NON NEOPLASTIC SALIVARY GLAND DISEASES

CLASSIFICATIONDEVELOPMENTAL DISTURBANCES

AplasiaAtresiaAbberancyDevelopmental lingual mandibular salivary gl.

Depression

OBSTRUCTIVE LESIONSSialolithiasisMucous escape reactionMucous retention reaction

INFECTIOUS DISEASESCat scratch diseaseCytomegalovirus infectionMumpsSarcoidosisCytomegalovirus sialadenitisBacterial sialadenitis

IDIOPATHIC DISEASESNercrotizing sialometaplasiaLyphoepithelial cystCheilitis glandularisSjogren’s syndrome

OBSTRUCTIVE LESIONS

SIALOLITHIASISMUCOCELE

RANULASALIVARY DUCT CYST

SIALOLITHIASISAlso k/as SALIVARY STONES or SALIVARY CALCULI

It is the occurrence of calcareous concretions in the salivary duct or glands.

They are formed by depositions of calcium salts around a central nidus which may consist of desquamated epithelial cells, bacteria, foreign bodies, or products of bacterial decomposition.

Cause is unclear.

Its formation is promoted by chronic sialadenitis & partial obstruction.

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CLINICAL FEATURES:-

Patient complain of moderately severe pain ,particularly just before,during ,after meals, owing to pscyhic stimulation of salivary flow, associated with swelling of the salivary gland.

The occlusion of the duct prevents the flow of Saliva & this accumulation of saliva under pressure produces pain & swelling.

Swelling is diffuse & stimulates cellulitis.

Occasionally the stone present may be firm mass ,palpable in the duct or gland.

Age- Most common in middle aged adults.

Site- Submandibular gland & duct.(60-80%) as its mucin content,adheres to any foreign particle

Parotid gland, Sublingual gland & their ducts Upper lip & buccal mucosa Buccal sulcus,lower lip,palate & tongue

Appearance- Usually presents as solitary,firm,freely movable,small masses of nodules & may or may not be symptomatic..

Sialolith may be round,ovoid,or elongated.May be 2 cm or more in diameter.

Involved duct may contain a single stone or many.Usually it is yellow

HISTOLOGIC FEATURES

Microscopically sialoliths shows concentric laminations around a central nidus of amorphous debris .

Associated duct exhibits squamous ,oncocytic,or mucous cell metaplasia.Periductal inflammation may be seen.

Involved gland usually shows features of acute or chronic sialadenitis.

TREATMENT

Small calculi removed by manipulation.

Large stones require surgical exposure for removal.

If multiple stones are present surgical extirpation of the gland is necessary.

MUCOCELEAlso k/as MUCOUS EXTRAVASTION PHENOMENON or

MUCOUS ESCAPE REACTION.Common lesion of oral mucosa involving salivary gland and

their ducts.

ETIOLOGYTrauma to salivary glandLips bitingCheek bitingPinching the lips by extraction forceps leading to spillage of

mucin into surrounding tissues

CLINICAL FEATURES

Age: in all decades of life.(increased chances in children & young adults due to trauma)

Sites: Most common sites are lower lip(60%) lateral to midline.Less common sites are :- Buccal mucsa; Anterior ventral tongue

(involving glands of Blandin Nuhn); Floor of mouth.

Clinically appear as raised dome shaped vesicles.

Size varies from 1-2 mm to few cm.

There may be history of rupture,collapse & refilling which may be repeated.

May present deep into tissues exceptionally superficial depending on location.

SUPERFICIAL LESION: bluish,translucent cast (blue colour is imparted by spilled mucin below the mucosal surface)

DEEP LESION: is of normal colour because of thickness of overlying tissues.

It often arises within a few days,reach to a certain size & may persist as such for months unless treated.

Contains thick mucin material.

It may recur.

SUPERFICIAL MUCOCELE- (Variant of mucocele)

Commonly seen in soft palate,retromolar area & posterior buccal mucosa.

Size: 1-4 mm in diameter.

Present as single or multiple huge vesicle.

Vesicular appearance is created by superficial nature of mucin spillage,resulting in separateion of epithelium from underlying connective tissue.

These vesicles often rupture leaving shallow painful ulcers that heal within few days.

May recur.

In some cases its occurrence is related to meal times.

HISTOLOGIC FEATURES

Consist of circumscribed cavity in C.T. & submucosa,producing elevation of mucosa with thinning of epithelium as though it were stretched.

Wall of cavity made up of a lining of compressed fibrous C.T. & fibroblast.C.T. show infiltration by abundant number of PMNs,lymphocytes &

plasma cells.Lumen of the cyst like cavity is filled with the spilled mucin containing

variable no. of cells,mainly leucocytes & foamy histiocytes(macrophages).Occasional mucoceles show an intact,flattened epithelial lining. It represents the portion of excretory duct bordering the line of severance.The flattened epi. lining has been referred to as epi. of “feeder duct”.Epithelium lined mucocele represents a Mucous Retention Cyst.

Salivary gland acini which lie adjacent to mucocele area show alteration like intestitial inflammation or Sialadenitis,dilatation of intralobular & interlobular ducts with collection of mucous & breakdown of individual acinar mucous cells resulting in formation of tiny areas of pooled mucous.

TREATMENT

Excision because the chances of recurrence is less if it is excised with associated salivary gland acini.

If lesion is simply incised,chances of recurrence is high.

RANULAA form of Mucocele which occurs in the floor of mouth.

Name is derieved fron latin word ‘rana’ which means frog because swelling may resemble frog’s translucent underbelly.

This term is used to describe the other similar swelling in the floor of mouth including true salivary duct cyst,dermoid cysts & cystic hygromas.

Most common source of mucin spillage is sublingual gland.May also arise from submandibular duct, minor salivary glands in floor of the mouth.

CLINICAL FEATURES

Appear as dome shaped,fluctuant swelling in floor of the mouth with a translucent blue colour.(Deeper ranula-normal in colour)

Develops as a slowly enlarging painless mass located lateral to midline of floor of the mouth.(distinguishing feature from a midline dermoid cyst)

Ranula usually grows to a larger size as compared to ranula of other areas of oral cavity.

Large ranula-several cm in diameter, filling the floor of the mouth & elevating the tongue.

PLUNGING or CERVICAL RANULA- Rare suprahyoid type of ranula which occurs due to herniation of spilled mucin through the mylohyoid muscle,producing swelling in the neck.

HISTOLOGIC FEATURES

Similar to that of smaller mucoceles that occur in other locations.

Spilled mucin elicits a granulation type of response that typically contains foamy histiocytes.

TREATMENT

To Unroof the lesion is preferred than to excise it totally.Occasionally it recurs. Initially-excise the entire sublingual gland.

SALIVARY DUCT CYSTAlas k/as MUCOUS RETENTION CYST , MUCOUS DUCT CYST

or SIALOCYST

These are epithelium lined cysts arising from salivary gland tissue.

These are true cysts due to presence of epithelium lining.

ETIOLOGY- not clear. Ductal obstruction may lead to ductal dilatation resulting in increased

intraluminal pressure & thus in formation of an epi. lined cavity.

CLINICAL FEATURES

Age:Adult age groupSite:Both major & minor salivary glandsParotid gland(most commonly involved) Intra oral cyst involve:minor salivary gland floor of the mouth buccal mucosa lipsAppearance: Slow growing asymptomatic swelling soft & fluctuant bluish or of normal colour (depending on depth) painless,sessile dome shaped mass

In few patients multiple cysts that involve the excretory ducts of many minor salivary glands throughout the mouth have been reported.

HISTOLOGIC FEATURES

Epithelial lining- cuboidal,columnar or of atrophic squamous cells.Lumen- thin or with mucoid secretions

Some cyst show Oncocytic Metaplasia of epi. with papillary folds of epi. into lumen.

Papillary Cystadenoma: if proliferation is very extensive.Characteristic feature is oncocytic metaplasia.Epithelium- pseudostratified,columnar cellsC.T.-eosinophillic & contains proteinaceous material

TREATMENT

Conservative surgical T/t for isolated cysts.

Partial or complete removal of gland-for major salivary gland cyst.

Local excision-for more problematic swellings.

Recurrence do not occur.