HEAD AND NECK IMAGING
OO
Adam R. Silvers, MD, and Peter M. Som, MD
Overall, diseases of the salivary glands are rela-
tively uncommon; however, as an organ system
they have one of the greatest diversities of pathol-
ogy. The vast majority of lesions are of an inflam-
matory origin; however, some arise from posttrau-
matic, systemic, or an uncertain pathogenesis.
There also is a wide spectrum of benign and malig-
nant neoplasms.74
As a group, the salivary neoplasms account for
less than 3% of all head and neck tumors and they
account for less than 0.1% of all cancer deaths.I4
The relative incidence of salivary gland tumors is
estimated to be that for every 100 parotid tumors,
there are 10 submandibular tumors, 10 minor sali-
vary tumors, and 1 sublingual tumor.lo2The pa-
rotid, submandibular, and sublingual glands are
often referred to as the major salivary glands,
whereas the minor salivary glands line the oral
cavity and upper aerodigestive tracts.
With regards to the pathogenesis of salivary
gland neoplasms, it was assumed for decades that
there were but two potential stem cells from which
the variety of different salivary tumors originated.
It was generally thought that because the basal
cells of the excretory duct and the intercalated
duct cells acted as the reserve cells for the more
differentiated cells of the salivary gland unit, all of
the epithelial tumors arose from these reserve cells
rather than from the acini! Implicit in this concept
was the assumption that the differentiated end
cells were incapable of further dividing and there-
fore were incapable of giving rise to tumors? Re-
cent evidence has shown, however, that salivary
glands proliferate and regenerate after injury and
that the proliferating cells are not confined to one
cell type?7 Further, in cell cultures from human
salivary glands, all of the differentiated cell types
have now been shown to be capable of cycling.Z8
Thus, the once simple theory for the pathogenesis
From the Mount Sinai School of Medicine, City University of New York, New York, New York
~~~~ ~~~~ ~~~
RADIOLOGIC CLINICS OF NORTH AMElUCA
VOLUME 36 * NUMBER 5 * SEPTEMBER 1998
0033-8389/98 $8.00 + .
SALIVARY GLANDS
of the salivary gland tumors appears to be far
more diverse than previously thought.
EMBRYOLOGY
The parotid anlagen are the first to develop,
followed by the anlagen of the submandibular
gland and then the sublingual gland. The minor
salivary glands do not start to develop until later.@,
61,68,98 The epithelial buds of each gland enlarge,
elongate, and branch, initially forming solid struc-
tures. They eventually canalize, however, creating
lumina. This ductal canalization process is com-
pleted before the terminal buds, or eventual acini,
develop.98The lining epithelial cells of the ducts,
tubules, and acini then differentiate both morpho-
logically and functionally and the contractile myo-
epithelial cells become placed about the a ~ i n iIt. ~ ~
has also been shown that an interaction of the
salivary gland parenchymal and stromal elements
with the autonomic system is necessary for normal
salivary development and function to occur; sym-
pathetic nerve stimulation leads to acinar differen-
tiation, whereas parasympathetic nerve stimula-
tion is necessary for overall glandular growth.98
Although the parotid anlagen are the first to
develop, they become encapsulated after the sub-
mandibular and sublingual glands. This delayed
encapsulation is critical, because during the period
after the submandibular and sublingual glands en-
capsulate, but prior to the parotid gland encapsu-
lation, the emergence of the lymphatic system oc-
curs in the mesoderm. Because of this, in the adult
there are intraglandular lymph nodes and lym-
phatic channels only within the parotid glands. In
addition, during the encapsulation of the intrapa-
rotid and periparotid lymph nodes, salivary epi-
thelial cells can be included within these nodes.
941
942 SILVERS & SOM
This unusual situation is, in fact, unique to the
parotid and periparotid nodes! It is this special
embryogenesis of the parotid glands that is be-
lieved to play a role in the development of War-
thin's tumors and possibly lymphoepithelial cysts.
The parotid gland is also unique in that as its
epithelial buds grow and branch, they extend be-
tween and around the divisions of the facial nerve
incorporating the distal portion of this nerve
within the adult gland.M, 98
ANATOMY
Parotid Glands
The parotid is the largest of the salivary glands
and its superficial portion is palpable as it overlies
the ramus of the mandible. The average gland
weighs between 14 and 28 g and in men averages
5.8 cm in craniocaudal dimension and 3.4 cm in
the ventrodorsal axis; the parotid gland tends to
be slightly smaller in women.*,61
Nearly 80% of the gland lies on the outer surface
of the masseter muscle and the ascending ramus
Figure 1. Normal anatomy of parotid glands. A, Axial CT scan. B, Axial T1-weighted sequence. C,
Axial TP-weighted sequence. The retromandibular portion of the gland is indicated by the arrow.
and angle of the mandible. This portion of the
gland lies caudal to and ventral to the external
auditory canal and the mastoid tip. The remaining
approximately 20% of the gland extends medially
through the stylomandibular tunnel, which is
formed ventrally by the posterior edge of the man-
dibular ramus; dorsally by the anterior borders of
the sternocleidomastoid muscle and the posterior
belly of the digastric muscle; and more deeply and
dorsally by the stylomandibular ligament, which
extends from the tip of the styloid process to the
angle and posterior edge of the mandible. This
stylomandibular ligament also separates the pa-
rotid gland from the submandibular gland. Be-
cause of these anatomic relationships, the retro-
mandibular or deep portion of the parotid gland
lies anterior to the styloid process, its musculature,
and the carotid sheath. This places the deep por-
tion of the parotid gland in the prestyloid compart-
ment of the parapharyngeal space (Fig 1).8,61
The parotid gland, despite the commonly used
terminology, is not actually anatomically divided
into separate superficial and deep lobes. This no-
menclature is based on using the facial nerve and
its associated interstitial structures as a reference

plane within the gland. More recently, an anatomi-
cally correct terminology has become more popu-
lar. In this system, the superficial portion of the
gland is that region that overlies the ramus of the
mandible and masseter muscle. The retromandibu-
lar portion of the gland refers to the smaller region
behind and deep to the mandibular ramus.
The main trunk of the facial nerve exits the skull
base via the stylomastoid foramen and immedi-
ately gives off three small branches: (1)the poste-
rior auricular, (2) the posterior digastric, and (3)
the stylohyoid nerves. The facial nerve then
courses laterally around the styloid process and
follows the lateral surface of the posterior belly of
the digastric muscle a variably short distance be-
fore the nerve pierces the posterior capsule of the
parotid gland. The nerve then continues within the
gland lateral to the posterior facial vein and the
more medial external carotid artery. It then divides
in one of several anatomic patterns into the tempo-
ral, zygomatic, buccal, mandibular, and cervical
bran~hes?~
In the parotid gland the intercalated ducts are
long and thin. By comparison, in the submandibu-
lar gland, the intercalated ducts are shorter and
wider. The sublingual gland has the shortest and
widest intercalated ducts of the major salivary
glands. This may relate to the increasing viscosity
of the secretions of these three glands. The parotid
gland parenchyma also has abundant fatty tissue
with a ratio of adipose to acinar tissue of about 1:l.
Stensen‘s duct emerges from the anterior parotid
gland, courses over the masseter muscle and buc-
cal fat pad, and then turns medially, almost at a
right angle, to pierce the buccinator muscle at the
level of the second upper molar tooth. As Stensen’s
duct passes over the masseter, it may receive the
duct of an accessory parotid gland, which is found
in about 20% of people overlying the masseter
muscle, usually situated cranial to Stensen’s duct.
The parotid and periparotid lymph nodes drain
primarily into the internal jugular chain nodes,
with some drainage also going to the upper spinal
accessory chain of nodes. The innervation of the
parotid gland is such that sympathetic innervation
is mainly responsible for vasoconstriction, whereas
parasympathetic fibers are related to secretory
function40
Submandibular Glands
The submandibular gland is the second largest
salivary gland, being about one half the weight of
the parotid gland (Fig. 2). It occupies most of the
submandibular triangle of the neck, and the gland
is folded around the dorsal free edge of the mylo-
hyoid muscle. Despite the fact that there are no
separate lobes to the gland, by convention it is
often referred to as being divided into superficial
and deep lobes, with the larger superficial lobe
lying in the submandibular triangle, superficial
and caudal to the mylohyoid muscle, and the deep
SALIVARY GLANDS 943
portion lying above the mylohyoid muscle. It is
from the deep portion of the gland that Wharton’s
duct extends to the anterior floor of mouth on the
sublingual papilla. Along its course, the duct
makes an approximately 45-degree angle with
both the sagittal and axial planes. As the duct
courses upward, the lingual nerve winds around
it, being first lateral, then inferior, and finally me-
dial to it. Lying superficial to the gland are the
lingual nerve and submandibular ganglion,
whereas deep to the gland is the hypoglossal nerve
with its accompanying vein. Lateral to the gland
are the facial nerve and vein. The submandibular
gland is a mixed serous and mucous gland, with
about 10% of the acini being mucinous. By com-
parison with the parotid gland, adipose tissue is
not a significant component of the glandular pa-
renchyma. Its lymphatic drainage is into the sub-
mandibular nodes.40,75
Sublingual Glands
The sublingual gland is the smallest of the major
salivary glands, weighing only about 2 g. It lies
just below the sublingual mucosa in the floor of
the mouth, lying against the anterior lingual sur-
face of the mandible (Fig. 3). The gland rests on
the mylohyoid muscle and its medial contour is
separated from the genioglossus muscle by the
lingual nerve and Wharton’s duct. There are about
20 individual small ducts, the ducts of Rivinus,
which open independently into the floor of the
mouth along the sublingual papilla and fold. Occa-
sionally, some of the ducts of Rivinus fuse to form
Bartholin’s duct, which in turn opens into Whar-
ton’s 61 The gland’s lymph drains into the
submental and submandibular lymph nodes.
Minor Salivary Glands
These glands are situated beneath the mucosa of
the oral cavity, palate, paranasal sinuses, pharynx,
larynx, trachea, and bronchi. They are most nu-
merous in the buccal, labial, palatal, and lingual
regions. The gingivae, the anterior aspect of the
hard palate, and the true vocal cords have rela-
tively few minor salivary glands. The minor sali-
vary glands have the same basic structure as the
major salivary glands but are either entirely mu-
cous glands, on the hard palate, or mixed seromu-
cous glands, as in the sinonasal and oral cavities.
It has been estimated that there are more than 750
minor salivary glands.
PHYSIOLOGY
The physiologic control of the salivary glands is
almost entirely by the autonomic nervous system
and parasympathetic effects predominate. If the
parasympathetic innervation is interrupted, glan-
944 SILVERS & SOM

Figure 2. Normal anatomy of the submandibular gland. A, Axial contrast-enhanced CT scan.

B, Axial T1-weighted sequence. C, Coronal T1-weighted sequence. The facial artery and vein
are lateral to the gland (arrow) and the lingual artery is medial (curved arrow).

dular atrophy occurs. If sympathetic innervation is DEVELOPMENTAL ANOMALIES

interrupted, there is little, if any, effect on the
glandss9 Normal saliva is 99.5% water and the
total daily production of saliva is between 1000
and 1500 mL, most of which is produced during
meals. Of this total, the parotid glands contribute
about 45%, the submandibular glands about &YO,
the sublingual glands 5%, and the minor salivary
glands 5y0."~Although the minor salivary glands
and the sublingual glands together produce only
10% of the total salivary volume, they are re-
sponsible for the majority of the mucous secretions
and when these glands are affected by either auto-
immune disease or irradiation, xerostomia
develops.61,114
The antibacterial activity of saliva is accom-
plished by secretory IgA; enzymes, such as lyso-
zyme, peroxidase, a-amylase, and lactoferrin; and
ions, such as thiocyanate and hydrogen. The nor-
mal range of salivary pH is 5.6 to 7.61,114
Developmental anomalies of the salivary glands
are rare, are usually associated with other facial
abnormalities, and are associated with xerostomia
and thus sialadenitis and dental caries. Parotid
gland agenesis has been reported with hemifacial
microstomia, mandibulofacial dysostosis, cleft
palate, and anophthalmia. Atresia of one or more
major salivary gland ducts, usually the subman-
dibular or sublingual glands, is very rare and is
associated with xerostomia and possibly the devel-
opment of a retention cyst.", Hypoplasia of the
parotid gland has been reported in the Melkers-
son-Rosenthal syndrome, and congenital fistula
formation of the ductal system has been associated
with branchial cleft abnormalities, accessory pa-
rotid ducts, and diverticula.61
Aberrancy of salivary gland tissue has been re-
ported in a large variety of locations including the
 SALIVARY GLANDS 945

Figure 3. Normal anatomy of the submandibular and sublingual glands. A, Axial contrast-en-
hanced CT scan. B, Axial T1-weighted sequence. C,Axial contrast-enhanced fat-suppressed T1-
weighted sequence. D, Coronal T1 -weighted sequence.The curved arrows identify the sublingual
gland. The genioglossus muscle is medial to the sublingual gland (arrow) and the myelohyoid
lateral to the sublingual gland (arrowhead).

middle ear cleft and external auditory canal; the
neck; the inner-posterior mandible (Stafne cyst);
the anterior mandible; the pituitary; and the cere-
bellopontine angle.61Congenital intraglandular
cysts also occur and these are discussed in the
Thus, if the patient's history suggests an in-
flammatory disease, CT not only demonstrates the
actual salivary gland disease, but also potential
sialoliths that may be responsible for the
disea~e.'~,75 By comparison, if there is clinical find-

section on nonneoplastic diseases.
IMAGING APPROACH
Over the recent two decades, the choice of which
imaging modality to use when investigating a pa-
tient with major salivary gland disease has
changed. The old approach relied on plain films
and sialograms, whereas today the emphasis is on
CT, MR imaging, and ultrasound. Although there
are no set rules in the literature as to when a
particular modality should be used in preference
to the others, the general rule utilized by many
radiologists is that inflammatory diseases are prob-
ably best imaged by CT, whereas tumors are best
imaged by MR imaging.
ing of a mass, the initial imaging modality that
best evaluates the borders of the lesion is usually
MR imaging.*Because of concerns regarding radi-
ation in children and adolescents, it has been sug-
gested that ultrasound be used for inflammatory
and superficially located disease, whereas MR im-
aging be utilized for more deeply positioned
masses.3oIf a minor salivary gland tumor is clini-
cally suspected, either enhanced MR imaging or
CT can serve as the examination of choice.
Although most of the CT studies of salivary
gland disease utilize contrast, often no new clini-
cally useful information is obtained over that
available on a noncontrast study. When MR im-
*References 18, 20, 26, 52, 56, 59, 63, 66, 72, 73, 86, 88,
95, 100, 103, 107
946 SILVERS & SOM
aging is used, however, contrast may help distin-
guish a cystic mass from a solid tumor and thus
the routine use of contrast may be more justified
than with CT. When contrast is used with MR
imaging, fat suppression sequences are necessary
to improve lesion conspicuity. Contrast is also very
useful when evaluating perineural tumor spread
from salivary gland malignan~ies.7~
Plain films are rarely used today for the evalua-
tion of salivary calculi because even if a plain film
study is normal, a sialolith or soft tissue calcifica-
tion may be present that can be easily identified
by either ultrasound or CT. Even if a calcification
is seen on a plain film, another nonvisualized,
but clinically important calcification, may still be
present. Because of these limitations, today most
imaging for soft tissue calcifications involves either
CT or ultrasound.
Sialography used to be one of the mainstays of
major salivary gland imaging and today it remains
the most detailed way to image the ductal system.
With the improved use of CT and MR imaging,
however, the new and more reliable clinical tests
available, and the changes in the clinical approach
to the management of major salivary gland dis-
ease, there is little need to perform sialography
today. In addition, if the patient has a clinically
active infection or has an allergy to the contrast
agents used, the procedure is contraindicated. If a
sialogram is performed, a water-soluble contrast
agent should be used.%,55
Most CT studies of the major salivary glands
and the neck are performed as axial 3-mm contigu-
ous scans. Spiral or helical scans can also be uti-
lized, especially in children and patients who may
have difficulty remaining quiet or motionless
throughout the examination. At present, however,
the soft tissue images from the spiral studies are
not as detailed as those of direct sectional images.
Coronal scans through the parotid and subman-
dibular glands can also be obtained to complement
the axial examination. Unfortunately, image degra-
dation artifact from dental amalgam often makes
these coronal images of little diagnostic use.
MR imaging studies of the major salivary glands
are usually performed as 3-mm-thick slices with a
1-mm interslice gap. Noncontrast T1-weighted and
T2-weighted sequences are obtained and then T1-
weighted, postcontrast, fat-suppressed images are
obtained. Fat suppression may be needed for fast-
spin echo TZweighted scans as well. Axial views
are obtained for all sequences, and coronal and
sagittal views may be obtained as needed, usually
as part of the postcontrast study.20,56, loo, lol
In the adult, the parotid gland normally is a
relatively fatty gland with numerous thin intersti-
tial strandlike structures seen interlacing through-
out it. These strands represent the interstitial struc-
ture of the gland, the facial nerve branches, and
the ductal system. In children and in some adults,
a clinically normal parotid gland can have a low
fat content, which affects its CT and MR imaging
appearance. Unfortunately, it is often impossible
to differentiate such a normal less fatty gland from
one that has been infiltrated with cells resulting
from a variety of causes.
The external carotid artery and the more later-
ally placed posterior facial vein are situated dorsal
to the ramus of the mandible. These vessels course
from medially to laterally as one goes from the
caudal to the cranial portions of the parotid gland.
Some variable, but normal glandular lobulations
can also be seen primarily in relationship to the
sternocleidomastoid muscle and the mastoid tip.
Normally, the facial nerve itself is not imaged. The
recent use of high-resolution three-dimensional
Fourier transform MR imaging, however, has al-
lowed the facial nerve to be consistently visualized
on contiguous scans.62The submandibular glands
have a less fatty parenchyma than do the parotid
glands. As a result, compared with the parotid
glands, the submandibular glands are more homo-
geneous and cellular on imaging. In addition, the
thicker mucoid secretions can normally be identi-
fied in the major collecting ducts and hilum of the
submandibular gland. After contrast, both sub-
mandibular glands should enhance to the same
degree. If not, one gland is abnormally function-
ing.
CALCIFICATIONS
Solitary or multiple calcifications within the pa-
rotid or submandibular glands usually indicate the
presence of chronic sialadenitis. The finding is
nonspecific and specific etiologies for the sialade-
nitis cannot be distinguished based on the pattern
of calcifications. If the calcification is within a sali-
vary gland mass, however, the most likely lesion
is a pleomorphic adenoma. Less often, calcification
within a salivary gland mass can be seen in a
schwannoma, a mucoepidermoid carcinoma,
rarely within parotid lymph nodes in such condi-
tions as posttreatment lymphoma and long-stand-
ing amyloidosis, and rarely within a chronic in-
traglandular hematoma. Ossification within a
parotid mass is also rare; the most common lesion
is a pleomorphic adenoma. Thus, once a calcifica-
tion is seen within the parotid or submandibular
glands, the localization of the calcification to either
the gland parenchyma or to a discrete mass evokes
a limited differential diagnosis. The inability of
MR imaging to detect such small calcifications is
one of the major limitations of this modality when
imaging the major salivary glands.
DIFFERENTIATING BENIGN AND
MALIGNANT MASSES
The distinction between benign and malignant
lesions frequently cannot be made based solely on
the morphology as demonstrated by CT and MR
imaging. By utilizing the imaging and clinical
findings, however, such a distinction may be able

to be made in almost 90% of the cases?1,95,105 The
imaging difficulties reflect the fact that whereas
most benign salivary lesions (i.e., cysts, tumors,
and nodes) have a capsule and thus are smoothly
contoured and sharply delineated from the adja-
cent salivary tissues (Fig. 4), the most common
low-grade salivary gland malignancies (i.e., low-
grade mucoepidermoid carcinomas, some acinic
cell carcinomas, and some adenoid cystic carcino-
mas) develop pseudocapsules that cause them to
appear on sectional imaging as smoothly outlined
benign-appearing lesions.
Conversely, high-grade malignancies (i.e., high-
grade mucoepidermoid carcinomas, adenocarcino-
mas, undifferentiated carcinomas, and squamous
cell carcinomas) have irregular, infiltrating, indis-
tinct margins with the adjacent salivary tissue and
it is only rarely that a benign mass is surrounded
by inflammation or hemorrhage and presents an
aggressive sectional imaging appearance.
Thus, based on morphology, a well-delineated
mass is most likely benign, although a low-grade
tumor cannot be excluded from the diagnosis. An
infiltrating, irregularly delineated mass, however,
is most likely to be a high-grade malignancy.
Whereas the attenuation of most benign and
malignant masses is the same on CT, MR imaging
may provide a means of differentiating between
benign or low-grade masses and high-grade tu-
mors. The benign lesions and low-grade tumors
tend to be sufficiently well differentiated that they
contain significant regions of watery serous and
mucinous secretions. Thus, on MR imaging they
have low T1-weighted and high T2-weighted sig-
nal intensities (Fig. 5). The highly cellular high-
grade malignancies are undifferentiated and thus
tend to contain little serous and mucinous secre-
tions. These tumors tend to have low to intermedi-
ate signal intensities on all imaging sequences?l
Less often, there are other lesions that can have a
relatively low T2-weighted signal intensity. Such
lesions include fibrosis, granulomas, and rarely
some benign tumors. Whenever a salivary mass
Figure 4. Pleomorphic adenoma. (A) Axial and (B)coronal CT. Borders of the lesion (arrowhead)
within the leit parotid gland are well-defined with no evidence of infiltration into the surrounding gland.
SALIVARY GLANDS 947
has a low T2-weighted signal intensity, however,
it should alert the radiologist to the possibility that
a high-grade malignancy may be present (Fig. 6).
Clinically, benign tumors are usually slow grow-
ing, painless, nontender, mobile, and firm. Facial
nerve paralysis is rarely present with benign
masses. Benign cysts usually develop rapidly over
several days and are nontender unless infected, in
which case they are both tender and painful. These
cysts are moderately firm to palpation and often
have a history of prior recurrent clinical episodes.
By comparison, malignant tumors tend to enlarge
over a period of several weeks, and they can be
either painless or slightly painful and minimally
tender, depending on how rapidly they are enlarg-
ing. In general, the faster these malignancies grow,
the more symptomatic they are. When palpated,
these malignancies are usually rock hard, and they
may be fixed in position. There may be an associ-
ated facial nerve paralysis. In fact, the overall inci-
dence of facial nerve paralysis with a parotid ma-
lignancy is 12% to 14?'0.~~
NEWER IMAGING TECHNIQUES
Three-dimensional MR imaging is a good com-
munication tool when describing pathology to cli-
nicians who have difficulty assimilating serial CT
and MR images and the use of MR imaging con-
trast may improve the identification of salivary
masses on such three-dimensional images.'OgLittle
if any information, however, is provided to the
clinician that aids in the surgical decision-making
process and thus this technique is uncommonly
used.
MR imaging spectroscopy is still a relatively
new field as applied to clinical imaging. It has
been shown that 31-phosphorus spectroscopy of
salivary malignancies has a significant increase in
the concentration of phosphomonoesters, phos-
phodiesters, and inorganic phosphates compared
with normal patients, whereas there was a large
948 SILVERS & SOM

Figure 5. Pleomorphic adenoma. (A) Axial CT and (B) axial T2-

weighted sequence. The adenoma has high signal intensity on
the T2-weighted sequence (arrow) and is sharply marginated.

reduction in creatine phosphate.lmThis work may
lead the way to more pathologic and prognostic
information being attainable on MR imaging; how-
ever, at present, because of the considerable time
necessary to gather sufficient data and the limited
clinical application of MR imaging spectroscopy, it
is primarily an investigative tool.
Ultrasound has traditionally been used to differ-
entiate solid and cystic salivary gland masses and
to identlfy salivary calculi. It can also be used to
identify the more advanced stages of autoimmune
disease (Sjogren’s syndrome). Although ultra-
sound can, in some cases, differentiate lympho-
matous nodes from nonlymphomatous nodes; bi-
opsy is still necessary. It is fair to say that overall
in the last decade, ultrasound has become a more
useful imaging technique particularly for the pa-
rotid and submandibular glands and especially in

Figure 6. Mucoepidermoid carcinoma. A, Axial T i -weighted sequence. B, Axial T2-weighted se-

quence. Both demonstrate low signal intensity and slightly irregular margins (arrow) suggesting a
more aggressive lesion.

children, where there is a fear of radiation effects
from CT. For more extensive lesions that have
spread beyond the gland’s capsule, however, ultra-
sound does not provide the detailed information
possible from CT and MR imagingm, 46, 57, 70 Usu-
397
ally, the ultrasound examination is performed with
a linear high-frequency (7 to 10 MHz) transducer.
This gives higher resolution images, but does not
penetrate as deeply as lower megahertz transduc-
ers.
Radionuclide salivary studies are based on the
fact that the salivary glands normally concentrate
technetium (Tc) 99m pertechnetate and some
masses also excessively accumulate the radionu-
clide. Such masses, however, are not as accurately
localized as on CT or MR imaging studies. In
addition, masses that do not highly accumulate
the radionuclide are poorly, if at all, seen. As a
result, radionuclide sialograms are not routinely
utilized to study parotid and submandibular gland
masses. The lesions that most concentrate the Tc
99m pertechnetate are Warthin’s tumors and onco-
~ytomas.’~, 23
The use of skinny needle biopsy of salivary
masses is becoming increasingly more accurate
and the diagnostic yields are highest when a cyto-
pathologist or a cytotechnologist is present at the
time of the procedure to check the specimen for
adequacy. The biopsy is performed with a 22-
gauge needle and can be done with or without CT
or MR imaging guidance.’,34, 52 The use of image-
guided biopsies of the parotid glands is variable
depending on the surgical philosophy of the refer-
ring head and neck surgeons. At our institution,
most surgeons feel that any parotid or subman-
dibular gland mass should be removed and thus
the skinny needle diagnosis is immaterial to the
outcome. There is differing surgical opinion, how-
ever, as to whether all parotid masses need to be
resected and at some institutions needle biopsy is
used as a guide for treatment options.
Figure 7. Sialadenitis. A, Axial CT scan, right parotid. 6, Axial CT scan, left parotid. Both cases
demonstrate skin thickening, injection of the subcutaneous fat, irregularity of the borders of the
parotid gland, and increased attenuation within the gland reflecting cellular infiltration.
SALIVARY GLANDS 949
NONNEOPLASTIC AND INFLAMMATORY
CONDITIONS
Viral and Bacterial Diseases
As a group, the acute viral and bacterial in-
flammatory diseases are the most common sali-
vary gland abnormalities. Most of the bacterial
infections ascend from the oral cavity and are re-
lated to a decrease in the salivary flow. The pro-
duction of saliva can be decreased by prior infec-
tions; dehydration; trauma; surgery; radiation;
some medications; and obstruct@g masses, such
as stones or tumors.n The most common salivary
gland viral disease is mumps.68 It primarily in-
volves the parotid glands but can occur in the
submandibular and sublingual glands. The disease
is most reliably diagnosed during epidemics, and
the diagnosis can be confirmed by measuring se-
rum antibody titers? Other viruses that can cause
parotitis include Coxsackie viruses; parainfluenza
viruses (types I and 111); influenza virus type A;
herpesvirus; echovirus; and choriomeningitis vi-
IUS.~,a, Epstein-Barr virus and cytomegalovirus
may be found in the saliva, but these viruses are
not believed directly to affect the major salivary
glands. Similarly, to date, HIV has not been shown
directly to infect the salivary glands.19, 87s
When imaging a patient with an acute sialadeni-
tis, the primary clinical concern is to differentiate
between a sialadenitis without an abscess, which
is routinely treated only with antibiotics, and sial-
adenitis with an abscess, which requires immedi-
ate surgery. This differentiation is easily accom-
plished on CT, where the involved gland is dense,
enhances slightly, and is somewhat enlarged (Fig.
7). If an abscess is present, it is clearly seen as a
localized lower-attenuation walled-off region (Fig.
8). The most common offending agents are Staphy-
lococcus aureus, Streptococcus viridans, Haemophilus
influenzae, Streptococcus pyogenes, Escherichia coli,
950 SILVERS & SOM

Figure 8. Parotid abscess. Axial CT, right parotid gland. There

is a mucoid attenuation lesion with a thick wall (arrow) within
the right parotid gland. The remainder of the gland shows typical
changes of sialadenitis. There are secondary inflammatory
changes in the overlying subcutaneous fat and skin.

and Streptococcus pneumoniae. Intraparotid and peri-
parotid lymph nodes may be involved in the in-
flammatory reaction.64,n It is usually the undiag-
nosed or incompletely treated acute suppurative
sialadenitis that develops an intraglandular ab-
scess. Patients with such abscesses have fever and
malaise, and rather quickly the abscess may extend
into the parapharyngeal space or upper neck.
Calcified sialolithiasis can be clearly identified
on CT and may be located within the ductal sys-
tem of the gland or within Stensen's or Wharton's
duct. Occasionally, even a noncalcified stone can
be identified in these ducts as the stone obstructs
and dilated intraglandular ducts are seen proxi-
mally. Between 80% and 90% of salivary gland
stones occur in the submandibular gland (Fig. 9),
10% to 20% occur in the parotid glands, and only
1%to 7% occur in the sublingual Most
sialoliths are solitary; however, about 25% of pa-
tients with one stone have multiple stones.17* 77 In
patients with chronic sialadenitis, at least one cal-
culus is present in two thirds of the cases, and 80%
of submandibular and 60% of parotid stones are
radiopaque on plain films.*
Nearly 85% of submandibular gland stones oc-
cur within Wharton's duct; 30% near the duct os-
tium, 20% in the middle portion of the duct, 35%
at the bend in the duct as it goes around the back
of the mylohyoid muscle, and only 15% occur in
the hilum and gland
Symptomatic parotid gland stones occur primar-
ily in Stensen's duct; however, incidental asymp-
tomatic small intraparotid ductal calculi are com-
monly seen on CT scans. If the cause of the
interruption to salivary flow is near the buccal
orifice of the duct, localized surgery may be cura-
tive. If the obstruction is more proximal in the
main duct or in the gland, and if repeated infec-
tions have occurred, however, today the tendency
is surgically to remove the gland. If the obstruction
to salivary flow is complete, glandular atrophy
eventually occurs. If an incomplete obstruction oc-
curs, the gland usually continues to produce saliva
and a glandular mucocele may develop.
The chronic inflammatory diseases of the major
salivary glands may be due to recurrent bacterial
infection, a granulomatous process, prior irradia-
tion, autoimmune disorders, or be idiopathic. The
radiologist should attempt to differentiate the ob-
structive and nonobstructive diseases, because the
treatment and prognosis often vary considerably.
The chronic nonobstructive diseases tend to in-
volve the parotid glands with a greater frequency,
whereas the obstructive disorders are more com-
mon in the submandibular glands. Chronic recur-
rent sialadenitis is clinically characterized by re-
current diffuse or localized painful swelling of the
salivary gland and it is usually associated with an
incomplete ductal obstruction.
Autoimmune Disease
Sjogren's syndrome is a systemic autoimmune
disorder of the exocrine glands that occurs either
alone (primary Sjogren's syndrome) or with any
of several connective tissue diseases (secondary
Sjogren's syndrome). Traditionally, the diagnosis is
established when two or more of the following
clinical hallmarks are present: keratoconjunctivitis
sicca; xerostomia; and a connective tissue disease,
which usually is rheumatoid arthriti~."~ The auto-
immune diseases represent a diffuse exocrinopa-
thy that primarily affects the lacrimal and salivary
glands. Other exocrine glands, however, can also
be involved and cause symptoms, such as tracheo-
bronchitis, dry skin, dysphagia, and atrophic vagi-
nitis. Involvement of the glands of the gastrointes-
tinal tract also can occur, but it is less frequent.38,42
Often, the involvement of these other exocrine
gland systems is histologically present, but not
clinically apparent. The actual incidence of Sjo-

Figure 9. Submandibular gland with stone. A, Axial and 6,coronal CT showing calcified stone
(arrows) within right submandibular gland and hilum. C,A more caudal axial CT shows dilatation
of the intraglandular ducts (curved arrow).
gren’s syndrome is difficult to establish because
the symptoms can be nonspecific, and the specific
autoimmune antibodies (SS-A and SS-B) may be
elevated only during active disease or not at all.
Among the autoimmune diseases, however, Sjo-
gren‘s syndrome is considered second in frequency
only to rheumatoid Previous terminol-
ogy referring to this disease is confusing and has
included recurrent parotitis in children, Mikulicz’s
disease, and sicca syndrome.
The childhood form of the disease is one tenth
as common as the adult form, and children have a
lower incidence of developing the advanced form
of parotid disease.I3It is important to establish the
diagnosis as early in the course of the disease as
possible because many cases spontaneously re-
solve at puberty and unnecessary surgery prior to
puberty can be avoided. There are only a few
cases of recurrent parotitis in children that have
SALIVARY GLANDS 951
progressed into the adult form of Sjogren’s syn-
drome.6l
The adult form of the disease is most common
between the ages of 40 and 60 years and nearly
90% to 95% of the patients are women. In adults,
the parotid disease tends to be progressive, occa-
sionally requiring a parotidectomy to relieve the
symptoms of recurrent infection.”, The incidence
of parotid enlargement has varied from 25% to
55% of cases, and either parotid or submandibular
gland enlargement occurs in 80% of all patients
with Sjogren’s syndrome. The risk of developing
non-Hodgkin’s lymphoma is estimated to be about
44 times greater in patients with Sjogren’s syn-
drome than in control subjects and the lymphoma
may develop in both extraparotid and intraparotid
sites.%,61 Local irradiation or immunosuppression
(either secondary to therapy or a primary disease)
further increases the risk of developing lymphoma.
952 SILVERS & SOM

Because Sjogren‘s syndrome initially involves
the most peripheral intraglandular ducts and acini,
in the initial stages of the disease the sialogram
shows a normal central duct system and numerous
peripheral punctate collections of contrast material
uniformly scattered throughout the gland. These
punctate changes are the earliest sialographic
findings that are diagnostic of Sjogren‘s syndrome
and they cannot be identified on CT or MR im-
aging. Eventually, larger globular collections of
contrast material may also be seen uniformly scat-
tered throughout the gland and once the disease
destroys the acini, infection from the mouth results
in a destroyed, abscessed gland, the so-called cuvi-
t u y and desfrucfive forms of Sjogren’s syndrome.%
If a secretogogue is given at the end of the si-
alogram, the contrast material drains from the
main ducts, but remains within the punctate and
globular collections. Occasionally, patients with
chronic bacterial or granulomatous infection can
develop multiple abscesses within the parotid
gland. These collections tend to vary in size, and
they are not usually uniformly distributed
throughout the 96
On both CT and MR imaging in the earliest
stages of Sjogren’s syndrome, the involved glands
appear normal. As the disease progresses, glandu-
lar enlargement occurs and on CT the gland is
denser than normal, a nonspecific finding. As the
parotid disease continues to progress, on CT a
honeycomb glandular appearance develops.58This
CT appearance was once thought to be diagnostic
of Sjogren’s syndrome. Other granulomatous dis-
eases and even chronic sialadenitis, however, also
can give similar CT findings. On MR imaging,
once globular changes are present within the pa-
rotid glands, these collections can be seen on T1-
weighted images as discrete collections of low
signal intensity. This MR imaging appearance is
diagnostic of Sjogren’s syndrome. Rarely, diffuse,
bilateral macroscopic cystic change can develop.
The cysts can vary from a few millimeters to sev-
eral centimeters in diameter. When this occurs, the
CT and MR imaging appearances in the parotid
gland may be similar to those of the lymphoepi-
thelial cysts associated with HIV infection (Fig. 10).
A distinguishing feature is that in the autoimmune
disease there is no diffuse cervical adenopathy,
whereas such lymph node enlargement is part of
the H N disease process.
Sialosis
Sialosis or sialadenosis refers to a nonneoplastic,
noninflammatory, nontender, chronic or recurrent
enlargement of the parotid glands.13,69 Less com-
monly, the submandibular, sublingual, and minor
salivary glands can also be affected.74The parotid
disease is usually bilateral and symmetric, but can
be unilateral or asymmetric. The onset is usually
insidious and the disease is associated with a vari-
ety of endocrine diseases, nutritional states, and
certain medications. Sialosis is especially prevalent
in patients with diabetes, and the parotid gland
enlargement may be the first clinical evidence of
the underlying disease. Sialosis has also been asso-
ciated with a variety of medications. With these
pharmacologic sialoses both the submandibular
and parotid glands may be involved, and the glan-
dular swelling may be painful.42,60, 69 Sialosis may
also lead to x e r ~ s t o m i a It.~~
has been suggested
that a degeneration of the autonomic nervous sys-
tem may be the common pathologic principle in
all types of s i a l ~ s i s . ~ ~
On sialography, the parotid gland is enlarged,
and the ducts are usually normal in appearance
but splayed by the increased gland volume. On

Figure 10. Sjogren’s syndrome. Axial CT scan through

the parotid glands of a patient with advanced Sjogren’s
syndrome. There are diffuse cysts (arrowheads) throughout
both parotids. There was no cervical adenopathy or naso-
pharyngeal lymphoid hyperplasia present, which distin-
guishes this from multiple lymphoepithelial cysts associated
with HIV infection.

both CT and MR imaging, the parotid glands are
enlarged, but may appear either dense or fatty
depending on the dominant pathologic change. As
such, the CT and MR imaging appearances are
nonspecific and the diagnosis requires correlation
with the clinical findings and the patient's his-
tory.ll1
Postirradiation Sialadenitis
Postirradiation sialadenitis can occur in either
an acute or chronic form. Today, the acute type is
rare and is characterized by a tender, painful swell-
ing of the gland within 24 hours after it has been
irradiated, usually by a single dose of 1000 cGy or
more. These manifestations usually subside within
3 to 4 days, and there may be an associated tran-
sient xerostomia. The chronic form occurs in
glands irradiated as part of a curative treatment
plan, usually for oral cavity or pharyngeal tu-
mors? After a full dose of irradiation, the gland
atrophies and xerostomia occurs because of direct
effects both on the major and minor salivary
glands. CT and MR imaging usually show the
involved gland(s) to be smaller than normal, cellu-
lar, and fibrotic. On CT these glands appear denser
than normal, whereas on MR imaging the glands
are usually of lower signal intensity than normal
on most sequences. Only in the acute phase of this
disease does the gland have a higher than normal
T2-weighted signal intensity due to edema. Exter-
nal irradiation is a tumor promoter, with an in-
creased incidence of salivary malignancies being
found as a late sequela (10 to 25 years) in children
who were irradiated for nonmalignant condi-
tions."
Granulomatous-type Diseases
These diseases may affect the intraparotid or
juxtaglandular lymph nodes. The gland paren-
chyma can also be directly involved, and this may
occur either as an ascending infection from the
oral cavity or as part of a systemic process. The
so-called granulomatous diseases that may involve
the major salivary glands include sarcoidosis, tu-
berculosis, atypical mycobacterial infection, syphi-
lis, cat-scratch fever, toxoplasmosis, and actinomy-
cosis.n In reality, some of these infections do not
actually produce histologic granulomata.
Sarcoidosis is a systemic disease of presumed
infectious etiology characterized by noncaseating
granulomas involving multiple organ systems. The
parotid glands are affected in 10% to 30% of pa-
tients, and in some cases the parotid disease may
be the initial and only manifestation of the disease.
In 83% of these patients bilateral parotid gland
enlargement is present and in some patients
involvement of the minor salivary glands can
cause xerostomia.60,77, 94 In most patients a non-
tender, nonpainful, chronic enlargement of the
SALIVARY GLANDS 953
gland occurs. The gland is often multinodular and
clinically may mimic a malignancy.
The parotid glands can also be involved in pa-
tients with sarcoidosis who have uveitis and facial
nerve paralysis. This triad of findings is called
Heerfordt's syndrome. Most cases of such salivary
gland sarcoidosis usually resolve as the underlying
disease is treated.
On CT and MR imaging, the parotid disease
appears as multiple, benign-appearing noncavitat-
ing masses. In fact, these nodes are frequently ra-
diographically described as being "foamy" in ap-
pearance and there is often an associated cervical
adenopathy. The main differential diagnosis is
lymphoma. If the sarcoid granuloma is a solitary
parotid mass, however, it cannot be differentiated
from the other benipappearing parotid lesions.
Primary tuberculous involvement of the salivary
glands is rare. For cases that do affect the salivary
glands, 70% involve the parotid glands, 27% in-
volve the submandibular glands, and only 3% in-
volve the sublingual glands.= Most often the sali-
vary disease arises from a focus in the tonsils or
teeth and spreads to the gland via the regional
lymph nodes. The clinical presentation may either
be that of an acute tuberculous sialadenitis that
can mimic other acute infections or a more indo-
lent disease that may mimic a tumor." Similar
to the clinical findings, the imaging findings are
nonspecific.
Cat-scratch (animal-scratch) fever is a granulo-
matous disease that may involve the parotid
lymph nodes and mimic primary salivary gland
disease.n Its radiographic findings can resemble
either those of sarcoidosis or tuberculosis.
Toxoplasmosis is caused by the protozoa Toxo-
plasma gondii, and this disease is one of the most
common infections occurring in humans, infecting
from 5% to 95% of the population, depending on
geographic location. Most commonly the disease
causes asymptomatic lymphadenopathy, and in
the parotid region the disease may be indistin-
guishable from cat-scratch fever, sarcoidosis, and
tuberculosis.
Actinomycosis is caused by the bacterium Acti-
nomyces israelii, and the disease in humans usually
arises in the oral cavity of patients with poor denti-
tion. The disease i s an indolent, chronic infection
that invades the salivary glands from a focus usu-
ally in the mandible. Sinus tracts are commonly
infected, and nodal disease can occur in and
around the parotid gland and in the submandibu-
lar lymph nodes.= An inflammatory infiltration of
the soft tissues usually occurs in association with
the nodal disease, and this reaction usually in-
volves the masticator space. Rarely, the disease can
spread to the parotid gland in a retrograde manner
from the mouth. The associated sinus tracts and
masticator space disease allows this diagnosis to
be suggested on CT and MR imaging.
Cystic Lesions
Cystic lesions account for up to 5% of all sali-
vary gland masses; however, if neoplasms are ex-
954 SILVERS & SOM

cluded, the number of true cysts is greatly re-
duced? The majority of the true cysts occur in
the parotid gland and may be classified as either
congenital or acquired.
A cystic salivary gland lesion has a limited dif-
ferential diagnosis. The imaging character of the
cyst wall (i.e., thickness, nodularity) often allows
further refinement of the differential diagnosis,
which includes primarily Warthin’s tumor (either
solitary or multiple) and lymphoepithelial cyst (ei-
ther solitary as a result of any chronic infection or
multiple as seen in HIV infection). Most com-
monly, with HIV infection there are multiple, bilat-
eral parotid lymphoepithelial cysts with a diffuse
cervical adenopathy (Fig. 11). In about one third
of patients there are hyperplastic adenoids. The so-
called intrapurotid brunchid cleft cyst is most likely a
solitary lymphoepithelial cyst, because the parotid
gland is not a branchial derivative. It is believed
that the lymphoepithelial cyst arises from intrano-
dal salivary inclusions, rather than from branchial
cleft remnants.12A solitary lymphoepithelial cyst
may develop in response to any chronic inflam-
matory disease with or without any relationship
to an immune disorder. In distinction to those cysts
that are entirely within the parotid gland, cysts
that have a fistulous connection in or around the
external auditory canal are clearly of a first
branchial cleft origin. Less often, a cystic region
can be seen in a low-grade mucoepidermoid carci-
noma, the papillocystic variant of acinic cell carci-
noma, an oncocytic cystadenoma, and either an
abscessed node or a necrotic metastatic node.
Rarely a dermoid cyst occurs and parotid cysts can
occur in association with fibrocystic and polycys-
tic disease?
Many acquired cysts of the major salivary
glands develop as a result of an obstruction to part
of the ductal system that may be caused by a
postinflammatory stricture, a calculus, trauma, a
postsurgical complication, or a mass. Almost al-
ways the ductal obstruction is incomplete or inter-
mittent, because complete obstruction of the glan-
dular ducts results in acinar and glandular atrophy
rather than cyst formation.61,74 The resultant thin-
walled cyst has been called a retention cyst, a
mucocele of the major salivary gland, or an extra-
vasation cyst. These cysts occur most often in the
submandibular gland. When such a cyst arises in
the sublingual gland, it is called a runulu.
A sialocele arises when saliva accumulates
within a cyst area that develops secondary to a
complete or incomplete traumatic interruption of
the excretory ducts draining the region. These si-
aloceles develop rapidly after trauma, and needle
aspiration of saliva from the cyst confirms the
diagnosis.22,
The term runulu specifically refers to a mucous
retention cyst in the sublingual gland, and the
ranula occurs in two forms. A simple ranula,
which is the most common form, is a retention
cyst that remains in the floor of the mouth above
the level of the mylohyoid muscle (Fig. 12). The
simple ranula is a true cyst because it has an
epithelial lining around its entire periphery. The
deep or plunging ranula develops from the rup-
ture of the wall of a simple ranula. As such, it
usually extends below the level of the mylohyoid
muscle, and in reality is a pseudocyst. Pathologi-
cally, inflammatory tissue forms part of the cyst
wall where the irritating saliva penetrated into the
muscles and soft tissues.
The simple ranula occurs as a mass in the floor
of the mouth, extending from the sublingual gland
along the lingual border of the mandible toward
the submandibular gland. The portion in the lat-
eral floor of the mouth has been referred to as the
tail of the ranula and is a fairly specific imaging
finging. Because of the simple ranula’s location,
the differential diagnosis includes a lateral der-

Figure 11. HIV-related disease. Axial CT. Numerous bilateral

lymphoepithelial cysts (arrow) and cervical adenopathy (curved
arrow). The presence of multiple cystic lesions within the parotid
glands associated with cervical adenopathy and lymphoid hyper-
plasia should prompt the evaluation of a patient’s immune status
even in patients who deny risk factors for HIV disease.
 SALIVARY GLANDS 955

Figure 12. Ranula axial T2-weighted sequence. Ranula

(arrow) extending posteriorly from right sublingual gland. The
ranula extends from the floor of mouth into the subrnandibu-
lar triangle of the neck.

moid or epidermoid cyst, a lipoma, or a salivary
gland tumor. The plunging ranula appears clini-
cally as a painless mass in the submandibular or
submental triangles of the neck, with or without
evidence of a mass in the floor of the mouth.
The differential diagnosis includes dermoid and
epidermoid cysts, thyroglossal duct cysts, cystic
hygroma, and lymphadenopathy (Fig. 13)."
The cystic nature of the lesion is easily identified
on CT; however, if postcontrast MR imaging is not
used, a watery solid mass and a cyst may appear
the same. On CT, the cyst contents usually have
a watery attenuation and the cyst wall is easily
identified. On postcontrast MR imaging, the cyst
wall enhances whereas the cyst contents do not en-
hance.
On MR imaging, most of the cysts have low
T1-weighted signal intensity, but may have inter-
mediate and even high signal intensity. Virtually
all of the cysts have a high T2-weighted signal
intensity. Definition of the cyst wall thickness,
smoothness, or uniformity may occasionally be
made on T1-weighted images, but this is usually
better accomplished on postcontrast fat sup-
pressed studies.85,90, 112
A pneumocele of a major salivary gland results
from the retention of air in the gland parenchyma
or ductal system. This occurs after an increase in
intrabuccal pressure. Although it is uncommonly
associated with adult occupations, such as glass
blowing and trumpet playing, it commonly occurs
in children who cause retrograde insufflation of
air into the gland via Stensen's or, less commonly,
Wharton's duct.
TUMORS AND TUMORLIKE CONDITIONS
Salivary gland neoplasms cause about 750
deaths a n n ~ a l l y . ~A* higher
,~ incidence of salivary

Figure 13. Obstructed submandibular duct simulates a ranula. Axial CT scan through the floor of
mouth (A) and the submandibular gland (6)demonstrate a dilated submandibular gland duct. In
6,the duct can be followed back into the gland (curved arrow) confirming that this is not a ranula.
956 SILVERS & SOM

neoplasms has been reported in Eskimos, survi-
vors of atomic bomb blasts, and those exposed to
previous radiation.77,78
Between 70% and 80% of parotid gland tumors,
40% and 58% of submandibular gland tumors, 15%
and 30% of sublingual gland tumors, and 20% and
51% of minor salivary gland tumors are benign.
Generally, these figures indicate that the smaller
the salivary gland involved, the greater the likeli-
hood that a tumor is malignant?,n,78
The TNM staging of salivary gland tumors ac-
cording to the American Joint Committee on Can-
cer is weighted heavily on the size of the primary
lesion (Table 1). By using this staging system, it
becomes evident that the higher the stage, the
greater the recurrence rate, the greater the inci-
dence of metastasis, and the lower the survival
rate. Although the overall cure rates traditionally
are calculated on the basis of no evidence of dis-
ease for 5 years, several of the major salivary gland
tumors, notably adenoid cystic carcinoma, may
have late recurrences. Because of this, statistics
citing 5 years of curability must be viewed with
some circum~pection.~~, 77 Overall for predicting
prognosis, this grading system overrides histology
except for salivary ductal carcinoma, which by
virtue of its diagnosis indicates a grave prognosis.
Although salivary gland tumors are uncommon
in children, there is a higher frequency of malig-
nancies in children compared with adults. Of all
epithelial and nonepithelial salivary gland tumors
in children, 35% are malig1ant.4~The most com-
mon tumors in the pediatric age group are heman-
giomas, followed in descending frequency by pleo-
morphic adenomas, mucoepidermoid carcinomas,
lymphangiomatous-type tumors, acinic cell carci-
nomas, and undifferentiated carcin0mas.4~
For all salivary gland malignancies, the presence
of metastatic regional lymph node disease is a
poor prognostic finding.4Similarly, facial nerve tu-
mor invasion predicts an increased rate of nodal
metastasis (66% to 77%) and thus an unfavorable
prognosis. Overall, if the facial nerve is paralyzed
at clinical presentation, the 5-year survival rate is
only between 9% and 14%.The presence of distant
metastasis is also associated with a very poor prog-
nosis and about 20% of all parotid malignancies
have distant metastasis.*
The presence of pain is not necessarily a crite-
rion of malignancy because 5.1% of benign tumors
and 6.5% of malignant tumors present with pa-
rotid pain. Pain in a patient with a known malig-
nancy, however, is a very poor sign. Overall, the
5-year survival rate in such patients with pain is
35%, compared with 68% in patients who do not
have pain. The pain in these malignancies is prin-
cipally secondary to neural invasion.8
In the past decade, the treatment philosophy for
parotid gland malignancies has changed as the
limitations of surgery for the more aggressive neo-
plasms have become known. Postoperative irradia-
tion is now used frequently to improve local con-

Table 1. PAROTID TNM STAGING SYSTEM

Primary Tumor (T)

TX = primary tumor cannot be assessed
TO = no evidence of primary tumor
T1 = tumor 2 cm or less in greatest dimension without extraparenchymal extension
T2 = tumor greater than 2 cm but not more than 4 cm in greatest dimension without extraparenchymal extension
T3 = tumor more than 4 cm but not more than 6 cm in greatest dimension or tumor having extraparenchymal
extension without seventh nerve involvement
T4 = tumor more than 6 cm in greatest dimension or tumor invades skull base or seventh nerve
Regional Lymph Nodes (N)
NX = regional lymph nodes cannot be assessed
NO = no regional lymph node metastasis
N1 = metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
N2 = metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension, or
multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or bilateral or contralateral lymph
nodes, none more than 6 cm in greatest dimension
N3 = metastasis in a lymph node more than 6 cm in greatest dimension
Distant Metastasis (M)
MX = distant metastasis cannot be assessed
MO = no distant metastasis
M1 = distant metastasis
Stage Grouping
Stage I = T1 or T2, NO, MO
Stage II = T3, NO, MO
Stage 111 = T1 or T2, N1, MO
Stage IV = T4, NO, MO or
T3 or T4, N1, MO or
Any T, N2 or N3, MO or
Any T, Any N, M1

From American Joint Committee on Cancer: Manual for Staging Cancer, ed 5. Philadelphia, JB Lippincott, 1997; with permission from
the American Joint Committee on Cancer (AJCC), Chicago, IL.
 SALIVARY GLANDS 957

trol, and chemotherapy is being utilized more of-
ten to control distant metastasis!
What is clear from the literature is that imaging
cannot be relied upon to provide a definitive histo-
logic diagnosis. More important to the clinician
than giving a specific pathologic diagnosis based
on the imaging is to provide accurate tumor map-
ping. Has the tumor spread outside the confines
of the gland? If so, is there bone or carotid artery
invasion? What is the relationship of a parotid
mass to the plane of the facial nerve? Are there
metastatic lymph nodes? A brief discussion of key
imaging findings on some of the more common
tumors follows.
Epithelial Tumors
The pleomorphic adenoma, also referred to as
the benign mixed tumor, is the most common sali-
vary gland tumor and represents 70% to 80% of
all benign tumors of the major salivary glands. Of
all pleomorphic adenomas, 84% occur in the pa-
rotid gland, 8% in the submandibular gland, 6.5%
in the minor salivary glands, and 0.5% in the sub-
lingual glands. Of the parotid tumors, 90% arise
lateral to the plane of the facial nerve (Fig. 14).74,n
Although about 50% of all minor salivary gland
tumors are malignant, the pleomorphic adenoma
is still the single most common tumor of these
glands.74
The lesions are usually solitary, ovoid, well-de-
marcated masses despite their having a capsule of
variable thickness and completeness. The larger
tumors may have pedunculated contour. The
larger lesions can have sites of necrosis, hemor-
rhage, and focal calcification or occasionally ossi-
f i ~ a t i o n They
. ~ ~ are the most common salivary
gland tumors to have calcifications and ossifica-
tions within the tumor matrix. Surgical extirpation
with an intact capsule is essential to prevent seed-
ing of the operative field. If such seeding occurs,
multiple recurrences within the operative bed de-
velop within 5 to 10 years after surgery (Fig. 15).

Figure 14. Pleomorphic adenoma. A, Axial CT. 6,Axial T1-weighted sequence. C,Axial T2-weighted
sequence. 0,Axial postgadolinium T1-weighted sequence. W-defined lesion within the left parotid
gland showing typical intermediate signal and moderate enhancement on T1-weighted sequences
with high signal intensity on T2-weighted sequence.
958 SILVERS & SOM

Figure 15. Recurrent pleomorphic adenoma. A and 6, Coronal T2-weighted sequences showing
cluster of grapes appearance (arrows).

Because of their grouping in the operative field, lial subtype can and does occur in approximately
these tumors have been described as appearing as 2% to 5% of all mixed tumors.74* 95 It has been

a cluster of grapes.I5,36, 95 estimated that left untreated, nearly 25% of all

The carcinoma ex pleomorphic adenoma is ei-
ther a malignant change in a benign mixed tumor,
in which elements of the benign lesion can still be
identified, or the development of a malignant tu-
mor in a patient known to have a previously re-
sected pleomorphic adenoma (Fig. 16). Usually the
malignancy is an adenocarcinoma, but any epithe-
pleomorphic adenomas may undergo malignant
change.74,95
The imaging of pleomorphic adenoma shows
the typical picture of a benign-appearing mass.
The smaller lesions are usually homogeneous in
appearance and ovoid. The larger masses most
often have a nonhomogeneous appearance, with

Figure 16. Carcinoma ex pleomorphic. A, Axial T1-weighted sequence. 6, Axial T2-weighted se-
quence. C, Axial T1-weighted sequence postgadolinium with fat suppression. On the axial T2-
weighted sequence, there is an area of decreased signal intensity (arrow) suggesting that a more
aggressive lesion may be present. The area of nonenhancement (curved arrow) on the postgadolinium
sequence also raises the possibility of malignant degeneration.
 SALIVARY GLANDS 959

sites of lower attenuation representing areas of
necrosis, and cystic change. Localized areas of in-
creased attenuation most often represent sites of
recent hemorrhage and are associated clinically
with a sudden increase in tumor size and localized
pain. The larger tumors tend to develop a lobu-
lated contour that, when present, is highly sugges-
tive of the diagnosis.
A carcinoma ex pleomorphic adenoma may
have one of several CT appearances. (1) It may
look like a large pleomorphic adenoma with no
evidence of malignancy. ( 2 ) It may look like a
benign mixed tumor with a focally aggressive ap-
pearance. This aggressive area has a necrotic cen-
ter, thick, irregular walls, and infiltrating margins.
(3) Last, the tumor may be entirely aggressive in
its appearance, with no remaining evidence of any
benign pleomorphic adenoma.
Warthin’s tumor, adenolymphoma or papillary
cystadenoma lymphomatosum, is the second most
common benign lesion of the parotid gland, repre-
senting 2% to 10% of all parotid tumors.74The
lesion is exclusively limited to the parotid gland
and the periparotid lymph nodes. As many as 10%
of cases have bilateral involvement. It is also the
most common lesion to occur as multifocal unilat-
eral and bilateral disease. The tumor is benign and
most patients are in their fourth to seventh dec-
ades of life; this tumor is rarely found in non-
whites.
Most Warthin’s tumors appear as small, ovoid,
homogeneous, smoothly marginated masses in the
posterior and inferior aspect of the superficial lobe
(tail) of the parotid gland. Cyst formation is com-
mon, especially in larger tumors (Fig. 17). The cyst
wall is usually thin and fairly smooth, but at some
point there is a focal tumor nodule, differentiating
it from a lymphoepithelial cyst. When a Warthin’s
tumor is large and arises either from the periphery
of the parotid gland or from a juxtaparotid lymph
node, imaging confusion with a second branchial
cleft cyst or a necrotic node possibly may occur.
When multiple lesions are seen either in one
parotid gland or bilaterally, the most likely diagno-
sis is Warthin’s tumors. The differential diagnosis
includes lymphoepithelial cysts of HIV-positive
patients and possibly multiple cavitated metastatic
nodes. If the multiple Warthin’s tumors are solid,
the imaging differential diagnosis includes lym-
phoma; granulomatous disease (primarily sarcoid-
osis); and benign adenopathy.@
Although mucoepidermoid carcinomas account

Figure 17. Warthin’s tumor. A, Axial CT bilateral and multiple

Warthin’s tumor. B, Axial CT unilateral cystic Warthin’s tumor.
There is slight nodularity of the cyst wall, differentiating this
tumor from a benign cyst. Warthin’s tumors often present as
multiple masses within one or both parotids. Cystic changes are
common especially in larger lesions.
960 SILVERS & SOM
for less than 10% of all salivary gland tumors,
they represent about 30% of the salivary gland
malignancies. Nearly 50% of these lesions occur in
the parotid gland, and about 45% arise in the mi-
nor salivary glands, primarily in the palate and
buccal mucosa.5,74 In adults, mucoepidermoid car-
cinomas are the most common parotid gland ma-
lignancy and the second most common malig-
nancy in the submandibular gland after adenoid
cystic carcinoma. Mucoepidermoid carcinomas are
also the most common salivary gland malignancies
in children?*,74,
These tumors can be classified histologically as
low, intermediate, or high grade, and the grade
correlates well with prognosis.4’ The imaging find-
ings of mucoepidermoid lesions vary with the
grade of the tumor. Low-grade lesions are benign
in appearance. Cystic areas may be present and,
rarely, focal calcification may be seen. The appear-
ance is similar to that of a benign mixed tumor. By
comparison, the high-grade lesions have indistinct
infiltrating margins.
Adenoid cystic carcinoma accounts for 2% to 6%
of parotid gland tumors, 12% of submandibular
gland tumors, 15% of sublingual gland tumors,
30% of minor salivary gland tumors, and 50% of
lacrimal gland tumors.5,25, 74 Overall, 4% to 8%
of all salivary gland tumors are adenoid cystic
carcinomas, and they occur most commonly in the
parotid gland, the submandibular gland, and the
palate. The tumor usually arises in patients be-
tween 20 and 80 years of age and is rare in patients
who are under 20 years old. Most patients are in
the fifth and sixth decades of life. Although a
relentless tumor, it may often have a slow rate of
growth, so that prolonged survivals are reported
even after metastases are present. Because of this,
the true survival must be evaluated by looking
beyond the usual 5-year survival figures. Perineu-
ral invasion (seen in 50% to 60% of cases) is a
pathologic hallmark of this tumor and accounts
for the relatively frequent clinical presentation
with pain.
On imaging, the parotid lesions tend to appear
as benign well-delineated tumors, whereas the mi-
nor salivary gland neoplasms usually have malig-
nant infiltrative margins. Retrograde tumor exten-
sion to the skull base often occurs via the facial
nerve or the mandibular nerve. This neural inva-
sion is best demonstrated by postcontrast MR im-
aging, where nerve enhancement and enlargement
signify tumor spread (Fig. 18).
Acinic cell carcinoma represents only 2% to 4%
of all major salivary gland tumors. They occur
almost exclusively in the parotid gland and repre-
sent 15% to 17% of all malignant parotid tumors.
Bilateral parotid gland tumors occur in 3% of
cases, making these tumors second only to War-
thin’s tumor as being the most common parotid
lesion to occur b i l a t e r a l l ~ .At , ~ ~ 80% of these
~ ~least
tumors occur in the parotid gland; 4% in the sub-
maxillary gland; and about 10% intraorally, pri-
marily in the buccal mucosa or lip. These tumors
Figure 18. Perineural spread. Sagittal T1-weighted se-
quence through the parotid gland demonstrates a tumor
within the parotid gland with thickening of the facial nerve
(arrow) secondary to perineural spread.
usually occur in patients in their fifth and sixth
decades of life. It should be noted, however, that
acinic cell carcinomas are the second most com-
mon parotid malignancy (after mucoepidermoid
carcinoma) in The 5-year survival rate
is 80% to 90%, but the 20-year survival rate is only
Metastases to regional lymph nodes occur
in 10% to 19% of patients, and distant metastases
(primarily to lung and bone) occur in nearly 15%
of the 74 Tumor stage at the time of
presentation is the most important survival pre-
d i ~ t o r The
. ~ ~ imaging characteristics of these tu-
mors are nonspecific, with most lesions having a
generally benign appearance.
Salivary duct carcinoma is an uncommon, ex-
tremely aggressive malignancy that has a male
predominance and a predilection for the parotid
gland. Histologically, this tumor resembles breast
carcinoma, replete with intraductal in situ carci-
noma and comedonecrosis. This tumor may be
confused histologically with mucoepidermoid car-
cinoma or squamous carcinoma and distant metas-
tasis may develop. Following surgical resection,
adjuvant radiotherapy is recommended. Survival
is generally very poor and of the limited number
of reported cases, 75% of the patients have died of
their disease.’” 74
Despite the scores of well-recognized diagnostic
categories of salivary tumors, some tumors persist
in eluding current classification schemes. Because
some form of gland formation is common to most
of these tumors, the group is referred to as adeno-
carcinoma, not otherwise specified. These tumors usu-
ally are painful, rapidly enlarging masses and the
majority of tumors occur at minor salivary gland
sites (68%), followed by the parotid gland (28%)
and the submandibular gland (4%).
Although squamous epithelium is not a normal
component of the salivary glands, squamous meta-
plasia can arise secondary to chronic inflammation.
Primary squamous carcinomas of salivary origin
represent 0.1% to 0.5% of all parotid tumors, and

3% to 10% of the malignant parotid neoplasms.",
33, 74 They account for 3% of submandibular gland
neoplasms and 4% of the carcinomas. Approxi-
mately two thirds of the cases occur in the parotid
glands, and most of the remaining cases occur in
the submandibular glands.
Before establishing the diagnosis of a primary
salivary squamous carcinoma, the possibility must
be considered of recurrence of a periparotid skin
primary or metastasis to periparotid lymph nodes
from another source, such as a carcinoma of the
upper face or scalp, or much more rarely, an occult
primary from the oral cavity, nasal cavity, or naso-
pharynx. The incidence of metastasis to the parotid
gland from squamous cell carcinoma of the skin is
believed to be more than twice the incidence of
primary salivary gland squamous cell carcin0ma.7~
The imaging characteristics are those of a high-
grade infiltrating tumor.
Of the major salivary glands, the parotid glands
are most frequently involved by metastatic disease.
This fact reflects the presence of intraglandular
lymph nodes, which drain the face, external ear,
and scalp. The most common tumor to metastasize
to the parotid glands and the periparotid lymph
nodes is melanoma of the temporal scalp, which
has such spread in 80% of the cases. In light of
this, the diagnosis of primary melanoma of the
parotid should virtually never be accepted. Parotid
metastasis from melanomas in other areas of the
head and neck occurs in approximately 50% of
the cases. Less commonly, basal cell carcinomas,
metastases from renal cell carcinomas (3% of litera-
ture cases), lung carcinomas (4% of literature
cases), breast carcinomas (2.5% of literature cases),
and gastrointestinal carcinomas YO of literature
cases) can occur both to the intraparotid and peri-
parotid lymph nodes.32,37, 43, 74
Nonepithelial Tumors
Nonepithelial tumors of the salivary glands rep-
resent less than 5% of all salivary gland neoplasms.
In children, however, they may account for over
50% of the lesions.8,74 The only tumors of statistical
consequence are hemangiomas, lymphangiomas,
lymphomas, neurogenic lesions, lipomas, and sar-
comas.
Hemangiomas of the parotid gland represent 1%
to 5% of all salivary gland tumors, but they are
the most common salivary gland neoplasm in chil-
dren.s,74, lO4 Submandibular gland involvement is
rare, and in these cases it has been difficult to
distinguish between tumors that arose within the
gland and those that arose in the soft tissues adja-
cent to the gland. The congenital capillary heman-
gioma is the predominant tumor in the first year
of life, representing 90% of parotid gland tumors
in this age group. This lesion is usually discovered
shortly after birth, is unilateral, compressible, and
soft. Rapid enlargement can occur, and a bluish
coloration can be seen in the overlying skin, espe-
SALIVARY GLANDS 961
cially when the infant is crying. There also may be
an associated hemangioma in the overlying skin.
These nonencapsulated and lobulated lesions are
more common in girls. The differential diagnosis
includes cystic lymphangioma and the rare, malig-
nant hemangioendothelioma,both of which can be
distinguished histologically. If possible, surgery is
to be avoided until adulthood, because many of
these tumors may spontaneously regress.74In addi-
tion, there are no known instances of malignant
transformation of this lesion.1o4
Cavernous hemangiomas occur in older children
and adults, with most patients being older than
16 years of age. These tumors tend to be well-
circumscribed lesions and involve the extraparotid
tissues. Surgery is the treatment of choice, because
spontaneous regression is unlikely.74Capillary
hemangiomas appear to be very rare in the pa-
rotid gland.
On CT these tumors enhance, are often lobular
in contour, may be seen to extend to the overlying
skin, or may have phleboliths within the tumor
tissues. Often, the mass effect of the tumor on
the surrounding soft tissues is relatively minimal,
reflecting the soft nature of these lesions. On MR
imaging, the majority of the lesions have a low to
intermediate, nonhomogeneous T1-weighted sig-
nal intensity and a high T2-weighted signal inten-
sity. There may be sites of high signal intensity on
both T1-weighted and T2-weighted images, which
are caused by prior hemorrhage and slow flow.
There also can be vascular flow voids.
Lymphangiomas are benign tumors that are
composed primarily of lymphatic vessels. These
tumors are classified as lymphangioma simplex,
cavernous lymphangioma, and cystic lymphangi-
oma or cystic hygroma. All three pathologic types
may coexist within the same tumor. Most of the
lesions that are found in the head and neck are
cystic hygromas. Lymphangiomas represent 5% to
6% of all benign tumors of infancy and childhood,
with 50% to 60% of the cases being present at
birth. Between 80% and 90% of patients are diag-
nosed by the age of 2 years. This age range corres-
ponds to the period of greatest lymphatic growth.
It is uncommon for cystic hygromas to be reported
in adults.7.44.90.97.104
Most commonly, these lesions arise in the poste-
rior triangle of the neck. They can spread to invade
the parotid and submandibular glands, muscles,
and vessels. Most tumors are painless, soft or semi-
firm masses, and some fluctuation in size is com-
mon. Sudden enlargement is associated with infec-
tion or hemorrhage. Facial nerve paralysis can
occur either secondary to nerve compression by a
parotid lesion with hemorrhage, or secondary to
an acute otitis media caused by a lesion obstruct-
ing the eustachian tube.97
On CT, these lesions are usually cystic masses
filled with homogeneous low-attenuation material.
The cysts usually have thin walls and most com-
monly there are multiple intercommunicating cys-
tic components. Areas of higher attenuation within
962 SILVERS & SOM
the cysts usually correspond to sites of hemor-
rhage?7
Infection is identified by an enhanced, thick-
ening of the cyst wall and infiltration of the adja-
cent soft tissues. In cases of multiple repeated in-
fections, the attenuation of the cyst contents may
approach that of muscle. On MR imaging, the sig-
nal intensities are typically low on T1-weighted
images and high on T2-weighted images. Fluid-
fluid levels are commonly seen on MR imaging.
Primary lymphoma of the salivary gland is very
rare. This diagnosis can be made only if there
is histologic proof of lymphoma in the salivary
parenchyma without any evidence of intraglandu-
lar or extraglandular nodal involvement. Overall,
provided that these patients do not have bone
marrow involvement and are therefore stage IV
lymphomas, the prognosis of stage I salivary lym-
phoma is good. At 5 to 8 years, 33% to 50% of
patients are disease free.45The mean age is over 50
years, with only 10% of patients being younger
than 30 years of age. Womeh represent 64% of the
cases (Fig. 19).
Secondary lymphomatous involvement of the
salivary glands is also rare, with about 80% of the
cases involving the parotid gland. The incidence
of such salivary gland lymphoma varies from 1%
to 8% of the cases of lymphoma. Most commonly,
large cell lymphoma is the pathologic tumor type.
All forms of non-Hodgkin’s and Hodgkin’s lym-
phomas, however, have been reported.n Because
there is disseminated lymphoma outside of the
parotid gland, the prognosis in these patients is
poor. There is a well-documented relationship be-
tween Sjogren’s syndrome and non-Hodgkin’s
lymphoma, as well as with HIV infection and Wal-
denstrom’s macroglobulinemia. The lymphomas
usually are of the large cell type, are extraglandu-
lar, and ultimately have a poor prognosis.
The CT appearance of secondary lymphoma of
the parotid gland varies as the pathologic distribu-
tion of the disease. Most commonly, the parotid
disease is confined to the intraparotid lymph
Figure 19. Lymphoma. Axial CT of lymphoma,left parotid
gland. The appearance of lymphoma within the parotid
gland is nonspecific and cannot be differentiated from
other aggressive primary lesions of the parotid gland.
nodes. Each node is homogeneous and may en-
hance slightly on postcontrast CT scans. If the
parenchyma is involved, a diffuse infiltration is
seen either with poorly defined margins or with
involvement of the entire gland. The identification
of extraparotid nodal disease can be helpful in
suggesting the diagnosis. On MR imaging the lym-
phoma tends to have a homogeneous intermediate
signal intensity on all imaging sequences.
Enlargement of an intraparotid lymph node can
occur as a result of a variety of causes. These
include hyperplastic adenopathy; acute viral or
bacterial adenopathy; lymphoma; infectious gran-
ulomatous disease; and metastatic disease from
primary sites in the scalp, periauricular region,
face, or at a distant site below the clavicles. The
rapid, painful nodal enlargement that usually ac-
companies inflammatory adenopathy may simu-
late a parotid malignancy, especially in children.
Because about 5% of facial nerve paralysis is
caused by acute otitis media, if there is also an
associated ear infection, a facial nerve paralysis
can be present. Clinically, the patient has a painful,
rapidly growing parotid mass with an accompa-
nying facial nerve paralysis and a tumor, such as
a rhabdomyosarcoma, is suspected. In such cases,
if an MR image is performed, the node usually has
a fairly high T2-weighted signal intensity, whereas
the high-grade malignancies tend to have low to
intermediate T2-weighted signal intensity. Al-
though this information can be helpful in distin-
guishing these entities, in most cases needle aspi-
ration or surgery is necessary to establish the
diagnosis. Such inflammatory nodes may enhance
on postcontrast CT scans and have a slightly irreg-
ular margin as a result of the inflammatory reac-
tion, further simulating a malignancy.
Even when a parotid node is enlarged with met-
astatic disease, the mass may simulate a benign
lesion on imaging. This is especially true in cases
of metastatic melanoma from a facial or scalp pri-
mary.
Lipomas can arise either within the parotid
gland or in the immediate periparotid region. At
times, it may be clinically and radiographically
impossible to distinguish the true site of origin.
Lipomas represent about 1%of parotid gland tu-
mors, and approximately 90% of the cases are ordi-
nary lipomas. The remaining lesions are either in-
filtrating lipomas, or they occurred as part of a
lipomatosis syndrome.44, 77, 93
The ordinary lipomas are discrete lesions that
usually have a homogeneously low attenuation
( - 65 to - 125 H). They have no definable capsule
on imaging, yet they are easily delineated from
the adjacent soft tissues (Fig. 20). The infiltrating
lipoma is similar in appearance to the ordinary
lipoma except with poorly defined margins and
infiltration of adjacent muscles may be demon-
strated on imaging. Hemorrhage and fibrotic
changes can occur within lipomas; and on CT
these changes may cause an increased attenuation
that approaches that of muscle. Usually, these

Figure 20. Lipoma. Axial (A) and coronal (B) CT scans. This lesion is easily identified as
a fat attenuation lesion without a definable capsule but can easily be separated from the
more dense underlying structures and parotid gland (curved arrows).
changes are focal within the lipoma; however, the
entire lesion may be hemorrhagic, rendering im-
possible the CT diagnosis. On MR imaging lipo-
mas have a high T1-weighted and an intermediate
T2-weighted signal intensity, which may be mini-
mally heterogeneous. An important diagnostic
point is that whenever a lipomatous mass has an
overall heterogeneously dense matrix, it may rep-
resent a liposar~oma.~~
Neurogenic tumors of the parotid gland are the
second most common benign mesenchymal neo-
plasm after vascular or lymphatic tumors. They
may be either schwannomas or neurofibromas.
Both lesions are usually ovoid, sharply delineated
masses that arise primarily from the facial nerve
trunk or its branches. The schwannomas are soli-
tary, whereas the neurofibromas often are multiple
and associated with other manifestations of neuro-
fibromatosis type 1 (NF-1) or von Recklinghausen’s
disease. On CT these tumors can enhance, be
cystic, or be isodense with muscle. The cystic
changes usually are small and multiple. The neu-
rofibromas may have a low, almost fatty attenua-
tion that may simulate a lipoma. On MR imaging
these tumors are indistinguishable from other
benign masses.47,48, 92
SUMMARY OF DISEASE PATTERNS
A history of recurrent parotid swelling, with or
without associated pain, suggests an inflammatory
process. A CT scan may identify a calcified sialo-
lith, show the sialadenitis, or suggest Sjogren‘s
syndrome or sialosis. On MR imaging, multiple
collections of contrast material that are uniform in
size and distribution throughout the gland suggest
Sjogren’s syndrome.
Salivary tumors in children are uncommon and
represent less than 5% of tumors in all age groups.
Hemangioma is the most common tumor, repre-
senting over 50% of all lesions. Next in decreasing
SALIVARY GLANDS 963
frequency are pleomorphic adenomas, mucoepi-
dermoid carcinomas, lymphangiomas, and acinic
cell carcinomas. Rarely, undifferentiated carcino-
mas, adenocarcinomas, and adenoid cystic carcino-
mas can occur. About 30% to 35% of the cases
are malignant, a higher percentage than found in
adults.8,49, 53,77 A solitary benign-appearing mass in
a pediatric patient may also be inflammatory.
Masses that result from autoimmune disease and
chronic sialadenitis may on occasion simulate a
parotid tumor, and intraparotid lymphadenopathy
may also mimic a parotid neoplasm.
A solitary benign-appearing mass in an adult
patient is most likely a benign mixed tumor, a
Warthin’s tumor, a low-grade mucoepidermoid
carcinoma, a carcinoma ex pleomorphic adenoma,
or an adenoid cystic carcinoma. A solitary malig-
nant-appearing mass is most likely to be a high-
grade mucoepidermoid carcinoma, an adenocarci-
noma, or an undifferentiated carcinoma. Multiple
masses suggest Warthin’s tumors, acinic cell tu-
mors, lymphoma, granulomatous disease, onco-
cytic tumors, pleomorphic adenomas, or metasta-
ses. Multiple cystic masses, especially in
association with benign cervical adenopathy, sug-
gest that the patient is HIV positive. Multiple par-
tially cystic masses are most likely Warthin’s tu-
mors. A solitary cystic mass most likely is a
lymphoepithelial cyst or a Warthin’s tumor.
All salivary masses are probably better identi-
fied on MR imaging than on CT. Calcifications are
better seen on CT, however, and when within the
gland ducts indicate sialoliths. Calcification within
a mass suggests a benign mixed tumor or, less
commonly, a mucoepidermoid carcinoma. Phlebo-
liths indicate a hemangioma.
If the tumor accumulates Tc-99m pertechnetate,
a Warthin’s tumor or an oncocytoma is present. If
a tumor mass has low to intermediate signal inten-
sity on all MR imaging sequences, a high-grade
malignancy may be present. Although other enti-
ties can give these signal intensities, the high-
964 SILVERS & SOM
grade lesion is the most important one to rule out
of the differential diagnosis.
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