Salivary glands 1 /certified fixed orthodontic courses by Indian dental academy

Salivary gland disorders.
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Classification of
salivary gland disorders
1 . Developmental
Aplesia
Atresia
2. Inflammatory (Sialodenitis)
Acute
Chronic
- Bacterial
- Viral
Suppurative
Non. Suppurative

3. Obstructive
– Sialoithiasis
– Retention cyst
– Atropy –, radiation damage
4. Functional disorders
– Xerostomia
– Increased salivation/ Ptyalism


5. Neoplastic
A) Benign
Malignant

B) Epithelial
Non epithelial

6. Autommune


Epithelia tumors
A) Adenomas
1)Plemorphic adenoma (mixed tomuor)
2)Monomorhic adenoma
a.Adenolymphoma (Warthin’s tumuor)
b.Oxyphilic adenoma (oncocytoma)
c. Other monomorphic adenomas



B)Mucoepidermiod tumous



C)Acinic cell tumour



D)Carcinoma
1. Adenoid cystic carctnoma
2. Adenocarcinoma
3. Squamous cell carcinoma
4. Undifferentiated carcinoma
5. Carcinoma in pleomorphic adenoma

NON EPITHLIAL TUMORS
•

1)Hemangioma

•

2)Lymphangioma

•

3)Neurofibroma

•

4)Lipoma
Other including malignant variation of the above


SIALOLITHIASIS


Calcified organic matter that develop in the parenchyma of
major/ minor salivary gland



Appears laminated with layer of organic material covered with
concentric shells of calcified matter



Contains hdroxyapatitie & octatacalciuam phosphate and
carbon with traces of magnesium



Etiology is debatable



Inflammation / local irritation/drugs causing stasis -leading to
build up of organic nidus that calcifies




Disorder of Ca PO4 metabolism



80 to 90% occur in – sub mandibular gl. / duct



Warthin’s duct contains sharp curves which trap
mucin plugs / cellular debris



Dependable position of gland – chances of stiais



15% occur in parotid, 2-5 sublingual & minor sgl.

CLINICAL FEATURES


Painful intermittent gl. swelling during eating & later
resolves



Pain originates from backup of saliva distal to stone



Palpable if present in peripheral portion of duct




Investigations
Radiographs
Ultrasound
sialography


Complications:
1. Bacterial infection of the gland.
2. Sialoangiectasis.
3. Mucous retention cyst.
4. Atrophy of gland


TREATMENT


Acute infections secondary to stasis are treated with antibiotics



Stones in the duct removed by milking.



Deeper stones require surgery[TRANSORAL
SIALOLITHOTOMY]



Lithotripsy- disintegrates sialoliths. SHOCK WAVE
LITHOTRPSY using a piezoelectic lithotriipter.



Surgical excision of submandibular salivary gland

Sialadenitis






Inflammation and infection of salivary glands
Acute or chronic
Viral, bacterial, allergic


Mumps


Acute, contagious disease.



Parotid gland, less frequently SM gland, SL gland.



Incubation period of 2 to 3 weeks.



Clinical features

Complications
1.

Bacterial sialadenitis of the affected gland.

2.

Inflammation of gonads and central nervous system
resulting in meningitis, encephalitis, orchitis deafness,
myocarditis.


Acute Bacterial
sialadenitis
Caused by staph. Aureus and pyogenus, strep.
Viridians, pneumococci
 Retrograde infection usually affecting parotid gland
 Etiologic factors: 1) reduced salivary
flow(dehydration)
2) partial obstruction of the duct
 Clinical features: pain, brawny oedematous swelling,
cellulitus of overlying skin, pus thro the duct,
fluctuation.





Treatement : 1) Antibiotics
2) palliative – hydration
- salivary stimulation
3) Needle Aspiration
4) Surgical treatment.
- Incision is given vertically in front of the tragus and
curves under the lobe of the ear to reach the tip of
the mastoid.
- A transeverse incision is placed on the parotid fascia
to protect the facial nerve.
- Abscess is drained by hilton’s method.
- Corrugated rubber drain is placed.

Chronic Bacterial
Sialadenitis
Etiology : 1) Duct obstruction
2) Congenital Stenosis
3) Sjogrens syndrome
4) Viral infection
Microorganism – Strep. Viridans, E. Coli, proteus
Clinical Features – Recurrent attacks of pain and
swelling, pus discharge, reduced salivary flow, gland
atrophy possible.

SALIVARY GLAND
TUMORS


GENERAL FEATURES


Rare, < 3% of all tumours of head and neck.



General predilection for females.



Affects both major and minor salivary glands; most commonly
parotid.



80% of all salivary gland tumours occur in parotid; 80% of them are
benign; 80% of them is pleomorphic adenoma.



Etiology: viruses- EBV, CMV, HPV
radiation
habits- alcoholism, smoking
hormones- estrogen

CLASSIFICATION
BENIGN

MALIGNANT

Pleomorphic
Warthins
Basal

adenoma

tumour

cell adenoma

Myoepithelioma
Canalicular
Ductl

adenoma

papilloma

Mucoepidermoid
Adenoid

cystic ca

Malignant

adenoma

Basal

pleomorphic

cell ca

Salivary


ca

duct ca

Revised WHO histological
classification








Adenomas
Carcinomas
Non-epithelial tumours
Malignant lymphomas
Secondary tumours
Unclassified tumours
Tumour like lesions


PLEOMORPHIC
ADENOMA


Mixed tumor; varied
appearance.



Term coined by Willis in 1948.



Most common in parotid; also
in glands of palate and lip.



Comprise more than 50% of all
tumors and 80% of all benign
tumors of the parotid gland.


Clinical features


4-6th decade of life.



M:F = 1:2.



Usually asymptomatic slow growing painless swelling at the angle of
the mandible or in front of and below the tragus.



Well circumscribed, encapsulated.



Not fixed to overlying or underlying tissues therefore freely mobile.



Becomes indurated and firm with time but does not ulcerate.



In the minor glands, difficulty in speech and mastication.



No pain or facial paralysis

Histopathology





Arise from ductal epithelial and myoepithelial cells
Epithelial cells are arranged in ducts, sheets,
strands or clumps
Varied pattern; may contain chondroid, myxoid,
osteoid, fibrous, lipid or haemorrhagic matter


Differential diagnosis





Warthins tumor
Lipoma
Hyperplastic lymph nodes
Neurilemmoma of the facial nerve

Investigations






Plain radiographs
CT & MRI
Sialography – ball in hand
appearance
Excisional biopsy

Treatment




Surgical excision
Parotid – superficial parotidectomy
Submandibular – excision along with gland
Minor – excision along with gland
Irradiation contraindicated.

Complications



Incomplete excision – recurrence
Long standing untreated pleomorphic adenoma may turn
malignant (carcinoma ex pleomorphic adenoma)

WARTHIN’S TUMOUR


Also called papillary cystadenoma
lymphomatosum.



5 th decade, M>F, Usu parotid gland.



Associated with smoking habit.



Painless firm circumscribed mass below
the lobule of ear.



Cystic spaces lined by double layer of
epithelium in a lymphoid stroma.



Treatment – surgical excision

OXIPHILIC ADENOMA








Also called oncocytoma
<1% of all salivary gland tumours
Soft slowly growing painless tumour diagnosed
histologically
H/P – oncocytes group around duct like lumen with
very little stroma
Treated by excision


MUCOEPIDERMOID CA


Most common malignant tumour.



Affects mostly the minor glands – palate, buccal mucosa and at
times the parotid.



Clinical features depend upon the grade of the tumour
Low grade – behaves like a benign tumour, slow painless mass,
may undergo cystic degeneration
High grade – pain, ulceration, facial paralysis, local destruction,
metastasis to regional lymph nodes or to lungs
Can occur intraosseously, usually within mandible.





Treated by radical excision


MUCOEPIDERMOID CARCINOMA PALATE


MUCOEPIDERMOID CARCINOMA PAROTID

ADENOID CYSTIC CA


Also called cylindroma due to its histologic appearance.



Commonly seen in parotid and submandibular glands.



Slow growing swelling, locally destructive.



Invaesiveness along perineural spaces - therefore painful,
may also extend into medullary bone.



H/P- cribriform appearance due to duct like arrangement of
ductal and myoepithelial cells.



Treatment – excision with long follow up / radiotherapy.

ADENOID CYSTIC CARCINOMA

ADENOCARCINOMA







Rare but typical malignant neoplasm
Noticed early yet a poor prognosis
4rth decade onwards
Usu affects parotid gland
Pain, facial paralysis, ulceration
H/P – tubular or papillary formation of epithelial,
mucus secreting and oncocytic cells


ADENOCARCINOMA

SUPERFICIAL
PAROTIDECTOMY








Removal of the gland superfcial to
the facial nerve
Incisions – 1) ‘Y’ shaped
incision
2) Preauricular
3) Retromandibular
Ear lobe is retracted upwards and
skin flap is raised at the plane of
deep fascia
Care should be taken about facial
artery & vein, parotid duct and
posterior auricular artery



RELATIONS OF PAROTID GLAND









Branches of facial nerve are identified either electrically or by sight.
The nerve trunk can be seen as a white cord 2-3cm thick.
Course of nerve is followed and the superficial lobe is freed from its
attachments by blunt dissection using curved mosquito artery
forceps
External carotid artery, posterior facial vein and retromandibular
vein are ligated
Remove half centimeter of normal tissue around the palpable mass
in case of pleomorphic adenoma (more in case of malignant
tumours)
Flush the wound liberally with saline, repair the nerve branches
where necessary, place a drain and close in 2 layers.


SUBMANDIBULAR GLAND
EXCISION


Submandibular Incision is placed 2cm below the lower border of the
mandible and about 5-6cm in length.



Blunt dissection is carried out at the deep fascial plane. Marginal
mandibular n. is isolated and the fascia is divided at the lower
border of mandible.



The lower pole of the gland is exposed and turned upwards and
forwards, freeing it from ant and post bellies of digastric and the
stylohyoid muscles.



The facial artery and vein are identified and ligated.

RELATIONS OF SUBMANDIBULAR GLAND



The gland is seperated from the mandible.



The lingual and hypoglossal n are identified and protected.



The mylohyoid muscle is retacted and the deep portion of the gland
is dissected out.



The gland is removed along with its investing fascia (posteriorly the
angular tract of fascia has to be cut with a scissors)



The duct is divided close to the papilla and the wound is closed in
layers with placement of a drain.


SUBMANDIBULAR GLAND EXCISION

Complications of salivary
gland surgery
Frey,s syndrome :
•

Seen in 1 in 10 patients

•

Damage to auriculotemporal nerve severes the secretomotor
parasympathetic nerves from the otic ganglion and also the
sympathetic fibres to the sweat glands.

•

Following regeneration, the sweat glands are supplied by fibres from
the otic ganglion leading to flushing and sweating of the skin of the
upper cheek, temporal region and forehead coincident with eating.

•

Treatment is by dividing the parasympathetic fibres from the
glossopharyngeal n.

Facial paralysis :
•

Damage to the branches of the facial nerve lying within
the substance of the gland may cause facial paralysis.

•

Commonly the marginal mandibular or the zygomatic
branches are affected.

•

Onset of paresis is usually 1-3 hrs post-operatively.

•

Protect the eye from any irritation.

•

Full recovery occurs within days to months.

•

In severe cases symmetry of the face can be restored by
using ribbons of fascia lata from the patient’s thigh.

Thank you
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