B) Functional disorders Sialorrhoea XerostomiaC) Obstructive disorders Sialolithiasis Mucus plug Stricture & stenosis Foreign bodies Extra ductal causes
D) Cyst Mucocele RanulaE) Asymptomatic enlargement Sialosis Allergic Associated with malnutrition and alcoholism
F) Infection Viral Bacterial MycoticG) Autoimmune disorders Sjogren’s syndrome Mikulicz’s disease Uveoparotid fever Recurrent non specific parotitis
Developmental anomalies Aberrant salivary glands An aberrant or ectopic is salivary gland tissue that develops at a site where it is not normally found. Clinical features Site – cervical region near the parotid gland or body of mandible. Posterior to first molar Clinical signifance Site for development of retention cyst or neoplasm
Aplasia & hypoplasiaIt is congenitally absence of salivary gland. Aplasia occurs in combination with congenital anomalies. Hypoplasia in patient with Melkersen Rosenthal syndrome.Clinical features One or group of glands missing unilaterally or bilaterally. Xerostomia Dental caries Early loss of teeth Dry & smooth oral mucosa Cracking & Fissuring at corner of mouth.Management Good oral hygiene.
Hyperplasia Cause- Hormonal MetabolicClinical features Site minor salivary glands of palate. Asymptomatic when surface firm,sessile & normal in color.Management Excision for microscopic examination.
Accesory ductsMost common developmental anomoli. Site- superior and anterior to normal stenson’s duct orifice.Atresia Congenital occlusion or absence of one or two major salivary gland ducts. Site- submandibular duct in floor of mouth. Causes severe xerostomia.
Diverticuli Small pouches or outpocketing of ductal system of one of the major salivary glands.Congenital fistula Sinus tract form either in crease behind the pinna or in front of tragus. Management Complete surgical excision of sinus tract.
Functional disordersSialorrhoea or ptyalism It is increase salivary secretion. Stimulation of parasympathetic causes profuse secretion of watery saliva. Etiology Drugs like sialogogues Local factors ANUG,erythema multiforme Systemic like paralysis Misc. like metal poisoning
Clinical features Drooling from mouth Lip chapping Infection from constant exposure to saliva Cheek scarring.Management Oral motor draining Biofeed Removal of local factors Anti cholinergic drugs (atropine sulphate 0.4 mg in adults .01 mg / kg in children upto 0.4 Surgery
Xerostomia Dryness of mouth.Etiology Radiation induced Drug induced NutritionalClinical features Increase thirst Dry leathery tongue Difficulty in speech, swallowing & eating dry food Burning sensation Blurred vision Fissuring of tongue.Management Preventive therapy Symptomatic treatment Topical salivary stimulation Systemic salivary stimulation Bromhexiene 8mg T.D.S. adult 4mg B.D. children
Obstructive disordersSialolithiasis Salivary gland stone or salivary gland calculus within major & minor salivary gland.Clinical features Site Submandibular 83% Parotid 10% Sublingual 7% Severe pain Swelling during meals Pus from duct orifice Inflammatory reaction to surrounding soft tissue Overlying mucosa may ulcerate along calculus to extend into oral floor Radiographically almost radio opaque, oval shape & with multiple layers of calcification, smooth borders.
Management Manual manipulation of stone within duct. If in submandibular duct then incision is made directly over it. If in gland then excision is done Antibiotics if acute infection is present.Mucus plug Incompletely mineralized sialolithes.
Foreign Bodies Tooth brush bristles Tooth picks Spikes of wheat Finger nailsExtraductal causes Muscle pressure Tumors Enlarged lymph nodes Denture flanges associated with the primary salivary duct.
Cysts of salivary glandMucocele Swelling caused by pooling of saliva at site of injured minor salivary gland.Types Mucous extravasation cyst Mucous retention cystClinical features Site inner aspect of lower lip, palate, cheek,tongue,floor of mouth. Painless swelling which is frequently recurrent develops at meal time and drains simultaneously at intervals. Shape round or oval & smooth. Consistency soft or hard depend upon tension of fluid.
Blue pigmented nodule Exophytic lesionSuperficial vesicle like Nodule
Management Complete excision of cyst under L.A. Injection steroid & cryosurgery.
Ranula It is used for the mucoceles occurring in the floor of the mouth in association with ducts of sub mandibular or sub lingual glandsTypes Superficial PlungingClinical features Site – floor of mouth on side of frenum Unilateral bluish swelling Shape – spherical or dome shaped only top visible
Fluctuation & Transillumination – positive brilliantly translucent On aspiration – sticky clear fluid Slowly enlarging swelling on side of floor of big ranula may cause difficulty in speech or eating.Plunging ranula when intra buccal ranula has cervical prolongation it is called deep or plunging ranula. It is located along post border of mylohyoid muscles in submandibular region.
Management Surgical excision including portion of surrounding tissue. Partial excision & marsupilization.
Blue pigmented swelling Ranula Plunging Ranula
Viral InfectionsMumpsContagious viral infection caused by para myxo virusClinical features Unilateral & bilateral swelling of salivary gland Fever, malaise, anorexia. Tender & pain on eating sore food Involved gland continues to enlarge for 2-3 days & comes back to normal.Complicationoophritis, orchitis, meningitis, encephalitis.Management Self limiting MMR vaccine Systemic corticosteroids
Unilateral Bilateral Parotid enlargement
Bacterial InfectionAcute bacterial sialadenitis (acute supprative parotitis)CausesStaph aureusStaph viridansClinical features Site- unilateral involvement of parotid Fever Pain at angle of jaw Elevation of ear lobule Cervical lymphadenopathyManagement Oral hygiene Soft diet I.V. fluids Parentral antibodies active against pencillin resistence staphylococcus Surgical drainage of affected gland
Acute bacterial sialadenitis
Mycotic Infections Actinomycosis Cause A.Israliae Types Primary ascending canalicular inflammation. Infection penetrates from mouth into gland and affects it entirely. Secondary when transferred to gland from tissue surrounding, non tender, non fluctuant indurated lesion with formation of multiple fistulae with discharge of sulphur granules.
Autoimmune Disorders Sjorgen’s syndromeChronic inflammatory disease thatpredominantly affects salivary, lacrimal &other exocrine glandsIt was first described by HENNIK SJOGRENin 1933. Types primary – dry eyes, dry mouth. secondary – dry eyes , dry mouth , collagen disorders usually rheumatoid arthritis & SLE.
Clinical Features Middle aged and female are commonly infected Xerostomia Soreness and difficulty in controlling dentures Pus from duct Difficulty in eating and unpleasant taste Unilateral and bilateral enlargement of parotid gland Frothy saliva Severe dental caries Depapillation of tongue Dry eyes Vaginal dryness Connective tissue disorder Enlargement of lymph nodesRadiographic Findings Snow storm appearance In some cases cherry blossom appearanceMANAGEMENT SYMTOMATIC TREATMENT Occular lubricant- artificial tears coating methyl cellulose Saliva substitute Oral hygiene Surgery for enlargement of glands
MIKULICZ’S DISEASE Symmetric or bilateral chronic painless enlargement of lacrimal or salivary gland has inflammatory characteristics.Clinical Features Women in middle and later life Site- unilateral or bilateral enlargement of parotid or submandibular gland Fever Upper respiratory tract infection Occasional pain Xerostomia Diffuse poorly outline and enlargement of glandManagement Surgical excision
InvestigationsNon-invasive investigations Radiographs Computerized Tomography Ultrasound scanning Magnetic resonance imaging Single Photon emission Computed TomographyInvasive Investigations Biopsy Fine needle Aspiration cytologySialography
SIALOGRAPHY “It is a specialized radiographic view of salivary gland taken by introduction of soluble contrast material into the ductal system.” The radiographs are called Sialographs.Indications Detection of sialoliths, calculus, foreign bodies. Evaluation of extend of irreversible ductal damage. Detection/diagnosis of recurrent swelling & inflammatory process.
Evaluation of diverticulas, strictures and fistulae. Tumor location & size. Selection of a site for biopsy. Outline the plane of facial nerve. Residual stone/tumor, fistulae & stenosis.Contraindications Acute infection of salivary gland. Allergic reaction to any radio opaque material to be used. Thyroid disorders.
Phases Filling phase Emptying phase Parenchyma phaseAgents usedContrast mediaX-ray filmContrast media (Ideal requisites) Physiologic properties similar to saliva. Miscibility with saliva. Absence of systemic/local toxicity. Low surface tension & low viscosity. Easy elimination.
Types of contrast media Water soluble - Hyopaque Fat soluble - LipidolSialographic appearance Normal Calculus Inflammation/blockage (Sialadenitis) Strictures Sjogren’s syndrome Tumors
SialadenitisLarge calcified stone Sjogren’s syndrome