Salivary Gland Pathology § Diagnosis of salivary gland disorders § Non neoplastic pathology Metabolic conditions Infectious conditions Immunologic conditions § Neoplastic pathology § Postoperative complications

Diagnosis of Salivary Gland Disorders Diagnosis of salivary gland disorders is based on presenting signs and symptoms, preexisting diseases, and physical examination. plain-film radiography and sialography to assist with diagnosis of nonneoplastic pathology CT and MRI to delineate the size and extent of salivary neoplasms

Non-neoplastic Disorders Reactive conditions mucoceles and ranulas irradiation reactions sialolithiasis necrotizing sialometaplasia Infectious Nutrition disorders Medication reactions Immunologic disorders

Mucoceles § Most common reactive condition of the minor salivary glands § Mucoceles form when trauma to excretory ducts of the minor glands allows the spillage of mucus into the surrounding connective tissue § formation of painless, smooth surfaced, bluish lesions

§ The lower lip is the most frequent site followed by the buccal mucosa, the ventral surface of the tongue, the floor of the mouth, and the retromolar region § Treatment: observation surgical excision

Ranulas § The result of blocked sublingual gland ducts § Ranulas are unilateral, soft-tissue lesions, often with a bluish appearance. § They vary in size and may cross the midline of the mouth and cause deviation of the tongue § A mucosal extravasation that herniates the mylohyoid muscle is called a "plunging" ranula

Treatment of a Ranula Surgical excision of the involved gland and marsupialization Marsupialization: suturing its walls to an adjacent structure, leaving the packed cavity to close by granulation

Irradiation Reaction § A common side effect of tumoricidal doses of ionizing radiation is xerostomia § Frequent sips of water and frequent mouth care are the most effective interventions for xerostomia § Saliva substitutes (eg, mixed solutions of methylcellulose, glycerin, and saline) or pilocarpine hydrochloride may help these symptoms

Sialolithiasis § Middle-aged patients most frequently affected § 85% of all salivary stones are located in the submandibular gland § Patients with sialolithiasis typically complain of recurrent episodes of pain and swelling when the gland is stimulated to secrete, as when chewing food

Sialolithiasis Treatment excision of salivary calculi from Wharton's duct (ie, sialolithotomy) and the administration of antibiotics for underlying salivary gland infections and/or excision of the entire submandibular gland

Necrotizing Sialometaplasia § Usually involves minor salivary glands § Occurs secondary to vascular infarct due to smoking, trauma, DM, vascular disease, L/A § Age range yrs § 1-4 cm ulceration § resembles mucoepidermoid carcinoma and SCCA clinically and histologically § Usually heal in 6-10 weeks

Nutrition Disorders § Nutrition disorders such as pellagra (ie, niacin deficiency), kwashiorkor (ie, protein deficiency), beriberi (ie, thiamine deficiency), and vitamin A deficiency are associated with parotid gland enlargement § Malabsorption syndromes also can cause malnutrition and result in salivary gland dysfunction

Medication Reactions Many medications (eg, amitriptyline, imipramine, nortriptyline, atropine, phenothiazine derivatives, antihistamines) decrease salivary flow and cause parotid enlargement

Metabolic Conditions § Patients with alcoholic cirrhosis often experience asymptomatic enlargements of their parotid glands, which are attributed to chronic protein deficiency § Diabetes mellitus and hyperlipidemia cause fatty infiltrations that replace the functional parenchyma of the salivary glands and decrease the flow of saliva

Infectious Conditions § Mumps § Cytomegalovirus (CMV), which is a DNA virus of the herpes family that is transmitted by human contact

Bacterial infections acute and recurrent chronic sialadenitis § Etiology: Staphylococcus aureus, Staphylococcus pyogenes, Streptococcus pneumoniae, and Escherichia coli § Predisposing factor: reduction in salivary flow (ie, secondary to dehydration, debilitation, medication side effects) § Treatment is directed at elimination of the causative agent, rehydration of the patient, and surgical drainage of purulence when indicated

Immunologic conditions § HIV may manifest with parotid gland enlargement and parotid lymphadenopathy often are observed in these immunocompromised patients.

Sjogren's syndrome § Autoimmune disorder characterized by a chronic inflammatory reaction of exocrine glands +/or systemic connective tissues § Sjogren's syndrome includes any of the three findings: keratoconjunctivitis sicca (ie, dry eyes) ` salivary gland enlargement, and xerostomia vasculitis purpura hepatosplenomegally obstructive pulmonary disease anemia rheumatoid arthritis

Neoplasms § Salivary neoplasms generally present as painless, slow-growing masses § Neoplasms of the major salivary glands usually are benign § Neoplasms of the minor salivary glands usually are malignant § Rapidly expanding salivary neoplasms that are associated with pain and neural dysfunction are more likely to be malignant

85% of salivary neoplasms arise in the parotid § 10% in the submandibular gland § 5% in the minor salivary glands § Salivary neoplasms rarely occur in the sublingual glands

Benign salivary neoplasms Histologically, benign neoplasms are classified as: pleomorphic adenomas / benign mixed tumors papillary cystadenolymphomas /Warthin's tumors oncocytomas monomorphic adenomas benign lymphoepithelial lesions

Benign salivary neoplasms § The most common benign neoplasm is pleomorphic adenoma § parotid gland 92.5% § submandibular gland 6.5% § The treatment of choice for benign neoplasms is surgical excision

Malignant salivary neoplasms Malignant salivary neoplasms are classified as: malignant mixed tumors mucoepidermoid carcinoma adenocarcinoma acinic cell carcinoma squamous cell carcinoma adenoid cystic carcinoma metastatic melanoma

Malignant salivary neoplasms § Surgery is the treatment of choice for resectable malignant salivary neoplasms § Surgeons also may perform neck dissections if lymph node involvement is present or suspected § Postoperative radiation therapy may be used as an adjunctive treatment to eradicate microscopic or residual disease

Complications § Xerostomia § Hemorrhage § Temporary facial nerve paralysis 15% § Long-term facial nerve paralysis § Frey's syndrome

Salivary Gland Disorders § Clinicians are frequently confronted with the necessity of assessing and managing salivary gland disorders § This basic knowledge of salivary gland anatomy, physiology, pathophysiology is necessary to treat your patients properly