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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
16
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