22. diseases of salivary glands kk

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