Professional Documents
Culture Documents
masses
Differential Diagnosis
Parotid Gland Area- of Salivary
Enlargements
UNILATERAL
Bacterial sialadenitis
Sialodochitis
Cyst
Benign neoplasm
Malignant neoplasm
Intraglandular lymph node
Masseter muscle
hypertrophy
Lesions of adjacent osseous
structures
BILATERAL
Bacterial sialadenitis
Viral sialadenitis (mumps)
Sjgren syndrome
Alcoholic hypertrophy
Medication-induced
hypertrophy (iodine, heavy
metals)
Human immunodefi ciency
virus associated
multicentric
cysts
Masseter muscle
hypertrophy
Accessory salivary glands
Temporomandibular joint
Differential Diagnosis
Submandibular Area- of Salivary Enlargements
UNILATERAL
Bacterial
sialadenitis
Sialodochitis
Fibrosis
Cyst
Benign neoplasm
Malignant
neoplasm
BILATERAL
Bacterial
sialadenitis
Sjgren syndrome
Lymphadenitis
Branchial cleft
cyst
Submandibular
space infection
PLAIN FILM
RADIOGRAPHY
Plain film radiography is a fundamental part of
PLAIN FILM
RADIOGRAPHY
Panoramic and conventional posteroanterior (PA) skull
INTRAORAL
RADIOGRAPHY
Sialoliths in the anterior two thirds of the submandibular duct are
EXTRAORAL
RADIOGRAPHY
A panoramic projection frequently demonstrates
EXTRAORAL
RADIOGRAPHY
Sialoliths in the distal portion of Stensen duct
Over-theshoulder
occlusal projection revealing a sialolith.
CONVENTIONAL
SIALOGRAPHY
First performed in 1902, sialography is a radiographic technique
CONVENTIONAL
SIALOGRAPHY
These iodine-containing agents render the ductal system
Sialography
A, Lateral projection of the parotid demonstrating opacification all the
way to the terminal ducts and acini.
B, Anteroposterior projection of the same gland demonstrating
parenchymal blushing from acinar opacifi cation.
COMPUTED
TOMOGRAPHY
CT is useful in evaluating structures in and
MAGNETIC RESONANCE
IMAGING
MRI for soft tissue mass details and
localization
Differanciates :
St vs. Ht
Normal vs. abnormal tissue
Identifies facial nerve ( parotid )
Containdications:
-pacemaker
-cochlear implant .
ULTRASONOGRAPHY
For superficial , soft tissue swilling
Differentioates cystic vs. solid
Us-guide FNA
sialolithiasis
** calculus and salivary stones
** Formation of calcified obstruction within salivary gland
duct
** Clinical features :
Chronic retrograde infection
Swelling and pain with eating
Major or minor S.G
Usually one S.G involved
Submandibular S.G >> 83% of the cases
**Raiographic features :
Radiopaque :
* Vary from cigar to oval or round shape
* Homogeneous radiopaque internal structure
Radiolucent : ductal filling defect
** sialography is helpful when obstruction is
undetectable on plain RG .
** CT may also detect minimally calcified
sialoliths not visible on plain films.
D/D:
phleboliths
dystrophic calcification of LN
palatine tonnsiliths
Tx:
sialogogs to stimulate saliva secretion.
Sialography may also stimulate discharge .
Surgical removal of the sialolith
Removal of the whole involved S.G
Bacterial sialadentis
Parotitis and sabmandibulitis
Acute or chronic bacterial infection of terminal
Clinical features :
swelling
redness
Tenderness
Malaise
Enlarged regional lymph nodes
suppuration may also be noted
Untreated acute suppurative infections typically form abscesses.
RG features :
Treatment
attention to oral hygiene
local massage
increased fluid intake
oral sialogogs (sour citrus fruit wedges or
salivary stimulants).
antibiotic regimen may also be indicated.
surgical remedies ranging from partial to total
excision of the gland
Sialodochitis
Ductal sialadenitis
inflammation of the ductal system of the
salivary glands.
Clinical features :
** sialectasia or dilation of ductal system
** sausage-string appearance of the main
duct and its major branches
Tx : as tx of sialadenitis
Sausage
string
appearance
of
sialodochitis
Autoimmune Sialadenitis
Myoepithelial sialadenitis, Sjgren syndrome,
Clinical features :
** range from recurrent painless swelling of
the salivary glands (usually the parotid gland)
to a stage that includes enlargement of the
lacrimal glands
** xerostomia and xerophthalmia
diagnosis can be made on the basis of any
two of the following three features:
Dry mouth, dry eyes, and rheumatoid
disease.
Hodgkin lymphoma
RG features :
early stages :
** punctate and globular spheric collection
of contrast agent throughout the G >>>> sialectases
**main duct may appear normal, but the intraglandular ducts may be
narrowed or not even evident
As the disease progresses :
** the collections of contrast agent increase in size and are irregular in
shape >> cavitary sialectases
** larger cavities of contrast agent and dilation of
the main ductal system may also be present
**Cavitation and glandular fibrosis are the result of recurrent
inflammation
At the end point of this disorder, complete destruction of the gland occurs
D/D :
chronic bacterial OR granulomatous
infections
multiple parotid cysts associated with (HIV)
infection.
Conventional
Sialography of
Left Parotid.
Anteroposterior projec
.the same
Tx :
Relief of symptoms.
Underlying systemic rheumatoid conditions are
typically treated with anti-inflammatory agents,
corticosteroids, and immunosuppressive therapeutic
agents .
Salivary stimulants
increased fluid intake
artificial saliva and tears
surgically by local or
total excision of the symptomatic gland.
Non-inflammatory
disorders
1- Sialadenosis
2- Cystic Lesions
3- Benign tumers : Benign Mixed Tumor
Warthin Tumor
Hemangioma
4- malignant tumers :
Mucoepidermoid
Carcinoma
Malignant Mixed Tumor
Sialadenosis
Sialosis
nonneoplastic, noninflammatory enlargement
Tx :
identifying the cause of the metabolic or
secretory disorder
Conservative tx : local massage
increased fluid intake
oral sialogogs
Sialadenosis
Cystic lesion:
Radiographic features:
cystic lesion typically appear as well-
circumscribed ,nonenhancing(with
contrast)
low density areas when examined on CT
appear as well-circumscribed,high-signal
areas on 2T-weighted MRI
Cont
when imaged with us,cysts are sharply
marginated and echo free as dark area
treatment : typically surgical , involving
local or total excision of the gland
benign tumors
-relatively uncommon
-occur in less than 0.003% of the population
-3% of all tumors
-80% of salivary tumors arise in the parotid
-5% in the submandibular
-1% sublingual
-10%-15% minor salivary gland
-most are bengine or low-grade
malignancies
-high-grade malignancies are uncommon
Cont
the chance of neoplasm of major salivary
cont
-benign masses are typically less echogenic
than parenchyma, sharply defined, and of
essentially homogeneous echo strength and
density
-Sialography may suggest a space occupying
mass when the ducts are compressed or
smoothly displaced around the lesion (the
ball-in-hand appearance)
Treatment
typically surgical
the parotid gland may be either partially
or totally excised
submandibular and sublingual glands are
in variably totally excised
Radiographic feature:
Adenoma)
In the T2-weighted image, note the
increased signal of the tumor, which is
now hyperintense to muscle.
cont
In the axial MRI T1-weighted image, the
tissue signal of the tumor is isointense
with muscle
Warthin tumor:
Papillary cystadenoma lymphomatosum,
Clinical
features
the second most common benign
neoplasm of the salivary glands
accounting for 2% to 6% of the parotid
tumor
slow-growing, painless, round-to-ovoid
mass
In 20% of cases the tumors are multiple
Typically afflicts males older than 40
years and may be unilateral or bilateral
Radiographic features:
CT and MRI are the preferred techniques
not specific and istypical of benign salivary
tumors
On CT, this tumor may be of either soft
tissue or cystic density
On MRI, it is heterogeneous and may
demonstrate hemorrhagic foci
characteristically intensely hot on 99m
Tcpertechnetate scans
The US presentation of Warthin tumor is that
of a solid mass (anechoic), if the massis not
cystic
CONT
An axial soft tissue algorithm CT image of
a case of bilateral
Warthin tumor, a large tumor involving
the left parotid (white arrow) and a much
smaller tumor on the right side (black
arrow)
Hemangioma:
Vascular nevus
a benign neoplasm of proliferating
Clinical features:
the most frequently occurring nonepithelial
Treatment:
by local excision for those who do not
radiographic features:
Phleboliths are common
They appear as discrete soft tissue calcifications
Malignant tumor:
About 20% of tumors in the parotid are
malignant
50% to 60% of submandibular tumors
90% of sublingual tumors
60% to 75% of minor salivary gland
tumors
Radiographic features:
variable and is related to the grade,
Treatment:
typically surgical
Low-grade malignant tumors of the
Mucoepidermoid Carcinoma:
a malignant tumor composed of a
Clinical features :
the most common malignant salivary gland
CONT.
high-grade tumors often cause facial pain and
Radiographic features:
low-grade mucoepidermoid carcinoma may
CONT
..
high-grade mucoepidermoid carcinoma
has homogeneous low signal intensity
(dark) on T1-weighted images, but T2weighted images are more heterogeneous
and intense(brighter) than T1-weighted
images but still slightly darker (low signal)
relative to the surrounding tissues
Cavitary sialectasia and ductal
displacement may be noted on
sialographic images of this tumor
CONT .
The other two, which are extremely
rare :
1-true malignant mixed tumor (from
both epithelial and mesenchymal
components of a mixed tumor)
2-the metastasizing mixed tumor,
which appears histologically benign
but behaves in a malignant fashion
CONT..
The tissue signal in this T1weighted magnetic resonance
image is very slightly less than
the remaining gland
.CONT
a T1-weighted postgadolinium, fat-
Clinical features:
typically begins as a slowly growing mass
Radiographic features:
The presentation of this tumor is similar
CONT.
cell carcinoma occurring with even less frequency
Pain, paresthesia and even paralysis may be present,
Radiographic features:
nonspecific and similar to that of the high-
CONT .
This axial soft tissue algorithm CT image reveals an
CONT.
Ultrasonography. The mass in the
submandibular gland(arrows) demonstrates a
heterogeneous hypoechoic pattern compared
with the adjacent tissue.
The histopathologic diagnosis was adenoid
cystic carcinoma
CONT.
Contrast-enhanced axial soft tissue algorithm CT
image
demonstrating a mass in right parotid gland with
a poorly marginated.
heterogeneous, slightly lobulated appearance
(white arrows).
Poorly defined margins suggest a low-grade
malignancy rather than benign tumor , although
the CT appearance of both is similar .
Histopathologic diagnosis was low-grade
mucoepidermoid carcinoma
CONT.