 |
|
|
|
|
|
|
|
|
|
|
|
 |
 |
 |
 |
 |
|
 |
SALIVARY GLAND RED HERRINGS III -- PHLEBOLITHS
Previously in the Newsletter, the Salivary Gland Center (SGC) called attention to two red herrings in salivary gland disease - masseteric hypertrophy and somatoform problems. A third red herring seen in the SGC is the phlebolith.
Phleboliths are calcified thrombi most frequently found in pelvic veins. The next most common site is the head and neck, where phleboliths are associated with the intramuscular hemangioma (IMH). The congenital IMH may become manifest in an adultÌs cervicofacial musculature, typically the masseter and buccinator muscles. Because the purposeless and tortuous IMH vascular channels favor a sluggish vascular flow, thrombi form. Calcification ensues and layering with visible radiographic lamellation develops.
Since the facial IMH is in close proximity to the salivary glands, it can mimic a salivary neoplasm. It is a slowly growing commonly painless mass, and diagnosis is complicated by the fact that the IMH often presents without discoloration or pulsation. Furthermore, a phlebolith within it can be interpreted as a salivary stone. The difference? Sialoliths cause an obstructive sialadenitis with glandular swelling and pain, especially with meals, and a suppurative saliva.
Ordinarily, a normal sialographic pattern will be seen in patients with a facial IMH and phleboliths. However, ductal displacement may result from the physical mass of the IMH. Conversely, sialography will clearly demonstrate a sialolith and the consequent ductal changes seen in obstructive sialadenitis. The CT scan, MRI and ultrasound further enhance preoperative differential diagnosis.
The therapeutic approach to the IMH and its phleboliths is dependent upon a variety of clinical factors - patient age, rapidly of IMH growth, size and location, cosmetics, etc. Steroids, radiotherapy, sclerosing agents, lasers, cryotherapy, and embolization have all been utilized, but surgical excision remains the method of choice. The Salivary Gland Center (SGC) was developed because a void existed in the diagnostic and comprehensive care of patients with salivary gland problems and/or secretory dysfunction. Since the diversity of these salivary conditions presents challenges to the clinician, the SGC is available for referrals. Louis Mandel, DDS Director, Salivary Gland Center (212) 305-9982
|
The
radiologic hallmark of a phlebolith is its laminated concentric
ring (onion-like) appearance while the sialolith is evenly opaque.
Phleboliths usually are multiple in number, small and ovoid in shape.
Sialoliths tend to occur singly, frequently are larger than phleboliths
and have an elliptical shape resulting from confinement within a
salivary duct. Phleboliths are distributed in a randomized pattern,
while sialoliths, particularly when several are present, anatomically
trace the configuration of the involved salivary duct.