Mistakes in ultrasound examination of salivary glands

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Journal of Ultrasonography

Polish Ultrasound Society (Polskie Towarzystwo Ultrasonograficzne)

Subject: Medicine

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ISSN: 2084-8404
eISSN: 2451-070X

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VOLUME 16 , ISSUE 65 (September 2016) > List of articles

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Mistakes in ultrasound examination of salivary glands

Ewa J. Białek * / Wiesław Jakubowski

Keywords : salivary gland, parotid gland, submandibular gland, ultrasound, mistake

Citation Information : Journal of Ultrasonography. VOLUME 16 , ISSUE 65 , Pages 191-203 , ISSN (Online) 2451-070X, DOI: 10.15557/JoU.2016.0020, September 2016 © 2016.2016 Polish Ultrasound Society. Published by Medical Communications Sp. z o.o. All rights reserved.

License : (CC BY-NC-ND 3.0)

Received Date : 31-January-2016 / Accepted: 13-April-2016 / Published Online: 29-June-2016

ARTICLE

ABSTRACT

Ultrasonography is the first imaging method applied in the case of diseases of the salivary glands. The article discusses basic mistakes that can be made during an ultrasound examination of these structures. The reasons for these mistakes may be examiner-dependent or may be beyond their control. The latter may include, inter alia, difficult conditions during examination (technical or patient-related), similarity of ultrasound images in different diseases, the lack of clinical and laboratory data as well as the lack of results of other examinations, their insufficient number or incorrectness. Doctor-related mistakes include: the lack of knowledge of normal anatomy, characteristics of ultrasound images in various salivary gland diseases and statistical incidence of diseases, but also attaching excessive importance to such statistical data. The complex anatomical structures of the floor of the oral cavity may be mistaken for benign or malignant tumors. Fragments of correct anatomical structures (bones, arterial wall fibrosis, air bubbles in the mouth) can be wrongly interpreted as deposits in the salivary gland or in its excretory duct. Correct lymph nodes in the parotid glands may be treated as pathologic structures. Lesions not being a simple cyst, e.g. lymphoma, benign or malignant tumors of the salivary glands or metastatic lymph nodes, can be mistaken for one. The image of disseminated focal changes, both anechoic and solid, is not pathognomonic for specific diseases in the salivary glands. However, in part, it occurs typically and requires an extended differential diagnosis. Small focal changes and infiltrative lesions pose a diagnostic problem because their etiology cannot be safely suggested on the basis of an ultrasound examination itself. The safest approach is to refer patients with abnormal focal changes for an ultrasoundguided fine-needle aspiration biopsy.

Badanie ultrasonograficzne jest pierwszą metodą obrazową stosowaną w przypadku chorób ślinianek. W artykule omówiono podstawowe pomyłki, które można popełnić podczas badania ultrasonograficznego tych gruczołów. Przyczyny błędów mogą być zależne i niezależne od lekarza badającego. Do przyczyn niezależnych należą m.in. trudne warunki badania (techniczne lub ze strony osoby badanej), podobieństwo obrazów ultrasonograficznych w różnych jednostkach chorobowych oraz brak danych klinicznych, laboratoryjnych i wyników innych badań lub ich zbyt mała liczba czy nieprawidłowość. Wśród przyczyn pomyłek zależnych od lekarza wykonującego badanie ultrasonograficzne należy wymienić nieznajomość: anatomii prawidłowej, cech obrazów ultrasonograficznych w różnych chorobach ślinianek, statystycznej częstości występowania chorób, ale również zbytnie sugerowanie się nią. Skomplikowane struktury anatomiczne okolicy dna jamy ustnej mogą być mylone z łagodnymi lub złośliwymi nowotworami. Fragmenty prawidłowych struktur anatomicznych (kości, zwłókniałe ściany tętnic, pęcherzyki powietrza w jamie ustnej) mogą zostać nieprawidłowo zinterpretowane jako złogi w śliniance lub jej przewodzie wyprowadzającym. Prawidłowe węzły chłonne obecne w śliniankach przyusznych można potraktować jako struktury patologiczne. Zmiany niebędące torbielą prostą mogą zostać z nią pomylone, np. chłoniak, niezłośliwe i złośliwe nowotwory ślinianek, węzły chłonne przerzutowe. Obraz rozsianych zmian ogniskowych, zarówno bezechowych, jak i litych, nie jest w śliniankach patognomoniczny dla konkretnych jednostek chorobowych, chociaż w części występuje typowo i wymaga poszerzonej diagnostyki różnicowej. Problem diagnostyczny stanowią małe zmiany ogniskowe oraz zmiany naciekowe, ponieważ na podstawie samego badania ultrasonograficznego nie można bezpiecznie sugerować ich etiologii. Najbezpieczniejszym sposobem postępowania jest kierowanie pacjentów z obecnością nieprawidłowych zmian ogniskowych na biopsję aspiracyjną cienkoigłową celowaną, monitorowaną ultrasonograficznie.

Graphical ABSTRACT

Ultrasound is the first and basic imaging method employed in the case of diseases affecting superficial tissues and organs, including the salivary glands. The article discusses basic mistakes that can be made during an ultrasound examination of these structures.

The following reasons may account for mistakes in ultrasound imaging of the salivary glands:

  • difficult conditions during examination (technical or patient-related);

  • the lack of knowledge of normal anatomy (doctor-related);

  • the lack of familiarity with characteristics of ultrasound images in various salivary gland diseases (doctor-related);

  • the similarity of ultrasound images in different diseases;

  • the lack of knowledge of statistical incidence of diseases, but also attaching excessive importance to such statistical data (doctor-related);

  • the lack of clinical and laboratory data as well as the lack of results of other examinations, their insufficient number or incorrectness.

Difficult conditions of examination

An ultrasound examination may be significantly hindered by short and thick neck of the examined patient, poor tissue transparency for ultrasounds or limited neck mobility, making it impossible to tilt the head as far back as needed or turn it sideways. What greatly impedes and at times even prevents a reliable examination is the lack of contact with the patient or cooperation on their part, e.g. patient's moving during an examination. The clinical condition of the examined patient, e.g. rapid, deep breathing, may impede or preclude a reliable Doppler evaluation.

Tissue transparency for ultrasounds is worse in some patients than in others. This can be due to, among other things, obesity, postoperative changes or other reasons for fibrosis and tissue architectonics dysfunctions. Subcutaneous emphysema can make it impossible to examine tissues located deeper.

The description of the examination should include information about the presence and nature of encountered difficulties to make the referring doctor aware of potential limitations of the examination reliability and, in the case of incompatibility with the clinical picture, to make it possible for them to decide on the need for additional examinations, such as computed tomography or magnetic resonance imaging.

Mistakes resulting from the lack of knowledge of normal anatomy

The key element necessary for reliable ultrasound evaluation of the area of the salivary glands and lymph nodes, and basically the entire area of the neck and face, is the knowledge of normal anatomy. A large number of anatomical structures in this area, their course and arrangement as well as complicated mutual spatial relations make an ultrasound image of the area complex, and the lack of knowledge about these issues precludes proper performance of an examination and interpretation of an image. In addition, an ultrasound image of the discussed areas may be changeable, e.g. may depend on the history of neck irradiation or content of fat tissue. One of correct anatomical structures may be easily mistaken for a focal change. For instance, one of the muscles of the neck base, the genioglossus muscle in the transverse section in the area of the attachment to the bone of the mandible, may mimic a focal lesion that might even seem like a malignant one on ultrasound (Fig. 1). Another example: anterior belly of the digastric muscle in the transverse or oblique section has an oval shape and may mimic a well-delineated focal change (Fig. 1: structure No 4). Proper performance of an examination, i.e. in at least two perpendicular planes, along with knowledge of the course and image of muscles in an ultrasound examination enables easy identification of the viewed structures.

Fig. 1

The structure marked with arrows in the first image might be described as a heterogeneous focal lesion with blurred, irregular contours and outgrowths, i.e. with standard characteristics of a lesion that appears as malignant on ultrasound. In fact, it is the genioglossus muscle in the transverse section (1). Correct ultrasound anatomy of the floor of the mouth area in the transverse section: (2) – geniohyoid muscle; (3) – mylohyoid muscle; (4) – anterior belly of the digastric muscle; (5) – tongue; (6) – sublingual gland; (7) – oral cavity; (8) – subcutaneous tissue

10.15557_JoU.2016.0020-g001.jpg

Yet another example of a misdiagnosis based on wrong interpretation of an anatomical ultrasound image is suggesting sialolithiasis, for instance on the basis of an image of fibrosis (e.g. transverse or oblique section through an artery wall), fragments of correct anatomical bone structures or air bubbles in the region of the floor of the oral cavity (Fig. 2, 3, 4, 5).

Fig. 2

In the submandibular gland parenchyma (outlined with a dotted line), one can observe a hyperechoic linear structure (arrowheads) with acoustic shadow (arrows), i.e. a standard image of a deposit on a presented still image in the grey scale. During a dynamic examination, it can be seen that the hyperechoic line is an outer contour of a tubular structure that passes through the salivary gland in spirals and runs on upwards on the cheek and, below, toward the external carotid artery. The complete image suggests that it is a fragment of the facial artery wall affected by fibrosis, whereas the “acoustic shadow” is the vascular lumen captured in the oblique section. A Doppler examination, e.g. with the power Doppler, may serve as additional, unambiguous confirmation that the structure is the facial artery (Fig. 3)

10.15557_JoU.2016.0020-g002.jpg
Fig. 3

Unambiguous confirmation with the power Doppler that the structure in Fig. 2 is the facial artery (arrowheads). The parenchyma of the submandibular gland is marked with arrows

10.15557_JoU.2016.0020-g003.jpg
Fig. 4

Deep in the parenchyma of the parotid gland (2), a linear hyperechoic structure (arrows) can be seen which might be confused with a deposit. In fact, it is a fragment of the head of the mandible. The continuation of an echo of the anterior contour of the mandible ramus is marked with arrowheads; 1 – subcutaneous tissue

10.15557_JoU.2016.0020-g004.jpg
Fig. 5

The hyperechoic linear structure (arrows) in the area of the mouth floor is not a deposit in the excretory duct of the gland (Wharton's duct) but rather an echo at the boundary of air bubbles mixed with saliva. Arrowheads – mandibular gland

10.15557_JoU.2016.0020-g005.jpg

The following may present themselves as a deposit (stone) on an ultrasound image(1):

  • fibrosis;

  • bone;

  • gas (e.g. air bubbles);

  • foreign body.

Small salivary glands

Small glands are located in the oral mucosa and submucosa of the mouth, palate, nasal sinuses, throat, larynx, trachea and bronchi as well as in the tongue area. Tumors arising from the parenchyma of the salivary glands can also be located there and should be taken into account in differential diagnosis(2). In the case of small salivary glands, malignant tumors definitely prevail.

Deep lobe of the parotid gland and fatty infiltration of the salivary glands

In the case of the parotid gland, it is impossible to visualize and thus evaluate potential focal changes in the deep lobe. Penetration of ultrasounds into the parotid gland and even into deeper areas of the submandibular gland is further hindered if there is high content of fat in the parenchyma. Attenuation of ultrasounds is then significant and echogenicity of the parenchyma is raised and blurred (Fig. 6). If the entire focal change cannot be seen in an ultrasound examination or if a malignant lesion is suspected, magnetic resonance imaging or computed tomography should be ordered so as to visualize the entire lesion or evaluate lymph nodes that are located deeper or are inaccessible for ultrasound.

Fig. 6

The first image shows the submandibular gland (arrows) with low fat content and sharp borders. Organs and tissues located in the vicinity and below the submandibular gland can be clearly seen. (1) – palatine tonsil; (2) – tongue; (3) – posterior belly of the digastric muscle; (4) – mylohyoid muscle; (5) – hyoglossus. The second image presents the submandibular gland (arrowheads) with high fat content – the anterior contour of the parenchyma is hardly visible, whereas the posterior contour of the gland cannot be unambiguously traced. Structures located deeper are not visible

10.15557_JoU.2016.0020-g006.jpg

Borders

The borders of the salivary glands, in particular the parotid glands but also the submandibular ones, may be difficult to trace even if their condition is correct, especially when steatosis of the parenchyma occurs, which further blurs echogenicity in the center and contours of the glands causing segmental „merging” with the surrounding connective tissue, e.g. the subcutaneous one. For this reason, it may be difficult to unambiguously locate focal changes in the parenchyma of the salivary gland or outside of it, particularly in the region of the poles of the parotid glands and within the submandibular area (Fig. 7, 8, 9). One should also pay attention to lesions in neighboring organs so as not to describe their pathology as a salivary gland disease, e.g. changes in the mandible, muscles, tonsils or subcutaneous tissue(3, 4).

Fig. 7

Focal lesion (arrows) in the area of the lower pole of the parotid gland (SP) on the panoramic ultrasound image. The location of the lesion is difficult to determine unambiguously. The fact that the sternocleidomastoid muscle (M) penetrates above the lesion suggests that it is likely that the lesion is located outside of the parenchyma of the gland. Branchial cleft cyst (following FNAB and postoperative histopathological examination)

10.15557_JoU.2016.0020-g007.jpg
Fig. 8

Focal lesion (arrows) in the area of the lower pole of the parotid gland (SP) on the panoramic ultrasound image. The location of the lesion is difficult to determine unambiguously. However, it seems that it is surrounded by the parenchyma of the gland from the above. M – sternocleidomastoid muscle; T – common carotid artery. Wharton's tumor (following FNAB and postoperative histopathological examination)

10.15557_JoU.2016.0020-g008.jpg
Fig. 9

Reactive lymph node (arrows) with central blood flow (regular, symmetrical vessel segments – ramification of the longitudinal vessel) in the submandibular area (2), above the submandibular gland. Yet, it is difficult to unambiguously trace the outer contour of the submandibular gland; 1 – subcutaneous tissue

10.15557_JoU.2016.0020-g009.jpg

Intrasalivary lymph nodes

There may be lymph nodes located in the parenchyma of the salivary glands. They should not be described as pathology if they present correct ultrasound features(5).

Small focal changes

Another significant issue is differentiating small (not exceeding 20 mm in diameter) focal changes of the salivary glands(6, 7). Even if they are oval, well-delineated and have regular contours as well as a uniform structure, i.e. even if they present a standard ultrasound image of a benign lesion, their malignant nature cannot be ruled out. Small malignant neoplastic changes of the salivary glands and metastases to salivary glands may present an image of a benign lesion in an ultrasound examination (Fig. 10). For this reason, the safest approach in the case of focal changes in the salivary glands is their verification by an ultrasound-guided fine-needle aspiration biopsy (FNAB).

Fig. 10

Oval, quite well-delineated (high-resolution probe) focal lesion (arrows) with posterior acoustic enhancement. Mucoepidermoid carcinoma in an ultrasound-guided fine-needle aspiration biopsy

10.15557_JoU.2016.0020-g010.jpg

Certain symptoms or clinical data, such as pain, which may suggest infiltration of nerves, or the patient's age, may further contribute to the urgent need for a biopsy. The necessity for this procedure is of course undisputed if the ultrasound image itself suggests a malignant lesion.

Changes in the entire parenchyma of the salivary gland

A large hypoechoic focal change occupying the entire or almost the entire parenchyma of the salivary gland may be mistaken for inflammation (!) due to its statistically higher incidence. Even focal changes of considerable sizes may have regular margins without any outgrowths, which does not rule out their malignant nature. They can infiltrate neighboring tissues and structures, e.g. bones, and therefore one should always pay attention to whether the contours of bone surfaces seen in an ultrasound image are regular and correct, according to their anatomical shape (Fig. 11).

Fig. 11

Hypoechoic, well-delineated focal lesion (arrowheads) causing clear destruction of the mandible ramus (arrows); only a narrow streak of the preserved correct parenchyma of the parotid gland can be seen around the lesion (anterior contour of the superficial lobe marked with hollow arrows). Acinic-cell carcinoma

10.15557_JoU.2016.0020-g011.jpg

Invasive neoplasms destroying the entire parenchyma of the salivary gland may have blurred borders but in the case of chronic inflammation, contours of the salivary glands can also be irregular (Fig. 12). If irregular finger-like outer contours of the salivary gland have been visualized, ultrasound-guided FNAB is the procedure to be followed.

Fig. 12

Changes in the view of the submandibular glands in two ultrasound images (power Doppler examination) of two different patients look similar: uneven margins, blurred contours, irregular shape, heterogeneous echogenicity, single flow segments. The inflamed parenchyma of the submandibular gland in the first US image (arrows) and adenoid cystic carcinoma whose infiltration destroyed the entire parenchyma of the salivary gland in the second US image (arrowheads)

10.15557_JoU.2016.0020-g012.jpg

One should always look for the correct parenchyma of the salivary gland around a large focal change located close to the salivary glands as this procedure makes it easier to correctly suggest a focal lesion rather than inflammation (Fig. 11). There are two reasons why the visualization and identification of a correct fragment of the parenchyma can be troublesome: the above-mentioned difficulty in tracing contours of the salivary glands, even healthy ones, as well as a small size of the preserved fragment of the parenchyma. One should also search for signs of infiltration of the neighboring structures, e.g. bones or muscles as well as lymph nodes having an abnormal ultrasound image, which could suggest a malignant nature of the lesion.

What should be alarming to the examining doctor is the lack of clinical symptoms of sialolithiasis and inflammation as well as the lack of deposits seen during an ultrasound when hypoechoic and heterogeneous salivary glands have been found. This particularly applies for the submandibular glands because the incidence of malignant neoplasms in this area is close to 50%(1). However, the co-occurrence of sialolithiasis does not automatically rule out a neoplasm of the salivary gland. On the other hand, a focal change in the sublingual gland is in the vast majority of cases a malignant neoplasm. In case of any doubts, it is best to perform FNAB.

Pseudocyst – a misdiagnosis of a cyst

One should exercise particular caution when suggesting the presence of a simple cyst in the head and neck area since many other pathologic changes, including malignant neoplasms, may look very much the same on ultrasound. Oval, well-delineated shape, anechoic center and clear posterior acoustic enhancement, i.e. standard characteristics of a simple cyst on ultrasound, may be very misleading in organs and soft tissues of the face and neck(1, 811). Primary reasons for that include: statistically low incidence of simple cysts in the salivary glands and neck, a number of changes that may mimic the image of a simple cyst and the fact that, in the considerable majority of cases, branchial cleft cysts paradoxically present themselves as solid lesions on grey-scale ultrasound.

Each of the following may present standard features of a simple cyst(1, 811):

  • lymph nodes in lymphomas;

  • benign and malignant neoplasms of the salivary glands;

  • metastatic lymph nodes;

  • reactive lymph nodes;

  • benign lymphoepithelial lesions in HIV-positive patients.

The lower the resolution of the ultrasound probe and the lower the grey scale available in the ultrasound machine used by the examining doctor, the more suggestive the imitation of a cyst by other histopathological focal changes on ultrasound.

Not only may benign and malignant neoplasms of the salivary glands mimic a cystic lesion when their interior is filled with fluid and the layer of cancer cells is located only on the periphery, but also when they are completely solid. In some cases, the use of sensitive color Doppler or power Doppler imaging may unequivocally suggest a proper diagnosis. Still, neoplasms of the salivary glands can be poorly vascularized and even with the use of sensitive power Doppler, the flow inside a solid lesion might not be seen (Fig. 13).

Fig. 13

Oval, well-delineated, nearly anechoic focal lesion (arrowheads) with posterior acoustic enhancement in the parotid gland (SP). Color Doppler showed no evidence of flow (the option is not visible in the picture). The image may suggest a simple cyst, when in fact it is pleomorphic adenoma. Arrows – anterior contours of the mandible; T – external carotid artery; Z – retromandibular vein

10.15557_JoU.2016.0020-g013.jpg

In the case of lesions that are indeed filled with fluid whose nature is determined solely by the type of lining cells in the peripheral part, even the highest-class ultrasound machine may not be helpful in making a proper diagnosis. The preoperative examination that may enable their verification is FNAB.

Lymph nodes that may misleadingly appear on an ultrasound as a simple cyst may occur in the typical position in the neck (e.g. in the submandibular area, along the edges and underneath the sternocleidomastoid muscle, along the large neck vessels), but also in the area of the parotid gland parenchyma(1).

Neoplastic infiltration vs inflammatory infiltration

Both inflammatory infiltrations and neoplastic infiltrations of the salivary glands and soft tissues may have a very similar image on ultrasound. An irregularly shaped, heterogeneous hypoechoic area with outgrowths may be typical of both types of infiltration. As neoplastic infiltration, inflammatory infiltration may spread onto neighboring tissues, e.g. the sternocleidomastoid muscle.

A certain type of salivary gland inflammation, the so-called Küttner's tumor, may mimic a malignant lesion in a clinical examination – it is hard. Similarly, it can present blurred borders and heterogeneous structure on ultrasound(12, 13).

Disseminated lesions

The image of oval, hypoechoic or nearly anechoic lesions disseminated in the parenchyma may occur in the case of(8, 1417):

  • Sjögren's syndrome (Fig. 14);

  • lymphoma;

  • inflammation (acute);

  • granulomatous disease (e.g. tuberculosis, sarcoidosis);

  • hematogenous metastases;

  • benign lymphoepithelial lesions in HIV-positive patients.

Fig. 14

A. Multiple, nearly anechoic, oval focal lesions disseminated in the parenchyma of the parotid gland (symmetrical in both glands). B. Power Doppler shows increased blood flow. Sjögren's syndrome. The image is not pathognomonic

10.15557_JoU.2016.0020-g014.jpg

Multiple solid lesions

The image of solid lesions disseminated in the parenchyma may be caused by(4, 1820):

  • Warthin's tumor (lymphatic cystadenoma);

  • recurrent pleomorphic adenoma (tumor mixtus);

  • oncocytoma;

  • acinic cell carcinoma;

  • correct or affected lymph nodes.

Conclusion

Ultrasonography is the first imaging method applied in the case of diseases of the salivary glands. The article discussed basic mistakes that can be made during an ultrasound examination of these structures. The reasons for these mistakes may be examiner-dependent or may be beyond their control. The latter may include, inter alia, difficult conditions during examination (technical or patient-related), similarity of ultrasound images in different diseases, the lack of clinical and laboratory data as well as the lack of results of other examinations, their insufficient number or incorrectness. Doctor-related mistakes include: the lack of knowledge of normal anatomy, characteristics of ultrasound images in various salivary gland diseases and statistical incidence of diseases, but also attaching excessive importance to such statistical data.

The complex anatomical structures of the floor of the oral cavity may be mistaken for benign or malignant tumors. Fragments of correct anatomical structures (bones, arterial wall fibrosis, air bubbles in the mouth) can be wrongly interpreted as deposits in the salivary gland or in its excretory duct. Correct lymph nodes in the parotid glands may be treated as pathologic structures. Lesions not being a simple cyst, e.g. lymphoma, benign or malignant tumors of salivary glands, metastatic lymph nodes, can be mistaken for one. The image of disseminated focal changes, both anechoic and solid, is not pathognomonic for specific diseases in the salivary glands. However, in part, it occurs typically and requires an extended differential diagnosis. Small focal changes and infiltrative lesions pose a diagnostic problem because their etiology cannot be safely suggested on the basis of an ultrasound examination itself. The safest approach is to refer patients with abnormal focal changes for an ultrasound-guided fine-needle aspiration biopsy.

In conclusion, it should be stated that diagnostic pitfalls in an ultrasound examination can happen to anyone, even if the highest-class machine is used. However, one should aim at decreasing the number and, ultimately, at total elimination of mistakes resulting from the lack of knowledge. According to the authors, the necessity to continuously obtain new information applies to everyone, regardless of the level of knowledge that they already possess.

Conflict of interest

Authors do not report any financial or personal connections with other persons or organizations, which might negatively affect the contents of this publication and/or claim authorship rights to this publication.

This paper was prepared based on Ewa J. Białek, “Błędy i pomyłki w diagnostyce USG ślinianek i węzłów chłonnych położonych powierzchownie”, In: „Błędy i pomyłki w diagnostyce ultrasonograficznej”, ed. by Wiesław Jakubowski, Roztoczańska Szkoła Ultrasonografii, Warszawa – Zamość 2005: p. 45–58.

References


  1. Białek EJ,Jakubowski W,Zajkowski P,Szopiński KT,Osmólski A,US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls Radiographics 2006 26 745 763
    [PUBMED] [CROSSREF]
  2. Białek EJ,Jakubowski W,Zajkowski P,Wareluk P,Obraz ultrasonograficzny gruczolaków wielopostaciowych podniebienia w badaniu z dostępu wewnątrzustnego. Opis 2 przypadków Ultrasonografia 2003 14 58 60
  3. Białek EJ,Jakubowski W,Osmólski A,Zajkowski P,Ultrasonography as the method of incidental detection of mandible lesions Acta Otorhinolaryngol Belg 2004 58 157 159
    [PUBMED]
  4. Białek EJ,Jakubowski W,Karpińska G,Role of ultrasonography in diagnosis and differentiation of pleomorphic adenomas: work in progress Arch Otolaryngol Head Neck Surg 2003 129 929 933
    [PUBMED] [CROSSREF]
  5. Ying M,Ahuja A,Metreweli C,Diagnostic accuracy of sonographic criteria for evaluation of cervical lymphadenopathy J Ultrasound Med 1998 17 437 445
    [PUBMED]
  6. Schick S,Steiner E,Gahleitner A,Böhm P,Helbich T,Ba-Ssalamah A,Differentiation of benign and malignant tumors of the parotid gland: value of pulsed Doppler and color Doppler sonography Eur Radiol 1998 8 1462 1467
    [PUBMED] [CROSSREF]
  7. Shimizu M,Ussmüller J,Hartwein J,Donath K,Kinukawa N,Statistical study for sonographic differential diagnosis of tumorous lesions in the parotid gland Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999 88 226 233
    [PUBMED] [CROSSREF]
  8. Martinoli C,Pretolesi F,Del Bono V,Derchi LE,Mecca D,Chiaramondia M,Benign lymphoepithelial parotid lesions in HIV-positive patients: spectrum of findings at gray-scale and Doppler sonography AJR Am J Roentgenol 1995 165 975 979
    [PUBMED] [CROSSREF]
  9. Martinoli C,Derchi LE,Solbiati L,Rizzatto G,Silvestri E,Giannoni M,Color Doppler sonography of salivary glands AJR Am J Roentgenol 1994 163 933 941
    [PUBMED] [CROSSREF]
  10. Ahuja AT,Ying M,Yuen YH,Metreweli C,'Pseudocystic’ appearance of non-Hodgkin's lymphomatous nodes: an infrequent finding with highresolution transducers Clin Radiol 2001 56 111 115
    [PUBMED] [CROSSREF]
  11. Kessler A,Rappaport Y,Blank A,Marmor S,Weiss J,Graif M,Cystic appearance of cervical lymph nodes is characteristic of metastatic papillary thyroid carcinoma J Clin Ultrasound 2003 31 21 25
    [PUBMED] [CROSSREF]
  12. Białek EJ,Osmólski A,Karpińska G,Fedorowicz M,Jakubowski W,Zajkowski P,US-appearance of a Küttner tumor resembling a malignant lesion: US-histopathologic correlation Eur J Ultrasound 2001 14 167 170
    [PUBMED] [CROSSREF]
  13. Osmólski A,Osmólski R,Jakubowski W,Białek E,Küttner tumor – review of the literature and report of 3 cases Otolaryngol Pol 2004 58 1199 1202
    [PUBMED]
  14. Makula E,Pokorny G,Rajtár M,Kiss I,Kovács A,Kovács L,Parotid gland ultrasonography as a diagnostic tool in primary Sjögren's syndrome Br J Rheumatol 1996 35 972 977
    [PUBMED] [CROSSREF]
  15. Shimizu M,Ussmüller J,Donath K,Yoshiura K,Ban S,Kanda S,Sonographic analysis of recurrent parotitis in children: a comparative study with sialographic findings Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998 86 606 615
    [PUBMED] [CROSSREF]
  16. Rubaltelli L,Sponga T,Candiani F,Pittarello F,Andretta M,Infantile recurrent sialectatic parotitis: the role of sonography and sialography in diagnosis and follow-up Br J Radiol 1987 60 1211 1214
    [PUBMED] [CROSSREF]
  17. Chiou HJ,Chou YH,Chiou SY,Chen WM,Chen W,Wang HK,High-resolution ultrasonography of primary peripheral soft tissue lymphoma J Ultrasound Med 2005 24 77 86
    [PUBMED]
  18. Zajkowski P,Jakubowski W,Białek EJ,Wysocki M,Osmólski A,Serafin-Król M,Pleomorphic adenoma and adenolymphoma in ultrasonography Eur J Ultrasound 2000 12 23 29
    [PUBMED] [CROSSREF]
  19. Yu GY,Ma DQ,Zhang Y,Peng X,Cai ZG,Gao Y,Multiple primary tumours of the parotid gland Int J Oral Maxillofac Surg 2004 33 531 534
    [PUBMED] [CROSSREF]
  20. Eneroth CM,Hamberger CA,Jakobsson PA,Malignancy of acinic cell carcinoma Ann Otol Rhinol Laryngol 1966 75 780 792
    [PUBMED] [CROSSREF]

FIGURES & TABLES

Fig. 1

The structure marked with arrows in the first image might be described as a heterogeneous focal lesion with blurred, irregular contours and outgrowths, i.e. with standard characteristics of a lesion that appears as malignant on ultrasound. In fact, it is the genioglossus muscle in the transverse section (1). Correct ultrasound anatomy of the floor of the mouth area in the transverse section: (2) – geniohyoid muscle; (3) – mylohyoid muscle; (4) – anterior belly of the digastric muscle; (5) – tongue; (6) – sublingual gland; (7) – oral cavity; (8) – subcutaneous tissue

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Fig. 2

In the submandibular gland parenchyma (outlined with a dotted line), one can observe a hyperechoic linear structure (arrowheads) with acoustic shadow (arrows), i.e. a standard image of a deposit on a presented still image in the grey scale. During a dynamic examination, it can be seen that the hyperechoic line is an outer contour of a tubular structure that passes through the salivary gland in spirals and runs on upwards on the cheek and, below, toward the external carotid artery. The complete image suggests that it is a fragment of the facial artery wall affected by fibrosis, whereas the “acoustic shadow” is the vascular lumen captured in the oblique section. A Doppler examination, e.g. with the power Doppler, may serve as additional, unambiguous confirmation that the structure is the facial artery (Fig. 3)

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Fig. 3

Unambiguous confirmation with the power Doppler that the structure in Fig. 2 is the facial artery (arrowheads). The parenchyma of the submandibular gland is marked with arrows

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Fig. 4

Deep in the parenchyma of the parotid gland (2), a linear hyperechoic structure (arrows) can be seen which might be confused with a deposit. In fact, it is a fragment of the head of the mandible. The continuation of an echo of the anterior contour of the mandible ramus is marked with arrowheads; 1 – subcutaneous tissue

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Fig. 5

The hyperechoic linear structure (arrows) in the area of the mouth floor is not a deposit in the excretory duct of the gland (Wharton's duct) but rather an echo at the boundary of air bubbles mixed with saliva. Arrowheads – mandibular gland

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Fig. 6

The first image shows the submandibular gland (arrows) with low fat content and sharp borders. Organs and tissues located in the vicinity and below the submandibular gland can be clearly seen. (1) – palatine tonsil; (2) – tongue; (3) – posterior belly of the digastric muscle; (4) – mylohyoid muscle; (5) – hyoglossus. The second image presents the submandibular gland (arrowheads) with high fat content – the anterior contour of the parenchyma is hardly visible, whereas the posterior contour of the gland cannot be unambiguously traced. Structures located deeper are not visible

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Fig. 7

Focal lesion (arrows) in the area of the lower pole of the parotid gland (SP) on the panoramic ultrasound image. The location of the lesion is difficult to determine unambiguously. The fact that the sternocleidomastoid muscle (M) penetrates above the lesion suggests that it is likely that the lesion is located outside of the parenchyma of the gland. Branchial cleft cyst (following FNAB and postoperative histopathological examination)

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Fig. 8

Focal lesion (arrows) in the area of the lower pole of the parotid gland (SP) on the panoramic ultrasound image. The location of the lesion is difficult to determine unambiguously. However, it seems that it is surrounded by the parenchyma of the gland from the above. M – sternocleidomastoid muscle; T – common carotid artery. Wharton's tumor (following FNAB and postoperative histopathological examination)

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Fig. 9

Reactive lymph node (arrows) with central blood flow (regular, symmetrical vessel segments – ramification of the longitudinal vessel) in the submandibular area (2), above the submandibular gland. Yet, it is difficult to unambiguously trace the outer contour of the submandibular gland; 1 – subcutaneous tissue

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Fig. 10

Oval, quite well-delineated (high-resolution probe) focal lesion (arrows) with posterior acoustic enhancement. Mucoepidermoid carcinoma in an ultrasound-guided fine-needle aspiration biopsy

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Fig. 11

Hypoechoic, well-delineated focal lesion (arrowheads) causing clear destruction of the mandible ramus (arrows); only a narrow streak of the preserved correct parenchyma of the parotid gland can be seen around the lesion (anterior contour of the superficial lobe marked with hollow arrows). Acinic-cell carcinoma

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Fig. 12

Changes in the view of the submandibular glands in two ultrasound images (power Doppler examination) of two different patients look similar: uneven margins, blurred contours, irregular shape, heterogeneous echogenicity, single flow segments. The inflamed parenchyma of the submandibular gland in the first US image (arrows) and adenoid cystic carcinoma whose infiltration destroyed the entire parenchyma of the salivary gland in the second US image (arrowheads)

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Fig. 13

Oval, well-delineated, nearly anechoic focal lesion (arrowheads) with posterior acoustic enhancement in the parotid gland (SP). Color Doppler showed no evidence of flow (the option is not visible in the picture). The image may suggest a simple cyst, when in fact it is pleomorphic adenoma. Arrows – anterior contours of the mandible; T – external carotid artery; Z – retromandibular vein

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Fig. 14

A. Multiple, nearly anechoic, oval focal lesions disseminated in the parenchyma of the parotid gland (symmetrical in both glands). B. Power Doppler shows increased blood flow. Sjögren's syndrome. The image is not pathognomonic

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REFERENCES

  1. Białek EJ,Jakubowski W,Zajkowski P,Szopiński KT,Osmólski A,US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls Radiographics 2006 26 745 763
    [PUBMED] [CROSSREF]
  2. Białek EJ,Jakubowski W,Zajkowski P,Wareluk P,Obraz ultrasonograficzny gruczolaków wielopostaciowych podniebienia w badaniu z dostępu wewnątrzustnego. Opis 2 przypadków Ultrasonografia 2003 14 58 60
  3. Białek EJ,Jakubowski W,Osmólski A,Zajkowski P,Ultrasonography as the method of incidental detection of mandible lesions Acta Otorhinolaryngol Belg 2004 58 157 159
    [PUBMED]
  4. Białek EJ,Jakubowski W,Karpińska G,Role of ultrasonography in diagnosis and differentiation of pleomorphic adenomas: work in progress Arch Otolaryngol Head Neck Surg 2003 129 929 933
    [PUBMED] [CROSSREF]
  5. Ying M,Ahuja A,Metreweli C,Diagnostic accuracy of sonographic criteria for evaluation of cervical lymphadenopathy J Ultrasound Med 1998 17 437 445
    [PUBMED]
  6. Schick S,Steiner E,Gahleitner A,Böhm P,Helbich T,Ba-Ssalamah A,Differentiation of benign and malignant tumors of the parotid gland: value of pulsed Doppler and color Doppler sonography Eur Radiol 1998 8 1462 1467
    [PUBMED] [CROSSREF]
  7. Shimizu M,Ussmüller J,Hartwein J,Donath K,Kinukawa N,Statistical study for sonographic differential diagnosis of tumorous lesions in the parotid gland Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999 88 226 233
    [PUBMED] [CROSSREF]
  8. Martinoli C,Pretolesi F,Del Bono V,Derchi LE,Mecca D,Chiaramondia M,Benign lymphoepithelial parotid lesions in HIV-positive patients: spectrum of findings at gray-scale and Doppler sonography AJR Am J Roentgenol 1995 165 975 979
    [PUBMED] [CROSSREF]
  9. Martinoli C,Derchi LE,Solbiati L,Rizzatto G,Silvestri E,Giannoni M,Color Doppler sonography of salivary glands AJR Am J Roentgenol 1994 163 933 941
    [PUBMED] [CROSSREF]
  10. Ahuja AT,Ying M,Yuen YH,Metreweli C,'Pseudocystic’ appearance of non-Hodgkin's lymphomatous nodes: an infrequent finding with highresolution transducers Clin Radiol 2001 56 111 115
    [PUBMED] [CROSSREF]
  11. Kessler A,Rappaport Y,Blank A,Marmor S,Weiss J,Graif M,Cystic appearance of cervical lymph nodes is characteristic of metastatic papillary thyroid carcinoma J Clin Ultrasound 2003 31 21 25
    [PUBMED] [CROSSREF]
  12. Białek EJ,Osmólski A,Karpińska G,Fedorowicz M,Jakubowski W,Zajkowski P,US-appearance of a Küttner tumor resembling a malignant lesion: US-histopathologic correlation Eur J Ultrasound 2001 14 167 170
    [PUBMED] [CROSSREF]
  13. Osmólski A,Osmólski R,Jakubowski W,Białek E,Küttner tumor – review of the literature and report of 3 cases Otolaryngol Pol 2004 58 1199 1202
    [PUBMED]
  14. Makula E,Pokorny G,Rajtár M,Kiss I,Kovács A,Kovács L,Parotid gland ultrasonography as a diagnostic tool in primary Sjögren's syndrome Br J Rheumatol 1996 35 972 977
    [PUBMED] [CROSSREF]
  15. Shimizu M,Ussmüller J,Donath K,Yoshiura K,Ban S,Kanda S,Sonographic analysis of recurrent parotitis in children: a comparative study with sialographic findings Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998 86 606 615
    [PUBMED] [CROSSREF]
  16. Rubaltelli L,Sponga T,Candiani F,Pittarello F,Andretta M,Infantile recurrent sialectatic parotitis: the role of sonography and sialography in diagnosis and follow-up Br J Radiol 1987 60 1211 1214
    [PUBMED] [CROSSREF]
  17. Chiou HJ,Chou YH,Chiou SY,Chen WM,Chen W,Wang HK,High-resolution ultrasonography of primary peripheral soft tissue lymphoma J Ultrasound Med 2005 24 77 86
    [PUBMED]
  18. Zajkowski P,Jakubowski W,Białek EJ,Wysocki M,Osmólski A,Serafin-Król M,Pleomorphic adenoma and adenolymphoma in ultrasonography Eur J Ultrasound 2000 12 23 29
    [PUBMED] [CROSSREF]
  19. Yu GY,Ma DQ,Zhang Y,Peng X,Cai ZG,Gao Y,Multiple primary tumours of the parotid gland Int J Oral Maxillofac Surg 2004 33 531 534
    [PUBMED] [CROSSREF]
  20. Eneroth CM,Hamberger CA,Jakobsson PA,Malignancy of acinic cell carcinoma Ann Otol Rhinol Laryngol 1966 75 780 792
    [PUBMED] [CROSSREF]

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