Professional Documents
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Imaging of Salivary Glands
Imaging of Salivary Glands
Presented by:
I functional disorders
II obstructive disorders
III non neoplastic disordes
IV 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)
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
Sjogren’s 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 wharton’s
duct :- it can be
imaged by To
pographic
mandibular
occlusal projection
[B] Posterior part of duct :- can be
demonstrated by posterior oblique view,
where patient’s 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 stenson’s 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?!
Kinds :
Def:
→ Water- soluble (ionic):-
Is a radiographic diagnostic agent urographin (diatrizoate)
of high opacification ( In dental
field iodine compounds are Soluble in saliva can diffuse to
mainly used ) glandular tissue → ↓ RG density
= poor visualization.
Sausage appearance
* Sialectasis : is the appearance of
focal collection of contrast medium
within the gland, seen in sialadenitis,
Sjogren’s 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
sjogren’s 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
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: