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DOI: 10.1148/rg.263055024
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US of the Major Salivary Glands: Anatomy and Spatial Relationships, Pathologic Conditions, and Pitfalls1

Ewa J. Bialek, MD, PhD, Wieslaw Jakubowski, MD, PhD, Piotr Zajkowski, MD, PhD, Kazimierz T. Szopinski, MD, PhD and Antoni Osmolski, MD, PhD

1 From the Department of Diagnostic Imaging, Second Faculty of Medicine, Medical University of Warsaw, ul. Kondratowicza 8, 03-242 Warsaw, Poland (E.J.B., W.J., P.Z., K.T.S.); and the Department of Otolaryngology, Center of Postgraduate Medical Education, Warsaw, Poland (A.O.). Recipient of an Excellence in Design award for an education exhibit at the 2004 RSNA Annual Meeting. Received February 8, 2005; revision requested March 18 and received November 8; accepted November 9. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  Transverse panoramic US image (a) and corresponding diagram (b) show the normal anatomy of the left parotid gland and part of the cheek. m = muscle.

 

Figure 1
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  		Figure 1b.  Transverse panoramic US image (a) and corresponding diagram (b) show the normal anatomy of the left parotid gland and part of the cheek. m = muscle.

 

Figure 2
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  		Figure 2.  Drawing shows the major blood vessels in the area of the salivary glands. 1 = retromandibular vein, 2 = external carotid artery, 3 = facial artery and vein, 4 = lingual artery and vein, 5 = external carotid artery, 6 = internal jugular vein, 7 = external jugular vein.

 

Figure 3
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  		Figure 3a.  Transverse (a) and longitudinal (b) US images show the normal anatomy of the left parotid gland. The positions of the US probe are shown in the inset diagrams. 1 = retromandibular vein, 2 = external carotid artery, 3 = echo from the surface of the mandible, 4 = parotid gland, 5 = masseter muscle.

 

Figure 3
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  		Figure 3b.  Transverse (a) and longitudinal (b) US images show the normal anatomy of the left parotid gland. The positions of the US probe are shown in the inset diagrams. 1 = retromandibular vein, 2 = external carotid artery, 3 = echo from the surface of the mandible, 4 = parotid gland, 5 = masseter muscle.

 

Figure 4
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  		Figure 4a.  Transverse US image of the right parotid gland (a) and corresponding diagram (b) show the border between the superficial and deep lobes of the gland. The position of the US probe is shown in the inset diagram.

 

Figure 4
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  		Figure 4b.  Transverse US image of the right parotid gland (a) and corresponding diagram (b) show the border between the superficial and deep lobes of the gland. The position of the US probe is shown in the inset diagram.

 

Figure 5
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  		Figure 5.  Transverse panoramic US image of the left parotid gland (arrows) and cheek shows that the gland has a high fat content. The parenchyma is hyperechoic with marked suppression of ultrasound waves, and no vessels are visible. The position of the US probe is shown in the inset diagram. 1 = masseter muscle.

 

Figure 6
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  		Figure 6a.  (a) Diagram shows the location of the Stenon duct. 1 = parotid gland, 2 = Stenon duct, 4 = masseter muscle, 5 = surface of the mandible, 6 = buccal muscle, large arrow = retromandibular vein and external carotid artery. (b) Panoramic US image shows a dilated Stenon duct in a patient with sialolithiasis and inflammation. 1 = inflamed left parotid gland, 2 = dilated Stenon duct, 3 = stone, 4 = masseter muscle, 5 = surface of the mandible, 6 = buccal muscle, large arrow = retromandibular vein and external carotid artery.

 

Figure 6
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  		Figure 6b.  (a) Diagram shows the location of the Stenon duct. 1 = parotid gland, 2 = Stenon duct, 4 = masseter muscle, 5 = surface of the mandible, 6 = buccal muscle, large arrow = retromandibular vein and external carotid artery. (b) Panoramic US image shows a dilated Stenon duct in a patient with sialolithiasis and inflammation. 1 = inflamed left parotid gland, 2 = dilated Stenon duct, 3 = stone, 4 = masseter muscle, 5 = surface of the mandible, 6 = buccal muscle, large arrow = retromandibular vein and external carotid artery.

 

Figure 7
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  		Figure 7.  Three-dimensional US images show a normal intraparotid lymph node (arrows), which is oval with a homogeneous cortex and a central hyperechoic hilum. The hilum is connected to surrounding connective tissue (arrowhead).

 

Figure 8
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  		Figure 8a.  US image obtained obliquely relative to the mandible (a) and corresponding diagram (b) show the left submandibular gland with surrounding structures.

 

Figure 8
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  		Figure 8b.  US image obtained obliquely relative to the mandible (a) and corresponding diagram (b) show the left submandibular gland with surrounding structures.

 

Figure 9
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  		Figure 9.  US image shows the tortuous facial artery (arrowheads) crossing the parenchyma of the right submandibular gland (arrows).

 

Figure 10
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  		Figure 10a.  (a) US image shows a nondilated Wharton duct (arrow) in a slim patient. Arrowheads = submandibular gland, 1 = mylohyoid muscle. (b) Diagram shows the course of the Wharton duct (arrow). Arrowheads = submandibular gland, 1 = mylohyoid muscle, 2 = sublingual gland.

 

Figure 10
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  		Figure 10b.  (a) US image shows a nondilated Wharton duct (arrow) in a slim patient. Arrowheads = submandibular gland, 1 = mylohyoid muscle. (b) Diagram shows the course of the Wharton duct (arrow). Arrowheads = submandibular gland, 1 = mylohyoid muscle, 2 = sublingual gland.

 

Figure 11
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  		Figure 11a.  Transverse US image (a) and corresponding diagram (b) show the sublingual gland and its surrounding structures. White circle = Wharton duct, m = muscle.

 

Figure 11
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  		Figure 11b.  Transverse US image (a) and corresponding diagram (b) show the sublingual gland and its surrounding structures. White circle = Wharton duct, m = muscle.

 

Figure 12
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  		Figure 12.  Power Doppler US image shows an acutely inflamed right submandibular gland (arrows) containing a stone (arrowhead). The gland is enlarged and hypoechoic with rounded edges and increased blood flow.

 

Figure 13
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  		Figure 13.  Gray-scale US image shows an acutely inflamed right parotid gland (arrows) in a 5-year-old child. The gland is enlarged and inhomogeneous with multiple small, oval, hypoechoic areas (arrowheads). The position of the US probe is shown in the inset diagram.

 

Figure 14
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  		Figure 14.  Power Doppler US image shows chronic inflammation of the left submandibular gland (arrowheads). The gland is inhomogeneous with decreased parenchymal echogenicity but without increased blood flow. Arrows = stones.

 

Figure 15
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  		Figure 15.  US image obtained obliquely relative to the mandible shows a sialolith (arrowheads) in the inflamed parenchyma of the right submandibular gland (dashed line), which appears hypoechoic and inhomogeneous. The intraglandular excretory duct (arrows) above the stone is dilated. T = tongue.

 

Figure 16
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  		Figure 16.  US image shows a stone (arrows) in the dilated Wharton duct (arrowheads) near its orifice at the sublingual caruncle. M = acoustic shadow behind the surface of the body of the mandible. The position of the US probe is shown in the inset diagram.

 

Figure 17
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  		Figure 17.  US image shows hyperechoic linear structures (arrows), which may be mistaken for sialoliths in the Wharton duct. These structures represent air bubbles in the oral cavity. Note the "dirty" (not purely anechoic) shadow behind the hyperechoic lines and points. Arrowheads = submandibular gland.

 

Figure 18
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  		Figure 18a.  Gray-scale (a) and power Doppler (b) US images show advanced-stage Sjögren syndrome in the parotid gland. The gland has an inhomogeneous structure with multiple small, oval, hypoechoic areas (arrowheads) and increased blood flow. The position of the US probe is shown in the inset diagram.

 

Figure 18
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  		Figure 18b.  Gray-scale (a) and power Doppler (b) US images show advanced-stage Sjögren syndrome in the parotid gland. The gland has an inhomogeneous structure with multiple small, oval, hypoechoic areas (arrowheads) and increased blood flow. The position of the US probe is shown in the inset diagram.

 

Figure 19
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  		Figure 19.  Gray-scale US image shows the typical appearance of a pleomorphic adenoma (arrows). The lesion is hypoechoic and lobulated with distinct borders and posterior acoustic enhancement.

 

Figure 20
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  		Figure 20.  US image shows an inhomogeneous pleomorphic adenoma (arrows).

 

Figure 21
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  		Figure 21.  Power Doppler US image shows a pleomorphic adenoma (arrows) in the lower pole of the parotid gland. No blood vessels are visible in the lesion.

 

Figure 22
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  		Figure 22.  Gray-scale US image shows the typical appearance of a Warthin tumor (arrows). The lesion, which is located in the lower pole of the parotid gland, is oval, well defined, hypoechoic, and inhomogeneous with multiple irregular anechoic areas (arrowheads) and posterior acoustic enhancement.

 

Figure 23
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  		Figure 23.  Panoramic gray-scale US image shows two Warthin tumors (arrows) in the lower pole of the left parotid gland. The lesions are oval, well defined, hypoechoic, and inhomogeneous.

 

Figure 24
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  		Figure 24.  Power Doppler US image shows a hypervascularized Warthin tumor (arrows) in the parotid gland.

 

Figure 25
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  		Figure 25.  US image shows a pleomorphic adenoma (arrows) with an anechoic area (arrowheads), an appearance that mimics a Warthin tumor.

 

Figure 26
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  		Figure 26.  Panoramic gray-scale US image shows the typical appearance of a lipoma (arrowheads). The lesion, which is located in the left parotid gland (arrows), is hypoechoic with regularly distributed linear structures. 1 = echo from the surface of the ramus of the mandible, 2 = masseter muscle.

 

Figure 27
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  		Figure 27.  Panoramic gray-scale US image shows an acinic cell carcinoma (arrowheads) in the left parotid gland (solid arrows). The tumor is well defined and has regular margins; however, there are signs of mandibular destruction (open arrows), a finding that suggests malignancy.

 

Figure 28
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  		Figure 28.  Panoramic gray-scale US image shows metastatic lymph nodes (open arrows), which are oval or round and inhomogeneous without hyperechoic hila. There is a primary adenocarcinoma (arrowheads) in the left parotid gland (solid arrows).

 

Figure 29
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  		Figure 29.  US image shows an oval, well-defined, homogeneous tumor with even margins (arrows) in the right submandibular gland; the parenchyma of the gland (arrowheads) has been changed by therapeutic neck irradiation. Despite its benign features, the tumor proved to be a metastasis from a squamous cell carcinoma at the base of the tongue.

 

Figure 30
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  		Figure 30.  Power Doppler US image shows a metastasis (arrowheads) to the superficial lobe of the parotid gland (arrows) from a melanoma. The tumor is lobulated, inhomogeneous, and virtually anechoic with posterior acoustic enhancement and chaotic, mainly peripheral vessel segments.

 

Figure 31
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  		Figure 31.  US image of a patient with follicular lymphoma shows affected lymph nodes (arrowheads) in the parotid gland (arrows = external outline of the superficial lobe). Affected nodes were also located beneath and along the sternocleidomastoid muscle.

 

Figure 32
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  		Figure 32.  Gray-scale US image of a patient with non-Hodgkin lymphoma shows a lymphomatous lymph node (arrows) in the parotid gland. The oval, well-defined, anechoic lesion demonstrates discrete posterior enhancement and mimics a simple cyst.

 

Figure 33
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  		Figure 33.  Gray-scale tissue harmonic US image shows a simple cyst (arrowheads) in the lower pole of the parotid gland (arrows).

 

Figure 34
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  		Figure 34.  US image shows the left submandibular gland (arrows) 9 years after therapeutic irradiation of the neck. The gland is hypoechoic and inhomogeneous, contains separate hyperechoic linear structures, and has partially irregular and difficult to follow outlines. ? = equivocal lower margin of the submandibular gland.

 




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