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Major Salivary Gland Imaging¹

¹ From the Department of Radiology, Johns Hopkins Hospital, 600 N Wolfe St, Houck B-112, Baltimore, MD 21287 (D.M.Y., M.A.K.), and the Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Medical Center, Philadelphia (A.A.C.). Received January 22, 1999; revision requested March 30; final revision received August 6; accepted August 18. Address correspondence to D.M.Y. (e-mail: yousem@rad.jhu.edu).

View larger version (94K): [in a new window]   Figure 1. Bilateral Warthin tumors. Bilateral parotid masses (arrows) are seen on this transverse, contrast material-enhanced, fat-saturated T1-weighted spin-echo (SE) (750/30 [repetition time msec/echo time msec]) MR image. The multiplicity and location at the tail of the parotid gland (near the lower mandible) are typical features of this tumor.

View larger version (96K): [in a new window]   Figure 2. Submandibular pleomorphic adenoma. Transverse, contrast-enhanced CT scan shows that the pleomorphic adenoma (A) arises in the right submandibular gland. The attenuation characteristics leave little indication as to whether the lesion is benign or malignant.

View larger version (136K): [in a new window]   Figure 3a. Pleomorphic adenomas. (a) Transverse 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 transverse, 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.

View larger version (146K): [in a new window]   Figure 3b. Pleomorphic adenomas. (a) Transverse 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 transverse, 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.

View larger version (139K): [in a new window]   Figure 3c. Pleomorphic adenomas. (a) Transverse 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 transverse, 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.

View larger version (150K): [in a new window]   Figure 4a. Perineural infiltration of cranial nerve VII by adenoid cystic carcinoma. (a) Transverse T1-weighted SE (600/11, two signals acquired) MR image shows that the right parotid mass (m) enters the notch of the stylomastoid foramen (arrow). (b) Coronal, gadolinium-enhanced T1-weighted SE (600/17, one signal acquired) MR image shows vertical extension of the enhancing tumor (arrows) through the stylomastoid foramen (line is at the plane of transverse image in a).

View larger version (156K): [in a new window]   Figure 4b. Perineural infiltration of cranial nerve VII by adenoid cystic carcinoma. (a) Transverse T1-weighted SE (600/11, two signals acquired) MR image shows that the right parotid mass (m) enters the notch of the stylomastoid foramen (arrow). (b) Coronal, gadolinium-enhanced T1-weighted SE (600/17, one signal acquired) MR image shows vertical extension of the enhancing tumor (arrows) through the stylomastoid foramen (line is at the plane of transverse image in a).

View larger version (135K): [in a new window]   Figure 5. Seeding of pleomorphic adenoma. Parotid (arrow) and deep lobe or parapharyngeal (arrowheads) masses are present on the left side on this transverse T1-weighted SE (500/11) MR image. The patient underwent prior attempted resection of a deep lobe pleomorphic adenoma, but the capsule of the tumor was violated. Months later she presented with this picture of tumor infiltrating the operative bed and the surrounding tissue.

View larger version (94K): [in a new window]   Figure 6. Right submandibular gland adenocarcinoma. Transverse CT scan shows an exophytic, well-defined mass (M) in the right submandibular region that proved to be an adenocarcinoma. First and foremost, one should attempt to determine whether this lesion is a submandibular lymph node metastasis or a primary lesion from the submandibular gland (as in Fig 2). The anterior facial vein, which usually lies between submandibular and extraglandular masses (1), was not conspicuous in this case. The gland and mass were resected together, and the origin from the submandibular gland was uncovered. Although this lesion was well defined, it was malignant (compare with Fig 2).

View larger version (145K): [in a new window]   Figure 7a. Pleomorphic adenoma. (a) Transverse T2-weighted SE (3,000/80, one signal acquired) MR image shows that the lesion (*) is hyperintense. This may raise the question of a cyst versus a pleomorphic adenoma. (b) With administration of a gadolinium-containing contrast agent and fat saturation, the mass (*) is seen to enhance avidly on this coronal T1-weighted SE (600/17, one signal acquired) MR image, compatible with a solid mass.

View larger version (136K): [in a new window]   Figure 7b. Pleomorphic adenoma. (a) Transverse T2-weighted SE (3,000/80, one signal acquired) MR image shows that the lesion (*) is hyperintense. This may raise the question of a cyst versus a pleomorphic adenoma. (b) With administration of a gadolinium-containing contrast agent and fat saturation, the mass (*) is seen to enhance avidly on this coronal T1-weighted SE (600/17, one signal acquired) MR image, compatible with a solid mass.

View larger version (143K): [in a new window]   Figure 8a. Mucoepidermoid carcinoma of the parotid gland. (a) Transverse T2-weighted SE (3,000/90) MR image shows an intermediate-signal-intensity mass (arrow) slightly lower in intensity than that of the native parotid tissue. (b) The ill-defined nature of the mass (arrow) was exemplified by the fuzzy margins on this transverse, contrast-enhanced, fat-saturated, T1-weighted SE (600/30) MR image. The diagnosis was high-grade mucoepidermoid carcinoma.

View larger version (140K): [in a new window]   Figure 8b. Mucoepidermoid carcinoma of the parotid gland. (a) Transverse T2-weighted SE (3,000/90) MR image shows an intermediate-signal-intensity mass (arrow) slightly lower in intensity than that of the native parotid tissue. (b) The ill-defined nature of the mass (arrow) was exemplified by the fuzzy margins on this transverse, contrast-enhanced, fat-saturated, T1-weighted SE (600/30) MR image. The diagnosis was high-grade mucoepidermoid carcinoma.

View larger version (127K): [in a new window]   Figure 9a. Lipomas. (a) Although the attenuation of this patient's parotid glands is low due to fatty infiltration on this transverse CT scan, a palpable (see marker superficially) lipoma (L) in the left parotid gland was appreciated. (b) This lipoma (arrow), hyperintense on this transverse T1-weighted SE (600/11) MR image, was extraglandular but still contained by the deep cervical fascia surrounding the gland.

View larger version (128K): [in a new window]   Figure 9b. Lipomas. (a) Although the attenuation of this patient's parotid glands is low due to fatty infiltration on this transverse CT scan, a palpable (see marker superficially) lipoma (L) in the left parotid gland was appreciated. (b) This lipoma (arrow), hyperintense on this transverse T1-weighted SE (600/11) MR image, was extraglandular but still contained by the deep cervical fascia surrounding the gland.

View larger version (115K): [in a new window]   Figure 10. Mucoepidermoid carcinoma of the parotid gland. Transverse CT scan shows an ill-defined mass (C) that has less attenuation than that of enhancing parotid tissue in the right parotid gland. The attenuation of this mass is the same as that of the pleomorphic adenoma in Figure 2 and less than that of the carcinoma in Figure 6.

View larger version (129K): [in a new window]   Figure 11. Markers for the seventh cranial nerve. Transverse T1-weighted SE (500/11) MR image shows that the seventh cranial nerve emerges from the stylomastoid foramen to course through the fat (straight arrow) immediately below this exit. In its course through the parotid gland (p), it runs lateral to the retromandibular vein (curved arrow). This is the best sequence for defining anatomic landmarks.

View larger version (144K): [in a new window]   Figure 12. CT-guided aspiration of deep lobe parotid mass. Via a transbuccal approach, the needle passed between the ascending ramus of the mandible and the maxilla, with its tip (arrow) at the edge of the deep lobe parotid mass (P). Several 2-cm thrusts into the mass under syringe suction and transverse CT guidance yielded cells compatible with mucoepidermoid carcinoma. The well-defined margins belied the malignant nature of the mass.

View larger version (123K): [in a new window]   Figure 13a. (a-d) Transverse CT scans of ductal and glandular calcifications. (a) There is a large solitary sialolith (arrow) in the right submandibular duct. (b) These glandular calcifications (arrows) could easily be mistaken for vessels on this contrast-enhanced CT scan. (c) Are these vessels or calcifications (arrows) along this ill-defined monomorphic adenoma of the submandibular gland? (d) Image obtained with bone window settings is equivocal due to the small size of the opacities (arrows), but the nonenhanced scans showed that the posterolateral one was a calcification and the anteromedial structure was a vessel, hence the value of a nonenhanced scan.

View larger version (124K): [in a new window]   Figure 13b. (a-d) Transverse CT scans of ductal and glandular calcifications. (a) There is a large solitary sialolith (arrow) in the right submandibular duct. (b) These glandular calcifications (arrows) could easily be mistaken for vessels on this contrast-enhanced CT scan. (c) Are these vessels or calcifications (arrows) along this ill-defined monomorphic adenoma of the submandibular gland? (d) Image obtained with bone window settings is equivocal due to the small size of the opacities (arrows), but the nonenhanced scans showed that the posterolateral one was a calcification and the anteromedial structure was a vessel, hence the value of a nonenhanced scan.

View larger version (112K): [in a new window]   Figure 13c. (a-d) Transverse CT scans of ductal and glandular calcifications. (a) There is a large solitary sialolith (arrow) in the right submandibular duct. (b) These glandular calcifications (arrows) could easily be mistaken for vessels on this contrast-enhanced CT scan. (c) Are these vessels or calcifications (arrows) along this ill-defined monomorphic adenoma of the submandibular gland? (d) Image obtained with bone window settings is equivocal due to the small size of the opacities (arrows), but the nonenhanced scans showed that the posterolateral one was a calcification and the anteromedial structure was a vessel, hence the value of a nonenhanced scan.

View larger version (104K): [in a new window]   Figure 13d. (a-d) Transverse CT scans of ductal and glandular calcifications. (a) There is a large solitary sialolith (arrow) in the right submandibular duct. (b) These glandular calcifications (arrows) could easily be mistaken for vessels on this contrast-enhanced CT scan. (c) Are these vessels or calcifications (arrows) along this ill-defined monomorphic adenoma of the submandibular gland? (d) Image obtained with bone window settings is equivocal due to the small size of the opacities (arrows), but the nonenhanced scans showed that the posterolateral one was a calcification and the anteromedial structure was a vessel, hence the value of a nonenhanced scan.

View larger version (136K): [in a new window]   Figure 14a. Submandibular calculi visualized at MR imaging. (a) Transverse T1-weighted SE (500/11) MR image shows two areas of low signal intensity (arrows) in the floor of the mouth on the left. (b) These calculi (arrows) are confirmed on this transverse T2-weighted SE (4,000/80) MR image, and the obstructed duct (arrowhead) is evident. Inflammation around the stones accounts for some peripheral high signal intensity. (c) The duct (arrowhead) can also be seen on this contrast-enhanced, T1-weighted, fat-saturated, spoiled gradient-echo (35/2.1, 30° flip angle) MR image. The walls enhanced, presumably due to inflammation (sialodochitis). (d) There was coincidental sialadenitis of the left submandibular gland seen as enlargement and high signal intensity on this transverse, fat-saturated, T2-weighted fast SE (4,000/80) MR image. Note intraglandular ductal dilatation (arrows).

View larger version (142K): [in a new window]   Figure 14b. Submandibular calculi visualized at MR imaging. (a) Transverse T1-weighted SE (500/11) MR image shows two areas of low signal intensity (arrows) in the floor of the mouth on the left. (b) These calculi (arrows) are confirmed on this transverse T2-weighted SE (4,000/80) MR image, and the obstructed duct (arrowhead) is evident. Inflammation around the stones accounts for some peripheral high signal intensity. (c) The duct (arrowhead) can also be seen on this contrast-enhanced, T1-weighted, fat-saturated, spoiled gradient-echo (35/2.1, 30° flip angle) MR image. The walls enhanced, presumably due to inflammation (sialodochitis). (d) There was coincidental sialadenitis of the left submandibular gland seen as enlargement and high signal intensity on this transverse, fat-saturated, T2-weighted fast SE (4,000/80) MR image. Note intraglandular ductal dilatation (arrows).

View larger version (135K): [in a new window]   Figure 14c. Submandibular calculi visualized at MR imaging. (a) Transverse T1-weighted SE (500/11) MR image shows two areas of low signal intensity (arrows) in the floor of the mouth on the left. (b) These calculi (arrows) are confirmed on this transverse T2-weighted SE (4,000/80) MR image, and the obstructed duct (arrowhead) is evident. Inflammation around the stones accounts for some peripheral high signal intensity. (c) The duct (arrowhead) can also be seen on this contrast-enhanced, T1-weighted, fat-saturated, spoiled gradient-echo (35/2.1, 30° flip angle) MR image. The walls enhanced, presumably due to inflammation (sialodochitis). (d) There was coincidental sialadenitis of the left submandibular gland seen as enlargement and high signal intensity on this transverse, fat-saturated, T2-weighted fast SE (4,000/80) MR image. Note intraglandular ductal dilatation (arrows).

View larger version (131K): [in a new window]   Figure 14d. Submandibular calculi visualized at MR imaging. (a) Transverse T1-weighted SE (500/11) MR image shows two areas of low signal intensity (arrows) in the floor of the mouth on the left. (b) These calculi (arrows) are confirmed on this transverse T2-weighted SE (4,000/80) MR image, and the obstructed duct (arrowhead) is evident. Inflammation around the stones accounts for some peripheral high signal intensity. (c) The duct (arrowhead) can also be seen on this contrast-enhanced, T1-weighted, fat-saturated, spoiled gradient-echo (35/2.1, 30° flip angle) MR image. The walls enhanced, presumably due to inflammation (sialodochitis). (d) There was coincidental sialadenitis of the left submandibular gland seen as enlargement and high signal intensity on this transverse, fat-saturated, T2-weighted fast SE (4,000/80) MR image. Note intraglandular ductal dilatation (arrows).

View larger version (88K): [in a new window]   Figure 15. MR sialography in a healthy volunteer. The main submandibular duct (arrows) and some of its tributaries (arrowheads) can be seen on this transverse, maximum intensity projection reformatted image from a three-dimensional, T2-weighted fast SE (5,000/102, one signal acquired) data set.

View larger version (134K): [in a new window]   Figure 16. Acute right-sided parotitis. Transverse, contrast-enhanced, fat-saturated, T1-weighted SE (600/30) MR image shows marked enhancement of the right parotid gland (thick and thin arrows) compared with the left. The superficial subcutaneous tissue is also inflamed.

View larger version (145K): [in a new window]   Figure 17a. Simple ranula. (a) In the right sublingual gland, the hyperintense lesion (arrow) on this transverse T2-weighted SE (3,000/102) MR image could represent a pleomorphic adenoma or a cyst. (b) The absence of enhancement on this fat-saturated, T1-weighted SE (600/17) MR image suggests a cystic lesion, in this case a simple ranula of the sublingual gland. (c) The nonenhancing ranula (curved arrow) lies superior to the geniohyoid muscles (g) and has not perforated through the mylohyoid musculature on this coronal T1-weighted SE (600/17) MR image with fat saturation.

View larger version (133K): [in a new window]   Figure 17b. Simple ranula. (a) In the right sublingual gland, the hyperintense lesion (arrow) on this transverse T2-weighted SE (3,000/102) MR image could represent a pleomorphic adenoma or a cyst. (b) The absence of enhancement on this fat-saturated, T1-weighted SE (600/17) MR image suggests a cystic lesion, in this case a simple ranula of the sublingual gland. (c) The nonenhancing ranula (curved arrow) lies superior to the geniohyoid muscles (g) and has not perforated through the mylohyoid musculature on this coronal T1-weighted SE (600/17) MR image with fat saturation.

View larger version (135K): [in a new window]   Figure 17c. Simple ranula. (a) In the right sublingual gland, the hyperintense lesion (arrow) on this transverse T2-weighted SE (3,000/102) MR image could represent a pleomorphic adenoma or a cyst. (b) The absence of enhancement on this fat-saturated, T1-weighted SE (600/17) MR image suggests a cystic lesion, in this case a simple ranula of the sublingual gland. (c) The nonenhancing ranula (curved arrow) lies superior to the geniohyoid muscles (g) and has not perforated through the mylohyoid musculature on this coronal T1-weighted SE (600/17) MR image with fat saturation.

View larger version (104K): [in a new window]   Figure 18. HIV-related lesions. Transverse, contrast-enhanced CT scan depicts a right-sided parotid cyst (straight arrow) and multiple small nodules in the left parotid gland (curved arrow) in this patient who was HIV positive but had not fulfilled criteria for acquired immunodeficiency syndrome.

View larger version (104K): [in a new window]   Figure 19. Sjögren disease. While both parotid glands (arrowheads) show cystic changes in and enlargement of the gland on this coronal T2-weighted SE (4,000/80) MR image, the left side also shows periparotid adenopathy (arrow). This pattern may be seen with Sjögren disease or HIV-related lymphoepithelial cysts and nodules.

View larger version (121K): [in a new window]   Figure 20. Conventional sialography. The extent of the ductal system and its tributaries is well seen on this conventional sialogram in a patient who has Sjögren disease. Note the tiny areas of cavitation (arrows) in the periphery.

View larger version (93K): [in a new window]   Figure 21. Glandular calcifications in a patient with sarcoidosis. Transverse nonenhanced CT scan shows the presence of multiple small calcifications in the parotid glands bilaterally.