Introduction: Cheek/Buccal ultrasound examination is a high-resolution imaging technique used to assess the soft tissue structures of the cheek, including the buccinator muscle, parotid duct, minor salivary glands, and adjacent fat planes, for detecting inflammatory, cystic, vascular, traumatic, or neoplastic conditions.
Contents (Topic-wise)
Patient preparation and positioning
Patient can be examined in a seated or supine position with the head slightly turned toward the opposite side. Ask the patient to relax the jaw. For intraoral assessment, instruct the patient to open the mouth and gently retract the cheek if needed.
Settings
Select a superficial preset with high frequency and low-to-medium penetration. Adjust the focal zone at the level of interest. Reduce gain to minimize noise. Use compound imaging and tissue harmonic imaging if available for better lesion characterization.
Documentation
Save representative images in both transverse and longitudinal planes. Record color/power Doppler clips for vascularity. Apply calipers for lesion measurements (length × width × depth). Note the precise anatomical location (e.g., 2 cm anterior to the tragus at mid-buccal level).
Procedure guidance
Ultrasound can guide fine-needle aspiration cytology (FNAC), biopsy, or abscess drainage. An in-plane needle approach is preferred for real-time visualization of the needle and surrounding structures to avoid vascular injury.
Acute bacterial sialadenitis
Ultrasound findings: The gland is enlarged and diffusely hypoechoic to heterogeneous due to oedema. Color/power Doppler commonly shows increased vascularity (hyperemia). Ductal dilatation may be present and an echogenic intraductal focus with posterior shadowing suggests an obstructing sialolith. If abscess has formed, expect a focal complex fluid collection with internal echoes, septations, irregular walls and peripheral hyperemia; possible mobile debris on real-time scanning.
Clinical correlation: Presents with acute pain, swelling, fever, erythema and tenderness of the preauricular/cheek region; symptoms often worsen with meals. Predisposing factors include dehydration, recent surgery or intubation, poor oral hygiene, duct obstruction and systemic illness. Ultrasound helps distinguish cellulitis/edema from drainable abscess and can guide aspiration or drainage.
Management notes: Correlate with clinical exam and start appropriate antibiotics and supportive measures (hydration, sialogogues, gland massage). Perform ultrasound-guided aspiration/drainage if collection is identified. Consider sialendoscopy for obstructing stones.
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Viral parotitis (e.g., mumps, HIV, influenza)
Ultrasound findings: Diffuse, bilateral (often) gland enlargement with relatively homogeneous hypoechoic change reflecting interstitial oedema. The gland margins remain smooth; focal fluid collections are uncommon. Color Doppler may show mild to moderate increased flow early in the inflammatory phase but typically less focal hyperemia than bacterial infection. No discrete abscess unless superinfected.
Clinical correlation: Systemic viral prodrome (fever, malaise, myalgia) and often bilateral swelling (classic for mumps). Pain is usually milder than bacterial infection; orchitis/parotitis associations may be present (mumps). Consider immune status (HIV) or recent viral illness. Ultrasound mainly excludes abscess or obstructive causes.
Management notes: Supportive care (analgesia, hydration, sialogogues). Reserve antibiotics only if bacterial superinfection is suspected. Follow up with ultrasound if symptoms fail to resolve or if focal collections develop.
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Chronic recurrent parotitis (children & adults)
Ultrasound findings: The gland demonstrates heterogeneous echotexture with multiple small hypoechoic or anechoic foci representing sialectasis (ductal ectasia) and microcystic change. There may be focal scarring, lobulated contours, and occasional intraductal echogenic foci (stones or inspissated secretions). During acute flares, increased vascularity and transient enlargement occur.
Clinical correlation: Recurrent painful swelling episodes with or without systemic features; often triggered by meals. In children it is commonly idiopathic; in adults consider obstructive aetiologies, previous infection, or autoimmune overlap. Correlate with history of recurrent episodes and response to treatment.
Management notes: Conservative therapy between attacks (oral hygiene, sialogogues), antibiotics for flares, and interventional options such as sialendoscopy with ductal clearance or dilation for refractory cases. Ultrasound is useful for monitoring progression and guiding intervention.
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Autoimmune sialadenitis (e.g., Sjögren’s syndrome, IgG4-related disease)
Ultrasound findings: Characteristic heterogeneous, coarse echotexture with multiple small, scattered hypoechoic areas or cystic spaces (punctate or larger), sometimes described as a "snowstorm" or "honeycomb" pattern in Sjögren’s. In later stages the gland may be atrophic and echogenic from fatty replacement. IgG4-related sialadenitis often shows diffuse gland enlargement with nodular or hypoechoic regions and may have increased vascularity on Doppler.
Clinical correlation: Xerostomia, dry eyes, systemic autoimmune features (arthralgia, fatigue); in IgG4 disease there may be multisystem involvement (pancreas, bile ducts). Serologic tests (anti-Ro/La, serum IgG4) and minor salivary gland biopsy assist diagnosis. Ultrasound helps stage disease and target biopsy sites.
Management notes: Refer to rheumatology; manage symptoms (saliva substitutes, cholinergic agents). In suspected IgG4 disease consider steroid therapy after multidisciplinary assessment. Use ultrasound for follow-up and to guide biopsy if focal nodules require histology.
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Granulomatous sialadenitis (tuberculosis, sarcoidosis, actinomycosis)
Ultrasound findings: Focal or multifocal hypoechoic nodules or rounded lesions within or adjacent to the gland; lesions may have irregular margins and heterogeneous internal echoes. Caseating granulomas (TB) can cavitate and form fluid collections or sinus tracts; calcifications may be seen in chronic disease. Regional lymphadenopathy with matting or necrosis may be present. Doppler patterns vary from minimal to increased peri-lesional flow.
Clinical correlation: Consider granulomatous causes with chronic indolent swelling, systemic symptoms (weight loss, fever, night sweats in TB), or multisystem involvement (sarcoid). History of exposure or endemic risk for TB/actinomyces and lack of response to routine antibiotics increases suspicion. Tissue sampling (FNAC/biopsy) and microbiology/mycobacterial studies are often required.
Management notes: Targeted microbiology/culture and histology are essential. Anti-tubercular therapy for confirmed TB; specific therapy for actinomycosis or sarcoidosis per specialist guidance. Use ultrasound to guide needle biopsy or drainage of cavitary lesions.
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Abscess / phlegmon
Ultrasound findings: Abscess appears as a localized complex fluid collection with heterogeneous internal echoes, septations, and irregular walls. Compression may show echogenic debris movement; posterior enhancement is common. Surrounding soft tissue oedema and marked peripheral hyperemia on color Doppler are typical. Phlegmon appears as ill-defined hypoechoic, non-encapsulated tissue infiltration without a discrete drainable cavity.
Clinical correlation: Severe, focal pain with erythema, fluctuance (sometimes), fever and raised inflammatory markers. Abscess may complicate bacterial sialadenitis or traumatic/foreign-body infection. Rapid progression or airway compromise requires urgent attention.
Management notes: Prompt ultrasound-guided aspiration or surgical drainage combined with broad-spectrum antibiotics. Image guidance reduces complication risk and helps confirm adequate evacuation. Re-scan after drainage to confirm resolution.
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Suppurative parotitis
Ultrasound findings: Features overlap with acute bacterial sialadenitis and abscess. Diffuse gland enlargement with heterogeneous echotexture, increased intraglandular vascularity on Doppler in the inflammatory phase, and potential focal collections consistent with suppuration. Gas-forming organisms may produce echogenic foci with dirty shadowing or reverberation. Regional lymphadenopathy and overlying soft tissue oedema are common.
Clinical correlation: Rapid onset severe pain, high fever, purulent discharge from Stensen’s duct, and systemic toxicity are classic. Risk factors include dehydration, immunosuppression, postoperative state and poor oral hygiene. If not treated promptly, it can progress to Ludwig’s angina or systemic sepsis.
Management notes: Urgent broad-spectrum IV antibiotics, supportive care, hydration and consideration of immediate drainage for collections. Coordinate with ENT/maxillofacial surgery for airway assessment and operative management if required. Use ultrasound for monitoring and guiding interventions.
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Sialolithiasis (stones) in Stensen’s duct / intraglandular
Ultrasound findings: Echogenic foci within the duct or gland parenchyma with posterior acoustic shadowing are classic. Stones may be intraductal (along the expected course of Stensen’s duct) or intraglandular within dilated ductules. Upstream ductal dilatation and proximal gland enlargement are frequently seen. Small stones may produce only subtle shadowing or reverberation; dynamic compression and graded scanning (longitudinal + transverse) help localize the calculus. Color/power Doppler typically shows periductal hyperemia when there is secondary inflammation.
Clinical correlation: Patients present with episodic painful swelling of the gland—often meal-related—reduced salivary flow and sometimes purulent discharge from the duct. A history of prior duct manipulation, dehydration or thickened secretions can predispose to stone formation. Plain radiography may detect radiopaque stones, but ultrasound is superior for radiolucent material and for assessing dilatation and associated inflammation.
Management notes: Small distal stones may be milked out manually or removed via sialendoscopy. Stones causing obstruction with recurrent infection often require endoscopic retrieval or surgical removal. Treat superimposed infection with antibiotics and consider ultrasound-guided aspiration if an associated collection is present. Document stone size, exact location (distance from oral orifice), degree of ductal dilatation and presence of inflammatory change for surgical planning.
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Sialodochitis (ductal inflammation)
Ultrasound findings: Thickening of the duct wall, irregular ductal lumen, and variable ductal dilatation are typical. Intraluminal debris (echoic mobile material) or mucous plugs may be visualized. Periductal soft tissue edema and increased vascularity on color/power Doppler suggest active inflammation. When chronic, scarring and multifocal strictures may produce a beaded appearance of the duct.
Clinical correlation: Presents with pain and swelling localized to the duct distribution, often aggravated by meals. Patients may report intermittent drainage of viscid saliva or transient relief after ductal expression. Causes include infection, obstruction by small stones or mucus, autoimmune disease and post-procedural inflammation.
Management notes: Conservative measures (hydration, sialogogues, gland massage) and antibiotics for bacterial exacerbations. Sialendoscopy allows direct visualisation, clearance of debris and balloon dilatation of strictures. Ultrasound is useful for monitoring ductal calibre, detecting residual debris and guiding therapeutic decisions.
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Ductal strictures / stenosis
Ultrasound findings: Segmental narrowing of the duct with proximal (prestenotic) dilatation is the hallmark. On transverse and longitudinal scans the stenotic segment appears as a narrowed lumen often with upstream tubular anechoic dilatation. Chronic strictures may show wall fibrosis and lack of normal compressibility. Secondary intraductal debris or small calculi may be present. Color Doppler is usually non-contributory for the stricture itself but may show adjacent inflammatory hyperemia if present.
Clinical correlation: Strictures cause persistent obstructive symptoms—recurrent painful swelling, reduced saliva flow and predisposition to recurrent sialadenitis. Etiologies include prior trauma, surgical injury, inflammatory scarring, radiation or chronic ductal inflammation.
Management notes: Endoscopic assessment with sialendoscopy is often both diagnostic and therapeutic (balloon dilatation, stent placement). Surgical repair is reserved for refractory or complex strictures. Ultrasound documents the level and degree of obstruction and helps follow response after dilatation or surgery.
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Post-traumatic ductal disruption → Sialocele
Ultrasound findings: A sialocele appears as a well-defined anechoic or complex fluid collection in the para-parotid or cheek soft tissues that may communicate with the ductal system. Collections can be unilocular or multiloculated and may contain internal echoes if infected or mixed with blood/debris. Real-time scanning may show movement of fluid or communication tract; use graded compression to assess compressibility. Surrounding inflammatory changes and peripheral hyperemia suggest secondary infection.
Clinical correlation: Often follows facial trauma, surgical injury or iatrogenic duct damage. Patients present with a fluctuant swelling that may increase with salivary stimulation (e.g., meals). A history of recent trauma, biopsy, or facial surgery raises suspicion for ductal disruption.
Management notes: Initial management includes aspiration for diagnostic relief and to reduce tension; confirm saliva content (amylase). Persistent sialoceles may require pressure dressings, repeated aspiration, botulinum toxin injection to reduce salivary secretion, or definitive surgical repair of the duct and excision of the sialocele. Ultrasound guides aspiration and monitors resolution or recurrence.
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Ranula (plunging / extension) involving parotid tail
Ultrasound findings: A ranula is usually a unilocular anechoic cystic lesion with thin walls and posterior acoustic enhancement arising from the floor of mouth (sublingual gland) that can dissect through the mylohyoid into the submandibular or para-pharyngeal spaces (plunging ranula). When extension reaches the para-parotid or parotid tail region it appears as a simple anechoic or mildly complex cystic mass tracking along fascial planes without intrinsic vascularity. Internal septations or debris may be present if infected or hemorrhagic. Correlate with intraoral exam to identify the primary sublingual origin.
Clinical correlation: Presents with floor-of-mouth swelling and an external neck or cheek mass when plunging occurs. Patients may report fluctuant swelling that increases with salivation. History of prior minor trauma or ductal rupture may be elicited.
Management notes: Definitive treatment commonly involves excision of the sublingual gland (the source) with evacuation of the cyst; simple aspiration or marsupialization alone may have high recurrence. For plunging ranula with parotid/para-parotid extension, surgical planning should account for the path of extension and relationship to the parotid tail; ultrasound aids in mapping the lesion and guiding safe drainage if urgent decompression is required. ENT/maxillofacial consultation is recommended for operative management.
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Simple parotid cysts
Ultrasound findings: Well-defined, anechoic, round or ovoid lesions with thin imperceptible walls and posterior acoustic enhancement. No internal septations, nodules, or internal vascularity on color/power Doppler. Compressible with graded probe pressure and typically show simple cyst behavior on real-time scanning.
Clinical correlation: Often asymptomatic and discovered incidentally. When large, may present as a palpable, fluctuant mass in the preauricular or parotid tail region. No systemic signs unless secondarily infected. Correlate with duration, growth rate and any history of trauma or prior intervention.
Management notes: Document size, location (intra- vs extra-parenchymal), and relation to adjacent structures. Simple cysts without suspicious features generally require conservative management or clinical follow-up. Atypical features (internal echoes, mural nodules, septations, or vascularity) warrant further imaging (MRI) or FNAC/biopsy to exclude neoplasm or infected cyst.
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Retention cysts (ductal)
Ultrasound findings: Tubular or rounded anechoic to hypoechoic dilated duct segments with thin walls; may appear multiloculated if multiple ductules are involved. Often contiguous with a visible dilated Stensen’s duct. No internal vascularity; mild periductal edema or hyperemia may be present if inflamed.
Clinical correlation: Associated with ductal obstruction (small stones, strictures, mucus plugs) causing intermittent swelling and discomfort, typically meal-related. Patients may report transient relief after manual expression of saliva. Differentiate from extravasation cysts by demonstration of continuity with ductal system.
Management notes: Treat underlying cause (clear obstruction via sialendoscopy, stone removal or dilation). Aspiration gives temporary relief but recurrence is common if obstruction persists. Ultrasound documents communication with duct and monitors response after interventions.
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Extravasation pseudocysts
Ultrasound findings: Unilocular or multilocular anechoic to complex fluid collection located in soft tissues adjacent to the gland (subcutaneous, para-parotid or submandibular spaces). Walls may be ill-defined; internal debris or septations can appear if chronic or secondarily infected. Typically no true epithelial lining (hence pseudocyst) and lack intrinsic vascularity.
Clinical correlation: Commonly result from ductal rupture or trauma with leakage of saliva into surrounding tissues producing a fluctuating swelling (may increase with salivation). History often includes preceding trauma, surgery, or ductal manipulation.
Management notes: Diagnostic aspiration often yields saliva (high amylase). Conservative measures (compression, repeated aspiration) may be attempted initially; persistent lesions often need surgical excision of the pseudocyst and repair of ductal defect or ligation. Ultrasound is useful to map extent and guide aspiration or surgical planning.
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Lymphoepithelial cysts (HIV, congenital)
Ultrasound findings: Typically multiple, well-circumscribed cystic lesions within the parotid or periparotid tissue; may be uni- or multilocular with thin septations. Cysts are anechoic or contain low-level internal echoes. Surrounding gland may show heterogeneous echo pattern if associated with lymphoid hyperplasia. Little to no internal vascularity within the cysts; nodes may show preserved fatty hilum unless involved.
Clinical correlation: Strongly associated with HIV infection (benign lymphoepithelial cysts) and may present as bilateral parotid swelling. Congenital cystic lymphoepithelial lesions can occur in children. Consider HIV testing if multiple cystic parotid lesions are identified without other explanation.
Management notes: Correlate with serology and clinical findings. Asymptomatic lesions may be observed; symptomatic or cosmetically concerning lesions can be managed by surgical excision or superficial parotidectomy. FNAC may aid diagnosis but risks fistula/recurrence—use selectively. Ultrasound is valuable for surveillance and for guiding safe biopsy if required.
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First / Second Branchial Cleft Cysts (esp. parotid tail region)
Ultrasound findings: Well-defined unilocular or multilocular cystic masses situated at characteristic locations — along the preauricular, parotid tail, or anterior to the sternocleidomastoid (second cleft). Cysts are anechoic or contain internal septa/debris if infected; may track along fistulous tracts. Relationship to the parotid tail and course relative to the facial nerve should be assessed with complementary imaging (CT/MRI) for surgical planning.
Clinical correlation: Present as congenital or developmental masses that may become apparent in childhood or later; can become infected or drain externally via sinus/fistula. Recurrent swelling or discharge in the preauricular/upper neck region suggests branchial cleft anomaly.
Management notes: Definitive treatment is surgical excision, often requiring careful dissection near the facial nerve and parotid tissue. Avoid simple aspiration as recurrence and infection are common. Ultrasound helps in initial diagnosis and mapping, but cross-sectional imaging (CT/MRI) is often required to define full anatomical extent and fistulous tracts prior to surgery.
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Dermoid / epidermoid cysts (rare)
Ultrasound findings: Variable appearance — epidermoid cysts are commonly well-defined, hypoechoic to heterogeneous with internal echogenic keratinaceous debris and may show a characteristic “onion-skin” layering; dermoid cysts can demonstrate mixed echogenicity with fat components and calcified Rokitansky protuberances. No internal vascularity; posterior enhancement may be present. If infected, wall thickening and internal echoes increase.
Clinical correlation: Usually slow-growing, painless masses in the parotid tail or adjacent soft tissues. May become symptomatic if infected or large. Consider in differential for cystic preauricular/parotid lesions, especially in younger patients or when fatty components are suspected.
Management notes: Surgical excision is recommended for diagnosis and prevention of recurrence or infection. Preoperative imaging with ultrasound supplemented by MRI is helpful to identify fat or calcified components and to plan safe excision while preserving facial nerve function. FNAC is often non-diagnostic and may risk rupture/inflammation, so use cautiously.
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Pleomorphic adenoma (most common)
Ultrasound findings: Typically a well-defined, ovoid or lobulated hypoechoic to heterogeneous solid mass with smooth or gently lobulated margins. May show mixed echotexture due to myxoid and chondroid areas. Small lesions are often homogeneous; larger lesions can be heterogeneous with calcification or cystic degeneration. Internal vascularity is usually present but relatively low to moderate on color/power Doppler.
Clinical correlation: Painless, slow-growing preauricular or parotid tail mass in adults. Most common benign parotid tumor. Longstanding lesions may become larger and occasionally undergo malignant transformation (carcinoma ex pleomorphic adenoma).
Management notes: Surgical excision (superficial parotidectomy or extracapsular dissection depending on location and size) with preservation of facial nerve. Preoperative FNAC / core biopsy aids diagnosis but may be inconclusive; ultrasound guides FNAC. Document size, depth, relation to facial nerve and deep lobe extension for operative planning. MRI may be used for complex or deep lesions.
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Warthin’s tumor (adenolymphoma)
Ultrasound findings: Well-circumscribed, often multilobulated lesion that can be cystic, solid or mixed. Characteristic features include internal cystic spaces with low-level echoes and papillary projections; sometimes multiple lesions bilaterally. Moderate internal vascularity may be evident on Doppler, often peripheral or septal. Echogenic intralesional debris and septations are common.
Clinical correlation: Typically occurs in older male smokers; may present as a slow-growing painless parotid mass. Bilateral or multifocal presentations are more common than with pleomorphic adenoma.
Management notes: Surgical excision (superficial parotidectomy) is typical for symptomatic or enlarging lesions. FNAC is often diagnostic (cystic debris + oncocytic cells and lymphoid background). Ultrasound helps map multifocality and guide biopsy of cystic components.
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Oncocytoma
Ultrasound findings: Usually a well-defined, solid, hypoechoic to isoechoic mass; may show homogeneous echotexture. Vascularity can be variable—some show marked internal flow due to rich capillary network. Lesions are often solitary and compact without cystic change.
Clinical correlation: Occurs in middle-aged to older adults and presents as a painless parotid lump. Oncocytomas are benign but can mimic other solid neoplasms clinically and on imaging.
Management notes: Surgical excision recommended both for diagnosis and treatment. FNAC may suggest oncocytic features but definitive diagnosis usually requires histopathology. Preoperative imaging (US, MRI) evaluates extent and deep lobe involvement.
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Lipoma
Ultrasound findings: Well-defined, compressible, hypoechoic to isoechoic lesion with fine linear internal echoes reflecting fat striations; may demonstrate characteristic increased echogenicity relative to muscle. Usually avascular on color Doppler. Shape is often ovoid and located in superficial soft tissue or within the parotid.
Clinical correlation: Soft, mobile, painless mass; slow growing. Clinical suspicion for lipoma is high when lesion is soft and non-tender.
Management notes: Conservative management for asymptomatic lesions. Excision if symptomatic or for cosmetic reasons; ultrasound helps plan incision and define relationship to facial nerve and parotid capsule. MRI may better characterise fat content when uncertain.
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Hemangioma (common in children; vascular with Doppler flow)
Ultrasound findings: In infants, hemangiomas appear as well-defined or lobulated heterogeneous masses with multiple tubular/cavernous vascular channels. High flow signals are present on color Doppler with low-resistance arterial waveforms on spectral Doppler during proliferative phase. Phases may show varying echotexture (more echogenic with involution).
Clinical correlation: Presents in infancy or early childhood as a rapidly enlarging, often bluish preauricular/parotid mass. Can cause cosmetic deformity or functional issues (feeding, airway) depending on size and location.
Management notes: Many infantile hemangiomas involute; treatment decisions depend on symptom severity. Propranolol is first-line medical therapy for problematic hemangiomas. Interventional radiology (embolization) or surgery reserved for refractory or complicated cases. Ultrasound monitors flow, size, and response to therapy.
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Lymphangioma / cystic hygroma
Ultrasound findings: Multiloculated, cystic, thin-walled lesions with internal septations and fluid levels. Lesion content is typically anechoic but may contain low-level echoes if proteinaceous. No intrinsic arterial flow, although peripheral vascularity may be present. Lesions often infiltrate along fascial planes and can extend into deep neck spaces.
Clinical correlation: Congenital lesions presenting in infancy or childhood as soft, compressible masses that may enlarge with infection or hemorrhage. Can cause mass effect or airway compromise depending on extent.
Management notes: Sclerotherapy (OK-432, doxycycline, bleomycin) or surgical excision depending on extent and involvement. Ultrasound guides aspiration and sclerotherapy and maps extent for surgical planning. MRI is useful to delineate deep extension.
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Neurogenic tumors (schwannoma, neurofibroma)
Ultrasound findings: Well-defined, oval to fusiform solid masses that may be hypoechoic or heterogeneous. Schwannomas often show eccentric location relative to nerve and may contain cystic degeneration; neurofibromas can be more infiltrative. Doppler signal is usually minimal to moderate. A characteristic “target” appearance may be seen on cross-section with central echogenicity and peripheral hypoechoic rim (better appreciated on MRI).
Clinical correlation: Painless, slow-growing mass; may be associated with nerve palsy or sensory symptoms if large. Consider neurofibromatosis history for multiple lesions.
Management notes: Surgical excision is typical but may require nerve sacrifice or reconstruction if tumor involves major facial nerve branches. Preoperative imaging (MR) and careful mapping with ultrasound are essential. FNAC can be helpful but may be non-diagnostic—core biopsy or excision often required for definitive histology.
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Basal cell adenoma
Ultrasound findings: Well-circumscribed, homogeneous, solid lesion that is typically hypoechoic to isoechoic. Margins are smooth and internal vascularity is variable but usually modest. Rare cystic degeneration may be present.
Clinical correlation: Benign epithelial tumour occurring in middle-aged to older adults, presenting as a slow-growing painless mass in the parotid region.
Management notes: Surgical excision with attention to facial nerve preservation. Preoperative FNAC and ultrasound help distinguish from other solid parotid tumours; MRI may assist when deep lobe or perineural spread is a concern.
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Myoepithelioma
Ultrasound findings: Solid, well-defined or ill-defined mass with variable echotexture — hypoechoic, heterogeneous, or occasionally cystic areas. Vascularity on color Doppler ranges from scant to moderate. Imaging appearance often overlaps with pleomorphic adenoma and other epithelial tumours.
Clinical correlation: Presents as a painless parotid lump; can occur across adult age groups. May be benign or show malignant behavior (myoepithelial carcinoma) — rapid growth, pain or facial nerve involvement raises concern.
Management notes: Surgical excision with histopathological examination required for definitive diagnosis. FNAC/biopsy can guide preoperative planning but may not reliably distinguish subtypes. MRI helps assess deep lobe extension and perineural invasion if suspected.
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Mucoepidermoid carcinoma (most common malignant)
Ultrasound findings: Variable appearance depending on grade — low-grade lesions may be partially cystic with internal septations and low-level echoes, while higher-grade tumours are solid, heterogeneous and poorly defined. Ill-defined margins, infiltration into adjacent fat or muscle, and irregular vascularity on color/power Doppler (moderate to marked) raise suspicion for malignancy. Regional lymphadenopathy may be present.
Clinical correlation: Presents as a progressively enlarging parotid mass; pain, facial nerve dysfunction or rapid growth suggest higher grade. Age and clinical tempo vary; correlate with history of prior benign lesion or recent change in a longstanding lump.
Management notes: Urgent tissue diagnosis (FNAC/core biopsy) and cross-sectional staging (MRI/CT) are required. Management typically involves surgical resection (parotidectomy with facial nerve preservation where possible) and neck dissection if nodal disease. Adjuvant radiotherapy is used for high-grade lesions, positive margins, or perineural/vascular invasion. Multidisciplinary oncologic follow-up is essential.
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Adenoid cystic carcinoma (perineural spread)
Ultrasound findings: Solid, often ill-defined lesion with heterogeneous echotexture. Perineural tumour extension may be suggested by elongation or thickening along expected nerve pathways and by loss of normal fascial planes; however, perineural spread is better demonstrated on MRI. Color Doppler may show variable internal vascularity. Small satellite nodules and regional nodes are less common than with other carcinomas.
Clinical correlation: Classically presents with slow but relentless growth and pain or early facial nerve symptoms due to perineural invasion. Consider in patients with persistent pain, paraesthesia or nerve palsy even when mass is small.
Management notes: Wide surgical excision with attention to margins and nerve involvement; adjuvant radiotherapy is frequently recommended because of high risk of perineural and local recurrence. MRI with dedicated skull base/perineural protocol is important for preoperative mapping. Long-term surveillance is necessary due to late recurrences.
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Acinic cell carcinoma
Ultrasound findings: Usually a well-defined to partially lobulated solid mass that may be homogeneous or heterogeneously echogenic. Cystic degeneration can occur. Internal vascularity is variable but often present on color Doppler. Deep-lobe tumours may be difficult to fully visualize from an external approach.
Clinical correlation: Often presents in adults as a slow-growing painless parotid mass; generally lower-grade behaviour but can recur or metastasize. Clinical suspicion increases with growth or pain.
Management notes: Surgical parotidectomy with histologic assessment; selective neck dissection when nodal disease suspected. Postoperative radiotherapy considered for adverse histologic features. Ultrasound assists in FNAC guidance and postoperative surveillance.
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Carcinoma ex pleomorphic adenoma
Ultrasound findings: A malignant transformation within a preexisting pleomorphic adenoma often appears as a complex mass with irregular or infiltrative margins, heterogeneous echotexture, focal solid nodules within a previously cystic/benign-appearing lesion, and increased internal vascularity. Rapid growth or new areas of invasion on serial imaging are suspicious.
Clinical correlation: History of a long-standing stable parotid lump with recent rapid enlargement, pain or facial nerve changes suggests malignant transformation. Older patients and prior incomplete excision increase risk.
Management notes: Prompt tissue diagnosis (core biopsy or excision) and staging imaging (MRI/CT). Management usually requires total parotidectomy with facial nerve management and often neck dissection and adjuvant radiotherapy depending on histologic grade and margins.
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Squamous cell carcinoma
Ultrasound findings: Usually a solid, irregular, hypoechoic mass with infiltrative margins and often necrotic areas; central necrosis may create complex cystic components. Marked peripheral or internal vascularity and suspicious regional lymphadenopathy with loss of fatty hilum and necrosis are common when metastatic from cutaneous primaries.
Clinical correlation: Frequently represents metastasis from cutaneous squamous cell carcinoma of the head and neck (especially in elderly patients) rather than primary parotid origin. Look for a skin primary or regional mucosal primary and correlate with clinical exam.
Management notes: Workup includes biopsy of the parotid lesion and search for primary tumour (dermatologic and ENT evaluation). Management often requires surgery (parotidectomy ± neck dissection) and adjuvant radiotherapy/chemoradiation based on stage. Ultrasound is useful for guided biopsy and nodal surveillance.
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Salivary duct carcinoma
Ultrasound findings: Aggressive solid mass, often poorly defined and heterogeneous with areas of necrosis and irregular internal vascularity on color Doppler. May show rapid growth and early nodal metastases. Imaging appearance may mimic high-grade ductal carcinomas of other organs.
Clinical correlation: Presents as rapidly enlarging painful mass, sometimes with facial nerve palsy. Tends to behave aggressively with propensity for regional and distant metastasis, occurring more often in older adults.
Management notes: Early aggressive management with wide surgical resection (total parotidectomy ± neck dissection) and postoperative radiotherapy is commonly recommended. Systemic therapy considered for metastatic disease. Multimodality oncology input is required.
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Undifferentiated carcinoma
Ultrasound findings: Highly variable but often appears as a large, poorly marginated, highly heterogeneous mass with necrosis and marked internal vascularity; rapid growth between studies is typical. Extensive adjacent tissue invasion and suspicious nodes are common.
Clinical correlation: Presents with rapid enlargement, pain, skin invasion or facial nerve dysfunction. Histology shows poorly differentiated cells—aggressive clinical course is common.
Management notes: Prompt biopsy and staging. Treatment usually requires extensive surgery, radiotherapy and systemic therapy as indicated. Palliative approaches considered for advanced unresectable disease. Ultrasound helps in biopsy guidance and short-interval monitoring.
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Primary parotid lymphoma
Ultrasound findings: Typically presents as a hypoechoic, homogeneous, sometimes multilobulated mass or diffuse gland enlargement. Lesions may be relatively avascular or show mild vascularity on color Doppler. Multiple parotid and peri-parotid nodal masses can be seen. Preservation of gland architecture in some cases helps suggest lymphomatous infiltration.
Clinical correlation: Presents as painless gland enlargement; may be associated with systemic B symptoms or Sjögren’s syndrome. Rapid bilateral enlargement can occur. Consider lymphoma in the differential for diffuse parotid swelling, particularly in immunocompromised patients.
Management notes: Tissue diagnosis (core biopsy or excisional biopsy of accessible node) is essential and treatment is primarily non-surgical (chemotherapy ± radiotherapy) guided by histologic subtype. Ultrasound assists in guided core biopsy and staging of nodal disease.
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Metastases (skin cancers, head & neck primaries)
Ultrasound findings: Metastatic deposits are usually solid, irregular, and may show central necrosis producing complex cystic areas. Multiple nodules and abnormal regional lymph nodes (rounded, absent hilum, necrotic centers) are common. Vascularity may be increased peripherally.
Clinical correlation: Frequently seen from cutaneous squamous cell carcinoma or melanoma of the scalp/face, and other head & neck primaries. A history of skin cancer or mucosal tumour should prompt careful parotid evaluation. Metastases may present as new parotid mass or nodal enlargement.
Management notes: Biopsy to confirm metastatic histology and search for a primary lesion. Treatment is dictated by primary site and stage—surgery (parotidectomy ± neck dissection), radiotherapy and systemic therapy as appropriate. Ultrasound guides biopsy of suspicious nodes and monitors treatment response.
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Rhabdomyosarcoma (children)
Ultrasound findings: In children, rhabdomyosarcoma presents as a solid, often heterogeneous and rapidly enlarging mass. Areas of necrosis and cystic degeneration may be present; increased vascularity is common on Doppler. Lesions can invade adjacent soft tissues and bone.
Clinical correlation: Rapidly progressive painless swelling in a child, sometimes with facial nerve involvement or overlying skin changes. Systemic signs may be absent early. Consider rhabdomyosarcoma in the differential for aggressive pediatric parotid/soft tissue tumours.
Management notes: Urgent tissue diagnosis and staging (MRI, CT chest for metastasis) are required. Multimodal therapy (surgery, multi-agent chemotherapy and radiotherapy) is the mainstay. Ultrasound is valuable for initial assessment, biopsy guidance, and short-term treatment monitoring.
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Venous malformations
Ultrasound findings: Typically present as multilobulated, compressible, hypoechoic to heterogeneous lesions with internal phleboliths (echogenic foci with posterior shadowing) when chronic. Slow-flow channels are seen on color/power Doppler as patchy, low-velocity flow; spectral Doppler demonstrates low-velocity venous waveforms when sampled. Lesions often expand with Valsalva or dependency and may show slow filling on dynamic imaging.
Clinical correlation: Congenital or early-life lesions that present as soft, non-pulsatile, bluish or compressible swellings which may enlarge with exertion or puberty. Pain, recurrent thrombosis, or cosmetic concern are common reasons for presentation. Phleboliths cause hard palpable foci.
Management notes: Confirm extent with MRI (T2/STIR) for pre-treatment mapping. Treatment options include compression, sclerotherapy (ethanol, STS, doxycycline), and surgical excision for accessible focal lesions. Ultrasound guides sclerotherapy and monitors thrombotic or hemorrhagic complications.
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AV malformations / Hemangiopericytoma (SFT-like lesions)
Ultrasound findings: AV malformations show a tangle of high-flow vascular channels with turbulent, high-velocity signal on color Doppler and low-resistance arterial waveforms on spectral Doppler. Flow may be continuous with arterialized venous channels. Hemangiopericytoma (historically named; often grouped with solitary fibrous tumor spectrum) appears as a well-defined solid mass with marked internal vascularity and large feeding vessels; heterogeneous echotexture with possible necrotic areas in larger tumours.
Clinical correlation: AV malformations present with pulsatile, sometimes warm or bruit-bearing masses and may cause bleeding or high-output symptoms if extensive. Hemangiopericytoma/SFT presents as a painless, vascular mass that may grow and occasionally recur or behave aggressively.
Management notes: High-flow lesions need multidisciplinary care — angiography/CTA for mapping and possible embolization prior to surgery. Surgical excision is indicated for symptomatic SFT/hemangiopericytoma with preoperative vascular control. Ultrasound helps initial assessment and guides referral for vascular imaging and interventional planning.
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Paraganglioma (very rare)
Ultrasound findings: Usually a well-defined, highly vascular solid mass with marked internal color flow and low-resistance arterial waveforms on spectral Doppler. May be lobulated and show flow pulsatility. Lesions can be mistaken for other highly vascular tumours—definitive characterization typically requires cross-sectional imaging (MRI/CT) and nuclear medicine (functional) studies.
Clinical correlation: Rare in the parotid region; consider paraganglioma when a highly vascular mass is present, especially in the region of carotid body, jugular foramen or along cranial nerve paths. Symptoms may include pulsatile tinnitus, cranial neuropathies, or catecholamine-related signs (rare for head & neck paragangliomas).
Management notes: Do not biopsy blindly if paraganglioma suspected because of bleeding risk—refer for MRI/angiography and multidisciplinary vascular/ENT planning. Management may include preoperative embolization and surgical resection or radiotherapy for unresectable lesions. Biochemical testing for catecholamine secretion is recommended if clinically suspected.
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Hematoma (post-trauma)
Ultrasound findings: Appearance depends on age: acute hematomas are heterogeneously hypoechoic to echogenic; subacute lesions become more complex with internal echoes and septations; chronic hematomas may become anechoic or show organized echogenic clot and calcification. No internal vascularity within the clot on color Doppler; surrounding hyperemia may be present early. Compression and serial imaging show evolution/resolution.
Clinical correlation: History of recent trauma, surgery, or invasive procedure. Presents with painful swelling, ecchymosis, and sometimes restricted facial movement. Rapidly expanding hematoma may threaten airway or facial nerve and needs urgent assessment.
Management notes: Small stable hematomas are observed with analgesia and cold compresses; enlarging or symptomatic hematomas may need evacuation. Ultrasound guides aspiration/drainage if liquefied and helps monitor resolution. Evaluate for associated vascular injury or pseudoaneurysm if pulsatile flow or ongoing bleeding suspected.
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Post-radiation sialadenitis
Ultrasound findings: Diffuse gland atrophy with heterogeneous echotexture and increased echogenicity from fatty/fibrotic replacement. Ductal changes, focal areas of scarring, or small cystic areas may be present. Vascularity is often reduced compared with normal gland, though early inflammatory phases may show transient hyperemia.
Clinical correlation: Occurs after therapeutic head & neck irradiation; patients report xerostomia, reduced salivary flow, and sometimes recurrent infections. Onset may be progressive months to years after treatment.
Management notes: Symptomatic management (saliva substitutes, sialogogues if residual function), dental care and prevention of caries. Ultrasound documents chronic changes and guides management of secondary complications (e.g., strictures, sialadenitis). Consider referral for rehabilitation and specialist ENT/dental support.
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Amyloidosis with parotid involvement
Ultrasound findings: Diffuse or focal enlargement with heterogeneous echotexture; small hypoechoic nodules or coarse parenchymal change may be seen. Findings are non-specific; lack of prominent vascularity can be noted. Ultrasound cannot confirm amyloid—histology with Congo red staining is required.
Clinical correlation: May occur with systemic amyloidosis or localised deposits; patients can present with painless gland enlargement and systemic features depending on subtype. Consider in the appropriate clinical setting (cardiac, renal, neuropathic symptoms).
Management notes: Tissue diagnosis (biopsy) is essential. Manage systemic disease per hematology/rheumatology guidance. Ultrasound helps localize target for biopsy and document gland involvement.
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Systemic disease manifestations (HIV, sarcoid, Sjögren’s, IgG4)
Ultrasound findings: Variable depending on disease:
- HIV: Multiple lymphoepithelial cysts or diffuse glandular enlargement with cystic change and intraparotid lymphadenopathy.
- Sarcoidosis: Hypoechoic nodules or diffuse heterogeneous enlargement; associated regional lymphadenopathy may show matting.
- Sjögren’s syndrome: Multiple small hypoechoic or anechoic foci, heterogeneous “honeycomb/snowstorm” appearance, and gland atrophy in advanced disease.
- IgG4-related disease: Diffuse or nodular enlargement, hypoechoic regions, and often increased vascularity; may be multifocal with other salivary or pancreatic involvement.
Clinical correlation: Presentations include xerostomia (Sjögren’s), painless bilateral swelling (HIV-related cysts), systemic symptoms (sarcoid, IgG4) or recurrent infections. A thorough history for autoimmune disease, immunodeficiency, systemic symptoms and medication/radiation history is essential.
Management notes: Direct further workup with serology (anti-Ro/La, serum IgG4), chest imaging (for sarcoid), HIV testing where indicated, and targeted biopsy for histopathology. Management is disease-specific (immunomodulation for Sjögren’s/IgG4, antiretroviral therapy for HIV, steroid/immunosuppressive therapy for sarcoid/IgG4). Ultrasound is useful for surveillance, guiding biopsies, and monitoring response to therapy.
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Reactive (benign) lymphadenopathy
Ultrasound findings: Oval, hypoechoic nodes with preserved central echogenic hilum, maintained hilar vascularity on color Doppler, and cortical thickness usually mild and uniform. Nodes are compressible and show benign features such as a short-axis to long-axis ratio <0.5 in many cases.
Clinical correlation: Associated with nearby infection/inflammation (skin, ear, dental, salivary). Presents with tender or non-tender swelling depending on cause and timing. Usually multiple nodes along the superficial and deep lymphatic chains.
Management notes: Treat underlying infection if present and follow clinically. Ultrasound follow-up to document resolution; consider FNAC if nodes persist, enlarge, or lose benign features.
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Metastatic lymphadenopathy (cutaneous/head & neck primaries)
Ultrasound findings: Rounded nodes, cortical thickening, eccentric or absent fatty hilum, irregular margins, intranodal necrosis (complex cystic areas), microcalcifications, and peripheral or mixed vascularity on color Doppler. Multiple abnormal nodes or extranodal spread raises suspicion.
Clinical correlation: Often in older patients with known cutaneous squamous cell carcinoma, melanoma, or mucosal primaries. May present as a new firm parotid/cheek lump or persistent node after treatment of a primary.
Management notes: Prompt FNAC/core biopsy for histology, search for primary tumor, and staging imaging (CT/MRI/PET as indicated). Management usually surgical (parotidectomy/neck dissection) and/or radiotherapy depending on extent.
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Tuberculous / granulomatous lymphadenitis
Ultrasound findings: Nodes may be heterogeneous with central hypoechoic necrosis, matting of multiple nodes, irregular margins, and occasionally calcification in chronic disease. Sinus tracts or soft-tissue collections adjacent to nodes can occur. Vascularity tends to be peripheral.
Clinical correlation: Chronic, often painless swelling; systemic features (fever, weight loss, night sweats) may be present. Endemic exposure or previous TB increases likelihood.
Management notes: FNAC with mycobacterial studies (AFB stain, culture, PCR) or excisional biopsy. Anti-tubercular therapy guided by microbiology; ultrasound can guide drainage of cold abscesses and monitor treatment.
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Para-parotid abscess / cellulitis (buccal, masseteric, subcutaneous)
Ultrasound findings: Focal complex fluid collection with internal echoes, septations, irregular walls and peripheral hyperemia on color Doppler; surrounding soft-tissue oedema and increased echogenicity of subcutaneous fat in cellulitis. Small collections may be loculated and track along fascial planes.
Clinical correlation: Painful, erythematous, fluctuant swelling often with fever and raised inflammatory markers. Common sources include odontogenic infection, parotid sialadenitis extension, or penetrating trauma.
Management notes: Prompt antibiotic therapy; ultrasound-guided needle aspiration or catheter drainage for collections. Document size, depth, and relationship to facial nerve and parotid capsule to plan safe drainage.
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Parapharyngeal / deep fascial space collections (extension)
Ultrasound findings: Deep hypoechoic or complex collections that may abut or extend from the para-parotid region. Often partially obscured by mandible acoustic shadowing; collections may track medially and posteriorly. Use transoral or lateral neck windows when possible; Doppler shows peripheral hyperemia.
Clinical correlation: Severe neck/face infection, trismus, dysphagia, or airway symptoms suggest deep extension. Odontogenic or tonsillar sources commonly seed these spaces.
Management notes: Urgent ENT/surgical assessment, cross-sectional imaging (CT/MRI) for full extent and airway planning, and image-guided or surgical drainage. Ultrasound assists bedside aspiration for accessible pockets.
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Foreign body (penetrating, retained)
Ultrasound findings: Echogenic linear or irregular focus with posterior shadowing (metal, glass) or variable reverberation (wood, plastic). Surrounding hypoechoic halo may reflect edema, granuloma, or abscess. Real-time scan often shows limited mobility and adjacent reactive changes.
Clinical correlation: History of penetrating trauma, laceration, or prior intervention. Localized pain, chronic drainage or non-healing wound should raise suspicion.
Management notes: Ultrasound localizes radiolucent foreign bodies not seen on X-ray; guide surgical removal. Preoperative mapping reduces tissue dissection and nerve injury risk.
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Sialocele (post-traumatic / iatrogenic)
Ultrasound findings: Well-defined anechoic or complex fluid collection adjacent to the parotid or in soft tissue planes that may communicate with Stensen’s duct. Collections may be unilocular or loculated and can show internal echoes if infected.
Clinical correlation: Common after facial trauma, parotid surgery, or ductal injury; presents as a fluctuant swelling that enlarges with salivation.
Management notes: Diagnostic aspiration (saliva with high amylase), pressure dressings, botulinum toxin to reduce secretion, repeated aspiration or surgical repair if persistent. Ultrasound guides aspiration and tracks recurrence.
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Ranula (plunging / para-parotid extension)
Ultrasound findings: Simple anechoic cystic mass tracking from the floor of mouth through mylohyoid into submandibular/para-pharyngeal/parotid tail area. Appears as a well-defined non-vascular cystic lesion, sometimes loculated or containing debris if infected.
Clinical correlation: Oral floor swelling with external neck/cheek mass when plunging occurs. Symptoms increase with saliva stimulation.
Management notes: Definitive treatment usually involves excision of sublingual gland with cyst evacuation; ultrasound maps extension and guides urgent decompression when needed.
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Branchial cleft cysts / fistulae (para-parotid region)
Ultrasound findings: Well-circumscribed cystic lesions near the parotid tail or along the anterior border of SCM; may show internal septa or debris if infected. Fistulous tracts may be visualized as thin tubular hypoechoic channels extending toward skin or oropharynx.
Clinical correlation: Congenital swelling, recurrent infection, or external draining sinus in preauricular/upper neck region. May present in childhood or adulthood after infection.
Management notes: Surgical excision after full tract mapping (US ± CT/MR fistulogram). Avoid simple aspiration as recurrence is likely.
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Lipoma / benign soft-tissue tumours (para-parotid)
Ultrasound findings: Well-defined, soft, compressible ovoid lesion with hyperechoic or isoechoic pattern relative to subcutaneous fat, thin internal linear echoes; typically avascular on color Doppler.
Clinical correlation: Painless, slow-growing soft mass in subcutaneous tissue adjacent to parotid. Often mobile and soft on palpation.
Management notes: Observe if asymptomatic; excise for cosmesis or if diagnostic uncertainty. MRI useful if deep extension suspected.
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Vascular malformations (venous / lymphatic)
Ultrasound findings: Venous malformations: compressible heterogeneous hypoechoic channels with phleboliths (echogenic foci with shadow) and low-velocity flow on Doppler. Lymphatic malformations: multiloculated anechoic/complex cystic spaces with thin septa, minimal intrinsic flow. Both may infiltrate fascial planes.
Clinical correlation: Congenital lesions presenting early in life (lymphatic) or growing slowly (venous). May fluctuate in size with Valsalva, infection, or hormonal changes.
Management notes: MRI for planning; sclerotherapy or surgical debulking depending on type and extent. Ultrasound guides sclerotherapy/aspiration and monitors response.
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Hematoma (post-trauma) — para-parotid
Ultrasound findings: Time-dependent appearances: acute heterogenous echogenic zone, subacute complex fluid with septations, chronic organized fluid or calcified clot. No intrinsic flow; peripheral hyperemia may be present early.
Clinical correlation: History of recent trauma, anticoagulation, or surgery. Presents with tender swelling, ecchymosis or firmness.
Management notes: Observation if small and stable; aspiration or surgical evacuation if large, expanding, infected or compressing vital structures. Ultrasound for follow-up.
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Post-operative seroma / scar tissue (para-parotid bed)
Ultrasound findings: Simple anechoic seromas/collections or complex fluid with septations early post-op; scar tissue appears as echogenic, hyperechoic bands with reduced compressibility and potential tethering of adjacent structures. No intrinsic vascularity in scar but increased perilesional flow may occur with inflammation.
Clinical correlation: Develops after parotid surgery or neck dissection—swelling, fluctuance, or firmness at operative site.
Management notes: Aspiration for symptomatic seromas; compression dressings; surgical revision for persistent collections or symptomatic scarring. Ultrasound guides aspiration and documents healing.
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Para-parotid extension of parotid tumors / deep-lobe lesions
Ultrasound findings: Solid masses extending from parotid into adjacent soft tissues (para-parotid fat, masseteric space, or subcutaneous plane). May be heterogeneous, vascular, and show ill-defined margins when infiltrative. Assess relationship to mandible, facial nerve plane, and deep lobe involvement.
Clinical correlation: Presents as preauricular or cheek mass that may be fixed to deep structures; facial nerve symptoms may indicate aggressive behavior.
Management notes: Cross-sectional imaging (MRI/CT) for operative planning; ultrasound guides FNAC/biopsy and maps superficial extension. Surgical planning must consider facial nerve preservation and possible wide resection for malignant lesions.
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Para-parotid benign cystic lesions (dermoid, epidermoid, lymphoepithelial)
Ultrasound findings: Unilocular or multilocular cystic masses: dermoid/epidermoid may show internal echogenic debris, “onion-skin” layering or fat components; lymphoepithelial cysts often multiple and may be associated with intraparotid lymphoid changes. Typically avascular internally.
Clinical correlation: Slow-growing, painless masses; consider HIV testing with multiple lymphoepithelial cysts. Dermoid/epidermoid lesions may occur congenitally or present later.
Management notes: Surgical excision for diagnosis and cure; MRI helpful to evaluate fat or complex components and to plan dissection avoiding facial nerve.
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Para-parotid lymphoma / systemic infiltration
Ultrasound findings: Hypoechoic, often homogeneous masses or diffuse gland enlargement; multiple confluent nodal masses in para-parotid chains. Vascularity may be mild. Appearance may mimic other infiltrative processes.
Clinical correlation: Painless swelling, possible systemic B symptoms; association with autoimmune disease (e.g., Sjögren’s) may increase risk.
Management notes: Core biopsy/FNAC for histology and immunophenotyping; systemic staging and hematology/oncology referral. Ultrasound assists biopsy and follow-up.
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Stensen’s Duct — Anatomy & Scanning Technique
Ultrasound findings / Technique: Stensen’s duct (parotid duct) courses anteriorly from the parotid gland across the masseter muscle, perforates the buccal fascia, turns medially and opens into the oral cavity at the parotid papilla opposite the upper second molar. For sonographic assessment, use a high-frequency linear transducer (10–15 MHz). Begin with a longitudinal scan along the expected external course (preauricular → masseter → buccal region) and perform transverse sweeps to define duct calibre. Use graded compression, dynamic maneuvers (asking patient to blow, squeeze or stimulate salivation) to accentuate ductal dilatation. Intraoral scanning (sterile covered small probe) can visualize the intramucosal segment when necessary.
Clinical correlation: Accurate localization of ductal pathology informs minimally invasive management (sialendoscopy, stone extraction, ductal dilation). Recognize normal anatomic variants (tortuosity, short duplications) and relation to masseter and facial nerve branches.
Management notes: Document probe frequency, patient posture, maneuvers used (sialogogue), and whether intraoral views were obtained. Use color/power Doppler to exclude vascular mimics and to identify periductal hyperemia with active inflammation.
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Normal Sonographic Appearance — Stensen’s Duct
Ultrasound findings: The normal duct is often not visualized along its full length on external scanning unless distended. When visible, it appears as a thin, tubular anechoic structure with imperceptible walls and no internal echoes or flow. Typical external diameter is small (<1–2 mm); visible lumen increases with salivary stimulation. Surrounding tissues are normal in echotexture and there is no periductal edema or hyperemia.
Clinical correlation: Difficulty visualizing the duct does not imply pathology — absence of dilation is normal. Use comparison with contralateral side and dynamic maneuvers to elicit abnormal dilation or obstruction.
Management notes: When duct is not visualized but symptoms persist, consider sialography or sialendoscopy for further assessment. Record whether duct was visualized, maximal luminal diameter (mm), and response to sialogogue stimulation.
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Sialolithiasis — Stones within Stensen’s Duct
Ultrasound findings: Echogenic foci within the expected course of Stensen’s duct often with posterior acoustic shadowing when calcified. Stones may be mobile on dynamic compression or fixed if embedded. Upstream (proximal) ductal dilatation is a key secondary sign; associated periductal soft tissue edema and hyperemia may indicate secondary inflammation. Small radiolucent stones may show reverberation artifact rather than dense shadowing.
Clinical correlation: Episodic painful swelling (especially at mealtimes), reduced salivary flow, or purulent discharge from duct opening. Local tenderness along duct course is common. Document distance of stone from oral orifice (useful for endoscopic planning).
Management notes: Report stone size, exact anatomic location (measured from parotid papilla or preauricular landmark), number of calculi, degree of upstream dilation and inflammatory changes. Small distal stones may be milked into the mouth or removed endoscopically; larger/proximal stones may require sialendoscopy with basket extraction or surgical removal. Ultrasound can be used to guide percutaneous removal in selected cases and to follow post-procedural clearance.
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Sialodochitis — Ductal Inflammation (Debris / Mucous Plugs)
Ultrasound findings: Wall thickening of the duct, visible intraluminal echogenic mobile debris or plugs, and variable dilatation proximal to obstruction. Periductal hypoechoic halo and increased color/power Doppler signal indicate active inflammation. Chronic cases may show scarring or beaded ductal irregularity.
Clinical correlation: Meal-related discomfort and transient swelling, viscous saliva, or intermittent obstruction are typical. May follow infection, autoimmune disease or ductal trauma.
Management notes: Describe ductal calibre, length of involvement, presence of mobile debris, and periductal hyperemia. Conservative measures (hydration, sialogogues, massage) often suffice; sialendoscopy allows lavage and clearance of debris. Ultrasound is useful for pre- and post-treatment assessment.
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Ductal Strictures / Stenosis (Beading)
Ultrasound findings: Segmental narrowing of the duct with proximal (pre-stenotic) dilatation. On longitudinal views a focal narrowed lumen with upstream tubular anechoic dilation is typical; multiple strictures create a beaded appearance. Wall fibrosis may reduce compressibility. Color Doppler usually shows periductal inflammatory flow only if active.
Clinical correlation: Recurrent obstructive symptoms, persistent swelling, and predisposition to infection. Causes include chronic inflammation, prior instrumentation, radiation, or traumatic scarring.
Management notes: Report level(s) and length of stricture, degree of upstream dilation, and whether multiple segments are involved. Sialendoscopic balloon dilatation, stenting or surgical revision are treatment options; ultrasound monitors response and detects restenosis.
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Ductal Diverticulum / Pseudodiverticulum
Ultrasound findings: Focal outpouching from the ductal lumen seen as a saccular anechoic structure contiguous with the duct; may contain debris if infected. The communication with the main duct can often be demonstrated on dynamic scanning or by sialogogue stimulation producing filling of the sac.
Clinical correlation: Can present with recurrent localized swelling, food-dependent fullness, or mucoid discharge. Often congenital or secondary to chronic ductal pressure/obstruction.
Management notes: Map size and communication; small asymptomatic diverticula may be observed while symptomatic lesions may require endoscopic management or surgical excision. Ultrasound is helpful to demonstrate communication prior to intervention.
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Ductal Cysts / Retention Cysts of Stensen’s Duct
Ultrasound findings: Localized anechoic or hypoechoic cystic dilatation of the ductal segment often continuous with the duct. Thin walls, posterior enhancement, and absence of internal vascularity characterize retention cysts. If infected, internal echoes, wall thickening and peripheral hyperemia may develop.
Clinical correlation: Intermittent or persistent swelling, sometimes meal-related, with possible mucous discharge. Distinguish from extravasation pseudocyst (no epithelial lining) by demonstrating continuity with duct.
Management notes: Report location, size, communication with duct, and signs of infection. Endoscopic clearance or excision and addressing underlying obstruction are usual treatments for symptomatic retention cysts.
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Ductal Tumors — Papilloma & Malignant Ductal Lesions
Ultrasound findings: Papillomas and other benign intraductal lesions appear as small, focal intraluminal echogenic nodules often with internal vascularity on Doppler. Malignant ductal lesions may be irregular, infiltrative, with heterogeneous echotexture and increased internal flow; they can cause fixed obstruction and upstream dilation. Periductal infiltration and regional nodes indicate aggressive behavior.
Clinical correlation: Symptoms include persistent obstruction, mucopurulent discharge, or blood-streaked saliva. Rapid change in symptoms or firm mass raises concern for malignancy.
Management notes: Small intraductal nodules can be sampled via sialendoscopic biopsy or ultrasound-guided FNAC where accessible. Surgical excision with histopathology is required for malignant lesions; report lesion size, ductal level and nodal status.
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Post-traumatic Ductal Disruption → Sialocele (Ductal-specific)
Ultrasound findings: Anechoic or complex fluid collection along the ductal course or in the buccal/masseteric soft tissues with possible demonstrable tract/communication to the duct. Collections typically increase with salivation and show no intrinsic vascularity; secondary infection produces internal echoes and peripheral hyperemia.
Clinical correlation: History of facial trauma, penetrating injury, surgery, or instrumentation to the duct. Patients present with fluctuant swelling that enlarges with chewing or salivation.
Management notes: Aspirate for diagnostic confirmation (saliva, high amylase). Conservative measures include pressure dressings and repeated aspiration; persistent cases may need surgical repair of the ductal defect or botulinum toxin to suppress salivary secretion. Ultrasound guides aspiration and monitors for recurrence.
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Reporting Template — Stensen’s Duct (Suggested)
Ultrasound report should include:
- Clinical indication and side examined.
- Probe frequency and maneuvers used (e.g., sialogogue stimulation, intraoral views).
- Whether duct was visualized and maximum luminal diameter (mm) at rest and after stimulation.
- Presence, number, size and exact location of calculi (measured distance from papilla or preauricular landmark).
- Intraluminal debris, strictures (level and length), diverticula, cysts or intraductal lesions.
- Upstream ductal dilatation and parotid gland changes (edema, hyperemia, focal collections).
- Color/power Doppler findings (periductal or intraductal vascularity) and lymphadenopathy.
- Comparative assessment of contralateral duct/gland and recommended next steps (sialendoscopy, MRI, FNAC, aspiration, ENT referral).
Management note: Provide clear localization for interventional planning (e.g., stone at 25 mm from papilla in mid-duct with 6 mm upstream dilation — suitable for endoscopic basket extraction). Suggest targeted imaging (intraoral ultrasound, sialography or MR sialography) when external ultrasound is inconclusive.
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Submandibular Gland — Anatomy & Scanning Technique
Ultrasound findings / Technique: The submandibular gland lies in the submandibular triangle beneath the mandible, superficial to the mylohyoid muscle and posterolateral to the sublingual space. The main duct (Wharton’s duct) emerges from the deep aspect of the gland, courses anteriorly medial to the mandible, and opens at the sublingual caruncle. Sonographic assessment uses a high-frequency linear transducer (7–15 MHz). Scan in longitudinal and transverse planes from the gland body inferiorly up to the duct along the floor of mouth. Intraoral or sublingual windows (sterile covered small probe) can help visualize the distal duct and intramucosal segment. Dynamic maneuvers (sialogogues, chewing, Valsalva) and graded compression aid detection of ductal dilation or small stones.
Clinical correlation: Knowledge of the gland’s relationship to the mandible, mylohyoid and sublingual space is important for distinguishing primary submandibular disease from oral floor lesions or plunging ranula.
Management notes: Document probe frequency, planes scanned, whether intraoral views obtained, and maneuvers used. Use color/power Doppler to exclude vascular mimics and evaluate inflammatory hyperemia.
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Normal Sonographic Appearance — Submandibular Gland
Ultrasound findings: The gland is ovoid to bean-shaped, with homogeneous echotexture slightly more echogenic than muscle and lobulated contour. The normal Wharton’s duct is usually not visible unless distended; when seen it is a thin anechoic tubular structure. No periductal edema or focal masses should be present. Typical adult gland dimensions vary (approx. 3–4.5 cm length), influenced by age and body habitus.
Clinical correlation: Asymmetry or focal lesions compared to the contralateral gland warrants further assessment. Failure to visualize the duct is normal—document if distended after stimulation.
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Sialolithiasis — Wharton’s Duct & Intraglandular Stones
Ultrasound findings: Echogenic foci with posterior acoustic shadowing along the expected course of Wharton’s duct or within the gland parenchyma are classic. Stones in the submandibular system are often larger and more common than in parotid. Upstream ductal dilatation, proximal gland enlargement, and periductal edema or hyperemia (if inflamed) are frequent. Small radiolucent stones may show reverberation artifact.
Clinical correlation: Meal-related painful swelling beneath the jaw, reduced salivary flow, and possible purulent discharge from duct orifice. Palpable firm focus in floor of mouth is common for distal stones.
Management notes: Report stone number, size, exact distance from papilla, degree of upstream dilation and inflammatory signs. Distal stones may be milked out or removed transorally; proximal/large stones may require sialendoscopy, combined approach or surgical excision. Ultrasound aids preoperative planning and post-procedural follow-up.
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Acute Bacterial Submandibular Sialadenitis
Ultrasound findings: Enlarged, diffusely hypoechoic or heterogeneous gland due to oedema. Color/power Doppler typically shows increased vascularity (hyperemia). Focal complex collections (abscess) appear as irregular fluid collections with internal echoes, septations and peripheral hyperemia. Look for obstructing stones in the duct or within gland.
Clinical correlation: Acute painful swelling, fever, erythema and tenderness beneath the mandible, often worse with meals. Predisposing factors: dehydration, ductal obstruction, poor oral hygiene or recent intubation.
Management notes: Start appropriate antibiotics, hydration, sialogogues and gland massage. Use ultrasound-guided aspiration/drainage for abscess. Consider sialendoscopy if obstruction suspected.
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Chronic Recurrent Sialadenitis & Sialadenosis
Ultrasound findings: Heterogeneous gland with multiple small hypoechoic foci (ductal ectasia) or microcystic changes. In sialadenosis (non-inflammatory enlargement) the gland may be diffusely enlarged and hyperechoic due to fatty change; vascularity is usually normal or mildly increased. Scarring and lobulated contour may occur with chronic disease.
Clinical correlation: Recurrent painful swelling episodes triggered by meals or chronic painless enlargement in sialadenosis associated with metabolic conditions (diabetes, malnutrition, alcohol use). Differentiate inflammatory from non-inflammatory causes clinically.
Management notes: Conservative measures (oral hygiene, sialogogues); sialendoscopy for ductal clearance or dilation; treat metabolic contributors for sialadenosis. Ultrasound is useful for monitoring progression and response.
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Wharton’s Duct — Sialodochitis, Strictures & Diverticula
Ultrasound findings: Visible ductal dilatation proximal to obstruction, intraluminal echogenic debris or mucous plugs, segmental narrowing (stricture) with beading, and saccular outpouchings (diverticula) contiguous with ductal lumen. Wall thickening and periductal hypoechoic halo indicate active inflammation. Dynamic filling with sialogogue stimulation may demonstrate communication.
Clinical correlation: Intermittent meal-related swelling, mucous discharge, or persistent obstructive symptoms. Prior duct trauma or instrumentation predisposes to strictures.
Management notes: Sialendoscopic lavage, basket retrieval of debris, balloon dilatation or stenting for strictures. Ultrasound documents level/length of stricture and post-treatment surveillance.
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Ranula (plunging / submandibular extension)
Ultrasound findings: Anechoic unilocular or multilocular cystic lesion originating from the floor of mouth that can dissect through the mylohyoid into submandibular/neck spaces. Appears as a well-defined non-vascular cystic mass; debris or septations may be seen if infected. Assess relationship to submandibular gland and platysma.
Clinical correlation: Oral floor swelling with an external submandibular neck mass when plunging occurs. Swelling often increases with salivation.
Management notes: Definitive management usually requires excision of sublingual gland and cyst evacuation; ultrasound maps extent and guides urgent decompression if required.
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Abscess / Phlegmon (submandibular)
Ultrasound findings: Localized complex fluid collections with internal echoes, septations and irregular walls; peripheral hyperemia on color Doppler. Phlegmon appears as a poorly marginated hypoechoic infiltrative area without a discrete cavity. Deep extension to parapharyngeal spaces or airway-compromising collections should be suspected if medial tracking is seen.
Clinical correlation: Odontogenic infections, sialadenitis extension or penetrating trauma commonly cause submandibular abscesses. Patients have painful swelling, fever, trismus, and dysphagia.
Management notes: Prompt antibiotics and image-guided or surgical drainage; note relationship to airway structures and major vessels. Ultrasound-guided aspiration reduces risk and confirms microbiology.
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Simple & Retention Cysts / Extravasation Pseudocysts
Ultrasound findings: Simple cysts: well-defined, anechoic, thin-walled with posterior enhancement and no internal vascularity. Retention cysts: ductal continuity to Wharton’s duct may be demonstrated. Extravasation pseudocysts: ill-defined collections in adjacent soft tissues, may contain debris and lack true epithelial lining.
Clinical correlation: Fluctuant, often painless swellings; extravasation pseudocysts usually follow trauma or ductal rupture and may enlarge with meals.
Management notes: Simple cysts observed or excised if symptomatic. Extravasation pseudocysts often require aspiration, pressure management, or surgical repair of ductal defect; ultrasound guides intervention.
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Neoplasms — Benign & Malignant (Pleomorphic adenoma, Mucoepidermoid, Lymphoma, Metastases)
Ultrasound findings: Benign tumours (pleomorphic adenoma) are typically well-defined, ovoid, hypoechoic or heterogeneous masses with smooth or lobulated margins and mild internal vascularity. Malignant tumours (mucoepidermoid, carcinoma ex-PA, salivary duct carcinoma) appear heterogeneous with ill-defined margins, invasion into adjacent tissues, irregular vascularity and possible necrotic areas. Primary lymphoma presents as homogeneous hypoechoic enlargement or focal nodal masses; metastatic deposits are irregular with necrotic nodes. Deep-lobe extension or submandibular fossa invasion diminishes surgical options.
Clinical correlation: Painless or painful mass depending on tumour type; rapid growth, pain, or facial/lingual nerve dysfunction suggests malignancy. Lymphoma may present with systemic symptoms.
Management notes: FNAC/core biopsy under ultrasound guidance for diagnosis; MRI/CT for staging and surgical planning. Surgical excision (submandibulectomy) with preservation of hypoglossal/lingual nerve when possible for benign lesions; oncologic resection ± adjuvant therapy for malignant tumours. Ultrasound aids in biopsy planning and follow-up.
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Vascular Lesions — Hemangioma & Lymphatic Malformation
Ultrasound findings: Hemangiomas: lobulated heterogeneous masses with prominent internal vascular channels and high-flow/low-resistance arterial waveforms in proliferative phase. Lymphatic malformations: multiloculated cystic lesions with thin septa and minimal internal flow. Phleboliths (echogenic foci with shadow) may be present in venous malformations.
Clinical correlation: Pediatric hemangiomas present early with rapid growth; lymphatic malformations are congenital and may enlarge with infection or hemorrhage.
Management notes: Propranolol for infantile hemangiomas, sclerotherapy or surgical excision for lymphatic/venous malformations. Ultrasound guides sclerotherapy and monitors therapeutic response.
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Post-traumatic Hematoma & Sialocele (Submandibular)
Ultrasound findings: Hematomas evolve from heterogeneous/echogenic in acute stage to complex and then anechoic or organized with time; no internal vascularity. Sialoceles show anechoic or complex fluid collections contiguous with or near the gland or duct, typically increasing with salivation.
Clinical correlation: History of trauma, surgery, biopsy or ductal injury. Fluctuant swelling, ecchymosis or meal-related expansion favors sialocele.
Management notes: Small hematomas observed; enlarging or infected collections may need evacuation. Sialoceles: aspiration, compression, botulinum toxin or surgical repair when persistent. Ultrasound is essential for guided aspiration and follow-up.
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Post-radiation Changes & Systemic Disease (Sjögren’s, HIV, Sarcoid, IgG4)
Ultrasound findings: Post-radiation: gland atrophy, heterogeneous echotexture, increased echogenicity from fatty/fibrotic replacement and reduced vascularity. Autoimmune/systemic disease: multiple small hypoechoic foci, cystic change, gland enlargement (e.g., Sjögren’s, HIV lymphoepithelial cysts) or nodular hypoechoic lesions (sarcoid/IgG4). Patterns overlap and require serologic/biopsy correlation.
Clinical correlation: Xerostomia (Sjögren’s), painless gland enlargement (HIV), systemic symptoms for sarcoid/IgG4. Radiation history supports post-radiation sialadenitis.
Management notes: Serology, targeted biopsy, and multidisciplinary management. Ultrasound maps disease, guides biopsy, and monitors therapy response.
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Reporting Template — Submandibular Gland (Suggested)
Ultrasound report should include:
- Clinical indication and side examined.
- Probe frequency and planes scanned; note if intraoral views or sialogogue stimulation were used.
- Gland size, echotexture (homogeneous/heterogeneous), and focal lesions (size, shape, margins).
- Wharton’s duct visualization, luminal diameter, presence of calculi (number, size, distance from papilla), intraluminal debris, strictures or diverticula.
- Periglandular collections, abscesses, vascularity on color/power Doppler, and regional lymphadenopathy.
- Comparison with contralateral gland and recommended next steps (sialendoscopy, MR sialography, FNAC, ENT referral).
Management note: Provide precise localization for intervention (e.g., stone at 18 mm from papilla in mid-duct with 8 mm proximal dilation — candidate for transoral removal/sialendoscopy). Recommend cross-sectional imaging when deep extension, airway risk, or malignancy suspected.
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Buccal Space Cellulitis
Ultrasound Report- Line: The buccal space reveals diffuse ill-defined hyperechoic changes of the subcutaneous fat with increased echogenicity and thickening of the overlying soft tissues. There is loss of normal fascial plane differentiation with evidence of edema extending into the buccal fat pad. No well-formed fluid collection or drainable abscess is seen. Color Doppler demonstrates increased vascularity consistent with inflammatory hyperemia.
Cnclusion: Findings are consistent with buccal space cellulitis, characterized by diffuse soft tissue edema and inflammatory changes without evidence of a well-defined abscess/collection
Recommendation: Recommend clinical correlation and appropriate medical management Follow-up ultrasound may be performed if symptoms persist or worsen.
Buccal space Subcutaneous abscess with celulitis
Ultrasound Report- Line: Shows diffuse hyperechoic thickening of subcutaneous fat with linear hypoechoic streaks (“cobblestoning”), increased echogenicity of fascial planes, and ill-defined hypoechoic fluid pockets compatible withabsces measuring approximately 20 × 22 × 18 mm. Color Doppler shows hyperemia. In abscesses, focal complex fluid collections with irregular walls and peripheral vascularity are seen.
Conclusion: Sonographic appearances consistent with buccal space subcutaneous abscess with surrounding cellulitis.
Recommendation: Obtain contrast CT/MRI if deeper space extension suspected; observe airway and follow up in 24–48 hours.
Masseteric Space abscess
Ultrasound findings: The masseteric space shows a well-defined hypoechoic to anechoic collection within the substance of the masseter muscle, measuring approximately 28 × 22 × 18 mm. The lesion shows internal low-level echoes and debris with posterior acoustic enhancement. Peripheral hyperechoic rim with increased vascularity on color Doppler is noted, consistent with inflammatory hyperemia. Adjacent soft tissue edema and loss of normal muscle architecture are present. No extension into the parotid or submandibular space identified. No evidence of underlying vascular thrombosis or bony erosion seen.
Conclusion: Findings are consistent with a Masseteric Space Abscess with associated cellulitis
Recommendation: Recommend prompt clinical and surgical evaluation for incision and drainage or ultrasound-guided aspiration, depending on accessibility and clinical status.
Buccal Fat Pad hemangioma
Ultrasound reort- Line : A Well-defined, heterogeneous hyperechoic lesion with internal vascular channels noted in the left buccal fat pad region, measuring approximately 28x23 mm. The lesion shows multiple tubular anechoic channels with color Doppler demonstrating prominent internal vascularity and low-velocity venous flow. No calcification or cystic degeneration seen. Surrounding fat planes are preserved, with no evidence of invasion into adjacent masticatory muscles or bone.
Conclusion: Findings are sugestive of bucal fat pad hemangiom.
Recommendation: Follow-up ultrasound- Interval ultrasound or contrast-enhanced MRI.
Subcutaneous Lymphatic malformation (Cheek Soft Tissue)
Ultrasound findings: Subcutaneous soft tissue of the cheek demonstrates a multiloculated cystic lesion with thin septations, avascular on Doppler, compatible with lymphatic malformation.
Concluson: Bucal subcutaneous lymphatic malformation (D/D venous malformation, dermoid/epidermoid cyst)
Vascular malformation (Cheek Soft Tissue)
Ultrasound findings: Subcutaneous soft tissue of the left cheek shows a well-defined, compressible, heterogeneous lesion composed of multiple tubular hypoechoic channels. On color Doppler, there is low-velocity venous flow with no arterialization. No solid component or calcification noted. Surrounding fat planes are preserved.
Concluson: Findings are consistent with a low-flow venous vascular malformation of the cheek soft tissue
RecommendationRecommend further evaluation with contrast-enhanced MRI
Foreign Body (Cheek Soft Tissues)
Ultrasound findings: Echogenic focus with posterior shadowing (metal, glass) or comet-tail/reverberation (wood, plastic). Surrounding hypoechoic halo may reflect edema, granulation, or abscess. Dynamic scanning shows immobility within tissue.
Clinical correlation: History of penetrating injury or dental/surgical trauma. Presents with persistent pain, swelling, or discharging sinus.
Management notes: Ultrasound precisely localizes radiolucent foreign bodies, guiding surgical removal and reducing tissue trauma.
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Odontogenic Extension into Cheek Soft Tissue
Ultrasound findings: Hypoechoic or complex collections adjacent to mandibular/maxillary alveolus extending into cheek tissues. Associated muscle edema, loss of fascial plane definition, and increased vascularity on Doppler. Often associated with periapical dental abscess.
Clinical correlation: Dental pain, caries, or recent dental procedure; facial swelling, fever, trismus.
Management notes: Ultrasound confirms abscess, guides drainage. Underlying dental source requires dental/OMFS management.
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Cheek Soft Tissue Tumors
Ultrasound findings: Benign lesions (lipoma, fibroma, neurofibroma) are well-defined, homogeneous and show minimal vascularity. Malignant tumors (rhabdomyosarcoma, sarcoma, SCC extension) are heterogeneous, irregular, infiltrative, and often hypervascular. Adjacent fascial plane invasion is a red flag.
Clinical correlation: Painless, slow-growing lumps are more likely benign; rapidly enlarging, painful, or ulcerated masses suggest malignancy. Pediatric rhabdomyosarcoma should be suspected in aggressive lesions in children.
Management notes: FNAC/core biopsy under ultrasound guidance. MRI for surgical planning. Early referral to oncology for malignant suspicion.
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Post-traumatic Hematoma
Ultrasound findings: Time-dependent: acute echogenic heterogeneous mass; subacute complex hypoechoic collection with septations; chronic organized fluid with capsule. Absence of internal vascularity; peripheral hyperemia may be present early.
Clinical correlation: Recent blunt or penetrating cheek trauma, anticoagulation, or surgery. Painful swelling with ecchymosis.
Management notes: Small, stable hematomas observed; aspiration or evacuation if enlarging, symptomatic, or infected. Ultrasound tracks resolution.
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Post-radiation Changes — Cheek Soft Tissue
Ultrasound findings: Atrophy and increased echogenicity of soft tissues and muscles, reduced vascularity, fibrosis (hyperechoic bands) with reduced compressibility. Loss of normal fat planes and reduced salivary gland volume may coexist.
Clinical correlation: History of radiotherapy to head/neck. Presents with chronic induration, xerostomia, or trismus.
Management notes: Symptomatic treatment, physiotherapy, hydration, and careful monitoring for recurrence of malignancy. Ultrasound helps differentiate fibrosis from recurrent tumor (the latter appears irregular, vascular, and infiltrative).
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Systemic & Infiltrative Disorders (Cheek Involvement)
Ultrasound findings: Sarcoidosis, amyloidosis, or IgG4-related disease may present as diffuse hypoechoic or heterogeneous thickening of cheek soft tissues with ill-defined borders, sometimes mimicking chronic infection. Lymphadenopathy may coexist. Vascularity is variable.
Clinical correlation: Associated systemic disease history, multisystem involvement, or bilateral symmetrical swelling (e.g., IgG4, sarcoid).
Management notes: Biopsy often required for confirmation. Ultrasound helps detect lesions, guide biopsy, and monitor therapy response.
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Regional Lymph Nodes — Cheek / Preauricular / Parotid Region (Overview)
Summary: The regional lymphatic stations relevant to the cheek include preauricular (superficial parotid), buccal/facial, malar, infraorbital, masseteric, submandibular, and superficial cervical nodes. These nodes drain skin and soft tissues of the lateral face, eyelids, external auditory canal, and portions of the oral cavity. Sonographic assessment of these nodes is essential in evaluating infection, inflammatory disease, lymphoma, or metastatic involvement (skin cancers, oral cavity primaries).
Anatomic stations (commonly described):
- Preauricular / superficial parotid nodes: Along the anterior edge of the ear and over the parotid gland.
- Buccal / facial nodes: Superficial along the course of the facial vessels over the buccal fat pad and masseter.
- Infraorbital / malar nodes: In the infraorbital region and cheek prominence.
- Masseteric nodes: Deep to or over the masseter muscle near the mandibular ramus.
- Submandibular nodes: Along the submandibular triangle, drain much of the oral cavity and cheek.
- Superficial cervical / level II nodes: May be involved with extension from cheek/parotid disease.
Clinical relevance: Localization of the involved nodal station helps identify the likely source (cutaneous lesions, odontogenic infection, salivary gland disease, or cutaneous malignancy). Sonography is the first-line bedside modality for characterization and guided sampling.
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Normal Sonographic Appearance & Measurement Technique
Ultrasound findings: Normal nodes are small, oval, with an echogenic central fatty hilum and a thin hypoechoic cortex. Hilar vascularity (central flow) is often seen on color Doppler. Typical shape is elongated (long axis > short axis) and compressible with probe pressure.
Measurement technique: Measure and report both long-axis (L) and short-axis (S) diameters in millimetres using the plane showing maximal short-axis. Record cortical thickness (in mm) if cortex is thickened. Calculate shape metrics: S/L ratio or short-axis/long-axis ratio — a rounder node has a higher S/L ratio. Document the station, side, and distance from skin surface.
Common size references (adult): Size thresholds vary by location and clinical context — superficial preauricular/cheek nodes are normally small (often <6–8 mm short-axis). In general, a short-axis >10 mm is commonly considered abnormal for many cervical nodes; however, for superficial facial nodes smaller cut-offs (e.g., >6–8 mm) or presence of suspicious morphology are more relevant than size alone. Always interpret size with morphology and Doppler pattern.
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Reactive (Benign) Lymphadenopathy
Ultrasound findings: Enlarged but oval nodes with preserved echogenic hilum, uniform cortical thickening (often concentric), and maintained central (hilar) vascularity on color Doppler. Nodes are frequently multiple in the drainage chain and compressible on probe pressure.
Clinical correlation: Associated with nearby infection or inflammation (skin infection, conjunctivitis, otitis, dental disease, parotitis). Tenderness, warmth, and temporal relation to infection support reactive aetiology.
Management notes: Treat the underlying cause and perform short-interval ultrasound follow-up (2–6 weeks) to ensure resolution. Consider FNAC if nodes persist, enlarge, or lose benign sonographic features.
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Metastatic Lymph Nodes (Skin / Head & Neck Primaries)
Ultrasound findings: Rounded or irregular nodes, focal cortical bulging or asymmetric cortical thickening, loss or displacement of the echogenic hilum, intranodal necrosis (complex cystic areas), microcalcifications, extracapsular spread (ill-defined margins), and peripheral or mixed vascularity on color Doppler. Matting of nodes and fixed immobility suggest extranodal spread.
Clinical correlation: Commonly associated with cutaneous squamous cell carcinoma, melanoma, or oral cavity primary tumours. Look for suspicious skin lesions or prior cancer history. New firm, rapidly enlarging, or non-tender nodes should raise concern.
Management notes: Early tissue diagnosis (ultrasound-guided FNAC or core biopsy) and staging imaging (CT/MRI/PET-CT) are indicated. Document number, size, morphology, level and suspected extracapsular extension to guide surgery/neck dissection.
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Tuberculous / Granulomatous Lymphadenitis
Ultrasound findings: Heterogeneous nodes with central hypoechoic necrosis or complex cystic change, matting of multiple adjacent nodes, irregular margins, and possible calcification in chronic lesions. Peripheral (rim) vascularity is typical. Sinus tracts or adjacent cold abscesses may be identified.
Clinical correlation: Chronic painless or minimally painful swelling, systemic symptoms (weight loss, night sweats) in some cases, and epidemiologic risk factors for TB. Consider TB with non-resolving nodes or poor response to conventional antibiotics.
Management notes: FNAC with AFB smear/culture and molecular testing (e.g., PCR) or excision biopsy for histology and microbiology. Start anti-tubercular therapy when confirmed. Ultrasound guides biopsy/aspiration of necrotic foci.
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Primary Parotid/Para-parotid Lymphoma & Nodal Involvement
Ultrasound findings: Homogeneous, hypoechoic, often rounded or lobulated nodal masses which may coalesce into bulky confluent masses. Vascularity is typically mild to moderate and often preserved centrally. Nodes may lack the fatty hilum early in disease.
Clinical correlation: Painless progressive swelling, sometimes bilateral; systemic B symptoms may be present. Sjögren’s disease increases risk of parotid lymphoma.
Management notes: Core biopsy or excisional biopsy for histologic subtyping and immunophenotyping is essential. Staging with CT/PET and hematology referral required. Ultrasound guides safe tissue sampling.
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HIV-associated Lymphadenopathy & Lymphoepithelial Changes
Ultrasound findings: Multiple enlarged nodes, often bilateral, with variable echotexture. Associated intraparotid lymphoepithelial cysts may be present. Nodes can be small but numerous, and may have preserved hilum in reactive states.
Clinical correlation: History or risk factors for HIV; nodes may fluctuate and be accompanied by parotid enlargement from benign lymphoepithelial cysts.
Management notes: Consider HIV testing when unexplained multifocal cystic parotid or nodal disease is present. Management is disease-specific with antiretroviral therapy and targeted ENT follow-up.
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Suppurative Nodes & Secondary Abscess
Ultrasound findings: Complex nodal architecture with central liquefaction, internal echoes, septations and peripheral hyperemia. Adjacent soft tissue edema and tracking sinus may be present.
Clinical correlation: Acute painful swelling, fever, erythema, and often a known site of infection (dental, skin, salivary). Nodes may become fluctuant and require drainage.
Management notes: Ultrasound-guided needle aspiration or drainage for microbiology and relief, plus appropriate antibiotics. Monitor with serial ultrasound to confirm resolution.
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Pediatric Considerations — Regional Cheek Nodes
Ultrasound findings: Children commonly have reactive enlargement of regional nodes following infection or immunization. Nodes are often larger but retain benign features (oval shape, preserved hilum). Concerning features for malignancy or atypical infection include rounded shape, loss of hilum, marked cortical thickening, rapid growth, or systemic signs.
Clinical correlation: Consider age-appropriate infectious causes (viral exanthems, streptococcal/ staphylococcal infections), atypical mycobacterial disease, and, rarely, malignancy. Correlate with systemic examination and history.
Management notes: Conservative follow-up is reasonable for nodes with benign sonographic features; expedite biopsy if concerning morphology, progressive enlargement, or systemic symptoms.
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Sonographic Criteria & Doppler Interpretation — Practical Tips
Key sonographic features to record: Shape (oval vs round), size (S and L in mm), S/L ratio, cortical thickness (mm), presence/absence of echogenic hilum, internal architecture (homogeneous/heterogeneous), necrosis/cystic change, calcifications, matting, extracapsular extension, and relationship to adjacent structures.
Doppler patterns:
- Hilar (central) vascularity: Typical of benign/reactive nodes.
- Peripheral or mixed chaotic vascularity: Suggests malignancy or metastatic involvement.
- Absent internal flow: May indicate necrosis (e.g., suppurative or necrotic metastatic node) — correlate with B-mode features.
- Increased peri-nodal flow: Seen with acute inflammation.
Practical scanning tips: Use high-frequency linear transducer, compare with contralateral side, use graded compression to assess compressibility, sample entire drainage chain (preauricular → buccal → submandibular → superficial cervical), and use color/power Doppler with low PRF/scale to detect low flow.
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Indications for Biopsy (FNAC / Core) & Guidance
When to sample: Nodes with suspicious morphology (loss of hilum, eccentric cortical thickening, round shape, intranodal necrosis, calcifications), persistent/enlarging nodes >4–6 weeks despite therapy, systemic symptoms, known malignancy requiring staging, or unexplained bulky nodal disease.
Sampling modality: Ultrasound-guided FNAC is first-line for cytology and microbiology (including Gram/AFB/PCR). Core biopsy provides larger tissue for histology/immunophenotyping when lymphoma is suspected or FNAC is non-diagnostic.
Guidance notes: Target viable cortical tissue (avoid necrotic center), sample the largest or most sonographically suspicious node, and submit material for cytology, culture, and molecular tests as clinically indicated. Coordinate with pathology for on-site adequacy assessment when possible.
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Reporting Template — Regional Lymph Nodes (Cheek / Preauricular)
Suggested ultrasound report items:
- Clinical indication and side(s) examined.
- Probe frequency and planes scanned; note use of dynamic maneuvers or sialogogue if relevant.
- For each abnormal node: station (preauricular/buccal/masseteric/submandibular/level II), size (L × S in mm), cortical thickness, S/L ratio, shape, presence/absence of echogenic hilum, internal architecture (necrosis, calcification), Doppler pattern (hilar/peripheral/avascular), mobility and compressibility.
- Number of abnormal nodes and presence of matting or extracapsular extension.
- Comparison with contralateral side.
- Recommendation: correlate clinically, short-interval ultrasound follow-up, or ultrasound-guided FNAC/core biopsy (specify target node) with rationale.
Management note: Provide precise localization (e.g., "Right preauricular node #2: 12 × 8 mm, rounded, loss of hilum, peripheral vascularity — recommend US-guided FNAC/ core biopsy") to facilitate targeted sampling and surgical planning.
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