This document provides an overview of salivary gland anatomy, physiology, disorders, and diagnostic modalities. It discusses the three major salivary glands - parotid, submandibular, and sublingual glands. Common salivary gland disorders are classified and diagnostic tools such as sialography, flow rate studies, sialoendoscopy, and imaging modalities like CT, MRI, radioisotope imaging are described. The document aims to inform about salivary gland structure, function, and approaches to diagnosis of salivary gland diseases.
Odontogenic keratocyst (OKC) is the cyst arising from the cell rests of dental lamina. It can occur anywhere in the jaw, but commonly seen in the posterior part of the mandible. Radiographically, most OKCs are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cyst.
Odontogenic keratocyst (OKC) is the cyst arising from the cell rests of dental lamina. It can occur anywhere in the jaw, but commonly seen in the posterior part of the mandible. Radiographically, most OKCs are unilocular when presented at the periapex and can be mistaken for radicular or lateral periodontal cyst.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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SALIVARY GLAND DISORDERS ANDSALIVARY GLAND DISORDERS AND
DIAGNOSISDIAGNOSIS
15. Nerve supply:
It is supplied by branches 'from the submandibular ganglion. These
branches convey: (a) Secretomotor fibres: (b) sensory fibres from the
lingual nerve. and (c)vasomotor sympathetic fibres 'from the plexus on the
facial artery.
16. Smallest of the 3 salivary glands,lies above the mylohyoid,below the mucosa of
floor of the mouth medial to sublingual fossa of the mandible,lateral to the
genioglossus.
About 15 ducts emerge from the gland most of them directly open into floor of
mouth.the acinar ducts are called Bartholin’s ducts and in most instances coalesce
to form 8to 20 ducts of rivinus.
SUBLINGUAL SALIVARY GLAND:
17. Serous cells: produce a thin watery secretion
Mucous cells: produce a more viscous secretion
Parotid: serous
Submandibular: mucous & serous
Sublingual: mucous
18. Physiologic control of the SG is almost entirely by the autonomic nervous
system; parasympathetic effects predominate.
If parasympathetic innervation is interrupted, glandular atrophy occurs.
Normal saliva is 99.5% water
Normal daily production is 1-1.5L
PHYSIOLOGY
19. Keeps the mouth moist-lubricates food and mouth during chewing,
swallowing and phonation
Renders food substances soluble-thus aiding in taste sensation
Digestion of starch in the diet is first by œ-amylase
ptyalin in the saliva
Noxious substances increase the salivary secretion
there by help in diluting the noxious stimuli
Bicarbonate & protein contribute to the buffering
power of saliva-restores physiologic pH of the oral cavity
FUNCTIONS OF SALIVA
20. May be used as a diagnostic tool in monitoring
physiologic disorders and systemic hormone & drug
levels.
Protective & Anti bacterial Functions:
Salivary mucins (glycosaminoglycans) coating the oral
mucosa protect against the harmful effects of noxious
stimuli, Microbial toxins & minor trauma. This coat
traps the microbes and transfers them to the stomach
where the acidic Ph of the gastric juice degrades
them.
Lysozyme-an enzyme that has little effect on the
normal flora inhibits the noncommensals by
combining with IgA immunoglobulin and lyses the
bacteria.
21. Thiocynate dependent factors –the presence of which increases the
chances of oral malignancy is increased with decrease in saliva
as seen in smokers and tobacco chewers.
Green’s factor-Anticariogenic, presence is now questioned
Lactoferrin-binds with the available iron and does not
allow it to enter bacterial metabolism.
Antifungal property-by a histidine rich peptide-inhibits
candidal growth.
25. COMMONLY USED
RADIOGRAPHIC PROJECTIONS
Parotid gland •OPG
•Oblique lateral
•Rotated PA or AP
•Intra oral view of cheek
Submandibular
gland
•OPG
•Oblique lateral
•Lower 90degree occlusal to show duct
•Lower oblique occlusal to show gland
•True lateral skull with tongue depressed
26. Sialography can be defined as the radiographic
demonstration of the major salivary glands by introducing
a radiographic contrast medium into their ductal system.
The procedure is divided into three phases:
Preoperative phase
The filling phase
The emptying phase
SIALOGRAPHY
27. To determine the presence or position of calculi or other
blockages.
To assess extent of ductal and glandular destruction secondary
to an obstruction.
To determine the extent of glandular breakdown and as a crude
assesment of function in cases of dry mouth.to determine the
location ,size,nature and origin of a swelling or mass.
INDICATIONS:
28. Allergy to compounds containing iodine.
Acute inflammation or infection.
When calculus is close to the duct opening,as injection of the
contrast medium may push the calculus back down the main duct
where it may be inaccessible.
CONTRAINDICATIONS:
29. Involves taking preoperative radiographs before the introduction of
contrast medium
To note the position and presence of any radiopaque
obstruction
To assess the position of shadows cast by normal anatomical
structures that may overlie the gland,such as the hyoid
bone.
To assess the exposure factors.
PREOPERATIVE PHASE
30. Having obtained the films,the relevant duct orifice need to
be found,probed and dilatedand then cannulated.
Three main techniques for introducing contrast medium
are:
Simple injection technique
Hydrostatic technique
Continous infusion pressure monitored technique
31.
32. Oil based or aqueous contrast medium is introduced using
gentle hand pressure until patient experiences tightness or
discomfort in the gland,about 0.7ml for parotid gland,0.5mlfor
Submandibular gland.
Hydrostatic technique:
Aqueous contrast media is allowed to flow freely into the
gland under the force of the gravity until patient experiences
discomfort.
Continuous infusion monitored technique:
A constant flow rate is adopted and the ductal pressure is
monitored through out the procedure
33. Ionic aqueous solutions including:
Iothalamate
Metrizoate.
Oil based solutions:
Iodized oil eg.lipiodol
Water insoluble organic iodine compounds eg.pantopaque.
Most commonly used are aqueous solutions.
CONTRAST MEDIA:
34. The cannula is removed and the patient is allowed to rinse out. The use of lemon
juice at this stage to aid excretion of contrast medium is advocated but is seldom
necessary.
EMPTYING PHASE
35. Parotid gland:
The main duct is of even diameter1-2mm and should be filled completely and uniformly.
Tree in winter appearance.
Submandibular gland:
The main duct is of even diameter 3-4mm .
Bush in winter appearance.
NORMAL SIALOGRAPHIC
APPEARANCES
36. These are used to investigate salivary gland function . Comparative flow rates of
saliva from major salivary glands are measured over a known time period .
Indications:
Dry mouth
Poor saliva flow
Excess salivation
FLOW RATE STUDIES
37. Advantages :
Ionizing radiation is not used
Simple to perform
Provides information on salivary gland function
Disadvantages:
No indication of nature of underlying disease
Time consuming
38. It is a specialized procedure that uses a small video
camera (endoscope) with light at the end of a flexible
cannula; which is introduced into the ductal orifice .
The endoscope can be used diagnostically and
therapeutically.
It has demonstrated strictures in the ductal system ,
as well as mucous plugs and calcifications.
May also be used to dilate small strictures and flush
clear small mucous plugs .
Specialized devices such as balloon catheters may be
used to dilate sites of ductal constriction.
SIALOENDOSCOPY
39. An examination of the electrolyte composition of the
saliva of each gland may indicate a variety of disorders.
Principally the concentration of sodium and
potassium,which normally change with salivary flow rate
are measured .
Certain changes in the relative concentrations of these
electrolytes are seen in specific disorders.
SIALOCHEMISTRY
40. This procedure has a high accuracy rate for distinguishing between benign and
malignant lesions in the superficial locations.
Performed using a syringe with a 20guage or smaller needle.
FINE NEEDLE ASPIRATION
BIOPSY
41. Either incisional or excisional can be used to diagnose a
tumor of one of the major salivary gland.
But is usually performed as an aid in the diagnosis of
sjogrens syndrome .
The lower lip labial salivary gland biopsy has been shown
to demonstrate certain histopathological changes.
Around 10 minor salivary glands are removed for
histopathological examination.
SALIVARY GLAND BIOPSY
42. Indications:
Discrete swellings both extrinsic and intrinsic to the
salivary glands.
Advantages:
Provides accurate localization of masses especially in the
deep lobe of the parotid.
The nature of the lesion can often be determined.
Images can be enhanced by using contrast media,either
in the ductal system or more commonly intravenously .
COMPUTED TOMOGRAPHY
43. Disadvantages:
Provides no indication of salivary gland function.
Small calculi may not be detected.
Risks associated with intravenous contrast media.
44. Indications:
Dry mouth due to salivary
gland diseases such as
sjogrens syndrome.
To assess salivary gland
function.
Advantages:
Allows bilateral
comparison and images all
four major salivary glands at
the same time.
Computer analysis of
results is possible.
Can be performed in cases
of acute infection
RADIOISOTOPE IMAGING
45. Disadvantages:
Provides no indication of salivary gland anatomy or ductal architecture.
Relatively high radiation dose to the whole body.
Images are not diseases specific.
46. Indications:
Discrete swellings both extrinsic and
intrinsic to the salivary glands.
Advantages:
Ionizing radiation is not used.
Provides excellent soft tissue
detail,readily enables differentiation
between normal and abnormal.
Accurate location of masses
Images in all planes and facial nerve
is usually identifiable.
MAGNETIC RESONANCE
IMAGING
47. Scintigraphy is the only method available that can provide qualitative and
quantitative functional assessments of the major salivary glands
The isotopes used for salivary gland is Technetium-99m pertechnetate
Technetium-99m about 5 mCi is injected intravenously into antecubital vein. The
activity is at 1st
, 20th
, and 40th
min]. Twenty minutes after the injection, vitamin C
chewable tablet was given to stimulate the secretion and continued until the end
of the study period (40 min)
SCINTIGRAPHY
48. Sialosis: Non neoplastic and noninflammatory
enlargement of salivary glands
Sialadenitis: Inflammation of salivary glands
Sialodochitis: Inflammation of salivary duct
Xerostomia: Salivary production < 0.2ml min
Sialolithiasis: Calculi / stone in duct or gland
Sialactesis: Atrophy of total / part of salivary gland
Ptyalism : Excessive secretion of saliva > 4 ml / min
TERMINOLOGIES
49. Xerostomia is salivary production less than 0.2ml / min.
XEROSTOMIA
(PTYALISM / DRY MOUTH
SYNDROME)
52. MANAGEMENT:
Use of water or gels
Lozenges / sour candies
Non fermentable carbohydrates
Saliva stimulating agents
Glycerol
Lemon juice
Oral hygiene
Chewing gums (Fluorides)
Hexidine mouth washes
Artificial saliva (lacks mucus)
53. Causes:
Acute inflammation oral mucosa.
During eruption of teeth in infants.
Mental retardation.
Parkinsonism.
Epilepsy .
Schizophrenia.
Acrodynia.
Rabies.
Psychosis .
Neurosis.
Drugs like sialogogues.
SIALORRHOEA (PTYALISM)
54. Mucous extravasation phenomenon
mucous escape reaction
Common lesion of oral cavity involving
salivary glands and ducts
Result from traumatic severance of
salivary duct by biting lips or cheek,
pinching the lips by extractions forceps
thus leading to spillage of mucin into
surrounding tissues
Lack epithelial lining, they are not true
cysts
MUCOCELE
55. Most common on lower lip and usually found laterally to
midline
Less common sites include buccal mucosa, anterior
ventral tongue and floor of the mouth
Increased predilection in children and young adults,
possibly because of higher incidence of trauma
Appear as raised dome shaped vesicle ranging in size
from 1to 2mm to several centimeters
May lie fairly deep in the tissue or be exceptionally
superficial and thus depending on the location will
present a variable clinical appearance
56. Extravasation is the leakage of fluid from the ducts or
acini into the surrounding tissue.
Extra: outside, vasa: vessel
Retention: narrowed ductal opening that cannot
adequately accommodate the exit of saliva produced,
leading to ductal dilation and surface swelling. Less
common phenomenon
57. Superficial lesions present a bluish transluscent cast the blue color imparted by
spilled mucin below the mucosal surface
Treatmennt is excision Excision with strict removal of any projecting peripheral
salivary glands
Avoid injury to other glands during primary wound closure
58.
59. Form of mucocele that specifically occurs in floor of the mouth
Derived from the latin word rana meaningmeaning frog,because the swelling may
resemble a frogs transluscent belly
Most common source of mucin spillage is sublingual gland, may also arise from
submandibular duct or from minor salivary glands in floor of mouth
Mostly located laterally to midline
RANULA
60. Develops as a slowly enlarging painless mass in the floor of
mouth
A rare suprahyoid type termed plunging or cervical ranula
occurs due to herniation of spilled mucin through the
mylohyoid muscle producing swelling in the neck
Treatment is removal of sublingual gland or marsipulization
Entails removal of roof of the lesion potentially allowing the
sublingual gland ducts to reestablish communication with the
oral cavity.
Most authors emphasize removal of offending gland is the
most important consideration in preventing recurrence.
CLINICAL FEATURES
61.
62. Sialocyst or mucous duct cyst
Epithelium lined cyst arising from salivary gland tissues
Commonly observed in adult age group
Can arise in both major and minor salivary glands.
Parotid gland is the most commonly involved presenting
as slowly growing asymptomatic swelling.
Conservative surgical excicion is the treatment of choice
for isolated cysts.
SALIVARY DUCT CYST
63. Also called sicca syndrome
Triad of keratoconjunctivitis sicca, xerostomia and
rheumatoid arthritis.
Primary sjogrens syndrome present only with dry eyes
and dry mouth.
Secondary sjogrens syndrome present with systemic
lupus erythematosus ,polyarteritis nodosa,rheumatoid
arthritis and scleroderma.
Etiology;
Combination of factors like
genetic,hormonal,infectious and immunologic have
been suggested.
SJOGREN SYNDROME
64.
65. Predominantly in women over 40yrs of age.
Male to female ratio is 1:10.
90% cases occur in women
Dryness of mouth and eyes as a result of hypo function of
salivary and lacrymal glands,burning sensation of oral
mucosa
Classic monograph on the disease published in 1933 by
Sjögren, a Swedish ophthalmologist
CLINICAL FEATURES
66. Keratoconjuntivitis sicca: diminished tear production
caused by lymphocytic cell replacement of the
lacrimal gland parenchyma.
Evaluate with Schirmer test. Two 5 x 35mm strips of
red litmus paper placed in inferior fornix, left for 5
minutes. A positive finiding is lacrimation of 5mm or
less.
Approximately 85% specific & sensitive
67. Diagnosis:
Single 1.5 to 2cm horizantal incision labial mucosa.
Not in midline, fewer glands there.
Include 5+ glands for identification
Glands assessed semi-quantitatively to determine the number of foci of
lymphocytes per 4mm2
/gland
69. Sialolithiasis results in a mechanical obstruction of the salivary duct
Is the major cause of unilateral diffuse parotid or submandibular gland swelling.
OBSTRUCTIVE SG DISORDERS:
SIALOLITHIASIS
70. The exact pathogenesis of sialolithiasis remains unknown.
Thought to form via….
an initial organic nidus that progressively
grows by deposition of layers of inorganic and
organic substances.
May eventually obstruct flow of saliva from the gland to the oral cavity.
71. Acute ductal obstruction may occur at meal time when saliva
producing is at its maximum, the resultant swelling sudden and can be
painful.
• Gradually reduction of the swelling can
result but it recurs repeatedly when flow is
stimulated.
• This process may continue until complete
obstruction and/or infection occurs.
72. Etiology :
Water hardness ↑likelihoodHypercalcemia
Xerostomic meds
Tobacco smoking, positive correlation
Smoking has an increased cytotoxic effect on saliva, decreases PMN phagocytic
ability and reduces salivary proteins
73. Organic; often predominate in the center
Glycoproteins
Mucopolysaccarides
Bacteria!
Cellular debris
Inorganic; often in the periphery
Calcium carbonates & calcium phosphates in the form of hydroxyapatite
STONE COMPOSITION
74. Saliva more alkaline
Higher concentration of calcium and phosphate in the saliva
Higher mucus content
Longer duct
Anti-gravity flow
REASONS SIALOLITHIASIS MAY
OCCUR MORE OFTEN IN THE
SMG
75. Painful swelling (60%)
Painless swelling (30%)
Pain only (12%)
Sometimes described as recurrent salivary
colic and spasmodic pains upon eating
CLINICAL PRESENTATION
76. History of swellings / change over time?
Trismus?
Pain?
Variation with meals?
Bilateral?
Dry mouth? Dry eyes?
Recent exposure to sick contacts (mumps)?
Radiation history?
Current medications?
CLINICAL HISTORY
78. Palpate for cervical lymphadenopathy
Bimanual palpation of floor of mouth in a posterior to anterior direction
Have patient close mouth slightly & relax oral musculature to aid in detection
Examine for duct purulence
Bimanual palpation of the gland (firm or spongy/elastic).
PALPATION
79. Effective for intraductal stones,
while….
intraglandular, radiolucent or
small stones may be missed.
DIAGNOSTICS: PLAIN OCCLUSAL
FILM
80. CT Scan:
large stones or small CT slices done
also used for inflammatory disorders
Ultrasound:
operator dependent, can detect small stones (>2mm), inexpensive, non-invasive
DIAGNOSTIC APPROACHES
81. Consists of opacification of the ducts by a retrograde injection of a water-soluble
dye.
Provides image of stones and duct morphological structure
May be therapeutic, but success of therapeutic sialography never documented
DIAGNOSTIC APPROACHES:
SIALOGRAPHY
83. Allows complete exploration of the ductal system, direct
visualization of duct pathology
Success rate of >95%2
Disadvantage: technically challenging, trauma could result in
stenosis, perforation
DIAGNOSTIC APPROACH:
DIAGNOSTIC SIALENDOSCOPY
84. If patients DO defer treatment, they need to know:
Stones will likely enlarge over time
Seek treatment early if infection develops
Salivary gland massage and hyper-hydration when symptoms develop.
SIALOLITHIASIS TREATMENT
85. Diagnosis
Digital manipulation:
Gland – firm and larger
Produces flow of saliva – visual inspection of fluid
Location of hard calcific stone along ductal course
Yellowish colour of calcific deposit seen through distended and thin
mucous membrane
Sialography
89. Acute infection more often affects the
major glands than the minor glands1
SIALADENITIS
90. 1. Retrograde contamination of the salivary ducts and parenchymal tissues by
bacteria inhabiting the oral cavity.
2. Stasis of salivary flow through the ducts and parenchyma promotes acute
suppurative infection.
PATHOGENESIS
91. More common in parotid gland.
Suppurative parotitis, surgical parotitis, post-operative parotitis, surgical mumps,
and pyogenic parotitis.
The etiologic factor most associated with this entity is the retrograde infection
from the mouth.
20% cases are bilateral7
ACUTE SUPPURATIVE
92. The composition of parotid secretions differs from
those in other major glands.
Parotid is primarily serous, the others have a
greater proportion of mucinous material.
PREDILECTION FOR PAROTID
SALIVARY COMPOSITION
93. Mucoid saliva contains elements that protect against
bacterial infection including lysozymes & IgA antibodies
(therefore, parotid has ↓ bacteriostatic activity)
Mucins contain sialic acid which agglutinates bacteria and
prevents its adherence to host tissue.
Specific glycoproteins in mucins bind epithelial cells
competitively inhibiting bacterial attachment to these cells.
SALIVARY COMPOSITION
94. Minor role in formation of infections
Stensen’s duct lies adjacent to the maxillary mandibular molars and Wharton’s
near the tongue.
It is thought that the mobility of the tongue may prevent salivary stasis in the area of
Wharton's that may reduce the rate of infections in SMG.
PAROTID PREDILECTION
ANATOMIC FACTORS
96. Neoplasms (pressure occlusion of duct)
Sialectasis (salivary duct dilation) increases the risk for retrograde contamination.
Is associated with cystic fibrosis and pneumoparotitis
Extremes of age
Poor oral hygiene
Calculi, duct stricture
RISK FACTORS CONTINUED…
97. Mumps classically designates a viral parotitis caused by the paramyxovirus
However, a broad range of viral pathogens have been identified as causes of AVI
of the salivary glands.
Derived from the Danish word “mompen”
Means mumbling, the name given to describe the characteristic muffled speech
that patients demonstrate because of glandular inflammation and trismus.
As opposed to bacterial sialadenitis, viral infections of the salivary glands are
SYSTEMIC from the onset!
MUMPS
98.
99. Mumps is a non-suppurative acute sialadenitis
Is endemic Communicable disease
Enters through upper respiratory tract
2-3 week incubation after exposure (the virus multiplies in the
URI or parotid gland)
3-5day viremia
Then localizes to biologically active tissues like salivary glands,
germinal tissues and the CNS.
100. Classic mumps syndrome is caused by paramyxovirus, an
RNA virus
Others can cause acute viral parotitis:
Coxsackie A & B, ECHO virus, cytomegalovirus and adenovirus
Clinical presentation
VIROLOGY
30% experience prodromal symptoms prior to development of parotitis
Headache, misaligns, anorexia, malaise
Onset of salivary gland involvement is heralded by ear ache, gland pain,
dysphagia and trismus
101. Glandular swelling (tense, firm) Parotid gland involved frequently, SMG & SLG
can also be affected.
May displace ispilateral pinna
75% cases involve bilateral parotids, may not begin bilaterally (within 1-5 days
may become bilateral)….25% unilateral
Low grade fever
PHYSICAL EXAM
102. Leukocytopenia, with relative lymphocytosis
Increased serum amylase (normal by 2- 3 week of disease)
Viral serology essential to confirm:
Complement fixing antibodies appear following exposure to the virus.
DIAGNOSTIC EVALUATION
103. Orchitis, testicular atrophy and sterility in approximately 20% of young men
Oophoritis in 5% females
Aseptic meningitis in 10%
Pancreatitis in 5%
Sensorineural hearing loss <5%
Usually permanent
80% cases are unilateral .
COMPLICATIONS
106. Diverse histopathology
Relatively uncommon
2% of head and neck neoplasm's
Distribution
Parotid: 80% overall; 80% benign
Submandibular: 15% overall; 50% benign
Sublingual/Minor: 5% overall; 40% benign
SALIVARY GLAND NEOPLASMS
107. Most common of all salivary gland neoplasms
70% of parotid tumors
50% of submandibular tumors
45% of minor salivary gland tumors
6% of sublingual tumors
4th
-6th
decades
F:M = 3-4:1
PLEOMORPHIC ADENOMA
108. Slow-growing, painless mass
Parotid: 90% in superficial
lobe, most in tail of gland
Minor salivary gland: lateral
palate, sub mucosal mass
Gross pathology
Smooth
Well-demarcated
Solid
Cystic changes
Myxoid stroma
109. Histology
Mixture of epithelial, myopeithelial
and stromal components
Epithelial cells: nests, sheets, ducts,
trabeculae
Stroma: myxoid, chrondroid, fibroid,
osteoid
No true capsule
Tumor pseudopods
110. Papillary cystadenoma lymomatosum
6-10% of parotid neoplasms
Older, Caucasian, males
10% bilateral or multicentric
3% with associated neoplasms
Presentation: slow-growing, painless mass
WARTHIN’S TUMOR
112. 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
MUCOEPIDERMOID CARCINOMA
113. Presentation
Low-grade: slow growing, painless mass
High-grade: rapidly enlarging, +/- pain
**Minor salivary glands: may be mistaken for benign or inflammatory process
Hemangioma
Papilloma
Tori
115. 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
ADENOID CYSTIC CARCINOMA
117. 2nd
most common parotid and pediatric malignancy
5th
decade
F>M
Bilateral parotid disease in 3%
Presentation
Solitary, slow-growing, often painless mass
ACINIC CELL CARCINOMA
119. Rare
5th
to 8th
decades
F > M
Parotid and minor
salivary glands
Presentation:
Enlarging mass
25% with pain or facial weakness
ADENOCARCINOMA
120. Carcinoma ex-pleomorphic adenoma
Carcinoma developing in the epithelial component of preexisting pleomorphic adenoma
Carcinosarcoma
True malignant mixed tumor—carcinomatous and sarcomatous components
Metastatic mixed tumor
Metastatic deposits of otherwise typical pleomorphic adenoma
MALIGNANT MIXED TUMORS
121. 2-4% of all salivary gland neoplasms
4-6% of mixed tumors
6th
-8th
decades
Parotid > submandibular > palate
Risk of malignant degeneration
1.5% in first 5 years
9.5% after 15 years
Presentation
Longstanding painless mass that undergoes sudden enlargement
CARCINOMA EX-PLEOMORPHIC
ADENOMA
123. Rare: <.05% of salivary gland neoplasms
6th
decade
M = F
Parotid
History of previously excised pleomorphic adenoma, recurrent pleomorphic
adenoma or recurring pleomorphic treated with XRT
Presentation
CARCINOSARCOMA
127. Frey syndrome (gustatory sweating) is now considered an universal
sequel following parotidectomy surgery
It results from of the innervation of the salivary gland during
dissection in which there is inappropriate regeneration of
parasympathetic autonomic nerve fibres which thus stimulate the
sweat glands of the overlying skin.
The clinical features of Frey syndrome include sweating and
erythema over the region of the parotid glands surgical bed as a
consequence of autonomic stimulation of salivation by the smell or
taste of food.
The symptoms are entirely variable and are clinically demonstrated
by a starch iodine test.
FREY’S SYNDROME
128. Starch iodine test:
Involves painting the affected area with iodine which is allowed to dry before
applying dry starch, which turns blue on exposure to iodine in the presence of
sweat. Sweating is stimulated by salivary stimulation .
FREY’S SYNDROME
129. Management:
Antiperspirants,usually astringents such as alumium
chloride.
Denervation by tympanic neurectomy
The injection of Botulinum toxin into the affected skin
The last remains the most modern, effective method,
which can be performed on an out-patient basis.
FREY’S SYNDROME
130. Human anatomy vol.3 –B.D.Chaurasia 4th
edn.
Textbook of oral pathology –Shaffer
Textbook of oral medicine –Burkett
Principles of surgery –Peterson
Oral and maxillofacial surgery clinics of North America
REFERENCES
Editor's Notes
Largest of the salivary gland, weighs about 15g.
Situated below the external acoustic meatus ,between the ramus of mandible and the sternocleidomastoid. the gland overlaps these structures.
Anteriorly gland overlaps the masseter muscle. a part of this forward extension is often detached and is known as accessory parotid and it lies between the zygomatic arch and parotid duct.
Parotid capsule :
The investing layer of deep cervical fascia forms a capsule for the gland ,the fascia splits to enclose the gland. the superficial lamina thick and adhere rent is attached above to the gland .the deep lamina is thin and is attached to the styloid process.
A portion of the deep lamina extending between the styloid process and the mandible, is thickened to form the stylomandibular ligament which separates the parotid gland from submandibular salivary gland.
Blood supply:
The parotid gland is supplied by the external carotid artery and its branches that arise near the gland. The veins drain into the external jugular vein.
Parotid duct:
It is thick walled and is 5cm long.it emerges from the middle of anterior border of the gland.it runs forwards and slightly downwards on the masseter.
The duct runs forwards for a short distance between the buccinator and the oral mucosa. Finally.the duct turns medially and opens into the vestibule of the mouth (gingivo-buccal vestibule) opposite the crown of the upper second molar tooth.
Nerve supply:
Parasympathetic nerves are secretomotor they reach the gland through the auriculotemporal nerve. The preganglionic fibres begin in the inferior salivatory nucleus; pass through the glossopharyngeal nerve. its tympanic branch. The tympanic plexus and the lesser petrosal nerve; and relay in the otic ganglion. The postganglionic fibres pass through the auriculotemporal nerve and reach the gland.
Sympathetic nerves are vasomotor, and are derived from the plexus around ,the external carotid artery.
Sensory nerves to the gland come from the auriculotemporal nerve. but the parotid fascia is innervated by the sensory fibres of the great auricularnerve (C2).
Lymphatic drainage:
Lymph drains first to the parotid nodes and from there to the upper deep cervical nodes.
Parotid lymph nodes:
The parotid lymph nodes lie partly in the superficial fascia and partly deep to the deep fascia over the parotid gland They drain: (a) The temple.(b) the side of the scalp, (c) the lateral surface of the auricle. (d) the extemal acoustic meatus, (e) the middle car. (f) the parotid gland. (g) the upper part of the cheek. (h) parts of the eyelids, and (i) the orbit.
Efferents from these nodes pass to the upper group of deep cervical nodes.
Situated in the anterior part of digastric triangle
Two parts ,superficial and deep
Superficial part fills digastric triangle extends upwards deep to the mandible upto mylohoid line.
Deep part is small in size. It lies deep to the mylohoid and superficial to the hyoglossus and the styloglossus.
Posteriorly. it is continuous with the superficial part round the posterior border of the mylohoid.Anteriorly. it extends up to the posterior end of thesublingual gland
It is thin walled. and is about 5 cm long. It emerges at the anterior end of the deep part of the gland and runs forwards on the hyoglossus between the lingual and
hypoglossal nerves. At the anterior border of the hyoglossus the duct is crossed by the lingual nerve.
It opens on the floor of the mouth. on the summit of the sublingual papilla. at the side of the frenulum of the tongue.
Blood supply and lymphatic drainage:
It is supplied by the facial artery. The veins drain into the common facial or lingual vein. Lymph passes to submandibular lymph nodes
Minor salivary glands:
Tonsillar: Weber&apos;s glands.
Retro molar :Carmalt’s glands.
Lingual(inferior apical):Glands of Blandin Nuhn.
Taste buds:Ebners glands.
is a benign tumor of epithelial tissue with glandular origin
Carcinoma is a type of cancer that develops from epithelial cells.[1] Specifically, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that generally arises from cells originating in the endodermal or ectodermal germ layer during embryogenesis