1975, British Journal of Radiology, 48, 1032-1033 Case reports
fetus, except for those of the fetal head, are not clearly identified with present ultrasonic techniques (Kobayashi, Hellman and Comb, 1972). Garrett and Robinson (1970) diagnosed polycystic fetal kidneys at 31 weeks gestation using a water-coupling scanner. But we are unaware of any previously reported case of fetal gastro-intestinal abnormality demonstrated by ultrasound. It is now realized that the two intra-abdominal fluid-filled spaces demonstrated by ultrasound at 34 weeks were the distended stomach, and duodenum proximal to the atresia. In fact, the ultrasound appearances correspond with the neonatal X-ray appearances, except that the distended organs are filled with fluid alone instead of gas and fluid. It is suggested that these intra-uterine ultrasound appearances are as constant as the neonatal radiological signs, and that in any pregnancy where fetal abnormality is suspected, a transverse ultrasound scan of the fetal abdomen should be taken in an attempt to make the diagnosis of duodenal atresia antenatally.
ACKNOWLEDGMENTS
We are grateful to Major M. C. C. Houlton, R.A.M.C. and Major M. Sutton, R.A.M.C. for allowing us to publish this case. REFERENCES 2. Erect abdominal X ray showing the typical appearances of duodenal atresia. FIG.
the fetal limbs appear as blobs. But it has been considered that in general, gross malformations of the
GARRETT, W. J., and ROBINSON, D. E., 1970.
Ultrasound in
clinical obstetrics (Charles C. Thomas, Springfield, Illinois). KOBAYASHI, M.,
HELLMAN, L. A., and
COMB, E.,
1972.
Atlas of Ultrasonography in obstetrics and gynaecology (Appleton-Century-Crufts. New York). SUNDEN, B., 1964. Acta Gynaecologica Scandinavia, 43, Supplement 6.
Submandibular sialography: an unusual complication By R. H. Corbett, M.B., Ch.B., D.M.R.D. X-ray Department, Victoria Infirmary, Glasgow G42 9TY {Received April, 1975)
The various techniques of sialography have been well reviewed in the past and recent literature (Rubin and Holt, 1957; Park and Mason, 1966; Park and Bahn, 1968; Lilliequist and Welander 1969; Blair, 1973). Nowadays most operators use the plastic cannula first described with the hydrostatic technique (Park and Mason, 1966). The main advantage of the plastic cannula is that a leak-proof system is obtained by advancing the cannula about 0-5 to 1 cm along the duct (Park and Bahn, 1968). I wish to describe a case in which this resulted in a sublingual examination.
The sublingual gland has multiple excretory ducts, from 8-20 in number, most of which open directly into the floor of the mouth. Occasionally, a few open into the duct of the submandibular gland. Rarely several ducts may join to form a major sublingual duct which opens with, or near to, the submandibular duct {Gray's Anatomy, 1955). Radiological text-books vary in their approach to sublingual sialography. Sutton states "that the sublingual gland cannot be demonstrated because of its duct system" (Sutton, 1975), but a Text-book of X-ray Diagnosis (British authors, 1969) warns of
1032
DECEMBER 1975
Case reports
FIG. 1. Normal submandibular sialogram showing origin and first clue to the presence of a major sublingual duct (arrowed).
the possibility of catheterizing the sublingual duct when performing submandibular sialography. Case history A 34-year-old man presented with a swelling in the midline, under the jaw with episodes of infection and ulceration of the adjacent skin. He later developed left submandibular swelling and was thought to have an obstructed submandibular duct. Sialography was performed and the sublingual and submandibular glands pronounced normal (Figs. 1, 2, 3).
FIG. 2. Sublingual sialogram following selective catheterization.
DISCUSSION
It has been stated that the sublingual duct can only rareiy be cannulated and only one example of this can be found in the recent literature (Lilliequist and Welander, 1969). Definitive works (Rubin and Holt, 1957; Blair, 1973) do not describe or comment on this "complication". If a cannula is inserted up to 1 cm through the sublingual papilla, it will generally pass into the submandibular duct and so exclude the possibility of examining the sublingual gland, should a major sublingual duct exist. FIG. 3. In rare cases, the cannula may pass directly into the Reflux of contrast into submandibular duct from sublingual duct. sublingual duct. It is suggested that an early radiograph is taken with the cannula just inside the papilla to look for this possibility and appropriate PARK, W. M., and MASON, D. K., 1966. Hydrostatic sialosteps taken to visualize any duct so found, as useful graphy. Radiology, 86, 116-122. PARK, W. M., and BAHN, S. L., 1968. Sialography simplified. information may be obtained. Oral Surgery, 26, 728-735.
BLAIR,
REFERENCES G. S., 1973. Hydrostatic sialography. An analysis
of a technique. Oral Surgery, 36, 116-130. Gray's Anatomy, 1955. 32nd edn, pp. 1,355 (Longman, Green & Co., London).
LILLIEQUIST, B., and WELANDER, U., 1969. Sialography;
new application of the subtraction technique. Ada Radiologica (Diagtiostic), 8, 228-234.
RUBIN, P., and HOLT, J. F., 1957. Secretory sialography in
diseases of the major salivary glands. American Journal of Roentgenologv, Radium Therapy and Nuclear Medicine, 77, 575-598." SHANKS, S. C , and KERLEY, P. (eds.), 1969. A text-book
of X-ray diagnosis, 4th edn., Vol. 4 (H. K. Lewis & Co. Ltd., London). SUTTON, D., 1975. Text-book of Radiology, 2nd ed., pp. 689 (Churchill Livingstone).
1033
fetus, except for those of the fetal head, are not clearly identified with present ultrasonic techniques (Kobayashi, Hellman and Comb, 1972). Garrett and Robinson (1970) diagnosed polycystic fetal kidneys at 31 weeks gestation using a water-coupling scanner. But we are unaware of any previously reported case of fetal gastro-intestinal abnormality demonstrated by ultrasound. It is now realized that the two intra-abdominal fluid-filled spaces demonstrated by ultrasound at 34 weeks were the distended stomach, and duodenum proximal to the atresia. In fact, the ultrasound appearances correspond with the neonatal X-ray appearances, except that the distended organs are filled with fluid alone instead of gas and fluid. It is suggested that these intra-uterine ultrasound appearances are as constant as the neonatal radiological signs, and that in any pregnancy where fetal abnormality is suspected, a transverse ultrasound scan of the fetal abdomen should be taken in an attempt to make the diagnosis of duodenal atresia antenatally.
ACKNOWLEDGMENTS
We are grateful to Major M. C. C. Houlton, R.A.M.C. and Major M. Sutton, R.A.M.C. for allowing us to publish this case. REFERENCES 2. Erect abdominal X ray showing the typical appearances of duodenal atresia. FIG.
the fetal limbs appear as blobs. But it has been considered that in general, gross malformations of the
GARRETT, W. J., and ROBINSON, D. E., 1970.
Ultrasound in
clinical obstetrics (Charles C. Thomas, Springfield, Illinois). KOBAYASHI, M.,
HELLMAN, L. A., and
COMB, E.,
1972.
Atlas of Ultrasonography in obstetrics and gynaecology (Appleton-Century-Crufts. New York). SUNDEN, B., 1964. Acta Gynaecologica Scandinavia, 43, Supplement 6.
Submandibular sialography: an unusual complication By R. H. Corbett, M.B., Ch.B., D.M.R.D. X-ray Department, Victoria Infirmary, Glasgow G42 9TY {Received April, 1975)
The various techniques of sialography have been well reviewed in the past and recent literature (Rubin and Holt, 1957; Park and Mason, 1966; Park and Bahn, 1968; Lilliequist and Welander 1969; Blair, 1973). Nowadays most operators use the plastic cannula first described with the hydrostatic technique (Park and Mason, 1966). The main advantage of the plastic cannula is that a leak-proof system is obtained by advancing the cannula about 0-5 to 1 cm along the duct (Park and Bahn, 1968). I wish to describe a case in which this resulted in a sublingual examination.
The sublingual gland has multiple excretory ducts, from 8-20 in number, most of which open directly into the floor of the mouth. Occasionally, a few open into the duct of the submandibular gland. Rarely several ducts may join to form a major sublingual duct which opens with, or near to, the submandibular duct {Gray's Anatomy, 1955). Radiological text-books vary in their approach to sublingual sialography. Sutton states "that the sublingual gland cannot be demonstrated because of its duct system" (Sutton, 1975), but a Text-book of X-ray Diagnosis (British authors, 1969) warns of
1032
DECEMBER 1975
Case reports
FIG. 1. Normal submandibular sialogram showing origin and first clue to the presence of a major sublingual duct (arrowed).
the possibility of catheterizing the sublingual duct when performing submandibular sialography. Case history A 34-year-old man presented with a swelling in the midline, under the jaw with episodes of infection and ulceration of the adjacent skin. He later developed left submandibular swelling and was thought to have an obstructed submandibular duct. Sialography was performed and the sublingual and submandibular glands pronounced normal (Figs. 1, 2, 3).
FIG. 2. Sublingual sialogram following selective catheterization.
DISCUSSION
It has been stated that the sublingual duct can only rareiy be cannulated and only one example of this can be found in the recent literature (Lilliequist and Welander, 1969). Definitive works (Rubin and Holt, 1957; Blair, 1973) do not describe or comment on this "complication". If a cannula is inserted up to 1 cm through the sublingual papilla, it will generally pass into the submandibular duct and so exclude the possibility of examining the sublingual gland, should a major sublingual duct exist. FIG. 3. In rare cases, the cannula may pass directly into the Reflux of contrast into submandibular duct from sublingual duct. sublingual duct. It is suggested that an early radiograph is taken with the cannula just inside the papilla to look for this possibility and appropriate PARK, W. M., and MASON, D. K., 1966. Hydrostatic sialosteps taken to visualize any duct so found, as useful graphy. Radiology, 86, 116-122. PARK, W. M., and BAHN, S. L., 1968. Sialography simplified. information may be obtained. Oral Surgery, 26, 728-735.
BLAIR,
REFERENCES G. S., 1973. Hydrostatic sialography. An analysis
of a technique. Oral Surgery, 36, 116-130. Gray's Anatomy, 1955. 32nd edn, pp. 1,355 (Longman, Green & Co., London).
LILLIEQUIST, B., and WELANDER, U., 1969. Sialography;
new application of the subtraction technique. Ada Radiologica (Diagtiostic), 8, 228-234.
RUBIN, P., and HOLT, J. F., 1957. Secretory sialography in
diseases of the major salivary glands. American Journal of Roentgenologv, Radium Therapy and Nuclear Medicine, 77, 575-598." SHANKS, S. C , and KERLEY, P. (eds.), 1969. A text-book
of X-ray diagnosis, 4th edn., Vol. 4 (H. K. Lewis & Co. Ltd., London). SUTTON, D., 1975. Text-book of Radiology, 2nd ed., pp. 689 (Churchill Livingstone).
1033
