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


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

  1. 1. Salivary gland disorders. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Classification of salivary gland disorders 1 . Developmental Aplesia Atresia 2. Inflammatory (Sialodenitis) Acute Chronic - Bacterial - Viral Suppurative Non. Suppurative
  3. 3. 3. Obstructive – Sialoithiasis – Retention cyst – Atropy –, radiation damage 4. Functional disorders – Xerostomia – Increased salivation/ Ptyalism
  4. 4. 5. Neoplastic A) Benign Malignant B) Epithelial Non epithelial 6. Autommune
  5. 5. 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
  6. 6.  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
  7. 7. NON EPITHLIAL TUMORS • 1)Hemangioma • 2)Lymphangioma • 3)Neurofibroma • 4)Lipoma Other including malignant variation of the above
  8. 8. 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
  9. 9.  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.
  10. 10. 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
  11. 11.  Investigations Radiographs Ultrasound sialography
  12. 12. Complications: 1. Bacterial infection of the gland. 2. Sialoangiectasis. 3. Mucous retention cyst. 4. Atrophy of gland
  13. 13.
  14. 14. 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
  15. 15. Sialadenitis    Inflammation and infection of salivary glands Acute or chronic Viral, bacterial, allergic
  16. 16. 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.
  17. 17. 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. 
  18. 18.  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.
  19. 19. 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.
  21. 21. 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
  22. 22. 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
  23. 23. Revised WHO histological classification        Adenomas Carcinomas Non-epithelial tumours Malignant lymphomas Secondary tumours Unclassified tumours Tumour like lesions
  24. 24. 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.
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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)
  29. 29. 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
  30. 30. 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
  31. 31. 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
  33. 33. 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.
  35. 35. 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
  37. 37. 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
  39. 39.      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.
  40. 40. 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.
  42. 42.  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.
  44. 44. 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.
  45. 45. 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.
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