In this video, Dr. Bailey gives us an overview of salivary gland lesions, including briefly reviewing the normal anatomy and appearance of the salivary glands, common benign and malignant neoplasms, and other infectious, inflammatory, and systemic processes that may affect the salivary glands.
Salivary gland overview
There are three major sets of salivary glands, the parotid, submandibular, and sublingual glands. There are also minor salivary rests elsewhere. The parotid gland is the largest salivary gland, and drains through Stinson’s duct which empties near the 2nd molar. The submandibular and sublingual glands are in the floor of the mouth in the sublingual space.
Benign salivary gland neoplasms
There are a lot of salivary gland neoplasms, most of which are benign. A good tip is that the larger glands are more likely to have benign lesions. Most parotid lesions are benign, while minor glands have a higher percentage of malignant gland. The parotid is the most common location for both benign and malignant lesions.
The most common benign lesions are pleomorphic adenoma (benign mixed tumor) and Warthin tumors. Pleomorphic adenomas are the most common and tend to be homogeneously dense on CT. On MRI, they are relatively homogeneous, hypointense on T1, and VERY hyperintense on T2. They may have a fibrous rim. Warthin tumors are also benign, and are more common in older men. They are often bilateral, and tend to be more heterogeneous and less T2 hyperintense than pleomorphic adenomas. Bilateral tumors are more likely to be Warthin tumors.
Malignant salivary gland neoplasms
Mucoepidermoid carcinomas are the most common parotid malignancy. There is a lot of overlap with the appearance of benign lesions, but the margins tend to be more irregular. They may also have lower signal on T2. When you have malignant salivary gland lesions, you should check specifically for perineural spread, which can occur along the facial nerve up to the geniculate ganglion or along the trigeminal nerve to the foramen ovale.
Adenoid cystic carcinomas are more common in minor salivary glands and are the most common sinonasal salivary tumor. As the grade increases, they tend to be more T2 hypointense. There are also well known for perineural spread.
Parotid metastases are quite common because of intraparotid lymph nodes. Skin cancers and melanoma as well as lymphoma are common causes of metastatic disease. Like the other malignancies, they tend to have very irregular margins.
Inflammatory and other
Sjogren disease is an autoimmune disease of exocrine glands which results in a multinodular appearance of the parotid glands. Patients may have atrophy of the lacrimal glands. These patients have an increased risk of lymphoma.
Lymphoepithelial cysts are multifocal cystic lesions which are most often seen in patients with HIV due to lymphatic obstruction. They appear as bilateral parotid gland cysts.
Sialolithiasis is formation of stones (calculi) in the duct or parenchyma of glands. They are most common in middle age me and in the submandibular gland. This appears as very dense, calcified and well defined lesions either in gland or along the duct.
Sialadenitis is inflammation of the gland which can be caused by infection or inflammatory conditions. Ascending bacteria from the pharynx is the most common, but viruses and immune mediated causes are also possible.
This is a relatively well-defined lesion in the superficial aspect of the left parotid gland. It is hyperdense and somewhat homogeneous, but superficial to the gland. If you review further, there is an additional superficial nodule, and this is spread of an adjacent malignancy. So, this case is malignant. An important lesson in evaluating salivary gland lesions is that you often cannot tell the difference between benign and malignant lesions, so biopsy is required.
Hopefully these cases taught you something about the normal appearance and anatomy of the salivary glands, some common tumors (both benign and malignant), and other conditions affecting the salivary glands. Be sure to check out the other videos on other head and neck topics.
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