Figure 1
CT after iodinated contrast injection
Enlarged submandibular gland with intraglandular ductal dilatation.
Trismus and pain in the neck in a 28-year-old man
SectionHead & neck imaging
Case TypeClinical Cases
AuthorsAinhoa Viteri Jusué, MD., M. Asunción Fariña Sarasqueta, MD.
Connected authors
28 years, male
Clinical History
A 28-year-old man presented with trismus and pain in his mouth and neck, refractory to amoxicillin and anti-inflammatory drugs. A firm, rounded 5 cm right submandibular mass was the only remarkable finding on his physical examination. He was febrile and the leukocyte count and RCP levels were elevated.
Imaging Findings
Clinicians suspected a cervical abscess and requested a computed tomography (CT) examination.
CT after iodinated contrast injection showed an enlarged submandibular gland with intraglandular ductal dilatation (Fig. 1). A fluid-filled tubular structure with enhancing walls was visible in the floor of the mouth, next to a 15 mm long calcium-density image (Fig. 2).
CT after iodinated contrast injection showed an enlarged submandibular gland with intraglandular ductal dilatation (Fig. 1). A fluid-filled tubular structure with enhancing walls was visible in the floor of the mouth, next to a 15 mm long calcium-density image (Fig. 2).
Discussion
Background and Clinical Perspective:
Sialolithiasis is the presence of concrements inside the ducts or parenchyma of the salivary glands and usually affects the submandibular glands and their ducts [1]. Typical presentation of sialolithiasis includes swelling and pain that worsen with eating. The two most important complications of sialolithiasis are sialadenitis and sialocele.
Bacterial sialadenitis occurs due to ascending infection of the submandibular duct and the salivary gland [2].
Sialocele is the formation of a saliva cyst in the obstructed main salivary duct.
Imaging perspective:
The two most important complications of sialolithiasis were present in this case: sialocele and sialoadenitis.
Most lithiasis are radio-opaque and can be seen on plain film. However, in the emergency setting, ultrasound and/or CT are preferred to diagnose or rule out the suspected complications [1].
CT findings of sialadenitis comprise enlargement of the affected gland, intraglandular ductal dilatation, and enhancement of duct walls after contrast administration.
Sialocele is easily diagnosed at CT and consists of a cystic lesion along the sublingual space.
Differential diagnosis:
In this case, the differential diagnosis included infected cystic masses of the oral cavity and neck. The location in the sublingual space and the presence of sialolithiasis were the key findings. Other entities were discarded for the following reasons:
- ranula: also cystic and appearing in the sublingual-submandibular space, its shape is lenticular (simple ranula) or comet-shaped with the "tail sign" (double ranula). Only displays thick, enhancing walls when infected.
- cervical abscess: the presence of the sialolithiasis is the key. Also, abscess walls are usually thicker.
- epidermoid cysts in the sublingual space: again, the presence of the sialolithiasis and the location at Wharton´s duct are the key. Otherwise, epidermoid cysts may mimic other cystic conditions.
- infected thyroglossal duct cyst: typically located in the midline and embedded in infrahyoid strap muscles.
- second branchial cleft cysts: typically located posterolateral to submandibular gland.
Outcome:
In this case, resolution of the acute episode was achieved with antibiotics and anti-inflammatory drugs. Occasionally, surgical removal of the lithiasis is necessary. Alternatives include endoscopic stone removal and extracorporal sialolithotripsy.
Sialolithiasis is the presence of concrements inside the ducts or parenchyma of the salivary glands and usually affects the submandibular glands and their ducts [1]. Typical presentation of sialolithiasis includes swelling and pain that worsen with eating. The two most important complications of sialolithiasis are sialadenitis and sialocele.
Bacterial sialadenitis occurs due to ascending infection of the submandibular duct and the salivary gland [2].
Sialocele is the formation of a saliva cyst in the obstructed main salivary duct.
Imaging perspective:
The two most important complications of sialolithiasis were present in this case: sialocele and sialoadenitis.
Most lithiasis are radio-opaque and can be seen on plain film. However, in the emergency setting, ultrasound and/or CT are preferred to diagnose or rule out the suspected complications [1].
CT findings of sialadenitis comprise enlargement of the affected gland, intraglandular ductal dilatation, and enhancement of duct walls after contrast administration.
Sialocele is easily diagnosed at CT and consists of a cystic lesion along the sublingual space.
Differential diagnosis:
In this case, the differential diagnosis included infected cystic masses of the oral cavity and neck. The location in the sublingual space and the presence of sialolithiasis were the key findings. Other entities were discarded for the following reasons:
- ranula: also cystic and appearing in the sublingual-submandibular space, its shape is lenticular (simple ranula) or comet-shaped with the "tail sign" (double ranula). Only displays thick, enhancing walls when infected.
- cervical abscess: the presence of the sialolithiasis is the key. Also, abscess walls are usually thicker.
- epidermoid cysts in the sublingual space: again, the presence of the sialolithiasis and the location at Wharton´s duct are the key. Otherwise, epidermoid cysts may mimic other cystic conditions.
- infected thyroglossal duct cyst: typically located in the midline and embedded in infrahyoid strap muscles.
- second branchial cleft cysts: typically located posterolateral to submandibular gland.
Outcome:
In this case, resolution of the acute episode was achieved with antibiotics and anti-inflammatory drugs. Occasionally, surgical removal of the lithiasis is necessary. Alternatives include endoscopic stone removal and extracorporal sialolithotripsy.
Differential Diagnosis List
Sialoadenitis and sialocele secondary to sialolithiasis at Wharton's duct.
Infected ranula
Cervical abscess
Thyroglossal duct cyst
Second branchial cleft cyst
Epidermoid cyst
Final Diagnosis
Sialoadenitis and sialocele secondary to sialolithiasis at Wharton's duct.
Case information
| URL: | https://www.eurorad.org/case/12333 |
| DOI: | 10.1594/EURORAD/CASE.12333 |
| ISSN: | 1563-4086 |
Figure 2
CT after iodinated contrast injection
A fluid-filled tubular structure with enhancing walls was visible in the floor of the mouth, next to a 15 mm long calcium-density image.
CT after iodinated contrast injection
Enlarged submandibular gland with intraglandular ductal dilatation.
Radiology Department. Hospital Universitario Basurto. Bilbao, Spain.
Radiology Department. Hospital Universitario Basurto. Bilbao, Spain.
CT after iodinated contrast injection
A fluid-filled tubular structure with enhancing walls was visible in the floor of the mouth, next to a 15 mm long calcium-density image.
Radiology Department. Hospital Universitario Basurto. Bilbao, Spain.
Radiology Department. Hospital Universitario Basurto. Bilbao, Spain.