Sonography of Major Salivary Glands

  • Andreas Knopf


Major salivary glands represent a melting pot of inflammatory, neoplastic, and dysontogenetic diseases. Diagnostic approaches are of major clinical impact to achieve both sufficient radicality of epithelial malignancy and a minimum of functional loss in benign lesions. Whereas B-mode ultrasound demonstrates high sensitivity and specificity in the identification of sialolithiasis, B-mode ultrasound and color-coded duplex sonography fail to reliably distinguish inflammatory and neoplastic conditions. Recent advances in elastography increased precision of diagnostic regimens in inflammatory conditions but require great personal expertise. Modern diagnostic algorithms including elastography and contrast-enhanced ultrasound result in significantly higher precision in the identification of glandular malignancy. However, complex algorithms are not part of the daily ultrasonographic routine, and detailed anamnesis and clinical examination remain mandatory in these cases.


Sialadenitis Sjögren’s syndrome Sialolithiasis Salivary gland tumor Pleomorphic adenoma Warthin’s tumor Salivary gland carcinoma Parotid gland metastasis 


  1. 1.
    Hofauer B, Chaker A, Strenger T, Bas M, Mansour N, Knopf A. Swelling of the submandibular and parotid glands: a description of possible differential diagnoses. HNO. 2016;64:333–48. German.CrossRefGoogle Scholar
  2. 2.
    Knopf A, Szyper M, Mansour N, Sonnenberg J, Hofauer B, Niedermeyer H. A critical review of 20 years of parotid gland surgery. Acta Otolaryngol. 2016;136:711–6.CrossRefGoogle Scholar
  3. 3.
    Knopf A, Cortolezis N, Bas M, Mansour N, Hofauer B. Multimodal ultrasonographic algorithm in the differentiation of submandibular masses. Acta Otolaryngol. 2017;137:640–5.CrossRefGoogle Scholar
  4. 4.
    Zengel P, Schrotzlmair F, Reichel C, Paprottka P, Clevert DA. Sonography: the leading diagnostic tool for diseases of the salivary glands. Semin Ultrasound CT MR. 2013;34:196–203.CrossRefGoogle Scholar
  5. 5.
    Lee YY, Wong KT, King AD, Ahuja AT. Imaging of salivary gland tumours. Eur J Radiol. 2008;66:419–36.CrossRefGoogle Scholar
  6. 6.
    Christe A, Waldherr C, Hallett R, Zbaeren P, Thoeny H. MR imaging of parotid tumors: typical lesion characteristics in MR imaging improve discrimination between benign and malignant disease. AJNR Am J Neuroradiol. 2011;32:1202–7.CrossRefGoogle Scholar
  7. 7.
    Milic VD, Petrovic RR, Boricic IV, Marinkovic-Eric J, Radunovic GL, Jeremic PD, et al. Diagnostic value of salivary gland ultrasonographic scoring system in primary Sjögren’s syndrome: a comparison with scintigraphy and biopsy. J Rheumatol. 2009;36:1495–500.CrossRefGoogle Scholar
  8. 8.
    Cornec D, Jousse-Joulin S, Saraux A, Devauchelle-Pensec V. Salivary gland ultrasound to diagnose Sjögren’s syndrome: a claim to standardize the procedure. Rheumatology (Oxford). 2015;54:199–200.CrossRefGoogle Scholar
  9. 9.
    Rudack C, Jörg S, Kloska S, Stoll W, Thiede O. Neither MRI, CT nor US is superior to diagnose tumors in the salivary glands--an extended case study. Head Face Med. 2007;3:19.CrossRefGoogle Scholar
  10. 10.
    de Ru JA, van Leeuwen MS, van Benthem PP, Velthuis BK, Sie-Go DM, Hordijk GJ. Do magnetic resonance imaging and ultrasound add anything to the preoperative workup of parotid gland tumors? J Oral Maxillofac Surg. 2007;65:945–52.CrossRefGoogle Scholar
  11. 11.
    Knopf A, Bas M, Chaker A, Strassen U, Pickhard A, Stark T, et al. Rheumatic disorders affecting the head and neck: underestimated diseases. Rheumatology (Oxford). 2011;50:2029–34.CrossRefGoogle Scholar
  12. 12.
    Lakshmi NM, Azeem Mohiyuddin SM, Mohammadi K, Devnikar AV, Prasad KN. Parotid abscess in children – a tertiary rural hospital experience. Int J Pediatr Otorhinolaryngol. 2015;79:1988–90.CrossRefGoogle Scholar
  13. 13.
    Terraz S, Poletti PA, Dulguerov P, Dfouni N, Becker CD, Marchal F, Becker M. How reliable is sonography in the assessment of sialolithiasis? AJR Am J Roentgenol. 2013;201:W104–9.CrossRefGoogle Scholar
  14. 14.
    Francis CL, Larsen CG. Pediatric sialadenitis. Otolaryngol Clin N Am. 2014;47:763–78.CrossRefGoogle Scholar
  15. 15.
    Wilson KF, Meier JD, Ward PD. Salivary gland disorders. Am Fam Physician. 2014;89:882–8.PubMedGoogle Scholar
  16. 16.
    Hofauer B, Chaker A, Thurmel K, Knopf A. Manifestations of autoimmune disorders in otorhinolaryngology: classical symptoms and diagnostic approach. HNO. 2017;65:695–708.CrossRefGoogle Scholar
  17. 17.
    Knopf A, Hofauer B, Thürmel K, Meier R, Stock K, Bas M, Manour N. Diagnostic utility of Acoustic Radiation Force Impulse (ARFI) imaging in primary Sjoegren’s syndrome. Eur Radiol. 2015;25:3027–34.CrossRefGoogle Scholar
  18. 18.
    Knopf A, Lahmer T, Chaker A, Stark T, Hofauer B, Pickhard A, et al. Head and neck sarcoidosis, from wait and see to tumor necrosis factor alpha therapy: a pilot study. Head Neck. 2013;35:715–9.CrossRefGoogle Scholar
  19. 19.
    Carsons S. A review and update of Sjögren’s syndrome: manifestations, diagnosis, and treatment. Am J Manag Care. 2001;7:S433–43.PubMedGoogle Scholar
  20. 20.
    Patel R, Shahane A. The epidemiology of Sjögren’s syndrome. Clin Epidemiol. 2014;6:247–55.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Makula E, Pokorny G, Rajtar M, Kiss I, Kovacs A, Kovacs L. Parotid gland ultrasonography as a diagnostic tool in primary Sjögren’s syndrome. Br J Rheumatol. 1996;35:972–7.CrossRefGoogle Scholar
  22. 22.
    Makula E, Pokorny G, Kiss M, Voros E, Kovacs L, Kovacs A, et al. The place of magnetic resonance and ultrasonographic examinations of the parotid gland in the diagnosis and follow-up of primary Sjögren’s syndrome. Rheumatology (Oxford). 2000;39:97–104.CrossRefGoogle Scholar
  23. 23.
    Hocevar A, Ambrozic A, Rozman B, Kveder T, Tomsic M. Ultrasonographic changes of major salivary glands in primary Sjögren’s syndrome. Diagnostic value of a novel scoring system. Rheumatology (Oxford). 2005;44:768–72.CrossRefGoogle Scholar
  24. 24.
    Hofauer B, Mansour N, Heiser C, Gahleitner C, Thuermel K, Bas M, Knopf A. Sonoelastographic modalities in the evaluation of salivary gland characteristics in Sjögren’s syndrome. Ultrasound Med Biol. 2016;42:2130–9.CrossRefGoogle Scholar
  25. 25.
    Mansour N, Hofauer B, Knopf A. Ultrasound elastography in diffuse and focal parotid gland lesions. ORL J Otorhinolaryngol Relat Spec. 2017;79:54–64.CrossRefGoogle Scholar
  26. 26.
    Hofauer B, Mansour N, Heiser C, Wirth M, Strassen U, Loeffelbein D, et al. Reproducibility of Acoustic Radiation Force Impulse imaging in thyroid and salivary glands with experienced and inexperienced examiners. Ultrasound Med Biol. 2016;42:2545–52.CrossRefGoogle Scholar
  27. 27.
    Mulholland GB, Jeffery CC, Satija P, Cote DW. Immunoglobulin G4-related diseases in the head and neck: a systematic review. J Otolaryngol Head Neck Surg. 2015;44:24.CrossRefGoogle Scholar
  28. 28.
    Hamano H, Kawa S, Horiuchi A, Unno H, Furuya N, Akamatsu T, et al. High serum IgG4 concentrations in patients with sclerosing pancreatitis. N Engl J Med. 2001;344:732–8.CrossRefGoogle Scholar
  29. 29.
    Kleger A, Seufferlein T, Wagner M, Tannapfel A, Hoffmann TK, Mayerle J. IgG4-related autoimmune diseases: polymorphous presentation complicates diagnosis and treatment. Dtsch Arztebl Int. 2015;112:128–35.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid Cancer. Thyroid. 2016;26:1–133.CrossRefGoogle Scholar
  31. 31.
    Epstein JB, Thariat J, Bensadoun RJ, Barasch A, Murphy BA, Kolnick L, et al. Oral complications of cancer and cancer therapy: from cancer treatment to survivorship. CA Cancer J Clin. 2012;62:400–22.CrossRefGoogle Scholar
  32. 32.
    Baum BJ, Bodner L, Fox PC, Izutsu KT, Pizzo PA, Wright WE. Therapy-induced dysfunction of salivary glands: implications for oral health. Spec Care Dentist. 1985;5:274–7.CrossRefGoogle Scholar
  33. 33.
    Lee HN, An JY, Lee KM, Kim EJ, Choi WS, Kim DY. Salivary gland dysfunction after radioactive iodine (I-131) therapy in patients following total thyroidectomy: emphasis on radioactive iodine therapy dose. Clin Imaging. 2015;39:396–400.CrossRefGoogle Scholar
  34. 34.
    Jeong SH, Hong HS, Lee EH. Diagnostic utility of acoustic structure quantification for evaluation of radiation sialadenitis after radioactive iodine therapy. Ultrasound Med Biol. 2016;42:2553–61.CrossRefGoogle Scholar
  35. 35.
    Badea AF, Tamas SA, Ciuleanu E, Chioreanu I, Baciut G, Lupsor PM, Badea R. ARFI quantitative elastography of the submandibular glands. Normal measurements and the diagnosis value of the method in radiation submaxillitis. Med Ultrason. 2013;15:173–9.CrossRefGoogle Scholar
  36. 36.
    Badea I, Tamas-Szora A, Chiorean I, Crisan M, Ciuleanu E, Baciut G, Badea M. Acoustic Radiation Force Impulse quantitative elastography: a new noninvasive technique for the evaluation of parotid glands. A preliminary study in controls and in patients with irradiated nasopharyngeal carcinoma. Med Ultrason. 2015;17:308–14.CrossRefGoogle Scholar
  37. 37.
    Zengel P, Reichel CA, Vincek T, Clevert DA. Ultrasound elastography in diagnosis and follow-up for patients with chronic recurrent parotitis. Clin Hemorheol Microcirc. 2017;67:389–97.CrossRefGoogle Scholar
  38. 38.
    Sanan A, Cognetti DM. Rare parotid gland diseases. Otolaryngol Clin N Am. 2016;49:489–500.CrossRefGoogle Scholar
  39. 39.
    Koch M, Iro H, Zenk J. Stenosis and other non-sialolithiasis-related obstructions of the major salivary gland ducts. Modern treatment concepts. HNO. 2010;58:218–24.CrossRefGoogle Scholar
  40. 40.
    Zenk J, Iro H, Klintworth N, Lell M. Diagnostic imaging in sialadenitis. Oral Maxillofac Surg Clin North Am. 2009;21:275–92.CrossRefGoogle Scholar
  41. 41.
    Katz P, Hartl DM, Guerre A. Clinical ultrasound of the salivary glands. Otolaryngol Clin N Am. 2009;42:973–1000.CrossRefGoogle Scholar
  42. 42.
    Zengel P, Schrotzlmair F, Schwarz F, Paprottka P, Kramer M, Berghaus A, Clevert DA. Elastography: a new diagnostic tool for evaluation of obstructive diseases of the salivary glands; primary results. Clin Hemorheol Microcirc. 2012;50:91–9.PubMedGoogle Scholar
  43. 43.
    Zengel P, Berghaus A, Weiler C, Reiser M, Clevert DA. Intraductally applied contrast-enhanced ultrasound (IA-CEUS) for evaluating obstructive disease and secretory dysfunction of the salivary glands. Eur Radiol. 2011;21:1339–48.CrossRefGoogle Scholar
  44. 44.
    Vinayachandran D, Sankarapandian S. Salivary duct cyst: histo-pathologic correlation. J Clin Imaging Sci. 2013;3:3.CrossRefGoogle Scholar
  45. 45.
    Dumitriu D, Dudea SM, Botar-Jid C, Baciut G. Ultrasonographic and sonoelastographic features of pleomorphic adenomas of the salivary glands. Med Ultrason. 2010;12:175–83.PubMedGoogle Scholar
  46. 46.
    Pinkston JA, Cole P. Incidence rates of salivary gland tumors: results from a population-based study. Otolaryngol Head Neck Surg. 1999;120:834–40.CrossRefGoogle Scholar
  47. 47.
    Biorklund A, Eneroth CM. Management of parotid gland neoplasms. Am J Otolaryngol. 1980;1:155–67.CrossRefGoogle Scholar
  48. 48.
    Drivas EI, Skoulakis CE, Symvoulakism EK, Bizaki AG, Lachanas VA, Bizakis JG. Pattern of parotid gland tumors on Crete, Greece: a retrospective study of 131 cases. Med Sci Monit. 2007;13:CR136–40.PubMedGoogle Scholar
  49. 49.
    Seifert G, Hennings K, Caselitz J. Metastatic tumors to the parotid and submandibular glands--analysis and differential diagnosis of 108 cases. Pathol Res Pract. 1986;181:684–92.CrossRefGoogle Scholar
  50. 50.
    Bialek EJ, Jakubowski W, Zajkowski P, Szopinski KT, Osmolski A. US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls. Radiographics. 2006;26:745–63.CrossRefGoogle Scholar
  51. 51.
    Bialek EJ, Jakubowski W, Karpinska G. Role of ultrasonography in diagnosis and differentiation of pleomorphic adenomas: work in progress. Arch Otolaryngol Head Neck Surg. 2003;129:929–33.CrossRefGoogle Scholar
  52. 52.
    Knopf A, Mansour N, Chaker A, Bas M, Stock K. Multimodal ultrasonographic characterisation of parotid gland lesions--a pilot study. Eur J Radiol. 2012;81:3300–5.CrossRefGoogle Scholar
  53. 53.
    Mansour N, Stock KF, Chaker A, Bas M, Knopf A. Evaluation of parotid gland lesions with standard ultrasound, color duplex sonography, sonoelastography, and acoustic radiation force impulse imaging – a pilot study. Ultraschall Med. 2012;33:283–8.CrossRefGoogle Scholar
  54. 54.
    Mansour N, Bas M, Stock KF, Strassen U, Hofauer B, Knopf A. Multimodal ultrasonographic pathway of parotid gland lesions. Ultraschall Med. 2017;38:166–73.PubMedGoogle Scholar
  55. 55.
    Klintworth N, Mantsopoulos K, Zenk J, Psychogios G, Iro H, Bozzato A. Sonoelastography of parotid gland tumours: initial experience and identification of characteristic patterns. Eur Radiol. 2012;22:947–56.CrossRefGoogle Scholar
  56. 56.
    Matsuzuka T, Suzuki M, Saijo S, Ikeda M, Matsui T, Nomoto Y, et al. Stiffness of salivary gland and tumor measured by new ultrasonic techniques: virtual touch quantification and IQ. Auris Nasus Larynx. 2015;42:128–33.CrossRefGoogle Scholar
  57. 57.
    Mantsopoulos K, Koch M, Klintworth N, Zenk J, Iro H. Evolution and changing trends in surgery for benign parotid tumors. Laryngoscope. 2015;125:122–7.CrossRefGoogle Scholar
  58. 58.
    Knopf A, Heiser C, Karasoy O, Hofauer B, Bier H, Mansour N. Bipolar dissection technique in parotid gland surgery. Acta Otolaryngol. 2017;137:1210–4.CrossRefGoogle Scholar
  59. 59.
    Teymoortash A, Werner JA, Moll R. Is Warthin’s tumour of the parotid gland a lymph node disease? Histopathology. 2011;59:143–5.CrossRefGoogle Scholar
  60. 60.
    Teymoortash A, Werner JA. Tissue that has lost its track: Warthin’s tumour. Virchows Arch. 2005;446:585–8.CrossRefGoogle Scholar
  61. 61.
    Seifert G, Bull HG, Donath K. Histologic subclassification of the cystadenolymphoma of the parotid gland. Analysis of 275 cases. Virchows Arch A Pathol Anat Histol. 1980;388:13–38.CrossRefGoogle Scholar
  62. 62.
    Strassen U, Hofauer B, Jacobi C, Knopf A. Management of locoregional recurrence in cutaneous squamous cell carcinoma of the head and neck. Eur Arch Otorhinolaryngol. 2017;274:501–6.CrossRefGoogle Scholar
  63. 63.
    Knopf A, Bas M, Hofauer B, Mansour N, Stark T. Clinicopathological characteristics of head and neck Merkel cell carcinomas. Head Neck. 2017;39:92–7.CrossRefGoogle Scholar
  64. 64.
    Franzen A, Buchali A, Lieder A. The rising incidence of parotid metastases: our experience from four decades of parotid gland surgery. Acta Otorhinolaryngol Ital. 2017;37:264–9.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Bradley PJ. Frequency and histopathology by site, major pathologies, symptoms and signs of salivary gland neoplasms. Adv Otorhinolaryngol. 2016;78:9–16.PubMedGoogle Scholar
  66. 66.
    Zengel P, Notter F, Reichel CA, Clevert DA. Does Virtual Touch IQ elastography help to improve the preoperative diagnosis of parotid tumors: a prospective trial. Clin Hemorheol Microcirc. 2017;67:425–34.CrossRefGoogle Scholar
  67. 67.
    Badea AF, Bran S, Tamas-Szora A, Floares A, Badea R, Baciut G. Solid parotid tumors: an individual and integrative analysis of various ultrasonographic criteria. A prospective and observational study. Med Ultrason. 2013;15:289–98.CrossRefGoogle Scholar
  68. 68.
    Abdel Razek AA, Ashmalla GA, Gaballa G, Nada N. Pilot study of ultrasound parotid imaging reporting and data system (PIRADS): inter-observer agreement. Eur J Radiol. 2015;84:2533–8.CrossRefGoogle Scholar
  69. 69.
    Wei X, Li Y, Zhang S, Li X, Wang H, Yong X, et al. Evaluation of microvascularization in focal salivary gland lesions by contrast-enhanced ultrasonography (CEUS) and Color Doppler sonography. Clin Hemorheol Microcirc. 2013;54:259–71.PubMedGoogle Scholar
  70. 70.
    Ambrosetti A, Zanotti R, Pattaro C, Lenzi L, Chilosi M, Caramaschi P, et al. Most cases of primary salivary mucosa-associated lymphoid tissue lymphoma are associated either with Sjoegren syndrome or hepatitis C virus infection. Br J Haematol. 2004;126:43–9.CrossRefGoogle Scholar
  71. 71.
    Kassan SS. Immunogenetics of Sjögren’s syndrome. Ann Med Interne (Paris). 1998;149:45–8.Google Scholar
  72. 72.
    D’Souza AR, Uppal HS, De R, Zeitoun H. Updating concepts of first branchial cleft defects: a literature review. Int J Pediatr Otorhinolaryngol. 2002;62:103–9.CrossRefGoogle Scholar
  73. 73.
    Gahleitner C, Scherer E, Knopf A. A specific type of cyst. HNO. 2013;61:958–60.CrossRefGoogle Scholar
  74. 74.
    Sun RW, Tuchin VV, Zharov VP, Galanzha EI, Richter GT. Current status, pitfalls and future directions in the diagnosis and therapy of lymphatic malformation. J Biophotonics. 2017. [Epub ahead of print].CrossRefGoogle Scholar
  75. 75.
    Guneyli S, Ceylan N, Bayraktaroglu S, Gucenmez S, Aksu K, Kocacelebi K, et al. Imaging findings of pulmonary granulomatosis with polyangiitis (Wegener’s granulomatosis): lesions invading the pulmonary fissure, pleura or diaphragm mimicking malignancy. Wien Klin Wochenschr. 2016;128:809–15.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Andreas Knopf
    • 1
  1. 1.Department of Otorhinolaryngology–Head and Neck SurgeryUniversity of FreiburgFreiburgGermany

Personalised recommendations