Salivary gland imaging radiology ppt
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Salivary gland imaging radiology ppt . This powerpoint presentation includes important anatomy and important pathology of salivary gland with its imaging feature as well as its ct mri image. This will help alot. this will help for radiology resident as well as ent .
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Salivary gland imaging radiology ppt
- 1. Salivary gland imaging Radiology
- 2. Accessory parotid gland • 20% cases • Clearly detached accessory glands at variable distances anteriorly from main gland • could be a cause of tumor recurrence
- 3. Imaging modalities: Plain films Lateral plain film (A) with the patient’s index finger depressing the tongue Intraoral Occlusal film (B) shows a large calculus in Wharton’s duct.
- 4. Sialography- Conventional • Performed on parotid & submandibular glands • Retains role in chronic inflamn & autoimmune dis in parotid & submandibular glands. • Immediate & post secretory films (to diagnose sialectasis) Parotid Submandibular
- 5. Parotid- transverse view 1. Retromandibular vein 2. External carotid artery 3. Echo from the surface of the mandible, 4. Parotid gland 5. Masseter muscle Ultrasound
- 6. Parotid- longitudinal view 1 Retromandibular vein 2 External carotid artery 4 Parotid gland
- 8. Wharton’s Duct Wharton duct (arrow). Arrowheads submandibular gland, 1 mylohyoid muscle, 2 sublingual gland.
- 10. Radionuclide Salivary Studies Major adv both parenchymal fn & excretion fraction of both parotid and submandibular glands can be quantified Oblique frontal technetium sialogram shows multiple masses with intense uptake in both parotid glands. This patient had bilateral Warthin's tumors. Panda sign
- 11. CT and MRI
- 12. CT &MRI • Virtually all parotid lesions are well visualized on T1WI because of hyperintense (fatty) background of gland.
- 13. FNA or Biopsy- image guided • Indications: Nonpalpable lesions & lesions difficult to approach endoscopically: deep lobe parotid mass parapharyngeal space ectopic minor salivary gland lesion • Approach: retromaxillary (transbuccal) or transparotid approach • Aspiration>>Biopsy (facial N)
- 14. Pathology Obstructive & inflammatory lesions: • Sialolithiasis • Acute parotitis including sialdenitis • Chronic sialdenitis • Ranula • Sialosis • Strictures • Sialectasis Neoplastic: • Adenoma • Carcinoma Systemic Conditions with Salivary Gland Involvement: • Infectious • Viral • Metabolic
- 17. Sialolithiasis • Formation of concrements (sialoliths) inside ducts or parenchyma of salivary glands. Submandibular gland- 80-90% . Parotid gland-10-20% Sublingual gland-1-7% Minor salivary gland – rare (often in upper lip and buccal mucosa) • 75% stones solitary; 25% multiple, with 32% of parotid calculi and 22% of submandibular stones being multiple. Bilateral salivary stones are rare (2.2%).
- 18. Plain film
- 20. Ultrasound
- 22. MRI Submandibular calculi (a) Transverse T1WI: two areas of low SI (arrows) in mouth floor on left. (b) Confirmed on transverse T2WI: obstructed duct (arrowhead) is evident
- 23. Sialography (MR vs Conventional) MR: Small calculi may be missed Fails to show the fine detail of smaller ducts necessary to diagnose sialectasis The sensitivity of MR sialography for detecting stenoses is not impaired Sagittal-oblique 3D-EXPRESS MIP Lateral-oblique conventional sialography Bartholin duct Bartholin duct Stone Stone
- 24. Acute parotitis inc sialadenitis • Et: viral, mumps, EBV, CMV, sialolithiasis, Staphylococcal and streptococcal, tuberculosis, candidiasis and cat scratch disease. US:
- 25. Complications:
- 27. Chronic sialadenitis •intermittent swelling often painful+/- a/w food US: normal sized or smaller Increase in roughness of echotexture hypoechoic & inhomogeneous. Small cystic echo free domains. Usu no increased blood flow. Occasionally intraglandular concretions.
- 29. Chronic sclerosing sialdenitis Aka Kuttner tumor • Pseudotumour • may also involve the parotid gland - lesser extent.
- 30. AXIAL T1W CONTRAST Kimura Disease
- 31. Ranula • Aka mucous escape cyst/mucous retention cyst/mucocele of sublingual or neighboring minor salivary glands • High in T2WI & no enh in Fat Sat T1C+ • Types: Simple vs Plunging
- 34. Simple Plunging/pseudocyst Reln to mylohyoid muscle Superficial Plunges thru mylohyoid Epithelium lined Yes No Surgical approach transoral-resection/ marsupialisation transcervical Risk of Nerve damage (lingual/CN XII) Yes No
- 35. TRANSVERSE T2W Fat-sat T1W Coronal fat-sat T1W
- 36. T2
- 37. Sialosis • Diffuse, non-inflammatory, non- neoplastic recurrent enlargement of major salivary glands Normal but laterally displaced Stenson ducts
- 39. Strictures PAROTID DUCT STRICTURE BALLOON DILATATION POSTPROCEDURE
- 40. Sialectasis Punctate sialectasis Globular sialectasis Cavitating and destructive sialectasis Ultrasound
- 42. Salivary gland Tumors (<3% total tumors) ADENOMAS (65%) • Pleomorphic adenoma (mixed parotid tumour) - 50% • Adenolymphoma (Warthin's tumour) - 10% • Basal cell (monomorphic) adenoma - 3% • Myoepithelioma - 1% • Oncocytoma -1% CARCINOMAS (35%) • Mucoepidermoid tumour- 15% • Adenocarcinoma - 7 % • Adenoid cystic carcinoma - 3% • Acinic cell carcinoma – 6% • Carcinoma in mixed tumour – 3% • Undifferentiated carcinoma – 1%
- 43. • Enlarging mass • First step: if mass is painful Painful obstructive/inflammatory Painless neoplasm, cyst, LN • Neoplasm: Benign vs malignant (Regional LNadenopathy; facial N palsy, Skin infiltration, deep infiltration into the parapharyngeal space, muscles, and bone, well seen on T1WI; low to intermediate SI on T2WI (25% error), ill defined margins, diffuse growth favor malignancy) • The smaller the salivary gland, the higher the rate of malignancy. 20%–25% in parotid gland 40%–50% in submandibular gland 50%–81% in sublingual glands & minor salivary glands • Multiple parotid masses: LNadenopathy, Warthin
- 45. Commonest benign Commonest malignant Parotid (B>>M) Pleomorphic adenoma Mucoepidermoid Ca Submandibular (B>M) Pleomorphic adenoma Adenoid cystic Ca Sublingual & minor (M>B) Pleomorphic adenoma Adenoid cystic Ca
- 46. QQ-Pleomorphic Adenoma (Mixed Tumor of Salivary Glands) • Most common salivary gland tumour • Middle age women • Prior head & neck irradiation is a risk factor • Typically present with a smooth painless enlarging mass. • Distribution Parotid gland: 84% (commoner in the superficial lobe) Submandibular gland : 8% Minor salivary glands : 6.5% (widely distributed including the nasal cavity, pharynx, larynx, trachea) Sublingual glands : 0.5% • Also commonly found in lacrimal glands (approx 50% of lacrimal gland tumours)
- 47. Radiographic features • Depend on tumour size, • Well circumscribed rounded masses, most commonly located within parotid gland. • When arise from deep lobe of parotid, appear entirely extraparotid, seen in parapharyngeal space, without a fat plane between it & parotid, and widened stylomandibular tunnel. • Can also arise from salivary rest cells in parapharyngeal space itself without connection to parotid gland. • Sialography: pleomorphic adenoma displaces parotid duct smoothly around tumor mass
- 48. USG
- 49. CT C+ DELAYED PHASE• C+ EARLY PHASE
- 50. MRI • Well-circumscribed homogeneous when small; heterogeneous when larger • T1: low SI • T2: • Usu very high SI . • Often rim of low SI on T2WI (surrounding fibrous capsule) • T1 C+ (Gd) : usu homogeneous enhancement T1 T2 T1 C+
- 51. Axial T2-wi
- 52. a Complications
- 54. At US, Warthin tumors are oval, hypoechoic, well-defined tumors and often contain multiple anechoic areas . Warthin tumors are often hypervascularized. No calcification. Multiple or bilateral parotid or periparotid masses strongly suggest the diagnosis
- 59. Benign masses • Haemangioma • lymphangioma • Branchial cleft cysts: rare but may occur superficial to, within, or deep to the parotid gland. These cystic lesions have a variable wall thickness if there have been previous episodes of infection. • Other benign tumors (eg, oncocytoma, basal cell adenoma) occur less frequently in the salivary glands. Among nonepithelial lesions, lipomas, and neuromas or schwannomas may be found in salivary glands
- 60. Hemangioma
- 62. Lymphangioma
- 66. QQ-Mucoepidermoid carcinoma • All adult age groups, most common in middle age (35-65 years) • Most common malignant salivary gland tumor of childhood • Overall, mucoepidermoid carcinomas account for : 2.8 - 15.5% of all salivary gland tumors 1 - 10% of all major salivary gland tumors 6.5 - 41% of minor salivary gland tumors • In the parotid gland they are the most common malignant primary neoplasm (Vs Adenoid cystic Ca in submandibular gland). A slight female predilection has been described, and radiation has been implicated as a risk factor .
- 67. CT • Low grade tumours: well circumscribed, cystic component • High grade tumours: poorly defined margins, infiltrate locally • Solid components enhance, and calcification is sometimes seen. • Low grade tumor appears similar to benign mixed tumours.
- 68. MRI
- 70. QQ-Adenoid Cystic Carcinoma • Although slow growing, “sneaky” unpredictable tumors with the tendency to invade perineural space (50-60%) (thus most painful salivary gland neoplasm) and they are stubbornly recurrent. • Pain & mass over several years • 4-8% of all salivary gland tumors • Most commonly in parotid, submandibular gland & palate • Very wide age range (1st-9th decade); preponderance in 4th-7th decades. • F:M=3:2. • The key imaging feature suggestive of adenoid cystic carcinoma is an enhancing mass with perineural spread.
- 71. Imaging studies Indirect signs of perineural spread : 1. Foraminal enlargement on CT 2. Atrophy of muscles of mastication (in mandibular nerve infiltration) 3. Obliteration of the normal fat plane in the pterygopalatine fossa (in maxillary nerve infiltration). Direct signs of perineural spread: 1. Thickening & enhancement of affected nerves (with attention also paid to possible skip lesions). 2. Abnormal enhancement in Meckel's cave. 3. Lateral bulging of the cavernous sinus dural membrane.
- 72. T2 T1 C+ Fat sat
- 74. Squamous cell carcinoma •Primary squamous cell carcinoma of the parotid gland is very rare. •normally no squamous epithelial cells within the parotid. Chronic inflammation, however, can induce squamous metaplasia. • Imaging demonstrates an aggressive, large mass, often with nodal metastases.
- 77. • Primary tumor (T) • TX: primary tumor cannot be assessed • T0: no evidence of primary tumor • Tis: carcinoma in situ • T1: tumor ≤2 cm in greatest dimension without extraparenchymal extension* • T2: tumor >2 cm and ≤4 cm without extraparenchymal extension* • T3: • tumor >4 cm and/or • tumor with extraparenchymal extension* • T4: moderately or very advanced • T4a: moderately advanced local disease: • tumor invades skin, mandible, ear canal, and/or facial nerve • T4b: very advanced local disease: • tumor invades base of skull and/or pterygoid plates, or • tumor encases the carotid artery *Regional lymph node (N) Regional nodal status is defined the same as for most other cancers of the head and neck. cervical lymph node (staging). Distant metastases (M) cM0: no evidence of metastases cM1: distant metastasis pM1: distant metastasis, microscopically confirmed
- 80. Systemic Conditions with Salivary Gland Involvement Infectious disorders • Actinomycosis • Granulomatous disease (sarcoidosis, tuberculosis) • Tuberculosis Viral infection • HIV • Hepatitis • CMV infection Metabolic disorders • Sjögren’s syndrome • Thyroid disease • Granulomatous disease (sarcoidosis, tuberculosis) • Alcoholism • Malnutrition • Eating disorders (anorexia, bulimia) • Diabetes (uncontrolled)
- 81. Sjogren Syndrome
- 84. Sarcoidosis • Involvement of the parotid gland is seen in up to 30% of patients with sarcoidosis, • typically presenting as bilateral painless swelling. • Uveoparotid fever, which presents with bilateral uveitis, parotid enlargement, and facial nerve palsy, is considered pathognomonic for sarcoidosis. • Gallium-67 scintigraphy produces the classic panda sign from increased uptake by the lacrimal and parotid glands.
- 86. THANK YOU
Editor's Notes
- Anteroposterior (normal & soft-tissue exposure), lateral and lateral oblique plain radiographs calculi & soft-tissue swelling of parotid gland. Submandibular gland lat oblique view. Suppl by lateral view with pt's finger in mouth, depressing tongue & pushing submandibular gland into sight beneath mandible. Stones in anterior part of duct are best demonstrated by placing occlusal film in mouth & submentovertical type of projection
- Stensen’s duct: 6–7 cm long and has a small C-shaped curve anteriorly as it bends around the buccal fat pad and pierces the buccinator muscle to open opposite the second upper molar tooth. The duct’s normal luminal caliber is only 1 to 2 mm, and on a direct conventional posteroanterior film, the duct should lie within 15 to 18 mm of the lateral mandibular cortex. If the duct is more laterally placed, either hypertrophy of the masseter muscle or a mass in or near the masseter muscle. Wharton’s duct is seen to run downward and laterally at about a 45° angle to both the sagittal and horizontal planes. It is about 5 cm long and has a luminal caliber of 1 to 3 mm. may curve caudally over the back edge of the mylohyoid muscle. The intraglandular ducts are shorter and taper more abruptly than those in the parotid gland Contraindicated in acute sialadenitis for fear of exacerbation by: retrograde inj of contrast agents force inflammatory products into more peripheral parenchyma Instrumenting duct may irritate it, cause narrowing from posttraumatic edema or stricture formation & lead to reduced drainage MR sialography safe in acute sialadenitis
- Triangle shaped submandibular gland US image obtained obliquely relative to the mandible
- US image shows a non dilated Wharton duct (arrow) in a slim patient. In general, a nondilated duct is not visible at US. Wharton duct running from the area of the submandibular gland hilum at the level of the border of the mylohyoid muscle, then bends around the free part of the mylohyoid muscle and extends to its orifice at the sublingual caruncle
- Transverse US image show the sublingual gland and its surrounding structures. White circle Wharton duct, m muscle muscles of the oral cavity floor: the geniohyoid muscle. lateral side is adjacent to the mandible. transverse sections, the shape of oval Along its medial part runs the excretory duct of the submandibular gland
- parotid gland (P) with low attenuation due to normal fatty replacement. E external carotid artery, M masseter muscle, R retromandibular vein, S styloid process, fat-filled parapharyngeal space. (b) CT scan in a 6-month- old girl shows the parotid gland (P) with an attenuation similar to that of adjacent muscle. E external carotid artery, I internal carotid artery, J internal jugular vein, M masseter muscle, R retromandibular vein, fat-filled parapharyngeal space. Sublingual & minor salivary glandsnot routinely visualised. The minor salivary glands may give rise to masses in the parapharyngeal space.
- T1WI gives excellent assessment of tumour margin, its deep extent, and its pattern of infiltration. This sequence, coupled with fat-saturated, CE T1WI, used primarily to address perineural spread, bone invasion, or meningeal infiltration, is best means for ‘‘mapping’’ tumor. (MR for infiltrative neoplasm)
- Caveat: inflammatory masses of salivary glands may mimic epithelial neoplasms at cytology because desquamated cells frequently populate the former
- The vast majority of salivary calculi (80–90%) occur in the mucus-producing submandibular gland, due to its relatively viscous and alkaline secretions. Additionally, the submandibular duct has an uphill course, which predisposes to stasis. Submandibular gland- 80-90% (secretion: more thicker, viscous, alkaline; Wharton: dependent gland, uphill course, wider lumen, tight orifice) In patients with chronic sialadenitis, at least one calculus is present in two thirds of the cases.
- Plain film demonstrates an ovoid calcific density just below the angle of the mandible. CT confirms the presence of calcific density on the left in a location likely to place it within the submandibular duct near the gland.
- Able to visualize radiolucent stones Fig. Stone in submandibular duct causing proximal duct dilatation. Stone: strongly hyperechoic lines or points with distal acoustic shadowing. Acute obstructive cases, gland appears enlarged & excretory ducts proximal to stone may be visibly dilated. Examination is best performed with small high frequency intra-oral probes
- Stone: low signal regions (on all sequences) outlined by high signal saliva on T2WI Distinguish acute Vs chronic obstruction as well as glands with only incomplete obstruction
- FIG: Images in a 26-year-old man at presentation with recurrent submandibular glandular swelling during mastication. (a) Sagittal-oblique 3D-EXPRESS MIP reconstruction (10,000/190; echo-train length, 136) shows a 4-mm stone near the orifice of the Wharton duct (thick arrow). Bartholin duct (curved arrow), primary branches (large arrowhead), and secondary intraglandular branches (small arrowhead) are slightly dilated. Hyperintense saliva is seen within the oral cavity (thin arrow). (b) Lateral-oblique conventional sialographic image obtained after MR sialography confirms the diagnosis of sialolithiasis and shows the distal displacement of the calculus (long straight arrow) caused by active filling of the ductal system. Bartholin duct (curved arrow) and primary (large arrowhead), secondary (small arrowheads), and tertiary branches (short straight arrow) are slightly dilated. The calculus was removed endoscopically. The excretory ducts of the sublingual gland are from eight to twenty in number. Of the smaller sublingual ducts (ducts of Rivinus), some join the submandibular duct; others open separately into the mouth, on the elevated crest of mucous membrane (plica sublingualis), caused by the projection of the gland, on either side of the frenulum linguae. One or more join to form the major sublingual duct (larger sublingual duct, duct of Bartholin), which opens into the submandibular duct.
- Enlarged & round edges Hypoechoic, may be inhomogeneous rough echotexture; may contain multiple small, oval, hypoechoic areas May have increased blood flow. Enlarged lymph nodes with increased central blood flow (13) Gray-scale US image shows an acutely inflamed right parotid gland (arrows) in a 5-year-old child. The gland is enlarged and inhomogeneous with multiple small, oval, hypoechoic areas (arrowheads). The position of the US probe is shown in the inset diagram. Power Doppler US image shows an acutely inflamed right submandibular gland (arrows) containing a stone (arrowhead). The gland is enlarged and hypoechoic with rounded edges and increased blood flow.
- Fig. 1. Bacterial sialoadenitis. Axial contrast-enhanced CT scan shows diffuse enlargement of the right parotid gland with dilatation of the intraparotid ducts. Note the normal left parotid gland (star). Fig. 2. Parotid abscess. Axial contrast-enhanced CT scan shows a large necrotic lesion (star) with thick enhancing capsule in the right parotid gland.
- submandibular gland abscess
- predominantly seen in submandibular glands & in adult female patients. firm on palpation and are therefore easily mistaken as ‘tumour’ on clinical examination and also referred to as cirrhosis of the submandibular gland. US- well-defined, hypoechoic areas involving part of one or both submandibular glands with geographical pattern and rounded contour. Doppler reveals hypervascularity of the involved areas without vascular displacement.
- Grey-scale ultrasound of the parotid gland in a patient with Kimura disease. Note the solid, hypoechoic mass (arrows) and associated heterogenicity in the adjacent salivary tissue. post gadolinium T1W axial (a) MR shows the heterongeneous enhancement of the mass (arrows) with heterogeneous surrounding glandular parenchyma and associated deposits in the soft tissue of the neck (arrowhead).
- Simple ranula. (a) In the right sublingual gland, the hyperintense lesion (ar- row) on this transverse T2-weighted SE (3,000/ 102) MR image could represent a pleomorphic adenoma or a cyst. (b) The absence of enhance- ment on this fat-saturated, T1-weighted SE (600/17) MR image suggests a cystic lesion, in this case a simple ranula of the sublingual gland. (c) The nonenhancing ranula (curved arrow) lies superior to the geniohyoid muscles (g) and has not perforated through the mylo- hyoid musculature on this coronal T1- weighted SE (600/17) MR image with fat satu- ration.
- Ranulas are homogeneous, well-defined masses with fluid, extremely high T2-weighted signal intensity on MRI. Simple ranulas (A) are confined to the sublingual space. Plunging ranula (B), also known as diving ranula, dissects along facial planes beyond the confines of the sublingual space, around the posterior edge of the mylohyoid muscle (arrows).
- Patient 74, female, diabetic and no complaints of xerostomia. In recent months has been noticed in the bilateral volumetric increase the height of the mandible Commonest causes: diabetes mellitus & alcoholism; malnutrition, hormonal insufficiency and radiation therapy US enlarged hyperechoic glands without focal lesions or increased blood flow Sialography Gland is enlarged, & ducts are usu normal in appearance but splayed by increased gland volume CT & MR Parotid glands enlarged but may appear either dense or fatty, depending on dominant pathologic change. angle on both sides. Sialosis is a painless enlargement of the parotid glands that has been associated with numerous causes, including (1) diabetes, (2) alcoholism, (3) hypothyroidism, (4) medications including phenothiazines and some diuretics, (5) obesity, (6) starvation, and (7) idiopathic causes. This usually is a bilateral and symmetric process that may resolve when the underlying cause has been removed.
- increase bilateral and symmetrical parotid glands without signs of inflammation, nodules or cysts. No were shown enlarged lymph nodes. This condition is seen in malnourished patients, and immunosuppressed diabetic, and has image aspect that eventually resembles Sialoadenitis Chronicle and Sjogren's Syndrome. You can display or dense parenchyma with fat density. Extending non-neoplastic and non-inflammatory, attributed to degeneration of the autonomic nervous system in diabetic patients, malnourished, immunosuppressed. Sialadenitis (sialosis).
- Parotid sialogram shows an inflammatory parotid duct stricture (arrow) secondary to stone disease. Digital subtracted image. (C) Balloon dilatation of the stricture. (D) Postprocedure Sialogram Strictures involving main parotid or submandibular duct may be single or multiple. They are often sited at orifice of parotid or submandibular duct as a result of trauma from ill-fitting dentures. Cheek biting may also affect the orifice of the parotid duct. Small stones may pass spontaneously but leave duct strictures.
- most common minor salivary gland tumor is the benign pleomorphic adenoma; however, a tumor of minor salivary gland origin is much more likely to be malignant than a tumor arising from the submandibular or parotid gland RULE OF 80
- Most occur in the sDistribution Parotid gland: 84% (commoner in the superficial lobe) Submandibular gland : 8% Minor salivary glands : 6.5% (widely distributed including the nasal cavity, pharynx, larynx, trachea) Sublingual glands : 0.5% Also commonly found in lacrimal glands (approx 50% of lacrimal gland tumours) Superficial part of the gland and are typically solid, hypoechoic, and homogeneous with at least some detectable vascularity.
- Surgical excision is curative, however as tumor is poorly encapsulated, there is a significant rate of recurrence in the tumor bed. Percutaneous ultrasound biopsy (both FNAC and core biopsy) can be performed safely and a/w very low tumour seeding rates & without facial nerve injury provided meticulous technique is used Although pleomorphic adenoma is benign, complete surgical resection is the standard treatment. Left unexcised, the tumors can continue to grow, and there is an increasing risk for malignant transformation to carcinoma ex pleomorphic adenoma. Additionally, it is not possible to distinguish between benign pleomorphic adenoma and malignant mucoepidermoid carcinoma by imaging alone
- (a) CT scan shows a well-defined mass (arrows) in the superficial lobe of the right parotid gland. There is mild enhancement of the tumor. (b) delayed phase scan shows homogeneous and strong enhancement of the tumor (arrows). The smaller lesions are usually fairly homogeneous in appearance.
- CT is insensitive for detecting a small parotid tumor, so MRI is preferred. The T1 and T2 characteristics of a pleomorphic adenoma are similar to water.
- Fig. Axial T2-WI shows a lobulated predominately hyperintense mass (arrows) arising from the deep lobe of the parotid gland and extending through the stylomandibular canal into the parapharyngeal space.
- Carcinoma ex pleomorphic adenoma.-Axial contrast-enhanced CT scan shows a large right nonhomogeneous parotid mass (arrow) with ill-defined margins.
- Gray-scale US image shows the typical appearance of a Warthin tumor (arrows). The lesion, which is located in the lower pole of the parotid gland, is oval, well defined, hypoechoic, and inhomogeneous with multiple irregular anechoic areas (arrowheads) and posterior acoustic enhancement. Power Doppler US image shows a hypervascularized Warthin tumor (arrows) in the parotid gland. Warthin’s tumors in approximately 10% of parotid tumors, but are rare in the other salivary glands. They are hypoechoic but less homogeneous than the pleomorphic adenoma and often have cystic elements. They are the most likely tumor to be bilateral or multifocal up to 15%
- Bilateral WTs. Axial contrast-enhanced CT scan shows bilateral parotid masses (arrows). The largest lesion on the right side is partially cystic. Tumor in the left parotid gland is a well-defined
- Role of scintigraphy is usu limited to confirming clinical diagnosis of Warthin tumors in those patients with multiple parotid masses. unique in that they (including oncocytoma) show increased radiotracer uptake at technetium pertechnetate imaging No malignant potential course of observation (no aggressive mgm)
- Haemangioma lymphangioma Branchial cleft cysts: rare but may occur superficial to, within, or deep to the parotid gland. These cystic lesions have a variable wall thickness if there have been previous episodes of infection. Other benign tumors (eg, oncocytoma, basal cell adenoma) occur less frequently in the salivary glands. Among nonepithelial lesions, lipomas, and neuromas or schwannomas may be found in salivary glands
- Transverse sonogram - Big lobulated hypoechogenic lesion inside the gland indicative of hemangioma. hypervascularization inside the lesion.
- Parotid hemangioma. Axial T2-weighted (A) and coronal (B) T1-weighted, fat-suppressed,contrast-enhanced MRI showing lobulated mass (arrow) in the right parotid gland showing intense enhancement on the postcontrast scans.
- Transverse sonogram of right parotid gland. Very big hypoechogenic lesion of parotid gland with fine hyperechogenic cluster typical of lymphangioma. hypovascularization of the lesion.
- Parotid lymphangioma. Axial T2-weighted (A) and coronal (B) T2-weighted MRIshowing an infiltrative mass (arrow) in the right parotid gland . This mass is seen infiltrating the deep lobe as well as the superficial lobe of the gland
- Lipomas. (a) the attenuation of parotid glands is low due to fatty infiltration on this transverse CT scan, a palpable (see marker superficially) lipoma (L) in the left parotid gland was appreciated. (b) This lipoma (arrow), hyperintense on this transverse T1-weighted MR image.
- Lipomas are usually oval and hypoechoic with sharp margins and hyperechoic linear structures regularly distributed within the lesion in a striated pattern
- most common primary parotid malignancy. • Low-grade mucoepidermoid carcinoma typically appears as an enhancing mass that is hyperintense on T2-weighted images. indistinguishable from benign pleomorphic adenoma on MRI. All adult age groups, most common in middle age (35-65 years) Most common malignant salivary gland tumor of childhood Overall, mucoepidermoid carcinomas account for : 2.8 - 15.5% of all salivary gland tumors 1 - 10% of all major salivary gland tumors 6.5 - 41% of minor salivary gland tumors In the parotid gland they are the most common malignant primary neoplasm (Vs Adenoid cystic Ca in submandibular gland). A slight female predilection has been described, and radiation has been implicated as a risk factor .
- axial CT -demonstrates a single mass with central low density cystic component in the posterolateral aspect of the right parotid. The differential is that of a primary parotid neoplasm (e.g. mucoepidermoid carcinoma, Warthin tumour, adenoid cystic carcinoma) or a necrotic node from a squamous cell carcinoma of the head and neck. The mass was resected and shown to be a mucoepidermoid carcinoma.
- Figure Mucoepidermoid carcinoma of the parotid gland. (a) Transverse T2-weighted MR image shows an intermediate-signal-intensity mass (arrow) slightly lower in intensity than that of the native parotid tissue. (b) The ill-defined nature of the mass (arrow) is exemplified by the fuzzy margins on this transverse, contrast-enhanced, fat-saturated, T1- weighted SE (600/30) MR image. The diagnosis was high-grade mucoepidermoid carcinoma.
- most common submandibular and sublingual gland malignancy and the second most common parotid gland malignancy. has a tendency to spread along the nerves (perineural spread) and often presents with cranial nerve palsy or paresthesia. Adenoid cystic carcinoma has a very high risk of local recurrence. Although slow growing, “sneaky” unpredictable tumors with the tendency to invade perineural space (50-60%) (thus most painful salivary gland neoplasm) and they are stubbornly recurrent. Pain & mass over several years 4-8% of all salivary gland tumors Most commonly in parotid, submandibular gland & palate Very wide age range (1st-9th decade); preponderance in 4th-7th decades. F:M=3:2. The key imaging feature suggestive of adenoid cystic carcinoma is an enhancing mass with perineural spread.
- Axial T2-weighted MR image (A )with an adenoid cystic carcinoma in the deep and superficial lobe of the right parotid gland. The tumour presents as a large heterogeneous mass. The T1-weighted contrast medium enhanced fat suppressed image (B) shows strong enhancement with hypointense areas in the centre and slightly irregular margins in the posterior part of the lesion (arrow).
- A- solid hypoechoic mass with slightly infiltrative margin. B- soft tissue attenuation lesion C- shows soild vascularized areas that appears anechoic and cystic gray scale
- Primary squamous cell carcinoma of the parotid gland is very rare. normally no squamous epithelial cells within the parotid. Chronic inflammation, however, can induce squamous metaplasia. Imaging demonstrates an aggressive, large mass, often with nodal metastases.
- Extraparenchymal extension refers to clinical or macroscopic pathologic evidence of soft tissue invasion. Microscopic evidence does not suffice. The terms pM0 and MX are not valid TNM categories. The following categories may be used, either in the clinical classification (c) for patients with cancer identified before treatment and/or in the pathological classification (p) for patients for whom surgery is the first definitive therapy:
- Axial T1-weighted MR image (A) of a 46-year-old women presenting with a painful lesion in the right parotid gland. A focal lesion with irregular margins can be seen (arrow). The lesion shows strong contrast medium enhancement on the fat suppressed images (B). On histology this lesion turned out to be a benign lymphoepithelial lesion (BLEL)
- HIV: 3-tiered classification Persistent generalized parotid lymphadenopathy: Solid lesions Benign lymphoepithelial lesions (BLEL): Mixed solid and cystic lesions Benign lymphoepithelial cysts: Cystic lesions
- Lateral image from parotid sialogram shows foci of stenosis (black arrow) and dilatation (black curved) in Stenson duct ("string of beads"). The intraglandular branches are truncated, with cystic spaces ("apple tree") (white arrow). These findings can be seen in any chronic sialadenitis but are classic for Sjögren syndrome. Axial CECT shows multiple calcifications (white arrow) in parotid glands that have a multilobular configuration with fatty involution. Lobules of edematous glandular tissue with intervening fat and scattered calculi is characteristic of Sjögren syndrome.
- Sjogren syndrome. Axial T2-weighted image shows multiple punctate high signal intensity areas in both parotid glands (arrows). These are suggestive of mucous retention in the dilated ducts
- HIV lymphoepithelial lesions: Axial contrast enhanced CT through the parotid glands shows numerous peripherally enhancing cystic lesions bilaterally (arrows