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ZusammenfassungDie Aktualisierung der Leitlinie war ein wichtiger Schritt, um mit zunehmender Verbreitung der Sialendoskopie und anderer minimalinvasiver Verfahren Behandlungsstandards zur Therapie der Sialolithiasis und der Speichelgangstenosen zu definieren. Im Rahmen der Aktualisierung wurden die diagnostischen und therapeutischen Algorithmen dem aktuellen Wissensstand angepasst. Sie werden in diesem Artikel in verkürzter Form mit Betonung der praxisrelevanten konservativen Therapieoptionen wiedergegeben.

The update of this guideline was an important step to define standards for the use of sialendoscopy and other emerging minimally invasive techniques for the therapy of sialolithiasis and other obstructive salivary gland diseases. The current actualization was necessary to adapt the diagnostic and therapeutic algorithms to the current scientific knowledge. In this article they are presented in a shortened version with a focus on conservative therapeutic measures which are especially relevant for daily practice.Die Aktualisierung der Leitlinie war ein wichtiger Schritt, um mit zunehmender Verbreitung der Sialendoskopie und anderer minimalinvasiver Verfahren Behandlungsstandards zur Therapie der Sialolithiasis und der Speichelgangstenosen zu definieren. Im Rahmen der Aktualisierung wurden die diagnostischen und therapeutischen Algorithmen dem aktuellen Wissensstand angepasst. Sie werden in diesem Artikel in verkürzter Form mit Betonung der praxisrelevanten konservativen Therapieoptionen wiedergegeben.

Angesichts zunehmender Antibiotika-Resistenzen muss insbesondere der unkritische Einsatz von Antibiotika bei Infektionen der oberen Atemwege gestoppt werden — denn meist sind diese viral bedingt. Die jeweiligen Indikationen und aktuelle Anderungen erfahren Sie hier.

Introduction Diseases of the salivary glands are rare in children and adolescents, with the exception of viral-induced infections. Objective To determine the clinical course of the disease, the diagnostic procedures, the treatment and the outcome of all children and adolescents affected with salivary gland diseases at our clinic over a period of 15 years. Methods A retrospective chart review including a long-term follow-up was conducted among 146 children and adolescents treated for salivary gland disorders from 2002 to 2016. Results Diagnosing acute sialadenitis was easily managed by all doctors regardless of their specialty. The diagnosis of sialolithiasis was rapidly made only by otorhinolaryngologists, whereas diagnosing juvenile recurrent parotitis imposed difficulties to doctors of all specialties – resulting in a significant delay between the first occurrence of symptoms and the correct diagnosis. The severity-adjusted treatment yielded improvements in all cases, and a full recovery of 75% of the cases of sialolithiasis, 73% of the cases of juvenile recurrent parotitis, and 100% of the cases of acute sialadenitis. Conclusions Due to their low prevalence and the lack of pathognomonic symptoms, salivary gland diseases in children and adolescents are often misdiagnosed, resulting in an unnecessarily long period of suffering despite a favorable outcome following the correct treatment.

PURPOSE: Chronic recurrent parotitis (CRP) is a non-obstructive disease with episodes characterized by painful swelling of the parotid gland. It presents in both a juvenile and an adult form, with no clear information on its actual origin. Diagnosis is based on patient medical history and ultrasound examination but is frequently not correctly identified. Acoustic Radiation Force Impulse Imaging (ARFI) is a novel ultrasound elastography technology that has recently been implemented in the diagnostic work-up of patients with malignancies. This study aimed to answer whether ARFI can reasonably be employed in the initial examination and follow-up during therapy in patients with CRP. MATERIAL AND METHODS: Mechanical tissue properties of the salivary glands were analyzed by ARFI in 37 parotid glands of patients with CRP. RESULTS: Having integrated ARFI into our diagnostic protocol for CRP, affected parotid glands were found to exhibit lower tissue elasticity compared to both healthy contralateral glands in the same individuals as well as those of healthy individuals. Most importantly, this method enabled us to quantitatively assess the patient benefit of therapy regarding the recovery of the glands' diseased parenchyma. CONCLUSIONS: ARFI provides a quick, easy, and reliable diagnostic tool for the assessment of disease severity and progression in patients with CRP that can be seamlessly implemented into preexisting ultrasound protocols.

Die juvenile chronisch-rezidivierende Parotitis ist die zweithaufigste entzundliche Speicheldrusenerkrankung bei Kindern. Dennoch wird sie oft erst spat nach unnotig langem Leidensweg der Betroffenen erkannt. Der folgende Beitrag gibt eine Ubersicht uber die Erkrankung, deren Diagnostik sowie Therapiekonzepte und zeigt auf, wie sich Fehldiagnosen vermeiden lassen.

The aim of this study was to assess the interrater reliability of ultrasound for diagnosing sialolithiasis. A total of 100 consecutive patients with signs of obstructive sialadenopathy were evaluated. The patients all underwent ultrasound examinations in a standardized manner conducted by one specialist with extensive experience in the management of salivary gland disorders and proficiency in head and neck ultrasonography. The video recordings were sent to six colleagues with comparable experience without providing any further information about the patients' medical history and physical examination. The overall agreement between the seven observers was substantial, with a κ of 0.765 for the 100 cases and a percentage agreement level of 88.29 ± 3.01 % (range: 83-94 %). The range of agreement on this video set for observer pairs varied from substantial to almost perfect agreement (0.663 to 0.878). Among the few false-negative findings (5.4 %), 71.8 % were due to distal sialolithiasis. Two-thirds of the false-positive findings (3.7 %) were due to fibrotic stenosis. The study confirmed the diagnostic value of ultrasound in sialolithiasis and demonstrated a very high level of interrater agreement, even in the absence of additional clinical patient information, thus further underscoring the importance of ultrasound as the examination of first choice in sialolithiasis.ZIEL: Das Ziel dieser Studie war die Beurteilung der Interrater-Reliabilität der Sonografie in der Diagnose der Sialolithiasis. Insgesamt wurden 100 konsekutive Patienten mit Anzeichen einer obstruktiven Sialadenopathie untersucht. Die Patienten unterzogen sich einer standardisierten sonografischen Untersuchung, die von einem HNO- Arzt mit umfangreicher Erfahrung in der Sonographie und in der Behandlung von Speicheldrüsenerkrankungen durchgeführt wurde. Die Videoaufnahmen wurden an 6 Kollegen mit vergleichbarer Erfahrung gesendet, ohne weitere Informationen über die Krankengeschichte und die körperliche Untersuchung der Patienten zu geben. Die Gesamtübereinstimmung zwischen den 7 Beobachtern war substanziell, mit einem κ von 0,765 für die 100 Fälle und einem prozentualen Übereinstimmungsgrad von 88,29 ± 3,01 % (Bereich 83–94 %). Die Bandbreite der Übereinstimmung in diesem Video-Set für Beobachterpaare variierte von substanziell bis nahezu perfekt (0,663 bis 0,878). Unter den wenigen falsch negativen Befunden (5,4 %) waren 71,8 % auf distale Sialolithiasis zurückzuführen. Zwei Drittel der falsch positiven Befunde (3,7 %) waren auf eine fibrotische Stenose zurückzuführen. Die Studie bestätigte den diagnostischen Wert von Ultraschall bei Sialolithiasis und zeigte eine sehr hohe Interrater-Übereinstimmung, auch ohne zusätzliche klinische Patienteninformationen. Dies unterstreicht die Bedeutung von Ultraschall für die Untersuchung der ersten Wahl bei Sialolithiasis.

Background Radiologic imaging, especially ultrasound has an important role in the assessment of gallbladder alteration. Contrast-enhanced ultrasound (CEUS) is an easy and fast imaging technique that overcomes the limitations of greyscale ultrasonography. It is a safe tool that can be used as an additional imaging modality in order to elucidate and differentiate gallbladder pathological findings. Objective The aim of this retrospective study analysis is to assess the diagnostic performance of CEUS in gallbladder alterations and compare the results to the histopathological findings. Methods A total of 17 patients between 2009 and 2017 with uncertain gallbladder appearance were retrospectively analysed. A single experienced physician with more than fifteen years' experience performed CEUS examinations by applying a second-generation blood pool agent (SonoVue®, Bracco, Milan, Italy). Archived images were interpreted by the same physician and compared to the histopathological findings. Results CEUS results, when correlated to the respectively pathologic findings, presented a sensitivity of 100%, a specificity of 100%, a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 100%. All patients were successfully examined without any adverse reaction. Conclusion In conclusion, the excellent results in this study acknowledged that CEUS is a feasible alternative tool to differentiate gallbladder pathologic alterations.

Background Ultrasound is the method of choice for preoperative evaluation of masses of the parotid glands. However, existing methods do not allow for definite differentiation between the most common benign and malignant tumors. Objective Thus, we evaluated the benefits of Virtual Touch Quantification (VTQ) and Virtual Touch imaging quantification (VTIQ) for improving preoperative evaluation of parotid tumors. Methods We investigated eight lymph nodes and 41 tumors of the parotid gland via ultrasound, color Doppler ultrasound, VTIQ and VTQ shear wave imaging. Each examination consisted of pictures and videos, which were evaluated by twelve examiners. Initially, each examiner predicted whether the mass was benign or malignant based on B-mode and Doppler images. Then each examiner viewed the VTIQ and VTQ shear wave images and reevaluated the predictions, which were then compared with the histopathological outcomes. Results In tumors, the sensitivity was 36% based only on B-mode and color Doppler sonography, which increased to 42% with the addition of VTIQ and VTQ. Likewise, the specificity also increased from 78% to 85%. Conclusions VTQ and VTIQ provide additional data that improve the capability to distinguish between benign and malignant tumors allowing for an increase in both the sensitivity and specificity.

Background Contrast-enhanced ultrasound (CEUS) has been used as an additional imaging technique to conventional ultrasound in order to clarify gallbladder findings, CEUS is easy and fast to perform, overcomes the limitations of gray-scale ultrasonography and is a safe tool. Objective The aim of this retrospective mono-center analysis study is to evaluate the diagnostic performance of CEUS in the assessment of gallbladder disease by comparing its results with additional CT findings. Methods A total of 24 patients between 2009 and 2017 with unclear gallbladder appearance were retrospectively analysed. The contrast agent administered was a second-generation blood pool agent (SonoVue®, Bracco, Milan, Italy). Examinations were performed and interpreted by a single experienced radiologist with more than fifteen years' experience. Results 24 patients were successfully examined without any adverse reaction. CEUS presented a sensitivity of 75%, a specificity of 100.0%, a positive predictive value of 100.0% and a negative predictive value of 95%. Conclusions In conclusion, the excellent results in this study acknowledged that CEUS is a feasible alternative tool to differentiate gallbladder pathologic alterations.

PURPOSE To evaluate the diagnostic benefits of multimodality imaging using image fusion with magnetic-resonance-imaging (MRI) and contrast-enhanced-ultrasound (CEUS) in an experimental small-animal-squamous-cell-carcinoma-model for the assessment of tissue hemodynamics and morphology. MATERIAL AND METHODS Human hypopharynx-carcinoma-cells were injected subcutaneously into the left flank of 15 female athymic nude rats. After 10 daysof subcutaneous tumor growth, CEUS and MRI measurements were performed using a high-end-ultrasound-system and 3-T-MRI. After successful point-to-point or plan registration, the registered MR-images were simultaneously shown with the respective ultrasound sectional plane. Data evaluation was performed using the digitally stored video sequence data sets by two experienced radiologists using a subjective 5-point scale. RESULTS CEUS and MRI are well-known techniques for the assessment of tissue hemodynamics (score: mean 3.8 ± 0.4 SD and score 3.8 ± 0.4 SD). Real-time image fusion of MRI and CEUS yielded a significant (p < 0.001) improvement in score (score 4.8 ± 0.4 SD). Reliable detection of small necrotic areas was possible in all animals with necrotic tumors. No significant intraobserver and interobserver variability was detected (kappa coefficient = +1). CONCLUSION Image fusion of MRI and CEUS gives a significant improvement for reliable differentiation between different tumor tissue areas and simplifies investigations by showing the morphology as well as surrounding macro-/microvascularization.

Zervikale Raumforderungen sind haufig und konnen in jedem Lebensabschnitt auftreten. Die meisten sind harmlos und nicht therapiebedurftig, jedoch gibt es auch eine Anzahl von ernst zu nehmenden Krankheitsbildern, die einer sofortigen Intervention bedurfen. Wichtig ist es, schnell und sicher zu erkennen, was bei dem jeweiligen Patienten vorliegt.

Background and Objectives Sialolithiasis is a common disease of the major salivary glands. Owing to the variety of conservative and minimally invasive techniques, it is now possible to treat most cases of sialolithiasis without removal of the affected salivary gland. One treatment option is the endoscopic removal of the calculi. In cases of larger concretions, intraductal disintegration using laser-induced shock waves can be appropriate to allow endoscopic removal. In the present study, we investigated whether physical and radiological parameters of salivary stones can effectively predict the applicability of laser lithotripsy. Furthermore, we determined to what extent the applied laser energy resulted in tissue damage. Study Design/Materials and Methods In addition to basic parameters like size and density, we analysed 47 salivary stones using fluorescence spectroscopy, infrared spectroscopy, Raman spectroscopy, and dual-energy computed tomography. Subsequent fragmentation of all stones was performed with a Ho:YAG laser in a near-contact manner. Fragmentation rates were calculated and correlated with the previously measured physical and radiological parameters. Finally, to test for tissue damage, we performed HE-histology of salivary duct mucosa treated with the same laser energy used for stone fragmentation. Results Blue light excitation induced either green or red fluorescence emission. Dual-energy CT resulted in evidence of calcium-containing material. Infrared spectroscopy and Raman spectroscopy, both identified carbonate apatite as the main component of salivary stones. Disintegration into pieces smaller than 2 mm was possible in all cases. Fragmentation rates depended on the energy per pulse applied but not on any of the analysed physical and radiological parameters. In contrast to lithotripsy with 500 mJ per pulse, which was associated with no tissue damage, lithotripsy with 1,000 mJ per pulse resulted in damage of salivary duct mucosa. This suggests that the optimal laser energy for stone fragmentation is between 500 and 1,000 mJ per pulse. Conclusion Laser lithotripsy using Ho:YAG laser is a highly efficient treatment, at least in vitro. All salivary stones could be disintegrated irrespective of their physical and radiological composition. Lasers Surg. Med. 47:342–349, 2015. © 2015 Wiley Periodicals, Inc.

Background Novel anti-angiogenic treatments are increasingly complementing established cancer therapy strategies in head and neck tumors. Contrast-enhanced magnetic resonance imaging (MRI) can be applied for early and non-invasive therapy monitoring by non-invasive quantitative assessment of tumor microcirculation as in vivo imaging biomarkers of therapy response. Purpose To monitor the anti-angiogenic effects of a novel combination therapy on experimental head and neck squamous cell carcinomas (HNSCC) with dynamic contrast-enhanced (DCE)-MRI. Material and Methods Athymic rats ( n = 18) with subcutaneous HNSCC xenografts were investigated by DCE-MRI before and after 7 days of a daily triple therapy regimen combining the COX-II-inhibitor celecoxib, the matrix-metalloproteinase-inhibitor GM6001, and the uPA-inhibitor upamostat. Quantitative measurements of tumor blood flow (tBF), tumor blood volume (tBV), and permeability-surface area product (PS) were calculated and validated by immunohistochemistry. Results Mean tBF and tBV in triple-therapy animals decreased significantly from day 0 to day 7 (tBF, 41.0 ± 14.2 to 20.4 ± 5.7 mL/100 mL/min; P 0.05). Immunohistochemical analysis showed a significantly lower tumor vascularity in the therapy group than in the control group (CD31), significantly fewer Ki-67+ proliferating tumor cells and significantly more Capase-3+ apoptotic tumor cells ( P Conclusion DCE-MRI may be a suitable tool for the non-invasive monitoring of the anti-vascular effects of this innovative triple therapy regimen with potential for clinical translation.

BACKGROUND: It is difficult to assess tumors of the parotid gland preoperatively. However, it is essential for the surgeon to know which kind of tumor is present. Ultrasound is the method of choice, but there is still no reliable differential diagnostic tool for determining whether a tumor is malignant or benign. OBJECTIVE: The aim of our study was to examine the value of Virtual Touch imaging quantification (VTIQ) elastograpy in distinguishing between malignant and benign tumors as well as in identifying the most common benign tumor types. METHODS: The parenchyma of 100 parotid glands and 12 lymph nodes of healthy volunteers and 50 tumors of the parotid gland were analyzed via ultrasound, color Doppler ultrasound, and VTIQ, and the results were then compared with histopathology. RESULTS: In comparison with benign tumors, in malignant tumors the tumor border was diffuse, the perfusion higher, and the VTIQ quality much lower. Share wave velocity of the user-defined region of interest was more frequently higher than 6.8 m/s in malignant tumors in comparison to benign tumors. CONCLUSIONS: VTIQ in combination with ultrasound examination provides additional information for distinguishing between benign and malignant tumors and shows promise for integration into preexisting ultrasound protocols.

Karzinome des Oropharynx mit Assoziation zu Hochrisikotypen des humanen Papillomvirus (HPV) wurden als eine klinisch relevante und eigenstandige Tumorentitat mit gunstiger Prognose identifiziert, und von klassischen noxenassoziierten Karzinomen unterschieden. Sie entwickeln sich uber eine onkogene Transformation von Basalzellen des lymphoepithelial retikulierten Kryptenepithels der Gaumentonsillen und des Zungengrunds. Es besteht ein starker Zusammenhang zwischen HPV-Positivitat und atypischer nichtkeratinisierender histologischer Differenzierung sowie zystischem Charakter von Lymphknotenmetastasen. Eine stark positive immunhistologische Reaktion von p16 in Lymphknotenmetastasen und/oder im Primartumor erfasst zuverlassig eine transkriptionell aktive Hochrisiko-HPV-Infektion und wird unter bestimmten Voraussetzungen fur die Routinediagnostik als ausreichender Nachweis erachtet. Eine haufige lymphogene Metastasierung und eine oft erhebliche Grose der (zystischen) Metastasen begunstigen, zusammen mit einer haufig nur geringen Grose und submukosen Lokalisation der Primartumoren, eine initiale Manifestation als zervikales Karzinom unbekannter Herkunft (CUP). Bei entsprechender CUP-Konstellation ist bereits an der Lymphknotenmetastase eine HPV-Diagnostik (bei negativem Ergebnis ggf. anschliesend eine Epstein-Barr-Virus(EBV)-Diagnostik) wegen der zuverlassigen Vorhersage der Lokalisation von okkulten Primarkarzinomen sinnvoll. Eine intensive klinisch-pathologische Zusammenarbeit tragt zu einer moglichst haufigen Detektion von kleinen okkulten Primarkarzinomen bei. Die Bedeutung dieser neuen Karzinomentitat wird steigen, da weltweit eine starke Zunahme der Inzidenz beobachtet wird.

Speichelsteine treten vor allem in der dritten und funften Lebensdekade auf. In 90% der Falle ist die Glandula submandibularis betroffen. Typischerweise geben die Patienten essensabhangige Schwellungen an, die durch Verlegung des Gangsystems zu erklaren sind. Fruher erfolgte eine Drusenexstirpation mit dem Risiko der Gesichtsnervenverletzung. Heute ist dank technischer Innovationen die minimal-invasive, drusenerhaltende Therapie der Standard.

PURPOSE To evaluate the ultrasound tissue elasticity imaging by comparison to multimodality imaging using image fusion with Magnetic Resonance Imaging (MRI) and conventional grey scale imaging with additional elasticity-ultrasound in an experimental small-animal-squamous-cell carcinoma-model for the assessment of tissue morphology. METHOD AND MATERIALS Human hypopharynx carcinoma cells were subcutaneously injected into the left flank of 12 female athymic nude rats. After 10 days (SD ± 2) of subcutaneous tumor growth, sonographic grey scale including elasticity imaging and MRI measurements were performed using a high-end ultrasound system and a 3T MR. For image fusion the contrast-enhanced MRI DICOM data set was uploaded in the ultrasonic device which has a magnetic field generator, a linear array transducer (6-15 MHz) and a dedicated software package (GE Logic E9), that can detect transducers by means of a positioning system. Conventional grey scale and elasticity imaging were integrated in the image fusion examination. After successful registration and image fusion the registered MR-images were simultaneously shown with the respective ultrasound sectional plane. Data evaluation was performed using the digitally stored video sequence data sets by two experienced radiologist using a modified Tsukuba Elasticity score. The colors "red and green" are assigned for an area of soft tissue, "blue" indicates hard tissue. RESULTS In all cases a successful image fusion and plan registration with MRI and ultrasound imaging including grey scale and elasticity imaging was possible. The mean tumor volume based on caliper measurements in 3 dimensions was ~323 mm3. 4/12 rats were evaluated with Score I, 5/12 rates were evaluated with Score II, 3/12 rates were evaluated with Score III. There was a close correlation in the fused MRI with existing small necrosis in the tumor. None of the scored II or III lesions was visible by conventional grey scale. CONCLUSION The comparison of ultrasound tissue elasticity imaging enables a secure differentiation between different tumor tissue areas in comparison to image fusion with MRI in our small study group. Therefore ultrasound tissue elasticity imaging might be used for fast detection of tumor response in the future whereas conventional grey scale imaging alone could not provide the additional information. By using standard, contrast-enhanced MRI images for reliable and reproducible slice positioning, the strongly user-dependent limitation of ultrasound tissue elasticity imaging may be overcome, especially for a comparison between baseline and follow-up measurements.

Ultrasound examination is the imaging procedure with the best predictive diagnostic capability for the salivary glands. Due to the salivary glands' relatively superficial anatomical location, clear boundary from surrounding tissue and comparatively typical echogenicity, therefore sonography is ideal for diagnosis. In addition, the technical advances in recent years, including higher resolution, color Doppler sonography, contrast-enhanced ultrasound, elastography, and tissue harmonic have lead to an improvement in diagnostic accuracy of sonography further resulting in an expansion of the range of indications. Sonography allows detection of obstructive salivary gland diseases such as stenosis or sialolithiasis, as well as sialadenosis such as Sjögren syndrome. Ultrasound examination alone is sufficient to diagnose benign tumors. However, in the case of malignant tumors, computer tomography or MRI may be also required, especially to determine the question of infiltration of the skull base.

In order to remove stones from the salivary system, different methods are in clinical use. Because of insufficient information about laser impact on salivary stones and its possible interaction with tissue, experiences using clinically available laser systems were summarized. The role of the composition of the salivary stone, laser type, or laser parameter chosen by the physician is described. It was found that salivary stone composition showed no correlation with fragmentation properties using the Ho:YAG laser. Thus, a specific differential diagnostic and decision for specific laser parameter by the handling physicians is not needed. Optical techniques like intraoperative fluorescence guidance may support the physician directly targeting the stone and may prevent the soft tissue from laser impact. For Ho:YAG laser-assisted lithotripsy of salivary stones low energy per pulse and repetition rates, e.g., 0.5 J/pulse and 3 Hz, could be recommended. Thus, side effects to soft tissue can be reduced.

Bei der Bildfusion von Ultraschall mit anderen schnittbildgebenden Verfahren (CT, MRT) handelt es sich um ein relativ neuartiges Verfahren, welches unter Studienbedingungen jedoch bereits erfolgreich eingesetzt wurde. In der folgenden Machbarkeitsstudie soll der Nutzen weiterfuhrender Anwendungen der sonographischen Bildfusion, dem so genannten Global-Positioning-System- (GPS-) und Needle-Tracking, untersucht werden. Dabei handelt es sich um Instrumente, die insbesondere die Diagnostik und das Staging (GPS-Tracking) bzw. die bioptische Abklarung (Needle-Tracking) von Patienten mit fokalen Leberlasionen erleichtern. In diesem Artikel werden das Prinzip und die Anwendungsmoglichkeiten dieser neuen Techniken anhand konkreter Beispiele in einem Kollektiv von 20 Patienten mit fokalen Leberlasionen vorgestellt und erlautert.

Aims To investigate a large series of cases of carcinoma ex pleomorphic adenoma (CEPA) to determine prognostic factors. Methods and results Thirty cases of CEPA associated with primary pleomorphic adenoma (PA) and 11 cases of CEPA associated with recurrent PA were investigated. The median follow-up was 57.7 months, and ranged from 4 to 156 months. Purely intraductal carcinoma was found in 15 cases. Intraductal and extraductal intracapsular carcinoma together was found in one case. Extracapsular carcinoma was found in 25 cases. Prognosis was good for CEPA that was purely intraductal, extraductal intracapsular, or up to 5 mm extracapsular, and poor for CEPA that was 8 mm or more extracapsular. There were relatively more cases of CEPA with extracapsular invasion of 8 mm or more from recurrent PA than from primary PA, and the prognosis for CEPA associated with recurrent PA was worse than that for CEPA associated with primary PA. Conclusions The threshold for distinguishing minor extracapsular invasion with good prognosis from wide extracapsular invasion with poor prognosis is 5 mm. The worse prognosis for CEPA associated with recurrent PA indicates the necessity for close surveillance of patients with recurrent PA.

Obstructive diseases of the salivary glands are a common problem in otorhinolaryngology. They are mostly due to sialolithiasis followed by duct stenosis and other rarer causes. Several diagnostic modalities exist which allow classification of the disease; however, in 5-10% of all cases ultrasound and conventional radiological imaging do not provide a clear diagnosis. Ultrasound examination with contrast material injected into the duct (IA-CEUS, intraductal administered contrast-enhanced ultrasound) enables improved evaluation of obstructive diseases of the salivary glands and at the same time an evaluation of the parenchyma of the glands is possible. As a complementary method to conventional investigation techniques IA-CEUS is an economic and rapid method with low side-effects which improves the diagnostic assessment of ultrasound and results in a better treatment for patients.

Obstructive diseases of the salivary glands are a common problem, usually based on sialolithiasis, duct stenosis, foreign bodies or other more rare causes. Secretory dysfunction, often associated with Sjögren syndrome or post radiation treatment, is also a frequent problem. Several diagnostic tools exist to classify the disease; however conventional radiological imaging or ultrasound does not provide a diagnosis in 5-10% of all cases. Intraductally applied contrast-enhanced ultrasound (IA-CEUS) improves the visualization of obstructive diseases of the salivary glands. IA-CEUS is a promising tool for assessing the ductal system and to diagnose and characterize abnormalities. This study describes the assessment of IA-CEUS in diagnosing different obstructive and chronic inflammatory conditions of the salivary glands.

OBJECTIVES: Ultrasound is the method of choice for preoperative evaluation of tumours of the parotid glands. However, existing methods do not allow for clear differentiation between the most common benign tumours and malignant tumours. The aim of our study was to evaluate if acoustic radiation force, Virtual Touch Quantification (VTQ) elastography helps to improve the preoperative evaluation of parotid masses. METHODS: We investigated the parenchyma of 102 parotid glands, 14 lymph nodes of healthy volunteers and 51 tumours of the parotid gland via ultrasound, colour Doppler ultrasound and VTQ. The results were matched with histopathology and analyzed. RESULTS: The perfusion in pleomorphic adenoma, the most frequent benign tumour of the parotid gland, was significantly lower in comparison to malignant tumours. All tumours showed statistically significant higher perfusion in comparison to the parenchyma or the lymph nodes of the gland. Shear wave velocity of the user-defined region of interest was statistically significant more frequently an overflow value higher than 8.5 m/s in total tumours in comparison to parenchyma or lymph nodes. The different tumour types presented no significant difference in the shear wave velocity. CONCLUSIONS: VTQ in combination with classical ultrasound examination provides additional data useful in distinguishing between benign and malignant tumours and thus shows promise for integration into preexisting ultrasound protocols. However, despite the improvement, clear differentiation of tumours is still not possible and further investigation is recommended.

OBJECTIVES: This study aims to answer whether acoustic radiation force impulse imaging (ARFI) can reasonably be employed in initial examination and follow-up during therapy in patients with sialolithiasis, one of the most common non-malignant disorders of the salivary glands. METHODS: Mechanical tissue properties of affected and contralateral healthy salivary glands were analyzed by ARFI in 129 patients with sialolithiasis. In different subgroup analyses, ARFI shear wave velocity values were compared between healthy and diseased submandibular or parotid glands, salivary glands with calculi exhibiting different sizes, as well as before and after therapy. The patients’ symptoms were evaluated by a standardized questionnaire. The t-test (2 groups) or the One-way ANOVA test (>2 groups) was used for the estimation of stochastic probability in intergroup comparisons. RESULTS: Submandibular or parotid glands affected by sialolithiasis were found to exhibit significant lower ARFI values as compared to the healthy contralateral glands in the same individuals. ARFI values in submandibular glands with a single calculus of more than 5 mm in diameter or with multiple calculi as well as in parotid glands with calculi exhibiting diameters of more than 5 mm were significantly higher as compared to the respective healthy contralateral glands. No significant differences in ARFI values of affected salivary glands were detected between patients with low or high symptom perception. CONCLUSIONS: ARFI provides an easy, quick and reliable diagnostic tool for the objective assessment of disease severity and progression in patients with sialolithiasis that can simply be implemented in pre-existing ultrasound protocols.

Objectives The pathogenesis of acinar enlargement in sialadenosis is obscure. As myoepithelial cells had been reported to show degenerative changes, we decided to investigate the possible role of functionally deficient myoepithelial cells in the development of sialadenosis. Study design This study was a morphometric analysis of glands immunohistochemically stained for CK14, α-actin, and Ki67 in 10 cases of sialadenosis and 11 normal parotids. Results In sialadenosis, acini were much larger; there was a minor decrease in the density of the distribution of myoepithelial cells stained for CK14 and a major decrease in the density of the distribution and thickness of the myofilament component of myoepithelial cells stained for α-actin; and the proliferation of acinar and myoepithelial cells was reduced. Conclusions Our results demonstrate a major loss and thinning of the myofilament component of the myoepithelial cells and thereby a loss of mechanical support for the acini in sialadenosis. This possibly allows acinar cells to expand as secretory granules accumulate intracellularly to produce the great acinar enlargement. This functional myoepithelial insufficiency is possibly a consequence of an autonomic neuropathy secondary to severe metabolic or hormonal disorders.

The differential diagnosis between benign salivary oncocytoma (ONC) and low-grade malignant acinic cell carcinoma (ACC) can be difficult due to a significant histomorphological overlap of the structural and cytological presentation of both tumor types. To the best of our knowledge a comprehensive study comparing (immuno-)histological markers in cases of difficult differential diagnosis between ONC and ACC has not yet been performed. We investigated a panel of different immunohistochemical (CK5/6, CK14, CK7, CK18, p63 and Ki67) and histochemical (PAS, alpha-amylase) markers in 12 cases of ONC and 19 cases of ACC. The statistically significant stronger expression of CK7 in ONC and stronger expression of PAS and alpha-amylase in ACC in routine practice each is hampered by a pronounced overlap between both tumor groups. The obligate presence of an additional small basal cell component in all cases of ONC, demonstrable with p63 and CK5/6, enables a straightforward distinction from ACC, being constantly devoid of a basal cell component. Unexpectedly, CK14 is not a suitable marker for a reliable proof of these basal cells. The detection of this basal cell component in ONC in routine Hematoxylin-eosin stain is difficult and in some cases not possible; therefore, immunohistochemistry with p63 or CK5/6 is recommended for selected cases.

Carotid bleeding is one of the most severe complications in ear, nose and throat (ENT) surgery. It is a rare complication in patients with cancer of the head and neck after radiochemotherapy. We report the case of a 65-year-old man who suffered from cancer of the tonsils (pT2pN1M0) and was treated in 1987 with surgery and local chemotherapy. Since then he reported recurrent bleeding in the left cervical region especially during physical exertion. The patient was re-operated and during surgery the tip of a catheter was found in the external carotid artery, obviously a remnant from a catheter for intra-arterial chemotherapy. The tip was removed, the defect closed and covered with a pectoralis major muscle flap.

In der Mehrzahl der typischen vielgestaltigen Formen ist die Diagnose eines pleomorphen Adenoms (PA) unproblematisch. In schwierigen, weil eher „monomorphen“ Formen konnen sich bei dominierender epithelialer Differenzierung Abgrenzungsprobleme z. B. vom Basalzelladenom oder kanalikularen Adenom, bei dominierender mesenchymaler, z. B. spindelzelliger Differenzierung vom Myoepitheliom oder von Weichgewebstumoren wie dem Schwannom ergeben. Hier kann der Nachweis einer fokalen tubular-biphasischen Differenzierung mittels Darstellung von CK7/18-positiven Duktalzellen ein wichtiges Argument fur einen Tumor innerhalb des weiten Spektrums des PA darstellen. Eine fokale Pseudoinfiltration als physiologisches Wachstumsverhalten des PA kann Abgrenzungsprobleme von hochdifferenzierten Karzinomen wie dem adenoidzystischen und epithelial-myoepithelialen Karzinom bedingen. Auch diese Karzinome zeigen biphasische Tubulusstrukturen. Die verschiedenen Progressionsschritte zum Karzinom ex pleomorphes Adenom (CEPA), beginnend mit dem intraduktalen Fruhstadium, sind in prognostischer und therapeutischer Hinsicht relevant. Die Stadien bis zum CEPA mit geringer extrakapsularer Invasion sind dabei mit gunstiger Prognose, CEPA-Falle mit extensiver extrakapsularer Invasion dagegen mit sehr ungunstiger Prognose verbunden.

The rare entity of epithelial-myoepithelial carcinoma (EMC) belongs to a group of tumors with a biphasic ductular growth pattern, mostly with a dominating myoepithelial component and low-grade malignancy. We report on the rare constellation of a primary low-malignant EMC with high malignant transformation (so-called dedifferentiation) into a highly malignant myoepithelial carcinoma. In the eight published cases so far, the high-malignant component was reported to be either adenocarcinoma or undifferentiated carcinoma or was otherwise not specified. To the best of our knowledge, this is the first case report of a high-grade myoepithelial carcinoma transforming from a low-grade EMC. We discuss interesting parallels to the pathogenesis of secondary transformation of carcinoma ex pleomorphic adenoma.

Sialolithiasis is a common disease of the major salivary glands. Owing to the variety of conservative and minimally invasive techniques, it is now possible to treat most cases of sialolithiasis without removal of the affected salivary gland. One treatment option is the endoscopic removal of the calculi. In cases of larger concretions, intraductal disintegration using laser-induced shock waves can be appropriate to allow endoscopic removal. In the present study, we investigated whether physical and radiological parameters of salivary stones can effectively predict the applicability of laser lithotripsy. Furthermore, we determined to what extent the applied laser energy resulted in tissue damage.In addition to basic parameters like size and density, we analysed 47 salivary stones using fluorescence spectroscopy, infrared spectroscopy, Raman spectroscopy, and dual-energy computed tomography. Subsequent fragmentation of all stones was performed with a Ho:YAG laser in a near-contact manner. Fragmentation rates were calculated and correlated with the previously measured physical and radiological parameters. Finally, to test for tissue damage, we performed HE-histology of salivary duct mucosa treated with the same laser energy used for stone fragmentation.Blue light excitation induced either green or red fluorescence emission. Dual-energy CT resulted in evidence of calcium-containing material. Infrared spectroscopy and Raman spectroscopy, both identified carbonate apatite as the main component of salivary stones. Disintegration into pieces smaller than 2 mm was possible in all cases. Fragmentation rates depended on the energy per pulse applied but not on any of the analysed physical and radiological parameters. In contrast to lithotripsy with 500 mJ per pulse, which was associated with no tissue damage, lithotripsy with 1,000 mJ per pulse resulted in damage of salivary duct mucosa. This suggests that the optimal laser energy for stone fragmentation is between 500 and 1,000 mJ per pulse.Laser lithotripsy using Ho:YAG laser is a highly efficient treatment, at least in vitro. All salivary stones could be disintegrated irrespective of their physical and radiological composition.

Objective: It was the objective of this in-vitro study to investigate photon-based techniques for identifying the composition and fragmentation of salivary stones using a Ho:YAG laser. Materials and Method: Salivary stones (n=47) extracted from patients with clinical symptoms of sialolithiasis were examined in-vitro. After extraction, the stones were kept in Ringers solution until size and volume measurements could be performed. Thereafter, dual-energy CT scans (DECT) were performed to classify the composition of the stones. Subsequently, fluorescence measurements were performed by taking images under blue light excitation as well as by fluorescence spectroscopy, measuring excitation-emission-matrixes (EEM). Further investigation to identify the exact composition of the stone was performed by Raman spectroscopy and FTIR spectroscopy of stone fragments and debris. Fragmentation was performed in an aquarium set-up equipped with a mesh (hole: 1.5mm) using a Ho:YAG-laser to deliver laser pulses of 0.5, 1.0 and 1.5J/pulse at a frequency of 3Hz through a 200μm-fibre to the stone surface. The collected data were analyzed and fragmentation rates were calculated. Finally, correlation between stone composition and fragmentation was performed. Results: Blue light fluorescence excitation resulted in either fluorescence in the green spectral region or in a combination of green and red fluorescence emission. EEM-measurement showed the corresponding spectra. Raman spectroscopy showed a mixture of carbonate apatite and keratin. DECT results in evidence of calcium containing components. FTIR-spectroscopy results showed that carbonate apatite is the main component. Fragmentation experiment showed a dependency on the energy per pulse applied if the evaluation implies the ratio of fragmented weight to pulse, while the ratio fragmented weight to energy remains about constant for the three laser parameter used. Conclusion: The composition of salivary stones could be determined using different photonic techniques. Attempts to correlate salivary stone composition to fragmentation rates resulted in no correlation. Thus it could be concluded that each salivary stone could be easily destroyed using Ho:YAG-laser light by means of a 200μm bare fibre at lowest energy per pulse.

Eine kausale Therapie der Xerostomie ist bislang kaum moglich. Hier erfahren Sie, was Sie Ihren Patienten zum Schutz von Mundschleimhaut und Zahnen raten konnen, wie eine Restfunktion der Speicheldrusen auf unterschiedlichste Weise stimuliert werden kann und was hilft, wenn die Produktion ganz ausbleibt.

The standard of care for the initial diagnosis of carotid artery bifurcation diseases is carotid duplex ultrasound. Carotid abnormalities or difficult examinations may represent a diagnostic challenge in patients with clinical symptoms as well as in the follow-up after carotid endarterectomy, carotid artery stenting or other interventions. A promising new method in the diagnosis and follow-up of pathologic carotid diseases is contrast-enhanced ultrasound (CEUS). In comparison with magnetic resonance imaging or computed tomography, the contrast agents used for CEUS remain within the vascular space and hence can be used to study vascular disease and could provide additional information on carotid arterial diseases. This review describes the current carotid duplex ultrasound examination and compares the pathologic findings with CEUS.

Background The pentaspan protein CD133 (Prominin-1) is a predictive marker and part of the signature of tumour-initiating cells (TICs) for various cancer entities. Methods The correlation of CD133 expression with clinical parameters was assessed in primary samples of head and neck squamous cell carcinomas (n=98) and normal mucosas (n=24). Results A gradual and inversely proportional correlation between CD133 expression in primary tumours and decreased overall survival was observed, along with a positive correlation with the presence of lymph node metastases. Conclusions CD133 has the potential of being a novel clinically relevant prognostic marker for head and neck malignancies, which is possibly involved in regulation of tumourigenicity.

OBJECTIVE To evaluate patient benefit and health-related quality of life after lid loading with platinum chains in adult patients with facial palsy. STUDY DESIGN Retrospective data collection. SETTING Germany's largest university clinic for otorhinolaryngology, head and neck surgery. SUBJECTS AND METHODS Thirty-five patients received validated questionnaires determining the effects of the operation on the patients' health-related quality of life (Glasgow Benefit Inventory). Scores can range from -100 (maximal adverse effect), through 0 (no effect), to 100 (maximal positive effect). Furthermore, satisfaction, complaints, and complications regarding the platinum chain implant were inquired. RESULTS Twenty-two patients (63 %) returned a valid questionnaire. The mean follow-up time was 31.5 months. A complete coverage of the cornea was achieved in 95% of the patients after the first operation and in the remaining patients after a revision with implantation of a heavier weight. Complete symmetry to the nonaffected eye was perceived by 64%. Recurrent conjunctivitis was complained preoperatively by 18% and postoperatively only by a single patient. In 2 patients, a mild pseudoptosis was found postoperatively, and a single patient complained about blurred vision. The median total Glasgow Benefit Inventory score was 27.8 (p < 0.001). The health-related quality of life was raised in 91% of the patients; 87% were fully satisfied with the functional result, and 91% with the aesthetical result. 100% would again decide in favor of platinum chain lid loading. CONCLUSION Platinum chain lid loading in facial palsy patients can significantly increase patients' health-related quality of life and leads to a high rate of patient satisfaction.

The pentaspan protein CD133 (Prominin-1) is part of the signature of tumour-initiating cells for various cancer entities. The aim of the present study was to investigate the impact of ectopic CD133 expression on tumourigenic properties of otherwise CD133-negative, non-tumourigenic cells in vitro and in vivo. CD133 was stably transfected into human embryonic kidney 293 (HEK293) which was then sorted for the expression of CD133. The effects of CD133 on cell proliferation were assessed upon standard cell counting of sorted cells at various time points. Severe combined immunodeficient (SCID) mice (n = 30) were injected with HEK293 CD133(high) and CD133(low) transfectants (5 × 10(3), 1 × 10(5), or 5 × 10(6) cells per injection). The expression of CD133, Ki67, CD44s, CD44v6, and EpCAM was analysed upon immunohistochemical staining of cryosections with specific antibodies. In vitro, ectopic expression of CD133 did influence neither cell proliferation nor cell cycle distribution of otherwise CD133-negative HEK293 cells. However, CD133(high) cells generated tumours in vivo in SCID mice with at least 1,000-fold increased frequency compared to CD133(low) cells. Tumour load was also significantly increased in CD133(high) cells as compared to those tumours formed by high numbers of CD133(low) cells. Immunohistochemistry stainings disclosed no changes in Ki67, CD44s, CD44v6, or EpCAM once tumours were formed by either cell type. CD133 induces tumour-initiating properties in HEK293 cells in vivo and is potentially involved in the regulation of tumourigenicity. Future research will aim at the elucidation of molecular mechanisms of CD133-induced tumourigenicity.

PURPOSE To evaluate "bolus-tracking" (BT) and "flash-replenishment" (FR) for the assessment of tissue hemodynamics by contrast-enhanced ultrasound (CEUS) in an experimental small-animal-squamous-cell-carcinoma-model. Since the underlying tissue is the same, strong correlations between parameter outcomes of both techniques are expected. METHODS AND MATERIALS Human hypopharynx-carcinoma-cells were subcutaneously injected into the left flank of 18 female athymic-nude-rats. After 10 days of subcutaneous tumour growth, bolus tracking and flash-replenishment measurements were performed consecutively in the same imaging plane in each rat after bolus-injection of SonoVue via the lateral tail vein using a high-end ultrasound system with a 15 MHz probe. Video-sequences were analysed with dedicated software (VueBox®, Bracco-Suisse®). From BT measurements, the parameters peak enhancement (PEBT), wash-in area-under-the-curve (Wi-AUCBT), mean transit time (MTTBT), wash-in-rate (WiRBT) and perfusion-index (Wi-PIBT) were derived; FR yielded estimates of relative-blood-volume (rBVFR), mean transit time MTTFR, relative blood flow rBFFR and wash-in rate Wi-RFR. RESULTS In all rats, BT and FR measurements could be completed successfully. Highly significant correlations were observed between rBVFR and PEBT, rBVFR and Wi-AUCBT, rBVFR and MTTBT, rBVFR and WiPIBT, MTTFR and MTTBT, rBFFR and PEBT, rBFFR and Wi-AUCBT, rBFFR and WiRBT, rBFFR and WiPIBT, WiRFR and PEBT, WiRFR and Wi-AUCBT, WiRFR and WiRBT and WiRFR and WiPIBT. CONCLUSION Whereas bolus tracking can be used in a wide range of modalities including CEUS, CT and MR, FR as a technique for the assessment of tissue hemodynamics is unique to CEUS. Although BT and FR yield different parameters, the underlying tissue hemodynamics are equal. In this work, we were able to demonstrate strong correlations between different parameters of both modalities in a small-animal-tumor-model, indicating that flash-replenishment is a valid alternative to the more established bolus-tracking technique. Although the lack of absolute, quantitative parameters hinders a direct comparison of both modalities, FR and BT should both be suitable for a relative comparison, e.g. between baseline and follow-up examinations.

PURPOSE Obstructive diseases of the salivary glands, a common problem in the ENT field, are often based on sialolithiasis but can also result from rare circumstances. Due to recent technical innovations, there has been significant development in the treatment of obstructive diseases of the salivary glands such that minimally invasive glandula-sustaining therapy has now become standard. However, there is still no effective technique to assess and monitor the recovery of the parenchyma of the gland. As a result, recurrent infections often lead to modification of the gland in which fibrosis increases and the gland becomes coarse. After treatment, the parenchyma of the gland is able to recover. Thus, to more effectively monitor and promote the success of treatment, we have developed a new method to measure and quantify the stiffness of the glandula tissue using elastography (Virtual Touch TM Application) to assess the degree of recovery. MATERIALS AND METHODS First, we collected elastography data from 30 healthy volunteers as part of a conventional ultrasound (Siemens, ACUSON, S 2000, Germany) with a multi-frequency linear 9 MHz transducer in order to determine if normal findings are sufficiently quantifiable. We subsequently measured patients with sialolithiasis of the submandibular gland. RESULTS For healthy volunteers, the average value was 1.96 ± 0.48 m/s for the glandula submandibularis and 2.66+/- 0.89 for the parotid gland, a statistically significant difference. For patients with sialolithiasis of the submandibular gland, the average value was 2.98 ± 0.4 m/s, a highly significant difference in comparison to the healthy side of the patient. CONCLUSION Elastography is an easy to use diagnostic method that shows promise to become a valuable tool for the assessment of disease severity as it provides the possibility to quantify the level of treatment benefit for the patient.

Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OSCC) has been identified as a distinct entity within squamous cell carcinoma of the head and neck. It is associated with special characteristics and is preponderantly restricted to palatial tonsils and base of tongue. These primary locations have for long been associated with the clinical situation of cancer of unknown primary (CUP). In order to investigate the putative relationship between CUP and HPV, we investigated 26 patients who initially presented as CUP and were finally diagnosed with carcinomas of these two locations. Twenty-one cases proved to be positive for high-risk HPV. Primary carcinomas were small and frequently presented in a submucosal location. HPV-positive carcinomas, presented more often in women, showed atypical basaloid differentiation and correlated to cystic lymph node metastases. This study demonstrates an over-representation of HPV-associated OSCC in patients who were initially diagnosed with CUP. This finding indicates a strong relationship between HPV-association and CUP in OSCC. The frequent manifestation as CUP is presumably caused by the unusual predisposition for small size and submucosal location combined with early lymphatic metastization. In order not to miss clinically occult carcinomas, consequent interdisciplinary cooperation in combination with meticulous histological workup is mandatory.

To investigate a large series of cases of carcinoma ex pleomorphic adenoma (CEPA) to determine prognostic factors.Thirty cases of CEPA associated with primary pleomorphic adenoma (PA) and 11 cases of CEPA associated with recurrent PA were investigated. The median follow-up was 57.7 months, and ranged from 4 to 156 months. Purely intraductal carcinoma was found in 15 cases. Intraductal and extraductal intracapsular carcinoma together was found in one case. Extracapsular carcinoma was found in 25 cases. Prognosis was good for CEPA that was purely intraductal, extraductal intracapsular, or up to 5 mm extracapsular, and poor for CEPA that was 8 mm or more extracapsular. There were relatively more cases of CEPA with extracapsular invasion of 8 mm or more from recurrent PA than from primary PA, and the prognosis for CEPA associated with recurrent PA was worse than that for CEPA associated with primary PA.The threshold for distinguishing minor extracapsular invasion with good prognosis from wide extracapsular invasion with poor prognosis is 5 mm. The worse prognosis for CEPA associated with recurrent PA indicates the necessity for close surveillance of patients with recurrent PA.

Nonsebaceous lymphadenoma (NSLA) is a rare benign salivary gland tumor composed of lymphoid and epithelial components. By definition, the epithelial component lacks sebaceous differentiation and instead displays a wide range of histological differentiation. In this study, we have collected nine cases of NSLA to characterize their histological and immunohistochemical profiles. The samples were histologically reviewed and immunohistochemical stains for CK5/6, CK7, CK14, CK18, p63, and Ki67 performed. Patients were six males and three females (mean age, 50 years). All tumors were located in the parotid gland and showed intimate intermingling of lymphoid tissue with islands or strands of epithelium with a wide spectrum of histological differentiation. The immunohistochemical profiles mirrored the epithelial differentiation; hence, areas with basaloid or lymphoepithelial differentiation strongly expressed CK5/6, CK14, and p63, while areas with ductal differentiation showed strong positivity for CK18/CK7 and CK5/6/CK14/p63 in luminal and basal cell layers, respectively. A hilus structure with salivary inclusions or D2-40 (podoplanin)-positive marginal sinus was identifiable in four and nine of the cases, respectively, supporting origin within intra-/periparotid lymph nodes. Six cases were initially misdiagnosed as other benign (n = 4) or malignant tumors (n = 2). Our study on the second largest series of NSLA reported to date provides strong evidence that NSLA belongs to the group of salivary gland tumors that pathogenetically develop from embryonic salivary gland inclusions in intra-/periparotid lymph nodes. Knowledge of the wide histological spectrum of this rare and presumably underreported tumor is important in order to avoid misdiagnosis, particularly as malignant tumor.