SALIVARY GLANDS DISEASES

رياض الطائي0د : الاستاذ المساعدفرع جراحة الفم والوجه والفكين

كلية طب الاسنان

جراحة الفم والاسنان -المرحلة الخامسة

SALIVARY GLANDS ANATOMYThere are 3 paired major salivary glands in humans:1. Parotid gland:

located in front of the ear, and it secretes its mostlyserous saliva via the parotid duct (Stenson duct) into themouth, usually opening roughly opposite the maxillarysecond molar.

2. Submandibular gland:located medial to the angle of the mandible, and it

drains its mixture of serous and mucous saliva via the submandibular duct (Wharton duct) into the mouth, usually opening in a punctum located in the floor of mouth.

3. sublingual gland:located below the tongue, in the floor of the mouth. It

drains its mostly mucous saliva into the mouth via about 8-20 ducts which open along the plica sublingualis (a fold oftissue under the tongue).[1]

NOTE: About 800-1000 minor salivary glands in the oral mucosa of the mouth.

1. lubricating function: which protects the oral mucosa of the mouth during eatingand speaking .

2. Contains digestive enzymes (e.g. salivary amylase)3. Has antimicrobial action and acts as a buffer.

Persons with reduced salivary flow or hyposalivation often suffer from function of the salivary or xerostomia, which can result in severe dental caries (tooth decay) as a result of the loss of the protective effects of saliva.

FUNCTION OF THE SALIVARY

DIAGNOSTIC MODALITIES

1. 1-History and Clinical Examination Salivary Gland

2. 2-Radiology Plain Film Radiographs

3. 3-Sialography

4. 4-Computed Tomography,

5. 5-Magnetic Resonance Imaging

6. 6-Ultrasound Salivary

7. 7-Scintigraphy (Radioactive Isotope Scanning)

8. 8-Salivary Gland Endoscopy (Sialoendoscopy)

9. 9-Sialochernistry

10. 10-Fine-Needle Aspiration Biopsy

11. 11-Salivary Gland Biopsy

2)The primary purpose is to identify salivary stones (calculi),although only 80% to 85% of all stones are radiopaque andtherefore visible radiographically. The incidence ofradiopaque stones varies, depending on the specific glandinvolved.A. A mandibular occlusal film is most useful for detecting

sublingual and submandibular gland calculi in the anteriorfloor of the mouth.

B. Panoramic radiographs can reveal stones in the parotidgland, posteriorly located submandibular stones.

C. PA view : A “puffed cheek view,” in which the patientforcibly blows the cheek laterally to distend the soft tissuesoverlying the lateral ramus, can demonstrate parotidstones.

D. Periapical radiographs can show calculi in each salivarygland or duct, including minor salivary glands, dependingon film placement.

1)In most cases the patient will guide the doctor tothe diagnosis by relating the events that have

occurred in association with the presentingcomplaint. The diagnosis can be determined

without the necessity of further diagnostic evaluation. The clinician may be able to

categorize the problem as reactive, obstructive, inflammatory, infectious, metabolic, neoplastic, developmental, or traumatic in origin and guide

further diagnostic testing. Occasionally, the clinician may find it necessary to use any of

several diagnostic modalities.

3)Sialography is indicated as an aid in:1) The detection of radiopaque stones. 15% to

20% of stones are radiolucent.2) The extent of destruction of the salivary

duct or gland or both as a result ofobstructive, inflammatory, traumatic, andneo-plastic diseases.

3) Used as a therapeutic maneuver, becausethe ductal system is dilated during thestudy, and small mucous plugs or necroticdebris may be cleared during injection ofcontrast.

Sialography is a technique in which the salivary duct is cannulated with a plastic or metal catheter a radiographic contrast medium is injected into the ductal system and the substance of the gland, and a series of radiographs are obtained during this process. Approximately 0.5 to 1 ml of contrast material can be injected into the duct and gland before the patient begins to experience pain. The two types of contrast media available for sialographic studies are water-soluble and oil-based. Both types of contrast material contain relatively high concentrations (25% to 40%) of iodine .

4)The use of computed tomography (CT) has been generally reserved for the assessment of mass lesions of the salivary glands. Although CT scanning results in radiation exposure to patients, it is less invasive than sialography and does not require the use of contrast material. Additionally, CT scanning can demonstrate salivary gland calculi, especially submandibular stones.

5)Magnetic resonance imaging (MRI) is superior to CT scanning in delineating the soft tissue detail of salivary gland lesions, specifically tumors, with no radiation exposure to the patient or the necessity of contrast nhancement.

6)Ultrasonography is a relatively simple, noninvasive imaging modality, with poor detail resolution. The primary role of ultrasonography is in the assessment of superficial structures to determine whether a mass lesion that is being evaluated is solid or cystic (fluid-filled) in nature.

8)Salivary gland endoscopy (sialoendoscopy) is a specialized procedure that uses a small video camera (endo-scope) with a light at the end of a flexible cannula, which is introduced into the ductal orifice. The endoscope can be used diagnostically and therapeuticaly. Salivary gland endoscopy has:1. Demonstrated strictures and kinks in the ductal system, Mucous plugs and

calcifications. 2. May be used to dilate small strictures and flush clear small mucous plugs in the

salivary gland ducts. 3. Specialized devices such as small balloon catheters (similar to those used for

coronary angioplasty procedures) may be used to dilate sites of ductal constriction,

4. Small metal baskets may be used to remove stones in the ductal system

7)The use of nuclear imaging in the form of radioactive isotope scanning 1. Evaluation of the salivary gland parenchyma, with respect to the presence of mass lesions .2. The function of the gland itself. This study uses a radioactive isotope (usually, technetium [Tc] 99m) injected intravenously (IV), which is distributed throughout the body and taken up by a variety of tissues, including the salivary glands. The major limitation of this study, 1. Patient radiation exposure, 2. Poor resolution of the images obtained. Salivary gland scintigraphy may demonstrate:1. Increased uptake of radioactive isotope in an acutely inflamed gland 2. Decreased uptake in a chronically inflamed gland, 3. As well as the presence of a mass lesion, either benign or malignant.

SS. The procedure is performed using local anesthesia and approximately 10 minor salivary glands are removed for histologic examination

9) An examination of the electrolyte composition of the saliva ofeach gland may indicate a variety of salivary gland disorders.Principally the concentrations of sodium and potassium, whichnormally change with salivary flow rate, are measured. Certainchanges in the relative concentrations of these electrolytes are seenin specific salivary gland diseases. For example, an elevated sodiumconcentration with a decreased potassium concentration mayindicate an inflammatory sialadenitis.

Disorders affecting the salivary glands

1. Congenital2. Acquired

a) Idiopathicb) Vascularc) Infectived) Traumatice) Autoimmunef) Metabolicg) Inflammatoryh) Neurological Neoplastici) Degenerativej) Environmental

[3]

1. OBSTRUCTIVE SALIVARY GLAND DISEASESialolithiasis

2. MUCOUS RETENTION AND EXTRAVASATION PHENOMENAa. Mucoceleb. Ranula

3. SALIVARY GLAND INFECTIONSSialadenitis

4. NECROTIZING SIALOMETAPLASIASJOGREN'S SYNDROME

5. TRAUMATIC SALIVARY GLAND INJURIES6. NEOPLASTIC SALIVARY GLAND DISORDERS

1.Benign Salivary Gland Tumors2.Malignant Salivary Gland Tumors [5]

OR

include:

1. Aplasia:2. Atresia3. Ectopic salivary gland tissue4. Stafne defect

CONGENITAL 1. Salivary gland aplasia (also termed salivary glandagenesis) is the congenital absence of salivary glands.Usually the term relates to the absence of some or all ofthe major salivary glands.It is a rare condition, and most known cases have beenin association with syndromes of the ectodermal tissues,particularly the lacrimal apparatus, Example syndromeswhich have been reported with salivary gland aplasiainclude hereditary ectodermal dysplasia,mandibulofacial dysostosis and hemifacialmicrosomia.[3]

LACK OF SALIVA CAUSING:1. xerostomia (dry mouth)2. Susceptibility to dental caries (tooth decay)3. Infections of the mouth.4. Upper respiratory tract infections (e.g., candidiasis,

ascending sialadenitis, laryngitis and pharyngitis).[2]Patients with salivary gland aplasia typically require regular application of topical fluoride to prevent tooth decay

2.congenital blockage or absence ofthe orifice of a major salivary gland ductor part of the duct itself.It is a very rare condition. Thesubmandibular salivary gland duct isusually involved, having failed tocannulate during embryologicaldevelopment. The condition firstbecomes apparent in the first few daysafter birth where a submandibularswelling caused by a retention cyst isnoticed.[1,2]

3.Salivary gland tissue which is located in sites other than thenormal location is variously described as aberrant, accessory,ectopic, heterotopic or salivary gland choristoma.

ACCESSORY SALIVARY GLANDS:Is ectopic salivary gland tissue with a salivary gland duct system. The most common location of accessory salivary gland tissue is an extra major salivary gland in front of the parotid gland. It is typically about 3 cm or less in size, and drains into the parotid duct via a single tributary. Accessory parotid tissue is found in 21-56% of adults. Any disease process which affects the salivary glands, including cancer, may also occur within an accessory salivary gland tissue.

HETEROTOPIC SALIVARY GLAND TISSUE:Salivary gland heterotopia is where salivary gland acini cells are present in an abnormal location without any duct system. The most common location is the cervical lymph nodes. Other reported sites of heterotopic salivary gland tissue are the middle ear, parathyroid glands, thyroid gland, pituitary gland, cerebellar pontine angle, soft tissue medial to sternocleidomastoid, stomach, rectum and vulva. Salivary gland neoplasm occurrence within heterotopic salivary gland tissue is rare.[4]

4.The Stafne defect (also termed Stafne'sidiopathic bone cavity,, Stafne bone cyst,lingual mandibular cortical defect, latent

bone cyst, or static bone cyst),it is a depression of the mandible on the lingual surface (the side nearest the tongue). The Stafne defect is thought to be a normal anatomical variant, as the depression is created by ectopic salivary gland tissue

associated with the submandibular glandand does not represent a pathologic

lesion .

Idiopathic (OBSTRUCTIVE SALIVARY GLAND DISEASE)Sialolithiasis -Although several possibly coexisting factors have been suggested to be involved in the formation of salivary stones, including :1) Altered acidity of saliva2) Reduced salivary flow rate3) Abnormal calcium metabolism4) Abnormalities in the sphincter mechanism of the duct opening5) The exact cause in many cases is unknown.The clinical manifestations of the presence of sub-mandibular stones become apparent whenacute ductal obstruction occurs at mealtime, when saliva production is at its maximum andsalivary flow is stimulated against a fixed obstruction. The resultant swelling is sudden and is usuallyvery painful . Gradual reduction of the swelling follows, but swelling reoccurs repeatedly whensalivary flow is stimulatedObstruction, with or without infection, causes atrophy of the secretory cells of the involved gland.Infection of the gland manifests itself by swelling in the floor of the mouth, erythema, and anassociated lymphadenopathy.

Treatment: 1. If the stone anterior to lower 1st molar , exposure and removal of stone intraoraly.2. If posteriorly surgical removal of the gland is done.3. Recent clinical trials using extracorporeal shock lithotripsy (ECSWL) have been successful in

small salivary gland stones. This technology uses trarnscutaneous electromagnetic waves tobreak the calculus apart into smaller calcified debris particles

ACQUIRED

1. Vascular:Necrotizing sialometaplasia: a lesion that usually arises from a minor salivary gland on the palate. It isthought to be due to vascular infarction of the salivary gland lobules Potential causes of diminished bloodflow to the affected area include trauma, local anesthetic injection, smoking, diabetes mellitus,vascular disease and pressure from a denture prosthesis . The usual age range of affected patients isbetween 23 and 66 years. . It is often mistaken for oral cancer, but the lesion is not neoplastic.[2]usually heal spo ntaneously within 6 to 10 weeks after their onset and require no surgical management.

2. Infective:Infections involving the salivary glands can be viral or bacterial (or rarely fungal).1. Mumps: is the most common viral sialadenitis. It usually occurs in children.

Sign and Symptums:1.Preauricular pain (pain felt in front of the ear)2. swelling of the parotid, fever, chills, and headaches.[2]

2. Bacterial sialadentitis: is usually caused by ascending organisms from the oral cavity. Risk factorsinclude reduced salivary flow rate. in patients who are elderly, debilitated, malnourished, dehydrated,or plagued with chronic illness. In these cases, gland infections are usually bilateral. The mean age ofoccurrence of infections is 60 years, with a slight male predilection.Treatment: Antibiotics and I & D. In acute stage hospitalization is needed.

TRAUMATIC:

1. MUCOCELE (MUCOUS RETENTION )these are common and are caused by rupture of a salivary gland duct and mucin spillage into the surrounding tissues. Usually they are caused by trauma. Classically, a mucocele is pink or bluish , fluctuant, and most commonly occurs on the lower lip.

Treatment: Excision and removing all miner salivary glands on the sit of surgery to avoid recurrence.

2. RANULA:the name used when a mucocele occurs in the floor of the mouth (underneath the tongue).

Ranulas may grow to a larger size than mucoceles at other sites, and they are usually associated with the sublingual gland, although less commonly they may also arise from the submandibular gland or a minor salivary gland. Uncommonly, a ranula may descend into the neck rather than the mouth (plunging ranula).

Treatment: a) If small, the ranula may be left alone,b. If larger and causing symptoms, excision of the sublingual gland may be indicated.

3. Nicotinic stomatitis :the hard palate is whitened by hyperkeratosis caused by the heat from tobacco use or hot liquid

consumption. This irritation also causes inflammation of the duct openings of the minor salivary glands of the palate, and they become dilated. This manifests as red patches or spots on a white background.

Surgical removal of mucosal

Surgical by Laser

Treatment of ranula

AUTOIMMUNESjögren's syndrome (SjS, SS) is a long-term autoimmune disease in which the moisture-producing glands of the body are affected. This results primarily in the development of a dry mouth and dry eyes. Other symptoms can include dry skin, a chronic cough, vaginal dryness, numbness in the arms and legs, feeling tired, muscle and joint pains, and thyroid problems. Those affected are at an increased risk (5%) of lymphoma.[5]

TREATMENT:Neither a cure for SS nor a specific treatment is known to permanently restore gland secretion. Instead, treatment is generally symptomatic and supportive.

Inflammatory:

1) Post-irradiation sialadenitis

2) Sarcoidosis—there may be parotitis alone or uveoparotitis (inflammation of both the parotidand the uvea [The uvea is the vascular middle layer of the eye. It is traditionally divided intothree areas, from front to back, the: Iris, Ciliary body,& Choroid]), which occurs in Heerfordt'ssyndrome ( is a rare manifestation of sarcoidosis. The symptoms include inflammation of theeye (uveitis), swelling of the parotid gland, chronic fever, and in some cases, palsy ofthe facial nerves.

3) Cheilitis glandularis—This is inflammation of the minor salivary glands, usually in the lower lip,eversion and swelling of the lip, Suspected causes include sunlight, tobacco, syphilis, poororal hygiene and genetic factors. The openings of the minor salivary gland ducts becomeinflamed and dilated, and there may be muco purulent discharge from the ducts.

4) Chronic sclerosing sialadenitis is a salivary gland manifestation , chronic (long-lasting)inflammatory condition affecting the salivary gland. Relatively rare in occurrence, thiscondition is benign, but presents as hard, indurated and enlarged masses that are clinicallyindistinguishable from salivary gland neoplasms or tumors. It is now regarded as amanifestation of IgG4-related disease is a chronic inflammatory condition characterized bytissue infiltration with lymphocytes and IgG4-secreting plasma cells, various degrees offibrosis (scarring) and a prompt response usually to oral steroids. In approximately 51–70% ofpeople with this disease, serum IgG4 concentrations are elevated during an acute phase.

Neurological:

Frey's syndrome: is a rare neurological disorder resulting from damage to or near the parotid glands responsible for making saliva, and from damage to the auriculotemporal nerve oftenfrom surgery.

The symptoms of Frey's syndrome are redness and sweating on the cheek area adjacent to the ear. They can appear when the affected person eats, sees, dreams, thinks about or talks about certain kinds of food which produce strong salivation. Observing sweating in the region aftereating a lemon wedge may be diagnostic Causes:The Auriculotemporal branch of the Trigeminal nerve carries parasympathetic fibers to the sweat glands of the scalp and the parotid salivary gland. As a result of severance and inappropriate regeneration, the parasympathetic nerve fibers may switch course, resulting in "gustatory Sweating" or sweating in the anticipation of eating, instead of the normal salivatory response

Treatments:1. Injection of Botulinum Toxin A2. Surgical transection of the nerve fibers (only a temporary treatment)3. Application of an ointment containing an anticholinergic drug

such as scopolamine

Sialadenosis (sialosis) is an uncommon, non-inflammatory, non-neoplastic, recurrent swelling of the salivary glands. The cause is hypothesized to be abnormalities of neurosecretory control. It may be associated with alcoholism

Benign epithelial tumorsPleomorphic adenomaMyoepitheliomaBasal cell adenomaWarthin's tumorOncocytomaCanalicular adenomaLymphadenomaSebaceous lymphadenomaNonsebaceous lymphadenomaDuctal papillomaInverted ductal papillomaIntraductal papillomaSialadenoma papilliferumCystadenoma

Soft tissue tumorsHemangiomaHematolymphoid tumorsHodgkin lymphomaDiffuse large B-cell lymphomaExtranodal marginal zone B cell lymphoma

Mesenchymal tumoursNeural tissueNeurofibromaMuscular tissueRhabdomyosarcoma

Neoplastic

Salivary gland neoplasm WHO classification 2004

Neoplastic

Salivary gland neoplasm

Malignant epithelial tumorsMucoepidermoid carcinomaPolymorphous low-grade adenocarcinomaAdenoid cystic carcinomaAcinic cell carcinomaEpithelial-myoepithelial carcinomaClear cell carcinoma, not otherwise specifiedBasal cell adenocarcinomaSebaceous carcinomaSebaceous lymphadenocarcinomaCystadenocarcinomaLow-grade cribriform cystadenocarcinomaMucinous adenocarcinoma

Oncocytic carcinomaSalivary duct carcinomaSalivary duct carcinoma, not otherwise specifiedAdenocarcinoma, not otherwise specifiedMyoepithelial carcinomaCarcinoma ex pleomorphic adenomaCarcinosarcomaMetastasizing pleomorphic adenomaSquamous cell carcinomaLarge cell carcinomaLymphoepithelial carcinomaSialoblastoma

WHO classification 2004

Secondary tumors (i.e. a tumor which has metastasized to the salivary gland from a distant location)

Treatment

Treatment may include the following:

1) Surgery with or without radiation2) Radiotherapy

Fast neutron therapy has been used successfully to treat salivary gland tumors,[7] and hasshown to be significantly more effective than photons in studies treating unrespectablesalivary gland tumors.[8]

3. Chemotherapy

Neoplastic

Salivary gland neoplasm

Benign Salivary Gland TumorsThe pleomorphic adenoma, or benign mixed tumor, is the most common salivary gland tumor. The mean age ofoccurrence is 45 years, with a male-to-female ratio of 3:2. In the major glands, the parotid gland is involved inover 80% of cases, in the minor glands, the most common intraoral site is the palate.Pleomorphic adenomas are usually slowly growing, and painless masses.

The histopathology shows two cell types: (1) the ductal epithelial cell and (2) the myoepithelial cell, which maydifferentiate along a variety of cell lines (pleomorphic means many forms). A connective tissue capsule exists,which may be incomplete.

PLEOMORPHIC ADENOMA excision from the check and palate

The treatment of Pleomorphic Adenoma involves complete surgical excision with a margin of normaluninvolved tissue. Parotid lesions are treated with removal of the involved lobe along with the tumor.Recurrence is possible in rare occasions, as well as a small risk (5%) of malignant trans-formation to acarcinoma ex pleomorphic adenoma.

Superficial Parotidectomy

Parotidectomy

The mucoepidermoid carcinoma:Is the most common malignant salivary gland tumor. It comprises 10% of major glandes (mostly parotid) and 20% of minor gland tumors (mostly palate) .This lesion may occur at any age, but the mean age is 45 years .The ratio is 3:2 male-to-female .Treatment is wide surgical excision, followed in some cases by radiation therapy.

The polymorphous low-grade adenocarcinoma:is the second most common intraoral salivary gland malignancy. The most common site is the junction of the hard and soft palates. The male-to-female ratio is 3:1, with a mean age of 56 years. These tumors present as slow-growing, asymptomatic masses.4The treatment of this tumor is wide surgical excision, with a relatively high recurrence rate of 14%.

The adenoid cystic carcinoma:is the third most common intraoral salivary gland malignancy, with a mean age of 53 years and a

male-to-female ratio of 3:2. Approximately 50% of these tumors occur in theparotid gland, whereas the other 50% occur in the minor salivary glands of the palate .Treatment is wide surgical excision, followed in some cases by radiation therapy. The prognosis is poor despite

salivary gland malignancy

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