lecturer:Dr Khalaf Rasheed

Disorder of salivary gland Minor salivary gland Anatomy Distributed in oral cavity and upper aero digestive tract

Common disorder of MSG 1-cysts:extravasation cyst, common sit lower lip 2-tumor: A-90% are malignant same as major salivary gland histological B-common sits upper lip, palate, and retromolar regions C-it arise in submucosal seromucous gland D-very rarely a muco-epidemoid cyst can present as an intraosseous tumor of mandible E-malignant is firm, overlying mucosa have varied discolorations from pink to blue to black F-necrosis and ulceration may develop as late presentation

Benign tumor Painless, firm, slow growing tumor, ulceration is extremely rare Treatment by excision including the overlying mucous with primary closure Benign tumor of palate less than 1cm excision of the tumor and the defect healed by 2nd intention while more than 1cm incisional biopsy before excision of tumor

Sublingual gland 1-paired gland in anterior part of the floor of mouth between mucous membrane and mylohyoid muscle and the body of mandible close to mental symphysis 2-drain directly by numerous duct to oral cavity or indirectly to submandibular duct

Common disorder 1-cysts a-due to obstruction of the duct b-extrvasation of mucous forming term ranula it is translucent swelling appearance of a frog belly (ranula) c-plunging ranula : rare type arise either from sublingual or submandibular gland, , DX by US and MRI

2-tumor 1-it is rare extremely 2-usually 85% malignant 3- painless mass firm or hard mass 4-wide excision with over lying skin and immediate reconstruction and neck dissection

Submandibular glands This gland lies in the submandibular triangle formed by the anterior and posterior bellies of the Digastric muscle and the inferior margin of the mandible. Ant facial vein and art running over the surface The gland forms a ‘C’ around the anterior margin of the Mylohyoid muscle, which divides the gland into a superficial and deep lobe.

Ectopic /aberrant salivary gland 1-common ectopic salivary tissue (Stanfne bone cyst) 2-invagination of an ectopic lobe juxtaposed submandible gland into lingual aspect of of angle of mandible 3- asymptomatic 4- radiolucent 5- no treatment

Inflammatory disorder 1-acute sialadenitis 2- chronic 3 –acute on chronic Acute sialadenitis a-viral: paramyxovirus (mump) b-bacterial: more common the viral and due to obstruction 2-chronic sialadentis: stone most common causes . 85% of salivary stone formed in submandible gland due to high viscous secretion, 85% radio-opaque

Clinical symptoms 1-acute symptoms precipitated by meal, swelling occur rapidly resolved spontaneously over 1-2 hrs and due to complet duct obstruction as the stone usually at the opening gland 2-chronic : occur due to incomplete duct obstruction when the stone within hilum of the gland or in the duct in floor mouth, minimal discomfort and swelling , not confined to mealtime, examination showed enlarge, firm gland, tender on bimanual examination , pus may be drain from opening

Management and Complications of surgery ` Sub mandibulare gland excision 1-sialadentis 2- salivary tumor Complications of surgery 1-hematoma 2-wound infection 3-marginal mandibular nerve injury 4-lingual nerve injury 5-hypoglossal nerve injury 6-transection of the nerve to mylohyoid muscle producing submental skin anaesthesia

Tumor of the submandibular gland 1-uncommon 50% are malignant 2-painless , slow – growing tumor

Clinical features of malignant salivary tumors 1-facial nerve weakness 2-rapiad enlargement of the swelling 3-induration and or ulceration of the skin 4-cervical node enlargement

Investigations 1-MRI and CT scan show highlight either circumscribed indicate benign tumor or diffuse , invasion indicate malignant 2- FNCA using 18G is save 3-incisional biopsy is contraindication

Parotid gland Anatomy 1-located in space between ramus of mandible and base of skull and mastoid process 2-lies on carotid sheath and 11th and 12th cranial N 3-up ward extended just bellow zygomatic process and down ward to neck 4-ant extended over master muscle

Important structures passed through parotid gland 1-branch of facial N 2-terminal branch of ext carotid art as maxillary art and superfacial temporal art 3-the retromandibular vein 4-intraparotid LN

Developmental disorder Agenesis, duct atresia, congental fistula

Inflammatory disorders 1-viral infection(mump is the most common infection) 2-predromal symptom 1-2days and resolved within 5-10 days 3-complications

Bacterial infections 1-idiopathic 2- ascending infection in cases of severe dehydration 3- generalsed swelling or localized especially lower part 4-abscess may develop 5- common MO staphylococcus and streptococcus viridians

Recurrent parotitis of childhood 1-uknown cause 2- one or both parotid gland involved 3- rapid onset 4- symptoms remains for 3-7days 5-common age3-6 years (symptoms reported in infant as 4 months) 6-dx by history and sialogram (punctuate sialectasis like snowstorm) 7-treatment

HIV associated parotitis 1-chronic in childhood is pathognomonic of HIV 2-symptoms like Sjogren, s syndrome in adult and histologically but negative autoantibody in HIV 3-can be presented by multiple parotid cysts 4-MRI showed Swiss cheese appearance 5-mass is painless but surgery is indicated to improve the appearance

Obstructive parotitis a-papillary obstruction b-stone formation less common in the parotid ,20% usually radiolucent located at the the confluence of collecting duct or distal part of duct near papilla sialography is usually indicated

Tumor of the parotid gland 1-the most common site for salivary tumor 2-superfacial lobe the most common site 3-it is slow growing , painless tumor either below , in front of the ear, or in the upper neck and less common In the accessory lobe as a mass in the check 4-rarely the tumor arise in the deep lobe as parapharyngeal mass (difficulty in the swallowing and snoring 5-examination showed as firm swelling in soft palate and tonsil

Type of the tumor 1-low-grade malignant( acinic cell carcinoma) 2-high-grade malignant tumor either discrete or diffuse with cervical LN Investigations 1-CT-scan and MRI scan 2-FNCA and incisional biopsy if the malignant is suspected to arrange for radical parodidectomy`

Classification of salivary gland Common examplel Sub-group type Pleomoric adenoma adenolymphoma Pleomoric monomorphic 1-adenoma Acinic cell, adenoid cystic carcinoma, low-grade muco-epidermoid carcinoma   Adenocarcinoma, SCC, high grade muco-epidermoid carcinoma Low grade High grade 11-carcinama Hemangioma , lymphangioma 111-non epithelial tumor NHL Lymphomas in Sjogren, s syndrom Primary secondary 1V-lymphomas Head , neck Skin, bronchus Local distant V-2nd tumor VI-unclassified Lymphoepithelal , adenomatoid hyperplasia Salivary gland cyst Solid Cystic lesion VII-tumor like lesion Classification of salivary gland

Treatment and Complication of parotid gland surgery Surgery is the only option for treatment complications 1-hematoma 2-infection 3- temporary facial nerve o r permanent weakness 4-sialocele 5-facial numbness 6-permenant numbness of the ear lobule 7- frey, s syndrome

Freys s syndrome Result from damage to autonomic innervations of salivary gland with inappropriate regeneration of parasympathetic nerve that stimulate the sweat gland of overlying skin

Prevention and Management of established frey, s syndrome 1-sternomastoid muscle flap 2-temporalis muscle flap 3-insertion artificial membrane treatment 1-anti-perspirants ( containing aluminum chloride) 2-denervation by tympanic neurectomy 3-injection of botulinum toxin into the affected skin

Granulomatous sialadenitis a-TB 1-tumor like mass 2-painless 3- without systemic manifestation 4-DXby excision of submandibular or parotid gland b-sarcoidosis 1-swelling of gland usually localized(sarcoid pseudotumor) 2-may be associated by xerostomia 3-Heerfordt, s syndrome is sarcoid involve parotid gland, anterior uveitis, facial palsy c-others : cat scratch fever, toxoplasmosis, syphilis, deep mycosis, wegener, s granulomatosis, allergic and radiotherapy sialadenitis

Tumor like lesions a-sialadenosis 1-non-inflammatory swelling 2- occur with variety of conditions like DM, alcoholism, eating disorder, pregnancy, endocrine disorder 3-age between 40-70 4- swelling soft and symmetrical

Degenerative condition Sjogren, s syndrome 1-female more the male 2-primary type shows xerostomia and keratocojuctivitis without connective tissue disorder 3-lymphomatous transformation in primary is higher than 2nd 4- parotid more than other is affected 5-gland is painful and may be associated with ascending infection 6-DX on clinical basis 7-pathological appearance progressive lymphocytic infiltration , acinar cells destruction and proliferation of ductal epithelium of salivary and lacrimal gland

Benign lymphoepithelial lesion 1-20%change to lymphoma 2-cannot distinguish histollogically from sjogren, s syndrome 3-female more affected over 50 y 4-diffuse swelling of parotid gland, swelling is firm, often painful 5-20% is bilateral

Xerostomia 1-chronic anxiety and depression 2-dehydration 3-anti-cholinergic and ant-depressant 4-salivary gland disorder 5-radiotherapy to head and neck

Sialorrhoea Certain drug and oral infection cause transient increase in salivary flow Management Most resting salivary flow arise from submandibular gland and surgery should focused on this gland

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