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Non specific disease of parotid

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1 Non specific disease of parotid
Babak Saedi.MD Tehran university of Medical sciences Imam Khomeini Hospital

2 Anatomy & Physiology Parotid Sublingual Submandibular
Serous Sublingual Mucous Submandibular Mixed Minor salivary glands Controlled by sympathetic & parasympathetic

Non-Neoplastic Disease Benign Tumors Malignant Tumors Acute & Chronic Non-Autoimmune Autoimmune Sialadenitis Necrotizing Sialametaplasia Sialadenosis Salivary Lymphoepithelial Cysts Pleomorphic Adenomas Adenoid Cystic Carcinoma Basal Cell Adenomas Mucoepidermoid Carcinoma Myoepitheliomas Warthin’s Tumor Oncocytoma and Oncocytosis Sclerosing Polycystic Adenosis

4 Sialadenosis Non-specific term used to describe a non-inflammatory non-neoplastic enlargement of a salivary gland, usually the parotid. May be called sialosis The enlargement is generally asymptomatic Mechanism is unknown in many cases.

5 Sialadenosis (Sialosis)
Parotid glands most commonly. Probably due to abnormalities of neurosecretory control.

6 Sialadenosis (Sialosis)
Cause maybe due to: Nutritional (Alcoholism, Cirrhosis, Kwashiorkor and Pellagra Endocrine (Diabetes, Thyroid diasease, Gonadal dysfunction) Neurochemical (Vegetative state, Lead, Mercury, Iodine, Thiouracil)

7 Related to… Metabolic “endocrine sialendosis”
Nutritional “nutritional mumps” Obesity: secondary to fatty hypertrophy Malnutrition: acinar hypertrhophy Any condition that interferes with the absorption of nutrients (celiac dz, uremia, chronic pancreatitis, etc)

8 Related to… Alcoholic cirrhosis: likely based on protein deficiency & resultant acinar hypertrophy Drug induced: iodine mumps e. HIV

9 Sialadenosis (Sialosis)
Histopathology: Hypertrophy of serous acinar cells to about twice their normal size. Cytoplasm is densely packed with secretory granules.

10 Allergic sialadenitis
Caused by drugs or allergens Clinical presentation: Acute salivary gland enlargement Itching over the gland With/without rash Treatment Self-limiting Avoid allergen hydration

11 Salivary gland

12 Obstructive Salivary Gland Disorders
Sialolithiasis Mucous retention/extravasation Obstructive Salivary Gland Disorders  

13 Mucocele9 Mucus is the exclusive secretory product of the accessory minor salivary glands and the most prominent product of the sublingual gland. The mechanism for mucus cavity development is extravasation or retention

14 Etiology Clinical appearance Ranula
Mucoceles & Ranula Etiology Trauma  extravasation labial mucosa Obstruction  retention  palate & floor of mouth Clinical appearance Ranula extravasation / retention in floor of mouth Obstruction of Sublingual salivary gland duct Usually unilateral

15 Mucocele Mucoceles, exclusive of the irritation fibroma, are most common of the benign soft tissue masses in the oral cavity. Muco: mucus , coele: cavity. When in the oral floor, they are called ranula.

16 Mucocele9 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

17 Mucocele Consist of a circumscribed cavity in the connective tissue and submucosa producing an obvious elevation in the mucosa

18 Mucocele The majority of the mucoceles result from an extravasation of fluid into the surrounding tissue after traumatic break in the continuity of their ducts. Lacks a true epithelial lining.

19 Ranula9 Is a term used for mucoceles that occur in the floor of the mouth. The name is derived form the word rana, because the swelling may resemble the translucent underbelly of the frog.

20 Ranula9 Although the source is usually the sublingual gland,
may also arise from the submandibular duct or possibly the minor salivary glands in the floor of the mouth.

21 Ranula Presents as a blue dome shaped swelling in the floor of mouth (FOM). They tend to be larger than mucoceles & can fill the FOM & elevate tongue. Located lateral to the midline, helping to distinguish it from a midline dermoid cyst.

22 Plunging or Cervical Ranula
Occurs when spilled mucin dissects through the mylohyoid muscle and produces swelling in the neck. Concomitant FOM swelling may or may not be visible.

23 Treatment of Mucoceles9 in Lip or Buccal mucosa
Excision with strict removal of any projecting peripheral salivary glands Avoid injury to other glands during primary wound closure

24 Ranula Treatment9 Marsupialization has fallen into disfavor due to the excessive recurrence rate of 60-90% Sublingual gland removal via intraoral approach

25 Salivary gland

26 Immunologic Disease Sjögren’s Syndrome7
Most common immunologic disorder associated with salivary gland disease. Characterized by a lymphocyte-mediated destruction of the exocrine glands leading to xerostomia and keratoconjunctivitis sicca

27 Sjögren’s syndrome7 90% cases occur in women
Average age of onset is 50y Classic monograph on thediease published in 1933 by Sjögren, a Swedish ophthalmologist

28 SJOGREN’s SYNDROME All the above conditions plus; Dry eyes Generalized arthritis

29 Primary SS - Clinical picture
Mostly parotid gland is affected Persistent / intermittent gland enlargement bilateral, non-tender, firm, and diffuse swelling  saliva and altered saliva composition Check of any recent changes to the character of the glands (nodularity) significantly increased risk of developing B-cell lymphoma Keratoconjunctivitis sicca

30 Secondary SS - Clinical picture
Dryness of the skin & pruritis Dry and persistent cough >50% have arthralgia with or without arthritis Dysphagia, nausea, dyspepsia, and epigastric pain Peripheral & cranial neuropathy

31 Sjögren syndrome - Diagnosis
Different diagnostic criteria Objective measurement of decreased salivary & lacrimal gland function +ve autoimmune serologies Minor salivary gland biopsy Lymphocytic infiltration Silagoraphy is also useful

32 Sjögren’s Syndrome 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 finding is lacrimation of 5mm or less. Approximately 85% specific & sensitive

33 Sjögren’s Lip Biopsy15 Biopsy of SG mainly used to aid in the diagnosis Can also be helpful to confirm sarcoidosis

34 Sjögren’s Lip Biopsy15 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

35 Sjögren syndrome - Treatment
Symptomatic Systemic cholinergic (Pilocarpine) 5mg TID/QID (should not exceed 30mg/day) Follow up

36 Sjögren’s Treatment15 Avoid xerostomic meds if possible
Avoid alcohol, tobacco (accentuates xerostomia) Sialogogue (eg:pilocarpine) use is limited by other cholinergic effects like bradycardia & lacrimation Sugar free gum or diabetic confectionary Salivary substitutes/sprays

37 MICKULICZ’s SYNDROME 1) Symmetrical enlargement of salivary glands 2) Enlargement of the lachrymal glands 3) Dry mouth

38 Radiation induced pathology
Permanent salivary damage caused by doses 50Gy Radioactive iodine for thyroid cancer treatment has similar but less severe effect Clinical presentation Salivary gland dysfunction signs & symptoms Osteonecrosis Increased risk of tumors affecting radiated tissues

39 Management steps for patients with radiation-induced xerostomia

40 Radiation Injury7 Low dose radiation (1000cGy) to a salivary gland causes an acute tender and painful swelling within 24hrs. Serous cells are especially sensitive and exhibit marked degranulation and disruption.

41 Continued irradiation leads to complete destruction of the serous acini and subsequent atrophy of the gland7. Similar to the thyroid, salivary neoplasm are increased in incidence after radiation exposure7.

42 Granulomatous Disease7
Primary Tuberculosis of the salivary glands: Uncommon, usually unilateral, parotid most common affected Believed to arise from spread of a focus of infection in tonsils Secondary TB may also involve the salivary glands but tends to involve the SMG and is associated with active pulmonary TB.

43 6- Granulomatous conditions
Tuberculosis Granulation tissue formation in salivary gland Xerostomia Salivary gland enlargement Sarcoidosis Granulomas (T lymphocytes) affecting several organs Lungs Skin Eyes Parotid glands Severity and duration of disease varies Mild improvement noticed with steroid therapy

44 Granulomatous conditions
Tuberculosis Granulation tissue formation in salivary gland Xerostomia Salivary gland enlargement Sarcoidosis Granulomas (T lymphocytes) affecting several organs Lungs Skin Eyes Parotid glands Severity and duration of disease varies Mild improvement noticed with steroid therapy

45 Granulomatous Disease7
Sarcoidosis: a systemic disease characterized by noncaseating granulomas in multiple organ systems Clinically, SG involvement in 6% cases Heerfordts’s disease is a particular form of sarcoid characterized by uveitis, parotid enlargement and facial paralysis. Usually seen in 20-30’s. Facial paralysis transient.

46 Granulomatous Disease7
Cat Scratch Disease: Does not involve the salivary glands directly, but involves the periparotid and submandibular triangle lymph nodes May involve SG by contiguous spread. Bacteria is Bartonella Henselae(G-R) Also, toxoplasmosis and actinomycosis.

47 Cysts7 True cysts of the parotid account for 2-5% of all parotid lesions May be acquired or congenital Type 1 Branchial arch cysts are a duplication anomaly of the membranous external auditory canal (EAC) Type 2 cysts are a duplication anomaly of the membranous and cartilaginous EAC

48 Cysts Acquired cysts include: Mucus extravasation vs. retention
Traumatic Benign epithelial lesions HIV Association with tumors Pleomorphic adenoma Adenoid Cystic Carcinoma Mucoepidermoid Carcinoma Warthin’s Tumor

49 Other: Pneumoparotitis
In the absence of gas-producing bacterial parotitis, gas in the parotid duct or gland is assumed to be due to the reflux of pressurized air from the mouth into Stensen’s duct. May occur with episodes of increased intrabuccal pressure Glass blowers, trumpet players Aka: pneumosialadenitis, wind parotitis, pneumatocele glandulae parotis

50 Pneumoparotitis8 Crepitation, on palpation of the gland
Swelling may resolve in minutes to hours, in some cases, days. US and CT show air in the duct and gland Consider antibiotics to prevent superimposed infection

51 Necrotizing sialometaplasia
Benign self-limiting reactive inflammatory disorder Etiology Unknown Trauma (LA) Clinical presentation Red nodule Deep ulcer with rolled margin Necrosis Moderate dull pain 6-8 weeks Treatment

52 Other: Necrotizing Sialometaplasia
Cryptogenic origin, possibly a reaction to ischemia or injury Manifests as mucosal ulceration, most commonly found on hard palate. May have prodrome of swelling or feeling of “fullness” in some. Pain is not a common complaint

53 Necrotizing Sialometaplasia
Self limiting lesion, heals by secondary intention over 6-8 weeks Histologically may be mistaken for SCC

54 Importance of saliva Oral hygiene Taste acuity Mastication Deglutition
Digestion Voice acuity Speech articulation

55 Xerostomia 22 – 26% of total population
Occurs most common among elderly Associated with immunotherapy, radiotherapy Treatment Stringent oral and dental care Radiation therapy protectants Gene therapy Pharmacologic options

56 Diagnostic approach 1- evaluation of dry mouth
Symptoms of salivary gland dysfunction Dryness of all oral mucosal surfaces Difficulty chewing, speaking Increased sensitivity to spicy food Increased caries activity

57 Diagnostic approach 2- Past & present medical history
Radiotherapy Dryness at other body sites (eye, nose, skin) Medication Tricyclic antidepressant Antihypertensive Antihistamines Decongestants

58 Diagnostic approach 3- Clinical examination
Intra-Oral examination Notice signs of salivary gland dysfunction Red depapillated tongue Oral mucosa adhere to mirror Lipstick/food debris on anterior teeth Candidaiasis Increase caries & erosion If could detect mass Any mucosal ulcerations over the mass Milking of saliva

59 Diagnostic approach 3- Clinical examination
Extra-Oral examination Palpate cervical lymph nodes Palpate the gland Slightly rubbery Painless unless infected/inflamed Check motor function of facial nerve

60 Diagnostic approach 4- Saliva collection
Different methods to determine salivary flow rate Salivary flow rate fluctuate Abnormal low salivary flow rate Unstimulated whole saliva flow rate <0.1ml/min Stimulated whole saliva flow rate <1.0ml/min

61 Treatment of Xerostomia
Preventive therapy Florid rinses & gel Oral hygiene Symptomatic treatment Water Artificial saliva Avoid products containing sugar, alcohol Salivary stimulation Local / topical stimulation Chewing (flavoured) Systemic stimulation (sialogogues) Pilocrpine HCl

62 Frey’s Syndrome Etiologies: Trauma to parotid regions a. Parotidectomy
b. Penetrating trauma c. Closed mandibular fractures Trauma to cervical sympathetic chain Diabetic neuropathy Aberrant regeneration location a. CP angle b. Middle ear c. OTIC Ganglions

63 Treatment of Freys Syndrome
External radiotherapy Local or systemic applications of anticholinergic drugs Section of some portion of efferent arc Interposition of subcutaneous barrier Botox injection

64 Sialorrhea Causes: Change in oral perception Decrease swallowing
Neurologic changes (CVA, Parkinson’s) Extensive oral surgical procedure Decrease swallowing Treatment: Speech pathologist Xerostimia inducing drugs (antihistamine) Botulinum toxins (Botox injection) Surgery

65 Age Changes in Salivary Glands
Reduction in weight of parotid and submandibular glands related to atrophy of secretory tissue & replacement by fibrofatty tissue. Similar changes in labial minor glands. Oncocytic change in ductal epithelium. Reduction in flow rate in submandibular gland.

66 References McQuone, SJ: Acute viral and bacterial infections of the salivary glands. Oto Clinics North America, 32:793,1999 Marchal F, Dulguerov P. Sialolithiasis Management. Arch Oto, 129:951, 2003 Escudier MP, McGurk M. Symptomatic sialodenitiis and sialolithiasis in the english population:an estimate of the cost of hospital treatment. Br Dent J. 1999;186:463 Lustmann J, Regev E, Melamed Y. Sialolithiasis: a survey on 245 patients and a review of the literature. Int J Oral Maxillofacial. 1990; 19, 135 Crabtree GM, Yartington CT. Submandibular gland excision. Laryngoscope. 1988;98:1044

67 Sialadenitis Treatment:
The first step is to make sure about fluid balance. Patient needs to receive fluids intravenously Antibiotics to destroy the bacteria. Sugarless sour candies or gum is recommend ,they can stimulate the glands to produce more saliva. If the infection is not improving, surgery may be needed to open and drain the gland. Prevention: Always drink plenty of fluids. This is especially important after surgery, during illness or in elderly people

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