Goals

To be presented for consideration at the November 30th at AAO-HNS Salivary Gland Committee Zoom Meeting

To establish a sub-committee to prepare for full committee review: "Standardization in Salivary Gland Ultrasound Assessment"

Action Points

1. Request approval to create subcommittee to create a protocol and manuscript to identify suggestions regarding standardization of salivary gland ultrasound assessment
2. Solicit volunteers to join the subcommittee
3. Schedule zoom conference of subcommittee to refine a manuscript defining recommendations
4. Present a protocol with manuscript in-person for discussion at a future AAO HNS Salivary Gland Committee meeting 

Lorenzen (2022):

"The increasing application of SGUS [salivary gland ultrasound] in the assessment of pSS [primary Sjogrens syndrome] requires standardization of imaging modalities" Standardization of salivary gland ultrasound warrants attention to additional processes to include radiation-induced sialadenitis as well as assessment and then reassessment following interventions such as stone removal, stricture dilation, steroid infusion, botox injection and gene therapy. 

Problems in Standardizing Salivary Glands Ultrasound Assessment

•  Subsites within the parotid gland have been established anatomically for sialadenectomy, but not for ultrasound assessment (ultrasound-determined anatomic subsites should be defined for parotid, submandibular and sublingual glands)
  • example: Classification of parotidectomies: a proposal of the European Salivary Gland Society  Quer M, Guntinas-Lichius O, Marchal F, Vander Poorten V, Chevalier D, León X, Eisele D, Dulguerov P.  Eur Arch Otorhinolaryngol. 2016  Oct;273(10):3307-12.  PMID: 26861548.
• Quantitative assessment of salivary gland parenchymal fibrosis with shear-wave elastography is compromised by lack of a standardized approach to acknowledges differences in anatomic subsites and normal variability in the anatomy
  • "ARFI imaging [shear wave analysis]  is already part of the clinical routine in various specialties for the non-invasive detection and characterization of fibrotic parenchymatous lesions." (Hofauer 2016)
  • example: Möller I, et al The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology. Ann Rheum Dis. 2017 Dec;76(12):1974-1979. doi: 10.1136/annrheumdis-2017-211585. Epub 2017 Aug 16. PMID: 28814430.. Eur Arch Otorhinolaryngol. 2016 Oct;273(10):3307-12. doi: 10.1007/s00405-016-3916-6. Epub 2016 Feb 10.
• Salivary gland size measurements should have standardized methodology - acknowledging that this assessment by ultrasound is made difficult by complicated 3-dimensional anatomy often accompanied with anatomic varations (e.g. accessory lobe and facial process of parotid gland)
• AIUM (American Institute of Ultrasound Medicine) "AIUM-ACR_SPR_SRU Practice Parameter for the Performance and Interpretation of a Diagnostic Ultrasound Examination of the Extracranial Head and Neck" published Oct 2018 on-line: https://doi.org/10.1002/jum.14830 [accessed 11-27-2022] also reference (AIUM-ACR-SPR-SRU 2018)
  • Would benefit from an update (2018) - is incomplete with only one paragraph addressing salivary glands highlighted by the following:
    • Suggested exam of parotid and submandibular glands in 2 planes -
      • "Measurements of the parotid and submanidbular glands can be performed when appropriate..."
      • "The description of focal abnormalities within the salivary glands should include the size in 3 dimensions as previously described, margins, echogenicity, composition, and internal blood flow. Abnormal-appearing intraparotid lymph nodes should be reported"
      • "Salivary ductal dilatation and calculi should be reported"
      • "When possible, a dilated salivary gland duct should be traced to the level of obstruction"
        • But with the disclaimer:
          • "The parameters reflect what the AIUM considers the minimum criteria for a complete examination in each area but are not intended to establish a legal standard of care."

More Information in the Iowa Protocols

Shear Wave Elastography - Quantitative Salivary Gland Ultrasonography

Salivary ultrasound standardized diagnostic approach and report (also in: Hoffman HT, Pagedar NA. Ultrasound-Guided Salivary Gland Techniques and Interpretations. Atlas Oral Maxillofac Surg Clin North Am. 2018 Sep;26(2):119-132)

Ultrasound and Sjogren's Syndrome - Shear Wave Elastography (currently password protected)

References

Quer M, Guntinas-Lichius O, Marchal F, Vander Poorten V, Chevalier D, León X, Eisele D, Dulguerov P. Classification of parotidectomies: a proposal of the European Salivary Gland Society. Eur Arch Otorhinolaryngol. 2016 Oct;273(10):3307-12. doi: 10.1007/s00405-016-3916-6. Epub 2016 Feb 10. PMID: 26861548.

Lorenzon M, Spina E, Tulipano Di Franco F, Giovannini I, De Vita S, Zabotti A. Salivary Gland Ultrasound in Primary Sjögren's Syndrome: Current and Future Perspectives. Open Access Rheumatol. 2022 Sep 1;14:147-160. doi: 10.2147/OARRR.S284763. PMID: 36072437; PMCID: PMC9444027.

Hofauer B, Mansour N, Heiser C, et al. Sonoelastographic modalities in the evaluation of salivary gland characteristics in Sjögren’s syndrome. Ultrasound Med Biol. 2016;42(9):2130–2139. doi:10.1016/j.ultrasmedbio.2016.04.011

Hoffman HT, Pagedar NA. Ultrasound-Guided Salivary Gland Techniques and Interpretations. Atlas Oral Maxillofac Surg Clin North Am. 2018 Sep;26(2):119-132. doi: 10.1016/j.cxom.2018.04.001. PMID: 30077320.

AIUM-ACR-SPR-SRU Practice Parameter for the Performance and Interpretation of a Diagnostic Ultrasound Examination of the Extracranial Head and Neck. J Ultrasound Med. 2018 Nov;37(11):E6-E12. doi: 10.1002/jum.14830. Epub 2018 Oct 11. PMID: 30308087.

American Institute of Ultrasound in Medicine (AIUM). AIUM Practice Guideline for Documentation of an Ultrasound Examination. J Ultrasound Med. 2014 Dec;33(12):2219-24. doi: 10.7863/ultra.33.12.2219. PMID: 25425385.