22. diseases of salivary glands kk
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Diseases of Salivary Glands
Dr. Krishna KoiralaMBBS,MS (ENT)
2016/6/14
Anatomy
• Major salivary glands: Parotid,
submandibular, sublingual
• Minor glands : Distributed throughout
the oral cavity within the mucosa and
submucosa
• Basic unit : acinus, secretory duct and
collecting duct
• Acini: serous, mucous or mixed
Parotid Gland
• Largest salivary gland
• Lies between sternomastoid and mandible
• Parotid divided into superficial and deep
lobes by the facial nerve (Fasciovenous
plane of Patey)
Sublingual glands• Lies at the anterior part of floor of
mouth between the mucous membrane, mylohyoid muscle and body of mandible
Submandibular glands• Lies inferior to the mandible in
submandibular traingle• Indented by posterior border of
mylohoid muscle into superficial & deep lobes
Parotitis• Definition– Acute nonsuppurative viral parotitis
caused by paramyxovirus ( Mumps virus)
• Other viruses : Coxsackievirus A&B,
cytomegalovirus
• Mumps : Danish word ‘mompen’
meaning mumbeling• Secondary parotitis due to duct
obstruction• Spreads by droplet infection
Clinical Features• Prodrome – Fever, headache, myalgia, anorexia,
arthralgia
• Pain- severe, made worse on eating
(lemon juice)
• B/L parotid swelling : 75%
• Tender gland• Trismus - swelling, spasm of muscles• Other gland also enlarges in 1 to 5
days
Investigations
• Blood-–WBC count , ESR– Viral titers
• Radiology – Parotid stones radiolucent
• Sialography–Diagnostic and Therapeutic
Treatment• Conservative – Rest, oral hygiene, good nutrition,
plenty of liquids– Analgesia, local heat application to
gland– Adrenalin local application to reduce
duct edema– Antibiotic : Clindamycin– Vaccination : Jerry Lynn vaccine at 12
months
• Surgical: If patient develops abscess
Complications
• Aseptic meningitis
• Pancreatitis
• Nephritis
• Orchitis/ Oopheritis
• SNHL
Sialolith• Formation of calculi in the ductal system of
salivary glands
• SMG : mixed seromucinous gland, saliva has
high calcium and magnesium content - 70 to
90% stones
• Parotid : serous gland, low calcium and
magnesium content – 10 to 20% Stones
• High density stones are radiopaque
• Cause unknown
– Salivary stasis
–Ductal inflammation
– Duct Injury
Clinical Features
• Postprandial salivary colic with pain
and swelling
• Swelling on submandibular region due
to duct obstruction
• Duct opening : edematous, pouting
• Stone palpated in submandibular duct
or within the gland on bimanual
palpation
Oral cavity
External swelling and duct stone
Investigations
• Radiology – Plain x ray • Done to see radiopaque stone
– Sialogram • Diagnostic
– USG– CT scan of neck–MRI
Stone seen on CT scan
Sialogram
Treatment
• Sialogram therapeutically washes stones
• Finish Each meal with a citrus drink, massage
gland
• Per-oral removal of calculus
• Marsupialization of duct
• Removal of Submandibular salivary gland
• Total conservative Parotidectomy
Per-oral removal
Duct incised and stone removed
Stone specimen
Sjogren’s Syndrome• Chronic autoimmune disease of exocrine
glands• Classification– Primary • Confined to exocrine gland• Xerostomia and Xerophthalmia
– Secondary• Xerostomia and Xerophthalmia• Autoimmune disease (RA,SLE)
Clinical Features
• Multisystem disease
• Dryness of mouth and eyes, difficulty in chewing and swallowing food due to xerostomia
• Intolerance to acidic and spicy foods
• Dental caries ,smooth and fissured tongue
• Candidiasis/ Stomatitis / Parotid enlargement
• Decreased phonation due to dry oral mucosa
Investigations
• ESR Raised
• Presence of HLA1 and B8 antigen
• Schirmer’s test
– Wetting <5mm in 5 mins
• Salivary flow rate
– Flow < 0.5ml Xerostomia
Treatment
• Steroids
• Artificial tears
• Synthetic saliva
• Bromhexine 40mg/d for tenacious
cough
Treatment• Dry Mouth– Saliva substitutes:
sprays /rinses– Saliva stimulants:
hard candy, pilocarpine
– Cholinergic agents: cevimeline
– Special toothpaste, oral gels
– Active dental care
• Dry eyes– Lubricant eye
drops/ ointments– Punctal plugs– Lateral
Tarsorraphy
• Dry Nasal mucosa– Saline nasal sprays– Lavage
Salivary gland neoplasms
Etiology• Increased risk– Radiation exposure– Epstein-Barr : lymphoepithelial
carcinoma – Genetic alterations (p53, DNA ploidy)– Tobacco –Occupational exposure to silica dust– Rubber workers exposed to
nitrosamines
–Nickel compound/alloy, Hair dye
– Kerosene cooking fuels
– Vegetables preserved in salt
• Decreased risk
–High intake of liver
–High intake of dark yellow vegetables
Investigations
A. Laboratory tests
• TC, DC, ESR
• Peripheral blood smear
• RBS, Thyroid Function test,Uric
acid
• Antinuclear Antibody
• RA factor
B. Radiological Tests• Ultrasonography–Neoplasms appear solid– Provide guidance in obtaining FNAC
• CT scan– Gold standard
– Administration of contrast provides details
of tumor volume, relation to vascular and
bony structures– Irregular pattern - malignancy
• MRI scan
– Excellent soft tissue details
– Does not require contrast for vascular details
• Positron emission tomography (PET)
– Role in staging of salivary malignancy to rule
out distant and regional metastases
– Useful to follow-up patients with known
salivary malignancy after treatment
Smoothly marginated, multilobulated, solid lesion, without focal calcification or necrosis (pleomorphic adenoma)
Heterogeneous, low-density mass in the tail of the right parotid gland with minimal thin peripheral enhancement consistent with Warthin’s tumor
CT scan of left parotid showing superficial lobe tumor
C. Fine-Needle Aspiration Cytology
–Mainstay of diagnosis and
management
– Safe, simple and inexpensive
– If tumour is obviously malignant and
involving the skin: incisional biopsy
Pleomorphic Adenoma
• Most common of all salivary gland
neoplasms
– 80% of parotid tumors
– 50% of submandibular tumors
– 6% of sublingual tumors
– 45% of minor salivary gland tumors
• 4th-6th decades, F:M = 3-4:1
• Slow-growing, painless mass
• Parotid: 90% in superficial lobe, most in tail
of the parotid gland (lower posterior part of
gland)
• Capsule is a result of fibrosis of surrounding
salivary parenchyma, compressed by tumor
called as a false capsule
• Gross pathology– Smooth, well-
demarcated– Solid and cystic changes– Myxoid stroma
• Histology– Mixture of epithelial,
myopeithelial and stromal components
– No true capsule
Treatment• Complete surgical excision
–Parotidectomy with facial nerve
preservation
–Submandibular gland excision
–Wide local excision of minor salivary gland
• Avoid enucleation and tumor spill
Warthin’s Tumor
• Synonym : papillary cystadenoma lymphomatosum
• 6-10% of parotid neoplasms
• Older, Caucasians, males, obese persons
• 10% bilateral or multicentric
• 3% with associated neoplasms
• Presentation: slow-growing, painless
mass
• Ovoid shape, situated in the tail of the
parotid
• Gross pathology
– Encapsulated
– Smooth/ lobulated
surface
– Cystic spaces of
variable size, with
viscous CHOCOLATE
fluid, tubular
epithelium
• Histology– Papillary projections
into cystic spaces surrounded by lymphoid stroma
– Epithelium: double cell layer• Luminal cells• Basal cells
Mucoepidermoid Carcinoma
• Most common salivary gland malignancy
• 5-9% of salivary neoplasms• Parotid 45-70% of cases• Palate 18%• 3rd-8th decades, peak in 5th decade• F>M• Caucasian > African American
Clinical Features
• Presentation
– Low-grade: slow growing, painless mass,
re- occur locally
–High-grade: rapidly enlarging, +/- pain
–Metastasize to lymph nodes, lungs,
bones ,brain
• Gross pathology
–Well-
circumscribed to
partially
encapsulated to
unencapsulated
– Solid tumor with
cystic spaces
Histology• Low-grade – Mucus cell >
epidermoid cells
• Intermediate grade– Mucus = epidermoid– Fewer and smaller
cysts– Increasing
pleomorphism and mitotic figures
• High-grade– Epidermoid > mucus– Solid tumor cell
proliferation
Investigations
• Imaging
– CT and MRI Scans
• FNAC
• Avoid Biopsy (seeding with neoplastic
cells)
Treatment
• Influenced by site, stage, grade• Stage I & II–Wide local excision
• Stage III & IV– Radical excision–+/- neck dissection–+/- postoperative radiation therapy
Adenoid Cystic Carcinoma
• Overall 2nd most common malignancy• Most common in submandibular,
sublingual and minor salivary glands• M = F, 5th decade• Presentation– Asymptomatic enlarging mass– Pain, paresthesias, facial
weakness/paralysis
• Gross pathology–Well-circumscribed– Solid, rarely with cystic
spaces– Infiltrative
• Histology– Cribriform pattern• Most common• “Swiss cheese” appearance
Treatment
• Complete local excision
• Tendency for perineural invasion: facial
nerve sacrifice
• Postoperative RT
Acinic Cell Carcinoma
• 2nd most common parotid and pediatric
malignancy
• 5th decade
• F>M
• Bilateral parotid disease in 3%
• Presentation
– Solitary, slow-growing, often painless mass
• Gross pathology– Well-demarcated– Most often
homogeneous
• Histology– Solid and microcystic
patterns– Small, dark, eccentric
nuclei– Basophilic granular
cytoplasm
• Treatment
– Complete local excision
– +/- postoperative XRT
• Prognosis
– 5-year survival: 82%
– 10-year survival: 68%
– 25-year survival: 50%
Adenocarcinoma• Rare• 5th to 8th decades• F > M• Parotid and minor salivary
glands• Presentation– Enlarging mass– 25% with pain or facial
weakness
Treatment
• Complete local excision
• Neck dissection
• Postoperative chemoradiation
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