SALIVARY GLAND

IMAGING

Dept of Oral Medicine and Radiology

 •Introduction

Introduction

A brief on salivary glands

Investigations

Plain radiography

Sialography

Computed Tomography

MRI 2
 •Introduction

Flow rate studies

Radioisotope imaging

Cone beam computed tomography

Radiological appearances in various disorders

Conclusion

References

3
 Introduction
• Imaging is useful in identifying the
masses of salivary glands and also in
differentiating them from the
masses/pathologies of adjacent cervical
spaces, especially parapharyngeal,
masticator, and submental spaces and
mandibular lesions.
• In proven cases of salivary gland
tumors, imaging helps in delineating
the extent of the lesion and invasion of
adjacent cervical spaces, skull base,
mandible, and nerves/meninges.
 Introduction
• Salivary Gland is any cell or organ
discharging a secretion into the oral cavity.
– Major and minor Salivary Glands

• Major (Paired)
» Parotid
» Submandibular
» Sublingual
• Minor
» Those in the Tongue,
Palatine Tonsil, Palate, Lips
and Cheeks
anatomy of salivary glands
 PAROTID GLAND
• Largest

• Average Wt - 25gm

• Irregular lobulated mass lying mainly

below the external acoustic meatus
between mandible and sternomastoid.

• On the surface of the masseter, small

detached part lies b/w zygomatic arch
and parotid duct-accessory parotid gland
or ‘socia parotidis’
 Parotid Duct

• DUCTUS PAROTIDEUS;
STENSEN’S DUCT

• 5 cm in length

• Appears in the anterior border of the

gland

• Runs anteriorly and downwards on

the masseter b/w the upper and
lower buccal branches of facial N.
• At the anterior border of
masseter it pierces

• Buccal pad of fat

• Buccopharyngeal fascia
• Buccinator Muscle

• It opens into the vestibule of

mouth opposite to the 2nd upper
molar
 Blood supply

• Arterial
• Branches of Ext.
Carotid A
• Venous
• Into Ext. Jugular Vein
Lymphatic Drainage
Upper Deep cervical nodes

via Parotid nodes

Nerve Supply

• Parasymapthetic N
» Secretomotor via
auriculotemporal N

• Symapathetic N
» Vasomotor
» Delivered from plexus
around the external
carotid artery
• Sensory N
» Reach through the
Great auricular and
auriculotemporal N
 SUBMANDIBULAR SALIVARY GLANDS
• Irregular in shape

• Large superficial and small deeper part

continous with each other around the
post. Border of mylohyoid

• Superficial Part
– Situated in the digastric triangle
– Wedged b/w body of mandible and
mylohyoid
– 3 surfaces
– Inferior,Medial,Lateral
 WHARTONS DUCT

• 5 cm long
• Emerges at the anterior end
of deep part of the gland
• Runs forwards on
hyoglossus b/w lingual and
hypoglossal N
• At the ant. Border of
hyoglossus it is crossed by
lingual nerve
• Opens in the floor of mouth
at the side of frenulum of
tongue
 Blood Supply
• Arteries
– Branches of facial and lingual
arteries
• Veins
– Drains to the corresponding
veins
• Lymphatics
Submandibular gland
– Deep Cervical Nodes via
submandibular nodes
– Branches from
submandibular ganglion,
through which it receives
• Parasymapthetic fibers
from chorda tympani
• Sensory fibers from
lingual branch of
mandibular nerve
• Sympathetic fibers from
plexus on facial A
 SUBLINGUAL SALIVARY GLANDS

• Smallest of the three glands

• Weighs nearly 3-4 gm

• Lies beneath the oral mucosa

in contact with the sublingual
fossa on lingual aspect of
mandible.
• Duct
• Ducts of Rivinus
• 8-20 ducts
• Most of them open directly into
the floor of mouth
• Few of them join the
submandibular duct
• Blood supply
• Arterial from sublingual and submental arteries
• Venous drainage corresponds to the arteries

• Nerve Supply
• Similar to that of submandibular glands( via lingual nerve
, chorda tympani and sympathetic fibers)
 MINOR SALIVARY GLANDS
• LABIAL AND BUCCAL GLANDS
• Located in lips and cheek.
• They are mixed glands.
• GLOSSOPALATINE GLANDS
• Located in the isthmus in the glossopalatine fold.
• Pure mucous glands.
• PALATINE GLANDS
• Located in the posterolateral region of the hard
palate and submucosa of the soft palate and uvula.
• Pure mucous glands.

19
 Embryology
• Salivary glands develop as outgrowths of buccal epithelium
• Parotid – ectodermal in origin
• Submandibular &
Sublingual – endodermal in origin

• Parotid – 4th Wk
• Submandibular – 6th Wk
• Sublingual – 9th Wk
 Saliva
• Main function of
Salivary Gland-
secretion of saliva

• Daily secretion -800 to

1500 ml

• pH : 6-7
 Saliva Compositon

Water (99.5%) Solid (0.5%)

Organic Inorganic

Ptyalin Na+
Mucin K+
Lysozyme Ca+
IgA Cl-
Lactoferrin HCO3
Mg
 Functions of Saliva

• Keep the mouth moist

• Aids in swallowing
• Aids in speech
• Keeps the mouth and teeth
clean
• Antimicrobial action
• Digestive function
• Bicarbonate acts as buffer
 CLASSIFICATION OF DISEASES OF
SALIVARY GLAND

 DEVELOPMENTAL  OBSTRUCTIVE DISORDERS

• Aplasia • Sialolithiasis
• Atresia • Mucous plug
• Aberrancy or ectopic salivary glands • Stricture and stenosis
• Congenital fistula • Foreign bodies
• Accessory gland and duct • Extraductal causes
 FUNCTIONAL DISORDERS  Cysts
• Sialorrhea • Mucocele
• Xerostomia • Ranula
  • Lymphoepithelial cysts
•   • Brachial cysts
 ASYMPTOMATIC  AUTOIMMUNE
ENLARGEMENTS DISORDERS
• Sialosis • Sjogren’s syndrome
• Allergic • Mikulicz’s disease
• ASSOCIATED WITH • Uveoparotid fever
MALNUTRITION AND • Recurrent non specific parotitis
ALCOHOLISM
 NEOPLASMS
 Infections • Benign but seldom recurrent
• Bacterial infections • Warthins tumour
• Viral infections • Oncocytoma
• Mycotic infections • Monomorhic salivary adenomas
• Benign but often recurrent • Others
• Pleomorphic adenoma • Lymphomas
• Mucoepidermoid tumor • Metastatic tumors
• Malignant • Frey’s syndrome
• Carcinoma in pleomorphic • Melkersson Rosenthal
adenoma syndrome
• Adenoid cystic carcinoma • Salivary fistula
• Acinic cell tumor
 Investigations
• Plain radiographic examination
• Sialography (conventional, CT, MRI)
• Flow rate studies
• Ultrasound
• Computed tomography (CT)
• Cone beam Computed tomography (CBCT)
• Magnetic resonance imaging (MRI).
• Radionuclide scintigraphy
 INTRAORAL RADIOGRAPHY

• Sialoliths in the anterior two thirds of the submandibular duct -

crossectional mandibular occlusal .
• The posterior part of the duct is demonstrated with an over the
shoulder occlusal projection view, where the directing cone is placed
on the shoulder and the central ray is directed in an anterior
direction through the angle of the mandible, with the patient’s head
tilted to the unaffected side and rotated back.
• Parotid sialoliths are more difficult to demonstrate than the
submandibular variety as a result of the tortuous course of Stensen
duct around the anterior border of the masseter and through the
buccinator muscle.
• As a rule, only sialoliths in the anterior part of the duct,
anterior to the masseter muscle, can be imaged on an
intraoral film.
• To demonstrate sialoliths in the anterior part of the duct,
an intraoral film packet is held with a hemostat inside the
cheek, as high as possible in the buccal sulcus and over the
parotid papilla.
• The central ray is directed perpendicular to the center of
the film.
 PLAIN FILM RADIOGRAPHY

• Simplest , oldest, and cheapest way of studying the

salivary glands.
• Most common disorder :Obstruction caused either by
salivary stones(calculi) or stricture of the ducts.
• Salivary calculi –Radiopaque (40-60% in parotid and
80% in submandibular glands)
Salivary gland Radiographic projections used
Parotid gland Panoramic radiograph
Oblique lateral
Rotated PA or AP with cheek blown out

Submandibular Panoramic radiograph

gland Oblique lateral
Lower occlusal 90( to show duct)
Lower oblique occlusal (to show the gland)
True lateral with the tongue depressed
Rotated AP (below mandible)
• Parotid gland radiography requires posteroanterior
projection with extended chin, open mouth, and cheeks
blown out to delineate Stenson’s duct lesion.
• Submandibular gland radiography requires
posteroanterior and ipsilateral oblique projection with
extended chin, open mouth, and tongue depressed by
patients’ finger.
Submandibular duct stone; 55-year-old male with incidental finding of painless swelling in floor of
mouth, and no history of pain or variable swelling. A Intraoral occlusal view shows large stone in
Wharton’s duct (asterisk). B Clinical photograph during surgery shows stone after surgical incision
(arrow). C Clinical photograph of “released” stone (about 28 mm long).
 SIALOGRAPHY
• Sialography can be defined
as the radiographic
demonstration of the major
salivary glands by
introducing a radiopaque
contrast medium into their
ductal system.
• Effective for the diagnosis of
obstruction caused by stones
or strictures.
• Divided into 3 phases:
1. The preoperative
phase
2. The filling phase
3. The emptying phase
 Preoperative phase

• This involves taking preoperative (scout) radiographs, if not

already taken, before the introduction of the contrast medium,
for the following reasons:
• To note the position and/or presence of any radiopaque
obstruction
• To assess the position of shadows cast by normal anatomical
structures that may overlie the gland, such as the hyoid bone
• To assess the exposure factors.
 Filling phase

• Having obtained the scout films, the relevant duct orifice needs
to be found, probed and dilated and then cannulated.
• The contrast medium can then be introduced.
• When this is complete, the filling phase radiographs are taken,
ideally at least two different views at right angles to one another.
 Rabinov sialographic catheter

Salivary duct dilator

 Emptying phase
• The cannula is removed and the patient allowed to rinse
out.
• The use of lemon juice at this stage to aid excretion of
the contrast medium is often advocated but is seldom
necessary.
• After 1 and 5 minutes, the emptying phase radiographs
are taken, usually oblique laterals.
• These films can be used as a crude assessment of
function.
 Contrast media
• Physiological properties similar to that of saliva.
• Miscibility with saliva.
• Absence of local and systemic toxicity.
• Pharmacological inertness.
• Satisfactory opacification.
• Low surface tension and low viscosity to allow filling of fine
components of the ductal system.
• Easy elimination.
• Residual contrast media should be absorbed by the salivary
glands and detoxified by the liver and excreted by the kidney.
 Contrast media
• Ionic aqueous solutions., including:
— Diatrizoate (Urografin®)
— Metrizoate (Triosil®)
• Non-ionic aqueous solutions, including:
— lohexol (Omnipaque®)
• Oil-based solutions, including:
— Iodized oil, e.g. Lipiodol® (iodized poppy
seed oil)
— Water-insoluble organic iodine compounds,
e.g. Pantopaque®.
 INDICATIONS

1. To determine the presence and/or position of calculi or other

blockages, whatever their radiodensity.
2. To assess the extent of ductal and glandular destruction
secondary to an obstruction.
3. To determine the extent of glandular breakdown and as a crude
assessment of function in cases of dry mouth.
4. To determine the location, size, nature and origin of a swelling
or mass.
 CONTRAINDICATIONS

• Allergy to compounds containing iodine

• Periods of acute infection/inflammation, when there is
discharge of pus from the duct opening.
• When clinical examination or routine radiographs have
shown a calculus close to the duct opening, as injection
of the contrast medium may push the calculus back
down the main duct where it may be inaccessible.
 Sialographic techniques

• Simple injection
technique
• Hydrostatic technique
• Continuous infusion
pressure-monitored
technique
 SIMPLE INJECTION TECHNIQUE
• Oil-based or aqueous contrast medium is introduced using
gentle hand pressure until the patient experiences tightness
or discomfort in the gland, (about 0.7 ml for the parotid
gland, 0.5 ml for thesubmandibular gland).
• Advantages:
• • Simple
• • Inexpensive.
Disadvantages:
• The arbitrary pressure which is applied may cause
damage to the gland
• Reliance on patient's responses may lead to underfilling
or overfilling of the gland.
 HYDROSTATIC TECHNIQUE

Aqueous contrast media is allowed to flow freely into the gland under the
force of gravity until the patient experiences discomfort.
Advantages
• The controlled introduction of contrast medium is less likely to cause
damage or give an artefactual picture
• Simple& Inexpensive.
Disadvantages
• Reliant on the patient's responses
• Patients have to lie down during the procedure, so they need to be
positioned in advance for the filling-phase radiographs.
CONTINUOUS INFUSION PRESSURE-MONITORED
TECHNIQUE

• Using aqueous contrast medium, a constant flow rate is adopted and the
ductal pressure monitored throughout the procedure.
dvantages
• The controlled introduction of contrast media at known pressures is not likely
to cause damage.
• Does not cause overfilling of the gland
• Does not rely on the patient's responses.
Disadvantages
• Complex equipment is required
• Time consuming.
Parotid sialography; sialodochitis, normal parenchyma.
A Side view shows no signs of stone in Stensen’s duct.
B Plain film sialography shows stricture (arrow), and
dilatation proximal duct.C Plain film shows retention of
contrast material; only parenchyma is without contrast
material after 5 minutes (courtesy of Dr. B. Svensson,
Skövde Hospital, Sweden)
 SIALOGRAPHIC INTERPRETATION

Once again, the essential requirements include:

• A systematic approach
• A detailed knowledge of the radiographic appearances of
normal salivary glands.
• A detailed knowledge of the pathological conditions
affecting the salivary glands.
 NORMAL SIALOGRAPHIC APPEARANCES OF THE
PAROTID GLAND

• The main duct is of even

diameter (1-2 mm wide)
and should be filled
completely and uniformly.
• The duct structure within the
gland branches regularly
and tapers gradually
towards the periphery of the
gland, the so-called tree in
winter appearance.
 NORMAL SIALOGRAPHIC APPEARANCES OF THE
SUBMANDIBULAR GLAND

• The main duct is of even

diameter (3-4 mm wide) and
should be filled completely
and uniformly.
• This gland is smaller than
the parotid, but the overall
appearance is similar with
the branching duct structure
tapering gradually towards
the periphery — the so-called
bush in winter appearance.
 PATHOLOGICAL APPEARANCES

Based on the suggested systematic approach to sialographic

assessment, the main pathological changes can be divided into:
• Ductal changes associated with:
— Calculi
— Sialodochitis (ductal inflammation/infection)
• Glandular changes associated with:
— Sialadenitis (glandular inflammation/infection)
— Sjogren's syndrome
— Intrinsic tumours.
 SIALOGRAPHIC APPEARANCES OF
CALCULI
• Filling defect(s) in the main
duct
• Ductal dilatation proximal
to the calculus
• The emptying film usually
shows contrast medium
retained behind the stone.
 SIALOGRAPHIC APPEARANCES OF
SIALODOCHITIS

• Segmented sacculation or
dilatation and stricture of
the main duct, the so-
called sausage link
appearance.
• Associated calculi or
ductal stenosis.
 SIALOGRAPHIC APPEARANCES OF
SIALADENITIS

• Dots or blobs of contrast

medium within the gland, an
appearance known as
sialectasis caused by the
inflammation of the
glandular tissue producing
saccular dilatation of the
acini.
• The main duct is usually
normal.
 SIALOGRAPHIC APPEARANCES IN
SJOGREN 'S SYNDROME
• Widespread dots or blobs of contrast
medium within the gland, an
appearance known as punctate
sialectasis or snowstorm.
• This is caused by a weakening of
the epithelium lining the
intercalated ducts, allowing the
escape of the contrast medium out
of the ducts.
• Considerable retention of the contrast
medium during the emptying phase.
• The main duct is usually normal.
 Sialographic appearances of intrinsic tumours
include:
• An area of underfilling within
the gland, owing to ductal
compression by the tumour
• Ductal displacement — the
ducts adjacent to the tumour
are usually stretched around it,
an appearance known as ball in
hand
• Retention of contrast medium
in the displaced ducts during
the emptying phase.
 INTERVENTIONAL SIALOGRAPHY

• Conventional sialographic techniques can be supplemented and

expanded into minimally invasive interventional procedures by
using balloon catheters and small Dormia baskets under
fluoroscopic guidance.
• The balloon catheter, as the name implies, can be inflated once
positioned within a duct to produce dilatation of ductal strictures.
• The Dormia basket may be used to retrieve mobile ductal salivary
stones.
• Both these procedures are now being used successfully to relieve
salivary gland obstruction without the need for surgery.
Parotid sialography; occlusion of Stensen’s duct and no
filling of parenchyma before successful duct
ballooning.A Digital subtraction parotid sialography;
stricture occluding Stensen’s duct (arrow). B
Subtraction sialography after probing through duct with
guide wire shows stenosis (arrow) but filling of
parenchyma.C Subtraction sialography after dilatation
shows widening of stricture (arrow). A small filling
defect in gland (arrowhead) may be mucus or residual
stone. Patient
did well after procedure and no further intervention was
needed
 FLOW-RATE STUDIES

• These are used to investigate salivary gland function.

• Comparative flow rates of saliva from the major salivary
glands are measured over a time period.
Indications
• Dry mouth
• Poor salivary flow
• Excess salivation.
Advantages Disadvantages
• Ionizing radiation is not • Provides only limited
used information — no
• Simple to perform indication of the nature of
• Provides information on underlying disease
salivary gland function. • Time consuming
 ULTRASOUND IMAGING

Indications
• Discrete and generalized
swellings both intrinsic
and extrinsic to the
salivary glands
• Salivary obstruction.
•Advantages
• Ionizing radiation is not used
• Provides good imaging of superficial masses
• Useful for differentiating between solid and cystic masses and for
identifying nature and location of the margins of a lesion
• Different echo signals are obtained from different tumours
• Identification of radiolucent stones
• Lithotripsy of salivary stones
• Ultrasound-guided fine-needle aspiration
(FNA) biopsy possible
• Intraoral ultrasound possible with small probes.
DISADVANTAGES
• The sound waves used are blocked by bone, so limiting the areas available for
investigation.
• Provides no information on fine ductal architecture.

HRUS images show altered echopattern of the parotid gland with ductal dilatation (thin arrow) and
small calculus (thick arrow) at its terminal end
 High‑resolution Ultrasonography

• It is a quick and noninvasive method of evaluating parotid and

submandibular glands.
• Both glands appear homogeneously hyperechoic on HRUS, and
retromandibular vein can be noted within the parotid gland.
• It is performed by a high‑frequency linear (7-10 MHz) transducer.
• It helps in differentiating cystic from solid lesions and also aids in
guiding the exact site of Fine Needle Aspiration Cytology (FNAC)
in suspected salivary gland lesions.s

Pictorial essay:Salivary Gland Imaging:Indian journal of radiology Vol-22 Issue 4-Nov 2012
3D HRUS image shows parotid gland with altered HRUS image shows submandibular gland abscess (white
Echo patternwith ductal dilatation and small calculus arrows)
at its terminal end

Pictorial essay:Salivary Gland Imaging:Indian journal of radiology Vol-22 Issue 4-Nov 2012
 COMPUTED TOMOGRAPHY
Indication
• Discrete swellings both intrinsic and extrinsic to the salivary glands.
Advantages
• Provides accurate localization of masses, especially in the deep lobe
of the parotid.
• The nature of the lesion can often be determined
• Images can be enhanced by using contrast media, either in the
ductal system or more commonly intravenously
• Co-localization possible with PET scans
• CT sialography may be performed.
Disadvantages
• Provides no indication of
salivary gland function
• Risks associated with
intravenous contrast media
if used.
• Fine duct detail is not
well imaged.
 MAGNETIC RESONANCE IMAGING

Indication
• Discrete and generalized swellings both intrinsic and extrinsic to the salivary
glands.
Advantages
• Ionizing radiation is not used
• Provides excellent soft tissue detail, readily enables differentiation between
normal and abnormal
• Provides accurate localization of masses
• The facial nerve may be identifiable
• Images in all planes are available
• Co-localization possible with PET scans
• MR sialography may be performed
Disadvantages:
• Provides no information on
salivary gland function
• Limited information on
surrounding hard tissues
• May not distinguish benign
lesions with high water
content from cysts.
 SCINTIGRAPHY (NUCLEAR
MEDICINE)
• Nuclear medicine, or scintigraphy, provides a functional study of the
salivary glands, taking advantage of the selective concentration of specific
radiopharmaceuticals in the glands.
• When 99mTc-pertechnetaties injected intravenously, it is concentrated in
and excreted by glandular structures, including the salivary, thyroid, and
mammary glands.
• The radionuclide appears in the ducts of the salivary glands within minutes
and reaches maximal concentration within 30 to 45 minutes.
• A sialogogue is then administered to evaluate secretory capacity.
• Lesions that concentrate 99mTc-pertechnetate are Warthin tumor and
oncocytoma.
Indications
• Dry mouth as a result of salivary gland diseases such as Sjogren's
syndrome
• To assess salivary gland function
• PET for salivary gland tumours.
Advantages
• Provides an indication of salivary gland function
• Allows bilateral comparison and images all four major salivary
glands at the same time
• Computer analysis of results is possible
• Can be performed in cases of acute infection
• Co-localization of PET with CT or MRI scans.
Disadvantages
• Provides no indication of salivary gland anatomy or ductal
architecture
• Relatively high radiation dose to the whole body
• The final images are not disease-specific.
 POSITRON EMISSION
COMPUTED TOMOGRAPHY)

• Recently used for the evaluation of the salivary glands.

• Useful for measuring salivary gland function and recognizing
inflammatory changes.
• Combination of SGS and Flourodeoxyglucose(FDG)PET –
differentiation of various parotid gland tumours.
• 18 – FDG PET/CT –assessing autoimmune disease activity.
• Increased uptake of FDG is observed in Sjogren’s syndrome
patients.
 CONE BEAM COMPUTED TOMOGRAPHY

• Provides high spatial

resolution of osseous structures
at a lower dose of radiation than
the conevtional CT.
• CBCT sialography provides
several advantages over
conventional sialography
including 3D reconstruction
and allowing for manipulation
of image rotation,slice
thickness.
Assessment of the role of cone beam computed sialography in diagnosing salivary gland lesions:
Imaging Science in Dentistry 2013; 43 : 17-23
 Image Interpretation of Salivary
Gland Disorders

OBSTRUCTIVE AND INFLAMMATORY

DISORDERS
 SIALOLITHIASIS

Synonyms:Calculus and salivary stone

• Definition:Sialolithiasis is the
formation of a calcified obstruction
within the salivary duct.
• Sialoliths can obstruct the secretory
ducts, resulting in chronic retrograde
infections because of a decrease in
salivary flow.
• Clinical symptoms include intermittent
swelling and pain with eating and
signs of infection.
 Radiographic features
• Radiopaque or radiolucent on radiographic examinations.
• Long cigar shapes to oval or round shapes.
• When visible, they usually have a homogeneous radiopaque internal
structure.
• Sialography is helpful in locating obstructions that are undetectable with plain
radiography, especially if the sialoliths are radiolucent.
• The contrast agent usually flows around the sialolith, filling the duct proximal
to the obstruction.
• The ductal system is frequently dilated proximal to the obstruction and infers
the presence of an obstruction even when it is not visible.
• The contrast agent that flows around the sialolith is more radiopaque and may
obscure small sialoliths.
• US is of limited value. More than 90% of stones larger than 2 mm are
detected as echo-dense spots with a characteristic acoustic shadow.

Ultrasonogram of the left submandibular gland, small salivary stone (1.5 mm) in the hilum of
the left submandibular gland (arrow) without acoustic shadow
 BACTERIAL SIALADENITIS

Synonyms:
Parotitis and submandibulitis
Definition:
Bacterial sialadenitis is an acute or
chronic bacterial infection of
the terminal acini or
parenchyma of the salivary
glands.
Clinical Features
• Commonly affects the parotid gland, but the submandibular gland may also
• be involved.
• Unilateral and may occur at any age.
• Swelling , redness, tenderness, and malaise.
• Enlarged regional lymph nodes and suppuration may also be noted.
• Chronic inflammation may affect any of the major salivary glands, causing
extensive swelling and culminating in fibrosis.
• This may be a consequence of an untreated acute sialadenitis or associated with
some type of obstruction resulting from sialolithiasis, noncalcified organic
debris, or stricture (scar or fibrosis) formation in the excretory ducts.
 • During periods of painful swelling, pus may be expressed from
the ductal orifice and salivary stimulation may cause pain.
• Episodic in nature, signs of generalized sepsis are seldom
present.
• The obstruction may be congenital or secondary to sialolithiasis,
trauma, infection, or neoplasia. .
• Typical clinical symptoms are intermittent swelling, pain when
eating, and superimposed infection resulting from salivary stasis
Submandibular sialoadenitis due to duct stone; 59-year-old female with right submandibular swelling. A Axial
post-contrast CT image shows enlarged submandibular gland with stranding and reticulation of periglandular fat
(arrow). B Axial CT image shows stone in anterior part of Wharton’s duct (arrow
• Radiographic Features:
• Sialography is contraindicated.
• Epithelial flattening may lead to mildly dilated terminal ducts and saclike acini,
which is demonstrable with sialography.
• The saclike acinar areas are referred to as sialectasia.
• An even distribution throughout the gland is seen in recurrent parotitis and
autoimmune disorders.
• If connected to the ductal system,a bscessc avities may fill with contrast media
during sialography.
• Abscess cavities appear on CT as walled-off areas of lower attenuation within
an enlarged gland.
Advanced chronic sialoadenitis (another patient for comparison), with multiple
scattered non-uniform collections of contrast medium (sialectasias) due to radiolucent
stone, void of contrast filling (arrow)
• US may distinguish between diffuse
inflammation (echo-free, light image)
and suppuration (less echo-free, darker
image) and may detect sialoliths greater
than 2 mm in diameter.
• Contrast-enhanced CT may demonstrate
glandular enlargement
• On MRI inflamed glands are usually
enlarged and demonstrate a lower tissue
signal on T1-weighted images and higher
signal on T2- weighted images than that
of the surrounding muscle.
 SIALODOCHITIS

Synonym : Ductal sialadenitis

Definition : Sialodochitis is an inflammation of the ductal system of the
salivary glands.
Clinical Features
• Dilation of the ductal system or sialectasia is a prominent sialographic
presentation of sialodochitis
• If interstitial fibrosis develops, it is apparent in sialograms as a sausage-
stringa ppearance of the main duct and its major branches produced by
alternate strictures and dilations.
• Scintigraphy and CT are not typically indicated in the diagnosis of
inflammatory ductal diseases of the salivary glands.
 SJÖGREN SYNDROME

Definition
• Chronic, systemic autoimmune disease of exocrine
glands characterized by periductal lymphocytic
aggregates that extend into and destroy salivary and
lacrimal parenchyma primarily, but also other exocrine
glands.
Clinical Features
▬ Primary Sjögren syndrome or secondary; associated with a
connective tissue disease, usually rheumatoid arthritis
▬ Second in frequency to rheumatoid arthritis of all autoimmune
diseases
▬ Predominantly women, 40–60 years of age
▬ Tender glandular swelling; recurrent episodes
▬ Nonpainful glandular enlargement
▬ Xerostomia and keratoconjunctivitis sicca
▬ Higher risk of developing non-Hodgkin’s lymphoma, extranodal in
particular
• Earliest sialographic signs: multiple peripheral punctate
collections (1 mm or less) of contrast medium with conventional
sialography (“leafless fruit-laden tree”) uniformly distributed in
the gland, later with larger globular collections of contrast
medium due to parenchyma destruction but characteristically
with normal central duct system; contrast medium drains from
main ducts but remains in punctate and globular collections.
• With reduced salivary flow, ascending superimposed
sialoadenitis and sialodochitis will develop.
The classification in the filling phase is as follows:
1. Punctate: punctate ectasies less than 1 mm in diameter, normal
main duct, decrease in the number and narrowing of the
intraglandular ducts;
2. Globular: globules of contrast material 1 to 2 mm in diameter,
main duct normal, intraglandular duct division invisible;
3. Cavitary: coalescence of the globules, which become irregular
in size and distribution, and decrease in number;
4. Destructive: destruction of the gland parenchyma, marked
dilatation of the main duct
Rubin P & Holt JF (1957) Secretory sialography in diseases of the major salivary glands.
Am J Roentgenol 77: 575-598.
▬ T1-weighted MRI: multiple punctate
changes of low density uniformly
distributed in the gland earliest signs,
diagnostic for Sjögren syndrome.
▬ T2-weighted MRI:multiple punctate
changes have high signal reflecting
watery saliva.
▬ Punctuate changes will progress to
globular, cavitary and destructive
abnormalities.
▬ T1-weighted
At end-stage a honeycomb
MRI shows some swelling of right parotid gland which has a little
appearance
less signal than may develop,
left gland, with
and with multiple small irregularities. T2-weighted MRI shows
multiple
small cysticcystic lesions
fluidfilled and abnormally
irregularities consistent with chronic sialoadenitis. Note dilated
parotid duct along masseter muscle (arrow).
dense parenchyma.
 NONINFLAMMATORY DISORDERS

SIALADENOSIS
Synonym :Sialosis
Definition:
Sialadenosis is a nonneoplastic, noninflammatory enlargement of
primarily the parotid salivary glands. It is usuallv related to
metabolic and secretory disorders of the parenchyma associatedw
ith diseases of nearly all the endocrine glands (hormonal
sialadenoses), protein deficiencies, malnutrition in alcoholics
(dystrophicmetabolic sialadenoses), vitamin deficiencies, and
neurologic disorders (neurogenic sialadenoses).
Clinical Features:
Affected glands are typically enlarged.
Radiographic Features:
• Sialography may demonstrate enlargement of the affected glands
or a normal appearance.
• In enlarged glands, the ducts will be splayed.
• CT and MRI provide a more straightforward depiction of the
glands, but are nonspecific and require correlation with the
clinical findings and history.
 CYSTIC LESIONS

• Ranulas are retention cysts that usually occur secondary to

obstruction of the sublingual duct.
• Benign lymphoepithelial cysts -sequelae of cystic degeneration of
salivary inclusions within lymph nodes.
• Multicentric parotid cysts -associated with HIV have been
reported.
• These lesions are accompanied by cervical lymphadenopathy,
occur bilaterally, and are usually in the superficial portion of the
parotid gland .
• Radiographic Features
• On sialographic examination, cystic
masses are indirectly visualized only
by the displacement of the ducts
arching around them.
• ▬ T1-weighted MRI: low signal
• ▬ T2-weighted MRI: high (cyst) or
low (solid mass) signal
• When imaged with US, cysts are Axial T2-weighted MRI shows bilateral fluid-filled
sharply marginated and echo-free cysts (arrows) and a solid lesion (arrowhead).
(represented as a dark area)
BENIGN TUMORS

Imaging Features
▬ Well-defined mass, highly variable size,
cystic, lobulated
▬ Small tumors show homogeneous
enhancement; large, lobulated tumors
show heterogeneous enhancement
▬ May show calcification
▬ T1-weighted MRI: small tumors show
homogeneous, low signal; large,
lobulated tumors show
heterogeneous low to intermediate signal
 WARTHIN TUMOR

• Synonym:Papillary cystadenoma lymphomatosum

• Definition
• Warthin tumor is a benign tumor arising from proliferating salivary
ducts trapped in lymph nodes during embryogenesis of the salivary
glands.
• Clinical Features:
• Warthin tumor-second most common benign neoplasm, 2% to 6% -
parotid tumors(inferior lobe of the gland).
• slow growing , painless, and frequently bilateral,afflicts males over
the age of 40 years.
 Radiographic Features
• On CT, this tumor may be of either soft
tissue or cystic density.
• On MRI-heterogeneous and may
demonstrate hemorrhagic foci.
• Warthin tumor -'intensely hot on 99mTc-
pertechnetate scans.
• Oncocytoma (oxyphilic adenoma) may also
accumulate the 99mTc-pertecbnetate are
uncommon and less likely to be bilateral.
• The US presentation of Warthin tumor is
that of a solid mass (hypoechoic), unless, the
tumor mass happens to be cystic in nature.
 HEMANGIOMA

Definition
Benign tumor of proliferating endothelial cells.
Clinical Features
▬ Most frequent nonepithelial salivary gland tumor.
▬ Predominantly in parotid gland.
▬ Most common salivary gland tumor during infancy and childhood;
90% of all parotid tumors in first year of life.
▬ Premature infants in particular.
▬ Females more than males.
 Imaging Features

▬ Soft-tissue mass, frequently lobulated, isodense to muscle, contrast-

enhancing
▬ Uni- or bilateral, single or multiple
▬ T1-weighted MRI: isointense to muscle
▬ T2-weighted MRI: high signal
▬ T1-weighted post-Gd MRI: intense contrast enhancement.
• Although US usually demonstrates well-defined margins in the
hemangioma, ill-defined margins may also be noted and strongly
hypoechoic.
 Malignant Tumors
Mucoepidermoid Carcinoma
Definition
Tumor characterized by presence of
squamous cells, mucus-producing
cells, and cells of intermediate type
(WHO).
Imaging Features
▬ May look benign with well-defined,
smooth borders and cystic areas
▬ May have similar appearance to
pleomorphic adenomas, in particular
low-grade (less aggressive)
mucoepidermoid carcinomas
 CONCLUSION
• A variety of disease patterns involve the major salivary
glands with few characteristic features on imaging.
• HRUS should be the first screening imaging tool followed
by sialography, if required.
• CT is the mainstay of imaging in sialolithiasis while MRI
is more optimal for neoplastic processes with associated
invasion.
• CT and MRI are equally good in imaging of the cystic
and inflammatory lesions especially abscesses.
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1.King AD, Yeung DK, Ahuja AT, Tse GM, Yuen HY, Wong KT, et al. Salivary
gland tumors at in vivo proton MR spectroscopy. Radiology 2005;237:563 ‑9.
2. Shah VN, Branstetter BF 4th. Oncocytoma of the parotid gland: A potential
false‑positive finding on 18F‑FDG PET. AJR Am J Roentgeol
2007;189:W212‑4.
3. Marchal F, Dulguerov P. Sialolithiasis management: The state of the art. Arch
Otolaryngol Head Neck Surg 2003;129:951‑6.
4. Salivary gland calculi – contemporary methods of imaging :Pol J Radiol, 2010;
75(3): 25-37
5.Pictorial essay:Salivary gland imaging .IJRI/Nov 2012/ Vol 22/Issue 4.
6.Assessment of the role of cone beam computed sialography in diagnosing
salivary gland lesions:Imaging Science in Dentistry 2013; 43 : 17-23
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