Salivary gland pathology 2

1

Salivary Gland Pathology

Dr. Arsalan MalikAssistant Professor & HOD (Oral Pathology)

حيم الر حمن الر الله بسم

2Mucocele

Mucoceles result from an extravasation of fluid into the surrounding tissues after traumatic break in the continuity of their ducts.

Lacks a true epithelial lining.

3Mucocele

Incidence: commonAge: children and young adultsSite: Lower lip (60%)Duration of symptoms: days – yearsMay rupture, drain then recur

4Mucocele Submucosal cavitation Spilled mucin Granulation tissue Inflammation Foamy macrophages Ruptured duct Sialadenitis

5Mucocele

Treatment:Spontaneous resolutionSurgical excisionRemove associated salivary lobulesMarsupializationPrognosis: - excellent Differential diagnosis: salivary gland tumor

6Ranula

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.

7Ranula

Origin: - sublingual gland - submandibular duct - minor salivary glands

8Plunging Ranula

Dissection through mylohyoid Extension in cervical soft tissue May have limited intra-oral component

9Ranula

Treatment: Marsupialization Remove offending gland Complete dissection is unnecessaryPrognosis: Good

10

Salivary Duct Cyst(Mucous Retention

Phenomenon)

11Salivary Duct Cyst True epithelial lined cyst Ductal dilatation Obstruction – mucus plug Developmental duct cyst Adults Major glands

– parotid

Minor glands – floor of mouth, buccal/labial mucosa

12Salivary Duct Cyst

Asymptomatic Slow growing

Swelling

Soft fluctuant Bluish - amber

13Salivary Duct Cyst

Submucosal Epithelial lined cyst Cuboidal, columnar or

squamous epithelium Mucoid secretions Chronic saliadenitis

14Salivary Duct Cyst

Treatment: - conservative excision - removal of associated gland

Prognosis: - good - recurrence rare - multifocal lesions

15SialolithiasisCalcification within salivary duct system

Age: young to middle aged adults

Episodic pain and swelling

Symptoms related to meals – obstruction

Solitary – anywhere in duct system

Palpable hard sub mucosal mass

Round, ovoid or cylindrical yellowish mass

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17Etiology Water hardness likelihood? Maybe…. Hypercalcemia… Xerostomic meds Tobacco smoking, positive correlation Smoking has an increased cytotoxic effect on saliva,

decreases PMN phagocytic ability and reduces salivary proteins

18

Gout is the only systemic disease known to cause salivary calculi and these are composed of uric acid.

19Stone Composition Organic; often predominate in the center

Glycoproteins

MucopolysaccaridesBacterialCellular debris

Inorganic; often in the periphery Calcium carbonates & calcium phosphates in the form of

hydroxyapatite

20Sialolithiasis Major glands

-Submandibular Gland (75%)

-Parotid Gland (20%)

-Sublingual gland (5%)

Minor Glands

- upper lip, buccal mucosa

21

Sialolithiasis may occur more often in the SMG

Saliva more alkaline

Higher concentration of calcium and phosphate in the saliva

Higher mucus content

Longer duct

Anti-gravity flow

22Other Characteristics

Despite a similar chemical make-up, 80-90% of SMG calculi are radio-opaque

50-80% of parotid calculi are radiolucent

30% of SMG stones are multiple 60% of Parotid stones are multiple

23Sialolithiasis

Calcified mass Laminated Nidus Ductal metaplasia Sialadenitis

24Diagnostics: Plain occlusal film

Effective for intraductal stones, while….

intraglandular, radiolucent or

small stones may be missed.

25Diagnostic 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

26Sialography

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

27Sialography

Disadvantages: irradiation dose pain with procedureposs.perforation infection dye reactionpush stone furthercontraindicated in active infection.

28MR Sialography

T2 weighted fast spin echo slides in sagittal and axial planes. Volumetric reconstruction allows visualization of ducts

ADV: No dye, no irradiation, no pain DIS: Cost, possible artifact

29Diagnostic SialendoscopyAllows complete exploration of the ductal

system, direct visualization of duct pathology

Success rate of >95%Disadvantage: technically challenging,

trauma could result in stenosis, perforation

30TreatmentStone excision:

LithotripsyInterventional sialendoscopySimple removal (20% recurrence)

Gland excisionSialogoguesFluid intakeMoist heat

31Xerostomia

Subjective sensation of dry mouth Salivary hypofunction Incidence: common 25% of older adults Numerous causative factors Oral complications

32Causes of Xerostomia

Medications Aging Radiation therapy Sjogren’s syndrome Diabetes mellitus Sarcoidosis HIV infection

Graft vs host disease Diabetes incipidus Smoking Mouthbreathing Fluid/electrolyte

imbalance Salivary gland aplasia

33Drug Induced Xerostomia

Over 500 drugs are known to produce xerostomia 63% of 200 most frequently prescribed medications Prevalence of xerostomia increases with total number of

drugs taken

34Drugs Causing Xerostomia

Antihistamines Decongestants Antihypertensives Anticholinergics Antidepressants Antipsychotics

35Clinical Findings Reduced salivary pool Thick ropey or foamy saliva Dry sticky mucosa Fissured tongue Atrophy of filiform papillae “Cracker” sign

36Complications Mucositis - discomfort Candidiasis Dental caries Difficulty with mastication Dysphagia Difficulty with speech Altered taste Difficulty wearing dentures/prostheses

37Management

Symptomatic relief Water – artificial saliva Sugarless candy or gum Discontinue contributing factors Parasympathomimetic drugs Antifungal medication Dental maintenance care

38

Myoepithelial Sialadenitis(Benign Lymphoepithelial Lesion)

39Myoepithelial Sialadenitis

Firm diffuse swelling of salivary glands Lymphoid infiltrate Sjogren’s syndrome Age: mean age – 50 years old Gender: female – 60-80% Site: parotid gland – 85% Asymptomatic – mild discomfort

40Myoepithelial Sialadenitis

Diffuse lymphoid infiltrate Acinar destruction Germinal centers Epimyoepithelial islands

41Myoepithelial Sialadenitis

Treatment:

Surgical removal

Low grade marginal zone lymphoma of mucosa

associated lymphoid tissue (MALT lymphoma)

Prognosis:

- Good

42

Sjogren’s Syndrome

43Sjogren’s Syndrome

Autoimmune disease Salivary and lacrimal glands Xerostomia Keratoconjunctivitis sicca Primary Secondary

44 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

45 Sjögren’s Syndrome

Incidence: 0.2-3.0% of the population 90% cases occur in women Average age of onset is 50y Classic monograph on the diease published in 1933 by

Sjögren, a Swedish ophthalmologist

46 Sjögren’s Syndrome

Two forms: Primary: involves the exocrine glands only Secondary: associated with a definable

autoimmune disease, usually rheumatoid arthritis.80% of primary and 30-40% of secondary

involves unilateral or bilateral salivary glands swelling

47 Sjögren’s Syndrome Etiology – unknown Genetic - HLA-DRw52, HLA-B8, HLA-DR3 Viruses Epstein-Barr virus Human T-cell lymphotropic virus

48Sjogren’s Syndrome

Reduced salivary pool Mucositis Fissured atrophic

tongue Dysphagia Altered taste Speech difficulties Sialadenitis

Candidiasis Angular cheilitis Dental caries Difficulty wearing

prostheses Enlargement of salivary

glands

49Diagnosis

Ocular dryness - Schirmer’s test,

Xerostomia - reduced salivary flow rate, + focus score

Serologic evidence of autoimmunity – rheumatoid factor, ANA, SS-A, SS-B

Associated systemic autoimmune disease

50Diagnosis

Sialogram---Pooling of opaque

dye at the atropy site,--

resemble to fruit laden

branchless tree or gun shot

pallets throught the gland

51Labial Minor Salivary Gland Biopsy

Focal lymphocytic sialadenitis Focus = greater than fifty lymphocytes Greater than one focus per 4mm squared

52Histology

Acinar degeneration Infiltration of T-lymphocytes Epi-myoepithelial islands

53Clinical Laboratory Values Elevated erythrocyte sedimentation rate Hypergammaglobulinemia Rheumatoid factor (75%) Antinuclear antibodies (ANA) Anti-SS-A (Ro) Anti-SS-B (La) Salivary duct autoantibodies

54Keratoconjunctivitis Sicca

Reduced tear production Mucoid secretions Blurred vision Pain Gritty foreign body sensation Corneal erosion Lacrimal enlargement

55Extra-Glandular Manifestations

Nephritis Interstitial pneumonitis Vasculitis Neuropathy Primary biliary cirrhosis

Raynaud’s phenomenon

Fatigue Depression Lymphadenopathy Malignant lymphoma

56Management Rheumatologist Ophthalmologist Supportive care

saliva substitutes

sialogogues antifungal therapy

preventive dental care Risk of lymphoma (40X normal)

57

Necrotizing Sialometaplasia

58Necrotizing Sialometaplasia Necrotizing ulcerative process Ischemia – local infarction Trauma – predisposing factors Incidence: uncommon Palatal salivary glands (75%) Adults (mean age 46 years) Male gender predilection (2:1) Mimics a malignant process

59Necrotizing Sialometaplasia

Begins as a painful swelling Necrotic tissue sloughs “Part of the roof of my mouth fell out!” Pain subsides Craterlike ulceration (1 to 5 cm) Bone destruction is rare May have alarming clinical appearance

60Necrotizing Sialometaplasia Ulceration Acinar necrosis Lobular architecture Squamous metaplasia Inflammation Mucin release Pseudoepitheliomatous epithelial hyperplasia

61Management Biopsy to establish diagnosis No specific treatment Supportive care Spontaneous healing – 5 to 6 weeks Avoid misdiagnosis Prevent inappropriate therapy

62Salivary Gland Infections

Bacterial sialadenitis Viral infections

63Sialadenitis

Sialadenitis represents inflammation mainly involving the acinoparenchyma of the gland.

64BACTERIAL SIALADENTITIS Due to decreased salivary flow

Local causes Calculus, mucous plug, duct stricture

Systemic causes Diabetes mellitus, Sjogrens syndrome

Staphylococcus aureus, streptococci, anaerobes Clinical Features

Pain and swelling of the affected gland Pyrexia, malaise Erythema of overlying skin Pus may be expressed from the duct orifice

65BACTERIAL SIALADENTITIS Investigation and Diagnosis

Pus for culture and sensitivity Treatment

Antibiotics – amoxycillin or flucloxacillinEncourage drainage by use of sialogogues, chewing,

massageSialography after acute infection resolved

(calculi/strictures)Rarely incision and drainage of pus

66VIRAL SIALADENITIS (MUMPS)

Derived from the Danish word “mompen”

This means mumbling, the name given to describe the

characteristic muffled speech that patients demonstrate because of

glandular inflammation and trismus.

67Mumps

2-3 week incubation after exposure (the virus multiplies in the parotid gland)

3-5 day viremia Then localizes to biologically active tissues like salivary

glands, germinal tissues and the CNS.

68VIRAL SIALADENITIS (MUMPS) Common infection by paramyxovirus Predominantly effects children

Clinical Features Prodromal fever, malaise and sore throat Acute, tender, usually bilateral, swelling of the

parotid glands Usually self limiting

Investigations and Diagnosis Based on characteristic history and clinical features Confirmed by serology – elevated IgM to ‘S’ and ‘V’

antigens Treatment

Bed rest and analgesia