Imaging of salivary glands

Introduction:
Anatomy of salivary glands: there are
three major salivary glands: parotid,
submandibular and sublingual. These
are paired glands that secrete a
highly modified saliva through a
branching duct system.

Parotid saliva is released through

Stensons duct, the orifice of which
is visible on the buccal mucosa
adjacent to the maxillary 1st molars

Sublingual saliva may enter the

floor of the mouth via a series of
independent ducts, but will empty
into the submandibular (Whartons)
duct about half of the time.
The orifice of whartons duct is
located sublingually on either side

There are also thousands of minor

salivary glands throughout the mouth
named for their location ( labial,
buccal, palatal,etc) lie just below
mucosal surface and communicate
with oral cavity via short ducts.

They share basic

anatomic structure
composed of acinar and
ductal cells arranged much
like a cluster of grapes on
stems.
The acinar cells (the
grapes) = secretory
endpiece and are sole site
of fluid transport into the
duct.
The ductal cells ( the
stems) = branching system
carries the saliva from the
acini into the oral cavity

Salivary gland diseases:

I
II
III
IV

functional disorders
obstructive disorders
non neoplastic disordes
neoplastic disorders

I functional disorders:
- sialorrhea ( increase in saliva flow)

I functional disorders:
-xerostomia (decrease in saliva flow)

I functional disorders:
-mucocele (mucous retention cyst)

I functional disorders:
- ranula ( sublingual salivary gland
mucocele)

I functional disorders:

II obstructive disorders:
sialolithiasis:
(formation of
calcified
obstruction within
the duct)
submandibular
gland lithiasis

II obstructive diseases:
Parotid lithiasis:

III Non neoplastic disorders:

Acute Sialadenitis :viral( mumps)

bacterial (staph aureus, strept

pyogenes)

III Non neoplastic disorders:

Chronic sialadenitis( strept viridans)

III Non neoplastic disorders:

Necrotizing sialometaplasis;
Involves minor salivary glands in hard
palate of no definite etiology

IV Neoplastic disorders:
Epithelial:
-adenomas
e.g:pleomorphic adenoma

-mucoepidermoid tumor.
-acinic cell tumor
-carcinomas. E.g: adenocarcinoma

Non epithelial:
Malignant lymphoma.
Unclassified tumors.

Allied conditions:
Benign lymphoepithelial lesions.
Sialosis (hyperplasia)
oncocytosis

Sjogrens syndrome :

Salivary gland imaging

modalities:

[1] Plain Radiography

Importance : (1) It may
identify unrelated pathoses
in the areas of salivary
gland that can be
mistakenly identified as
salivary gland disease.
e.g. :- Resorptive or
osteoblastic changes in
adjacent bone causing
periauricular swelling
mimicking parotid tumor
panoramic or
posteroaterior view may
demonstrate bony lesion,
thus exclude salivary
pathosis

(2) It is useful when

patient history and
clinical examination
suggests
prescence of
sialolith

(3) Carcinomas can be apparent on

plain radiography But when
destructive changes occur to adjacent
osseous structures.

Intraoral
radiography :
Submandibular
sialolith
[A] Anterior 2/3 of
the whartons
duct :- it can be
imaged by To
pographic
mandibular occlusal
projection

[B] Posterior part of duct :- can be

demonstrated by posterior oblique view,
where patients head is tilted back &
inclined toward unaffected side. The central
ray is parallel with mandible in area of
submandibular fossa and posterior part of
floor of mouth.

 Parotid Saliolith :

In Ant part stensons duct anterior to

masseter :- imaged by Intraoral film
that is held by hemostate against the
cheek as high as possible in buccal
sulcus over the parotid papilla, the
central ray is perpendicular to the film.
The distal portion of the duct :- difficult
to demonstrate on intraoral film
because of tortuous course of the duct
around anterior border of masseter
muscle and buccinator muscle .

Extraoral Radiography
Submandibular Sialolith :
Panorama demonstrate sialotith in
posterior duct.
demonstrate Intaraglandular
sialolith .
Lateral projection demonstrate Sialolith in
the gland but the projection is modified by
opening patient mouth, extending the chin,
depressing the tongue with index finger
this usually moves image of sialolith inferior
to mandibular border where image is
apparent.

Parotid Saliolith :
Lateral projection difficult to demonstrate
parotid sialolith or in distal part of duct because it
is superimposed over ramus and body of mandible
But it can be demonstrated by posteroanterior
view.
Posteroanterior projection made with check
puffed out moving the image of sialolith free of
bone making it visible on image.
Also, this can demonstrate intraglandular sialolith.

Appearance of Sialolith in plain

radiography:
* Sialolith appears radiopaque object as it is
calcified
* Long standing stones appear more radiopaque
than surrounding bone.
* It is important to use about half the usual
exposure to avoid over exposure of sialolith.
* Some stones are not well calcified (of high
organic content) , that appear radiolucent , these
sialolith better demonstrated by sialography
20% of sialolith of submandibular gland
40% of Sialolith of parotid gland
Rarely in sublingual gland

Sialography

Definition:
Is radiographic visualization of
salivary gland following retrograde
instillation of radiopaque contrast
medium into ductal system of salivary
gland
The film obtained is called sialogram

what is a contrast medium?!

Def:
Is a radiographic diagnostic agent
of high opacification ( In dental
field iodine compounds are
mainly used )

Requirements :
1- Inert pharmacologically
2- Non Toxic
3- Similar to saliva physiologically
(PH & surface tension)
4- Easily evacuated through :
Blood , oral cavity & Kidney .

Kinds :
Water- soluble (ionic):urographin (diatrizoate)
Soluble in saliva can diffuse to
glandular tissue RG density
= poor visualization.
Oil based (non ionic) : lipidol
Used only intraductal never
intravenous ( can cause emboli )
Not diluted in saliva or across the
mucosa maximum
opacification
Higher viscocity water soluble
contrast agents or suspensions
are also available

Problem : iodine may induce allergic

reaction or interfere with thyroid
function or evaluation
Symptoms : pain , flushing ,
headache or it may be fataldeath
To avoid : History , skin test,
explanation, premedication
(antihistaminic)

Uses of sialography:
*Sialography provides clearest visualization
of branching ducts & acinar end pieces
*Chronic inflammatory diseases, ductal
pathosis & localized sialolith or stricures
(obstructions) are easily recognized.
* When patients present history of rapidonset , acute painful swelling of a single
gland (typically brought on by eating).
* Whereas potential neoplasms are better
visualized by CT or MRI.
*Valuable tool in presurgical planning prior
to the removal of salivary masses.

Mainly for:
Parotid gland & submandibular gland
although sublingual gland is difficult to
infuse intentionally it may be
opacified while infusing whartons
duct to image the submandibular
gland .

Method:
[a] pateint preparation :
1- Scout film , is initial plain film for :- Use as a background for
interpreting the sialogram
-Visualizing radiopaque stones
and potential bony destruction.
2- Antiseptic mouth wash to alleviate
bacterial activity
3- Anatomical demarcation of duct orifice
4- Application of local anaesthesia around
orifice to remove pain.

[b] Filling phase :

1- Successive graduated sizes of lacrimal probes
are used for duct dilatation
2- Place the cannula or polyethylene catheter.
3- Use empty syringe for sucking the residual
saliva present to avoid back pressure.
4- Hypodermic plastic syringe 2cm or 3cm loaded
with contrast medium is applied.
- Inject slowly till patient feels discomfort
(usually between 0.2 and 1.5 ml depending on the
gland being studied
- Fluoroscopic monitoring is recommended by
some otherwise static films monitoring . 0

[c] Taking the radiograph :

N.B: ( Dont remove the cannula till the
sialogram is processed)
I- Parotid gland : oblique lateral
true lateral-posteroanteior
(occipitofrontal) puffed cheek
II- Submandibular gland : best
seen with mandibular occlusal view

Normal appearance :
Normal ductal architecture is leafless
tree appearance.
The submandibular gland demonstrate
more abrupt transition in ductal
diameter whereas parotid
demonstrate a gradual decrease in
diameter .

What abnormalities can be

detected ??
* Ductal strictures , obstruction, dilatation
ductal ruptures & stone can be visualized

Sausage appearance

* Sialectasis : is the appearance of

focal collection of contrast medium
within the gland, seen in sialadenitis,
Sjogrens syndrome.
The progression of severity is
classified into punctate, globular and
cavitary.

* Ball between two fingers benign

tumors ( slowly growing well
capsulated pressure on ductule)

Non opaque sialoliths appear as

voids
Bizzar or beading appearance
malignant tumors.

[d] Emptying phase : (evacuation ):

- The gland is allowed to empty for 5 minutes
without stimulation.
- Then sialogogue such as lemon juice or 2%
citric acid, bubble gums or massage to the gland is
done to encourage evacuation
Post evacuation image after approximately 1 hour
to assure complete evacuation .
If substantial amount of contrast material
remains follow up visits until completely
emptying or fully resorption of it.
Otherwise look for : obstruction of salivary flow
extraductal or extravasated contrast collection of
contrast material in abcess cavities or impaired
secretory function .

Complication with sialography &

contraindications:
1- Allergic reaction against iodine
2- Perforation of duct during procedure
(extraductal injection ) that may lead to
granulomatous reaction
3- Acute exacerbation of chronic conditions
If performed during active infection may
further irritate & potentially rupture the
already inflamed gland
4- Anticipitated thyroid function tests.

Ultrasonography:

Principle:
x-ray equipment is replaced by a very high
frequency (3.5- 10 MHZ) ultrasound beam
which is directed in to body from a
transducer placed in contact with the skin .
US traveled through body and reflected back
by tissue interfaces to produce echoes that
is picked up by same transducer
electrical signal black, white & grey
visual echo picture which is displayed on
screen

uses:
Recently , it is reliable in demonstration
of sialolith, 90% of stones larger than
2mm are detected as echo-dense spots
with characteristic acoustic shadows.
It can distinguish between diffuse
inflammation (echo free light image ) and
suppuration (less echo free-darker)
image. Also it can detect abcess cavity if
present.

It is of low diagnostic importance to

sjogrens syndrom parenchymal
inhomogencity only .

The primary application of US is

differentiation of solid masses from cystic
ones.
Cystic lesions Sharply marginated &
echo-free (dark area )
Benign masses less echogenic than
parenchyma & well circumscribed .
Malignant masses homogenous echo
pattern with low reflectivity & attenuation,
poorly defined margins.

N.B Sonography is unable to

visualize deep lobe of parotid as it
lies medial to the ascending ramus of
the mandible

Nuclear medicine,
(Scintigraphy ),
Radioisotope scan

Definition
A technique provide functional study of
salivary gland taking advantage of
selective concentration of specific
radiopharmaceuticals in the glands.

Technique
- Intravenous injection of 99m Tc
pertechnetate , it is then concentrated in
and excreted by glandular structures
including salivary gland, thyroid, &
mammory glands.
- The radionuclide appear in ducts of salivary
glands .within minutes and reaches
maximal concentration within 30-45
minutes.
- A Sialogogue is administred to evaluate
secretory capacity .
- Importance: Pathosis can be
demonstrated by an increased, decreased
or absence of radionuclide uptake.

Examples :
Sjogrens syndrome Scintigraphy is
useful for diagnosis & monitoring
progression of syndrome.
Impairment of parotid and
submandibular is demonstrated by
decreased uptake of 99m Tc as well
as delay in its stimulated excretion.
In cystic lesions decreased
radioisotope uptake (cold spot )

But it doesnt give differential diagnosis

because Benign and malignant tumors also
appear as coldpot. So CT & MRI are
preferable for evaluation of salivary
masses.
Also , scintigraphy demonstrates little
morphology.
Scintigraphy is advantageous in conditions
in which sialography is contra indicated & in
patients where ducts cant be cannulated.

Computerized
Tomography

Principle:
ct scanners use x-ray to produce
sectional or slice image in which the
receptor is a gas detector or sensitive
crystal that measure the intensity of
the x-ray beam emerging from the
patient ( produce an attenuation or
penetration profile) convert it into
representing different tissue densities
= visual image

Equipment:

Planes:

Types:
Enhanced ct (contrast medium)
Ultra fast ct
Spiral ct

Thickness of the slice ( 1.5 ml 6 ml )

advantage of no superimposition
Manipulation: - window level: bony
level, soft tissue level differentiation
between soft and bony lesions
Window width:
narrow; enable to see minute differences
Wide

Reconstruction: to any other plane or

production of 3D image without
additional exposure to the patient

Applications in salivary gland:

Normal CT scan after right
submandibular sialogram

spiral ct

contrast enhanced
ct of the neck
demonstrate a
stone (blue arrow)
in the
submandibular
region of a dilated
Whartons duct
(red arrow)

Abscess of the submandibular salivary

gland. Post contrast CT shows
enlarged right submandibular gland
with central low density (small arrow)
and irregular peripheral contrast
enhancement (arrowhead).

Abscess of the submandibular salivary

gland. Post contrast axial CT image
demonstrates a calcified stone (arrow) in
the right submandibular gland. This is
consistent with an abscess of the right
submandibular gland secondary to an
obstruction from a stone (calculus).

Magnetic Resonance Image :

Idea:
It uses electrical and magnetic fields
and radiofrequency pulses rather
than ionizing radiation.
It involves the behaviour of Hydrogen
protons in a magnetic field to produce
the image.

Importance :
* It is better than CT in demonstrating soft
tissue image and vascular tumors .
* It demonstrates the margins of salivary
gland masses , Internal structures &
regional extension of lesions in to adjacent
spaces.
* But it is non specific in demonstration of
inflammatory duct disease or autoimmune
salivary gland disorders

Normally :
- Parotid gland appear in T1 weighted
image & T2 weighted image having
greater intensity than muscle & lower
intensity than fat.
- Structures that appear dark on both T1
& T2 weighted images include
calcifications, rapid blood flow & fibrous
tissue.

- In Benign tumors : may present as

low intensity (dark) or high intensity
(light) signal on T1 & T2 weighted
image & proton density weighted
format.

- In high grade malignancies : present as

low intensity (dark) signal on T1 & T2
weighted MRIs.
T1 Weighted image have low intensity
(dark) than surrounding structures & are
relatively homogenous.
T2 Weighted image brighter than T1
Weighted image and are slightly darker
than surrounding & are more
heterogenous.

Examples:

Conclusion

Ultrasonography
Indication: Biopsy guidance; mass
detection
Advantage: Noninvasive; cost-effective
Disadvantage: No quantification of
function; observer variability; limited
visibility of deeper portions of gland; no
morphologic information

Sialography
Indication: Stone, stricture; R/O
autoimmune or radiation-induced
sialadenitis
Advantage: Visualizes ductal
anatomy/blockage
Disadvantage: Invasive: require iodine
dye; no quantification

Radionuclide imaging
Indication: Autoimmune sialadenitis,
sialosis, tumor
Advantage: Quantification of function
Disadvantage: Radiation exposure; no
morphologic information

Computerized tomography
Indication: R/O calcified structure;
tumor
Advantage: Differentiate osseous
structures from soft tissue
Disadvantage: No quantification;
contrast dye injection ( in enhanced);
radiation exposure

Magnetic resonance imaging

Indication: R/O soft-tissue lesion
Advantage: Soft-tissue resolution
excellent, with ability to differentiate
osseous structures from soft tissue; no
radiation burden
Disadvantage: No quantification;
contraindicated with pacemaker or
metal implant; dental scatter

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