 Hello friends, welcome to another session of oral medicine radiology series, today we will deal with xylographic, these are my contents, by definition xylographic can be defined as the radiographic demonstration of the major salivary glands by introducing a radiopic contrast medium into their ductile system, I am not going into too much detail regarding the history part, just want to show you that as early as in 1902, there has been mentions of xylography in the pages of history, coming to the various indications, presence of calculate or any other blockages within the duct, it can also be used to exactly locate the position of the vascular, to check the extent of ductile and glandular destruction, secondary to an obstruction, to determine the extent of glandular breakdown to assess the function in cases of dry motor serostomia conditions, to determine the location, size, nature and origin of a swelling or mass of the salivary gland, obstructive disorders such as stone structures and mucous infections, gradual or progressive enlargements to locate those, to identify those, this could include chronic infections, xylosis, benign lymphoepithelial lesion, that is your mucous disease and sarcoidosis, postoperative or post-traumatic salivary fistula, to detect this and surgical considerations like amount of damage to the gland at its salvageability during or after delivery, to choose the perfect site for biopsy, to differentiate intrinsic as well as extrinsic tumor that is, to identify between, to differentiate between intrinsic tumors, to identify the relation of the tumor to the, officially now, so that it can be saved, recurrent xylodinitis, pain of unknown cause, for a cause, especially in that particular area, serostomia, therapeutic conditions, for a therapeutic reasons, that is dilation of duct or iodinated contrast to sterilize the ductile system. These are the various indications for xylography, let's go to the contraindications. Contraindications is a strict no-no, it is allergic to compounds containing iodine, so patient might undergo severe allergic reaction or even unify lacticis, so that should be checked first, periods of acute infection or inflammation, so why, because it could be really painful and the second is, it could actually introduce the infection deeper inside, that is, it could be transferred at regular infection, it could spread the infection deeper, and then calculus close to the globulin, so you should actually find out that calculus is a little bit more proximal, it is a little bit more near to the audit point, you can actually make it and remove it out, instead of using xylography technique, which could actually push the calculus deeper inside, then it may anticipate any thyroid function test in your patient, if you should ask the patient, he is going to be undergoing any thyroid function test, because it could mess up with the results, because some of the contraindications contain iodine. Coming to the various disadvantages, most of the xylography techniques which are done, especially those with two-dimensional use irradiation dose, when your CT, if at all it is used, uses irradiation dose, I will tell you, there are methods which do not use irradiation also, I will tell you. High skill is needed to conduct the procedure, so you need to have a trained technician of you, need to be very skilled or trained in order to conduct this procedure, it is a painful procedure or it could induce a lot of discomfort in your patient, there is probability of perforation if you do not do the procedure properly, it is a chance for you to push the stone further inside the ductile system. Okay, these are those are the disadvantages. Coming to the arborontarium, you can use another instruments also, but the standard instruments what we use listed here, Rabinox xylography, like ramial probes, contrast agent, contrast media, dental cotton rules and ambient lighting. Coming to the contrast media, the ideal requisites of that, it should have physiological properties similar to that of saliva, it should be miscible with saliva, it should not be like kerosene over water, it should be miscible, absence of systemic or local toxicity, low surface tension and low viscosity, EC elimination, it should be easily eliminated from your system, absorption and detoxification should be as normal as possible. Okay, so these are the ideal requisites of a contrast media. Coming to the various types of contrast media, it can be classified as ionic liquid solutions and non-ionic liquid solutions or oil-based and water-based. We have two types, okay, ionic or could include urographen, cyanographene and psiosy and non-ionic or omnipic or you could actually divide it into oil-based and water-based, oil-based, ethereal, lipidio, et cetera, and water-based and antopic. Okay, so there is a difference between oil-based and water-based, I'll show you what how. So examining each type of contrast media in detail, the advantages as well as the disadvantages. Coming to the advantages of oil-based media for a contrast agent, it's densely radiopic, thus it shows very good contrast, it has high viscosity and it slows the expression from the gland. So why this advantages is because you have sufficient amount of time so that you can click multiple radiograms. So that is why you actually do the solubility procedure in order to take proper radiograms. So you have sufficient time because it's sufficiently business. The flip side is that extra receded contrast may remain in the soft tissues for many months, it may produce a foreign body reaction and high viscosity means you need to apply considerable amount of pressure and this could actually cause a lot of discomfort for the patient. And then if there is any calculate, this excessive pressure could actually force it down into the deeper parts of the thoughts. Coming to the aqueous radiopic, sorry, contrast media, it is having low viscosity, thus it can be easily introduced, you need to apply a lot of pressure. Easily and rapidly it gets removed from the gland so you don't have to worry about the excretion part or the problem that it could stay there for a long, long time and cause any soft tissue or foreign body reaction because it's easily eliminated, it's easily absorbed and excreted with extra receding. So this is the advantages. But coming to the downside, since it is very easily removed as well as it is easily injected, it's less radiopic and it's a little bit difficult to see the ducts clear when compared to the oil-based ones. And elimination or excretion from the gland is very rapid unless it is a closed system. So the problem here is that you need to be very careful with your radiographs. You need to be very quick and all the setups should be as quick as possible. Otherwise, you wouldn't be able to get a proper radiograph during the autonomy. Coming to the procedure, it can be divided into three phases, pre-operative phase, the filling phase and the emptying phase. All the three phases are important. The pre-operative phase is when you, you know, the step before injection. The filling phase is the phase where you inject and take the result and emptying phase is when you eliminate or remove the contrast material. There also you need to take radiographs. So actually, speaking, you need to take radiographs in all the three phases. The radiographs which we take in the pre-operative phase is called as the out radiographs and they are taken so that we can actually note the position or presence of any radiopic obstruction or assess the position of shadows cast by normal anatomic structures that may overlie the plant, such as the thyroid bone or any other part of the bone to assess the explosion factor. So all these things are the reasons why you take a scout radiograph. So even if you notice any of these, you can actually pre-position the patient or, you know, tilt the head a little bit like this one like that. Or you may actually decide whether to take a radiograph or inject a radiopic diurnal. So suppose you see a calculator very close to the orbit. So you may consider, we consider, you know, that you should actually inject the diurnal or you can actually make the calculator out instead of injecting radiopic contrast because it stands a chance of, you know, introducing the calculator deeper inside the ducts. And then you can also assess the exposure factors. So suppose the exposure factors are not proper, then you can alter the process. This is both for pre-operative during the film phase as well as the injection phase. You can use all these radiographic projections. For the parotid, that's what we're going to do, for manoeuvrablac. For parotid, you can use panoramic, platyloblac, or catered posterior anterior or anterior posterior view and internal view, which you can use. For submaneuvrablac, you can use panoramic, platyloblac, true occlusion, true lateral skull with 10 degrees to it. There's no interference or soft tissue shadows. Coming to the film phase, this is the phase where we actually introduce the contrast media into the ductile system. So here what you do is you, the ductile orifice is located. After the orifice has been identified, the duct can be explored with the labanel probe. The cheek must be turned outward before the probe is inserted into the duct because the torsion, because the torsion is being interrupted, stands in the duct. So this is the phase where we actually locate the orifice, explore it, introduce the cannula, so that your contrast can be injected. And here, after injection, you take the acrylarylates. While exploring the water, the probe should pass through the length of the floor of the mouth to the level of the myelofed muscle. That is the requisite for the water step of the submaneuvrablac duct. The duct orifice is cannulated. The cannula can be held in place by taping the tubing to the face or having the patient bite on the tubing wrapped in a sponge. This is to stabilize the cannula to avoid discomfort to the patient. The contrast medium is introduced and radiographs are taken by two use in right angles. So why right angles is because for the localization purposes, especially if defined in the calculator, it may be localized. These pictures actually show the identification of the orifice, exploring the orifice using a laparoma reprove and then cannulating its cannula. So this what you see is the parotipland orifice and its cannulation. And here you see a submaneuvrablac, salivaricland ductal, identification, cannulation, and poripaxporic. Coming to the last and final phase, that is called as the emptying phase. So here the cannula is removed, the patient is allowed to rinse them out and then lemon juice is given so that the patient salivates and so that the contrast medium is eliminated as rapidly as possible. So here you actually take two different radiographs at two different times, that is after one minute and after five minutes. This is the standard repression to take two radiographs at one and five minute intervals. This is to check whether the contrast medium has been completely eliminated. Coming to the various techniques, there are three different techniques for phylography. The first one is a simple injection method. Similar, not just like, but very similar to how you inject the NLA. You use your hand to inject the NLA and you give the pressure to the hub or to the surface. So this is how you do this procedure. An oil based or an adverse contrast medium is introduced into the ductal orifice using gently hand pressure until the patient experiences tightness or discomfort. So you inject and ask the patient to give a response. So when you inject the patient will respond, we tell it's getting filled and it's filled enough. The patient will give all these prompts accordingly. So you have to rely on the patient's responses. So we might think we can inject a lot, but it's actually only 0.7 ml for the parotid gland and 0.5 ml for the submandibular gland that you inject. So really small amount. So you need to be very careful because you can overpull the duct and cause damage. Coming to the advantages, it's very simple and it's very inexpensive. Disadvantages as I happen to mention sometime back. The arbitrary pressure which is applied may cause damage to the gland. So the pressure which I applied might not be the same as you or might not be the same as another third person. So there is a lot of variation in the operator's pressure. And you have to rely on the patient's response. So you can go in for underfilling or overfilling. So if the patient is a very dramatic patient, you might not properly fill the gland. So it could be underfilling. And sometimes the patient may not respond properly. So you might tend to overfill the gland also. So these are the disadvantages. Coming to the next technique is called the hydrostatic technique. So here what we do is we actually hang the contrast media and candidate and the patient has to lie down. So it just drips down. We don't have to apply the pressure. It just trickles and fills the duct. So across contrast media is allowed to flow freely into the gland under the force of gravity until the patient experiences discomfort. So here the operator is not the person who is applying the pressure. It is the gravitational force that fills the duct. The advantage is that the control interaction of the contrast media is less likely to cause damage to the duct. And it's simple and considerably inexpensive. Disadvantages is that it's again relying on the patient's response because again we have to see for the patient's actions so that you can stop the filling or you can stop the candidate. And another big problem is that the patient has to lie down during the procedure. So you need to adjust the radiographic equipment in such a way that it is compatible with lying down procedure. And third method is called as the continuous infusion pressure-monitored method. So here you don't have to rely on gravity or you don't have to rely on operator or even the patient's response for that matter. You just need to leave everything to this particular equipment or instrument. So using across contrast medium, constant flow rate is adopted and the ductile pressure is monitored throughout the procedure. So just measure this computer or this instrument which calculates the amount of liquid of the contrast which has to be given and the pressure at which it has to be injected. So it's all controlled. Coming to advantages, this controlled mechanism is very less likely to cause damage to the duct and the client. And it does not cause over filling or under filling of the gland and it does not rely on the patient's response. So even if the patient is a very good actor or a very bad actor, you need to worry because the computer will handle it. And then coming to disadvantages, this complex equipment is required so you may have to be pulling a lot of money for that and then it's time consuming. So it will take a lot of time. It will test both your patient as well as that of the patient. Coming to the various interpretations, there are some normal appearances and pathological appearances. Let's go to each appearance. So the first appearance, the normal appearance is parotid gland. So this particular appearance is called the tree-invited appearance. I'll just show you the picture. See, this appearance is called as tree-invited appearance. So you can see why it is called as a tree-invited appearance because it resembles a tree-invited. That is, it's devoid of any leaves. It's just the branches that are seen here. So it appears as a leafless tree-invited appearance. Simply a tree-invited winter appearance. So this is the parotid gland. So you can just expect what the mandibular gland will look like in normal appearance. Yes, it's called as bush-invited appearance. So why is it called a bush-invited appearance? It's because it's not very huge as that of the parotid gland. It is somewhat smaller than that of the parotid gland. So it is called as a bush-invited appearance. So those were the normal salivary gland appearances. So let's go to the pathological changes. So you can see pathological changes in conditions where you have calculi, siloed arthritis, which is inflammation of the ductile epipelium or tux. And then you can see mandibular changes associated with siloed anitis. Jogrin syndrome or it's actually called as shogrin syndrome. But we are more accustomed to using this jogrin syndrome. So for time being let's go with that, jogrin syndrome. And then intrinsic tumors. So this appearance is the appearance of a calculi. This is called as a filling defect. So you might wonder why you need a silographic procedure to detect a calculi. You can simply take a radiograph. Yes, you are partially right. So if you have a radiopic calculi, then we can just go in for a normal radiograph. But what if you have a radiolucine calculi? Well, there are chances. There is a lusite silolith which is lodged inside the duct. And then you can have it as a radiolucine stone. So you might not be able to appreciate it in a normal radiograph. So you need to put in a radiographic contrast and take the siloed. Sorry, do the siloed procedure. So this is how you see it. It's called as a filling defect. So here you can see ductile dilation proximal to the calculus. And yeah, this is the proximal part or the part which is somewhat nearer to the orifice. And this is the distal part. And during the emptying phase, you can see that a little bit of contrast can remain here. So that's how you see a calculi. And coming to siloed octitis, yeah. Segmented saculation of dilation of the structure of the main duct is called as sausage link appearance. It's associated with ductile stenosis of calculus here. That is the inflammation of the duct. So you can see that there is a lot of saculation of the duct. So it appears like a sausage or a sausage link or chain of sausages. This is not a normal procedure. This is actually an MRI. Yeah. Silographic appearance of siloed octitis. So here you see dots or globs of contrast medium within the gland and appearance known as silactasis. Caused by the inflammation of the glandular tissue producing the sacular dilation of the acinib. So earlier you saw that the duct was actually inflamed. So here you see that acinia is inflamed for the ends of the terminal ends of the duct is actually inflamed. So when the terminal end is inflamed, you can see that the contrast medium is actually pulled or collected over this particular area. So here you see the lining epithelium. This is the proximal aspect of the duct. And this is the terminal or the distal aspect of the duct or the end part of the duct. So you can see that this part is actually narrow whereas this end is actually three more. So this extra thing you see here will appear as a blob here. This radiopic blob is actually this extra collection of fluid or extra collection of contrast agent here. Whereas this part is seen as a duct here. So the next condition is almost similar to this but there is a slight difference. This is the blob what you see. The next appearance is that of georgon syndrome or sorgon syndrome. So here you see an appearance which is called as a punctate cylectasis. Earlier appearance was called as cylectasis. This is punctate cylectasis or snowstorm appearance. So it is a symbol, a condition of a snowstorm. So by this terminology you can see, you can imagine that there will be a lot of blobs seen. So here you can see. In this picture you can see that there is weakening of the lining epithelium and the radiographic contrast material actually escapes. So it doesn't actually get collected here instead it actually escapes. So in the earlier condition you could see that this part was the part which retained the contrast material and that part was very obvious but here you see that a lot of small blobs are seen instead of a single big blob. So that gives the appearance of small, small, plenty of blobs in the particular pedigree. So this appearance is called as a punctate cylectasis or a snowstorm appearance. So earlier one the blobs were larger and fewer in number whereas here you see multiple minute blobs. So this is punctate cylectasis or snowstorm and the other one was cylectasis. Okay, this is the last appearance. It's called as the ball in hand appearances, sorry appearance. This is usually seen in intrinsic tumors. So in intrinsic tumors you don't actually visualize the tumor using a telegraphy technique but as the tumor expands it actually pushes the ducts away from each other so that we can actually see each duct separated or pushed out. It actually resembles the extended or the fingers wrapped around the ball. So here we can see each finger trying to wrap around the ball. So here this particular pedigree shows these ducts trying to wrap around a really loose and normal structure. See here actually we cannot see the tumor. It's because the contrast agent doesn't go inside the tumor. It goes only inside the ducts. So only the ducts are delineated, tumor isn't. But since the tumor is pushing the ducts away from each other, you can see the ducts very clearly. And this appearance is called as the ball in hand appearance. Okay, coming to the various advantages in cyleography. I'm not dealing with this in detail. I'll just show you in a quick glance. Interventional cyleography. You have something which is called as a dormia basket. This is this particular instrument. It's called a dormia basket. It resembles some of your kitchen instruments. But you know this works somewhat like an umbrella. The mechanism is somewhat like an umbrella. That is you can actually open and close it. When you open it looks like this. Whereas when you close it, it is just a single strand of. Metal or a string. So why you need this? I'll just show you. So it is like this. These pictures actually show a calculus lodged inside the duct. And this is how you introduce the. Pedographic contrast material. So you observe this calculate. And then what you do is you introduce the dormia basket in a closed condition. So it goes like that. Sorry. It goes like that and it bypasses the calculate. Sorry again. It bypasses the calculate and then goes like this. And then at this point, once it exceeds the limit of the calculus, you open it. Okay. So what happens is that three arms, it catches up, lodges the calculus for the calculate or a lid within it. And then it's easily retrieved. So this can be used in loosely adherent or loosely stuck calculate within the duct. Okay. So this is how it appears. And then the next is MR-celligraphy. So here, actually, the importance is that you don't need any radiation. That's just the magnetic resonance that you're using. Okay. There is no. It's not an invasive procedure. It's dangerous because you don't have to inject it inside the. You can actually intravenously inject the contacts needed so that it gets accumulated inside the particular region of interest. It can also be applied as an introductory contrast. Okay. So there are choices for this particular method. Okay. And another advantage with this method is that you can actually locate it three-dimensionally or pinpoint. So spot on. You can find out exactly the position of the calculus rather than take two separate radiographs to locate the calculus on a particular object of interest. Okay. So this is how the resulting images appear. It almost looks similar to a normal radiograph. And the stylographic picture of a normal radiograph. So you can see the punctured xylectasis and the open syndrome and xylectasis. There are various blobs which you see. Okay. And this is the normal appearance. The tree in the interior appearance. So all the numbers are normal. Two-dimension radiographs. And the other thing is to use MR. Okay. Coming to CT. Again you have the added advantage of using three-dimensional methods here. You can locate it. You can pinpoint the particular object of interest. And you can always view it in 3D resolution also. That is the most important thing. But again you are using a lot of radiations. You do not need to take multiple radiographs. But the amount of radiation used is more. Okay. Then the digital subtraction radiography where two different radiographs taken at two different time intervals can be joined together and all the parts can be removed so that you can track for any changes. Okay. That is digital subtraction radiograph. Okay. So with that I would like to wind up the session of xylography. Thank you. Stay safe and stay like it.