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Salivary gland disorders


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for dental students

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Salivary gland disorders

  1. 1. SALIVARY GLAND DISORDERS Thilanka Umesh Sugathadasa(D/10/064)
  2. 2. Thilanka Umesh Sugathadasa Page 1 Non-neoplastic diseases of salivary glands including dry mouth Classification Non- neoplastic SG disorders Congenital/ Developmental Inflammatory /Traumatic/ Ischemic Infective Endocrine/ Metabolic (Sialosis) Autoimmune/ Benign lymphoepithelial Obstructive Drug induced  Aplasia/ Hypoplasia  Agenesis  Atresia of the duct & congenital strictures  Aberrancy  Accessory ducts & lobes  Haemangioma s  Polycystic disease of parotid  Stomatitis nicotina  Necrotizing sialometapla sia  Cheilitis glandularis  Mucocele & other cystic lesions  Bacterial - Acute (Ascending) sialadenitis - Chronic non-specific Sialadenitis(with or without sialolithiasis) - Chronic specific sialadenitis(TB/ syphilis/ Sarcoidosis) & granulomatous inflammation. - Recurrent subacute/ chronic sialadenitis(eg- juvenile parotitis)  Viral - Mumps - Mumps like diseases (Cytomegalic inclusion disease/ Coxaskie A infection/ ECHO or Lymphocytic Choriomeningitis viral infection) - HIV induced SG disease. Painless salivary swellings  Alcoholic cirrhosis  DM  Acromegaly  Malnutrition  Chronic renal failure  Cystic fibrosis  Sjogren’s syndrome  Chlorhexidin e  Isoprenaline  Iodine  Phenyl butazone  Sialolithiasis  Strictures
  3. 3. Thilanka Umesh Sugathadasa Page 2 Dry Mouth/ Xerostomia Introduction  This is significantly a patient perception.  Dry mouth & Oral dryness are general terms that encompasses 2 medical entities - Xerostomia (This is a symptom) – subjective complaints - Hyposalivation – Objective reduction in salivary secretion  Mainly occur due to decreased salivary flow or decrease composition of the saliva. & there are many of other causes.  So this is a subjective clinical condition due to absolute or relative reduction in amount of saliva  Advancing of the age also increasingly associated with the dry mouth. But this is usually due to medications & diseases. Causes Causes Iatrogenic 1.Drugs -Atropine -Antidepressants : Tricyclic(eg: Amitriptyline, Nortriptyline), Selective serotonin reuptake inhibitors -Antihypertensive : Can also cause the compositional changes of the saliva as well as the changes of the flow rate. - Antihistamines - Opioids - Cytotoxic drugs -Antiemetics 2.Irradiation(External irradiation doses above 40 Gy & Iodine 131) 3.Graft versus host reaction Physiological Diseases of Salivary glands Dehydration Psychogenic(Anxiety, Depression) Post exercise/ mouth breathing  Salivary aplasia  Sjogren’s syndrome  Sarcoidosis  Parotidectomy  Cystic fibrosis  Ectodermal dysplasia  Infections  Controlled diabetes  CRF Mouth breathing due to nasal polyp, etc When doing presentation or social speech.
  4. 4. Thilanka Umesh Sugathadasa Page 3 Clinical features of dry mouth Symptoms 1. Sensation of burning. 2. Swallowing difficulty(Eating difficulty of dry foods “cracker sign”) 3. Stability & retention of dentures become low 4. Speaking difficulty(Clicking quality speech due to tongue sticking to the palate) 5. Sensation of taste reduction 6. Increase incidence of dental caries & periodontal disease. 7. Infection 8. Recurrent ulceration 9. Tongue or check getting accidental bitten frequently. Signs 1. Dryness of the lips & oral mucosa. 2. Pale & corrugated buccal mucosa. 3. Lack of salivary pooling in floor of the mouth. 4. Atrophy/ inflammation/ fissuring/ cracking/ of tongue 5. Erythema/ Ulceration 6. Infections 7. Lipstick sign 8. Crackers sign 9. Tongue blade sign 10. Increase levels of dental caries & periodontal disease. 11. Mucosa tends to stick to the dental mouth mirror & dry Complications of dry mouth Soft tissue changes Hard tissue changes Other  The mucosal tissues may become painful, “Burning”, dry & atrophic.  Cracked lips.  Soreness & redness due to candidosis.  Ascending suppurative sialadenitis.  Tingling sensation of the mouth.  Angular cheilitis  Severe & uncontrolled dental caries  Marked increase in erosions especially in the non- carious risk areas & the root surfaces, & even in the cusp tips.  Caries may be progressive even with the excellent oral hygiene.  Difficulty in speaking.  Difficulty in swallowing especially dry foods.  Reduced denture retention.  Reduced taste sensation.  Painful salivary gland enlargement.  Increased thirst.  Increase uptake of the fluids when eating.  Periodontal disease?  Halitosis Dry mouth patient can be classified in to 3 types Those having asymptomatic hyposalivation,ie reduction in the salivary secretion not significant enough to cause xerostomia. Those with symptomatically significant hyposalivation, thus suffering from xerostomia. Those suffering from xerostomia but with no evident decrease in salivary secretion
  5. 5. Thilanka Umesh Sugathadasa Page 4 Diagnosis & Ix Diagnosis is mainly by the combination of the - Hx - Ix - Clinical features. Investigations Salivary function studies 1. Salivary flow rate 2. Sialography 3. Salivary scintiscanning Other 1. Lacrimation flow – exclude sjogren's syndrome 2. Urinanalysis – exclude DM 3. Blood tests ESR – exclude Sjorgren’s syndrome or sarcoidosis antinuclear antibodies – exclude Sjorgren’s syndrome or sarcoidosis. Rheumatoid factor – Exclude Sjorgren’s syndrome Serology – Viral disease Serum calcium & phosphate – exclude hyperparathyroidism. 4. Imaging CXR –exclude Sarcoidosis Ultrasonography – exclude Sjorgren’s syndrome or Neoplasia MRI –exclude Sjorgren’s syndrome 5. Bx Biopsy is taken if there is a suspicion about the organic disease of the salivary glands. Here always possible to take biopsy from the major salivary glands but usually perform the minor SG Bx due to risks of nerve damage, scars. So usually preferable site is the lower labial mucosa. Management Can divide in to 3 categories 1. Symptomatic Rx 2. Preventive Rx 3. Curative Rx Salivary flow over a 24-hour period Sleep 40 ml saliva will be produced over 7 hours Awake 300 ml of unstimulated saliva over 16 hours 200 ml of stimulated saliva during meals over 54 minutes
  6. 6. Thilanka Umesh Sugathadasa Page 5 Symptomatic Rx Preventive Rx Curative Rx (- Directed at alleviating or minimizing complaints associated with decreased salivation. Range from simple methods of hydration & lubrication to systemic secretagogues to stimulate the salivary function)  Non sugar containing fluids & frequent small sips of them. Helps to hydrate the mucosa & removal of retained debris  Avoids fluids containing sugars.  Humidifiers specially closer to bed at night (Can use jug of water)  Lip moisturizers & emollients.  Penetrating creams are preferred over the petroleum based products.  Avoid dry foods.  Avoiding spicy foods, alcohol & strong flavoring may reduce oral mucosal sensitivity.  Avoid mouth rinses with high alcohol content. (Listerine), which can induce mucosal irritation & sensitivity.  Mechanical, local saliva induce with sugarless candy, gums or rinses. disadvantages of local stimulants - short lived - Frequent application can be inconvenient. - Citric acid may irritate the oral mucosa. - continue use may contribute to demineralization.  Systemic sialologues - Only use for the patients who have salivary tissues that can be stimulated. - Pilorcarpine hydrochloride- parasympathomimetic agonist that increase exocrine output. - Most widely tested sialagogue. - Recommended dose = 5mg tds - Cevimeline hydrochloride – similar to Pilorcarpine. (This product can’t use in high in high conc as it containing metals.)  Salivary replacement products (Substitute) commonly containing Carboxymethylcellulose or hydroxycellulose as lubricants, artificial sweeteners, preservatives, chloride & Fluorides (- To limit the consequences of salivary gland hypofunction on oral & dental tissues)  Increase oral hygiene measures.  Professional care.  Oral application of topical fluorides to minimize the dental caries risk.  If bacterial infection is identified, appropriate antibiotics should be identified. It may require prolonged therapy.  If swelling which is not due to infection a short course of steroids are beneficial.  NSAIDs are not helpful  If candidal infection presents use topical or systemic antifungals prolongly those antifungals should not contain sugars. Composition of the artificial saliva - Carboxymethylcellulose 10g/L(Keep the watery content of saliva) - Sorbitol 30mg/L - Sodium chloride - Magnesium chloride - Calcium chloride - Dipotasium hydrogen phosphate  Disadvantages - Regular use is inconvenient. - More viscous than the natural saliva so feel odd. - Expensive - No antimicrobial & other protective functions. (Managing underlying cause or symptoms)  If dry mouth is due to drugs, stopping/changing drugs if possible, in consultation with patient’s physician.  If possible alternative drug.  Identify the cause by history, examination & further investigations & Rx - Secretagogues can provide transient relief but will not address the underlying cause. - Patients may leave with gradual decline in function over time & worsening the symptoms & signs.
  7. 7. Thilanka Umesh Sugathadasa Page 6 Mx of the Xerostomia can be presents as 1. Replacement of saliva 2. Avoidance of harmful effects. 3. Prevention of oral disease 4. Stimulation of the residual secretory capacity. 5. Curative Rx. Replacement of saliva  Frequent sips of water  Glycerol & Thymol or Glycerol & lemon  Luborant- Methyl cellulose based products  Glandosane - ;;  Above having enough hydration but not enough lubrication  Saliva orthana is having (Mucin- based products) better lubrication properties Avoidance of harmful effects  Dry and cariogenic foods.  Tobacco smoking and alcohol intake  Alter treatment with medicaments if there are any medicines which cause dry mouth.  Avoid wearing dentures at night Prevention of oral disease  Meticulous (careful) oral hygiene.  Dietary advice  Topical F-  Chlorhexidine mouth wash 0.2%  Antifungal agents Stimulation of the residual secretory capacity  Sugar free chewing gums  Saliva orthana lozenges(release Mucin)  Pilorcarpine tablets 5mg tds  Pilorcarpine eye drops 0.5- 1% also can be swallowed (2-4 drops) every 4 hours.  Other drugs (Anethole trithione, yohimbine, neostigmine)
  8. 8. Thilanka Umesh Sugathadasa Page 7 Condition Features & etiology Clinical features/ Ix & Diagnosis Mx Sjogren’s syndrome  An autoimmune inflammatory disorder  Immunologically mediated chronic inflammatory disorder of exocrine glands mainly affecting salivary, lacrimal glands.  Common in the middle aged Females.  Two types present - Primary SS (sicca syndrome)-: Dry eyes (Keratoconjunctivitis/ xerophthalmia) & dry mouth. - Secondary SS-: Dry eyes, Dry mouth & connective tissue disorder (RA, SLE, Systemic sclerosis, mixed CT disease, primary biliary cirrhosis)  Causes - Genetic predisposition - Hormones - Inflammatory events - Auto antibodies - Liver disease - Processes mediating salivary gland dysfunction. -Viruses  A benign autoimmune inflammatory exocrinopathy (epithelitis) directed against alpha fodrin, a cytoskeletal protein involved in actin binding, with lymphocyte-mediated destruction of salivary, lacrimal and other exocrine glands. Tumor necrosis factor (TNF), interferon (IFN) and B cell activating factor (BAFF) are implicated. A viral etiology, possibly human retrovirus 5 (HRV-5), and a genetic predisposition May be implicated. A SS type of disease may follow HIV, EBV, HCV, or Helicobacter pylori infection, or graft- versus-host disease. Symptoms Mouth  Xerostomia is the main problem. But only some have unpleasant taste.  Angular cheilitis  Pus discharge from the ductal orifices.  Unilateral/ Bilateral intermittent enlargement of salivary glands mainly parotids.  Thick frothy saliva, later stage with loss of saliva pooling.  Glazed, dry mucosa that tend to form wrinkles.  Redness/soreness of the mucosa due to candida infection.  Lobulated, reddish, partial/complete depapillated tongue with reduced no of taste buds  Gross accumulation of plaque  Several dental caries including root caries.  Periodontal diseases  Recurrent attacks of the acute bacterial sialadenitis: SS is the most common cause for the acute bacterial sialadenitis.  Enlarged tender regional lymph nodes. Signs  Unpleasant taste  Difficulty in eating  Soreness of the mouth.  Difficulty in speech.  Most patients are treated with symptomatically  Oral hygiene improvement  Mx of dry mouth  Mx of dry eyes  Agents against CD20(B lymphocyte surface antigen) SS is characterized by glandular lymphocytic infiltration  As curative Rx most of the time Systemic steroids, cyclosporines, Methotrexate, etc…using
  9. 9. Thilanka Umesh Sugathadasa Page 8 Rheumatic Diseases associated with Sjogren’s’ syndrome - RA - SLE - Progressive systemic sclerosis - Mixed CT disease. - Dermatomyositis. - Polyarteritis nodosa. - Reynaud’s phenomenon. Immunologically related diseases associated with SS - 1ry biliary cirrhosis - Chronic active hepatitis - Autoimmune thyroid disease - Pemphigus vulgaris - Coeliac disease - Myasthenia gravis - Graft versus host disease Eye  Sensation of dryness  Burning sensation  Redness  Frequent conjunctival infections  Ulceration  Also dryness of pharynx, larynx, and genital areas also may present.  CT disorders clinical features also can present in the 2ry SS. Radiological features 1. Multiple sialectasias (snow storm app) in sialogram with atrophy of ductal system delayed emptying of dye. 2. Impaired salivary activity seen in salivary scintiscanning Reduced sialometry & abnormal sialochemistry. Positive ose Bengal staining test & schirmer test
  10. 10. Thilanka Umesh Sugathadasa Page 9 Diagnosis Dry mouth Reduced salivary flow (measured by sialometry) with dry eyes (measured by Schirmer test) Biopsy of labial salivary glands (> 1 focus of lymphocytes in 4 mm2 Laboratory test ANA, ENA ,SS-A and SS-B No Yes Sicca syndrome and Positive Negative Sjögren’s syndrome Others, autoimmune diseases associates No Yes 2ry SS If biopsy of labial salivary glands – positive(> 1 focus of lymphocytes in 4 mm2) review some months later syndrome and ask for laboratory test in a Consider an incomplete form of Sjogren’s Primary SS
  11. 11. Thilanka Umesh Sugathadasa Page 10 Diagnostic criteria (American-European) for Sjögren’s syndrome. I Ocular symptoms A positive response to at least one of the following questions: (1) Have you had daily ocular symptoms or persistent, troublesome dry eyes For more than three months? (2) Do you have a recurrent sensation of sand or gravel in the eyes? (3) Do you use tear substitutes more than 3 times a day? II Oral symptoms A positive response to at least one of the following questions (1) Have you had a daily feeling of dry mouth for more than 3 months? (2) Have you had recurrently or persistently swollen salivary glands as an adult? (3) Do you frequently drink liquids to aid in swallowing dry food? III Ocular signs That is, objective evidence of ocular involvement defined as a positive result for at least one of: In minor salivary glands (obtained through normal-appearing mucosa). (1) Schirmer test, performed without anesthesia (< 5 mm in 5 minutes). (2) Rose-Bengal score or other ocular dye score (> 4 according to van Bijsterveld’s scoring system). Focal lymphocytic sialadenitis evaluated by an expert histopathologist, with a focus score > 1, defined as a number of lymphocytic foci (which are adjacent to normal-appearing mucous acini and contain more than 50 lymphocytes) per 4 mm2 of glandular tissue. IV Histopathology V Salivary gland Involvement Objective evidence of salivary gland involvement, defined by a positive result for one of the following: (1) Unstimulated whole salivary flow ≤ 1.5 ml in 15 minutes. (2) Parotid sialography showing the presence of ductal sialectasis (punctate, cavitary or destructive pattern) without evidence of obstruction in the major ducts. (3) Salivary scintigraphy showing delayed uptake, reduced concentration and/or delayed excretion of tracer. VI Autoantibodies Presence in the serum of the following autoantibodies: Antibodies to Ro (SS-A) or La (SS-B) antigens, or both
  12. 12. Thilanka Umesh Sugathadasa Page 11 For the diagnosis of primary SS: In patients without any potentially associated disease, primary SS may be defined as follows:  The presence of any 4 of the 6 items is indicative of primary SS, as long as either item IV (histopathology) or VI (serology) is positive  The presence of any 3 of the 4 objective criteria items (that, is items III, IV, V, VI)  The classification tree procedure represents a valid alternative method of classification, although it should be more properly used in clinical “epidemiological survey For the diagnosis of secondary SS:  In patients with a potentially associated disease (for instance, another well-defined connective tissue disease), the presence of item I or item II plus any 2 from among items III, IV, and V may be considered as indicative of secondary SS Exclusion criteria: 1. Past head and neck radiation treatment 2. Hepatitis C infection 3. Acquired immunodeficiency disease (AIDS) 4. Pre-existing lymphoma 5. Sarcoidosis 6. Graft versus host disease 7. Use of anticholinergic drugs (since a time shorter than 3-fold the half-life of the drug).
  13. 13. Thilanka Umesh Sugathadasa Page 12 Obstructive disorders Condition Features & etiology Clinical features/ Ix & Diagnosis Sialolithiasis(S alivary gland calculi or stones)  Calculi composed of laminated layers of organic materials covered with concentric shells of calcified materials.  Mainly hydroxyapatite crystals containing octacalcium phosphate.  Etiology & pathogenesis Nuerohumoral mechanisms Metabolic mechanisms(eg: presence of existing inflammation)  Common in the submandibular glands(80%) 10% in the parotid gland.  Reasons for higher prevalence of sialoliths in the SMG Physiological factors - Saliva more alkaline - Presence higher conc of Calcium & Phosphate - Higher mucus content - Richness in phosphatase enzyme. - Low content of Co2 Anatomical factors - Longer duct - anti gravity flow(position of the gland) - Smaller orifice than the ductal luman. - Irregular course of duct.  Middle aged people with slight male predilection  Size can vary from few mm to several cm.  Intraglandular sialoliths cause less problems to the patients than extraglandular/ ductal sialoliths.  Symptoms - Sometimes there are no any symptoms - Meal time swelling (due to increase demands) - Moderate pain(due to increase pressure) - fever & malaise due to infections (If untreated)  Signs - Pus discharge through the orifice - Severe inflammation in the soft tissues. - Overlying mucosa may be ulcerated. - Sialoliths may be palpated if it presents in the extraglandular portion. - Reduce salivary flow - Enlargement of the glands.  Radiological features - Radiolucent calculi(Here 80-90% of SMG calculi are radio-opaque & 50-80% of parotid calculi are radiolucent.) - Solitary or Multiple(30% of the SMG stones are multiple & 60% of the parotid stones are multiple) - Usually oval shape & is cylindrical with multiple layers of calcifications.  Sialography is indicated when sialoliths are radiolucent, Here we can see easily the ductal dilatation & the sialodochitis.  Radiological DD - Hyoid bone - Myositis ossificans - Phleboliths - Calcific submandibular lymph nodes - Gas bubble in sialography  Plain radiographic views Parotid - DPT - Oblique lateral/ Rotated PA or AP Intraoral view of the cheek to show the duct using an occlusal radiographs SMG -DPT/ Oblique lateral - Lower 900 occlusal - Lower oblique occlusal(to show the gland)
  14. 14. Thilanka Umesh Sugathadasa Page 13 Diagram of submandibular sialogram. The subsidiary duct descending from the angle of the jaw to join the angle of the main duct is very constant. Sialolithiasis. Diagram of parotid sialogram. There are usually three ascending ducts as well as the duct of the socia, if present, and one or two descending ducts depending on the size of the gland. Several small retromandibular ducts drain the deep, part of the gland. Sialolithiasis. Sialadenitis showing pus from Stensen duct . Dormaia basket Tiny apparatus consisting of four wires that can be advanced through an endoscope to the body cavity or tube, manipulated to trap a calculus or other object,& withdrawn Used in the bile duct & the ureter
  15. 15. Thilanka Umesh Sugathadasa Page 14 Management of the sialolithiasis Traditional Mx of the sialolithiasis Non-surgical Mx of the sialolithiasis  Ductal dilatation  Incision & dissection  Sialadenectomy(Do when the gland has fibrosed) Side effects of the sialoendoscopy 1. Transient glandular swelling 2. Ductal strictures 3. Lacerations 4. Basket block 5. Infections 6. Temporary parasthesia 7. Bleeding 8. Ranula formation  Interventional radiology Various techniques are using - coronary angioplasty balloon - Wire loop - Embolectomy catheter Under fluoroscopy guidance Best method is the fluoroscopically guided stone retrieval (success rate 40-100%) Main complications are Gland swelling Infections Main limitation is the administration of ionizing radiation.  Antibiotics if acute infection is present  Increase salivation & allow stone to come out through orifice.  Manual manipulation(milking) E/O & I/O palpation behind the calculi in to the orifice.  Lithotripsy(shock wave)- sialolithotripsy - Introduced in 1989 - Noninvasive method of fragmenting the stones in to smaller portions to allow possible flushing out spontaneously. - stone fracture by producing a compressive wave that spread through calculus & expansive wave that pit stone & induce cavitations - shock wave can be generated Extra-corporeally using piezoelectric or electromagnetic techniques Intra-corporeally using electro-hydrolic, pneumatic or laser endoscopic techniques  Sialoendoscopy - First used to diagnosis but now also used for the calculi removal. - First describe in 1991 - Rigid, semi rigid, or moderately flexible endoscopes presents with different diametres. - Equipped with working channels & irrigation ports - Main problem is the entering through orifice - this problems are overcome by Dilatation with lacrimal probes/ guiding wires Papillotomy with CO2 laser Microsurgical dissection of anterior duct(ductal cut down) Graspers, miniforceps, dormaia baskets & balloons to remove stone - Not indicated if the calculi is located deeply inside the gland or embedded in wall. - Success rate is around 89% for submandibular & 83-86% for parotid calculi - Also effective in removing mucus plugs, foreign bodies, polyps & granulation tissue. - Contraindicated if there is complete distal obliteration of duct. - insertion of the sialostent averts recurrences
  16. 16. Thilanka Umesh Sugathadasa Page 15 Infective conditions Condition Features & etiology Mx & Diagnosis Acute bacterial sialadenitis(Ascen ding)  Definition Sialadenitis due to bacterial infection ascending from the oral cavity.  Prevalence (approximate): Rare.  Age mainly affected: Older adults.  Gender mainly affected: M = F.  Etiopathogenesis: The organisms most. commonly isolated in ascending sialadenitis are Streptococcus viridans and Staphylococcus aureus (often penicillin-resistant). The parotid glands are most commonly affected  Causes Host factors - Decreased host resistance - salivary secretion & bacterial effects - Composition of the saliva - Calculi, Mucus plugs, duct strictures Other predisposing factors - After radiotherapy to the head & neck. - In Sjogren’s syndrome - Occasionally in the GI surgery due to dehydration & dry mouth.  Clinical features Symptoms - Painful & tender enlargement in the gland -Trismus - Pain in TMJ region. -Fever - Taste disturbances Signs - The overlying skin can be redded. - Pus exuding from, or in milked form through the parotid duct orifice - Become hot, indurated & tender on percussion. - Can spread to the surrounding tissues also. - Leucocytosis - Malaise  Diagnosis Pus should be sent for a culture & ABST  DD Parotitis/ Submasseteric abcess Deep parotid abcess vs Otitis media  Mx - Must treat aggressively as it can cause death in debilitated patient, even with antibiotics - Improvement of oral hygiene - Pus for culture & ABST - High dose of parental antibiotics against staphylococcus. (flucloxacillin or amoxicillin/ clavulanate if staphylococcus and not allergic to penicillin; erythromycin or azithromycin in penicillin allergy).) - Improve hydration - Maintain electrolyte balance. - Analgesics. - soft diet as chewing is painful to the patient. - Stimulate salivation to facilitate drainage of pus - If there is no improvement drainage of the affected gland. - Lemon juice suction for promote salivary flow.
  17. 17. Thilanka Umesh Sugathadasa Page 16 Chronic bacterial sialadenitis  Definition: Chronic salivary gland infection.  Prevalence (approximate): Rare.  Age mainly affected: Older adults.  Gender mainly affected: M = F.  Etiopathogenesis: May develop after salivary calculus formation or acute sialadenitis, particularly if inappropriate antibiotics are used, or predisposing factors not eliminated. Serous acini atrophy when salivary outflow is chronically obstructed, further reducing saliva secretion.  Usually caused by streptococcus viridans  Recurrent forms are due to duct obstruction, congenital stenosis, Sjogren’s syndrome,Allergy or previous viral infection  Salivary flow is accompanied by the flecks of purulent material  Fibrosis of gland after several recurrences causing reduced salivary flow  Clinical features -Single, swollen, firm , non-tender salivary gland  Differential diagnosis: Calculus, neoplasm.  Diagnosis is from clinical features, and imaging (radiography, MRI, ultrasonography).  Mx - Intraductal injection of antibiotics - Ligation of duct to induce fibrosis. - Radiotherapy to induce fibrosis but this increase the risk of head & neck cancers. - Total removal of the gland Radiological features - Multiple ectasias & dilatations of main excretory duct in sialogram - Multiple cavitations in the USS Juvenile recurrent parotitis  Definition Repeated parotitis &sialectasis in a child, associated with a sialographic pattern of sialectasis  Prevalence (approximate): Uncommon.  Age mainly affected: Usually begins in pre- school children.  Gender mainly affected: M > F.  Etiopathogenesis: Congenital or autoimmune duct defects.  Symptoms - Intermittent pain, - Unilateral parotid swelling which lasts < 3weeks with spontaneous regression. - It may occur simultaneously or alternately contra- laterally. - fever  Signs - parotid swelling  DD Sjorgren’s syndrome  Diagnosis is mainly on clinical grounds but serum anti-SS-A and SS-B antibodies are indicated to exclude Sjögren's syndrome, and imaging with ultrasonography and CT scan or sialography showing sialectasis is confirmatory  Mx  In- patients hospital admission if condition warrants  Culture & ABST(from salivary exudate)  Appropriate antibiotics.  High fluid intake.  Lemon juice suction to promote salivary flow
  18. 18. Thilanka Umesh Sugathadasa Page 17 Chronic sclerosing sialadenitis(Kuttn er’s tumor)  Commonly seen in SMG  Is a chronic inflammatory disease of major salivary glands causing fibrosis & firm tumor like enlargement of the gland.  Due to ductal calculi causing subsequent bacterial infection resulting chronic inflammation, acinar destruction & replacement fibrosis.  Radiological features - Multiple globular sialectasias in sialogram. - Sialodochitis (sausage like appearance of ducts) in sialogram. - Absence of terminal branches & presence of constricted ductal lumens. - Multiple cavitations with reduced echogenicity in USS. Granulomatous diseases of salivary glands(Chronic specific sialadenitis)  Main one is Sarcoidosis which produce Heerfordt’s syndrome  Features of the Heerfordt’s syndrome are - Uveitis of the eye - Salivary gland swelling - Facial palsy Mumps  This is the most commonest & important condition.  Acute contagious viral infection  Characterized by bilateral/ unilateral gland enlargement.  Mainly affects the major salivary glands but also can affects testis, meninges, pancreas, heart & mammary glands.  Also called endemic parotitis  Caused by paramyxovirus  Endemic in most urban population  Airborne infection  Clinical features - more common in boys & often between 5-15 years of age. - Incubation period is 2-3 weeks - Prodromal symptoms(Onset of headache, chills, moderate fever, vomiting, pain below ear & last about 1 week) - Parotids are usually affected & mostly bilateral. - SMG is less commonly involved & when affected have less swelling & pain.  Symptoms – Prodromal symptoms followed by sudden onset of painful salivary gland swelling without purulent discharge from duct.  Signs- Elevation of ear lobe, Firm/ rubbery/ elastic gland enlargement., Puffy & reddened papilla.  No antiviral therapy or antibiotics advocated.  Bed rest & isolation  Hydration with plenty of fluid intake.  NSAIDs(ibuprofen) for children’s: Ibuprofen syrup 100mg/5ml
  19. 19. Thilanka Umesh Sugathadasa Page 18 Asymptomatic enlargement (Sialosis/ Sialadenosis)  Non- neoplastic, non- inflammatory enlargement of the salivary glands  Usually bilateral & may presents as recurrent painless enlargements.  Commonly in parotids in males.  Associated with systemic conditions such as cirrhosis, diabetes, thyroid insufficiency, alcoholism & malnutrition  Alteration occurs in the chemical composition of saliva.  Significant elevation of salivary potassium & decrease in sodium. Sialorrhea (Ptyalism)  Increase salivary secretions occurs.  2 types - True Sialorrhea: Rare, may be due to rabies, metal poisoning, inflammatory lesion in the mouth - Pseudo Sialorrhea: Common in infants(drooling), Neuromuscular problems, Down’s syndrome, paralysis, Mental handicaps  Etiology - Drugs - Local factors such as stomatitis, erythema multeforme & ANUG - Systemic disease such as rabies, paralysis, alcoholic neuritis, epilepsy, Down’s syndrome, Neuromuscular disorder - Miscellaneous causes such as psychic factors, metal poisoning & facial paralysis  Clinical features - Excessive production or inadequate swallowing due to neuromuscular in- coordination. - Affected individuals may need several cloths - Emotional & physical impairment. - Infections due to chronic exposure to saliva - Ulceration & cheek scarring due to recurrent infections & necrosis of tissues.  Botulinum toxin injection is an effective method  Cause selective chemical denervation by blocking neurotransmitter release at the cholinergic parasympathetic nerve terminals of the salivary glands. So secretory capacity of the gland is reduced.  Botulinum toxin therapy is also used to treat sialocele & chronic & recurrent parotitis. Diseases of minor salivary glands  Mucocele  Nicotinic Stomatitis  Necrotizing sialometaplasia  Neoplasms
  20. 20. Thilanka Umesh Sugathadasa Page 19 Tree in winter appearance(normal appearance of the parotid gland)
  21. 21. Thilanka Umesh Sugathadasa Page 20 Brush in winter appearance (SMG) Sjorgren’s syndrome Sialadenitis Sialadochitis(Sausage link appearance)
  22. 22. Thilanka Umesh Sugathadasa Page 21