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NON SPECIFIC DISEASE OF PAROTID Babak Saedi.MD Tehran university of Medical sciences Imam Khomeini Hospital.

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Presentation on theme: "NON SPECIFIC DISEASE OF PAROTID Babak Saedi.MD Tehran university of Medical sciences Imam Khomeini Hospital."— Presentation transcript:

1 NON SPECIFIC DISEASE OF PAROTID Babak Saedi.MD Tehran university of Medical sciences Imam Khomeini Hospital

2 ANATOMY & PHYSIOLOGY  Parotid Serous  Sublingual Mucous  Submandibular Mixed  Minor salivary glands  Controlled by sympathetic & parasympathetic

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

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: a.Nutritional (Alcoholism, Cirrhosis, Kwashiorkor and Pellagra b.Endocrine (Diabetes, Thyroid diasease, Gonadal dysfunction) c.Neurochemical (Vegetative state, Lead, Mercury, Iodine, Thiouracil)

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

8 RELATED TO… a.Alcoholic cirrhosis: likely based on protein deficiency & resultant acinar hypertrophy b.Drug induced: iodine mumps e. HIV

9 SIALADENOSIS (SIALOSIS) Histopathology: 1.Hypertrophy of serous acinar cells to about twice their normal size. 2.Cytoplasm is densely packed with secretory granules.

10 ALLERGIC SIALADENITIS  Caused by drugs or allergens  Clinical presentation: 1.Acute salivary gland enlargement 2.Itching over the gland 3.With/without rash  Treatment Self-limiting Avoid allergen hydration


12 OBSTRUCTIVE SALIVARY GLAND DISORDERS  Sialolithiasis  Mucous retention/extravasation

13 MUCOCELE 9  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 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 MUCOCELE 9 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 RANULA 9  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 RANULA 9  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 MUCOCELES 9 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 TREATMENT 9  Marsupialization has fallen into disfavor due to the excessive recurrence rate of 60-90%  Sublingual gland removal via intraoral approach


26 IMMUNOLOGIC DISEASE SJÖGREN’S SYNDROME 7  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 SYNDROME 7  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 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 1.Objective measurement of decreased salivary & lacrimal gland function 2.+ve autoimmune serologies 3.Minor salivary gland biopsy Lymphocytic infiltration 4.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 BIOPSY 15  Biopsy of SG mainly used to aid in the diagnosis  Can also be helpful to confirm sarcoidosis

34 SJÖGREN’S LIP BIOPSY 15  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 4mm 2 /gland

35 SJÖGREN SYNDROME - TREATMENT  Symptomatic  Systemic cholinergic (Pilocarpine) 5mg TID/QID (should not exceed 30mg/day)  Follow up

36 SJÖGREN’S TREATMENT 15  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 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 1.Salivary gland dysfunction signs & symptoms 2.Osteonecrosis 3.Increased risk of tumors affecting radiated tissues


40 RADIATION INJURY 7  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 gland 7.  Similar to the thyroid, salivary neoplasm are increased in incidence after radiation exposure 7.

42 GRANULOMATOUS DISEASE 7 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 1.Tuberculosis Granulation tissue formation in salivary gland 1.Xerostomia 2.Salivary gland enlargement 2.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 1.Tuberculosis Granulation tissue formation in salivary gland 1.Xerostomia 2.Salivary gland enlargement 2.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 DISEASE 7 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 DISEASE 7 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 CYSTS 7 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 PNEUMOPAROTITIS 8  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 1.Stringent oral and dental care 2.Radiation therapy protectants 3.Gene therapy 4.Pharmacologic options

56 DIAGNOSTIC APPROACH 1- EVALUATION OF DRY MOUTH Symptoms of salivary gland dysfunction 1.Dryness of all oral mucosal surfaces 2.Difficulty chewing, speaking 3.Increased sensitivity to spicy food 4.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 1.Preventive therapy 1.Florid rinses & gel 2.Oral hygiene 2.Symptomatic treatment 1.Water 2.Artificial saliva Avoid products containing sugar, alcohol 3.Salivary stimulation 1.Local / topical stimulation 1.Chewing (flavoured) 2.Systemic stimulation (sialogogues) 1.Pilocrpine HCl

62 FREY’S SYNDROME Etiologies: 1.Trauma to parotid regions a. Parotidectomy b. Penetrating trauma c. Closed mandibular fractures 2.Trauma to cervical sympathetic chain 3.Diabetic neuropathy 4.Aberrant regeneration location a. CP angle b. Middle ear c. OTIC Ganglions

63 TREATMENT OF FREYS SYNDROME 1.External radiotherapy 2.Local or systemic applications of anticholinergic drugs 3.Section of some portion of efferent arc 4.Interposition of subcutaneous barrier 5.Botox injection

64 SIALORRHEA Causes: 1.Change in oral perception 1.Neurologic changes (CVA, Parkinson’s) 2.Extensive oral surgical procedure 2.Decrease swallowing Treatment: 1.Speech pathologist 2.Xerostimia inducing drugs (antihistamine) 3.Botulinum toxins (Botox injection) 4.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 1.McQuone, SJ: Acute viral and bacterial infections of the salivary glands. Oto Clinics North America, 32:793, Marchal F, Dulguerov P. Sialolithiasis Management. Arch Oto, 129:951, 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 4.Lustmann J, Regev E, Melamed Y. Sialolithiasis: a survey on 245 patients and a review of the literature. Int J Oral Maxillofacial. 1990; 19, 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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