22. diseases of salivary glands Dr. Krishna Prasad Koirala

Diseases of salivary glands

1. Diseases of Salivary Glands
Dr. Krishna Koirala
MBBS,MS (ENT)
2020/05/15

2. Anatomy
•Major salivary glands: Parotid, submandibular,
sublingual
•Minor glands : Distributed throughout the oral cavity
within the mucosa and submucosa
•Basic unit : acinus, secretory ductand collecting
duct
•Acini: serous, mucousor mixed

3. •Acini in the parotid glands are almost exclusively of the serous
type
•Acini in the In the submandibular glands are composed of
both serous and mucus epithelial cells
•Acini in the sublingual glands are predominantly mucus cells

4. Parotid Gland
•Largestsalivarygland
•Dividedintosuperficialand
deeplobesbythefacial
nerve(Fasciovenousplane
ofPatey)

5. •Submandibulargland
−Indentedbyposteriorborderof
mylohyoid muscle into
superficial&deeplobes
•Sublingualgland
–Liesattheanteriorpartoffloor
ofmouthbetweenthemucous
membrane,mylohyoidmuscle
andbodyofmandible

6. Acute viral parotitis (Mumps)
•Acute nonsuppurative inflammation of the parotid
gland caused by paramyxovirus (Mumps virus)
•Other viruses like Coxsackievirus A&B,
cytomegalovirus also can cause parotitis
•Mumps : Danish word ‘mompen’ meaning mumbling
•Spreads by droplet infection
•Secondary parotitis due to duct obstruction

8. Clinical Features
•Prodrome:fever,headache,myalgia,
anorexia,arthralgia
•Pain-severe,madeworseoneating
sourfoods,duetotightfascia
•Poutingoftheopeningofparotidduct,
pusdischargefromtheductonparotid
massageifsuppuration
•Parotidswelling:75%within1-5days
•Tenderness
•Trismus-swelling,spasmofmuscles

9. Investigations
•Blood
–WBC count , ESR, viral titers might rise
–Increased serum amylase due to spillage to blood
circulation, subclinical form of pancreatitis
•USG Neck:
–Enlarged, heterogeneous gland, with ↑ed vascularity
–Parotid stones ? radiolucent
•Sialography
–Diagnostic and Therapeutic

10. Treatment
•Conservative
–Rest, oral hygiene, good nutrition, plenty of liquids
–Analgesics , local heat application to gland
–Adrenalinlocal application to reduce duct edema
–Antibiotic : Clindamycin
–Vaccination : Jerry Lynn vaccine at 12 months
–infection usually confers permanent immunity? recurrence
•Surgical
–Incision and drainage if patient develops abscess

11. Complications
•Aseptic meningitis: Frequent complication in children
•Pancreatitis
•Nephritis:
•Orchitis/ Oophoritis : common in adults (30-45%), unilateral or
bilateral , usually occurs during second week of infection
•SNHL: U/L> B/L, transient> permanent
•Myocarditis: precordial pain, bradycardia, fatigue, ST
depression rare finding in ECG
•Arthralgia, polyarthritis

12. Sialolith
•Formation of calculi in the ductal system of salivary glands
•Submandibular gland (70 to 90% stones)
–Mixed seromucinous gland with high calcium and
magnesium content, long and tortuous duct with
antigravity drainage, duct opening smaller than lumen
•Parotid (10 to 20% Stones)
–Serous gland, low calcium and magnesium content
•Predisposing factors: Salivary stasis, duct injury/inflammation

13. •Cause unknown
–Salivary stasis
–Ductal inflammation
–Duct Injury

14. Clinical Features
•Postprandialsalivarycolicwithpainandswelling
•Swellingonsubmandibularregionduetoduct
obstruction
•Ductopening:edematous,pouting
•Stonepalpatedinsubmandibularductorwithinthe
glandonbimanualpalpation

16. Oral cavity

17. External swelling and duct stone

18. Investigations
•Radiology
–Plain x ray
•Done to see radiopaque stone
–Sialogram
•Diagnostic
–USG
–CT scan of neck
–MRI

19. Stone seen on CT scan

20. Sialogram

21. Treatment
•Sialogram (therapeutically washes stones)
•Finish each meal with a citrus drink, massage gland
•Per-oral removal of calculus
•Marsupialization of duct
•Removal of Submandibular salivary gland
•Total conservative parotidectomy

22. Per-oral removal

23. Duct incised and stone removed

24. Stone specimen

25. Sjogren’s Syndrome
•Chronic autoimmune disease of exocrine glands
•Classification
–Primary
•Confined to exocrine gland
•Xerostomia and Xerophthalmia
–Secondary
•Xerostomia and Xerophthalmia
•Autoimmune disease (RA,SLE)

26. Clinical Features
•Multisystem disease
•Dryness of mouth and eyes, difficulty in chewing and
swallowing food due to xerostomia
•Intolerance to acidic and spicy foods
•Dental caries , smooth and fissured tongue
•Candidiasis/ Stomatitis / Parotid enlargement
•Decreased phonation due to dry oral mucosa

28. Investigations
•ESR Raised
•Presence of HLA1 and B8 antigen
•Schirmer’s test
–Wetting <5mm in 5 mins
•Salivary flow rate
–Flow < 0.5ml Xerostomia

29. Treatment
•Steroids : anti inflammatory purpose
•For dry Mouth:
–Saliva substitutes: sprays /rinses
–Saliva stimulants: hard candy, pilocarpine
–Cholinergic agents: cevimeline
–Special toothpaste, oral gels, active dental care
•For dry eyes:
–Lubricant eye drops /ointments, punctal plugs, lateral
tarsorraphy
•For dry nasal mucosa: Saline nasal sprays, lavage, etc.

30. Salivary gland neoplasms

31. Etiology
•Risk factors for salivary neoplasms
–Radiation exposure
–Epstein-Barr virus :lymphoepithelial carcinoma
–Genetic alterations(p53, DNA ploidy)
–Tobacco
–Occupational exposure to silica dust
–Vegetables preserved in salt

32. Investigations

33. Radiological Tests
•Ultrasonography
–Neoplasmsappearsolid
–ProvideguidanceinobtainingFNAC
•CTscan
–Goldstandard
–Administrationofcontrastprovidesdetailsof
tumorvolume,relationtovascularandbony
structures
–Irregularpattern-malignancy

34. •MRIscan
–Excellent soft tissue details
–Doesnot requirecontrast for vascular details
•Positron emission tomography (PET)
–Role in staging of salivary malignancy to rule out
distant and regional metastases
–Useful to follow-up patients with known salivary
malignancy after treatment

35. Smoothly marginated, solid lesion, without focal
calcification or necrosis(pleomorphic adenoma)

36. Heterogeneous,low-densitymassinthetailoftheright
parotidglandwithminimalthinperipheralenhancement
consistentwithWarthin’stumor

37. •Fine-Needle Aspiration Cytology
–Mainstay of diagnosis and management
–Safe, simple and inexpensive
•Incisional biopsy
–If tumour is obviously malignant and involvesthe
skin

38. Pleomorphic Adenoma
•Most common of all salivary gland neoplasms
–80% of parotid tumors
–50% of submandibular tumors
–6% of sublingual tumors
–45% of minor salivary gland tumors
•4
th
-6
th
decades, F:M = 3-4:1

39. •Slow-growing,painlessmass
•Parotid:90%insuperficiallobe,mostintailof
theparotidgland(lowerposteriorpartofgland)
•Capsuleisaresultoffibrosisofsurrounding
salivaryparenchyma,compressedbytumorcalled
asafalsecapsule

40. •Grosspathology
–Smooth,well-demarcated
–Solidandcysticchanges
–Myxoidstroma
•Histology
–Mixtureofepithelial,
myopeithelialandstromal
components
–Notruecapsule

41. Treatment
•Complete surgical excision
–Parotidectomy with facial nerve preservation
–Submandibular gland excision
–Wide local excision of minor salivary gland
•Avoid enucleation and tumor spill

42. Warthin’s Tumor
•Synonym:papillarycystadenomalymphomatosum
•6-10%ofparotidneoplasms
•Older,Caucasians,males,obesepersons
•10%bilateralormulticentric
•3%withassociatedneoplasms
•Presentsasaslow-growing,painlessmass,ovoidinshape,
situatedinthetailoftheparotid

43. •Gross pathology
–Encapsulated
–Smooth/ lobulated surface
–Cystic spaces of variable size, with
viscous CHOCOLATE fluid
•Histology
–Papillary projections into cystic
spaces surrounded by lymphoid
stroma
–Epithelium has double cell layer of
luminal cells and basal cells

44. Mucoepidermoid Carcinoma
•Most common salivary gland malignancy
•5-9% of salivary neoplasms
•Parotid 45-70% of cases
•Palate 18%
•F>M
•3
rd
-8
th
decades, peak in 5
th
decade

45. •Presentation
–Low-grade: slowgrowing,
painlessmass
–High-grade:rapidlyenlarging,
+/-pain,metastasizetolymph
nodes,lungs,bones,brain
•Grosspathology
–Well-circumscribedtopartially
encapsulatedtounencapsulated
–Solidtumorwithcysticspaces

46. Histology
•Low-grade
–Mucus cell > epidermoid cells
•Intermediate grade
–Mucus = epidermoid
–Fewer and smaller cysts
–Increasing pleomorphism and
mitotic figures
•High-grade
–Epidermoid > mucus
–Solid tumor cell proliferation

47. •Investigations
–Imaging : CT and MRI Scans
–FNAC
–Avoid open biopsy (seeding with neoplastic cells)
•Treatment
–Influenced by site, stage, grade
–Stage I & II : Wide local excision
–Stage III & IV: Radical excision ±neck dissection±postop
radiation therapy

48. Adenoid Cystic Carcinoma
•Overall 2
nd
most common salivary gland malignancy
•Commonest in submandibular, sublingual and minor
salivary glands
•M = F, 5
th
decade
•Presentation
–Asymptomatic enlarging mass
–Pain, paresthesias, facial weakness/paralysis

49. •Gross morphology
–Well-circumscribed solid lesion, rarely
with cystic spaces
–Infiltrative pattern
•Histology
–Cribriform pattern leading to “Swiss
cheese” appearance
•Treatment
–Complete local excision ±facial nerve
sacrifice due to its tendency for
perineural invasion
–Postoperative RT