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

Technique for Salivary Gland Ultrasound Examination of Sjogren'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.

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 ...