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EDUCATION EXHIBIT
745
US of the Major Sali-vary Glands: Anatomyand Spatial Relation-ships, Pathologic Con-ditions, and Pitfalls
1
Ewa J. Bialek, MD, PhD
●
Wieslaw Jakubowski, MD, PhD
●
Piotr  Zajkowski, MD, PhD
●
 Kazimierz T. Szopinski, MD, PhD
●
 Antoni Osmolski, MD, PhD
Ultrasonography (US) is useful for differential diagnosis of diseases of the salivary glands. In acute inflammation, salivary glands are enlargedand hypoechoic with increased blood flow; they may contain multiplesmall, oval, hypoechoic areas. In chronic inflammation, salivary glandsare normal sized or smaller, hypoechoic, and inhomogeneous. Sialoli-thiasis appears as markedly hyperechoic lines or points with distalacoustic shadowing. Sialosis appears as enlarged hyperechoic glandswithout focal lesions or increased blood flow. The US features of ad-vanced Sjo¨gren syndrome include inhomogeneous salivary glands withscattered small, oval, hypoechoic or anechoic areas, usually well de-fined, and increased parenchymal blood flow. Pleomorphic adenomasare usually hypoechoic, well-defined, lobulated lesions with posterioracoustic enhancement that may contain calcifications; Warthin tumorsare usually oval, hypoechoic, well-defined lesions that often containanechoic areas and are often hypervascularized. Malignant neoplasmsof the salivary glands may have irregular shapes, irregular borders,blurred margins, and a hypoechoic inhomogeneous structure or mayhave a benign appearance. Salivary gland cysts have well-defined mar-gins, anechoic contents, posterior acoustic enhancement, and no inter-nal blood flow. However, US appearances of some diseases may over-lap, thus producing diagnostic pitfalls.
©
RSNA, 2006
Abbreviation:
HIV
human immunodeficiency virus
RadioGraphics 2006;
26:745–763
●
Published online
10.1148/rg.263055024
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Content Codes:
1
From the Department of Diagnostic Imaging, Second Faculty of Medicine, Medical University of Warsaw, ul. Kondratowicza 8, 03-242 Warsaw, Po-land (E.J.B., W.J., P.Z., K.T.S.); and the Department of Otolaryngology, Center of Postgraduate Medical Education, Warsaw, Poland (A.O.). Recipi-ent of an Excellence in Design award for an education exhibit at the 2004 RSNA Annual Meeting. Received February 8, 2005; revision requestedMarch 18 and received November 8; accepted November 9. All authors have no financial relationships to disclose.
Address correspondence to
E.J.B. (e-mail:
ewajbmd@go2.pl 
).
©
RSNA, 2006
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TEACHINGPOINTS
 
Introduction
The algorithm proposed in the United States forimaging of salivary glands includes nonenhancedand contrast-enhanced computed tomography(CT), nonenhanced and contrast-enhanced mag-netic resonance (MR) imaging, and sialography(also MR sialography), applied in a different or-der depending on clinical data (1,2). In general,CT is considered the best single method for as-sessment of inflammatory diseases and MR imag-ing is considered the best single method for as-sessment of salivary gland tumors (1–3). Accord-ing to Yousem et al (2) ultrasonography (US) isunderused in most North American sites, but inexperienced hands it may supplant both CT andMR in imaging of superficial salivary gland le-sions.In Europe and Asia, US is widely accepted asthe first imaging method for assessment of lymphnodes and soft-tissue diseases in the head andneck, including major salivary glands (4–7). Re-sults of the US examination alone may suggestthe final diagnosis or supply important differentialdiagnostic data. As the head and neck region hasa complex anatomic structure, a sound knowl-edge of sonographic anatomy and spatial relation-ships is crucial for reliable performance of the ex-amination. Also, knowledge of the sonographicfeatures of the most common diseases in this areais a requisite.It is sometimes not possible to visualize exam-ined lesions completely at US because of theirlocation, penetrating to the deep lobe of the pa-rotid gland or behind the acoustic shadow of themandible. In these situations, performance of fur-ther imaging examinations—CT or MR imag-
Figure 1.
Transverse panoramic US image
(a)
and corresponding diagram
(b)
show the normal anatomy of theleft parotid gland and part of the cheek.
m
muscle.
Figure 2.
Drawing shows the major blood vessels inthe area of the salivary glands.
1
retromandibularvein,
2
external carotid artery,
3
facial artery andvein,
4
lingual artery and vein,
5
external carotidartery,
6 
internal jugular vein,
7 
external jugularvein.
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ing—is warranted. Also, in cases of suspected ma-lignant lesions, further diagnostic methods (ie,CT or MR imaging) should be applied to assesspossible infiltration of bones or deep structuresinvisible at US (the base of the skull, parapharyn-geal space) and to evaluate deep-lying lymphnodes (1,3,8,9). On the other hand, dynamicscintigraphy is still the method of choice in func-tional evaluation of the salivary glands (10,11).In this article, we present the anatomy of themajor salivary glands and neighboring structuresas seen at US, as well as the US features of themost common pathologic conditions affecting theparotid and submandibular glands. These condi-tions include inflammatory diseases, sialolithiasis,sialosis, Sjo¨gren syndrome, neoplasms, cysts, andtrauma, as well as the effects of irradiation.
Technique
The examination should be carried out with thehighest-frequency transducer possible. Usually,5–12-MHz wide-band linear transducers (medianfrequency, 7–7.5 MHz or more) are used (9). Inassessment of large tumors and lesions located indeep portions of the glands, 5–10-MHz transduc-ers may be useful (12). Probes with a median fre-quency above 10 MHz may be useful in evalua-tion of the internal structure of salivary glands(12,13).Entire salivary glands and all lesions have to beevaluated in at least two perpendicular planesduring a US examination. The whole neck shouldalso be scanned to assess lymph nodes and searchfor concomitant or related disease.
Anatomy
Parotid Gland
The parotid gland is located in the retromandibu-lar fossa, anterior to the ear and sternocleidomas-toid muscle. Parts of the superficial lobe cover theramus of the mandible and the posterior part of the masseter muscle (Fig 1).The border between the superficial and deepparotid lobes is created by a plane in whichthe facial nerve and its branches are located.Branches of the facial nerve are not visible atUS. Parts of the trunk of this nerve may be dem-onstrated only with high-frequency probes (above10 MHz) (13). Therefore, the retromandibularvein, which usually lies directly above the trunk of the facial nerve (14), is used as a US landmarkseparating the superficial and deep lobes of theparotid gland (Figs 2–4). Although the extracra-nial portion of the facial nerve may be visualizedon high-resolution MR images (15), the retro-mandibular vein is commonly used as an ana-tomic landmark in preoperative CT and MR im-aging examinations of parotid neoplasms (16).The deep parotid lobe can be visualized only par-tially at US. Some areas of glandular parenchymaand possible lesions may be hidden in the acous-tic shadow behind the mandibular ramus (Fig 4).
Figure 3.
Transverse
(a)
and longitudinal
(b)
US images show the normal anatomy of the left parotid gland.The positions of the US probe are shown in the inset diagrams.
1
retromandibular vein,
2
external carotidartery,
3
echo from the surface of the mandible,
4
parotid gland,
5
masseter muscle.
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