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Jadu Fatima M 201211 Phd T Development and Application of a Technique for Three-Dimensional Sialography Using Cone Beam Computed Tomography By Fatima M. Jadu BDS, MSc A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Oral Radiology Graduate Department of Dentistry University of Toronto © Copyright by Fatima M. Jadu BDS, MSc 2012 Development and Application of a Technique for Three-Dimensional Sialography Using Cone Beam Computed Tomography Fatima M. Jadu BDS, MSc Doctor of Philosophy Graduate Department of Dentistry University of Toronto 2012 ABSTRACT Introduction: Salivary gland obstructive conditions are common and may necessitate imaging of the glands for diagnosis and management purposes. Many imaging options are available but all have limitations. Sialography is considered the gold standard for examining obstructive conditions of the parotid and submandibular glands but it is largely influenced by the imaging technique to which it is coupled. Cone beam computed tomography (cbCT) is a relatively new and very promising imaging modality that has overcome many of the inherent limitations of other imaging modalities used in the past for sialography. Materials and methods: A RANDO®Man imaging phantom was used to determine the effective radiation doses from the series of plain film images that represent the current standard of practice for sialography. Similar experiments were then undertaken to determine the effective radiation doses from cbCT when varying the field-of-view (FOV) size and center, x-ray tube peak kilovoltage (kVp) and milliamperage (mA). Next, cbCT image quality, measured using the signal-difference-to-noise-ratio (SDNR) was used to determine those technical factors that optimized image quality. ii Finally, using the optimized image acquisition parameters, a prospective clinical study was conducted to test the diagnostic efficacy of cbCT sialography compared to plain film sialography. Results: Effective radiation doses were comparable between the plain film image series and cbCT examinations of the parotid and submandibular glands when a 6” FOV was chosen, and when the x-ray tube was operating at 80 kVp and 10 mA. We also found that these exposure settings optimized the image SDNR. Finally, we demonstrated that the diagnostic capabilities of cbCT sialography were superior to plain film sialography with regards to detecting sialoliths and strictures, and when differentiating normal salivary glands from those with changes secondary to inflammation. Conclusion: We have successfully developed a three dimensional (3D) sialography technique for imaging the parotid and submandibular salivary glands using cbCT that balances radiation effective dose with image quality. We also demonstrated the superior diagnostic capabilities of the new technique in a clinical setting. iii ACKNOWLEDGEMENT I would like to express my sincere gratitude to my supervisor Dr. EWN Lam for his unwavering support and for trusting me to be his first PhD student. A special thanks to my research committee members Drs. Pharoah, Yaffe and Jokstad for their constructive criticism and insightful comments. My sincere thanks also go to Dr. Baghdady, Perschbacher and Petrikowski for kindly volunteering their time and expertise to this project. To my best friends Susanne and Mariam, thank you for being my personal cheer squad. I am indebted to the residents in the Oral and Maxillofacial Radiology graduate program for helping with this project, Drs. Alsufyani, Madhavji, Khalifa, Chan, Lukat and Amintavakoli. Thank you for being amazing stimulating students. I especially wish to thank Dr. Madhavji for putting his computer genius to my service. I am grateful to the support staff in the oral radiology department for always, always helping me out. Lastly, and most importantly, I wish to thank my husband Ahmed for encouraging me to soar high in the skies of graduate education and research, and my parents who instilled in me the love of knowledge. I dedicate this PhD to my lovely children Saeed, Yousef and Maryam…I hope this experience was a lesson in the rewards of hard work and dedication. iv TABLE OF CONTENT Abstract ............................................................................................................................ii Acknowledgement ...........................................................................................................iv Table of content .............................................................................................................. v List of Tables ................................................................................................................. viii List of Figure ...................................................................................................................ix List of Appendices ...........................................................................................................xi 1 Introduction ............................................................................................................... 1 1.1 Review of the literature ...................................................................................... 1 1.1.1 Development of the salivary glands ............................................................. 1 1.1.2 Anatomy of salivary glands .......................................................................... 4 1.1.3 Histology of salivary glands ......................................................................... 8 1.1.4 Physiology of salivary glands ..................................................................... 11 1.1.5 Diseases of salivary glands ....................................................................... 15 1.1.6 Imaging of salivary glands ......................................................................... 25 1.1.7 Cone beam computed tomography ........................................................... 34 1.2 Summary .......................................................................................................... 41 1.3 Statement of the problem ................................................................................. 42 1.4 Aims ................................................................................................................. 42 1.5 Hypotheses ...................................................................................................... 43 1.6 Null hypotheses ................................................................................................ 43 v 2 A comparative study of the effective radiation doses from cone beam computed tomography and plain radiography for sialography. ...................................................... 44 2.1 Introduction ...................................................................................................... 44 2.2 Objectives ........................................................................................................ 45 2.3 Null hypotheses ................................................................................................ 45 2.4 Materials and methods ..................................................................................... 46 2.5 Results ............................................................................................................. 50 2.6 Discussion ........................................................................................................ 54 3 Optimization of exposure parameters for cone beam computed tomography sialography .................................................................................................................... 62 3.1 Introduction ...................................................................................................... 62 3.2 Objectives ........................................................................................................ 64 3.3 Null hypotheses ................................................................................................ 65 3.4 Materials and methods ..................................................................................... 65 3.5 Results ............................................................................................................. 71 3.6 Discussion ........................................................................................................ 75 4 a comparative study of the diagnostic capabilities of 2d plain radiography and 3d cone beam computed tomography for sialography ....................................................... 80 4.1 Introduction ...................................................................................................... 80 4.2 Objectives ........................................................................................................ 82 4.3 Null Hypothesis ................................................................................................ 82 4.4 Materials and methods ..................................................................................... 83 4.5 Results ............................................................................................................. 88 vi 4.6 Discussion ........................................................................................................ 97 5 General Discussion ............................................................................................... 104 5.1 Conclusion ..................................................................................................... 120 5.2 Future directions ...........................................................................................
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