Review Article

Review of the Major and Minor Salivary Glands, Part 1: Anatomy,

Infectious, and Inflammatory Processes
Alexander T Kessler, Alok A Bhatt

Department of Imaging The major and minor salivary glands of the head and neck are important structures

Abstract
Sciences, University of
Rochester Medical Center,
that contribute to many of the normal physiologic processes of the aerodigestive
Rochester, New York, USA tract. The major salivary glands are routinely included within the field of view
of standard neuroimaging, and although easily identifiable, salivary pathology is
relatively rare and often easy to overlook. Knowledge of the normal and abnormal
imaging appearance of the salivary glands is critical for forming useful differential
diagnoses, as well as initiating proper clinical workup for what are often incidental
findings. The purpose of this review is to provide a succinct image‑rich article
illustrating relevant anatomy and pathology of the salivary glands via an extensive
review of the primary literature. In Part 1, we review anatomy as well as provide
an in‑depth discussion of the various infectious and inflammatory processes that
can affect the salivary glands.
Received : 16‑06‑2018
Accepted : 06‑10‑2018
Keywords: Mumps virus, salivary gland calculi, salivary glands, sialadenitis,
Published : 15‑11‑2018 Sjogren’s syndrome

Introduction the gland itself, the parotid space is also comprised of

the facial nerve (CN VII), auriculotemporal branches
T he salivary glands constitute a diverse group of
anatomic structures that can give rise to a wide
variety of unique pathology. The major salivary glands
of the mandibular division of the trigeminal nerve (CN
V3), intraparotid lymph nodes, the external carotid
are easily identified on routine imaging and contribute artery, and the retromandiular vein.[1‑3] Although not
to many of the important deep neck spaces of the a true fascial plane, the intraparotid facial nerve
suprahyoid neck. The minor salivary glands are poorly separates the parotid gland into superficial and deep
visualized on routine imaging, but can also give rise portions, an important distinction to make when
to salivary pathology anywhere along the aerodigestive describing a lesion’s location before excision. The
tract. After an extensive review of the radiology, branches of the facial nerve are not always visualized
otolaryngology, and pathology literature, we present a on routine imaging, and therefore, the retromandibular
comprehensive discussion of salivary gland anatomy, vein or stylomandibular tunnel is commonly used as
as well as illustrate the broad range of nonneoplastic surrogate landmark for its location. It is important to
disease that can be visualized in the salivary glands. note that late encapsulation of the parotid gland during
embryogenesis results in the presence of lymphoid
Anatomy of the Major Salivary Glands tissue within the parotid gland. This is a unique feature
among the salivary glands and allows the parotid gland
The parotid gland is the largest of the three major
to develop lymphoid pathology.
salivary glands. It is superficial in location and enclosed
by the superficial layer of the deep cervical fascia Address for correspondence: Dr. Alexander T Kessler,
where it forms the aptly named parotid space. The 601 Elmwood Avenue, Box 648, Rochester,
parotid space is located posterolateral to the masticator New York 14642, USA.
E‑mail: [email protected]
space, lateral to the parapharyngeal space, and
anterolateral to the carotid space [Figure 1]. Aside from This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is
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How to cite this article: Kessler AT, Bhatt AA. Review of the Major and
Minor Salivary Glands, Part 1: Anatomy, Infectious, and Inflammatory
Processes. J Clin Imaging Sci 2018;8:47.
DOI: 10.4103/jcis.JCIS_45_18 Available FREE in open access from: http://www.clinicalimagingscience.
org/text.asp?2018/8/1/47/245527

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 Kessler and Bhatt: Review of the salivary glands: Part 1

The parotid (Stensen’s) duct arises from the anterior inferiorly [Figure 3]. Although not a true fascial plane, a
border of the parotid gland and courses ventrally line drawn through the submandibular gland at the level
along the superficial surface of the masseter muscle. It of the posterior margin of the mylohyoid muscle can be
then makes a gentle turn medially where it pierces the used to separate the submandibular  (superficial) portion
buccinator muscle and opens opposite the 2nd maxillary of the submandibular gland from the sublingual (deep)
molar [Figure  2]. It is important to note that 21%–61% portion of the submandibular gland. Aside from the
of individuals have accessory parotid tissue extending superficial portion of the submandibular gland, the
ventrally over the masseter muscle, often with a submandibular space is also comprised of level Ib
secondary duct that drains directly into the main parotid lymph nodes, the facial artery/vein, and branches of the
duct. hypoglossal nerve.[1‑4]
The submandibular gland is the second largest of the The submandibular (Wharton’s) duct arises from
three major salivary glands. It is located deep to the angle the anterior border of the submandibular gland and
of the mandible and straddles both the submandibular courses through the sublingual space in between the
and sublingual spaces. The submandibular space is mylohyoid muscle/sublingual gland laterally and
enveloped in the superficial layer of the deep cervical hyoglossus/genioglossus muscles medially [Figure  3].
fascia and is bounded by the mandible anteriorly, It then continues anteriorly and superiorly where it
anterior belly of the digastric muscle posteromedially, ultimately drains into the sublingual caruncle along the
mylohyoid muscle anterosuperiorly, and hyoid bone side of the frenulum in the floor of the mouth.

a b

c
Figure 1: Parotid space anatomy. (a) Illustration of parotid space anatomy with key landmarks labeled. (b) Axial computed tomography of parotid
space anatomy with key landmarks labeled. (c) Axial T2‑weighted magnetic resonance image of parotid space anatomy with key landmarks labeled.

a b
Figure 2: Parotid (Stensen) duct anatomy. (a) Axial computed tomography of parotid duct anatomy with key landmarks labeled. (b) Axial T2‑weighted
magnetic resonance image of parotid duct anatomy with key landmarks labeled.

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 Kessler and Bhatt: Review of the salivary glands: Part 1

a b

c d
Figure 3: Submandibular space anatomy. (a) Illustration of submandibular and sublingual space anatomy with key landmarks labeled. (b) Axial
computed tomography of submandibular space anatomy with key landmarks labeled. (c) Axial T2‑weighted magnetic resonance image of submandibular
space anatomy with key landmarks labeled. (d) Axial T2‑weighted magnetic resonance image of submandibular duct anatomy with key landmarks
labeled.

The sublingual gland is the smallest of the three major

salivary glands. It is located deep to the body of the
mandible and located with the sublingual space. The
sublingual space is enveloped in the superficial layer of
the deep cervical fascia and is bounded by the mandible
anteriorly, genioglossus/geniohyoid muscles medially,
a b
mylohyoid muscle posterolaterally, and intrinsic
muscles of the tongue superiorly [Figure  4]. Aside Figure 4: Sublingual space anatomy. (a) Axial computed tomography
of sublingual space anatomy with key landmarks labeled. (b) Axial
from the sublingual gland, the sublingual space is also T2‑weighted magnetic resonance imaging image of sublingual space
comprised of the deep portion of the submandibular anatomy with key landmarks labeled.
gland, the submandibular duct, the lingual artery/vein,
and the lingual branch of the mandibular division of Anatomy of the Minor Salivary Glands
the trigeminal nerve (CN V3).[1‑4] The sublingual gland Minor salivary gland tissue is comprised of 800-1000
itself is composed of a major sublingual gland and small salivary glands dispersed throughout the
8–30 small minor sublingual glands. The sublingual submucosa of the sinonasal cavity, oral cavity, pharynx,
duct (Bartholin’s duct) drains the major sublingual gland larynx, trachea, lungs, and middle ear cavity. Although
into Wharton’s duct while multiple tiny ducts of Rivinus minor salivary gland tissue can be found anywhere
drain the minor sublingual glands into the floor of the along the aerodigestive tract, it is most concentrated
mouth. along the buccal mucosa, labial mucosa, lingual mucosa,
The mylohyoid sling acts as the major anatomic soft/hard palate, and floor of mouth  [Figure  6].[1,2]
separator between the submandibular space Minor salivary gland tissue is not normally seen on
inferolaterally from the sublingual space superomedially. conventional imaging, but can become apparent when
However, it is important to note that these two spaces replaced by tumor or benign processes, most commonly
freely communicate via a gap along the posterior mucus retention cysts.[7]
margin of the mylohyoid muscle [Figure  5]. Up to
77% of individuals have a cleft  (boutonniere) in the
Infectious/Inflammatory Processes of
mylohyoid muscle allowing for a 2nd pathway for spread the Salivary Glands
of disease between the two spaces. This cleft is often Sialolithiasis
filled with fat or a herniated portion of the sublingual Sialolithiasis, or calculus disease, is the most common
gland [Figure 5].[5,6] benign process to affect the salivary glands, with a

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 Kessler and Bhatt: Review of the salivary glands: Part 1

reported prevalence of 1.2%.[8] The pathogenesis of is a high suspicion for a nonradiopaque calculus,
sialolithiasis is highly debated, but thought to be due conventional sialography can be performed [Figure 8].
to stagnation of saliva that is high in calcium. Risk Alternatively, many institutions have now adopted
factors include dehydration, smoking, and various magnetic resonance  (MR) sialography  (single‑shot
medications (most commonly anticholinergics and fast spin echo heavily T2‑weighted sequence
diuretics). The majority of calculi are found within similar to an MR cholangiopancreatography) as a
the submandibular gland  (80%–92%), likely due to means to identify these previously “occult” calculi.
the fact that the submandibular gland produces highly Sialography (conventional or MR imaging) provides
viscous saliva that needs to travel upward against the additional benefit of a global assessment of
gravity as it traverses Wharton’s duct.[9,10] The remaining the salivary gland ductal system, allowing for the
calculi are found in the parotid gland  (6%–20%) and identification of strictures and changes related to
sublingual/minor salivary glands (1%–2%). chronic inflammation.
Patients with sialolithiasis typically present with Sialadenitis
painful salivary glands, exacerbated by eating foods Sialadenitis is a general term used to denote an
that precipitate saliva production. Unenhanced CT infectious or inflammatory process of the salivary
has replaced radiography as the first‑line imaging glands. This is not to be confused with sialosis, which
test to workup sialolithiasis, mostly due to its
refers to bilateral symmetric painless enlargement of the
improved sensitivity for detecting calcifications,
salivary glands often due to diabetes, alcohol, obesity,
intraglandular masses, and adjacent inflammatory
or medications. Sialadenitis can be due to a variety
standing [Figure  7]. If no calculus is found and there
of causes including viral, bacterial, fungal, parasitic,

a b c
Figure  5: Mylohyoid sling/cleft.  (a) Axial T2‑weighted magnetic
resonance image demonstrates the mylohyoid sling with normal
free communication posteriorly between submandibular and
sublingual spaces  (white arrow).  (b) Axial T2‑weighted magnetic
resonance image demonstrates a fat‑filled mylohyoid cleft
(white arrow). (c) Axial T2‑weighted magnetic resonance imaging
image demonstrates a mylohyoid cleft containing herniated sublingual
gland (white arrow).

Figure 6: Minor salivary gland distribution in the oral cavity (purple).

Figure  8: Sialolithiasis  –  Sialography. Right submandibular duct

Figure  7: Sialolithiasis  –  computed tomography. Axial computed sialogram in a 36‑year‑old female demonstrates a filling defect
tomography image demonstrates a submandibular duct sialolith (white arrow) at the expected location of the hilum of the submandibular
(red arrow) with dilated proximal duct (yellow arrow). gland, compatible with a calculus.

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immunologically mediated disease, and granulomatous in HIV patients is most commonly due to the same
processes. Of these, infection is the most common cause viral/bacterial pathogens as non‑HIV patients, they can
of sialadenitis, typically due to viral or polymicrobial develop a separate entity referred to as HIV‑associated
bacterial pathogens. salivary gland disease. This is characterized by
Infectious sialadenitis progressive, painless swelling of the bilateral salivary
glands due to the formation of benign lymphoepithelial
Worldwide, viral sialadenitis is most commonly
cysts (BLECs).[14] Although rare in patients receiving
due to mumps virus; however, many other viruses
highly active antiretroviral therapy, this entity can
including parainfluenza, influenza, coxsackie,
be seen in HIV patients with poorly controlled CD4
Epstein–Barr virus, herpes simplex virus, and HIV
counts [Figure 10].
have also been implicated. In the United States,
aggressive vaccination has significantly decreased the Unlike viral sialadenitis, bacterial sialadenitis presents
prevalence of mumps sialadenitis, with approximately with acute unilateral salivary gland swelling without
300  cases reported annually.[11] That being said, a preceding prodromal period. The most common
mumps sialadenitis has been well described in the bacterial pathogens are Staphylococcus aureus and
literature and provides a framework for understanding anaerobes; however, Gram‑negative organisms
the pathophysiology of most types of viral predominate in the hospitalized subset of
sialadenitis. Clinically, mumps sialadenitis begins patients.[15] On imaging, classic findings include
with a prodromal period followed by acute bilateral unilateral enlargement of a salivary gland, fat
salivary gland swelling typically affecting the parotid stranding, and thickening of the superficial cervical
glands. However, it is important to note that up to fascia and platysma muscle [Figure  11]. In these
30% of mumps infections can be asymptomatic or patients, it is important to look for additional findings
may present as vague upper respiratory symptoms that suggest that the sialadenitis will not resolve with
without salivary gland swelling. On imaging, classic conservative therapy alone. These include the presence
findings include bilateral enlargement of the salivary of a drainable abscess or a large calculus  (>10 mm)
glands, fat stranding, and thickening of the superficial that will have difficulty passing on its own without
cervical fascia and platysma muscles [Figure  9].[12,13] surgical retrieval [Figure 12].[1] Many predisposing risk
Although bilateral involvement is seen in up to 75% factors for infectious sialadenitis have been identified
of patients, a small minority of patients may present and are generally broken down into two categories:
with only unilateral involvement. In these cases, modifiable and nonmodifiable. Modifiable risk factors
clinical confirmation through the detection of include dehydration, malnutrition, sialolithiasis,
anti‑mumps immunoglobulin‑M (IgM) antibodies, IgG recent surgery, and medications (anticholinergics,
titer, or viral polymerase chain reaction is required. diuretics, and chemotherapy). Nonmodifiable risk
factors include age (elderly), anorexia nervosa, cystic
HIV patients are an interesting demographic with
fibrosis, diabetes, HIV/AIDS, hepatic/renal failure,
regard to infectious sialadenitis. Although sialadenitis
and prior radiation.

Figure  10: HIV Sialadenitis. A  44‑year‑old female with HIV not on

highly active antiretroviral therapy (CD4 109) presenting with 1 month
Figure 9: Viral Sialadenitis. Axial computed tomography in a 14‑year‑old of progressive painless bilateral parotid swelling. Axial computed
female with bilateral parotid pain and swelling demonstrates symmetric tomography demonstrates heterogeneous attenuation throughout the
enlargement of the parotid glands with subtle stranding in the adjacent parotid glands with prominent cystic lesions (white arrows), benign
fat (white arrows). Blood work was positive for parainfluenza virus. lymphoepithelial cysts.

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 Kessler and Bhatt: Review of the salivary glands: Part 1

Inflammatory sialadenitis
Autoimmune sialadenitis refers to a group of
noninfectious disorders that result in chronic
inflammation and fibrosis of the salivary glands.
Two of the more common autoimmune processes
include Sjogren’s syndrome and sarcoidosis. Sjogren’s
sialadenitis is a female predominant disorder  (>90%)
most commonly seen in the postmenopausal age
group  (50–70  years of age). However, there is a
juvenile subtype seen in men aged  <20  years that
typically resolves at puberty. Sjogren’s sialadenitis a b
is classified into two types. Sjogren’s type  1 Figure  11: Bacterial sialadenitis. (a) Axial computed tomography
in a 70‑year‑old male with acute right parotid swelling and purulent
disease (Mikulicz’s disease or “sicca syndrome drainage. (b) Axial computed tomography in a 69‑year‑old female with
without a connective tissue disorder”) refers to acute left submandibular swelling. Both cases demonstrate asymmetric
autoimmune inflammation of the salivary glands enlargement of a salivary gland with thickening of the adjacent platysma
muscle and stranding in the subcutaneous fat (white arrows). Both cases
without a systemic collagen vascular disorder. These resolved clinically after antibiotics.
patients present with xerostomia and have been
recently incorporated into the IgG4 spectrum of
disease. Sjogren’s type 2 disease refers to autoimmune
inflammation of the salivary glands with a systemic
autoimmune process (rheumatoid arthritis > systemic
lupus erythematous > scleroderma). On imaging,
early changes of Sjogren’s sialadenitis include
enlarged parotid glands, small cysts, and mild fatty
replacement [Figure  13]. As the disease process
becomes chronic, imaging findings shift toward
parotid atrophy, larger areas of fatty replacement,
parenchymal calcifications, solid masses of lymph
node aggregates, and either large areas of cystic
destruction or multiple lymphoepithelial cysts (similar
to HIV BLECs).[16] On sialography, chronic Sjogren’s
sialadenitis demonstrates alternating ductal stenosis Figure  12: Salivary gland abscess. A  69‑year‑old male presents with
and dilatation (“string of beads” sign) [Figure  14]. left submandibular swelling and purulent drainage. Axial computed
It is important to note that patients with Sjogren’s tomography demonstrates asymmetric enlargement of the left
submandibular gland with thickening of the adjacent platysma and
sialadenitis carry a 14‑fold increased risk of fat stranding. A large 1.2 cm sialolith (white arrow) and 2 cm abscess
developing non‑Hodgkin’s lymphoma [Figure 15].[17] (yellow arrow) are also present. The patient ultimately required surgical
excision of the submandibular gland and abscess drainage.
Sarcoid sialadenitis refers to chronic inflammation of the
salivary glands in patients with sarcoidosis. It is seen
in 10%–30% of patients with sarcoidosis and patients
typically present with painless bilateral parotid swelling.
Imaging may show nonspecific intraparotid masses
corresponding to granulomatous lymph node aggregates.
Alternatively, imaging may show symmetric enlargement
and hypervascularity of the parotid and lacrimal a b
glands [Figure  16], producing the classic “Panda sign” Figure 13: Early Sjogren’s syndrome. Axial computed tomography (a) and
on gallium‑67 scans.[18] axial T2‑weighted magnetic resonance image (b) demonstrate enlarged
parotid glands with areas of cystic changes (white arrows).
Chronic sclerosing sialadenitis, also known as Kuttner’s
tumor, refers to chronic enlargement of the salivary majority of cases involve the submandibular glands, and
glands due to an immune‑mediated infiltration of recent literature has demonstrated a strong association
lymphoplasmacytic cells. Although quite rare, this with IgG4‑related disease. In fact, a recent case
disease entity has a peak incidence in the 6th–8th decades, series by Geyer et  al., demonstrated IgG4 plasma cell
with a slight male predilection.[19] The overwhelming infiltrates in 92% of patients with chronic sclerosing

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 Kessler and Bhatt: Review of the salivary glands: Part 1

sialadenitis.[20] On imaging, the involved gland is doses  >45  Gy and is thought to represent contrast
enlarged and demonstrates homogeneous enhancement, expanding the extracellular space that was once
often mimicking a malignant neoplasm. Advanced MR occupied by acinar cells lost from radiation.[23] Over
imaging with diffusion-weighted imaging and dynamic time, chronic scarring/fibrosis leads to volume loss and
contrast-enhanced (DCE) perfusion imaging is also MR imaging typically demonstrates low‑to‑intermediate
nonspecific, although low apparent diffusion coefficient signal intensity on all sequences.[24]
(ADC) signal and rapid washout on DCE time curves
have been described.[21] Although biopsy is often needed Conclusion
to confirm the diagnosis, knowledge of this entity can A variety of disease processes can occur within salivary
help avoid misdiagnosis, as well as initiate the workup gland tissue, and it is important to be familiar with their
for other sites of IgG4‑related disease. imaging findings. However, the rarity in which salivary
pathology is encountered often leads to improper
Postradiation sialadenitis
characterization or misidentification. By illustrating the
Radiation‑induced sialadenitis is frequently seen normal anatomy and common infectious/inflammatory
in patients who receive radiation treatment for processes within the major and minor salivary glands
oropharyngeal cancer. The first clinical signs of across multiple imaging modalities, we hoped to enhance
sialadenitis manifest as decreased saliva flow and have
been reported to occur with radiation dose thresholds
as low as 15  Gy.[22] The classic imaging findings of
radiation‑induced sialadenitis include hyperenhancement
of the salivary glands that progresses to atrophy over
time [Figure  17]. This hyperenhancement occurs with

a b
Figure 14: Chronic Sjogren’s syndrome. (a) Axial computed tomography
demonstrates atrophic parotid glands with multiple parenchymal Figure 15: Sjogren’s syndrome with lymphoma. A 76‑year‑old female
calcifications. (b) Sialogram of the left submandibular duct demonstrates with a history of Sjogren’s syndrome with bilateral palpable cervical
multifocal areas of narrowing/irregularity through the main duct with lymph nodes. Axial computed tomography demonstrates multiple mildly
pruning of the intraglandular ducts (white arrows). enlarged level Ib and IIb lymph nodes (white arrows). Biopsy proved
non‑Hodgkin lymphoma.

Figure  16: Sarcoid sialadenitis. A  51‑year‑old male with a history of

pulmonary sarcoidosis presents with bilateral parotid swelling. Coronal T1 Figure 17: Radiation‑induced sialadenitis. Axial computed tomography
FS + C images demonstrate marked enlargement and hyperenhancement demonstrates hyperenhancement of the bilateral submandibular glands in
of the bilateral parotid glands  (white arrows), presumably reflecting a patient recently treated with external beam radiation for oropharyngeal
sarcoid sialadenitis. cancer.

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