SIGNIFICANCE: Cone beam computed tomography (CBCT) is the best radiographic aid which is effective in delineating different types of bone in the mandibular posterior region.

Brief Report: Ultrasonographic Assessment of Salivary Gland Response to Rituximab in Primary Sjögren's Syndrome.

OBJECTIVE: To evaluate changes in salivary gland echostructure and vascularization after rituximab treatment in patients with primary Sjögren's syndrome (SS). METHODS: Twenty-eight patients with primary SS included in the multicenter, randomized, double-blind, placebo-controlled Tolerance and Efficacy of Rituximab in Primary Sjögren's Syndrome (TEARS) trial underwent salivary gland ultrasonography before the first placebo or rituximab infusion and then 6 months later. Trial inclusion criteria were scores of ≥50 mm on at least 2 of 4 visual analog scales (VAS) evaluating dryness, pain, fatigue, and global disease; and recent-onset (<10 years) biologically active primary SS and/or systemic primary SS. Patients were randomly assigned (1:1) to rituximab (1 gm at weeks 0 and 2) or placebo. Ultrasonography of both parotid and submandibular glands was performed to assess echostructure (using a semiquantitative score of 0-4, with improvement defined as a ≥1-point decrease), size of each gland, and vascularization based on the resistive index of the transverse facial artery of the parotid gland before and after lemon juice stimulation. RESULTS: Of the 28 patients, 5 (18%; 3 in the placebo group and 2 in the rituximab group) had clinically detectable bilateral parotid gland enlargement at baseline. Parotid parenchyma echostructure improved in 50% of the rituximab-treated patients versus 7% of the placebo-treated patients (P = 0.03). In the submandibular glands, echostructure also improved in a larger proportion of rituximab-treated patients, although the difference was not significant (36% versus 7% of placebo-treated patients; P = 0.16). Gland sizes and resistive index remained unchanged. CONCLUSION: Ultrasonography showed improved salivary gland echostructure in patients with primary SS receiving rituximab, with no changes in salivary gland size or vascularization, 6 months after the first infusion.

Lithotripsy for salivary stones with prospective US assessment on our first 25 consecutive patients.

OBJECTIVES: To evaluate the predictive value of sonographic fragmentation in the successful treatment of sialolithiasis. The main objective was to streamline the management by treating the patients with three sessions of ultrasonic lithotripsy, and to compare the success rate and complications with data from the literature. A second objective was to analyse the predictive value of data from the post procedure and follow-up sonography related to therapeutic success with regard to size, site and location of stones. MATERIAL AND METHODS: Prospective follow-up of 25 patients (mean age of 43 ± 17.2 years old 11-68; 13 women, 10 men) over a period of 31 months (October 2009-April 2012) with one or more salivary calculi (19 parotid, submandibular 6) treated with extracorporeal lithotripsy (electromagnetic MINILITH SL 1, Storz Medical, Switzerland). No anaesthesia or analgesia was used. Each session of lithotripsy lasted on average 30 min. Minor complications were collected on an anonymised sheet. RESULTS: Complete success (absence of clinical symptoms 3 months after the end of treatment (or the last session) and residual stones <2 mm) was observed in 36% of patients, partial success (persistence of symptoms least 3 months (lower intensity and lower frequency) or size of residual stones>2 mm) in 48% and failure (persistence of same or increased symptoms at 3 months or no change in size of the calculi) in 17% of patients. Sonographic fragmentation of the stone (p = 0.004), total energy delivered (p = 0.008) and the total number of shock waves (n = 0.045) are predictive factors of complete success. Size, salivary topography, ductal topography, mobilization of the stones, occurrence of minor side effects and total duration of treatment had no predictive value of complete success (p > 0.05). There was no significant difference between the first 5 and the last 20 patients (p = 0.367). In agreement with the literature data, the efficacy of treatment was greater for parotid than submandibular calculi. CONCLUSION: Extracorporeal lithotripsy is an alternative to conventional surgery with no major complications. Sonographic fragmentation of calculi, total energy and total number of shock waves are predictive factors of successful treatment.

Scintigraphic assessment of salivary function after intensity-modulated radiotherapy for head and neck cancer: correlations with parotid dose and quality of life.

OBJECTIVE: We investigated salivary function using quantitative scintigraphy and sought to identify functional correlations between parotid dose and quality of life (QoL) for head and neck cancer (HNC) patients receiving intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS: Between August, 2007 and June, 2008, 31 patients treated IMRT for HNC were enrolled in this prospective study. Salivary excretion function (SEF) was previously measured by salivary scintigraphy at annual intervals for 2 years after IMRT. A dose-volume histogram of each parotid gland was calculated, and the normal tissue complication probability (NTCP) was used to determine the tolerance dose. QoL was longitudinally assessed by the EORTC QLQ-C30 and H&N35 questionnaires prior to RT, and at one, three, 12 and 24 months after RT. RESULTS: A significant correlation was found between the reduction of SEF and the mean parotid dose measured at 1 year (correlation coefficient, R(2)=0.651) and 2 years (R(2)=0.310) after IMRT (p<0.001). The TD(50) of the parotid gland at 1 year after IMRT is 43.6 Gy, comparable to results from western countries. We further found that contralateral parotid and submandibular gland function preservation was correlated with reduced sticky saliva and a better QoL compared to the functional preservation of both parotid glands, as determined by the EORTC QLQ-H&N35 questionnaire. CONCLUSION: A significant correlation was found between the reduction of SEF and the mean parotid dose. Preservation of contralateral parotid and submandibular gland function predicts a better QoL compared to preservation of the function of both parotid glands.

Assessment of variations of the mandibular canal through cone beam computed tomography.

The neurovascular bundle may be vulnerable during surgical procedures involving the mandible, especially when anatomical variations are present. Increased demand of implant surgeries, wider availability of three-dimensional exams, and lack of clear definitions in the literature indicate that features of anatomical variations should be revisited. The objective of the study was to evaluate features of anatomical variations related to mandibular canal (MC), such as bifid canals, anterior loop of mental nerve, and corticalization of MC. Additionally, bone trabeculation at the submandibular gland fossa region (SGF) was assessed and related to visibility of MC. Cone beam computed tomography exams from 100 patients (200 hemimandibles) were analyzed and the following parameters were registered: diameter and corticalization of MC; trabeculation in SGF region; presence of bifid MC, position of bifurcations, diameter, and direction of bifid canals; and measurement of anterior loops by two methods. Corticalization of the MC was observed in 59% of hemimandibles. In 23%, MC could be identified despite absence of corticalization. Diameter of MC was between 2.1 and 4 mm for nearly three quarters of the sample. In 80% of the sample trabeculation at the SGF was either decreased or not visible, and such cases showed correlation with absence of MC corticalization. Bifid MC affected 19% of the patients, mostly associated with additional mental foramina. Clinically significant anterior loop (>2 mm of anterior extension) was observed in 22-28%, depending on the method. Our findings, together with previously reported limitations of conventional exams, draw attention to the unpredictability related to anatomical variations in neurovascularization, showing the contribution of individual assessment through different views of three-dimensional imaging prior to surgical procedures in the mandible.

Scintigraphic assessment of salivary gland function in a rat model.

BACKGROUND: Salivary gland dysfunction with xerostomia is a major clinical problem without a causal therapy in most cases. The development of an animal model for scintigraphic assessment of salivary gland function has great clinical relevance for the investigation of promising new diagnostic and therapeutic strategies for chronic salivary gland diseases. This study reports the first experiences with scintigraphic analyses of salivary gland function in a rat model. MATERIALS AND METHODS: Anatomical and scintigraphic studies were performed for topographic differentiation of major salivary glands of Wistar rats. (99m)technetium pertechnetate salivary gland scanning was performed, appropriate regions of interest were determined and the gland-to-background ratio was examined for the evaluation of salivary gland function. RESULTS: The quantitative analysis of salivary gland scintigraphy revealed a reliable comparison of major salivary glands on both sides with the gland-to-background ratio ranging from 1.26 to 1.94 with an average of 1.51. CONCLUSION: This model seems to be appropriate for functional studies in an experimental setting.

Sonographic assessment of the submandibular space.

There is a wide variety of pathological processes which may present with swelling in the submandibular space. Although the submandibular gland is the most important structure in this region, there are a number of extraglandular causes of swelling which frequently mimic submandibular gland enlargement. In this review the use of high-resolution ultrasound in the assessment of the submandibular gland and adjacent structures is discussed and illustrated.

Assessment of salivary gland dysfunction following chemoradiotherapy using quantitative salivary gland scintigraphy.

PURPOSE: To assess chemoradiotherapy-induced salivary gland dysfunction using quantitative salivary gland scintigraphy (QSGS), and whether QSGS is capable of predicting the grade of persistent salivary dysfunction after chemoradiotherapy. METHODS: From a time-activity curve using a stimulation test, the washout rate (WR) calculated was assessed. All glands (n = 155) were classified into four groups: a no-therapy group (n = 18), a chemotherapy alone group (n = 31), a radiotherapy alone group (n = 50), and a chemoradiotherapy group (n = 56). Subjective descriptions of xerostomia were recorded 1 year after the completion of the treatment period, and the 32 glands subjected to irradiation with or without chemotherapy were assessed. RESULTS: The WR values were significantly lower in glands that received chemoradiotherapy than in glands treated with radiotherapy alone (mean: 0.75 x 10(-3), n = 40 vs. 0.22, n = 36, p < 0.015), but there was no significant difference in the WR values between the no-therapy group and the chemotherapy alone group. The mean values of WR were lower in the chemoradiotherapy glands than in the radiotherapy alone glands in each of cumulative dose ranges of 1-20, 21-30, and 31-60 Gy. With regard to recovery from xerostomia, the WR values at a cumulative dose range of 20 to 40 Gy were significantly lower in the not improved group (-0.418, n = 16) than in the improved group (0.245, n = 16) (p < 0.0001). CONCLUSION: Chemotherapy per se has no or little adverse effect on salivary function, but combination chemotherapy can deteriorate radiation-induced injury of the salivary glands. QSGS appears useful in predicting the grade of persistent xerostomia following chemoradiotherapy.

A computer-assisted method for semi-quantitative assessment of salivary gland diseases.

The authors report on a computer-assisted method that allows a semi-quantitative assessment of salivary gland function under normal and pathologic conditions. They illustrate some mathematical procedures suitable for this purpose and the results achieved in various salivary gland diseases.