DISEASES OF SALIVARY GLAND

NUR AINA BINTI AB KADIR

INTRODUCTION Anatomy of salivary gland Non-neoplastic Neoplastic

PAROTID GLAND the

sternocleidomastoid muscle behind;

the ramus of mandible in front;

superiorly, the base of the trench is formed by the external acoustic meatus and the posterior aspect of the zygomatic arch.

SUBMANDIBULAR GLAND elongate

submandibular glands are smaller than the parotid glands, but larger than the sublingual glands.

Each is hook shaped

SUBLINGUAL GLAND Smallest Each is almond

shape Lateral to the

submandibular duct and associated lingual nerve in the floor of the oral cavity

INNERVATIONS

NON-NEOPLASTIC DISORDERS

Mumps (viral parotitis)

Acute suppurative

parotitis

Chronic recurrent

sialadenitis

Sialectasis

Granulomatous disease

Salivary calculi

Sjogren’s syndrome

Paramyxovirus Droplets

infection, fomities Children IP: 2-3 weeks(7-

23 days) Excreted through:

salivary, nasal and urinary

Orchitis Ophritis Pancreatitis Aseptic meningitis Unilateral

sensorineural hearing loss

Thyroiditis, myocarditis, nephritis, arthritis

COMPLICATIONS

INTRODUCTION

MUMPS (VIRAL PAROTITIS)CLINICAL FEATURES

Fever(103’F) Malaise Anorexia muscular pain Unilateral parotid

swelling Other gland also Subside- 1 week

Serum, urinary amylase- 1 week

Serology IgG,IgM: ASAP, after

10-14 days of illness IgG : past exposure,

rise more than 4x recent infection(presence of IgM)

IgM : day 5(100%)

• Proper hydration• Rest• Analgesics• Cold/hot

compresses• Avoid food:

encourages salivary flow

TREATMENT

DIAGNOSIS

PREVENTION

Maternal immunity- 1 year

MMR vaccine: 15 months

Older children, adolescents, adults: monoclonal mumps/MMR vaccine

INTRODUCTIONS Elderly,

debilitated, dehydrated patient

Predisposing factor: dry mouth

Staphy. Aureus Route: from

mouth Stensen’s duct(SD)

CLINICAL FEATURES Sudden onset Severe pain Enlargement of

gland Movements of

jaw- pain Opening of the

SD swollen,red, discharging pus

Febrile, toxaemic

ACUTE SUPPURATIVE PAROTITIS

WBC: leucocytosis+ increase in polymorphs

Blood culture Pus collection

Appropriate antibiotics

Adequate hydration

Measures to promote salivary flow

Oral hygiene Surgical drainage

TREATMENTS

INVESTIGATIONS

parotid gland recurrent bacterial infection

Acute: enlarged, tender, pus

Between acute episodes: firm, slightly enlarged

Culture: staph/strep

Sialography: normal duct system

TREATMENT: Similar to ABS Between attacks:

keep good oral hygiene, avoid drugs which dry oral mucosa

sialogogues: promote salivation

CHRONIC RECURRENT SIALADENITIS

Dilatation of the ductal system stasis of secretions infection

Clinically: ~ CRS sialography

Different degrees: Punctuate,

globular, cavitary

May be Congenital Granulomatous

disease Autoimmune

disease (Sjogren’s syndrome)

SIALECTASIS

Tuberculosis •Parenchyma/LN, non tender mass•Overlying skin undergoes necrosisfistula•Surgical excision, ATT

Sarcoidosis •Uveoparotid fever•Fever, enlargement of the parotid&lacrimal gland, chorioretinitis, cranial nerve palsies

Actino-mycosis •Uncommon, acute abscess with sinus formation discharging sulfur-like granule/indolent swelling•Surgical drainage, large doses of penicillin/tetracycline

GRANULOMATOUS DISEASE

Forms in the ducts of SM/ parotid

Deposition of calcium phosphate on the organic matrix of mucin or cellular debris

Ducts/parenchyma TREATMENT

Peripheral: removes intaorally

Hilum/parenchyma: excision of the gland

Intermittent swelling

Pain Stone:visible/

palpated 80%(radio-

opaque): X-rays Radiolucent:

sialography

SALIVARY CALCULICLINICAL FEATURES

Xerostomia Xeropthalmia Involvement:

salivary(P), lacrimal glands

Both sexes -equal Aka

Benign lymphoepithelial lesion of parotid

Mikulicz’s disease

Keratoconjuctivitis sicca (lacrimal gland)

Xerostomia(salivary, minor mucous gland of oral cavity)

Autoimmune CT disorder

Bilateral swelling 90%: female

SJOGREN’S SYNDROME(SICCA SYNDROME)

PRIMARY SECONDARY

DIAGNOSISHistory, physical

examinationSchirmer’s testBiopsy of lower

lipSS-A and SS-B

antibodies : DIAGNOSIS

Raised ESRPositive

rheumatoid factor & antinuclear antibodies

Epithelial or mesenchymal tissues Higher in larger size of glandsbenign 80% in parotid, 50-60% in

submandibular and 25% in minor salivary glands

Malignant features : rapid growth, restricted mobility, fixity of overlying skin, pain and facial nerve involvement

NEOPLASM OF SALIVARY GLAND

BENIGN TUMOURS

PLEOMORPHIC ADENOMA Most common P,SM, other minor

SG P: tail Slow-growing

tumour, quite large initially

3rd/4th decade of life

Female “mixed tumor”

Stroma: mucoid, fibroid,vascular, myxochondroid/ chondroid

TREATMENT Surgical excision+

normal gland tissue

Parotid: superficial parotidectomy

ADENOLYMPHOMA (PAPILLARY CYSTADENOMA LYMPHOMATOSUM,

WARTHIN TUMOUR) 5th-7th decade Male:female (5:1) Tail of parotid Bilateral- 10% Multiple Rounded,

encapsulated tumor, at times cystic, mucoid/brownish fluid

Histologically: epithelial, lymphoid

TREATMENT: Superficial

parotidectomy

ONCOCYTOMA(OXYPHIL ADENOMA)

Acidophilic cells (oncocytes)

<1% of all SG tumour

Elderly Not grow>5cm Superficial lobe of

P Benign: cystic Malignant also

seen

Increased uptake of technetium-99

TREATMENT Superficial

parotidectomy

HEMANGIOMAS Most common benign

tumor in children Females Discovered at birth Grows rapidly in the

neonatal period, involute spontaneously

50%: coexist with cutaneous hemangiomas

Soft,painless increase in size with crying/straining

Overlying skin: bluish discoloration

Not regress spontaneously surgical excision

LYMPHANGIOMAS Less common May involve P &

SM Soft, cystic Not regress

spontaneously surgical excision

Rare: lipoma, neurofibroma

MALIGNANT TUMOUR

MUCOEPIDERMOID Slow growing but

can invade facial nerve

Histologically: area of mucin-producing cells, squamous cells

Behaviour: Minor SG: akin to

adenoid cystic carcinoma

Major SG: pleomorphic adenoma

ADENOID CYSTIC CARCINOMA (CYLINDROMA)

Slow growing Infiltrates widely into

the tissue planes and muscles

Also: perineural spaces, lypmphatics pain and VII nerve paralysis

Metastases: lymh nodes Distant: lung, brain,

bone Local recurrences after

surgical is common, as late as 10-20 years

TREATMENT: Radical

parotidectomy +largest cuff of grossly normal tissue around the boundaries

Radical neck not done unless nodal metastases

Postoperative radiation: margin of resected specimen are not free of tumour

ACINIC CELL CARCINOMA Low grade tumor Similar to a

benign mixed tumour

Small, firm, movable, encapsulated tumor, sometimes bilateral

Metastases: RARE

Conservative approach of superficial/total parotidectomy is adopted

ADENOCARCINOMA Minor SG Highly aggressive

locally Distant

metastases

MALIGNANT MIXED TUMOUR Carcinoma

developing in pre-existing benign mixed tumor

A “de-novo” tumour Shorter history Rapid growth, pain

developing in benign tumour malignant

TREATMENT Radical

parotidectomy Facial nerve

sacrificed grafted immediately

SQUAMOUS CELL CARCINOMA Rapidly growing

tumour Infiltratespain,

ulcerates through skin Metastasize to neck

nodes Radical parotidectomy

+ cuff of muscle,a portion of mandible, temporal bone, involved skin

+ radical neck: nodal metastases

Followed by postoperative radiation to primary site& the neck

UNDIFFERENTIATED CARCINOMA Rare Aggressive Tendency to

spread rapidly Pain Fixed to skin,

ulcerates

Facial paralysis Cervical node

metastases

TREATMENT Wide excision Radical neck Post-operative

radiation

Rare Systemic disease May occasionally

be a primary tumour

TREATMENT: Same with other

lymphomas

Rarely other sarcomas Rhabdomyosarco

ma may arise from the parotid

SARCOMALYMPHOMA

FREY’S SYNDROME(GUSTATORY SWEATING

Complication of parotid surgery several months after surgery

Sweating, flushing of the preauricular skin during mastication-social embarrassment

d/t: aberrant innervation of sweat glands by parasympathetic secretomotor fibres- destined for the P

TREATMENT: Reassurance Tympanic neurectomy

which intercepts these PS fibres at the level of middle ear

Place sheet of fascia lata between the skin & the underlying fat, to prevent secretomotor fibers reaching the sweat gland

SC infiltration of botulinum toxin

DISEASES OF EAR, NOSE, AND THROAT & HEAD AND NECK SURGERY BY PL DHINGRA, 6TH EDITION, PAGE 231-236

GRAY’S ANATOMY FOR STUDENTS, BY RICHARD L DRAKE, 3YH EDITION

REFERENCES