Common salivary gland disorders.

1. SALIVARY GLAND
DISORDERS
Dr. Rasif Ahsan.
Honorary Medical Officer,
Shahid Sohrawardy Medical College Hospital

2. INTRODUCTION
• Saliva is a complex mixture of fluid, electrolytes, enzymes, and
macro-molecules that function together to perform several
important roles
• Lubrication to aid in swallowing and digestion
• Digestion of starches with salivary amylase
• Modulation of taste
• protection against dental caries
• Defence against pathogens.

3. • The major salivary glands are the paired parotid, submandibular, and
sublingual glands. The minor salivary glands line the mucosa of the
lips, tongue, oral cavity, and pharynx. Diseases of the major salivary
glands are occasionally encountered in the primary care setting (ta b l
e 1)
• Obstructive salinities (from stones or strictures) accounts for approximately
one-half of benign salivary gland disorders.1
• Neoplasms of the salivary glands are relatively rare; they make up 6% of all
head and neck tumour.2
• Infections and inflammation of the salivary glands have a wide range of
presentations (table 2).6

4. HISTORY
• The medical profile of the patient can provide helpful clues to the current condition of the
salivary glands,
• For dysfunction of these glands is often associated with certain systemic disorders such a
diabetes mellitus, arteriosclerosis, hormonal imbalances, and neurologic disorders.
• Either xerostomia or sialorrhea, for instance, may be due to factors affecting the medullary
salivary center, autonomic outflow pathway, salivary gland function itself, or fluid and
electrolyte balance.
• The autoimmune disorder known as Sjögren’s syndrome, for example, is common in
menopausal women,
• mumps, parotid swelling due to paramyxoviral infection, usually occurs in children between
the ages of 4 and 10 years.

5. • Drug history of the patient should also be considered, for salivary function is often
affected by drug usage. Xerostomia is often due to the use of diuretics and other
antihypertensive drugs [9, 18].
• A careful dietary and nutrition history should be obtained. Patients who are
dehydrated chronically from bulimia or anorexia or during chemotherapy are at
risk for parotitis. Swelling and pain during meals followed by a reduction in
symptoms after meals may indicate partial ductal stenosis.
• Xerostomia is a debilitating consequence of radiation therapy to the head and neck
and a history of prior radiation should be sought.

6. • Initial inspection involves the careful examination of the head and neck
regions, both intraorally and extra orally, and should be carried out in a
systematic way so as to not miss any crucial signs.
• The examiner should inspect symmetry, color, possible pulsation and
discharging of sinuses on both sides of the patient.
• Salivary gland swelling can generally be differentiated from those of lymphatic
neurorigin a smoother, buts being single, larger, and the two types are often
easily confused. Significant ologic deficits should be examined as well. Facial
nerve paralysis in conjunction with a parotid mass, for example, should
remind us of a malignant parotid neoplasm, although it does occur rarely with
benign neoplasms as well.
Clinical
Examination

7. CLINICAL EXAMINATION (CONT.)
• In addition to signs of possible asymmetry, discoloration, or pulsation, intraoral
inspection also includes assessment of the duct orifices and possible obstructions.
• The proper lighting with a headlight should always be used when inspecting within the
oral cavity and pharynx.
• The openings of Stensen’s and Wharton’s ducts can be inspected intraorally opposite the
second upper molar and at the root of the tongue, respectively.
• Drying off the mucosa around the ducts with an air blower and then pressing on the
corresponding glands will allow the examiner to assess the flow or lack of flow of saliva.
Sialolithiasis can sometimes be found by careful intraoral palpation.
• Dental hygiene and the presence of periodontal disease should also be noted since
deficient oral maintenance is major predisposing factor to various infectious diseases

8. • Size, consistency, and other qualities of the
salivary glands and associated masses can be
evaluated through extraoral and intraoral
palpation. Bimanual assessment should be
performed whenever possible with the
palmar aspect of the fingertips.
• During extraoral palpation of the face and
neck, the patient’s head is inclined forward to
maximally expose the parotid and
submandibular gland regions. The examiner
may stand in front of or behind the patient. It
should be noted that observable salivary or
lymphatic gland swellings
• do not rise with swallowing, while swellings
associated with the thyroid gland and larynx
do elevate.

9. • Finally, bimanual palpation (extra oral with one hand,
introral with the other) must be performed to examine
the parotid and submandibular glands. One or two
gloved fingers should be inserted within the oral cavity
to palpate the glands and main excretory ducts
internally, while using the other hand to externally
support the head and neck. By rolling the hands over
the glands both internally and externally, subtle mass
lesions can be identified. In the submandibular gland,
lymph nodes extrinsic to the
• gland can often be distinguished from pathology within
the gland itself using this technique. The neck should
then also be carefully examined for lymphadenopathy.
• Finally, a careful survey of minor salivary gland tissue
should be performed, especially in the anterior
labial,buccal, and posterior palatal mucosa.

11. INVESTIGATION
• For patients with these unclear symptoms and no physical signs,
radiographic diagnostic studies, such as sialography, plain-film
radiography, computed tomography, and magnetic resonance imaging,
can play in important role in clarifying the aetiology of such non
specific symptoms. For patients with known disease ,Imaging can
assist in treatment selection and planning

13. PTYALISM
-It is excessive salivation seen in affected patients. It can be mild, intermittent or
continuous profuse drooling.
-Profuse salivation is seen in rabies, heavy metal poisoning or after certain
medications like lithium.
-Mentally retarded children also have excessive salivation.
The treatment is conservative.
Anticholinergic medication can be tried (atropine).
Behavioural modification, physical therapy has been tried.
Suggested Surgical Treatment
• Submandibular gland resection
• Transposition of parotid duct
• Parotid duct ligation.

14. XEROSTOMIA
• This is a subjective sensation of a dry mouth. It affects women more
than the men, and seen more commonly in older people.
• Antihistamines, decongestants, antidepressants, antipsychotics,
antihypertensive, anticholinergics are known to cause xerostomia.
• Other causes of xerostomia are—salivary gland aplasia, aging,
excessive smoking, mouth breathing, local radiation therapy, Sjögren‘s
syndrome, HIV infection.
• Treatment is conservative, maintenance of oral hygiene, use of
sialagogues (pilocarpine), modification of medications in elderly
patients may help to improve the condition.

15. SIALILOTHIASIS
Sialolithiasis is the formation
of sialolith (salivary calculi, salivary
stone) in the salivary duct or the gland
resulting in the obstruction of the
salivary flow.
When a duct of the major gland is
involved, there is pain with the psychic
stimulation of the salivary flow.
Patients complain of pain and swelling
during and after eating the food. The
obstruction of the duct by the sialolith
causes prevention of salivary flow and
increased pressure producing the pain
• The smaller sialoliths, which are
located peripherally near the ductal
opening may be removed by
manipulation (Called milking the
gland).

16. MUCOCELE
This is a swelling due to the accumulation
of saliva, as a result of obstruction or
trauma to the salivary gland ducts.
Mucoceles occur as painless swellings. The
common sites of occurrences of mucoceles ,
especially the extravasation type, are the
lower lip and tongue. The retention type of
mucocele is less common and rarely occurs
in the lower lip. Instead, it occurs in palate,
cheek, floor of the mouth and maxillary
sinus.
Treatment
Mucoceles are treated by surgical excision.
It is common to see the recurrence after
excision. It can be minimized,if the
associated salivary gland acini are also
removed.

17. RANULA
It is a special type of mucocele,
which occurs in the floor of the
mouth. Since the lesion appears
like the belly of a frog, it is
called ‘ranula’.
Renula is formed because of
the trauma to submandibular or
sublingual ducts. It starts as a
painless swelling on one side of
the floor of the mouth.
Treatment
Large ranulas may be
marsupialized

18. PLEOMORPHIC
ADENOMA
Pleomorphic adenoma constitutes more
than 50 percent of all tumors and 90
percent of all the benign tumors of the
salivary glands.
Pleomorphic adenoma most commonly
affects the parotid gland, followed by minor
salivary glands of the palate, lip, less
frequently affects the submandibular
gland. Majority of the lesions are seen
between 4th to 6th decades, more
commonly in females. The tumor starts as a
small painless nodule.
Pleomorphic adenomas are
treated by surgical excision.

19. WARTHIN’S TUMOR
This benign tumor affects the parotid
glands. Involvement of the
submandibular or the minor salivary
glands is very rare. Usually, males are
affected more commonly in the 5th
decade.
The tumor is seen as a firm,
nontender, circumscribed mass in the
region of angle or ramus of the
mandible or beneath the ear lobe.
Though both side parotid glands may be
affected, the swelling might start on one
side following the other.
Treatment: The tumor is
surgically excised.

20. MUCOEPIDERMOID
CARCINOMA
The clinical features depend upon the
grade of the tumor. Thus, it may grow
slowly or rapidly; usually as a painless
swelling of the parotid or other major
salivary gland, or in the minor salivary
glands. Intraorally, it may affect the
minor glands of the palate, buccal
mucosa, tongue and retromolar areas.
The high-grade tumor may produce
pain, ulceration or facial paralysis,
local destruction and metastasis to
regional lymph nodes .
Treatment: The tumor should be
surgically excised

21. SJÖGREN’S SYNDROME
This is a condition originally
described as a triad, consisting of
dry eyes, xerostomia and
rheumatoid arthritis.
Clinically, this disease occurs
predominantly in women over 40
years of age. The female to male
ratio is 10:1. Typically, patients
present with dry eyes and dry
mouth due to hypofunction of
lacrimal and salivary glands. This
leads to pain, burning sensation
and ulcerations on the
oral/conjunctival mucosa.

23. REFERENCES
• Salivary Gland Disorders by Eugene N. Myers · Robert L. Ferris (Eds.)
• CAWSON’S ESSENTIALS OF ORAL PATHOLOGY AND ORAL MEDICINE
• SALIVARY GLAND DIAGNOSIS AND MANAGEMENT by Eric R. Carlson, DMD,
MD, FACS
• Journal of American Family Physicians
• Isa AY, Hilmi OJ. An evidence based approach to the management of salivary
masses. Clin Otolaryngol. 2009;34(5):470-473