Salivary Gland Imaging. Mary Scanlon MD FACR October 2016

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1 Salivary Gland Imaging Mary Scanlon MD FACR October 2016

2 Objectives Recognize normal and abnormal anatomy Discuss work up, management and differential diagnosis of commonly referred clinical scenarios Understand systemic diseases

3 Salivary Glands Parotid SMG Stenson s duct Wharton s duct Sublingual Ducts of Rivinus Minor Salivary Glands

4 Parotid Gland Contains: Ext Carotid Br, RMV, nodes/ lymphatic tissue, Facial N,Branch of V3 (Auriculotemporal) Lobes defined by course of facial nerve (stylomastoid foramen to RMV) or by stylomandibular tunnel.

5 Lobes : Superficial and Deep

6 Parotid Tail

7 Accessory lobe

8 Parenchyma- fatty to dense (don t see ducts)

9 Normal MRI Appearance

10 Submandibular Glands Span both submandibular and sublingual space Wharton s Duct

11 Normal to see branching ducts

12 Normal MRI Appearance (Bright on T1/Dark on T2)

13 Sublingual Glands paired glands floor of mouth Drained by Ducts of Rivenus Located beteween mylohyoid muscle and styloglossus- hyoglossus complex

14 Sublingual Glands

15 Sublingual Glands

16 Minor Salivary Glands All over aerodigestive tract (pharynx, larynx, sinuses) Most numerous in oral cavity (palate) No ducts Source of mucus retention cysts

17 Clinical Scenarios Palpable Mass

18 Palpable Mass Larger the gland lower the likelihood a mass will be malignant ( adults) Parotid 15% Mucoepidermoid SMG 50% Adenoid Cystic SL/ MSG 70% Adenoid Cystic

19 Parotid Mass 85% benign 70% Pleomorphic adenoma (PA) 80% superficial lobe MRI- modality of choice

20 Pleomorphic Adenoma Middle aged females Most common benign mass Infrequently undergoes malignant transformation Classic appearance Sharp margin Int T1 Bright T2 Mild to avid enhancement

21 What to report In parotid or not Location in parotid Chance not a PA Will influence surgical approach and consent risk

22 Chance not a PA 1. Margins: irregular, frayed, infiltrating 2. Signal-dark T2 3. Perineural spread of tumor 4. Multiplicity or Bilateralism

23 Adenoid Cystic

24 Poorly Dif adenocarcinoma

25 Poorly dif sq cell

26 Mucoepidermoid (low grade) Just cant tell

27 Mucoepidermoid (intermediate) Just cant tell

28 Myoepithelial carcinoma Just cant tell

29 Acinic cell cancer Just cant tell

30 Every Parotid mass CHECK FOR PERINEURAL SPREAD Stlyomastoid foramen fat

31 Every Parotid mass CHECK FOR PERINEURAL SPREAD Foramen Ovale Auricular Temporal (V3 Branch)

32 CHECK FOR PERINEURAL SPREAD Meckels Cave

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35 Multiple masses single parotid (very very rare to be PA) Lymph nodes-look for skin/scalp cancer Warthin s Less common : Acinic cell or Oncocytomas

36 Multiple Bilateral Parotid Masses Nodes: Sarcoid, Lymphoma Warthin s HIV benign lymphoepithelial aggregates (BLEA) and cysts. Sjogren s

37 HIV -BLEA

38 Warthin s Cystadenoma lymphomatosum Only parotid Elderly men and women (smoking, prior radiation) Most common multiple and bilateral tumor of the parotid Technetium 99M positive (like oncocytomas)

39 Recurrent PA Risk-enucleation or rupture of capsule at surgery Multiple subcut nodules near or distant to surgical bed T2 bright and cystic

40 Incidental supcapsular masses-what to do? Check not vessels If not then nodes bilateral symmetric less than 5 mm If dominant mass than work up

41 Clinical Scenarios Palpable Mass Jaw

42 Mass angle of jaw

43 Mass angle of jaw

44 Mass angle of jaw

45 Mass angle of jaw

46 Mass angle of jaw Node (IB or IIA) SMG Mass SLG Hernia or plunging ranula

47 Clinical Scenarios Palpable Mass FOM

48 Mass floor of mouth SLG

49 Mass floor of mouth -SLG

50 Mass floor of mouth Simple Ranula

51 Mass Floor of Mouth Ranula Mimic

52 Clinical Scenarios Palpable Mass Roof of Mouth

53 Roof of Mouth Mass Minor Salivary Glands

54 Roof of Mouth Mass Minor Salivary Glands

55 Palate Mass-Check the PPF

56 Clinical Scenarios Recurrent Swelling

57 Recurrent Swelling Inflammation or Obstruction

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59 Systemic Disease

60 Sialosis

61 Autoimmune-CVD-Sarcoid

62 Autoimmune Sjogren's

63 Autoimmune Sjogren's

64 Sialosis Systemic Disease Autoimmune Disease CVD HIV Sjogren s Sarcoid

65 Possible end stage sequellae

66 Objectives Recognize normal and abnormal anatomy Discuss work up, management and differential diagnosis of commonly referred clinical scenarios Understand systemic diseases

67 Salivary Glands Anatomy Clinical Presentations Palpable mass lesion Recurrent swelling Systemic Disease

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