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by: dr nikil
Salivary Glands& Disease
Embryology
The parotid anlagen are the first to develop, followed by the submandibular gland, and finally the sublingual gland.
Parenchymal tissue (secretory) of the glands arises from the proliferation of oral epithelium.
Embryology
The stroma (capsule and septae) of the glands originates from mesenchyme that may be mesodermal or neural crest in origin.
Parotid development
Although the parotid anlagen are the first to develop, they become encapsulated AFTER the SMG and SLG.
This delayed encapsulation is critical because after the encapsulation of the SMG and SLG but BEFORE encapsulation of the parotid, the lymphatic system develops.
Parotid development
Therefore, there are intraglandular lymph nodes and lymphatic channels entrapped within the parotid gland (PG).
PG is also unique because its epithelial buds grow, branch and extend around the divisions of the facial nerve.
Embryology
The epithelial buds of each gland enlarge, elongate and branch initially forming solid structures.
Branching of the glandular mass produces arborization.
Each branch terminates in one or two solid end bulbs.
Embryology
Elongation of the end bulb follows and lumina appears in their centers, transforming the end bulbs into terminal tubules.
These tubules join the canalizing ducts to the peripheral acini.
Duct Canalization
Canalization results from mitotic activity of the outer layers of the cord outpacing that of the inner cell layers
Canalization is complete by 6th month post conception.
Acinar cells
At around the 7-8th month in utero, secretory cells (acini) begin to develop around the ductal system.
Acinar cells of Salivary Glands
Classified as either:Serous cells: produce a thin watery
secretionMucous cells: produce a more viscous
secretion
Salivary gland secretory unit
Composed of terminal aciniIntercalated, striated and excretory ductsMyoepithelial cells
Major glands/Secretions
Major SG are paired structures and include the parotid, submandibular and sublingual
Parotid: serousSubmandibular: mucous & serousSublingual: mucous
Salivary Function
Aid is mastication, deglutinationSalivary lysozyme, IgA and other
antibacterial substances protect against caries and oral cavity infections
Saliva also aids in speech
Anatomy: Parotid Gland
Nearly 80% of the parotid gland (PG) is found below the level of the external auditory canal, between the mandible and the SCM.
Superficial to the posterior aspect of the masseter mm
Extensions of PG project to mastoid process Down the anterior aspect of the SCM for a short
distance Around the posterior border of the mandible. Superiorly to the to inferior margin of the zygomatic
arch
Anatomy:Parotid Gland
CN VII branches roughly divide the PG into superficial and deep lobes while coursing anteriorly from the stylomastoid foramen to the muscles of facial expression.
Anatomy: Deep Lobe
The remaining 20% extends medially through the stylomandibular tunnel, which is formed ventrally by the posterior edge of the ramus dorsally by the anterior border of the SCM & posterior
digastric muscle deeply and dorsally by the stylomandibular ligament.
Anatomy: Parotid Duct
Small ducts coalesce at the anterosuperior aspect of the PG to form Stensen’s duct.
Runs anteriorly from the gland and lies superficial to the masseter muscle
Follows a line from the EAM to a point just above the commissure. Is inferior to the transverse facial artery It is 1-3 mm in diameter 6cm in length
Anatomy: Parotid Duct
At the anterior edge of the masseter muscle, Stensen’s duct turns sharply medial and passes through the buccinator muscle, buccal mucosa and into the oral cavity opposite the maxillary second molar.
Anatomy: Parotid Fascia
Gland encapsulated by a fascial layer that is continuous w/the deep cervical fascia (DCF).
The stylomandibular ligament (portion of the DCF) separates the parotid and submandibular gland.
Anatomy: Parotid Lymphatics
Lymphatic drainage is to the superficial and deep cervical nodes
Preauricular lymph nodes (LN) in the superficial fascia drain the temporal scalp, upper face, anterior pinna
LN within the gland drain the parotid gland, nasopharynx, palate, middle ear and external auditory meatus
Parotid: Parasympathetic Innervation
Preganglionic parasympathetic (from CN9) arrives at otic ganglion via lesser petrosal n.
Postganglionic parasympathetic leaves the otic ganglion and distributes to the parotid gland via the auriculotemporal nerve.
Parotid: Sympathetic Innervation
Postganglionic innervation is provided by the superior cervical ganglion and distributes with the arterial system
Parotid Anatomy: Great Auricular Nerve (C2,C3)
Emerges from the posterior border of the SCM at Erb’s point. It crosses the mid-portion of the SCM about
6.5cm beneath the EAM.Passes parallel and superior to the
external jugular vein to supply the ear and pre-auricular region.
Parotid Anatomy: Auriculotemporal Nerve
Branch of V3Traverses the upper part of the parotid
gland and emerges from the superior surface with the superficial temporal vessels.
It carries sensory fibers from the trigeminal and post-ganglionic parasympathetic (secretory)fibers.
Parotid Anatomy: Facial Nerve
Emerges at the level of the digastric muscle, through the stylomastoid foramen.
Main trunk divides at the pes anserinus (intraparotid plexus of CN7) into the upper temporofacial and lower cervicofacial divisions.
Before it enters gland, gives off 3 branches: Posterior auricular, posterior digastric, stylohyoid
Parotid Anatomy: Vessels
Retromandibular Vein: located within the substance of the gland
External carotid : at the inferior level of the gland, the external carotid divides into the superficial temporal and internal maxillary artery.
Parotid Bed: Deep lobe lies on...
V: internal jugular veinA: external and internal carotid arteriesN: glossopharyngeal N vagus N spinal accesory N hypoglossal NS: styloid process styloglossus mm stylohyloid mm
Anatomy:Submandibular gland
Located in the submandibular triangle of the neck, inferior & lateral to mylohyoid muscle.
The posterior-superior portion of the gland curves up around the posterior border of the mylohyoid and gives rise to Wharton’s duct.
Anatomy: Submandibular Lymphatics
Submandibular gland drains into submandibular nodes.
Anatomy: Submandibular Duct
Wharton’s duct passes forward along the superior surface of the mylohyoid adjacent to the lingual nerve.
The nerve winds around the duct, first being lateral, then inferior, and finally medial.
Anatomy: Submandibular duct
2-4mm in diameter & about 5cm in length.
It opens into the floor of the mouth thru a punctum.
The punctum is a constricted portion of the duct to limit retrograde flow of bacteria-laden oral fluids.
Anatomy: Sublingual glandsLie on the superior
surface of the mylohyoid muscle and are separated
from the oral cavity by a thin
layer of mucosa.
Anatomy: Sublingual glands
The ducts of the sublingual glands are called Bartholin’s ducts.
In most cases, Bartholin’s ducts consists of 8-20 smaller ducts of Rivinus. These ducts are short and small in diameter.
Anatomy: Sublingual glands
The ducts of Rivinis either open…individually into the FOM near the
punctum of Wharton’s ducton a crest of sublingual mucosa
called the plica sublingualisopen directly into Wharton’s duct
Physiology
Physiologic control of the SG is almost entirely by the autonomic nervous system; parasympathetic effects predominate.
If parasympathetic innervation is interrupted, glandular atrophy occurs.
Normal saliva is 99.5% waterNormal daily production is 1-1.5L
ObstructiveSalivary Gland Disorders
SialolithiasisMucous retention/extravasation
Obstructive SG Disorders: Sialolithiasis
Sialolithiasis results in a mechanical obstuction of the salivary duct
Is the major cause of unilateral diffuse parotid or submandibular gland swelling2
Sialolithiasis Incidence
Escudier & McGurk 1:15-20 0003
Marchal & Dulgurerov 1:10-20 0002
Sialolithiasis remains the most frequent reason for submandibular gland resection5
Sialolithiasis
The exact pathogenesis of sialolithiasis remains unknown.
Thought to form via…. an initial organic nidus that
progressively grows by deposition of layers of inorganic and organic substances.
May eventually obstruct flow of saliva from the gland to the oral cavity.
Sialolithiasis
Acute ductal obstruction may occur at meal time when saliva
producing is at its maximum, the resultant swelling is sudden and
can be painful.
Gradually reduction of the swelling can result but it
recurs repeatedly when flow is stimulated.
This process may continue until complete obstruction and/or
infection occurs.
Etiology
Water hardness likelihood? …Maybe….Hypercalcemia…in rats onlyXerostomic medsTobacco smoking, positive correlationSmoking has an increased cytotoxic effect on
saliva, decreases PMN phagocytic ability and reduces salivary proteins
Etiology
Gout is the only systemic disease known to cause
salivary calculi and these are composed of uric acid.
Stone Composition
Organic; often predominate in the center Glycoproteins Mucopolysaccarides Bacteria! Cellular debris
Inorganic; often in the periphery Calcium carbonates & calcium phosphates in the form
of hydroxyapatite
Parotid (PG) vs. Submandibular Gland (SMG)….
Most authorities agree obstructive phenomemnon such as mucous plugs and sialoliths are most commonly found in the SMG Escudier et al3 Lustmann et al4
Rice7
Others note that parotid glands are most commonly affected2
Reasons sialolithiasis may occur more often in the SMG
Saliva more alkalineHigher concentration of calcium and
phosphate in the salivaHigher mucus contentLonger ductAnti-gravity flow
Other characteristics:
Despite a similar chemical make-up, 80-90% of SMG calculi are radio-opaque7
50-80% of parotid calculi are radiolucent7
30% of SMG stones are multiple 60% of Parotid stones are multiple
Clinical presentation
Painful swelling (60%)Painless swelling (30%)Pain only (12%)
Sometimes described as recurrent salivary colic and spasmodic pains upon eating
Clinical History
History of swellings / change over time?Trismus?Pain?Variation with meals?Bilateral?Dry mouth? Dry eyes?Recent exposure to sick contacts (mumps)?Radiation history?Current medications?
Exam: Inspection
Asymmetry (glands, face, neck)Diffuse or focal enlargementErythema extra-orallyTrismusMedial displacement of structures
intraorally?Examine external auditory canal (EAC)Cranial nerve testing
Exam: Palpation
Palpate for cervical lymphadenopathyBimanual palpation of floor of mouth in a
posterior to anterior direction Have patient close mouth slightly & relax oral
musculature to aid in detection Examine for duct purulence
Bimanual palpation of the gland (firm or spongy/elastic).
Diagnostics: Plain occlusal film
Effective for intraductal stones, while….
intraglandular, radiolucent or
small stones may be missed.
Diagnostic approaches
CT Scan:large stones or small CT slices done
also used for inflammatory disordersUltrasound:operator dependent, can detect small stones
(>2mm), inexpensive, non-invasive
Diagnostic approaches: Sialography
Consists of opacification of the ducts by a retrograde injection of a water-soluble dye.
Provides image of stones and duct morphological structure
May be therapeutic, but success of therapeutic sialography never documented
Sialography continued…Disadvantages:
irradiation dose pain with procedure poss.perforation infection dye reaction push stone further contraindicated in active infection.
Diagnostic approach: Radionuclide Studies
Useful to image the parenchymaT99 is an artificial radioactive element
(atomic #43, atomic weight 99) that is used as a tracer in imaging studies.
T99 is a radioisotope that decays and emits a gamma ray. Half life of 6 hours.
Helman & Fox 1987, found that Technitium-99 shares the Na-K-Cl transport system on the basement membrane of the parotid acinar cells
Diagnostic Approaches: Radionuclide Studies
Some say T99 is useful preoperatively to determine if gland is functional.
However, no evidence to suggest gland won’t recover function after stone removed. Not advised for pre-op decision making!
Diagnostic Approach: MR Sialography
T2 weighted fast spin echo slides in sagittal and axial planes. Volumetric reconstruction allows visualization of ducts
ADV: No dye, no irradiation, no painDIS: Cost, possible artifact
Diagnostic approach: Diagnostic Sialendoscopy
Allows complete exploration of the ductal system, direct visualization of duct pathology
Success rate of >95%2
Disadvantage: technically challenging, trauma could result in stenosis, perforation
Sialolithiasis Treatment
None: antibiotics and anti-inflammatories, hoping for spontaneous stone passage.
Stone excision: Lithotripsy Interventional sialendoscopy Simple removal (20% recurrence)7
Gland excision
Sialolithiasis Treatment
If patients DO defer treatment, they need to know:
Stones will likely enlarge over timeSeek treatment early if infection developsSalivary gland massage and hyper-hydration
when symptoms develop.
Stone excision
External lithotripsy Stones are fragmented and expected to pass
spontaneously The remaining stone may be the ideal nidus for
recurrenceInterventional Sialendoscopy
Can retrieve stones, may also use laser to fragment stones and retrieve.
Transoral vs. Extraoral Removal
Some say: if a stone can be palpated thru the mouth, it can be
removed trans-orally (TO) Or if it can be visualized on a true central occlusal
radiograph, it can be removed TO. Finally, if it is no further than 2cm from the punctum,
it can be removed TO.
Posterior Stones
Deeper submandibular stones (~15-20% of stones) may best be removed via sialadenectomy.
Some surgeons say can still remove transorally, but should be done via general anesthetic.
Floor of mouth (FOM) opened opposite the first premolar, duct dissected out, lingual nerve identified.
Duct opened & stone removed, FOM approximated.
Submandibular Sialoliths: Transoral Advantages
Preserves a functional glandAvoids neck scarPossibly less time from workNo overnight stay in hospitalAvoids risk to CN 7 & 12
Gland excision
After SMG excision, 3% cases have recurrence via: Retention of stones in intraductal portion or new
formation in residual Wharton's ductNo data regarding recurrence after
parotidectomy
Gland excision indicatedVery posterior stonesIntra-glandular stonesSignificantly symptomatic patientsFailed transoral approach
Gland excisionWhile some believe that a gland with
sialolithiasis is no longer functional, a recent study on SMGs removed due to sialolithiasis found there was no correlation between the degree of gland alteration and the number of infectious episodes.
50% of the glands were histopathologically normal or close to normal
A conservative approach to the gland/stone seems to be justified
ObstructiveSalivary Gland Disorders
SialolithiasisMucous retention/extravasation
Mucocele
Mucus is the exclusive secretory product of the accessory minor salivary glands and the most prominent product of the sublingual gland.
The mechanism for mucus cavity development is extravasation or retention
Mucocele
Mucoceles, exclusive of the irritation fibroma, are most common of the benign soft tissue masses in the oral cavity.
Muco: mucus , coele: cavity. When in the oral floor, they are called ranula.
Mucocele
Extravasation is the leakage of fluid from the ducts or acini into the surrounding tissue.Extra: outside, vasa: vessel
Retention: narrowed ductal opening that cannot adequately accommodate the exit of saliva produced, leading to ductal dilation and surface swelling. Less common phenomenon
Mucocele
Consist of a circumscribed cavity in the
connective tissue and submucosa producing an
obvious elevation in the mucosa
Mucocele
The majority of the mucoceles result from an extravasation of fluid into the surrounding tissue after traumatic break in the continuity of their ducts.
Lacks a true epithelial lining.
Ranula
Is a term used for mucoceles that occur in the floor of the mouth.
The name is derived form the word rana, because the swelling may resemble the translucent underbelly of the frog.
Ranula
Although the source is usually the sublingual gland, may also arise from the submandibular duct or possibly the minor salivary glands in the floor
of the mouth.
RanulaPresents as a blue dome shaped swelling
in the floor of mouth (FOM). They tend to be larger than mucoceles &
can fill the FOM & elevate tongue. Located lateral to the midline, helping to
distinguish it from a midline dermoid cyst.
Plunging or Cervical Ranula
Occurs when spilled mucin dissects through the mylohyoid muscle and produces swelling in the neck.
Concomitant FOM swelling may or may not be visible.
Treatment of Mucocelesin Lip or Buccal mucosa
Excision with strict removal of any projecting peripheral salivary glands
Avoid injury to other glands during primary wound closure
Ranula Treatment
Marsupialization has fallen into disfavor due to the excessive recurrence rate of 60-90%
Sublingual gland removal via intraoral approach
Salivary Gland Infections
Acute bacterial sialdenitisChronic bacterial sialdenitisViral infections
Sialadenitis
Sialadenitis represents inflammation mainly involving the acinoparenchyma of
the gland.
Sialadenitis
Awareness of salivary gland infections was increased in 1881 when President Garfield died from acute parotitis following abdominal surgery and associated systemic dehydration.
Sialadenitis
Acute infection more often affects the major glands than the minor glands1
Pathogenesis
1. Retrograde contamination of the salivary ducts and parenchymal tissues by bacteria inhabiting the oral cavity.
2. Stasis of salivary flow through the ducts and parenchyma promotes acute suppurative infection.
Acute Suppurative
More common in parotid gland. Suppurative parotitis, surgical parotitis, post-
operative parotitis, surgical mumps, and pyogenic parotitis.
The etiologic factor most associated with this entity is the retrograde infection from the mouth.
20% cases are bilateral7
Predilection for ParotidSalivary Composition
The composition of parotid secretions differs from those in
other major glands.Parotid is primarily serous, the others have a greater proportion
of mucinous material.
Salivary Composition
Mucoid saliva contains elements that protect against bacterial infection including lysozymes & IgA antibodies (therefore, parotid has bacteriostatic activity)
Mucins contain sialic acid which agglutinates bacteria and prevents its adherence to host tissue.
Specific glycoproteins in mucins bind epithelial cells competitively inhibiting bacterial attachment to these cells.
Parotid Predilection : Anatomic factors
Minor role in formation of infectionsStensen’s duct lies adjacent to the maxillary
mandibular molars and Wharton’s near the tongue. It is thought that the mobility of the tongue may
prevent salivary stasis in the area of Wharton's that may reduce the rate of infections in SMG.
Risk Factors for Sialadenitis
Systemic dehydration (salivary stasis)Chronic disease and/or immunocompromise
Liver failure Renal failure DM, hypothyroid Malnutrition HIV Sjögren’s syndrome
Risk Factors continued…
Neoplasms (pressure occlusion of duct)Sialectasis (salivary duct dilation) increases
the risk for retrograde contamination. Is associated with cystic fibrosis and pneumoparotitis
Extremes of agePoor oral hygieneCalculi, duct strictureNPO status (stimulatory effect of mastication on
salivary production is lost)
Complex picture
There must be other factors at work…..Sialolithiasis can produce mechanical
obstruction of the duct resulting in salivary stasis and subsequent gland infection.
Calculus formation is more likely to occur in SMG duct (85-90% of salivary calculi are in the SMG duct) However, the parotid gland remains the MC site of acute suppurative infection!
Differential Diagnosis of Parotid Gland Enlargement
LymphomaActinomycosesCat-scratch diseaseSjogren’s syndromeWegener’s granulomatosisViral infection
Acute Suppurative Parotitis - History
Sudden onset of erythematous swelling of the pre/post auricular areas extend into the angle of the mandible.
Is bilateral in 20%.
Bacteriology
Purulent saliva should be sent for culture. Staphylococcus aureus is most common Streptococcus pnemoniae and S.pyogenes Haemophilus Influenzae also common
Lab Testing
Parotitis is generally a clinical diagnosisHowever, in critically ill patients further
diagnostic evaluation may be requiredElevated white blood cell countSerum amylase generally within normal If no response to antibiotics in 48 hrs can
perform MRI, CT or ultrasound to exclude abscess formation
Can perform needle aspiration of abscess
Treatment of Acute Sialadenitis
Reverse the medical condition that may have contributed to formation
Discontinue anti-sialogogues if possibleWarm compresses, maximize OH, give
sialogogues (lemon drops)External salivary gland massage if tolerated
Treatment of Acute Sialadenitis/Parotitis
Antibiotics!70% of organisms produce B-lactamase or
penicillinaseNeed B-lactamase inhibitor like Augmentin or
Unasyn or second generation cephalosporinCan also consider adding metronidazole or
clindamycin to broaden coverage
Failure to respond
After 48 hours the patient should respondConsider adding a third generation cephPossibly add an aminoglycosideThe preponderance of MRSA in nursing
homes and nosocomial environments has prompted the recommendation of vancomycin in these groups
Surgery for Acute Parotitis
Limited role for surgeryWhen a discrete abscess is identified,
surgical drainage is undertakenApproach is anteriorly based facial flap with
multiple superficial radial incisions created in the parotid fascia parallel to the facial nerve
Close over a drain
Complications of Acute Parotitis
Direct extension Abscess ruptures into external auditory canal and TMJ
have been reportedHematogenous spreadThrombophlebitis of the retromandibular or
facial veins are rare complications
Complications
Fascial capsule around parotid displays weakness on the deep surface of the gland adjacent to the loose areolar tissues of the lateral pharyngeal wall (Achilles’heel of parotid)
Extension of an abscess into the parapharyngeal space may result in airway obstruction, mediastinitis, internal jugular thrombosis and carotid artery erosion
Complications
Dysfunction of one or more branches of the facial nerve is rare.
Occurs secondary to perineuritis or direct neural compression ; but resolves with adequate treatment of the parotitis.
These patients need to be followed to ensure resolution….must rule out TUMOR.
Chronic Sialadenitis
Causative event is thought to be a lowered secretion rate with subsequent salivary stasis.
More common in parotid gland. Damage from bouts of acute sialadenitis over
time leads to sialectasis, ductal ectasia and progressive acinar destruction combined with a lymphocyte infiltrate.
Chronic Sialadenitis
Of importance in the workup…
The clinician should look for a treatable predisposing factor such as a calculus or a stricture.
No treatable cause found:
Initial management should be conservative and includes the use of sialogogues, massage and antibiotics for acute exacerbations.
Should conservative measures fail, consider removing the gland.
Acute viral infection (AVI)
Mumps classically designates a viral parotitis caused by the paramyxovirus
However, a broad range of viral pathogens have been identified as causes of AVI of the salivary glands.
AVI
Derived from the Danish word “mompen”Means mumbling, the name given to describe
the characteristic muffled speech that patients demonstrate because of glandular inflammation and trismus.
Viral Infections
As opposed to bacterial sialadenitis, viral infections of the salivary glands are
SYSTEMIC from the onset!
Viral infection
Mumps is a non-suppurative acute sialadenitis
Is endemic in the community and spread by airborne droplets
Communicable diseaseEnters through upper respiratory tract
Mumps
2-3 week incubation after exposure (the virus multiplies in the URI or parotid gland)
3-5day viremiaThen localizes to biologically active tissues
like salivary glands, germinal tissues and the CNS.
Epidemiology
Occurs world wide and is highly contagious
Prior to the widespread use of the Jeryl Lynn vaccine (live attenuated), cases were clustered in epidemic fashion
Sporadic cases are observed today likely resulting from non-paramyxoviral infection, failure of immunity or lack of vaccination
Virology
Classic mumps syndrome is caused by paramyxovirus, an RNA virus
Others can cause acute viral parotitis: Coxsackie A & B, ECHO virus, cytomegalovirus and
adenovirus
HIV involvement of parotid glands is a rare cause of acute viral parotitis, is more commonly associated with chronic cystic dz
Clinical presentation
30% experience prodromal symptoms prior to development of parotitis
Headache, myalgias, anorexia, malaise
Onset of salivary gland involvement is heralded by earache, gland pain, dysphagia and trismus
Physical exam
Glandular swelling (tense, firm) Parotid gland involved frequently, SMG & SLG can also be affected
May displace ispilateral pinna
75% cases involve bilateral parotids, may not begin bilaterally (within 1-5 days may become bilateral)….25% unilateral
Low grade fever
Diagnostic Evaluation
Leukocytopenia, with relative lymphocytosis
Increased serum amylase (normal by 2- 3 week of disease)
Viral serology essential to confirm:Complement fixing antibodies appear
following exposure to the virus
Serology
“S” or soluble antibodies directed against the nucleoprotein core of the virus appear within the first week of infection, peak in 2 weeks.
Disappear in 8-9 months and are therefore associated with active or recent infection
Serology
“V ”, or viral antibodies directed against the outer surface hemagglutinin, appear several weeks after the S antibodies and persist at low levels for about 5 years following exposure.
V antibodies are associated with past infection, prior vaccination and the late stages of active infection
Serology
If the initial serology is noncontributory, then a non-paramyxovirus may be responsible for the infection.
Blood HIV tests should also be obtained
The mumps skin test is not useful in diagnosis an acute infection because dermal hypersensitivity does not develop until 3 or 4 weeks following exposure.
Treatment
SupportiveFluidAnti-inflammatories and analgesics
Prevention
The live attenuated vaccine became available in 1967
Commonly combined with the measles and rubella vaccines, the mumps vaccine is administered in a single subcutaneous dose after 12 months of age. Booster at 4-6yr
Complications
Orchitis, testicular atrophy and sterility in approximately 20% of young men
Oophoritis in 5% femalesAseptic meningitis in 10%Pancreatitis in 5%Sensorineural hearing loss <5%
Usually permanent 80% cases are unilateral
Immunologic Disease : Sjögren’s Syndrome
Most common immunologic disorder associated with salivary gland disease.
Characterized by a lymphocyte-mediated destruction of the exocrine glands leading to xerostomia and keratoconjunctivitis sicca
Sjögren’s syndrome
90% cases occur in womenAverage age of onset is 50yClassic monograph on thediease published in
1933 by Sjögren, a Swedish ophthalmologist
Sjögren’s Syndrome
Two forms:Primary: involves the exocrine glands onlySecondary: associated with a definable
autoimmune disease, usually rheumatoid arthritis. 80% of primary and 30-40% of secondary involves
unilateral or bilateral salivary glands swelling
Sjögren’s Syndrome
Unilateral or bilateral salivary gland swelling occurs, may be permanent or intermittent.
Rule out lymphoma
Sjögren’s Syndrome
Keratoconjuntivitis sicca: diminished tear production caused by lymphocytic cell replacement of the lacrimal gland parenchyma.
Evaluate with Schirmer test. Two 5 x 35mm strips of red litmus paper placed in inferior fornix, left for 5 minutes. A positive finiding is lacrimation
of 5mm or less. Approximately 85% specific &
sensitive
Sjögren’s Lip Biopsy
Biopsy of SG mainly used to aid in the diagnosis
Can also be helpful to confirm sarcoidosis
Sjögren’s Lip Biopsy
Single 1.5 to 2cm horizantal incision labial mucosa.
Not in midline, fewer glands there.Include 5+ glands for identificationGlands assessed semi-quantitatively to
determine the number of foci of lymphocytes per 4mm2/gland
Sjögren’s Treatment
Avoid xerostomic meds if possibleAvoid alcohol, tobacco (accentuates xerostomia)Sialogogue (eg:pilocarpine) use is limited by other
cholinergic effects like bradycardia & lacrimationSugar free gum or diabetic confectionary Salivary substitutes/sprays
Sialadenosis
Non-specific term used to describe a non-inflammatory non-neoplastic enlargement of a salivary gland, usually the parotid.
May be called sialosis
The enlargement is generally asymptomatic
Mechanism is unknown in many cases.
Related to…
a. Metabolic “endocrine sialendosis”
a. Nutritional “nutritional mumps” a. Obesity: secondary to fatty hypertrophyb. Malnutrition: acinar hypertrhophyc. Any condition that interferes with the absorption of
nutrients (celiac dz, uremia, chronic pancreatitis, etc)
Related to
a. Alcoholic cirrhosis: likely based on protein deficiency & resultant acinar hypertrophy
b. Drug induced: iodine mumps
c. HIV
Radiation Injury
Low dose radiation (1000cGy) to a salivary gland causes an acute tender and painful swelling within 24hrs.
Serous cells are especially sensitive and exhibit marked degranulation and disruption.
Continued irradiation leads to complete destruction of the serous acini and subsequent atrophy of the gland.
Similar to the thyroid, salivary neoplasm are increased in incidence after radiation exposure.
Granulomatous Disease
Primary Tuberculosis of the salivary glands: Uncommon, usually unilateral, parotid most common
affected Believed to arise from spread of a focus of infection in
tonsils
Secondary TB may also involve the salivary glands but tends to involve the SMG and is associated with active pulmonary TB.
Granulomatous Disease
Sarcoidosis: a systemic disease characterized by noncaseating granulomas in multiple organ systems
Clinically, SG involvement in 6% cases
Heerfordts’s disease is a particular form of sarcoid characterized by uveitis, parotid enlargement and facial paralysis. Usually seen in 20-30’s. Facial paralysis transient.
Granulomatous Disease
Cat Scratch Disease:Does not involve the salivary glands directly,
but involves the periparotid and submandibular triangle lymph nodes
May involve SG by contiguous spread.Bacteria is Bartonella Henselae(G-R)
Also, toxoplasmosis and actinomycosis.
Cysts
True cysts of the parotid account for 2-5% of all parotid lesions
May be acquired or congenital Type 1 Branchial arch cysts are a
duplication anomaly of the membranous external auditory canal (EAC)
Type 2 cysts are a duplication anomaly of the membranous and cartilaginous EAC
Cysts
Acquired cysts include:Mucus extravasation vs. retentionTraumaticBenign epithelial lesionsAssociation with tumors
Pleomorphic adenoma Adenoid Cystic Carcinoma Mucoepidermoid Carcinoma Warthin’s Tumor
Other: Pneumoparotitis
In the absence of gas-producing bacterial parotitis, gas in the parotid duct or gland is assumed to be due to the reflux of pressurized air from the mouth into Stensen’s duct.
May occur with episodes of increased intrabuccal pressure Glass blowers, trumpet players
Aka: pneumosialadenitis, wind parotitis, pneumatocele glandulae parotis
Pneumoparotitis
Crepitation, on palpation of the glandSwelling may resolve in minutes to hours, in
some cases, days. US and CT show air in the duct and glandConsider antibiotics to prevent superimposed
infection
Other: Necrotizing Sialometaplasia
Cryptogenic origin, possibly a reaction to ischemia or injury
Manifests as mucosal ulceration, most commonly found on hard palate.
May have prodrome of swelling or feeling of “fullness” in some.
Pain is not a common complaint
Necrotizing Sialometaplasia
Self limiting lesion, heals by secondary intention over 6-8 weeks
Histologically may be mistaken for SCC
References
1. Tex book of oral surgery- Peter wardbooth2. Principles of oral surgery – Peterson 3. Salivary glands disorder – Mayors
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