Dr Ahmed Esawy Salivary gland ultrasound

‫الرحيم‬‫الرحمن‬‫اهلل‬‫بسم‬
Dr Ahmed Esawy

Dr. Ahmed Abdallah Eisawy
MBBS M.Sc MD
Dr Ahmed Esawy

SALIVARY GLAND
ULTRASOUND
Dr Ahmed Esawy

Salivary Glands
 Major salivary
glands:
-Parotid
-Submandibular
-Sublingual
 Minor Salivary
glands:
-600-1000
-Half in the hard palate
Dr Ahmed Esawy

Normal Anatomy
 The Parotidlies anterior &
inferior to the ear (para=around
otid=ear).
 It is located on side of face, anterior
to the mastoid tip and external
auditory canal,
 and it overlaps the masseter muscle
anteriorly.
Dr Ahmed Esawy

Normal Anatomy
The main parotid duct is Stensen’s duct, which
enters the oral cavity through buccal mucosa opposite
upper second molar after coursing over masseter
muscle and piercing the buccinator muscle
Dr Ahmed Esawy

Normal Anatomy
 The facial nerve passes
the substance of the gland,
lateral to the external
carotid artery and
retromandibular vein,
giving off several smaller
branches
Dr Ahmed Esawy

Normal Anatomy
• Submandibular glands are the second largest
salivary glands.
• They are located beneath the floor of the mouth
Dr Ahmed Esawy

Normal Anatomy
• Warthon’s duct drains the gland and eventually
opens in the floor of the mouth a few mms
lateral to the lingual frenulum.
Dr Ahmed Esawy

Normal Anatomy
• The Sublingual glands are located below
the mucous membrane of the floor of the
mouth.
Dr Ahmed Esawy

Normal Anatomy
• About 10 to 12 small-caliber ducts drain the
gland. Some drain into the submandibular duct,
whereas others empty into the floor of the
mouth.
Dr Ahmed Esawy

Accessory Salivary tissue
Dr Ahmed Esawy

• Drawing shows the major blood vessels in the area of the
salivary glands .1 =retromandibular vein ,2 =external carotid
artery ,3 =facial artery and vein ,4 = lingual artery and vein ,
5 =external carotid artery ,6 = internal jugular vein ,7 =
external jugular vein .
Dr Ahmed Esawy

• Vascular landmarks of salivary glands.
• A, Schematic drawing of parotid gland. 1 = retromandibular vein/external jugular vein, 2
= cxternal carotid artery, 3 = external carotid vein,4 = maxillary vessels, 5 = transverse
facial artery,6 = anastomotic trunk between retromandibular vein and facial vein, 7 =
facial vein.
• B, Schematic drawing of submandibular and sublingual glands. 1 = Internal jugular vein,
• 2 = external carotid artery, 3 = facial vein, 4 = facial artery, 5 = lingual vessels, 6 =
submental yessels,7 = superior thyroid vessels
Dr Ahmed Esawy

What is
• What salivary gland has the highest incident of calculi/stones? Why
. submandibular gland
• Which salivary gland contains lymphoid tissue? What is the
significance of this tissue? parotid gland
• What is the most common benign tumor of the salivary glands?
pleomorphic adenoma
• What are the most common malignancies of the salivary glands?
mucoepidermoid carcinoma in parotid gland , adenoid cystic
carcinoma in the submandibular, sublingual glands
Dr Ahmed Esawy

Sonographic anatomy
Dr Ahmed Esawy

Anatomy
Parotid Gland
Dr Ahmed Esawy

Parotid Gland
1 = retromandibular vein ,
2 = external carotid artery ,
3 = echo from the surface of
the mandible ,
4 = parotid gland ,
5 = masseter muscle .
Dr Ahmed Esawy

Parotid
Gland
• Transverse panoramic US image of the left parotid gland (arrows) and cheek shows that the
gland has a high fat content .
• The parenchyma is hyperechoic with marked suppression of ultrasound waves, and no vessels
are visible. The position of the US probe is shown in the inset diagram .1 = masseter muscle .
Dr Ahmed Esawy

• Sonographically the parotid gland is a
triangular, uniformly hyperechoic structure in
the retromandibular fossa
Dr Ahmed Esawy

• Longitudinal section through the right parotid gland which demonstrates the
homogeneous and hyperechoic nature of the gland texture. The intraparotid
vessels are well demonstrated with the retro-mandibular vein (long arrow) lying
superficial to the external carotid artery (curved open arrow). Note the mandible
(arrowhead).
Dr Ahmed Esawy

• Transverse section through the tail of the left parotid gland
demonstrates a typical normal, intraparotid node (short
arrow). Note the prominent central, hyperechoic hilum and
also linear, hyperechoic intraparotid ducts (long arrow).
Dr Ahmed Esawy

the Stenon
duct
• a) Diagram shows the location of the
Stenon duct .
• 1 =parotid gland ,
• 2 =Stenon duct ,
• 4 = masseter muscle ,
• 5 = surface of the mandible ,
• 6 = buccal muscle, large arrow =
retromandibular vein and external
carotid artery .
• B) Panoramic US image shows a dilated
Stenon duct in a patient with
sialolithiasis and inflammation .
• 1 = inflamed left parotid gland ,
• 2 = dilated Stenon duct ,
• 3 = stone ,
• 4 = masseter muscle
• 5 = surface of the mandible ,
• 6 =buccal muscle, large arrow =
retromandibular vein and external
carotid artery .
Dr Ahmed Esawy

intraparotid
lymph node
• Three-dimensional US images show a normal intraparotid
lymph node (arrows), which is oval with a homogeneous
cortex and a central hyperechoic hilum. The hilum is
connected to surrounding connective tissue (arrowhead) .
Dr Ahmed Esawy

Submandibular
Gland
Dr Ahmed Esawy

Normal ultrasound anatomy and relations
of the submandibular gland
• Axial ultrasound through a normal
right submandibular gland showing its
relationship to adjacent structures.
• S, submandibular gland;
• M, mylohyoid muscle;
• H, hyoglossus muscle; White arrow,
intraglandular duct;
• D, posterior belly of digastric muscle.
Dr Ahmed Esawy

• Oblique axial ultrasound through a normal left
submandibular gland demonstrating the normal
Wharton's duct. Small white arrow, Wharton's duct;
Large white arrow, mylohyoid muscle.
Dr Ahmed Esawy

• Oblique axial ultrasound through a normal right submandibular gland
demonstrating the position of the Küttner lymph node.
• P, parotid gland;
• White arrow, Küttner lymph node;
• R, retromandibular vein;
• S, submandibular gland.
Dr Ahmed Esawy

• US image shows the
tortuous facial artery
(arrowheads) crossing
the parenchyma of the
right submandibular
gland (arrows)
Dr Ahmed Esawy

nondilated Wharton duct
• a) US image shows a nondilated Wharton duct
(arrow) in a slim patient .
• Arrowheads = submandibular gland,
• 1 = mylohyoid muscle .
• (b) Diagram shows the course of the Wharton
duct (arrow) .
• Arrowheads = submandibular gland ,
• 1 = mylohyoid muscle ,
• 2 = sublingual gland .
Dr Ahmed Esawy

Sublingual
Gland
• Transverse US image (a) and corresponding
diagram (b) show the sublingual gland and its
surrounding structures. White circle = Wharton
duct, m = muscle .
Dr Ahmed Esawy

• Vascular anatomy of parotid gland. A, Longitudinal sonogram of lower third of
gland shows
• retromandibular vein (arrowheads) has a straight course and continues as
external jugular vein (arrow) after exiting lower pole of gland.
• Asterisk = internal jugular vein.
• B, Longitudinal sonogram of upper third of gland shows
• retromandibular vein (arrows) reedy-Ing many small parenchymal veins
(arrowheads) running orthogonally to its longitudinal axis In a regular pattern.
Arterial branches run alongside.
Dr Ahmed Esawy

• Vascular anatomy of submandibular gland.
• A, Longitudinal sonogram shows facial artery (arrowheads)
looping anteriorly within gland.
• B and C, Longitudinal sonograms show facial artery
(arrowheads) providing a number of parenchymal branches
(curved arrow) characterized by regular peripheral
subdivisions (C).
• Asterisk = lingual vein
Dr Ahmed Esawy

• Vascular anatomy of submandibular gland.
• A and B, Corresponding gray-scale (A) and color Doppler (B)
sonograms show vein with echogenic walls (arrowheads)
mimicking cxcretory duct and longitudinally crossing
anterior portion of gland
Dr Ahmed Esawy

• Vascular anatomy of sublingual gland.
• A and B, Transverse (A) and longitudinal (B) submental sonograms show
lingual vein crossing gland toward tongue.
• S = sublingual gland,
• G = genioglossus muscle,
• asterisks = mylohyold muscle.
• C, Longitudinal sonogram shows several parenchymal branches
subdividing gland in a regular pattern.
Dr Ahmed Esawy

• Physiologic changes in vasculature when submandibular gland is stimulated A
and B, Duplex Doppler sonograms obtained before(A)and during (B)lemon
stimulation show changes In vasculature.
• During lemon stimulation, color Doppler sonogram shows
• diffuse increase of parenchymal signals
• and development of allasing artifact; spectral waveform shows marked increase
in arterial velocities and decrease of vascular Impedance.
Dr Ahmed Esawy

• well-capsulated glandular structure with uniform homogenous parenchymal
echo pattern.
• Almond-shaped superficial portion (asterisk) runs parallel to anterior belly of
digastric muscle (arrows) on this plane.
• Note position of posterior belly (star) of digastric muscle.
Dr Ahmed Esawy

• parotid An accessory parotid gland
appears homogenous with increased
echogencity compared to nearby muscle
Dr Ahmed Esawy

Sublingual
gland
• It is best visualised in transverse and longitudinal planes
obtained from the submental position.
Dr Ahmed Esawy

Submandibular Gland scan plane
The normal submandibular gland is
homogeneous in echotexture.
Dr Ahmed Esawy

Optional Intra-oral scanning
• Can assist with assessing the ampulla and
papilla.
• Use a probe with a small footprint (hockey
stick is ideal).
• Some patients will not be able to tolerate this
technique as they feel like "gagging" .
• Remove any false teeth as this will improve
the area for you to scan in.
• Performed with the patient erect
Dr Ahmed Esawy

Intra-oral view of the Wharton's duct ampulla.
Dr Ahmed Esawy

Size of salivary glands
• The parotid glands were measured 46.3 mm +/- 7.7 mm in
the axis parallel to the mandibular ramus and 37.4 mm +/-
5.6 mm in the transversel axis. The dimension of the
parotid parenchyma was measured with 7.4 mm +/- 1.7
mm lateral to the mandible and 22.8 mm +/- 3.6 mm dorsal
to the mandible.
• In the submandibular glands we found an anterior-
posterior length of 35 mm +/- 5.7 mm, a paramandibular
dimension to the depth of 14.3 mm +/- 2.9 mm and a
dimension in frontal scanning of 33.7 mm +/- 5.4 mm.
• The average size of the normal gland is 32 x 12mm.
Dr Ahmed Esawy

Role of US in salivary gland disease
• Diffuse : (inflammatory)
size
texture
vasularity
Any abnormality in the surrounding anatomy including the
lymph nodes.
Duct dilatation (use Colour Doppler so you do not mistake a
vessel to be a dilated duct)
• Localized : mass or stone
mass cystic or solid
benign or malignant
Dr Ahmed Esawy

SALIVARY GLAND INFLAMMATORY LESIONS
 Inflammatory Lesions:
Acute: -Viral (mumps)
- bacterial
Enlarged glands
Chronic:
Chronic recurrent sialoadenitis,
Granulomatous diseases
Sialolithiasis
Auto immune Sjögren SyndromeDr Ahmed Esawy

Acute inflammations of
the salivary glands
Dr Ahmed Esawy

(sonopalpation)
• The main indication for ultrasound is to assess
whether an obstructive sialadenitis with ductal
dilatation is present
•
• Enlarged intraglandular, hypoechoic lymph
nodes should not be confused with small
abscesses.
Dr Ahmed Esawy

Acute Inflammation
The gland is enlarged and hypoechoic with rounded edges
and increased blood flow .
Dr Ahmed Esawy

Acute Inflammation
• The gland is enlarged and inhomogeneous with multiple small, oval,
hypoechoic areas (arrowheads(Dr Ahmed Esawy

Acute Inflammation
• Gland (asterisk) is swollen
and heterogeneous in
echogenicity.
Dr Ahmed Esawy

Acute Inflammation
• sialdochitis,
• Swollen gland is moderately
heterogeneous in echo
pattern.
Dr Ahmed Esawy

Acute Inflammation
• enlarged right submandibular gland with
local tenderness.
• diffuse hypervascularity of gland
(arrowheads).
Dr Ahmed Esawy

Acute Inflammation
• multiple small oval hypoechoic
pseudocystic lesions (straight
arrows) distributed throughout
gland, resulting in diffuse
heterogeneous echotexture.
Dr Ahmed Esawy

Acute bacterial sialadenitis
• Enlarged submandibular gland,
Hypervascularisation is visualized
Dr Ahmed Esawy

Acute sialadenitis
• The gland is enlarged,
hypoechoic and of a
heterogeneous echotexture.
Dr Ahmed Esawy

Acute
sialadenitis
• Ultrasound demonstrating a
submandibular abscess
Dr Ahmed Esawy

Acute
Inflammation
• acute sialadenitis. Note the gland shows rounded contour and a
diffusely hypoechoic heterogeneous echopattern
Dr Ahmed Esawy

• The gland appears hypoechoic and inflamed and there is a poorly defined
hypoechoic mass in the superficial lobe.
Dr Ahmed Esawy

abscess
• Transverse gray scale
sonogram showing a
heterogeneous mass with ill-
defined edges, cystic changes
and internal debris.
Dr Ahmed Esawy

Chronic
inflammation
sialadenitis
Dr Ahmed Esawy

• Typically unilateral in presentation; causes
include recurrent bacterial infection,.
Strictures or stenoses of the ducts may be
precipitating factors
• The gland is less swollen than in acute
sialadenitis and is heterogeneous in
appearance, duct dilatation may be
detected
Dr Ahmed Esawy

Chronic Sialadenitis
The gland is inhomogeneous with decreased parenchymal
echogenicity but without increased blood flow. Arrows = stones .
Dr Ahmed Esawy

Chronic sialadenitis
Infective causes
• atrophic, hypoechoic, irregular gland.
• Note the associated intraglandular calculus (callipers).Dr Ahmed Esawy

• Küttner tumour.
• There is a well-defined, hypoechoic mass in the submandibular gland, which could
be mistaken, clinically and sonographically for a tumour.
Dr Ahmed Esawy

• Ultrasound of the same patient as in Figure 9 demonstrating increased
radial flow on Doppler examination within the lesion.
Dr Ahmed Esawy

• Küttner`s tumorr is a chronic sclerosing
sialadenitis of the submandibular gland.
Typical appearances are those of an ill-defined
heterogeneous submandibular gland
Dr Ahmed Esawy

SMG
• lobulated outline and ‘cirrhotic-like’ echopattern. These features
represent chronic sclerosing sialadenitis (Kuttner tumour).
Dr Ahmed Esawy

In children chronic cystic parotitis can be
diagnosed sonographically, small hypoechoic
lesions are visualized within the echogenic
parenchyma. Usually this disease is self limiting
Dr Ahmed Esawy

Chronic (recurrent) sialadenitis
• parotid gland in a child:
Multiple cystic lesions are
found in a gland with a normal
echogenic background of the
parenchyma: Chronic cystic
parotitis was diagnosed
Dr Ahmed Esawy

• Tuberculosis of the salivary glands often
exhibit a pseudotumorous appearance in
sonography. Parotid tuberculosis may be
confused with a malignant ill defined
hypoechogenic tumor.
Dr Ahmed Esawy

• intraglandular tuberculous
abscess. There is a complex
mass (callipers) in the
submandibular gland with a
central necrotic abscess cavity.
Dr Ahmed Esawy

Non-infective causes SMG
• The submandibular gland is enlarged, heterogeneous in texture
and hypoechoic. Subsequent glandular biopsy confirmed the
presence of sarcoid granulomata.Dr Ahmed Esawy

• the tail of the right parotid gland
• enlarged hypoechoic node (callipers) which is heterogeneous
and the fatty hilum is displaced peripherally.
Dr Ahmed Esawy

• right parotid gland. The parotid gland is enlarged and
hypoechoic and the texture is heterogeneous. Biopsy
confirmed infiltration with sarcoid granulomata.
Dr Ahmed Esawy

Sjögren's Syndrome
Dr Ahmed Esawy

Sjögren's Syndrome
• chronic sialadenitis is usually unilateral whereas
Sjögren's affects the salivary glands symmetrically
ie bilateral changes are identified.
• The glands are enlarged, heterogeneous in
echotexture, with multiple small hypoechoic
areas within.
• The appearances are sometimes likened to a
“currant cake”appearance or “leopard” skin
appearance
Dr Ahmed Esawy

Sjögren
Syndrome
• parotid gland .
• inhomogeneous structure with multiple small,
oval, hypoechoic areas (arrowheads) and
increased blood flow .
Dr Ahmed Esawy

• Sjogren’s syndrome.
• hypervascular color pattern
• heterogeneous parotid gland with cystlike structures (asterisk).
Dr Ahmed Esawy

• Sjögren's syndrome.
• enlarged and heterogeneous and small internal hypoechoic foci are
identified (arrow) which represent areas of sialectasis. Note a larger
septated cyst (curved open arrow).
Dr Ahmed Esawy

Sjögren's Syndrome
• parotid gland
• The gland is markedly hypoechogenic with multiple hypoechoic
areas, moderate hypervascularisation is present
Dr Ahmed Esawy

• Sjögren's syndrome
• SMG reticulated pattern (arrows)
characteristic of Sjögren's
syndrome.
• Parotid punctate hypoechoic
lesions (arrows) in heterogeneous
parenchyma..
Dr Ahmed Esawy

) Normal parotid gland demonstrates
homogeneous echogenicity.
multiple adjacent cystic areas (present bilaterally)
Sjögren's syndrome
Dr Ahmed Esawy

Sjognen syndrome
Dr Ahmed Esawy

Sjögren's
syndrome.
• SMG
• The gland is diffusely enlarged and of heterogeneous echotexture. Note the
hypoechoic foci within the gland representing early sialectatic changes.
Dr Ahmed Esawy

• lacrimal gland in a patient with Sjögren's syndrome.
• There are hypoechoic foci present within the enlarged gland
(white arrow),
Dr Ahmed Esawy

• SMG
• numerous prominent cystic spaces typical of florid sialectasis
in Sjögren's syndrome.
Dr Ahmed Esawy

• parotid gland
• diffuse involvement of parotid gland in Sjögren's syndrome.
• Gland appears coarse and hypoechoic and contains multiple
small hypoechoic foci Dr Ahmed Esawy

Post irradiative sialadenitis
Dr Ahmed Esawy

Effects of
Irradiation
• SMG
• hypoechoic and inhomogeneous, contains separate
hyperechoic linear structures ,
Dr Ahmed Esawy

• SMG
• small and atrophic.
Parenchymal echoes
(arrows) are reduced
compared with those of
mylohyoid muscle
(arrowhead).
Dr Ahmed Esawy

key feature
• whether there are stones within the main duct of
the salivary glands,
• within the small intraglandular ducts
• or within the salivary gland parenchyma.
• Common sites are the genu of the main
submandibular gland or within the intraglandular
ducts of the submandibular gland
• Calculi of the parotid gland usually arise in the
periphery of the duct system or within the
glandular parenchyma
Dr Ahmed Esawy

Sialolithiasis
• Salivary stones are most often located in the
submandibular gland(60-90 % of cases)
• may be multiple(40-70 %)
• Parotid glands are affected in about (10-20 %)
Dr Ahmed Esawy

• sialolith (arrowheads) in the inflamed parenchyma of the right
submandibular gland (dashed line), which appears hypoechoic
and inhomogeneous. The intraglandular excretory duct (arrows)
above the stone is dilated. T = tongue .
Dr Ahmed Esawy

• stone (arrows) in the dilated Wharton duct (arrowheads) near
its orifice at the sublingual caruncle ..
Dr Ahmed Esawy

• US image shows hyperechoic linear structures (arrows), which
may be mistaken for sialoliths in the Wharton duct. These
structures represent air bubbles in the oral cavity .
Dr Ahmed Esawy

Sialolithiasis
• Longitudinal section of the submandibular:
duct: Multiple stones are seen (Steinstrasse)
Dr Ahmed Esawy

• multiple small echogenic foci (arrows) in submandibular
gland, indicative of intraglandular sialolithiasis.Dr Ahmed Esawy

• Longitudinal section of a moderately dilated submandibular duct
(Wharton`s duct) A stone is located in the anterior portion of the duct
Dr Ahmed Esawy

Sialolithiasis
• SMG
• intraglandular sialolithiasis. Note the two large hyperechoic
calculi within the gland that cast acoustic shadows.Dr Ahmed Esawy

• Ultrasound demonstrating sialolithiasis with dilatation of
Wharton's duct (small white arrows) secondary to a meatal stone
Dr Ahmed Esawy

• tail of the left parotid gland
• small intraglandular calculus (arrow) with associated distal
acoustic shadowing.
Dr Ahmed Esawy

• SMG
• echogenic focus (arrow) with posterior acoustic shadowing,
diagnostic of a intraglandular ductal calculus.
Dr Ahmed Esawy

• parotid gland
• enlarged and hypoechoic. Multiple hyperechoic foci are
present within the gland (long arrow) which represent
air within intraglandular ducts secondary to sepsis. Note
associated comet-tail artefacts.
Dr Ahmed Esawy

Soft tissue lesions of the neck
Dr Ahmed Esawy

• Thyroglossal duct cyst.
Dr Ahmed Esawy

A ' pseudo solid ' homogenous lesion is visualized.Typical branchial cleft cyst
Dr Ahmed Esawy

• cervical lipoma
Dr Ahmed Esawy

• Carotid body tumor
Dr Ahmed Esawy

• neurogenic tumor
(schwannoma)
Dr Ahmed Esawy

• hypoechoic, compressible vascular mass :
diagnosis - hemangioma
Dr Ahmed Esawy

• Lymphangioma of the neck
Dr Ahmed Esawy

• Children typically have multiple detectable lymph nodes and in contrast to
adult cervical lymph nodes
• they are more bulky (i.e. more rounded or ovoid in shape) in appearance.
• The typical sonographic appearance of a reactive lymph node is that of an
ovoid,
well-circumscribed
hypoechoic lesion.
oval or elongated (sausage or bean shaped) configuration
an eccentric, echogenic hilus is characteristic of a benign
reactive lymph node
smooth or sharp borders
• In some cases, there is an eccentric bulging of the lymph cortex. The
hyperechoic hilum may be lost
Dr Ahmed Esawy

BENIGN versus malignant LN
• SHAPE
• SIZE
• SITE
• NUMBER
• OUTLINE
• ECHOGENICITY
• MATTING
Dr Ahmed Esawy

benign lymph nodes
• A longitudinal
image of a
reactive lymph
node with an
eccentric hilum
Dr Ahmed Esawy

• A small ovoid node
with hilar vascularity
Typical reactive
lymph node is
visualized
Dr Ahmed Esawy

• An ovoid lymph node
with a benign hilar
blood flow pattern is
seen in lymphadenits
Dr Ahmed Esawy

Tuberculous lymphadenitis
• In the acute stage
non-specific. Ovoid to round hypoechoic
enlarged lymph nodes are found,
• After several weeks
ill-defined, heterogenous node. The surrounding
fascia is indistinct or blurred,matting of the
nodes may be present
Dr Ahmed Esawy

Tuberculous lymphadenitis
• A hypoechoic
lesion undergoing
necrosis with an
associated
fistula.Diagnosis-
tuberculosis
Dr Ahmed Esawy

Malignant lymph nodes
• metastatic lymph nodes (open arrows), which are oval or round
and inhomogeneous without hyperechoic hila .
Dr Ahmed Esawy

Lymphoma
• the posterior cervical triangle
• conglomerate of enlarged lymph nodes.
• facet forming sign
• The nodes are round or polygonal in shape and are usually sharply defined.
• In aggressive forms of lymphoma, perinodal fluid collections or oedema is
detected and associated matting may be present.
• pseudocystic sign .
• Often small, moderately echogenic structures (a stippled or reticular
appearance) are found within the lymph node.
• small-vessel-sign. Dr Ahmed Esawy

Lymphoma
• lymph nodes (arrowheads) in the parotid gland (arrows = external
outline of the superficial lobe( Affected nodes were also located
beneath and along the sternocleidomastoid muscle .
Dr Ahmed Esawy

• lymphomatous lymph node
(arrows) in the parotid
gland. The oval, well-
defined, anechoic lesion
demonstrates discrete
posterior enhancement and
mimics a simple cyst .
Dr Ahmed Esawy

• A rounded lymph
node with multiple
peripheral arteries
Dr Ahmed Esawy

• Rounded lymph
nodes with areas of
vascular sparing
Dr Ahmed Esawy

• small vessel sign in
malignant lymphoma
Dr Ahmed Esawy

• A conglomerate of
nodes is visualized. In
the posterior triangle
of the neck in
malignant lymphoma
Dr Ahmed Esawy

• Power Doppler
demonstrates a
plethoric hilar flow
pattern in non
Hodgkin Lymphoma
Dr Ahmed Esawy

• enlarged abnormal submandibular lymph node (solid straight arrows) that
is heterogeneously hyperechoic with loss of normal hilum echo pattern.
Dr Ahmed Esawy

Salivary gland
neoplasm
Dr Ahmed Esawy

Benign tumors of the salivary glands
• Epithelial
• 1 Pleomorphic adenoma (benign mixed tumor) (cylindroma). Most common tumor
• 2 Monomorphic adenoma
• a Warthin tumor (papillary cystadenoma Iymphomatosum. Second most common
• b Oncocytoma (acidophilic cell adenoma). or oxyphilic adenoma
• c Myoepithelioma
• d Canalicular adenoma
• e Basal cell adenoma
• f Clear cell adenoma
• g Glycogen-rich adenoma
• 3 Ductal papillomas
• a Sialadenoma papilliferum
• b Intraductal papilloma
• c Inverted ductal papilloma
• Nonepithelial
• • Hemangioma. capillary type. cavernous type
• • Lymphangioma
• • Lymphangiohemangioma
• • Schwannoma/neurofibroma
• • Lipoma
• • Fibroma
Dr Ahmed Esawy

TUMOUR CHARACTERIZATION
• NUMBER
• LOCATION
• NERVE
• NATURE
• VASCULARITY
• SITE
• BILATERALITY
Dr Ahmed Esawy

80% rule in Parotid gland masses
• 80% are benign
• 80% are pleomorphic adenomas
• 80% occur in the superficial lobe
• 80% approximately of untreated pleomorphic
adenomas remain benign (up to 20% undergo
malignant degeneration to squamous cell
carcinoma).
Dr Ahmed Esawy

pleomorphic adenoma
• female
• rounded
• Most tumors are superficial to the facial nerve, which is not infiltrated. So-
called "Iceberg tumors
• Homogeneous
• relatively hypoechoic. They have a so-called "pseudo-cystic" appearance with
enhanced sound wave transmission with posterior acoustic shadowing
identified
• They are sharply bordered,
• the contour is often lobulated
• Rarely, cystic change and areas of calcification can be identified.
• In long standingcases - malignant transformation is a possibility
Dr Ahmed Esawy

• The lesion is hypoechoic and lobulated with distinct borders
and posterior acoustic enhancement .
Dr Ahmed Esawy

• US image shows an inhomogeneous pleomorphic
adenoma (arrows(
Dr Ahmed Esawy

• No blood vessels are visible in the lesion .
Dr Ahmed Esawy

• well-defined homogeneously
hypoechoic round solid mass
with lobulated contour
• Note posterior acoustic
enhancement (solid arrows).
Dr Ahmed Esawy

Pleomorphic adenoma
• parotid gland: A sharply
bordered hypoechoic lesion is
visualized in the superficial
portion of the parotid gland
Dr Ahmed Esawy

Pleomorphic
adenoma
• parotid gland
homogeneous,
hypoechoic and well
circumscribed with distal
acoustic enhancement.
Dr Ahmed Esawy

Pleomorphic adenoma
• lobulated mass in the superficial lobe of the gland distorting
the capsule. There is associated distal acoustic enhancement.
Note marked heterogeneity of internal architecture.Dr Ahmed Esawy

Pleomorphic
adenoma
• rounded and circumscribed hypoechoic solid mass in superficial
lobe of parotid. Distal acoustic enhancement is evident.
Dr Ahmed Esawy

• SMG
• rounded, well defined and hypoechoic with distal acoustic enhancement
present.
Pleomorphic
adenoma
Dr Ahmed Esawy

• welldefined,round, homogeneous, hypoechoic lesion SMG
• the posterior acoustic enhancement
Pleomorphic adenoma
Dr Ahmed Esawy

Pleomorphic adenoma Adenolymphoma.
Adenolymphoma. Oncocytoma
graded +. graded ++.
graded +. graded ++.
Color Doppler sonogram grading
Dr Ahmed Esawy

Adenolymphoma
(Wharthins tumor)
Dr Ahmed Esawy

ADENOLYMPHOMA
• MALE
• SEPTATED
• BILATERAL
• Adenolymphoma (also known as cystadenolymphoma) is the
second most common, benign salivary gland tumor.
• In 90% of cases they are located in the superficial parotid,
often in the caudal portion or tail of the parotid gland
• sharply bordered ie well-defined,
• hypoechoic,
• frequently contain a cystic component .
• usually ovoid in shape and may contain areas of calcification.
Dr Ahmed Esawy

• parotid gland
• oval, well defined, hypoechoic, and inhomogeneous
with multiple irregular anechoic areas (arrowheads)
and posterior acoustic enhancement .
Dr Ahmed Esawy

• two Warthin tumors (arrows) in the lower pole of the left
parotid gland. The lesions are oval, well defined,
hypoechoic, and inhomogeneous .
Dr Ahmed Esawy

• Power Doppler US image shows a hypervascularized
Warthin tumor (arrows) in the parotid gland .
Dr Ahmed Esawy

• US image shows a pleomorphic adenoma (arrows)
with an anechoic area (arrowheads), an appearance
that mimics a Warthin tumor .Dr Ahmed Esawy

Adenolymphoma (Wharthins tumor)
• parotid gland
• A sharply bordered hypoechogenic lesion with cystic parts is
visualized: An Adenolymphoma was diagnosed on histology
Dr Ahmed Esawy

Warthin's tumour (cystadenolymphoma)
• parotid gland obulated with internal cystic elements and
hyperechoic septation is demonstrated (arrow).
Dr Ahmed Esawy

Warthin's
tumour
• parotid gland demonstrates multifocal Warthin's tumour with a
smaller nodule (curved arrow) adjacent to a larger lesion.
Dr Ahmed Esawy

Warthin's
tumour
• circumscribed hypoechoic mass with inhomogeneous internal
architecture containing solid and prominent cystic components.
Dr Ahmed Esawy

Warthin's
tumour
• well-defined cystic lesion with slightly lobulated margin and
internal debris in the tail of parotid gland. Features suggest a
Warthin’s tumour.
Dr Ahmed Esawy

Other Benign tumours
Dr Ahmed Esawy

Oncocytoma
• parotid gland
• well circumscribed,
hypoechoic solid mass in
the superficial lobe near the
angle of the mandible.
Dr Ahmed Esawy

oncocytoma
• SMG oncocytoma
Dr Ahmed Esawy

lipoma
• hypoechoic with regularly distributed
linear structures .
Dr Ahmed Esawy

• parotid gland A hypoechoic lesion with a feathered structure is
visualized: Parotid lipoma
• A hypoechoic lesion with echogenic striae within is visualized in the
parotid gland: Parotid lipoma .
Dr Ahmed Esawy

• parotid gland lipoma
• This is well circumscribed with a striped internal
echotexture
Dr Ahmed Esawy

a lipoma
• Well defined hypoechoic lesion with fine linear striations
parallel to the transducer within the left parotid gland..
Dr Ahmed Esawy

Fatty infiltration
Fatty infiltration causes diffuse,
• usually bilateral
• homogeneous parotid enlargement sonographically.
Other benign lesions
Haemangiomas of the parotid gland are more common in
children and appear hypoechoic on ultrasound with
prominent internal vascular structures
Dr Ahmed Esawy

Malignant tumors of the salivary
glands
• Epithelial
• • Mucoepidermoid carcinoma. most common (adults and children)
• • Adenoid cystic carcinoma
• • Adenocarcinoma (mucin-producing)
• • Clear cell adenocarcinoma (nonmucinou5. glycogen-containing or
• non-glycogen-containing)
• • Adenocarcinomas. not otherwise specified
• • Acinic cell carcinoma (second most common in children)
• • Oncocytic carcinoma (malignant oncocytoma)
• • Malignant mixed cell tumor (true malignant mixed tumor or carcinosarcoma)
• • Carcinoma ex-pleomorphic adenoma (carcinoma arising in a
• benign mixed tumor)
• • Primary squamous carcinoma (rare)
• • Basal cell adenocarcinoma
• • Undifferentiated carcinoma
• • Epithelial-myoepithelial carcinoma (rare)
• • lymphoepithelioma·like carcinoma (carcinoma ex-IymphoepitheHallesion)
• • Stensen's duct carcinoma (rare)
• • Sebaceous carcinoma
Dr Ahmed Esawy

Malignant tumors of the salivary
glands
• Nonepithelial
• • lymphoma
• • Sarcoma (liposarcoma, fibrosarcoma, angiosarcoma, etc.)
• • Sarcoma in ex-pleomorphic adenoma (osteogenic-chondrogenic
• sarcoma)
• • Fibrohistiocytoma
• • Hemangiopericytoma
• • Synovial sarcoma
• • Giant-celt tumor
• • Malignant schwannoma
• • Neurofibrosarcoma
• Metastatic
• • Melanoma
• • Squamous cell carcinoma
• • Renal cell carcinoma
• • lung
• • Thyroid
• • Meningioma (unusual case reported).
Dr Ahmed Esawy

• High grade mucoepidermoidcarcinoma are
usually ill defined lesions whereas low grade
tumors may present as a sharply bordered
benign looking tumour on imaging
ultrasound can reliably diagnose malignancy if there is a
high level of blood supply, high index of resistance and high
systolic speed identified on colour Doppler
Colour Doppler may also aid in the assessment of malignancy;
the lesion with a disorganised colour Doppler flow pattern and
RI >0.8, PI >2 is more likely to be malignant.
Dr Ahmed Esawy

mucoepidermoid carcinoma
• SMG
• extraglandular extension of tumour with invasion of the
subcutaneous tissues and skin (small white arrows).
Dr Ahmed Esawy

mucoepidermoid carcinoma
• illdefined,Heterogeneous ,
hypoechoic lesion with
infiltrative margin in the right
parotid gland.
Dr Ahmed Esawy

mucoepidermoid
carcinoma
• parotid gland
• irregular, poorly defined mass in the superficial lobe with heterogeneous
internal architecture.
Dr Ahmed Esawy

acinic cell carcinoma
• is typically round in outline and possesses a
pseudo capsule which manifests itself on
ultrasound as a well-defined margin ie it
may have the same ultrasound
appearances as a pleoorphic adenoma
Dr Ahmed Esawy

acinic cell carcinoma
• parotid gland (solid arrows(
• well defined and has regular margins; however, there are signs of
mandibular destruction (open arrows), a finding that suggests malignancy .Dr Ahmed Esawy

adenoid cystic carcinoma
• SMG
• adenoid cystic carcinoma. This appears as an ill-defined,
hypoechoic and inhomogeneous mass.
Dr Ahmed Esawy

Adenoidcystic carcinoma
Epithelial, malignant tumors of the
salivary glands
• slightly ill-defined lesion is seen in the region of the
sublingual gland.
Dr Ahmed Esawy

adenoid
cystic
carcinoma
• parotid gland
• The margins are poorly defined and there is tumour extension
into the deep lobe (arrow) and through the superficial aspect
of the gland (curved open arrow) beneath the skin.Dr Ahmed Esawy

Lymphoma
• SMG
• large, hypoechoic intraglandular mass. This patient had known
disseminated B-cell lymphoma.
Dr Ahmed Esawy

Lymphoma
• Parotid gland
• glandular enlargement with hypoechoic and reticulated
echopattern. Features are compatible with lymphomaDr Ahmed Esawy

• parotid gland demonstrates multiple enlarged,
"pseudocystic" nodes in a patient with B-cell lymphoma.
Dr Ahmed Esawy

• Malignant nodules of salivary glands.
Non-Hodgkin’s lymphoma Mucoepidermoid carcinoma
Intratumor vascularity Is graded +++.
Dr Ahmed Esawy

Metastases
• metastasis (arrowheads) to the superficial lobe of the
parotid gland (arrows) from a melanoma .
• The tumor is lobulated, inhomogeneous, and virtually
anechoic with posterior acoustic enhancement and
chaotic, mainly peripheral vessel segments .Dr Ahmed Esawy

Metastases
• Ill defined,heterogeneous,
• hypoechoic lesion in the
• left parotid gland.
Dr Ahmed Esawy

Metastases
• SMG oval, well-defined, homogeneous tumor with
even margins (arrows(
• the parenchyma of the gland (arrowheads) has been
changed by therapeutic neck irradiation .Dr Ahmed Esawy

• parotid gland
• irregular, poorly defined mass in the superficial lobe.
metastatic squamous cell carcinoma
Dr Ahmed Esawy

Sonographically Guided Core Biopsy of A Parotid Mass
• Sonograms show 16-mm
pseudocystic mass in tail of right
parotid gland. Tip of biopsy needle
(arrow, A) is positioned so that on
needle discharge with 15-mm
setting of biopsy device, needle
traverses but does not exit lesion.
Confirmation of needle placement
is seen in B.
B
A
Dr Ahmed Esawy

Cysts
• Simple cysts are uncommon in salivary glands .
• US features of a cyst are classic (like in any other location in
the body): well-defined margins, anechoic content, posterior
acoustic enhancement, and no evidence of internal blood
flow at power Doppler or color Doppler imaging (
Dr Ahmed Esawy

• Gray-scale tissue harmonic US image shows a simple
cyst (arrowheads) in the lower pole of the parotid
gland (arrows (
Dr Ahmed Esawy

• parotid gland demonstrates a retention cyst—anechoic and
thin walled with distal acoustic enhancement.
Dr Ahmed Esawy

Differential diagnosis of salivary gland
calcification
• • Sialolithiasis
• • Chronic sialadenitis (dystropic calcification)
• • Chronic granulomatous sialadenitis (sarcoidosis, tuberculosis)
• • Chronic stage of autoimmune sialosis (punctate calcifications)
• • Postradiation chronic sialadenitis
• • Pleomorphic adenoma
• • Warthin tumor
• • Acinic cell carcinoma
• • Adenoid cystic carcinoma
• • Malignant degeneration (osteochondrosarcoma) in an ex-pleomorphic
• adenoma
• • Extension of synovial chondromatosis of TM] into parotid space
• • Extension of chondrosarcoma of TM] into the parotid space
Dr Ahmed Esawy

Differential diagnosis of parotid gland
enlargement
• • Infectious diseases (mumps. cat-scratch disease, suppurative
parotitis. actinomycosis)
• • Granulomas (sarcoidosis. tuberculosis, etc.)
• • Kimura disease
• • Immunological diseases
• • Collagen vascular autoimmune diseases (e.g .• Sjogren syndrome)
• • Metabolic and endocrine-related sialopathy
• • Vasculogenic (hemangioma. vascular malformation)
• • lymphangioma (cystic hygroma)
• • lymphoepithelial disorder (AIDS sialopathy)
• • lymphoma
• • Parotid neoplasms (epithelial, mesenchymal)
• • Metastasis (kidney, lung, breast. thyroid. malignant melanoma)
Dr Ahmed Esawy

Dr Ahmed Esawy Salivary gland ultrasound

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Dr Ahmed Esawy Salivary gland ultrasound