Diagnostic Imaging Pathways - Salivary Gland Swelling
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This pathway provides guidance on the imaging of adult patients with salivary gland swelling.
Date reviewed: January 2012
Date of next review: 2017/2018
Published: January 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1a |  |
Salivary Gland Swelling with Ductal Narrowing Image 1a and 1b (Sialogram): There is considerable dilatation of the intraglandular radicles particularly low in the gland. The parotid duct has a narrowing just distal to the confluence with the accessory duct (arrow), this latter not being dilated. The narrow segment is fairly short and is only a relative narrowing, not an obstruction. There is no calculus identified. |
| 1b |  |
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| 2a |  |
Salivary Gland Tumour Image 2a and 2b: Resection of the parotid gland showing a (a) pleomorphic adenoma with the typical well circumscribed, pale appearance and focal areas of chondroid (cartilagenous) differentiation (arrow) and a (b) Warthin's tumour (Papillary cystadenoma lymphomatosum) with a tan cut surface demonstrating several cystic spaces. |
| 2b |  |
|
Teaching Points
Teaching Points
- Ultrasound is the initial imaging modality in suspected salivary gland disease
- In suspected sialolithiasis, MR sialography is the prefered non-invasive investigation for further assessment of salivary gland calculi
- With a salivary gland mass, CT or MRI can be used for further investigation
ct
Computed Tomography (CT)
- CT is the method of choice in patients suspicious for inflammatory disease (abscess, calculi, major salivary duct dilatation, and acute inflammation) or in patients with contraindication for MR imaging 4,5,6,16
- Superior to plain radiographs and US in detection of sialolithiasis 9
- Allows detection and assessment of extent of salivary gland tumours 5,6,9
- Helpful in the differential diagnosis of salivary gland tumours 8
- Helpful in assessment of deep lobe of parotid gland and the minor salivary glands 17
- For lesions in the superficial parotid and submandibular gland, ultrasound is an ideal tool for initial assessment
- For CT imaging both pre- and post-contrast studies must be performed in order to detect calcifications (pre-contrast) and enhancement pattern (post-contrast) 16
- Limitations
mri
Magnetic Resonance Imaging (MRI)
- MRI is the method of choice for patients with palpable masses and a strong suspicion that the lesion is neoplastic 4,16
- MRI gives information on the exact localisation and extent of the lesion, addresses neighbouring structures, and allows perineural spread, bone invasion and meningeal infiltration to be assessed 16,18
- For all tumours in the sublingual gland, MRI should be performed as the risk of malignancy is high 17
- For lesions of the deep lobe of parotid gland and the minor salivary glands, MRI and CT are the modalities of choice 17
mrs
Magnetic Resonance Sialography
- Non-invasive alternative to conventional/digital sialography 3,4,13
- Allows accurate assessment of salivary gland calculi and stenoses 13
- Advantages
- Non-invasive
- No exposure to ionising radiation
- Does not require use of contrast material
- Limitations 4
- False negative readings may occur in patients with very small calculi that are causing no ductal dilatation
- Inability to distinguish solid calculi from inspissated mucus and/or debris
- Distortion artefacts caused by dental amalgam may impair visualisation of calculi or stenoses near the main ductal orifice
- Disadvantages
- Expensive
- Limited availability
sial
Conventional Sialography
- Most detailed way to image the salivary ductal system 3,11,12
- Disadvantages 11
- Invasive procedure with a risk of complications such as damage to the orifice, overfilling and rupture of the ductal system, exacerbation of infection, and adverse reaction to contrast material
- Exposure to ionising radiation
- Need for experienced operator to cannulate the small, often oedematous ductal orifices
- Pain during retrograde injection of contrast material (minimise with fluoroscopic screening)
- Contraindicated in acute salivary infection
us
Ultrasound
- Initial imaging modality of choice for evaluation of suspected salivary gland masses and inflammatory disease of the salivary glands 1,2
- Allows:
- Advantages
- Relatively inexpensive
- Safe (non-invasive and does not involve use of ionising radiation or contrast medium)
- Widely available
- Limitations 2
- Inability to evaluate deep parotid masses, lesions obscured by the mandible, parapharyngeal and deep neck adenopathy, and the intracranial or skull base extent of a mass
- Lacks specificity for cystic lesions
- Difficult to demonstrate relationship of a tumour to the facial nerve to the surgeons
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Murray ME, Buckenham TM, Joseph AEA. The role of ultrasound in screening patients referred for sialography: a possible protocol. Clin Otolaryngol Allied Sci. 1996;21:21-3. (Level III evidence)
- Gritzmann N. Sonography of the salivary glands. AJR Am J Roentgenol. 1989;153:161-6. (Level III evidence)
- Jager L, Menauer F, Holzknecht N, et al. Sialolithiasis: MR sialography of the submandibular duct - an alternative to conventional sialography and US? Radiology. 2000;216:665-71. (Level II evidence). View the reference
- Yousem DM, Kraut MA, Chalian AA. Major salivary gland imaging. Radiology. 2000;216:19-29. (Review article)
- Casselman JW, Mancuso AA. Major salivary gland masses: comparison of MR imaging and CT. Radiology. 1987;165:183-9. (Level III evidence)
- Bryan RN, Miller RH, Ferreyro RI, et al. Computed tomography of the major salivary glands. AJR Am J Roentgenol. 1982;139:547-54. (Level III evidence)
- Avrahami E, Englender M, Chen E, et al. CT of submandibular gland sialolithiasis. Neuroradiology. 1996;38:287-90. (Level II/III evidence)
- Choi DS, Na DG, Byun HS, et al. Salivary gland tumors: evaluation with two-phase helical CT. Radiology. 2000;214:231-6. (Level II/III evidence)
- Berg HM, Jacobs JB, Kaufman D, et al. Correlation of fine needle aspiration biopsy and CT scanning of parotid masses. Laryngoscope. 1986;96:1357-62. (Level III evidence)
- Kaneda T, Minami M, Ozawa K, et al. Imaging tumors of the minor salivary glands. Oral Surg Oral Med Oral Pathol. 1994;77:385-90. (Level IV evidence)
- Silvers AR, Som PM. Salivary glands. Radiol Clin North Am. 1998;36(5):941-66. (Review article)
- Buckenham TM, George CD, McVicar D, et al. Digital sialography: imaging and intervention. Br J Radiol. 1994;67:524-9. (Level II/III evidence)
- Becker M, Marchal F, Becker CD, et al. Sialolithiasis and salivary ductal stenosis: diagnostic accuracy of MR sialography with a three-dimensional extended-phase conjugate-symmetry rapid spin-echo sequence. Radiology. 2000;217:347-58. (Level II evidence). View the reference
- Sack MJ, Weber RS, Weinstein GS, et al. Image-guided fine-needle aspiration of the head and neck: five years' experience. Arch Otolaryngol Head Neck Surg. 1998;124:1155-61. (Level III evidence)
- Yousem DM, Sack MJ, Weinstein GS, et al. Computed tomography-guided aspirations of parapharyngeal and skull base masses. Skull Base Surg. 1995;5:131-6. (Level III evidence)
- Thoeny H C. Imaging of salivary gland tumours. Cancer Imaging. 2007;7(1):52-62. (Review article)
- Lee YY, Wong KT, King AD, Ahuja AT. Imaging of salivary gland tumours. Eur J Radiol. 2008;66(3):419-36. (Review article)
- Parker GD, Harnsberger HR. Clinical-radiologic issues in perineural tumor spread of malignant diseases of the extracranial head and neck. Radiographics. 1991;11(3):383-99. (Level III evidence)
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