SALIVARY GLAND IMAGING

DIAGNOSTIC IMAGING TECHNIQUES

Plain-film radiography
-to evaluate calculi or detecting calcification in hemangiomas, lymph nodes or pleomorphic adenoma
Sialography
-CT and MRI have replaced sialography in evaluation of salivary gland or adjacent tumour masses
-still most useful modality to evaluate intrinsic structure of salivary ducts
-indications:
-chronic, recurrent and nonspecific sialoadenitis
-Sjogren syndrome, Mikulicz syndrome
-submandibular or parotid gland sialolithiasis
-posttraumatic or postoperative fistula, stricture or cyst
-contraindications:
-acute infections
Computed Tomography
-Hounsfield units:
-a unit of x-ray attenuation used for CTs
-air: -1000 HU
-water: 0
-bone: +1000 HU
-fat: -20 HU
-muscle: +20 HU
-enhanced parotid: +35 HU
-submandibular glands: +40 HU
Magnetic Resonance Imaging
-T2 weighted images superior to T1-weighted images for differentiating tumour from normal salivary tissue
-tumours have high signal intensity on T2
Diagnostic Ultrasound
-differentiates solid vs cystic masses
-for U/S guided FNA
Nuclear Scintigraphy
-sodium pertechnetate Tc 99m
-most commonly used radioactive pharmaceutical
-uptake by normal salivary gland tissue
-tumours usually have no uptake filling defect
-Warthins tumour and oncocytoma readily take up pertechnetate hot spot
-gallium 67 citrate:
-used for studying inflammatory or neoplastic disease
-taken up by dividing cells - excessive accumulation observed in inflammatory or neoplastic
processes:
-sarcoidosis, melanoma, lymphoma
-anticarcinoembryonic antigen imaging has high negative predictive value (100%) in malignancy of the
salivary glands

F.Ling - Salivary Gland Imaging (1)

INFLAMMATORY DISEASE OF THE SALIVARY GLANDS

Sjogren Syndrome
-sialography:
-gland involvement tends to be bilateral
-parotid gland mild to markedly enlarged
-multiple punctate contrast collections
throughout gland can progress to become
larger collections that are more globular
-may have areas of tubular sialectasia or
strictures
-retention of contrast material
-CT:
-bilateral parotid enlargement with multiple
areas of low attenuation
-may have cyst formation with lymphoid
infiltration (pseudolymphoma)
-high incidence of non-Hodgkin lymphoma presents as intraglandular mass
Chronic Inflammatory Conditions
-sialography or CT may demonstrate inflammatory masses or more specific infections of salivary glands,
such as TB, symphilis, actinomycosis or animal-scratch fever
-abnormalities:
-sialectasia of main or intraglandular ducts
-stricture and filling defects within ducts related to debris
-fibrosis
-inflammatory infiltrate
-sialography contraindicated in acute sialadenitis; may amplify disease
-CT/MRI:
-fluctuant, enlarged, variably enhancing salivary gland and extraparotid inflammation involving
masseter muscle, subcutaneous soft tissues and masticator or parapharyngeal spaces
-may demonstrate abscess formation:
-CT: hypointense central region surrounded by variably enhancing rim
-MRI: T1 dark; T2 bright
-ultrasound: locate fluid collections for aspiration
Sialolithiasis
-can be diagnosed with plain-film radiography
-20% of calculi in submandibular and 20-40% in parotid gland are not visible on plain-film
-sialography: intraductal filling defects
Lesions of the Parapharyngeal and Masticator Space
-demonstration of a fat plane separating normal parotid gland from mass indicates parapharyngeal location
-lack of fat plane implies deep lobe parotid tumour
-poststyloid lesions
-displaces parapharyngeal fat anteriolaterally
-usually schwannoma or paraganglioma
-also: retropharyngeal lymphadenopathy, meningioma, hemangioma, chondrosarcoma,
rhabdomyosarcoma, perineural metastasis
-prestyloid lesion
-pushes fat medially
F.Ling - Salivary Gland Imaging (2)

-usually salivary gland neoplasm

-masticator space lesions:
-can be meningioma, neurolemma, sarcoma, SCC, dentigerous cyst or masseteric hypertrophy
-no salivary gland lesions
-four findings that indicate masticator space origin:
-location anterior and lateral to parapharyngeal fat
-limitation of tumour by boundaries of masticator space (ie, sphenoid bone, posterior
aspect of mandible, and zygomatic arch)
-obliteration of fat planes within masticator space
-tendency to spread through foramen ovale
-MRI:
-primary salivary gland tumours and minor salivary gland neoplasms displace internal carotid
artery
-schwannomas (vagus nerve) and paragangliomas arise posterior to ICA and displace it anteriorly
-similar signal characteristics:
-well-circumscribed lesion with intermediate signal on T1 and increasing signal on T2
-paragangliomas may have salt and pepper appearance d/t flow voids
Salivary Gland Cysts
-congenital
-first branchial cleft (type 2)
-dermoids
-epidermoid
-acquired
-posttraumatic (eg. sialocele)
-from blunt trauma, faulty dentures, buccal mucosal ulcerations, surgical sutures or
calculus removal
-lymphoepithelial
-pt may or may not have clinical signs of AIDS
-usually associated with cervical adenopathy
-retention cysts (mucocele, ranula)
-obstruction of sublingual or minor salivary gland duct
-CT: well-circumscribed low-density mass (0-20 HU)
-MRI: low intensity T1 and high intensity T2
SALIVARY GLAND NEOPLASMS
Benign Neoplasms
Pleomorphic Adenoma
-CT:
-well-circumscribed mass with homogeneous or heterogeneous density
-contrast enhancement varies but tends to be mild
-calcifications may be evident
-MRI:
-predominantly heterogeneous well-circumscribed mass
-T1 intermediate to low signal intensity
-T2 increased signal

F.Ling - Salivary Gland Imaging (3)

Warthin Tumour and Oncocytoma

-CT:
-homogeneous well-circumscribed mass
-hypodense or cystic areas
-calcification does not occur
-MRI:
-T1 intermediate to low signal intensity
-T2 increased signal
-both Warthin and oncocytoma are unique in that they accumulate technetium-99m pertechnetate
Hemangioma and Lymphangioma
-plain film: may demonstrate calcification of multiple phleboliths within tumour
-CT: well-defined heterogeneous mass
-MRI: heterogeneous signal on T1 and T2
Lipoma

-may be intraparotid or paraparotid

-CT: low attenuation (-50 to -150 HU)
-MRI: high signal T1; intermediate signal T2

Malignant Neoplasms
Mucoepidermoid Carcinoma
-low-grade MEC has CT and MRI characteristics resembling benign lesions
-well circumscribed and regularly marinated without infiltration into adjacent soft tissues
-low to intermediate signal intensity on T1 with increasing intensity on T2
-high-grade MEC:
-more irregular appearance with irregular margination and infiltration into soft tissues
-signal intensity intermediate on T1 and T2
Adenoid Cystic Carcinoma
-perineural infiltration common
-CT signs of perineural involvement:
-obliteration of normal fat plane beneath stylomastoid foramen
-tumour enhancement along course of facial nerve
-vascular enhancement with variable infiltration into adjacent soft tissues
-recurrent disease demonstrates CT enhancement and increased signal on T2 weighted images
Squamous Cell Carcinoma
-usually from metastasis
-loss of margination, irregularity and soft-tissue infiltration may be identified in aggressive tumours
Malignant Variations of Pleomorphic Adenoma
-indistinguishable from other neoplasms of parotid gland
Lymphoma
-multiple, well-circumscribed, homogeneous masses withing parotid gland and in paraparotid region that
may enhance slightly with contrast

F.Ling - Salivary Gland Imaging (4)

IMAGING PROCEDURES
Imaging Study

Indications

Comments

Plain films

Calculus disease

Limited value; may differentiate salivary gland disease from bony

abnormality

Sialography

Sjogren syndrome, chronic

inflammatory conditions

Best means of imaging ductal system; of limited value other than in

evaluating the ductal system

CT

Chronic inflammatory
conditions and complications,
intrinsic and extrinsic masses,
calculus disease

Excellent anatomic detail for intrinsic and extrinsic salivary gland

tumours; best means of identifying calculi or calcification

MRI

Chronic inflammatory
conditions and complications,
intrinsic and extrinsic masses

Excellent anatomic detail in tumour evaluation; may be better than CT

for parapharyngeal space and intracranial extensions

US

Abscess, cyst, intrinsic salivary

neoplasm (?)

Best means of determining solid vs cystic lesions, but limited

nasopharyngeal detail

Radionuclide imaging

Warthin Tumour

Sodium pertechnetate Tc 99m taken up by benign neoplasms; gallium

67 citrate and bone-scanning agents occasionally useful for
malignancies

F.Ling - Salivary Gland Imaging (5)