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 duct and collecting
duct
• Acini: serous, mucous or 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
• Largest salivary gland
• Divided into superficial and
deep lobes by the facial
nerve (Fasciovenous plane
of Patey)

5. • Submandibular gland
− Indented by posterior border of
mylohyoid muscle into
superficial & deep lobes
• Sublingual gland
– Lies at the anterior part of floor
of mouth between the mucous
membrane, mylohyoid muscle
and body of mandible

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, made worse on eating
sour foods, due to tight fascia
• Pouting of the opening of parotid duct,
pus discharge from the duct on parotid
massage if suppuration
• Parotid swelling : 75% within 1-5 days
• Tenderness
• Trismus - swelling, spasm of muscles

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
– Adrenalin local 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
• Postprandial salivary colic with pain and swelling
• Swelling on submandibular region due to duct
obstruction
• Duct opening : edematous, pouting
• Stone palpated in submandibular duct or within the
gland on bimanual palpation

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
– Neoplasms appear solid
– Provide guidance in obtaining FNAC
• CT scan
– Gold standard
– Administration of contrast provides details of
tumor volume, relation to vascular and bony
structures
– Irregular pattern - malignancy

34. • MRI scan
– Excellent soft tissue details
– Does not require contrast 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-density mass in the tail of the right
parotid gland with minimal thin peripheral enhancement
consistent with Warthin’s tumor

37. • Fine-Needle Aspiration Cytology
– Mainstay of diagnosis and management
– Safe, simple and inexpensive
• Incisional biopsy
– If tumour is obviously malignant and involves the
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
• 4th-6th decades, F:M = 3-4:1

39. • Slow-growing, painless mass
• Parotid: 90% in superficial lobe, most in tail of
the parotid gland (lower posterior part of gland)
• Capsule is a result of fibrosis of surrounding
salivary parenchyma, compressed by tumor called
as a false capsule

40. • Gross pathology
– Smooth, well-demarcated
– Solid and cystic changes
– Myxoid stroma
• Histology
– Mixture of epithelial,
myopeithelial and stromal
components
– No true capsule

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 : papillary cystadenoma lymphomatosum
• 6 -10% of parotid neoplasms
• Older, Caucasians, males, obese persons
• 10% bilateral or multicentric
• 3% with associated neoplasms
• Presents as a slow-growing, painless mass, ovoid in shape,
situated in the tail of the parotid

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
• 3rd - 8th decades, peak in 5th decade

45. • Presentation
– Low-grade: slow growing,
painless mass
– High-grade: rapidly enlarging,
+/- pain, metastasize to lymph
nodes, lungs, bones ,brain
• Gross pathology
– Well-circumscribed to partially
encapsulated to unencapsulated
– Solid tumor with cystic spaces

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 2nd most common salivary gland malignancy
• Commonest in submandibular, sublingual and minor
salivary glands
• M = F, 5th 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