40-year-old woman with upper neck pain

Images

Doctor's Information

Name : Makhtoum
Family : Shahnazi
Affiliation :Radiology Department, Loghman Hakim Hospital,SBMU
Academic Degree : Assistant Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Mohammad Ali karimi

Case Section

Head&Neck

Patient's Information

Gender : Female
Age : 40

Clinical Summary

40-year-old woman with upper neck pain worsening at mealtimes

Imaging Findings

Ultrasound images demonstrate enlarged hypoechoic and relatively hypervascular right submandibular gland with a stone (8mm) in the dilated Wharton's duct. Note the normal appearance of left submandibular gland in the first image.

Differential Diagnosis

• Acalculous sialadenitis: There is no detectable stone and/or dilated duct.
• Lymphadenopathy: Submandibular gland is intact in the absence of sialoadenitis.
• Tumors: Benign mixed tumor appears an distinct intraglandular mass, while carcinoma usually has infiltrating borders
• Metastases: Often from known primary tumors (mainly squamous cell carcinoma or non-Hodgkin lymphoma).
• Mandibular osteomyelitis: History of tooth decay and infection.

Final Diagnosiss

Sialadenitis due to sialolithiasis

Discussion (Related Text)

Salivary gland calculi most commonly occur in the submandibular glands because of thick and more mucinous content of submandibular secretions and upward courses of Wharton's duct. Most calculi (85%) occur in Wharton's duct while the remainder (15%) are found within the gland or at the ductal hilum. The accuracy of ultrasound in assessment of sialolithiasis is 90-96 %. Even non-opaque stones can be detected. On ultrasound stones appear as hyperechoic foci casting posterior acoustic shadowing. Small stones (less than 2 mm) are difficult to identify since the absence of posterior shadow. Indirect signs like ductal dilatations or inflammatory changes may be found. Ultrasound can also assess the complications of calculi, e.g. sialadenitis, sialocele, abscess and in chronic circumstances gland atrophy. In acute sialadenitis the gland appears enlarged and hypoechoic on ultrasound. Abscesses are seen as ill-defined hypoechoic foci, with intraglandular ducts passing through the lesion as opposed to ductal displacement, which would favour tumour. There may be adjacent regional lympadenopathy.

References

1. Alyas F, Lewis K, Williams M, Moody AB, Wong KT, Ahuja AT, et al. Diseases of the submandibular gland as demonstrated using high resolution ultrasound. Br J Radiol. 2005 ;78(928):362-9.
2. Ching AS, Ahuja AT, King AD, Tse GM, Metreweli C. Comparison of the sonographic features of acalculous and calculous submandibular sialadenitis. J Clin Ultrasound. 2001;29(6):332-8.