Modified Procedure Note

Procedure: Bilateral parotid duct cannulation dilation with radiocontrast insufflation (bilateral parotid sialograms)

Preop Diagnosis: Recurrent parotid swelling, xerostomia, positive ANA, report of negative lip biopsy and negative SSA SSB antibodies

Postop Diagnosis: Findings consistent with likely Sjogren's syndrome; Sialosis (Sialadenosis - h/o diabetes melllitus)

Anesthesia: Premedication with Augmentin (875 mg po bid for three days, beginning the morning of the procedure), oral rinse with dilute Betadine, topical 2% viscous lidocaine applied to the buccal region bilaterally over Stensen’s duct orifice

Description of Procedure: Following identification of the patient informed consent and a brief timeout in the fluoroscopy suite with the patient positioned supine, the right buccal area was examined with the microscope identifying the Stensen’s duct orifice into which a 0.015-inch COOK® fixed core wire guide (15 cm long) was readily placed. The guidewire was removed and followed by an unsuccessful effort to position a primed 22-gauge AngiocathTM without the guidewire. The guidewire was then replaced and - employing the Seldinger technique – permitted ready placement of the 22-gauge AngiocathTM.  The angiocatheter was readily ‘hubbed’ with no spontaneous appearance of saliva warranting filling of the catheter hub – addressed by placing Isovue 370 (delivered through 24-gauge angiocatheter) into the now formerly air-filled hub (to avoid bubbles in the exam). Attachment of an IV tubing allowed for performance of the sialogram as further described in the Radiology note below after securing the angiocatheter/IV tubing with a 4x4 gauze sponge placed around the assembly and having the patient maintain the teeth occluded over the sponge.

An identical procedure was done on the contralateral left side with the exception that the Seldinger technique was used from the start with a 0.015-inch guidewire placed and 22-gauge angiocatheter hubbed, filled with Isovue 370 in the same manner.

She tolerated the procedure well and was subsequently examined in the otolaryngology clinic and offered further counseling.

Modified Radiology Interpretation

Procedure: FL SIALOGRAM COMPLETE

Indication:  Parotid sialadenitis, 49 yo with bilateral recurrent parotid swelling h/o 'normal CT' two years ago (re-review of CT identified large symmetric homogeneous parotid glands)

Technique: The Otolaryngologist was present and performed cannulation of the bilateral parotid duct openings. After successful cannulation on the right, the sialogram was completed. Following image review, value was identified in assessing the contralateral left side as well. The patient was repositioned with 2% viscous lidocaine applied in the left buccal region with subsequent cannulation on the left was achieved for similar sialography.

For each side, a 10-cc syringe with Isovue 370 contrast agent was connected to the cannula and instilled into the duct under fluoroscopic monitoring. A total of 1 cc on the right and 1.5 cc on the left of contrastagent (Isovue 370) was utilized. After adequate duct opacification was achieved, AP and lateral spot films were obtained. The cannula was then removed and duct was allowed to empty following oral administration of lemon juice to patient with parotid massage and swish and spit of water. Post void AP image was then obtained.

Fluoro Time: 0:54

Radiation Dose: 254.7 cGy-cm2

Findings

Right parotid

1. Adequate opacification of the right parotid duct and branches was achieved
2. There is intra glandular sialectasis measuring predominantly 2-3 mm or less
3. Fewer larger areas of sialectasis measuring 3-4 mm were noted
4. There is slight splaying of the intraglandular ductal system.

Left parotid

1. Adequate opacification of the parotid duct and branches is achieved
2. There is intra glandular sialectasis measuring predominantly 2-3 mm or less
3. There is slight splaying of the intraglandular ductal system.
4. Post void film shows adequate emptying with minimal contrast retention noted on the left.

Impression: Findings compatible with Sjogren's disease with predominantly globular sialectasis is noted. Likely a component of sialosis (large glands with splaying of the intraglandular ductal system) is also noted.