(Fig.8).8). Sublingual vein - drains into the lingual vein and then internal jugular vein. Diagnostic imaging has a major impact on sorting out these possibilities and thereby significantly altering medical decision making in a high percentage of patients. Although rare within the head and neck, dermoid and epidermoid cysts have a predilection for the oral cavity, specifically the floor of the mouth [8]. Pathology Causes Obstruction sialolithiasis submandibular duct stenosis (e.g. Capps EF, Kinsella JJ, Gupta M, et al. Referred to as a plunging ranula, the herniated portion leaves behind a band-like portion of the cyst within the sublingual space, forming the tail sign (Fig. Most commonly diagnosed with CT, key findings include skin thickening, fat stranding and enhancement of fascial planes [18]. Agarwal AK, Kanekar SG. The arrow points to the tumor in the hilum. US may be used to determine whether there is ductal dilatation or stones or an abscess. The same is true of manifestations of human immunodeficiency virus (HIV) infection. Chronic sialadenitis due to the stone inside the accessory duct of Imaging of the sublingual and submandibular spaces Google Scholar, Odeh M, Bronshtein M, Bornstein J (2017) Congenital absence of salivary glands in fetuses with trisomy 21. Yilmaz MD, Yucel A, Derekoy S, et al. To accurately measure the volume of normal human parotid and submandibular glands, establish the normal values of the volumes of the glands, and apply the technique in the diagnosis of swollen salivary glands of the patients with IgG4-related sialadenitis. Moreover, all of the major salivary glands are not studied and other regional anatomy including the cervical lymph nodes and lacrimal glands are not as simply studied as in a comprehensive head and neck imaging examination than with CT and MRI. Such studies are no longer done for this purpose. Three patients illustrating that benign and malignant disease within the submandibular gland (SMG) may have a relatively nonaggressive morphologic appearance. Some of the distinguishing features are derived from their unique histological composition. Patel, S., Bhatt, A.A. FIGURE 182.1. Imaging plays a role in identifying airway patency, drainable collections and evidence of gas-forming bacteria. Dimensions of the submandibular glands were: anterior-posterior length, 35 +/- 5.7 mm; paramandibular extension to gland depth, 14.3 +/- 5.7 mm; extension in frontal scanning, 33.7 +/- 5.4 mm. Ozturk M, Yorulmaz I, Gunet E, et al. Radiology 216:1929. An official website of the United States government. As the lesion enlarges, areas of haemorrhage and cystic necrotic changes may develop, thus altering the classic imaging appearance [13]. Simple ranula. DH: Patient 3. The plunging ranula likely enters the SMS through the gap in the mylohyoid muscle anteriorly and inferiorly (arrowhead). The submandibular glands are the second largest of the three main salivary glandsabout the size of a walnut. Axial contrast-enhanced CT images at the level of the submandibular gland demonstrate two well-circumscribed calcifications in the distal right submandibular duct (a, arrow). Clinical examination of an acutely infected SMG/SMS may be limited by severe pain and toughness of the cervical fascia attachment to the mandible as well as the mandible itself. https://doi.org/10.3322/caac.21389, Kato H, Kanematsu M, Goto H et al (2012) Mucosa-associated lymphoid tissue lymphoma of the salivary glands: MR imaging findings including diffusion-weighted imaging. These changes extend posteriorly into bilateral parapharyngeal spaces, pharyngeal mucosa, and inferiorly along the anterior neck (b). AJNR Am J Neuroradiol 27:22142216, PubMed PMC The deep portion of the submandibular gland wraps around the posterior edge of the mylohyoid muscle, so a small part of the gland is cranial to the muscle in the sublingual space. Yousem DM, Chalian AA. An accessory parotid gland was present in 68% of patients, with a mean angle of confluence of its tributary duct with the parotid duct of 53. 5.9). 14, 15, and 16) [18, 28]. The mylohyoid muscle is traditionally depicted as a continuous muscular sling formed from two halves that join at the fibrous median raphe. Google Scholar, Jayasuriya NSS, Siriwardena S, Tilakaratne WM et al (2017) Malignant transformation of a long-standing submental dermoid cyst to a carcinosarcoma: a case report. Slow-flow lesions consist of lymphatic, venous and venolymphatic networks, while high-flow lesions exploit an arteriovenous communication. The important anatomic relationships of the SMG that impact medical decision making in benign and malignant tumors of the gland and SMS are reviewed in Chapter 175 and summarized here. It is a mixed gland that secretes both mucus as well as serous but predominantly serous secretion in the body. What are the boundaries of the submandibular space? Congenital cystic neck masses: embryology and imaging appearances, with clinicopathological correlation. Eur J Radiol 81:612617, White DK, Davidson HC, Harnsberger HR et al (2001) Accessory salivary tissue in the mylohyoid boutonniere: a clinical and radiologic pseudolesion of the oral cavity. (NOTE: The patients symptoms resolved on antibiotics.) Submandibular gland surgery is slightly different compared to parotid surgery as the submandibular area contains different neurovascular structures. Pediatric Radiology Normal Measurements | OHSU Contrast-enhanced computed tomography (CT) shows a well-circumscribed, surgically proven benign mixed tumor. Oral Maxillofac Surg Clin North Am. a Axial T2-weighted and b T1-weighted MR images of the sublingual space demonstrate a lobulated high T2 signal and low T1 signal lesion enlarging and distorting the left sublingual gland (arrow). FIGURE 181.3. MRI in particular can serve to assess the size, content, location and extent of the lesion, especially in preoperative planning [13]. A patient with pain and tenderness in the right submandibular region. The image in (D) demonstrates a fluid density mass occupying the SMS mainly posterior to the floor of the mouth and displacing the SMG (arrow) posteriorly. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. In (E), the axial section shows an additional area of possible connection with the floor of the mouth through an anatomic gap in the mylohyoid muscle (arrow) as it is in its more normal state on the opposite side transmitting a somewhat enlarged vein (arrowhead). MeSH Such expensive studies may not be necessary if the mass is discrete and freely mobile. On MRI, signal patterns depend on vessel size and range from hyperintense venous lakes to more solid appearing lesions that are isointense to muscle on T2-weighted imaging. Among the differential diagnosis of cystic lesions in the sublingual space, a ranula is a commonly acquired lesion (Table 2). Salivary stones (sialoliths) represent calcium concretions, most commonly within the submandibular ductal system, owing to the relatively higher calcium and phosphate salt concentrations of the glands secretions [21]. A: Ultrasound shows a lobulated mass within the submandibular gland (arrowheads) lying external to the mylohyoid muscle (arrow). The dimension of ductal system visualization added by MR sialography is typically not of enough critical value in cases of acute inflammation to supplant CT. MRI in particular can serve to assess the size, content, location and extent of the lesion, especially in preoperative planning [13]. I have gone through your MRI (magnetic resonance imaging) scans, I do not find any suspicious lesions or activities. a Conventional sialogram demonstrates multiple filling defects within Whartons (submandibular) duct, consistent with sialoliths. SUBMANDIBULAR GLAND DUCT - Sumer's Radiology Blog A significant proportion of these are dental infections (discussed in detail in Chapter 97). Many submandibular gland (SMG) and submandibular space (SMS) inflammatory conditions do not come to imaging. Simple ranula. Isr Med Assoc J 19:1214, Srinivasan A, Moyer JS, Mukherji SK (2006) Unilateral submandibular gland aplasia associated with ipsilateral sublingual gland hypertrophy. These lesions can be classified into congenital, infectious/inflammatory, vascular and neoplastic processes. Using US as a starting point is a very good approach, but only in experienced hands. On rare occasions, it can also extend into the parapharyngeal space or upper cervical soft tissues [16]. Clinical presentation is usually sufficient in diagnosis without imaging assistance [1]. Imaging can evaluate cervical metastasis in patients with a submandibular gland cancer. This leads to the variety of possible histologic diagnoses discussed in Chapter 22. I: Patient 4, also with a ranula presenting as an SMS mass (arrow) with a small component in the floor of the mouth. 2012 May;24(2):295-305, x. doi: 10.1016/j.coms.2012.01.005. The submandibular glands are about the size of a walnut or about 2 inches or 5cm with a weight of approximately 15 grams and are responsible for producing about 70% of the total saliva in the body. However, predicting in advance whether a mass is benign or malignant most often does not alter the initial, usually surgical, approach to care (Fig. Contrast-enhanced computed tomography (CT) in (A) and (B) show marked enhancement of the SMG (arrows) and very extensive edema around the gland (arrowheads). This review article discusses the relevant anatomy, clinical highlights and the characteristic imaging features of the various pathologies that occur within the sublingual and submandibular spaces. C: A third stone is present in the more proximal ductal system at the point where the main duct branches into the even more proximal intraglandular ductal system (arrowhead), and there is dilatation of the branching ducts within the gland (arrow). 2015 Jul 21;17(1):186. doi: 10.1186/s13075-015-0698-y. a Axial and b coronal contrast-enhanced CT images demonstrate an enhancing well-circumscribed round mass within the inferior aspect of the right submandibular gland (arrow). FH: Magnetic resonance (MR) sialography in Patient 2 to demonstrate the appearance of dilated ductal systems as seen on that examination. FOIA Characteristic appearance is that of a non-enhancing multiloculated cystic lesion with fluid-fluid levels without phleboliths [18]. Bilaterally Swollen and Painless Submandibular Glands: Do They Matter B: The stone is still present, and a second stone is impacted within the ductal system (arrow). True dermoid cysts (also known as benign cystic teratomas), epidermoid cysts and teratoid cysts represent a spectrum of congenital and acquired cystic malformations sharing the common characteristic of a squamous epithelial lining. A steady state image may be included that allows for MR depiction of the ductal system, sometimes referred to as MR sialography. PubMed Score: 4.4/5 (9 votes) . On MRI, signal patterns depend on vessel size and range from hyperintense venous lakes to more solid appearing lesions that are isointense to muscle on T2-weighted imaging. The right submandibular gland showed swelling with no tenderness, and the palpation was softer than the normal submandibular gland. Early changes are better delineated on MRI, with loss of homogenous high signal on T2-weighted images or rupture of the fibrous capsule [22]. Parotid glands, located below your ears. B, C: Patient 2. Radionuclide studies are not used routinely for the evaluation of SMG masses. Exact aetiology remains unknown; however, the condition has been attributed to first and second branchial arch abnormalities. Submandibular gland enlargement | Radiology Reference Article Specific magnetic resonance (MR) protocols for various indications appear in Appendix B. MRI should be done with 3- to 4-mm sections and a field of view of 12 to 16 cm. AE: Patient 1. Curr Probl Diagn Radiol 43:5567. Malignant lesions within this region typically represent invasive squamous cell carcinoma originating in the mucosa of the floor of the mouth or the relatively rare primary salivary gland neoplasms, most commonly adenoid cystic carcinoma in submandibular gland and mucoepidermoid carcinoma in the parotid gland. B: Cellulitis is still noted (arrowheads) and seen to be due to inflammatory sialoadenitis related to obstruction by a stone. 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