4SialadenosisNon-specific term used to describe a non-inflammatory non-neoplastic enlargement of a salivary gland, usually the parotid.May be called sialosisThe enlargement is generally asymptomaticMechanism is unknown in many cases.
5Sialadenosis (Sialosis) Parotid glands most commonly.Probably due to abnormalities of neurosecretory control.
6Sialadenosis (Sialosis) Cause maybe due to:Nutritional (Alcoholism, Cirrhosis, Kwashiorkor and PellagraEndocrine (Diabetes, Thyroid diasease, Gonadal dysfunction)Neurochemical (Vegetative state, Lead, Mercury, Iodine, Thiouracil)
7Related to… Metabolic “endocrine sialendosis” Nutritional “nutritional mumps”Obesity: secondary to fatty hypertrophyMalnutrition: acinar hypertrhophyAny condition that interferes with the absorption of nutrients (celiac dz, uremia, chronic pancreatitis, etc)
8Related to…Alcoholic cirrhosis: likely based on protein deficiency & resultant acinar hypertrophyDrug induced: iodine mumpse. HIV
9Sialadenosis (Sialosis) Histopathology:Hypertrophy of serous acinar cells to about twice their normal size.Cytoplasm is densely packed with secretory granules.
10Allergic sialadenitis Caused by drugs or allergensClinical presentation:Acute salivary gland enlargementItching over the glandWith/without rashTreatmentSelf-limitingAvoid allergenhydration
13Mucocele9Mucus 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
14Etiology Clinical appearance Ranula Mucoceles & RanulaEtiologyTrauma extravasation labial mucosaObstruction retention palate & floor of mouthClinical appearanceRanulaextravasation / retention in floor of mouthObstruction of Sublingual salivary gland ductUsually unilateral
15MucoceleMucoceles, 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.
16Mucocele9Extravasation 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
17MucoceleConsist of a circumscribed cavity in the connective tissue and submucosa producing an obvious elevation in the mucosa
18MucoceleThe 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.
19Ranula9Is 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.
20Ranula9 Although the source is usually the sublingual gland, may also arise from the submandibular ductor possibly the minor salivary glands in the floor of the mouth.
21RanulaPresents 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.
22Plunging 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.
23Treatment of Mucoceles9 in Lip or Buccal mucosa Excision with strict removal of any projecting peripheral salivary glandsAvoid injury to other glands during primary wound closure
24Ranula Treatment9Marsupialization has fallen into disfavor due to the excessive recurrence rate of 60-90%Sublingual gland removal via intraoral approach
26Immunologic 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
27Sjögren’s syndrome7 90% cases occur in women Average age of onset is 50yClassic monograph on thediease published in 1933 by Sjögren, a Swedish ophthalmologist
28SJOGREN’s SYNDROMEAll the above conditions plus; Dry eyes Generalized arthritis
29Primary SS - Clinical picture Mostly parotid gland is affectedPersistent / intermittent gland enlargementbilateral, non-tender, firm, and diffuse swelling saliva and altered saliva compositionCheck of any recent changes to the character of the glands (nodularity)significantly increased risk of developing B-cell lymphomaKeratoconjunctivitis sicca
30Secondary SS - Clinical picture Dryness of the skin & pruritisDry and persistent cough>50% have arthralgia with or without arthritisDysphagia, nausea, dyspepsia, and epigastric painPeripheral & cranial neuropathy
31Sjögren syndrome - Diagnosis Different diagnostic criteriaObjective measurement of decreased salivary & lacrimal gland function+ve autoimmune serologiesMinor salivary gland biopsyLymphocytic infiltrationSilagoraphy is also useful
32Sjögren’s SyndromeKeratoconjuntivitis 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 lacrimationof 5mm or less.Approximately 85% specific & sensitive
33Sjögren’s Lip Biopsy15Biopsy of SG mainly used to aid in the diagnosisCan also be helpful to confirm sarcoidosis
34Sjögren’s Lip Biopsy15Single 1.5 to 2cm horizantal incision labial mucosa.Not in midline, fewer glands there.Include 5+ glands for identificationGlands assessed semi-quantitatively to determine the number of foci of lymphocytes per 4mm2/gland
35Sjögren syndrome - Treatment SymptomaticSystemic cholinergic (Pilocarpine)5mg TID/QID (should not exceed 30mg/day)Follow up
36Sjögren’s Treatment15 Avoid xerostomic meds if possible Avoid alcohol, tobacco (accentuates xerostomia)Sialogogue (eg:pilocarpine) use is limited by other cholinergic effects like bradycardia & lacrimationSugar free gum or diabetic confectionarySalivary substitutes/sprays
37MICKULICZ’s SYNDROME1) Symmetrical enlargement of salivary glands 2) Enlargement of the lachrymal glands 3) Dry mouth
38Radiation induced pathology Permanent salivary damage caused by doses 50GyRadioactive iodine for thyroid cancer treatment has similar but less severe effectClinical presentationSalivary gland dysfunction signs & symptomsOsteonecrosisIncreased risk of tumors affecting radiated tissues
39Management steps for patients with radiation-induced xerostomia
40Radiation Injury7Low 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.
41Continued 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.
42Granulomatous Disease7 Primary Tuberculosis of the salivary glands:Uncommon, usually unilateral, parotid most common affectedBelieved to arise from spread of a focus of infection in tonsilsSecondary TB may also involve the salivary glands but tends to involve the SMG and is associated with active pulmonary TB.
436- Granulomatous conditions TuberculosisGranulation tissue formation in salivary glandXerostomiaSalivary gland enlargementSarcoidosisGranulomas (T lymphocytes) affecting several organsLungsSkinEyesParotid glandsSeverity and duration of disease variesMild improvement noticed with steroid therapy
44Granulomatous conditions TuberculosisGranulation tissue formation in salivary glandXerostomiaSalivary gland enlargementSarcoidosisGranulomas (T lymphocytes) affecting several organsLungsSkinEyesParotid glandsSeverity and duration of disease variesMild improvement noticed with steroid therapy
45Granulomatous Disease7 Sarcoidosis: a systemic disease characterized by noncaseating granulomas in multiple organ systemsClinically, SG involvement in 6% casesHeerfordts’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.
46Granulomatous Disease7 Cat Scratch Disease:Does not involve the salivary glands directly, but involves the periparotid and submandibular triangle lymph nodesMay involve SG by contiguous spread.Bacteria is Bartonella Henselae(G-R)Also, toxoplasmosis and actinomycosis.
47Cysts7True 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
48Cysts Acquired cysts include: Mucus extravasation vs. retention TraumaticBenign epithelial lesionsHIVAssociation with tumorsPleomorphic adenomaAdenoid Cystic CarcinomaMucoepidermoid CarcinomaWarthin’s Tumor
49Other: 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 pressureGlass blowers, trumpet playersAka: pneumosialadenitis, wind parotitis, pneumatocele glandulae parotis
50Pneumoparotitis8 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 glandConsider antibiotics to prevent superimposed infection
52Other: Necrotizing Sialometaplasia Cryptogenic origin, possibly a reaction to ischemia or injuryManifests 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
53Necrotizing Sialometaplasia Self limiting lesion, heals by secondary intention over 6-8 weeksHistologically may be mistaken for SCC
55Xerostomia 22 – 26% of total population Occurs most common among elderlyAssociated with immunotherapy, radiotherapyTreatmentStringent oral and dental careRadiation therapy protectantsGene therapyPharmacologic options
56Diagnostic approach 1- evaluation of dry mouth Symptoms of salivary gland dysfunctionDryness of all oral mucosal surfacesDifficulty chewing, speakingIncreased sensitivity to spicy foodIncreased caries activity
57Diagnostic approach 2- Past & present medical history RadiotherapyDryness at other body sites (eye, nose, skin)MedicationTricyclic antidepressantAntihypertensiveAntihistaminesDecongestants
58Diagnostic approach 3- Clinical examination Intra-Oral examinationNotice signs of salivary gland dysfunctionRed depapillated tongueOral mucosa adhere to mirrorLipstick/food debris on anterior teethCandidaiasisIncrease caries & erosionIf could detect massAny mucosal ulcerations over the massMilking of saliva
59Diagnostic approach 3- Clinical examination Extra-Oral examinationPalpate cervical lymph nodesPalpate the glandSlightly rubberyPainless unless infected/inflamedCheck motor function of facial nerve
65Age 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.
66ReferencesMcQuone, SJ: Acute viral and bacterial infections of the salivary glands. Oto Clinics North America, 32:793,1999Marchal F, Dulguerov P. Sialolithiasis Management. Arch Oto, 129:951, 2003Escudier MP, McGurk M. Symptomatic sialodenitiis and sialolithiasis in the english population:an estimate of the cost of hospital treatment. Br Dent J. 1999;186:463Lustmann J, Regev E, Melamed Y. Sialolithiasis: a survey on 245 patients and a review of the literature. Int J Oral Maxillofacial. 1990; 19, 135Crabtree GM, Yartington CT. Submandibular gland excision. Laryngoscope. 1988;98:1044
67Sialadenitis Treatment: The first step is to make sure about fluid balance.Patient needs to receive fluids intravenouslyAntibiotics 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