Salivary Gland Imaging Mary Scanlon MD FACR October 2016
Objectives Recognize normal and abnormal anatomy Discuss work up, management and differential diagnosis of commonly referred clinical scenarios Understand systemic diseases
Salivary Glands Parotid SMG Stenson s duct Wharton s duct Sublingual Ducts of Rivinus Minor Salivary Glands
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.
Lobes : Superficial and Deep
Parotid Tail
Accessory lobe
Parenchyma- fatty to dense (don t see ducts)
Normal MRI Appearance
Submandibular Glands Span both submandibular and sublingual space Wharton s Duct
Normal to see branching ducts
Normal MRI Appearance (Bright on T1/Dark on T2)
Sublingual Glands 30-40 paired glands floor of mouth Drained by Ducts of Rivenus Located beteween mylohyoid muscle and styloglossus- hyoglossus complex
Sublingual Glands
Sublingual Glands
Minor Salivary Glands All over aerodigestive tract (pharynx, larynx, sinuses) Most numerous in oral cavity (palate) No ducts Source of mucus retention cysts
Clinical Scenarios Palpable Mass
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
Parotid Mass 85% benign 70% Pleomorphic adenoma (PA) 80% superficial lobe MRI- modality of choice
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
What to report In parotid or not Location in parotid Chance not a PA Will influence surgical approach and consent risk
Chance not a PA 1. Margins: irregular, frayed, infiltrating 2. Signal-dark T2 3. Perineural spread of tumor 4. Multiplicity or Bilateralism
Adenoid Cystic
Poorly Dif adenocarcinoma
Poorly dif sq cell
Mucoepidermoid (low grade) Just cant tell
Mucoepidermoid (intermediate) Just cant tell
Myoepithelial carcinoma Just cant tell
Acinic cell cancer Just cant tell
Every Parotid mass CHECK FOR PERINEURAL SPREAD Stlyomastoid foramen fat
Every Parotid mass CHECK FOR PERINEURAL SPREAD Foramen Ovale Auricular Temporal (V3 Branch)
CHECK FOR PERINEURAL SPREAD Meckels Cave
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
Multiple Bilateral Parotid Masses Nodes: Sarcoid, Lymphoma Warthin s HIV benign lymphoepithelial aggregates (BLEA) and cysts. Sjogren s
HIV -BLEA
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)
Recurrent PA Risk-enucleation or rupture of capsule at surgery Multiple subcut nodules near or distant to surgical bed T2 bright and cystic
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
Clinical Scenarios Palpable Mass Jaw
Mass angle of jaw
Mass angle of jaw
Mass angle of jaw
Mass angle of jaw
Mass angle of jaw Node (IB or IIA) SMG Mass SLG Hernia or plunging ranula
Clinical Scenarios Palpable Mass FOM
Mass floor of mouth SLG
Mass floor of mouth -SLG
Mass floor of mouth Simple Ranula
Mass Floor of Mouth Ranula Mimic
Clinical Scenarios Palpable Mass Roof of Mouth
Roof of Mouth Mass Minor Salivary Glands
Roof of Mouth Mass Minor Salivary Glands
Palate Mass-Check the PPF
Clinical Scenarios Recurrent Swelling
Recurrent Swelling Inflammation or Obstruction
Systemic Disease
Sialosis
Autoimmune-CVD-Sarcoid
Autoimmune Sjogren's
Autoimmune Sjogren's
Sialosis Systemic Disease Autoimmune Disease CVD HIV Sjogren s Sarcoid
Possible end stage sequellae
Objectives Recognize normal and abnormal anatomy Discuss work up, management and differential diagnosis of commonly referred clinical scenarios Understand systemic diseases
Salivary Glands Anatomy Clinical Presentations Palpable mass lesion Recurrent swelling Systemic Disease