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بسم اهلل الرحمن الرحيم
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 Parotid lies 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
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 Syndrome
Dr 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
Abscess
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
granulomatous
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
Sialolithiasis
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
Soft tissue lesions of the neck
• Thyroglossal duct cyst.
Dr Ahmed Esawy
Soft tissue lesions of the neck
A ' pseudo solid ' homogenous lesion is visualized.Typical branchial cleft cyst
Dr Ahmed Esawy
Soft tissue lesions of the neck
• 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
Lymph nodes
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
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 lymphoma Dr 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
