Salivary glands

radiology

DONE BY
IBRAHIM AMER

Disease
mechanism of
Dental
diagnosticiansgland
have
salivary

responsibility for detecting disorders

of the salivary glands
A familiarity with salivary gland
disorders and
applicable current imaging
techniques is an essential element of
the clinician s armamentarium .

Disease mechanism
of salivary gland

inflammatory disorders

Inflmmatory disorders are acute or chronic and may be

secondary to ductal obstruction by sialoliths, trauma,
.infection, or space-occupying lesions such as neoplasia

Non inflammatory disorders

are metabolic and secretory abnormalities associated with
diseases of nearly all the endocrine glands, malnutrition, and
neurologic disorders
.

space-occupying masses.
are cystic or neoplastic; the neoplasms are
.benign or malignant

Clinical Signs
and Symptoms
Disease of major salivary glands may have
single or multiple feature :A. Swelling in the area of parotid and
submandibular gland
B. Pain and altered salivary flow
C. The periodicity and longevity of these
symptoms
D. a review of the medical history and physical
condition of the patient may provide
important information.

Differential
Diagnosis
of Salivary
Enlargements

Differential Diagnosis
Parotid Gland Area- of Salivary
Enlargements

BILATERAL

UNILATERAL

Bacterial sialadenitis
Viral sialadenitis
(mumps)
Sjgren syndrome
Alcoholic hypertrophy
Medication-induced
hypertrophy (iodine,
heavy metals)
Human immunodefi
ciency virus associated
multicentric
cysts
Masseter muscle
hypertrophy

Bacterial
sialadenitis
Sialodochitis
Cyst
Benign neoplasm
Malignant
neoplasm
Intraglandular
lymph node
Masseter muscle
hypertrophy
Lesions of adjacent

Differential Diagnosis
Submandibular Area- of
Salivary Enlargements
BILATERAL

UILATERAL

Bacterial
sialadenitis
Sjgren
syndrome
Lymphadenitis
Branchial cleft
cyst

Submandibular

Bacterial
sialadenitis
Sialodochitis
Fibrosis
Cyst
Benign
neoplasm
Malignant
neoplasm

Imaging
of the Salivary
Diagnostic imaging
Glands
of salivary gland

disease may be undertaken to

differentiate inflammatory processes from
neoplastic disease .
diffuse disease from focal suppurative
disease, identify and localize sialoliths,
and demonstrate ductal morphology
anddetermine the anatomic location of a
tumor, in addition , differentiate benign
from malignant tumor .

PLAIN FILM
RADIOGRAPHY
Plain film radiography is a fundamental part of
the examination of the salivary glands and
may provide sufficient information to preclude
the use of more sophisticated and expensive
imaging techniques .
It has the potential to identify unrelated
pathoses in the areas of the salivary glands
that may be mistakenly identified as salivary
gland disease, such as resorptive or
osteoblastic changes in adjacent bone .

PLAIN FILM
RADIOGRAPHY

Panoramic and conventional posteroanterior (PA) skull

radiographs may demonstrate bony lesions, thus eliminating
salivary pathosis from the differential diagnosis.

Unilateral or bilateral functional or congenital hypertrophy of the

masseter muscle may clinically mimic a salivary tumor. A plain
film extraoral radiograph may demonstrate a deep antegonial
notch, overdeveloped mandibular angle, and exostosis on the
outer surface of the angle in cases of masseter hypertrophy.
Plain film radiographs are useful when the clinical impression,
supported by a compatible history, suggests the presence of
sialoliths
(stones or calculi).

INTRAORAL
RADIOGRAPHY
Sialoliths in the anterior two thirds of the submandibular duct are
typically imaged with a cross-sectional mandibular occlusal
projection
The posterior part of the duct is demonstrated with an over-theshoulder occlusal projection view, where the directing cone is
placed on the shoulder and central

ray 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 anterior
to the masseter muscle

can be imaged on an intraoral film.

occlusal radiograph
demonstrating radiopaque
sialolith in
.
Wharton duct. Note the
classic laminated
.appearance

Periapical
radiographs of the
same case. The
radiopaque
calculus can be
localized lingual to
the teeth by
applying
appropriate object

An axial bone algorithm CT

image showing a sialolith in
the submandibular duct
.(arrow)

EXTRAORAL
RADIOGRAPHY

A panoramic projection frequently demonstrates

sialoliths in the posterior duct or reveals
intraglandular sialoliths in the submandibular
gland.
The image of most parotid sialoliths is
superimposed over the ramus and body of the
mandible .
To demonstrate sialoliths in the submandibular
gland, the lateral projection is modified by
opening the mouth, extending the chin, and
depressing the tongue with the index finger.

EXTRAORAL
RADIOGRAPHY
Sialoliths in the distal portion of
Stensen duct or in the parotid gland
are difficult to demonstrate by
intraoral or lateral extraoral views.
However, a PA skull projection with
the cheeks puffed out may move the
image of the sialolith free of the bone
.

Stereoscopic panoramic
plain film
.projection
Stereoscopic panoramic plain fi lm
projection. Note the laminated
appearance of
this sialolith in the submandibular
gland. The
image of the sialolith is magnifi ed
because of its
relatively lingual placement in the
image layer.
Taken from slightly different
horizontal angles, a
three-dimensional appearance can be

Overtheshoulder
occlusal
projection
revealing a
sialolith.

Anteroposterior
skull view with
cheek blown
out to provide
air contrast to
reveal a parotid
sialolith
(arrow).

Cropped panoramic
radiograph

Parotid sialolith
superimposed over
condylar neck
((arrow )) is
superior to the
plane of occlussion
which differentiate
from palatine
tonsillolith

Cropped panoramic
radiograph

Submandibular
sialolith (arrow )
near the
antagonial notch
of the mandibular
and superior to
the hyoid bone

CONVENTIONA
L
SIALOGRAPHY

First performed in 1902, sialography is a radiographic technique where

a radiopaque contrast agent is infused into the ductal system of a
salivary gland before imaging with plain films, fluoroscopy, panoramic
radiography, conventional tomography, or CT. Sialography remains
the most detailed way to image the ductal system .
The parotid and submandibular glands are more readily studied with

this technique.
A survey or scout film is usually made before the infusion of the
contrast solution into the ductal system
.
With this technique, Lipid-soluble (e.g., Ethiodol) or non Lipid-soluble
(e.g., Sinografi n) contrast solution is then slowly infused
until the patient feels discomfort (usually between 0.2 and 1.5 ml).

CONVENTIONA
L
SIALOGRAPHY

These iodine-containing agents render the ductal system

radiopaque, The image of the ductal system appears as tree
limbs, with no area of the gland devoid of ducts. With acinar
filling, the tree comes into bloom, which is the typical
appearance of the parenchymal opacification phase .
Non lipid-soluble contrast agents are preferred because of
reports of inflammatory reactions subsequent to inadvertent
extravasation of lipid-soluble agents .

Sialography is indicated for the evaluation of chronic inflammatory

diseases and ductal pathoses. Contraindications include acute
infection, known sensitivity to iodine-containing compounds,
and immediately anticipated thyroid function tests.

CONVENTIONAL
SIALOGRAPHY

Conventional sialography of gland imaged with CBCT imaging . The

images are rendered in lateral (A)and axial (B ) views

Sialography
Lateral projection
of the parotid
demonstrating
opacifi cation all
the way
to the terminal
ducts and acini. B,
Anteroposterior
projection of the
same gland
demonstrating
parenchymal
blushing from

Sialography
Sialogram of Normal
Submandibular Gland.
This lateral
view demonstrates
parenchymal blushing.
Normal fine branching is
visible. Lack of
parenchymal blushing at
the anteroinferior margin
is
caused by radiographic

COMPUTED TOMOGRAPHY
CT is useful in evaluating structures
in and adjacent to salivary glands; it
displays both soft and hard tissues
and minute differences in soft tissue
densities .
CT is useful in assessing acute
inflammatory processes and
abscesses as well as cysts,
mucoceles, and neoplasia.

COMPUTED
TOMOGRAPHY
CT Images with Soft
Tissue Algorithm. A, Axial
view
demonstrating bilateral
enlargement of the parotid
glands (arrowheads).
B, Coronal view of the
same patient. The
clinical/histopathologic
diagnosis was

.autoimmune parotitis

Cone beam computed tomographic

imaging (CBCT )
Advantage:CBCT imaging is useful in evaluating
structure in and adjacent to salivary gland
Use as record modality for conventional
sialogrphy
Providing 3D visualization of ductal structure

Disadvantage :Cannot resolve difference in soft tissue

densitis

CBCT imaging of submandibular sialolith . Coronal (A)

,axial (B) ,and 3D rendition (c)

Multidetector computed
tomographic imaging (MDCT )
Advantages : Its use in evaluating structure in and adjacent to
salivary gland
Display both soft and hard tissue
The parotid glang is moe radiopaque than the
surrounded fat but less than adjacent muscles
Its useful in assessing acute inflammatory
process
Disadvantage : Isnt recognized as sensitive study for salivary
tumor .

Multidetector computed
tomographic imaging

MAGNETIC RESONANCE
IMAGING
MRI for soft tissue mass details and
localization
Differanciates :
Soft tissue vs. hard tissue
Normal vs. abnormal tissue
Identifies facial nerve ( parotid )
Contraindications:1) -pacemaker
2) -cochlear implant

magnetic resonance images reveal a

lymphoepithelial cyst involving the right
.parotid gland

This axial T1weighted image

reveals a well-defi
ned circular lesion
involving the right
parotid gland with an
internal signal
isointense to muscle.

magnetic resonance images reveal

a lymphoepithelial cyst involving
.the right parotid gland

And the
matching T2weighted image
reveals that the
lesion has a high
internal signal

SCINTIGRAPHY (NUCLEAR
MEDICINE, POSITRON
EMISSION COMPUTED
TOMOGRAPHY)
Selective up take of techntium
Assesees silvary gland function (not
anatomy)
Expel technetium after stimulations

Scintigraphy
Scintigraphy. A, 99m Tcpertechnetate
scan of the salivary glands (right and left
anterior
oblique views) demonstrates increased
uptake of
radioisotope in the right parotid gland
(black
arrowhead). B, Scintigram taken after
administration
of a sialogog (lemon juice) demonstrates
retention of isotope in right parotid gland
(white
arrowheads). This is a typical presentation
of salivary
stasis, Warthin tumor, or oncocytoma.

ULTRASONOGRAPHY
For superficial , soft tissue swilling
Differentioates cystic vs. solid
Us-guide FNA
also be helpful in detecting sialoliths
and diagnosing advanced
autoimmune
lesions (Sj gren syndrome).

ULTRASONOGR
APHY
Ultrasonography
(US) Image of
Right Parotid
Gland. Awelldelineated solid
mass is suggested
by echo returns
within the

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