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Swelling at the Angle of the Mandible: Imaging of the Pediatric Parotid Gland and Periparotid Region¹

¹ From the Department of Radiology, Children’s Mercy Hospital, University of Missouri–Kansas City, 2401 Gillham Rd, Kansas City, MO 64108 (L.H.L.); the Departments of Radiology and Radiological Sciences (L.S.S., R.M.H., C.W., M.H.S.) and Pathology (J.E.J.), Vanderbilt Children’s Hospital, Nashville, Tenn; and the Department of Radiology, Children’s Hospital of Alabama, Birmingham (S.A.R.). Presented as an education exhibit at the 2000 RSNA scientific assembly. Received February 27, 2001; revision requested March 21 and received May 11; accepted May 14. Address correspondence to L.H.L. (e-mail: llowe@cmh.edu).

View larger version (93K): [in a new window]   Figure 1.   Schematic demonstrates gross parotid anatomy. A portion of the superficial parotid lobe has been removed to show its relationship with the facial nerve and retromandibular vein, which divide the parotid gland into superficial and deep lobes. M = masseter muscle. (Reprinted, with permission, from reference 4.)

View larger version (132K): [in a new window]   Figure 2a.   (a, b) Normal upper parotid space anatomy. (a) Schematic illustrates normal anatomy. (b) CT scan in a 6-month-old girl shows the parotid gland (P) with an attenuation similar to that of adjacent muscle. E = external carotid artery, I = internal carotid artery, J = internal jugular vein, M = masseter muscle, R = retromandibular vein, = fat-filled parapharyngeal space. (c, d) Lower parotid space anatomy. (c) Schematic illustrates normal anatomy. (d) CT scan in a 17-year-old boy shows the parotid gland (P) with low attenuation due to normal fatty replacement. E = external carotid artery, M = masseter muscle, R = retromandibular vein, S = styloid process, = fat-filled parapharyngeal space. (Reprinted, with permission, from reference 7.)

View larger version (101K): [in a new window]   Figure 2b.   (a, b) Normal upper parotid space anatomy. (a) Schematic illustrates normal anatomy. (b) CT scan in a 6-month-old girl shows the parotid gland (P) with an attenuation similar to that of adjacent muscle. E = external carotid artery, I = internal carotid artery, J = internal jugular vein, M = masseter muscle, R = retromandibular vein, = fat-filled parapharyngeal space. (c, d) Lower parotid space anatomy. (c) Schematic illustrates normal anatomy. (d) CT scan in a 17-year-old boy shows the parotid gland (P) with low attenuation due to normal fatty replacement. E = external carotid artery, M = masseter muscle, R = retromandibular vein, S = styloid process, = fat-filled parapharyngeal space. (Reprinted, with permission, from reference 7.)

View larger version (132K): [in a new window]   Figure 2c.   (a, b) Normal upper parotid space anatomy. (a) Schematic illustrates normal anatomy. (b) CT scan in a 6-month-old girl shows the parotid gland (P) with an attenuation similar to that of adjacent muscle. E = external carotid artery, I = internal carotid artery, J = internal jugular vein, M = masseter muscle, R = retromandibular vein, = fat-filled parapharyngeal space. (c, d) Lower parotid space anatomy. (c) Schematic illustrates normal anatomy. (d) CT scan in a 17-year-old boy shows the parotid gland (P) with low attenuation due to normal fatty replacement. E = external carotid artery, M = masseter muscle, R = retromandibular vein, S = styloid process, = fat-filled parapharyngeal space. (Reprinted, with permission, from reference 7.)

View larger version (117K): [in a new window]   Figure 2d.   (a, b) Normal upper parotid space anatomy. (a) Schematic illustrates normal anatomy. (b) CT scan in a 6-month-old girl shows the parotid gland (P) with an attenuation similar to that of adjacent muscle. E = external carotid artery, I = internal carotid artery, J = internal jugular vein, M = masseter muscle, R = retromandibular vein, = fat-filled parapharyngeal space. (c, d) Lower parotid space anatomy. (c) Schematic illustrates normal anatomy. (d) CT scan in a 17-year-old boy shows the parotid gland (P) with low attenuation due to normal fatty replacement. E = external carotid artery, M = masseter muscle, R = retromandibular vein, S = styloid process, = fat-filled parapharyngeal space. (Reprinted, with permission, from reference 7.)

View larger version (142K): [in a new window]   Figure 3.   Normal parotid gland in a 3-year-old girl. Longitudinal parotid US image obtained in the coronal plane (cranial, right; caudal, left) demonstrates a homogeneous, hyperechogenic parotid gland (P) at the angle of the mandible (M). Arrow indicates the retromandibular vein, arrowhead indicates the external carotid artery. = masseter muscle.

View larger version (103K): [in a new window]   Figure 4a.   Normal parotid gland in an 18-year-old man. Axial short-TR (a) and long-TR (b) MR images demonstrate the parotid gland (P), parotid duct (black arrows in a), and parapharyngeal space (white arrow). D = posterior belly of digastric muscle, I = internal carotid artery, J = jugular vein, M = masseter muscle, R = retromandibular vein, S = sternocleidomastoid muscle.

View larger version (90K): [in a new window]   Figure 4b.   Normal parotid gland in an 18-year-old man. Axial short-TR (a) and long-TR (b) MR images demonstrate the parotid gland (P), parotid duct (black arrows in a), and parapharyngeal space (white arrow). D = posterior belly of digastric muscle, I = internal carotid artery, J = jugular vein, M = masseter muscle, R = retromandibular vein, S = sternocleidomastoid muscle.

View larger version (92K): [in a new window]   Figure 5.   Accessory parotid gland in an 18-year-old woman who had undergone left parotidectomy at age 5 years for an unspecified neoplasm. CT scan demonstrates an accessory parotid gland (white arrow) with characteristic architecture and partial fatty replacement. Black arrow indicates the styloid process. M = masseter muscle.

View larger version (90K): [in a new window]   Figure 6a.   Second branchial cleft cyst in a 15-year-old boy. (a) Longitudinal US image shows a well-defined, hypoechoic cyst (calipers). (b) Contrast-enhanced CT scan demonstrates a fluid-attenuation mass ().

View larger version (117K): [in a new window]   Figure 6b.   Second branchial cleft cyst in a 15-year-old boy. (a) Longitudinal US image shows a well-defined, hypoechoic cyst (calipers). (b) Contrast-enhanced CT scan demonstrates a fluid-attenuation mass ().

View larger version (129K): [in a new window]   Figure 7.   Second branchial cleft cyst complicated by infection in an 18-year-old woman. Contrast-enhanced CT scan reveals a well-defined, fluid-attenuation mass with a thick rim of enhancement (arrows).

View larger version (113K): [in a new window]   Figure 8a.   Capillary hemangioma in a 2-month-old boy with increasing left cheek swelling since birth. (a) Coronal US image (cranial, left; caudal, right) demonstrates a solid, hypoechoic parotid mass (calipers). (b) Axial CT scan reveals a hypervascular mass with intense homogeneous enhancement (solid arrows) replacing the parotid gland. Note the deep lobe involvement with widening of the stylomandibular foramen (bracket) and extension into the parapharyngeal space (open arrow).

View larger version (105K): [in a new window]   Figure 8b.   Capillary hemangioma in a 2-month-old boy with increasing left cheek swelling since birth. (a) Coronal US image (cranial, left; caudal, right) demonstrates a solid, hypoechoic parotid mass (calipers). (b) Axial CT scan reveals a hypervascular mass with intense homogeneous enhancement (solid arrows) replacing the parotid gland. Note the deep lobe involvement with widening of the stylomandibular foramen (bracket) and extension into the parapharyngeal space (open arrow).

View larger version (111K): [in a new window]   Figure 9a.   Lymphangioma. (a) Photograph of a gross specimen shows the multilocular, thin-walled cystic appearance that is typical of lymphangioma. (b) Photomicrograph (original magnification, x31.5; hematoxylin-eosin [H-E] stain) demonstrates irregular thin-walled, slitlike spaces of varying sizes with a flat endothelial lining, admixed with fat. A small focus of uninvolved salivary tissue is also seen (arrow).

View larger version (186K): [in a new window]   Figure 9b.   Lymphangioma. (a) Photograph of a gross specimen shows the multilocular, thin-walled cystic appearance that is typical of lymphangioma. (b) Photomicrograph (original magnification, x31.5; hematoxylin-eosin [H-E] stain) demonstrates irregular thin-walled, slitlike spaces of varying sizes with a flat endothelial lining, admixed with fat. A small focus of uninvolved salivary tissue is also seen (arrow).

View larger version (127K): [in a new window]   Figure 10a.   Lymphangioma in a 13-month-old boy. (a) Transverse US image shows a hypoechoic multiloculated mass (). (b) Fat-suppressed long-TR MR image helps confirm a multiloculated mass with fluid levels and variable signal intensity (arrows). The mass is seen infiltrating the parotid, parapharyngeal, and masticator (M) spaces.

View larger version (138K): [in a new window]   Figure 10b.   Lymphangioma in a 13-month-old boy. (a) Transverse US image shows a hypoechoic multiloculated mass (). (b) Fat-suppressed long-TR MR image helps confirm a multiloculated mass with fluid levels and variable signal intensity (arrows). The mass is seen infiltrating the parotid, parapharyngeal, and masticator (M) spaces.

View larger version (110K): [in a new window]   Figure 11a.   Pleomorphic adenoma. (a) Photograph of a gross specimen shows a pleomorphic adenoma with a smooth border and a homogeneous cut surface without scarring or necrosis. Note the attached normal salivary tissue (SG). (b) Photomicrograph (original magnification, x62.5; H-E stain) shows an admixture of epithelial (E) and chondromyxoid (C) elements. = capsule.

View larger version (204K): [in a new window]   Figure 11b.   Pleomorphic adenoma. (a) Photograph of a gross specimen shows a pleomorphic adenoma with a smooth border and a homogeneous cut surface without scarring or necrosis. Note the attached normal salivary tissue (SG). (b) Photomicrograph (original magnification, x62.5; H-E stain) shows an admixture of epithelial (E) and chondromyxoid (C) elements. = capsule.

View larger version (133K): [in a new window]   Figure 12a.   Pleomorphic adenoma in a 14-year-old boy. (a) Coronal short-TR MR image reveals a left parotid mass (arrow) that is hypointense relative to parotid tissue (P). (b) On a contrast-enhanced MR image, the mass demonstrates increased enhancement. P = parotid tissue.

View larger version (117K): [in a new window]   Figure 12b.   Pleomorphic adenoma in a 14-year-old boy. (a) Coronal short-TR MR image reveals a left parotid mass (arrow) that is hypointense relative to parotid tissue (P). (b) On a contrast-enhanced MR image, the mass demonstrates increased enhancement. P = parotid tissue.

View larger version (93K): [in a new window]   Figure 13.   Warthin tumor. Photograph of a gross specimen shows an unusually large Warthin tumor (W) occupying more than half of the superficial lobe of the parotid gland. The smooth, fleshy portions represent the lymphoid stroma. Many of the nodules are cystic. Normal salivary tissue is also noted (S).

View larger version (110K): [in a new window]   Figure 14.   Warthin tumors in an 18-year-old man. Coronal contrast-enhanced fat-suppressed short-TR MR image demonstrates multiple bilateral parotid masses with enhancement (arrows).

View larger version (142K): [in a new window]   Figure 15a.   Angiolipoma in a 6-month-old girl with a gradually enlarging right cheek mass since 1 week of age. (a) Axial unenhanced CT scan demonstrates a well-circumscribed right parotid mass with low attenuation (<50 HU) (arrow). (b) On a contrast-enhanced CT scan, the parotid mass demonstrates marked enhancement with fatty elements designated as the region of interest (marker). (Reprinted, with permission, from reference 24.)

View larger version (147K): [in a new window]   Figure 15b.   Angiolipoma in a 6-month-old girl with a gradually enlarging right cheek mass since 1 week of age. (a) Axial unenhanced CT scan demonstrates a well-circumscribed right parotid mass with low attenuation (<50 HU) (arrow). (b) On a contrast-enhanced CT scan, the parotid mass demonstrates marked enhancement with fatty elements designated as the region of interest (marker). (Reprinted, with permission, from reference 24.)

View larger version (157K): [in a new window]   Figure 16a.   Leukemia in a 2-year-old boy with bilateral cheek swelling. (a) Right longitudinal US image reveals diffuse, heterogeneous echogenicity and parotid gland enlargement. (b) On a color Doppler US image, the parotid gland is hypervascular. The left side had a similar appearance.

View larger version (140K): [in a new window]   Figure 16b.   Leukemia in a 2-year-old boy with bilateral cheek swelling. (a) Right longitudinal US image reveals diffuse, heterogeneous echogenicity and parotid gland enlargement. (b) On a color Doppler US image, the parotid gland is hypervascular. The left side had a similar appearance.

View larger version (111K): [in a new window]   Figure 17.   Neurofibroma. Photograph of a gross specimen shows a fleshy, lobulated mass with smooth borders and a thin, fibrofatty capsule (arrows).

View larger version (159K): [in a new window]   Figure 18a.   Neurofibroma in a 16-year-old boy. (a) Axial short-TR MR image shows a hypointense mass (arrows) adjacent to the deep lobe of the parotid gland (P). (b) On an axial contrast-enhanced short-TR MR image, the mass shows heterogeneous enhancement (arrows). P = parotid gland.

View larger version (173K): [in a new window]   Figure 18b.   Neurofibroma in a 16-year-old boy. (a) Axial short-TR MR image shows a hypointense mass (arrows) adjacent to the deep lobe of the parotid gland (P). (b) On an axial contrast-enhanced short-TR MR image, the mass shows heterogeneous enhancement (arrows). P = parotid gland.

View larger version (201K): [in a new window]   Figure 19a.   Rhabdomyosarcoma. (a) Photomicrograph (original magnification, x62.5; H-E stain) shows a typical rhabdomyosarcoma with diffuse sheetlike growth. (b) High-power photomicrograph (original magnification, x250; H-E stain) shows primitive and pleomorphic nuclei with scant, variable cytoplasm.

View larger version (180K): [in a new window]   Figure 19b.   Rhabdomyosarcoma. (a) Photomicrograph (original magnification, x62.5; H-E stain) shows a typical rhabdomyosarcoma with diffuse sheetlike growth. (b) High-power photomicrograph (original magnification, x250; H-E stain) shows primitive and pleomorphic nuclei with scant, variable cytoplasm.

View larger version (138K): [in a new window]   Figure 20a.   Rhabdomyosarcoma in an 18-year-old man who complained of a lump in the throat. (a) Axial contrast-enhanced CT scan reveals a mass with heterogeneous enhancement (arrows) involving the left masticator and parotid spaces. There is mass effect on the mandible (M), and the stylomandibular foramen is widened (bracket). (b) Axial contrast-enhanced short-TR MR image shows the mass with heterogeneous enhancement (arrows). M = mandible.

View larger version (165K): [in a new window]   Figure 20b.   Rhabdomyosarcoma in an 18-year-old man who complained of a lump in the throat. (a) Axial contrast-enhanced CT scan reveals a mass with heterogeneous enhancement (arrows) involving the left masticator and parotid spaces. There is mass effect on the mandible (M), and the stylomandibular foramen is widened (bracket). (b) Axial contrast-enhanced short-TR MR image shows the mass with heterogeneous enhancement (arrows). M = mandible.

View larger version (146K): [in a new window]   Figure 21.   Parotitis in an 8-year-old girl. Contrast-enhanced CT scan shows an enlarged, enhancing left parotid gland containing multiple tiny, low-attenuation foci (arrows).

View larger version (150K): [in a new window]   Figure 22a.   Parotid abscess in a 10-month-old girl. (a) Transverse US image reveals necrotic nodes () with thickened overlying skin (S). (b) Contrast-enhanced CT scan shows an abscess (arrow) in an enlarged, enhancing right parotid gland (arrowheads). Note the medial shift of the parapharyngeal and carotid spaces due to swelling of the deep lobe of the parotid gland (). Multiple small nodes are noted on the patient’s left side.

View larger version (123K): [in a new window]   Figure 22b.   Parotid abscess in a 10-month-old girl. (a) Transverse US image reveals necrotic nodes () with thickened overlying skin (S). (b) Contrast-enhanced CT scan shows an abscess (arrow) in an enlarged, enhancing right parotid gland (arrowheads). Note the medial shift of the parapharyngeal and carotid spaces due to swelling of the deep lobe of the parotid gland (). Multiple small nodes are noted on the patient’s left side.

View larger version (150K): [in a new window]   Figure 23.   Tuberculosis in a 13-year-old girl. Axial CT scan of the neck demonstrates multiple bilateral calcifications and left cheek swelling.

View larger version (148K): [in a new window]   Figure 24.   Atypical mycobacterial infection in a 9-month-old girl. Axial CT scan reveals bilateral adenopathy and a right focal abscess (arrow). M = masseter muscle, P = parotid gland.

View larger version (155K): [in a new window]   Figure 25.   HIV infection in a 6-year-old boy with right cheek swelling. Coronal US image shows numerous small, hypoechoic lymphoepithelial lesions throughout the enlarged parotid gland. The left side had a similar appearance.

View larger version (147K): [in a new window]   Figure 26.   HIV infection with Hodgkin lymphoma in a 17-year-old boy. Axial CT scan shows multiple bilateral, enlarged intraparotid nodes with slight homogeneous enhancement (arrows).

View larger version (223K): [in a new window]   Figure 27.   Sarcoidosis. Photomicrograph (original magnification, x62.5; H-E stain) demonstrates confluent, nonnecrotizing epithelioid granulomas with an occasional lymphoid aggregate (arrowhead), findings that are typical of sarcoidosis.

View larger version (141K): [in a new window]   Figure 28.   Sarcoidosis in a 21-year-old woman with parotitis of 10 years duration. Axial contrast-enhanced CT scan reveals right parotid gland enlargement, heterogeneous enhancement, and ill-defined stranding through the parotid gland. Note the absence of the left parotid gland, which was removed for symptom control.

View larger version (215K): [in a new window]   Figure 29.   Sjögren disease. Photomicrograph (original magnification, x62.5; H-E stain) shows acinar tissue replaced by hyperplastic germinal centers; only scattered ducts remain (arrowheads).

View larger version (138K): [in a new window]   Figure 30.   Sjögren disease in a 25-year-old woman with xerostomia since age 16 years. Axial contrast-enhanced CT scan shows right parotid gland enlargement with the characteristic "honeycomb" appearance. Note the absence of the left parotid gland, which was removed for symptom control.