Salivary Gland Diseases

Front 1

Name the signs and symptoms of salivary gland disease

Back 1

1. Swelling (most common sign)
2. Pain
Pain and swelling may be signs of: infection obstruction, or neoplasms
3. Dry mouth (xerostomia)
4. Taste abnormalities: "bad taste" or salty taste - usually caused by pus-producing inflammation
5. Excessive Salivation (sialorrhea) - Very uncommon

Front 2

What are the four basic causes of xerostomia?

Back 2

- Problem at salivary center
- Problem at autonomic outflow pathway
- Reduced salivary gland function due to organic disease
- Alterations in fluid and electrolytes balance.

Front 3

List in order the locations of mucous Escape Reaction

Back 3

1. Lower lip
2. Buccal mucosa
3 Floor of mouth (=Ranula)
4. Tip of tongue, occasionally
5. Do NOT expect to find mucoceles at the hard palate or upper lip; these sites are VERY RARE

Front 4

A swollen area apparently filled with mucus

Back 4

Mucocele - Clinical term

Front 5

Back 5

Mucous Escape Reaction (Mucous Extravasion Phenomenon)
- Majority of clinical mucoceles
- Mucus escapes into the surrounding connective tissue following a rupture in the salivary duct system.
- Saliva in the C.T. causes an inflammatory reaction.
Location (ordered most common to least)
1. Lower lip
2. Buccal mucosa
3. Floor of mouth (ranula)
4. Tip of Tongue
5. Do NOT expect to find in hard palate or upper lip...

Front 6

Back 6

Mucous Escape Reaction (Mucous Extravasion Phenomenon)
- Cavity filled w/ mucus
- Cavity has NO epithelial lining; instead, is lined by layer of compressed granulation tissue or fibrous C.T.
- Foamy histiocytes and neutrophils are present in the wall and cavity
- Excise along w/ minor salivary gland at base - biopsy.

Front 7

Back 7

Ranula - mucocele that occurs specifically in the flour of the mouth.
- often larger than mucoceles in other locations
- Most are mucus escape reactions
- Excise along w/ minor gland at the base - biopsy
- Marsupialization may be useful to reduce size of lesion prior to excision.

Front 8

Back 8

Plunging ranula
- may develop due to herniation of the lesion through the mylohyoid muscle and along the fascial planes of the neck.

Front 9

May occur in areas not easily subjected to trauma...

Back 9

Mucus Retention cyst (salivary duct cyst)
Similar to mucous escape reaction except:
- More likely to occur in adults
- May occur in major or minor glands
- Often are firm than mucus escape reaction lesions.
HISTO
- Cavitary lesion filled w/ mucus
- Cavity is lined by epithelium
- Inflammation is typically absent.
Conservative surgical excision - biopys

Front 10

Back 10

Sialolithiasis
- Stones in salivary duct or gland.
- Stones develop due to deposition of calcium salts (and other minerals) around a nidus of debris w/in the duct lumen. Debris may include inspissated mucus, bacteria, ductal epithelial cells or foreign bodies.

Front 11

Originally this was mistaken for impacted tooth
- image superimposed on mandible

Back 11

Sialolithiasis
- Pain and sudden enlargement of the affected gland, especially at mealtimes.
Radiographs show opaque masses anywhere along the length of the glands duct, or w/in the gland itself.

Front 12

Back 12

Sialolithiasis
- Occlusal radiographs are useful to find stone in the DISTAL Wharton's duct.
- Stones in proximal Wharton's duct, submandibular gland itselg, or minor glands in the floor of mouth may appear superimposed over mandible on panoramic films
Conservative treatment
- Massage duct to evict stone
- Use sialogogues to force stone out; Lemon drops may help (painful)
- Moist heat and increased fluid intake may also help to pass the stone.
Surgical therapies
- Dialation of duct - Surgical extraction of stone - srugical removal of gland (only in severe cases).

Front 13

Back 13

Sialadenitis
- inflammation of the salivary gland, and may arise from infectious or non-infectious causes.
- Viruses - Mumps(most common virus), Coxsackia A...
- Bacteria - most arise from ductal obstruction - decreased salivary flow, allowing retrograde infection.
- Recent surgery, due to low fluid intake and anticholinergic drugs
- Non-infectious causes include sjogren syndrome, sarcoidosis, radiation therapy, and allergens

Front 14

Tender swelling of Submandibular gland

Back 14

Sialadenitis
Acute (often bacterial)
- Painful swelling involved in gland.
- Systemic manifestations such as low-grade fever, malaise and headaches
- Reduced salivary flow. Cloudy, thick saliva or purulent discharge from duct by pressure
- Trismus
-Erythema &/or edema of overlying skin.
HISTO - neutrophils and exudate accumulate w/in duct and glandular acini
Antibiotics as appropriate, Rehydration is crucial. Surgical drainage may be needed if abscess forms.

Front 15

Parotid sialogram demonstrating ductal dilation proximal to an area of obstruction.

Back 15

Chronic Sialadenitis.
- Periodic swelling and pain
- Symptoms often present at mealtime when salivary flow is stimulated
HISTO: may have patchy or diffuse infiltrates of lymphocytes and plasma cells. Longstanding disease may also result in atrophy and fibrosis of affected gland.
Management: depends on cause and severity. Elimination of underlying cause may be adequate.

Front 16

Arrow is pointing to an early SCC that has developed on pt.s lip. Risk due to actinic injury (18-35%)
Notice the red dots

Back 16

Cheilitis Glandularis
- Most common in middle aged men. and on lower lip.
- Lip features swelling and eversion (develops slowly)
- Openings to minor salivary gland ducts appear as tiny red dots on the exposed lip mucosa. May have suppuration and/or ulceration.
Systemic antibiotics w/ topical steriods
Lip shave or other surgery (cosmetic)

Front 17

Name the causes of xerostomia

Back 17

- Salivary gland aplasia
- Smoking
- Mouth breathing
- Local irradiation
- Chemotherapy
- Specific diseases- especially Sjogren syndrome
- Medications (MANY!)
- "aging"

Front 18

What are the effects of xerostomia?

Back 18

1. Microbial flora shifts to a more cariogenic flora
2. There is a dramatic increased risk of caries, especially on exposed roots.
3. Increased incidence and severity of periodontal disease
4. Difficulty in eating/swallowing.

Front 19

What disease is characterized by unilateral or bilateral swelling of the parotid glands, resulting from a benign infiltration of lymphoid cells? It could be caused by an immunologic disorder that may have genetic influences.

Back 19

Benign Lymphoepithelial Lesion (myoepithelial sialadenitis)
- Middle-aged females
- Progressive asymptomatic parotid gland enlargement
- Reduced salivary flow
- Commonly seen in Sjogren syndrome.
HISTO: Glandular tissue is overrun by proliferation of lymphocytes. Later, acini become necrotic or atrophic resulting in fibrosis.
No specific treatment: treat xerostomia and sialadenitis as needed.

Front 20

Chronic systemic autoimmune disease with unknown cause. May have genetic influences.

Back 20

SJogren Syndrome
Two types: Primary and secondary, both have
-Xeropthalmia and xerostomia.
Primary Sjogren syndome has - Serologic evidence of systemic autoimunity (rheumatoid factor, antinuclear antibodies, and anti-SS-A, or anti-SS-B
Secondary Sjogren syndome has - Clinical features diagnostic for rheumatoid arthritis, SLE, polymyositis, scleroderma or biliary cirrhosis.

Front 21

Has dryness of mucous membranes - Oral, nasal, and genital

Back 21

Sjogren syndome
- 80-90% of patients are women
- Most pts are middle aged
- Keratoconjuctivitis sicca
- Dry, gritty, burning eyes
- Redness, photophobia, discharge
- Lacrimal gland enlargement (uncommon)
-Signs of autoimmune CT disease.

Front 22

Back 22

Sjogren syndome
Oral Manifestations
- Xerostomia (90%)
- Difficulty swallowing and chewing
- Abnormal taste
- Increased fluid intake to keep mouth moist
- Soreness and ulceration of mucosae
- Rapidly progressive dental caries
- Salivary gland enlargement may or may not be present. If it is present, usually bilateral parotid.

Front 23

- Very Uncommon NON-inflammatory disorder characterized by asymptomatic salivary gland enlargement. (most often parotid)
- Causes include hormonal disorders, diabetes mellitus, alcoholism, anorexia, bulimia, malnutrition and drug reactions.

Back 23

Sialadenosis (Sialosis)

Front 24

- History of symptoms is short, 2-4 weeks.
- Presents as tender swelling which progresses to ulceration.

Back 24

Necrotizing sialometaplasia
- typically seen on palate
- Most commonly in men 30-40 (could be all ages)

Front 25

Back 25

Necrotizing sialometaplasia

- Caused by infarction of minor salivary glands
- Idiopathic (not post surgical)
- will probably resolve on it's own if do nothing.(6-10 wks)

Front 26

Back 26

Necrotizing sialometaplasia
HISTO: submucosa shows necrosis of minor glands w/ preservation of lobular architecture.
- Squamous metaplasia of residual salivary ducts is prominent.
- intact epitdhelial covering shows psuedoepitheliomatous hyperlasia which may join w/ metaplastic ducts
- May be misdiagnosed as mucoepidermoid carcinoma if biopsy is not deep enough.

Front 27

Most common salivary gland tumor
- 53-77% of Parotid tumors
- 44-68% of submandibular tumors.
- 33-43% of minor gland tumors.

Back 27

Benign Mixed tumor (pleomorphic Adenoma)
- Mainly in adults 30-50, slight female predilection
- Most are in the superficial portion of the parotid.
- slow-growing, painless swelling.
- as lesion enlarges, may become nodular and less mobile
- Most are small but may become VERY LARGE if left untreated

Front 28

Back 28

Benign Mixed tumor (pleomorphic Adenoma)
- Most are small but may become VERY LARGE if left untreated

Front 29

Back 29

Benign Mixed tumor (pleomorphic Adenoma)
HISTO:
- circumscribed mass often lacks a capsule. If present, the capsule is usually defective.
- Duct-like structures, inner linning cells and outer myoepithelial cells.
- Epithelial tissue intermingled w/ areas of mucoid, myxoid or chondroid tissue
- Proportion of epithelial to mesenchymal-appearing areas varies considerably.

Front 30

A benign tumor w/ epithelial cystic structures surrounded by a lymphoid stroma

Back 30

Warthin Tumor (papillary cystadenoma Lymphomatosum)
- Represents 5-14% of all parotid tumors
- Bilateral in ~5% of cases
- Very rarely seen in submandibular
- Males 5:1
- Adults 50-65 years
Slow growing localized; may reach a certain size and stop growing. Swelling may be fluctuant, but not usually painful.

Front 31

Back 31

Warthin Tumor (papillary cystadenoma Lymphomatosum)
- Cystic cavity lined by double-layered epithelium
- Benign lymphoid tissue w/ numerous germinal centers surrounds epithelial cystic components
- Entire neoplasm surrounded by thin fibrous capsule
Complete removal w/ margin

Front 32

Tumor shows long cords or strands of epithelial cells arranged in double rows to form a "party wall" pattern.
- May have cystic spaces
- Has loose fibrous stroma and usually a fibrous capsule

Back 32

Canilicular Adenoma (PKA: monomorphic Adenoma)

Front 33

Back 33

Canilicular Adenoma (PKA: monomorphic Adenoma)
- Significant predilection (75%) for the minor salivary glands of the UPPER LIP. May also occur in buccal mucosa
- Female 1:1.8
- more common over 60
- Slow growing well circumscribed, submucosal mobile mass. Firm to fluctuant, pink to bluish.
Conservative excision.