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2 윤대영 외: 귀밑샘 림프절병증 중 14명(70%)에서는 귀밑샘부위 종괴로 촉지되었고 10명 (50%)에서는 압통 및 불쾌감을 호소하였다. 전이암, 결핵성 림프절염, 림프종 12예의 경우, 전이암 및 결핵성림프절염 각 각 1예를 제외한 10예에서 귀밑샘부위 종괴로 촉지되었다. 비특이적 양성염증성림프절병증의 경우, 4예에서 세침흡인 생검술을 통한 병리조직학적 진단이 이루어졌으며 나머지 16 예에서는 2주부터 6개월 사이에 1회 이상의 초음파 추적검사 를 통해 병변의 소실이나 현저한 크기감소로 진단하였다. 병 변의 크기에 변화가 없었던 병변들은 정상 림프절이나 낭종 으로 판단하여 대상에서 제외하였다. 모든 예에서 초음파를 시 행하였고, 19예에서 색 도플러초음파, 8예에서는 조영증강 CT 를 같이 시행하였다. 전이암, 결핵성림프절염, 림프종의 경우, 귀밑샘림프절에 생긴 병변이 병리조직학적으로 확진된 경우 만을 대상에 포함하였고 모든 예에서 조영증강 CT를 시행하 였다. 전이암 5예의 원발성 병소는 후두암, 안면부 피부의 혈 관육종(angiosarcoma), 비인두암, 갑상선암 및 위암이 1예씩 이었으며 이중 후두암과 혈관육종은 수술 후 재발한 경우였 다. 사용한 초음파 기종은 모든 환자에서 Sequoia 512 (Acuson, Mountain View, CA, U.S.A.) 이었으며 15L8W 선형 탐촉자 A B Fig. 1. Nonspecified benign inflammatory lymphadenopathy in a 26-year-old woman. A. Longitudinal sonogram of the left parotid gland shows a well-marginated, elliptical, small hypoechoic nodule in the superficial lobe. Note the associated large area of hilar echogenecity and posterior sonic enhancement. B. Post-contrast CT scan shows a well-defined enhancing nodule (arrow) located superficially in the left parotid gland. Note low density located somewhat eccentrically within nodule, suggesting normal fatty hilum. A B C Fig. 2. Cytologically proved nonspecified benign inflammatory lymphadenopathy in an 18-year-old woman. A. Longitudinal sonogram of the right parotid gland shows a well-marginated, ovoid, small hypoechoic nodule (arrow), devoid of normal hilar echogenecity. B. Post-contrast CT scan shows a well-defined enhancing nodule (thick arrow) in the superficial lobe of right parotid gland. Note another separate intraparotid lymph node in the retromandibular area (not proven)(thin arrow). C. Follow-up sonogram obtained two weeks later reveals the decreased size of the node, compared with that shown in A. 94

3 Table 1. US and Color Doppler US Findings of Intraparotid Nonspecified Benign Inflammatory Lymphadenopathy Findings Number of Lymph Nodes Shape rounded 09 (35%) oval shape 17 (65%) US (n=26) Echogenicity (in comparison with normal parenchyma) hypoechoic 26 (100%) iso or hyperechoic 0 (0%)0 Central echogenic complex present 12 (46%) absent 14 (54%) Central vascularity 13 (68%) Doppler US Peripheral vascularity 0 (0%) (n=19) No vascularity 06 (32%) Fig. 3. Intraparotid metastases from stomach cancer in a 46- year-old woman. Transverse CT scan obtained after injection of contrast material shows two masses in the left parotid gland. Homogeneous strong enhancement is seen in the more anteriorly located mass (long arrow) and central low attenuation with peripheral enhancement in more posteriorly located mass (arrowhead). Also noted are multiple, enhancing lymph nodes (short arrows) in the ipsilateral neck. A B Fig. 4. Intraparotid tuberculosis in a 24-year-old woman. A. Transverse CT scan obtained after injection of contrast material shows an ill-defined mass (arrows) with central low attenuation and faint peripheral enhancement in the left parotid gland. Note peripheral rim enhancement. B. Transverse CT scan obtained just below A, shows another smaller necrotic lymph nodes within (black arrow) and outside (white arrow) the parotid gland. 95

4 Table 2. Enhancement Patterns of Various Intraparotid Lymphadenopathies on Contrast-Enhanced CT Enhancement Patterns Homogeneous Homogeneous Peripheral Except Central Hilum NBIL (n=8*) 4 3 Metastasis (n=5) 2 3 TB (n=4) 4 Lymphoma (n=3) 3 NBIL: Nonspecified benign inflammatory lymphadenopathy TB: Tuberculous lymphadenitis * Not visible on CT in 1 patient. Fig. 5. Intraparotid lymphoma in a 48-year-old woman. Transverse CT scan obtained after injection of contrast material shows a large, irregular, well-enhancing soft tissue mass (arrows) in the left parotid gland. A large, destructive soft tissue mass in the left maxillary sinus and soft tissue fullness in the nasopharynx are also seen. 96

5 1. Som PM, Biller HF. High-grade malignancies of the parotid gland: identification with MR imaging. Radiology 1989;173: McKean ME, Lee K, McGregor IA. The distribution of lymph nodes in and around the parotid gland: an anatomical study. Br J Plast Surg 1985;38: Marks NJ. The anatomy of the lymph nodes of the parotid gland. Clin Otolaryngol 1984;9: Pisani P, Ramponi A, Pia F.J. The deep parotid lymph nodes: an anatomical and oncological study. Laryngol Otol 1996;110: Seifert G, Hennings K, Caselitz J. Metastatic tumors to the parotid and submandibular glands-analysis and differential diagnosis of 108 cases. Pathol Res Pract 1986;181: Janmeja AK, Das SK, Kochhar S, Handa U. Tuberculosis of the parotid gland. Indian J Chest Dis Allied Sci 2003;45: Balm AJ, Delaere P, Hilgers FJ, Somers R, Van Heerde P. Primary lymphoma of mucosa-associated lymphoid tissue (MALT) in the parotid gland. Clin Otolaryngol 1993;18: Layfield LJ, Tan P, Glasgow BJ. Fine-needle aspiration of salivary gland lesions: comparison with frozen sections and histologic findings. Arch Pathol Lab Med 1987;111: van den Brekel MW, Stel HV, Castelijns JA, Nauta JJ, van der Waal I, Valk J, et al. Cervical lymph node metastasis: assessment of radi- criteria. Radiology 1990;177: ologic 97

6 10. Vassallo P, Wernecke K, Roos N, Peters PE. Differentiation of benign from malignant superficial lymphadenopathy: the role of high-resolution US. Radiology 1992;183: Chikui T, Yonetsu K, Nakamura T. Multivariate analysis of sonographic findings of metastatic cervical lymph nodes: contribution of blood flow features revealed by power Doppler sonography for predicting metastasis. AJNR Am J Neuroradiol 2000;21: Ying M, Ahuja A, Brook F. Gray scale and power Doppler sonography of normal cervical lymph nodes: comparison between Chinese and white subjects. J Ultrasound Med 2002;21: Na DG, Lim HK, Byun HS, Kim HD, Ko YH, Baek JH. Differential diagnosis of cervical lymphadenopathy: usefullness of color Doppler sonography. AJR Am J Roentgenol 1997;168: Biaek EJ, Jakubowski W, Karpiska G. Role of ultrasonography in diagnosis & differentiation of pleomorphic adenomas: work in progress. Arch Otolaryngol Head Neck Surg 2003;129: Chong VF, Fan YF. Parotid gland involvement in nasopharyngeal carcinoma. J Comput Assist Tomogr 1999;23: King AD, Ahuja AT, Leung SF, Lam WW, Teo P, Chan YL, et al. Neck node metastases from nasopharyngeal carcinoma: MR imaging of patterns of disease. Head Neck 2000;22: Som PM, Curtin HD. Neck; Lymph nodes, Head and Neck Imaging 4th ed. Missouri: Mosby, 2003: , Horii A, Yoshida J, Honjo Y, Mitani K, Takashima S, Kubo T. Preoperative assessment of metastatic parotid tumors. Auris Nasus Larynx 1998;25: Batsakis JG. Parotid gland and its lymph nodes as metastatic sites. Ann Otol Rhinol Laryngol 1983;92: Bhargava S, Watmough DJ, Chisti FA, Sathar SA. Case report: tuberculosis of the parotid gland-diagnosis by CT. Br J Radiol 1996; 69: Hirokawa N, Hareyama M, Akiba H, Satoh M, Oouchi A, Tamakawa M, et al. Diagnosis and treatment of malignant lymphoma of the parotid gland. Jpn J Clin Oncol 1998;28:

7 Intraparotid Lymphadenopathy: Ultrasonographic and CT Findings 1 Dae Young Yoon, M.D., Chul Soon Choi, M.D., Eun Joo Yoon, M.D., Young Lan Seo, M.D., Sang Joon Park, M.D., Soo-Hyun Lee, M.D., Jeung Hee Moon, M.D. 1 Department of Diagnostic Radiology, Hallym University College of Medicine, Kangdong Seong-Sim Hospital Purpose: The purpose of this study was to evaluate the ultrasonographic and CT findings of various diseases that affect the intraparotid lymph node. Materials and Methods: The subjects were 32 patients having various diseases involving the intraparotid lymph node. The final confirmed diagnoses were nonspecified benign inflammatory lymphadenopathy (n=20), metastasis (n=5), tuberculous lymphadenitis (n=4), and lymphoma (n=3). For the nonspecified benign inflammatory lymphadenopathy, there were multiple lesions in five patients and bilateral lesions in two patients, and a total of 26 lesions were included in this study. The pathologic proof of the diagnosis was made for 4 of 26 lesions, and by ultrasound follow-up on 22 of 26 lesions. All the patients underwent ultrasound. Color Doppler imaging was also performed in 19 patients and contrast-enhanced CT was also performed in 8 patients. All cases with metastasis, tuberculous lymphadenitis and lymphoma were pathologically confirmed and these patients were all examined with contrast-enhanced CT. Results: For the nonspecified benign inflammatory lymphadenopathy, all the lesions were seen at the superficial lobe. All twenty six lesions were observed as well-defined ovoid or round hypoechoic nodules with posterior sonic enhancement on ultrasonography. A central echogenic hilum was seen in 12 of 26 inflammatory lymphadenopathies (46%), and a central hilar vascularity was noted in 13 of 19 inflammatory lymphadenopathies (68%) on color Doppler imaging. Contrast-enhanced CT showed well-defined nodules with homogeneous enhancement in most lesions. In 3 lesions, a central low density hilum was seen within a lymph node. In 12 cases with metastasis, tuberculous lymphadenitis and lymphoma, there were multiple lesions in 6 cases. CT revealed intraparotid masses with or without central necrosis and the associated multiple lymph node enlargements in the ipsilateral neck region, and their appearances were similar to that of parotid mass. Conclusion: Nonspecified benign inflammatory lymphadenopathy involving intraparotid lymph nodes often demonstrated characteristic ultrasonographic findings, including a central echogenic hilum on gray scale US and central hypervascularity on color Doppler ultrasonography. In the metastasic lesions, the tuberculous lymphadenitis and the lymphomas, the multiplicity of lesions and the associated enlarged lymph nodes in the ipsilateral neck region could be helpful in the differential diagnosis. Index words : Lymphatic system, hyperplasia Lymphatic system, neoplasms Parotid gland, neoplasms Parotid gland, US Address reprint requests to : Dae Young Yoon, M.D., Department of Radiology, Kangdong Seong-Sim Hospital, Hallym University College of Medicine, 445 Gil-dong Kangdong-gu, Seoul , Korea. Tel Fax

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