1. SALIVARY GLAND DISEASES
Prof. Dr. İlhan TOPALOĞLU

2. Learning goal and objectives of the lesson
Learning goal of the lesson: The learner should know the main clinical features and investigation of salivary gland disorders
Learning objectives of the lesson the learner will be able to:
identify the most common etiologies of salivary masses based on history and physical exam
develop a clear concinse algorithm for use of diagnostic tests evaluation of salivary masses
describe available therapeutic options for malignant salivary gland masses
Understand how to approach the patient with “ a lump in the parotis or submandibular gland.
Skill objectives of the lesson the learner will be able to take a directed history and perform a physical exam on a patient with salivary gland masses.

3. Introduction
Salivary gland is any cell or organ discharging a secretion into oral cavity
Major (paired)
Parotid (Stensen’s duct)
Submandibular (wharton’s duct
Sublingual
Minor
Those in tongue, palatine tonsil, palate, lips and cheeks

4. Nonneoplastic Diseases of the Salivary Glands

5. Mumps Most common viral disorder of salivary glands Peak age 4-6
Prodrome period is 2-3 weeks
1 or both parotid glandes can be involved
Contagious from approximately 6 days before the onset of symptoms until about 9 days after symptoms start
Diagnosis: diagnosed on clinical grounds
Serum amylase is often elevated

6. Mumps

7. Complications: deafness, pancreatitis, meningitis, encephalitis, orchitis or epididymitis, Oophoritis (inflammation of ovaries)
Deafness generally unilateral rarely bilateral
Profound (91 dB or more) sensorineural hearing loss
Acute unilateral deafness occurs in about 0.005% of cases

8. No specific treatment
Paracetamol for pain relief
Warm saltwater gargles, soft foods, and extra fluids may also help relieve symptoms
Self-limiting, and general outcome is good
Most common preventative measure against mumps is a vaccination with a mumps vaccine

9. Other Viruses
CMV, Coxsackievirus A, Echovirus, Influenza A, Lymphocytic choriomeningitis Virus
Treatment: symptomatic for all viral diseases

10. Acute bacterial parotitis
most often caused by a bacterial infection of Staphylococcus aureus but may be caused by any commensal bacteria
Peak age 50’s-60’s
30-40% in post-op patients; most commonly gastrointestinal procedures

12. Presentation: sudden, diffuse enlargement with associated induration and tenderness. Massage produces purulent saliva
20% of cases bilateral
Treatment: hydration, improved oral hygiene, repeated massage of gland, IV antibiotics, warm compresses, sialogogues
If no significant improvement in 24-48h, then proceed to incision & drainage OR image-guided needle aspiration

13. Chronic Nonspecific Sialadenitis
Most commonly parotid
Usually from permanent damage during acute infection; occasionally from recurrent parotitis of childhood

14. Treatment
1) Underlying causes
2) Sialogogues, massage, heat, hydration, antibiotics during acute attacks
3) Periodic ductal dilatation, duct ligation,
4) Excision

15. Recurrent Parotitis of Childhood
More common in males; peak age 5-7
¾ give role of Mumps; heredity plays no role
Presentation: Usually unilateral; when bilateral, one side worse
Severe pain, fever, malaise during attacks
Recurs
55% of cases resolve with puberty
25% no improvement with puberty

16. Primary Tuberculosis Presentation: Unilateral parotid
May present as acute inflammatory lesion or as chronic tumorous lesion
Diagnosis: AFB (acid-fast bacilli) stain of saliva and PPD test
FNA (fine needle aspiration) if tumorous lesion
Treatment: Anti-TB meds; excision if resistant
Secondary TB: systemic dz.; submandibular and sublingual glands more often involved

17. Actinomycosis
Infectious bacterial disease caused by Actinomyces species
Dental work, poor oral hygiene, periodontal disease, or radiation therapy causing local tissue damage to the oral mucosa
Presentation: 61% visible sinus tracts; 40% adenopathy; some have purplish skin discoloration
Diagnosis: culture Histology sulfur granules
Treatment: Actinomyces bacteria are generally sensitive to penicillin

18. Sarcoidosis
Parotid enlargement is a classic feature of sarcoidosis, but clinically apparent parotid involvement occurs in less than 10% of patients.
Bilateral involvement is the rule.
The gland is usually not tender, but firm and smooth.
Xerostomia can occur
Other exocrine glands are affected only rarely

19. Heerfordt’s syndrome (Uveoparotid fever):
1) Parotid enlargement
2) Uveitis
3) Fever
4) CN VII paralysis

20. Sjogren’s Syndrome: Sjögren syndrome also known as "Sicca syndrome"
Systemic autoimmune disease in which immune cells attack and destroy the exocrine glands that produce tears and saliva
Chronic, slowly progressive, benign; 2nd most common autoimmune disease behind Rheumatoid arthritis

21. Although Sjögren's occurs in all age groups in both women and men
Nine out of ten Sjögren's patients are women
Average age of onset is after menopause in women

22. Presentation
Other exocrine gland involvement: dry nose, dry throat, xerotrachea, esophageal mucosal atrophy, atrophic gastritis, subclinical pancreatitis, vaginal dryness
1/3 = fatigue, low grade fever, myalgias/arthralgias
Extraglandular involvement in ¼: Lungs, kidneys, vasculitis, nervous system

23. Associated risks Increased risk of 1) NonHodgkin’s Lymphoma
2) Multiple Myeloma

24. Mikulicz disease:
Antiquated name for any enlargement of the parotid gland that was not tuberculosis, leukemia, or some other identifiable disease.

25. Sialadenosis (sialosis)
In this disorder, both parotid glands may be diffusely enlarged with only modest symptoms
Patients are aged 20–60 years at onset, and the sexes are equally involved
The glands are soft and non-tender.

26. Sialolithiasis
Formation of stones in the salivary glands
80% submandibular gland, 20% parotid
Only 1 stone in ¾ cases
Presentation: recurrent swelling, pain worse with eating
Complications: sialadenitis, ductal ectasia, and stricture

27. Diagnosis is usually made by characteristic history and physical examination
Diagnosis can be confirmed by x-ray (80% of salivary gland calculi are visible on x-ray), or by sialogram or ultrasound.
90% of submandibular stones radioopaque; 90% of parotid stones radiolucent
Treatment: If near duct orifice, transoral removal of stone with marsupialization
If near hilum, gland excision

28. Cysts Mucoceles vs. Mucous cysts: minor salivary glands
2-5% of all parotid lesions
Congenital: dermoid cysts, ductal cysts, 1st arch branchial cleft cysts
Acquired: trauma, parotitis, calculi, neoplasms

29. Neoplastic Diseases of the Salivary Glands

30. Salivary Gland Neoplasms
Benign Neoplasms
Pleomorphic Adenoma
Warthin’s Tumor
Oncocytoma
Monomorphic Adenomas
Myoepithelioma
Malignant Neoplasms
Mucoepidermoid Carcinoma
Adenoid Cystic Carcinoma
Acinic Cell Carcinoma
Adenocarcinoma
Malignant Mixed Tumor
Squamous Cell Carcinoma
Clear Cell Carcinoma
Epithelial-Myoepithelial Carcinoma

31. Salivary Gland Neoplasms
Diverse histopathology
Relatively uncommon
2% of head and neck neoplasms
Distribution
Parotid: 80% overall; 80% benign
Submandibular: 15% overall; 50% benign
Sublingual/Minor: 5% overall; 40% benign

32. Pleomorphic Adenoma 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

33. Pleomorphic Adenoma Slow-growing, painless mass
Parotid: 90% in superficial lobe, most in tail of gland
Minor salivary gland: lateral palate, submucosal mass

34. Pleomorphic Adenoma Gross pathology Smooth Well-demarcated Solid
Cystic changes
Myxoid stroma

35. Pleomorphic Adenoma Treatment: complete surgical excision
Parotidectomy with facial nerve preservation
Submandibular gland excision
Wide local excision of minor salivary gland
Avoid enucleation and tumor spill

36. Warthin’s Tumor Papillary cystadenoma lymphomatosum
6-10% of parotid neoplasms
Older, caucasian, males
10% bilateral or multicentric
3% with associated neoplasms
Presentation: slow-growing, painless mass

37. Warthin’s Tumor Gross pathology Encapsulated Smooth/lobulated surface
Cystic spaces of variable size, with viscous fluid, shaggy epithelium
Solid areas with white nodules representing lymphoid follicles

38. Oncocytoma Rare: 2.3% of benign salivary tumors 6th decade M:F = 1:1
Parotid: 78%
Submandibular gland: 9%
Minor salivary glands: palate, buccal mucosa, tongue

39. Oncocytoma Presentation Technetium-99m pertechnetate scintigraphy
Enlarging, painless mass
Technetium-99m pertechnetate scintigraphy
Mitochondrial hyperplasia

40. Monomorphic Adenomas
Basal cell, canalicular, sebaceous, glycogen-rich, clear cell
Basal cell is most common: 1.8% of benign epithelial salivary gland neoplasms
6th decade
M:F = approximately 1:1
Caucasian > African American
Most common in parotid

41. Myoepithelioma <1% of all salivary neoplasms 3rd-6th decades F>M
Minor salivary glands > parotid > submandibular gland
Presentation: asymptomatic mass

42. 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

43. Mucoepidermoid Carcinoma
Presentation
Low-grade: slow growing, painless mass
High-grade: rapidly enlarging, +/- pain

44. Mucoepidermoid Carcinoma
Gross pathology
Well-circumscribed to partially encapsulated to unencapsulated
Solid tumor with cystic spaces

45. 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

46. Adenoid Cystic Carcinoma
Gross pathology
Well-circumscribed
Solid, rarely with cystic spaces
infiltrative

47. Adenoid Cystic Carcinoma
Histology—cribriform pattern
Most common
“swiss cheese” appearance

48. Adenoid Cystic Carcinoma
Treatment
Complete local excision
Tendency for perineural invasion: facial nerve sacrifice
Prognosis
Local recurrence: 42%
Distant metastasis: lung
Indolent course: 5-year survival 75%, 20-year survival 13%

49. Acinic Cell Carcinoma 2nd most common parotid and pediatric malignancy
5th decade
F>M
Bilateral parotid disease in 3%
Presentation
Solitary, slow-growing, often painless mass

50. Acinic Cell Carcinoma Treatment Prognosis Complete local excision
+/- postoperative XRT
Prognosis
5-year survival: 82%
10-year survival: 68%
25-year survival: 50%

51. Adenocarcinoma Rare 5th to 8th decades F > M Parotid and minor
salivary glands
Presentation:
Enlarging mass
25% with pain or facial weakness

52. Adenocarcinoma Treatment Prognosis Complete local excision
Neck dissection
Postoperative XRT
Prognosis
Local recurrence: 51%
Regional metastasis: 27%
Distant metastasis: 26%
15-year cure rate:
Stage I = 67%
Stage II = 35%
Stage III = 8%

53. Malignant Mixed Tumors
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

54. Carcinoma Ex-Pleomorphic Adenoma
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

55. Carcinoma Ex-Pleomorphic Adenoma
Gross pathology
Poorly circumscribed
Infiltrative
Hemorrhage and necrosis

56. Carcinoma Ex-Pleomorphic Adenoma
Treatment
Radical excision
Neck dissection (25% with lymph node involvement at presentation)
Postoperative XRT
Prognosis
Dependent upon stage and histology

57. Carcinosarcoma 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

58. Carcinosarcoma Gross pathology Poorly circumscribed Infiltrative
Cystic areas
Hemorrhage, necrosis
Calcification

59. Carcinosarcoma Treatment Prognosis Radical excision Neck dissection
Postoperative XRT
Chemotherapy (distant metastasis to lung, liver, bone, brain)
Prognosis
Poor, average survival less than 2 ½ years

60. Squamous Cell Carcinoma
1.6% of salivary gland neoplasms
7th-8th decades
M:F = 2:1
MUST RULE OUT:
High-grade mucoepidermoid carcinoma
Metastatic SCCA to intraglandular nodes
Direct extension of SCCA

61. Squamous Cell Carcinoma
Gross pathology
Unencapsulated
Ulcerated
fixed

62. Squamous Cell Carcinoma
Treatment
Radical excision
Neck dissection
Postoperative XRT
Prognosis
5-year survival: 24%
10-year survival: 18%

63. other
Clear Cell Carcinoma
Epithelial-Myoepithelial Carcinoma