1. The Role of Gray Scale & Doppler Ultrasound in the Evaluation of Major Salivary Gland Lesions
Dr.Rajeev.B.D
Resident (III)
SSGH & Medical college
Vadodara
13/12/07

2. Role of Gray Scale & Doppler US
Ultrasound plays a significant and crucial role in the diagnosis and management of salivary gland lesions.
US is widely accepted as the first imaging method for assessment of major salivary glands. Results of the US examination alone may suggest the final diagnosis or provide important differential diagnostic data.
US can differentiate intraglandular from extraglandular lesions in 98% of cases. It can differentiate salivary gland lesions as focal or diffuse.

3. Further assessment of focal lesions and characterization of benignancy or malignancy can be done by evaluation of edges and adjacent adenopathy. With high resolution transducers ultrasound is better than CT scan or MRI in detection of unsharp borders.
Color Doppler sonography is a promising technique for analyzing the vascularity of the salivary glands and for characterizing pathologic conditions.
Color Doppler sonography help in differentiating pleomorphic adenomas from other salivary gland tumors.

4. A number of color Doppler criteria have been established to distinguish benign and malignant nodules.
US examination can be easily combined with fine needle aspiration cytology (FNAC), further enhancing its ability to differentiate between benign and malignant lesions.
Other benefits of US are easy availability, absent radiation, non-invasive & low cost.

5. Cases

6. Inflammatory Diseases

7. Acute sialadenitis Salivary glands are enlarged and hypoechoic.
US & Doppler appearance
Salivary glands are enlarged and hypoechoic.
They may be inhomogeneous; may contain multiple small, oval, hypoechoic areas.
Increased blood flow.

8. Rana Subhadraben
35Y/F
Rt pre-auricular region swelling&pain-5 Days

9. Chronic Sialadenitis
US & Doppler appearance
Salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous and
Mild or no increase in blood flow.

10. Rathod Durgaprasad
65Y/M
Lt pre-auricular region pain-2 wks

11. Abscess
Abscesses are hypoechoic or anechoic lesions with posterior acoustic enhancement and unclear borders.
Central liquefaction may be distinguished as an avascular area or identified by means of moving debris.
Hyperechoic foci due to microbubbles of gas may be seen within the abscess.

12. Tarakesh Baburam
28Y/M
Rt parotid region pain-20d
Fever

13. Tuberculous parotitis
Parenchymal type of tuberculosis show focal, intraparotid, nearly anechoic zones that might have cavities within them.
In necrotic caseous cavities, no color flow signals can be detected at US, in contrast to most salivary tumors.

14. Vasava Reshmaben
6Y/F
B/L neck & face swelling with fever-3m

15. Non-specific lymphadenitis
Babubhai Ganeshbhai
52Y/M
B/L parotid region pain-2m
Non-specific lymphadenitis

16. Sialolithiasis US & Doppler appearance
For the detection of salivary calculi, ultrasound is the investigation of choice.
On ultrasound stones appear as hyperechoic foci casting posterior acoustic shadowing.

17. Pathan Siddikabanu
42Y/F
Rt SMR pain-6m

18. Rathod Udesingh
52Y/M
Rt SMR pain-4m

19. Benign lymphoepithelial lesion
Benign Lymphoepithelial Parotid Lesions in HIV-Positive patients are nodules that occur in the parotid gland as an early manifestation of HIV infection.
Wide spectrum of sonographic appearances, ranging from simple cysts to mixed masses with predominantly solid components.

20. 50 Y/F
HIV +ve
B/L neck swelling – 3m

21. Pleomorphic adenoma US & Doppler appearance
Appears as a homogeneous, hypoechoic solid mass, usually less than 3cm in size. It is round or oval in shape and well-defined with lobulated margins with posterior acoustic enhancement.
Color Doppler sonography help in differentiating pleomorphic adenoma from other salivary gland tumors. Most pleomorphic adenoma show intermediate (1+ and 2+) grades of vascularity and a peripheral basketlike pattern.
When the pattern of tumor flow signals is peripheral, it could be considered specific enough to aid in diagnosing pleomorphic adenoma.

22. Vasava Ramilaben
35Y/F
Lt parotid region swelling-1y

23. Pathan Memudaben
44Y/F
Rt parotid region swelling-1yr

24. Atypical appearances of pleomorphic adenoma

25. Large & heterogeneous Vasava Ishwarbhai 35Y/M
Lt parotid region swelling -3yr
Large & heterogeneous

27. Macchi Ambubhai
50Y/M
Lt parotid sweling-1Yr
High PSV

28. Parmar Ashokbhai
45y/m
Lt parotid region swelling-10yr
Calcification

29. Warthin’s Tumor
At US, Warthin tumors are oval, hypoechoic, well-defined tumors and often contain multiple anechoic areas.
Show intermediate grade of vascularity and predominant hilar type of distribution.

30. Mali Kailashaben
45Y/F
Rt parotid region-1yr

31. Oncocytoma
Similar to pleomorphic adenoma on ultrasound.

33. Lipoma
Appear as a well-defined, ovoid or elliptical, slightly hypoechoic mass that contains multiple echogenic lines parallel to the skin surface giving a typical striped or feathered appearance.
Shows a good compressibility .
Usually no flow signals are detected with color Doppler examination.

34. Pathan Ismailbhai
48Y/M
Rt parotid-6m

35. Hemangioma
Typically they are heterogeneous hypoechoic lesions with sinusoidal spaces, internal slow flow and phleboliths on ultrasound.

36. Parmar Jignesh
1Y/M
Rt parotid region swelling-6m

37. Cyst

38. Giri Ramaben
45Y/F
Rt parotid region swelling-1m

39. Fatty infiltration
Fatty infiltration causes diffuse, usually bilateral and homogeneous parotid enlargement.
Fatty infiltration can make ultrasound assessment of the parotid difficult due to beam attenuation obscuring deeper parts of the gland.

40. Patel Zarinaben
48Y/F
B/L parotid swelling-1yr
Rt parotid
Lt parotid

41. Plunging ranula
US reveal smooth well delineated thin walled cystic lesion in the floor of mouth in case of simple ranula and extension of this lesion in submandibular space in case of plunging ranula.

42. Vasava Chaturbhai
35Y/M
Rt SM region swelling-1m

43. Malignant tumors
US is the initial modality of choice. The ultrasound distinction of benign and malignant lesions is not precise, but certain features should raise suspicion for malignancy.
These include: if the margin of the lesion is ill-defined, locally invasive, if the mass is in the deep lobe, and if abnormal cervical lymph nodes are present.
Sonographically, the best indication of a malignant nodule is the absence of sharply defined margins.

44. Doppler criteria
Grade of intratumor vascularity-Grade 2/3
Pattern of vascular supply-Mixed
Pulse-wave Doppler findings-PSV >25cm/sec, RI>0.8 and PI>1.8.

45. Parmar Motibhai
80y/m
Lt parotid region swelling-15yr

46. Mucoepidermoid Ca

47. Rathava Chitabhai
64y/m
Rt parotid region swelling-5yr

48. Adenoid Cystic Ca

49. Solanki Mahijibhai
60Y/M
Rt parotid swelling-1yr
Duadruparesis-1m

50. T2W

51. T1W
T2W

52. US-Liver

53. Diagnosis
Squamous cell carcinoma of Rt parotid with multiple vertebral and liver mets

54. Indrasinh Bhailal
48y/m
Rt SM region swelling -1yr

55. Rt SMG squamous cell carcinoma

56. Ajabasingh
52y/M
B/L parotid regn-6m
NHL

57. Parapharyngeal malignancy with involvement of Rt parotid
Bhaliya Dalubhai
50Y/M
Lt parotid region-1yr
Parapharyngeal malignancy with involvement of Rt parotid

58. THANK YOU