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Major Salivary Gland Imaging Michael A State of the Art 1 David M. Yousem, MD Major Salivary Gland Imaging Michael A. Kraut, MD, PhD Ara A. Chalian, MD The algorithm for imaging the salivary glands depends on the clinical scenario with which the patient presents to the clinician. Because of the importance of identifying Index terms: small calculi in the gland or salivary duct as the cause of the symptom complex, Salivary glands, calculi, 264.818 nonenhanced computed tomography is often the best initial study for the evaluation Salivary glands, CT, 264.12111, of the painful gland. If an infiltrative neoplasm is highly suspected, nonenhanced and 264.12112 Salivary glands, diseases, 264.247 enhanced magnetic resonance (MR) imaging may be superior in demonstrating Salivary glands, MR, 264.12141, perineural, meningeal, and skull base invasion. Sialography is reserved for the 264.12143 evaluation of chronic sialadenitides unrelated to sialolithiasis. Thin-section MR Salivary glands, neoplasms, 264.363, techniques for MR sialography may soon replace conventional sialography. 264.37 Radiology 2000; 216:19–29 Abbreviations: HIV ϭ human immunodeficiency virus While neoplasms of the major salivary glands constitute less than 3% of all tumors in the SE ϭ spin echo body, many people have an illness related to the salivary glands at some time in their lives. The process may be self-limited, such as with viral parotitis or mumps, but in others it may 1 From the Department of Radiology, be a relapsing and remitting illness, such as chronic sialadenitis secondary to sialolithiasis. Johns Hopkins Hospital, 600 N Wolfe Still others may be evaluated for what is thought to be a salivary gland mass but is actually a St, Houck B-112, Baltimore, MD 21287 mass peripheral to the glands, such as a lymph node. Very rarely, a nonnodal extraglandu- (D.M.Y., M.A.K.), and the Department lar lesion such as a schwannoma, masseteric hypertrophy, or other pseudomass may be mistaken of Otorhinolaryngology: Head and for a glandular process, even by experienced otorhinolaryngologists (1). The purpose of this Neck Surgery, University of Pennsylva- nia Medical Center, Philadelphia review is to illustrate the role of imaging in evaluating diseases of the major salivary glands. (A.A.C.). Received January 22, 1999; The range of studies needed to assess salivary gland lesions spans a wide gamut. Many of revision requested March 30; final the disease processes described above may not require imaging of any kind. Still others may revision received August 6; accepted be readily evaluated with palpation and direct visualization either endoscopically or August 18. Address correspondence to D.M.Y. (e-mail: [email protected]). transorally. At the other end of the spectrum are infiltrative deep lobe parotid masses such ௠ RSNA, 2000 as adenoid cystic carcinomas, which may require computed tomography (CT), magnetic resonance (MR) imaging, and/or conventional angiography as part of a preoperative evaluation for perineural, vascular, or skull base infiltration. Ultrasonography (US), underutilized in most North American sites, may supplant the role of CT and MR imaging for superficial salivary gland lesions when experienced sonographers use the technique. Patients with major salivary gland lesions may present to the otorhinolaryngologist or oral and maxillofacial surgeon with a suspected mass, with a suspected obstruction or inflammation, or with diffuse glandular enlargement (2). Although there are overlapping entities in this simple stratification, the imaging studies ordered may change with each presentation. For the purposes of this review, major salivary gland imaging will be divided into neoplastic lesions, obstructive or inflammatory lesions, and systemic diseases. NEOPLASTIC LESIONS The usual clinical manifestation of a salivary gland neoplasm is that of an enlarging mass. The first critical step in evaluating a mass is to determine whether or not it is painful. While painful masses may be produced by obstructive or inflammatory disease, the classic painless mass in the salivary glands is usually due to a neoplasm, cyst, or lymph node. A dull, gnawing pain may be produced by some neoplasms in the glands. Other signs that a parotid neoplasm is malignant are infiltration of the overlying skin, regional adenopathy, or facial nerve palsy. Regional lymph node spread is relatively infrequent with salivary gland primary malignancies. There are some general rules that apply to salivary gland neoplasms. The smaller the salivary gland, the higher the rate of malignancy. Thus, the rate of malignancy increases from 20%–25% in the parotid gland to 40%–50% in the submandibular gland and to 50%–81% in the sublingual glands and minor salivary glands (3–6). Nearly 80% of benign parotid neoplasms are pleomorphic adenomas (3,4). Pleomorphic adenomas, also known 19 Figure 1. Bilateral Warthin tumors. Bilateral parotid masses (arrows) are seen on this trans- verse, contrast material–enhanced, fat-satu- rated T1-weighted spin-echo (SE) (750/30 [rep- etition time msec/echo time msec]) MR image. The multiplicity and location at the tail of the parotid gland (near the lower mandible) are a. c. typical features of this tumor. Figure 3. Pleomorphic adenomas. (a) Trans- verse T1-weighted SE (600/11) MR image shows the mass (P) to be well highlighted against the normal hyperintensity of the parotid gland. The margination is not particularly sharp, yet the diagnosis was pleomorphic adenoma. (b) The mass (P) is hyperintense on this trans- verse, long repetition time (4,000 msec), T2- weighted fast SE MR image. (c) The mass (P ) enhances on this contrast-enhanced, T1- weighted SE (600/30) MR image, though it has a central nonenhancing component. If there is very strong suspicion that a lesion is neoplastic, there are some com- b. Figure 2. Submandibular pleomorphic ad- pelling reasons why MR imaging may be enoma. Transverse, contrast-enhanced CT scan preferred over other modalities. Virtually shows that the pleomorphic adenoma (A) arises in the right submandibular gland. The attenua- all parotid lesions are well visualized on tion characteristics leave little indication as to the other salivary glands do not. This T1-weighted MR images because of the whether the lesion is benign or malignant. accounts for the potential for malignant hyperintense (fatty) background of the adenopathy involving the parotid glands. gland (Fig 3) (8). The T1-weighted image This is usually seen in the setting of a gives an excellent assessment of the mar- as benign mixed tumors, occur most com- dermatologic malignancy (basal cell carci- gin of the tumor, its deep extent, and its monly in middle-aged women. Monomor- noma, squamous cell carcinoma, and pattern of infiltration. This sequence, phic adenomas and myoepitheliomas are melanoma), but occasionally an upper aero- coupled with fat-saturated, contrast mate- the other common benign tumors and digestive system squamous cell carcinoma rial–enhanced T1-weighted imaging, used may arise in both parotid and submandibu- may result in malignant parotid adenopa- primarily to address perineural spread lar glands. Oncocytomas and Warthin tu- thy. The lymph nodes must be deter- (9,10), bone invasion, or meningeal infil- mors are rare outside the parotid region. mined to be intraparotid or extraparotid tration, is the best means for ‘‘mapping’’ Multiple parotid masses are usually due at imaging. By the same token, lym- the tumor. If there is a superimposed to lymphadenopathy or Warthin tumors, phoma may occur primarily in the pa- diffuse inflammatory process, a focal mass the latter appearing almost exclusively in rotid gland as an infiltrative process or could possibly be obscured with this se- the parotid gland, usually in the tail of adenopathy, or as a manifestation of sys- quence. On fat-saturated images, both the gland in older men (Fig 1). The most temic disease. the bone marrow and cortex of the man- common malignancy of the parotid gland Some would advocate the use of MR dible, maxilla, and skull base will be is mucoepidermoid carcinoma (2,3). In imaging as the first (and only) technique hypointense. Enhancing (hyperintense) the submandibular gland, pleomorphic to evaluate a neoplasm of the major sali- tissue extending into this hypointense adenomas remain the most common be- vary glands. Implicit in such a decision is background is indicative of bone inva- nign tumor (Fig 2), but adenoid cystic that the clinicians are highly confident sion. At the skull base, where the abun- carcinoma is the most common malig- that the process in the gland is neoplastic dant fat and bony foramina will also have nant histologic diagnosis (5). The same and not obstructive or inflammatory. If suppressed signal (low signal intensity), diagnoses prevail in the sublingual and there is even a slight chance that the mass the fat-saturated, contrast-enhanced im- minor salivary glands (7), where malig- may in some way be related to sialolithia- age will show spread of hyperintense nancies outnumber benign tumors. sis, CT should be recommended first, enhancing tumors up the stylomastoid Lymph nodes may manifest as intrapa- since MR imaging is not as reliable in foramen (cranial nerve VII) (Fig 4), fora- rotid masses. Since the parotid gland en- detecting small calculi, and ‘‘pseudo- men ovale (cranial nerve V-3), or foramen capsulates late in the 2nd trimester, it masses’’ may accompany sialolithiasis (see rotundum (cranial nerve V-2). Therefore, incorporates lymphatic tissue, whereas Obstructive or Inflammatory Lesions). if a facial or trigeminal nerve palsy accom- 20 • Radiology • July 2000 Yousem et al long repetition time images (Fig 8). Some malignancies, however, exhibit elevated signal intensity on T2-weighted images. Most commonly, this is seen in low-grade mucoepidermoid carcinomas (14), in some adenoid cystic carcinomas (15), and rarely in adenocarcinomas. Among be- nign masses that are not hyperintense on long repetition time images, Warthin tu- mor, the second most common benign mass in the adult parotid gland, is often of intermediate, low, or mixed signal in- tensity on T2-weighted images (8).
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