ultrasound scanning of the submandibular gland for examining sjogren&#39;s syndrome

Technique for Salivary Gland Ultrasound Examination of Sjogren&#039;s Syndrome

Sjogren's syndrome (SS) is an autoimmune disease characterized by lymphocytic infiltration in exocrine glands, including the salivary and lacrimal glands. Xerostomia, keratoconjunctivitis sicca, and extraglandular manifestations, including arthralgia, cytopenia, and lymphoma, are described in patients with SS. SS can be divided into primary and secondary types, in which the latter occurs in association with other connective tissue diseases. In the 2016 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for primary SS, anti-SSA/Ro positivity and lymphocytic infiltration in labial salivary gland biopsy contributed to the two major criteria, whereas Schirmer's test, ocular staining score, and unstimulated salivary flow represented the rest of the minor criteria1. The criteria are summarized in Table 1. Labial biopsy is an invasive procedure with potential complications, including sampling error, sensory loss, and hematoma formation2. Ocular staining tests and salivary flow assessment require specialized settings and might not be widely available. 
Salivary gland ultrasonography (SGUS) is a non-invasive imaging modality that provides a detailed examination of the superficial salivary gland structure, which is commonly affected in patients with SS. Lymphocytic infiltration and inflammation in the salivary glands often lead to fatty infiltration, fibrosis, and loss of parenchyma, resulting in parenchymal inhomogeneity detected in SGUS3. The Outcome Measures in Rheumatology Clinical Trials (OMERACT) working group derived an ultrasound scoring system from grades 0 to 3 to semi-quantify inhomogeneity and the presence of hypoechoic areas within the parotid or submandibular glands4. A cutoff of grade 2 or above in at least one gland was found to correlate with positive labial biopsies, sialometry, and positive autoantibodies5. It demonstrated excellent specificity and good sensitivity in fulfilling the 2016 ACR/EULAR classification criteria for primary SS when given similar weight as the minor criteria. This protocol presents a standardized and practical approach for diagnosing SGUS in SS in clinical settings.

Author Spotlight: A Focus on Standardized Salivary Gland Ultrasound Protocol in Connective Tissue Disease Research

Ultrasonographic Evaluation of Salivary Glands for Sjogren's Syndrome: Diagnostic and Monitoring Insights

Our research focus is connective tissue diseases, including Sjogren's syndrome, and we will describe a standardized approach to saliva and ultrasound in diagnosing Sjogren's syndrome. We hope the protocol will be useful for clinicians unfamiliar with doing ultrasound to enhance its application in clinical practice. Ultrasound is a powerful tool in evaluating various rheumatological conditions, including arthritis, sjogren syndrome, and interstitial lung disease.It is helpful in diagnosis, monitoring and prognostication. It can be applied as an outcome measure in clinical studies such as detecting subclinical synovitis to assess the risk of rheumatoid arthritis progression. Ultrasound is an operator-dependent procedure and the result may be unreliable if inexperienced, hence performed.Well validated and quantitative measurements are often needed to standardize the description and reporting of pathological sonographic findings before they can be applied in clinical practice and research. In this procedure, we will describe how to conduct a salivary gland ultrasound in patients with sicker symptoms. This approach is easy to perform and can usually be completed within 10 to 15 minutes.We'll also demonstrate techniques to perform reliable and reproducible results to ensure the quality of the ultrasound scanning. Our center will continue to research on applying ultrasound in diagnosis and monitoring in rheumatology. We will research utilizing lung ultrasound for screening of interstitial lung disease associated with connective tissue diseases, hoping to improve the current screening strategy for lung fibrosis in rheumatology patients.

Ultrasound Scanning of the Submandibular Gland for Examining Sjogren&#39;s Syndrome

Position the patient in the supine position with the head maximally tilted to the back. To obtain the transverse view of the submandibular gland, position the transducer just below the angle of the mandible at the submandibular area. Examine the entire submandibular gland from anterior to posterior, the mandible, mylohyoid muscles, and the anterior belly of the digastric muscles bound it.Obtain the longitudinal view by placing the probe medial to the horizontal body of the mandible. Visualize the facial artery in this plane. Save and label the images in both transverse and longitudinal views of the submandibular gland.Assess the size of the submandibular gland. Examine the echogenicity of the submandibular gland, which is usually less echogenic than the parotid gland. Assess the degree of inhomogeneity, the clearness of the gland margin and the presence of hypo or an-echoic areas within the glands.Note the presence of focal lesions. Grade the degree of inhomogeneity using the OMERACT score. If the evaluation of the gland is not possible due to qualitative parameters, follow the alternate grading parameters.Measure the size of the submandibular lymph nodes, evaluate fatty hilums, shape, echogenicity and preservation. Repeat the scanning at the contralateral submandibular gland and compare the size and echo texture between the two submandibular glands. Normal submandibular glands demonstrated a clear demarcation with the overlying structures.

ultrasound-scanning-submandibular-gland-for-examining-sjogrens

Research

JoVE Journal

Medicine

Sjogren's syndrome (SS) is a chronic autoimmune condition commonly affecting the exocrine glands, causing oral or ocular dryness and extraglandular manifestations including arthralgia, cytopenia, and lymphoma. The presence of autoantibodies against SSA/Ro, labial salivary gland biopsy, ocular staining, Schirmer's test, or salivary flow assessment are included in the current classification criteria of SS. However, the availability and invasiveness of these procedures limit their widespread use in clinical settings. Salivary gland ultrasonography (SGUS) is a non-invasive imaging modality for the evaluation of the salivary gland parenchyma and is increasingly utilized to aid diagnosis and monitoring in SS. 
This article presents the protocol of SGUS for image acquisition at the parotid and submandibular glands. The objective is to present a standardized, reproducible, and practical approach to diagnostic SGUS for SS in daily clinical settings. Major salivary glands are scanned in a stepwise approach, beginning at the angle of the mandible for the superficial lobe of the parotid gland, followed by the deep lobe below the ramus of the mandible. Submandibular areas are then scanned for the submandibular glands. The steps in obtaining salivary gland images at each anatomical site are explained in the accompanying video. The echogenicity and echotexture at the thyroid gland are taken as a reference. The homogeneity, the presence and distribution of hypoechoic areas within the glands, and the border of the salivary glands are examined. The sizes and features of intra-/peri-glandular lymph nodes are recorded. The most distinctive sonographic feature in SS is glandular heterogeneity with the presence of hypoechoic/hyperechoic areas within the glands. 
In summary, while SGUS cannot diagnose SS on its own, it can supplement the current classification criteria of SS and guide the clinical decision for salivary gland biopsy to support the diagnosis of SS in patients with sicca syndrome or suspicious systemic features, combined with autoantibody testing.

Salivary gland ultrasonography is a promising tool for the diagnosis and evaluation of disease activity and complications in Sjogren's syndrome (SS). The scanning technique for salivary gland ultrasound examination relevant to SS is described in the article.

Sjogren's syndrome (SS) is a chronic autoimmune condition commonly affecting the exocrine glands, causing oral or ocular dryness and extraglandular ...

Ultrasound Setting and Scanning of the Thyroid Gland for Examining Sjogren&#39;s Syndrome

To begin, select a high frequency linear transducer of 10 megahertz. Set the ultrasound to B mode and use the highest frequency of the probe. Adjust the depth to three centimeters and gain 50%to 60%Position the patient in the supine position with the neck slightly extended, use a pillow to support the patient's head.For transverse images, orient the probe with the marker pointing towards the patient's right side. For longitudinal scanning, orient the marker at the cephalic side. Apply gel to the probe surface.Place the probe below the thyroid cartilage to scan the thyroid gland. Save the obtained images. connects the right and left lobes of the thyroid gland.Consider the echogenicity of a normal thyroid gland as a reference. For any concomitant thyroid disease, compare the echogenicity to that of the surrounding muscles.

Ultrasound Scanning of the Parotid Gland for Examining Sjogren&#39;s Syndrome

To begin, turn the patient's head to the opposite side of the gland being examined. Place the transducer longitudinally along the anterior border of the parotid gland, just anterior to the ear and parallel to the tragus, and move it from the superior to the inferior pole of the gland. To obtain the standard view, place the probe transversely at the angle of the mandible to obtain the transverse scan.Ideally, the parotid gland is located between the mastoid and mandible ramus in a transverse view. Scan the parotid gland transversely from the superior to the inferior pole. Slide the probe below the mandibles ramus to visualize the parotid glands deep part, which the mandible could partially obscure.Place the probe between the mastoid process and the angle of the mandible. Save and label the images in both the longitudinal and transverse views. Assess the size of the parotid gland.Compare the echogenicity with that of the thyroid gland, which is similar to the normal parotid gland. Turn on the color doppler to differentiate blood vessels from the dilated intraglandular duct, the retromandibular vein and external carotid artery divide the superficial and deep parotid lobes. Capture the degree of in homogeneity, the clearness of the gland margin, and the presence of hypo or anechoic areas.Note the presence of focal lesions and document the size, location, shape, and echogenicity. Turn on the color doppler to look for vascularity. Score the degree of sonographic involvement on a scale of zero to three as defined on the screen.The presence of lymph nodes within the parotid gland could be normal and common, especially when located in the superficial lobe. Measure the diameter of the lymph nodes. Evaluate the shape, echogenicity, and preservation of fatty hillam.Repeat the scanning at the contralateral parotid gland and compare the size and echo texture between the two parotid glands. Normal parotid glands appeared homogenous with clear demarcation with overlying tissues and muscles.