Diseases of salivary glands is a very important topic in the final MBBS/ MS ENT exam. Dr. Krishna Koirala has described the salivary gland diseases in a lucid way in this presentation.

1. Diseases of Salivary Glands
Dr. Krishna Koirala
MBBS,MS (ENT)
2019/05/06

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

4. • Parotid Gland
– Largest salivary gland
– Divided into superficial and deep lobes by the facial nerve
(Fasciovenous plane of Patey)
• Submandibular gland
– Indented by posterior border of myelohyoid muscle into
superficial & deep lobes
• Sublingual gland
– Lies at the anterior part of floor of mouth between the
mucous membrane, myelohyoid muscle and body of
mandible

6. Parotitis
• Definition
– Acute nonsuppurative viral parotitis caused by
paramyxovirus (Mumps virus)
• Other viruses : Coxsackievirus A&B, cytomegalovirus
• Mumps : Danish word ‘mompen’ meaning mumbeling
• Secondary parotitis due to duct obstruction
• Spreads by droplet infection

9. Clinical Features
• Prodrome
– Fever, headache, myalgia, anorexia, arthralgia
• Pain- severe, made worse on eating (sour foods)
• B/L parotid swelling : 75%
• Tender gland
• Trismus - swelling, spasm of muscles
• Other gland also enlarges in 1 to 5 days

10. Investigations
• Blood-
– WBC count , ESR
– Viral titers
• Radiology
– Parotid stones radiolucent
• Sialography
– Diagnostic and Therapeutic

11. Treatment
• Conservative
– Rest, oral hygiene, good nutrition, plenty of liquids
– Analgesia, local heat application to gland
– Adrenalin local application to reduce duct edema
– Antibiotic : Clindamycin
– Vaccination : Jerry Lynn vaccine at 12 months
• Surgical: If patient develops abscess

12. Complications
• Aseptic meningitis
• Pancreatitis
• Nephritis
• Orchitis/ Oopheritis
• SNHL

13. Sialolith
• Formation of calculi in the ductal system of salivary
glands
• SMG : mixed seromucinous gland, saliva has high
calcium and magnesium content - 70 to 90% stones
• Parotid : serous gland, low calcium and magnesium
content – 10 to 20% Stones
• High density stones are radiopaque

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

15. 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

17. Oral cavity

18. External swelling and duct stone

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

20. Stone seen on CT scan

21. Sialogram

22. 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

23. Per-oral removal

24. Duct incised and stone removed

25. Stone specimen

26. 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)

27. 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

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

30. Treatment
• Steroids
• Artificial tears
• Synthetic saliva
• Bromhexine 40mg/d for tenacious cough

31. Treatment
• Dry Mouth
– Saliva substitutes: sprays
/rinses
– Saliva stimulants: hard
candy, pilocarpine
– Cholinergic agents:
cevimeline
– Special toothpaste, oral
gels
– Active dental care
• Dry eyes
– Lubricant eye drops/
ointments
– Punctal plugs
– Lateral Tarsorraphy
• Dry Nasal mucosa
– Saline nasal sprays
– Lavage

32. Salivary gland neoplasms

33. Etiology
• Increased risk
– Radiation exposure
– Epstein-Barr virus : lymphoepithelial carcinoma
– Genetic alterations (p53, DNA ploidy)
– Tobacco
– Occupational exposure to silica dust
– Vegetables preserved in salt

34. Investigations

35. 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

36. • 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

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

38. Heterogeneous, low-density mass in the tail of the right
parotid gland with minimal thin peripheral enhancement
consistent with Warthin’s tumor

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

40. 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

41. • 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

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

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

44. 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
• Presentation: slow-growing, painless mass, ovoid
shape, situated in the tail of the parotid

45. • Gross pathology
– Encapsulated
– Smooth/ lobulated
surface
– Cystic spaces of
variable size, with
viscous CHOCOLATE
fluid, tubular
epithelium

46. • Histology
– Papillary projections into
cystic spaces surrounded
by lymphoid stroma
– Epithelium: double cell
layer
• Luminal cells
• Basal cells

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

48. Clinical Features
• Presentation
– Low-grade: slow growing, painless mass, re- occur
locally
– High-grade: rapidly enlarging, +/- pain
– Metastasize to lymph nodes, lungs, bones ,brain

49. • Gross pathology
– Well-circumscribed to
partially encapsulated
to unencapsulated
– Solid tumor with
cystic spaces

50. 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

51. Investigations
• Imaging
– CT and MRI Scans
• FNAC
• Avoid Biopsy (seeding with neoplastic cells)

52. Treatment
• Influenced by site, stage, grade
• Stage I & II
– Wide local excision
• Stage III & IV
– Radical excision
– +/- neck dissection
– +/- postoperative radiation therapy

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

54. • Gross pathology
– Well-circumscribed
– Solid, rarely with cystic spaces
– Infiltrative
• Histology
– Cribriform pattern
• Most common
• “Swiss cheese” appearance

55. Treatment
• Complete local excision
• Tendency for perineural invasion: facial nerve
sacrifice
• Postoperative RT