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Non Neoplastic Lesions Of Salivary Glands

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Presentation on theme: "Non Neoplastic Lesions Of Salivary Glands"— Presentation transcript:

1 Non Neoplastic Lesions Of Salivary Glands

2 CLASSIFICATION OF SALIVARY GLAND DISORDERS

3 CLASSIFICATION DEVELOPMENTAL DISORDERS
APLASIA of Salivary Gland CLASSIFICATION HYPOPLASIA ACESSORY Salivary Gland And Ducts ABERRANT Salivary Glands DIVERTICULI

4 CLASSIFICATION OBSTRUCTIVE DISORDERS MAJOR SALIVARY GLAND
SIALOLITHIASIS CLASSIFICATION MINOR SALIVARY GLAND EXTRAVASATION MUCOCELE RETENTION

5 OBSTRUCTIVE DISORDERS
RANULA CLASSIFICATION FOREIGN BODIES

6 FUNCTIONAL DISORDERS XEROSTOMIA CLASSIFICATION PTYLASM

7 INFLAMMATORY & REACTIVE DISORDERS
NECROTISING SIALOMETAPLASIA RADIATION INDUCED SIALADENITIS ALLERGIC SIALADENITIS

8 VIRAL DISEASES MUMPS VIRAL INFECTIONS : HCV INFECTION HIV INFECTIONS
CYTOMEGALOVIRUS INFECTION

9 BACTERIAL DISEASES ACUTE BACTERIAL SIALADENITIS
CHRONIC OR RECURRENT SIALADENITIS

10 WITH SALIVARY GLAND INVOLVEMENT
SYSTEMIC CONDITIONS WITH SALIVARY GLAND INVOLVEMENT SYSTEMIC METABOLIC CONDITIONS : Diabetes mellitus anorexia Bulimia Alcoholism

11 AUTOIMMUNE DISEASES: SJOGREN’S SYNDROME (prim & sec)
MICKULICZ’S DISEASE

12 GRANULOMATOUS DISEASES:
TUBERCULOSIS SARCOIDOSIS

13 Necrotising sialometaplasia
salivary gland infarction Non neoplastic ,inlf condition Significance Abrams et al in 1973 Etiology Local trauma Surgical manipulation local anesthesia Radiation therapy Vascular ischemia local infarction

14 Predisposing factors Traumatic injuries Dental infections Ill fitting dentures Adjacent tumors Previous surgeries Clinical features Minor salivary glands of palate Others areas Parotid, smg, minor mucous glands of lungs nasal cavity, larynx, trachea and max sinus

15 C/f Initial lesion swelling with or with out ulceration Crateriform ulcer of palate 1 to 3 cms Unilateral Erosion of the palate Age 17 to 80 yrs m:f 2:1

16 Histologic features • Necrosis of acini and ducts • Squamous metaplasia, accompanied by fibrosis, increases with evolution of the lesion • Varying degrees of acute and chronic inflammation depending on the age of the lesion

17 • Squamous nest relatively small and fairly uniform in size
• In minor salivary gland related lesions, the overlying epithelium may show pseudoepitheliomatous hyperplasia

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19 D/D: SCC Syphilic gumma, deep fungal infection Wegener’s granulomatosis Extranodal lymphomas Treatment: Resolves spontaneously Periodic evaluation Prognosis excellent

20 Obstructive SG Disorders: Sialolithiasis
A stone in the salivary duct or gland Mechanical obstruction of the salivary duct Major cause of unilateral diffuse parotid or submandibular gland swelling Most frequent reason for submandibular gland resection

21 Sialolithiasis The exact pathogenesis of sialolithiasis remains unknown. Thought to form via…. an initial organic nidus that progressively grows by deposition of layers of inorganic and organic substances. May eventually obstruct flow of saliva from the gland to the oral cavity.

22 Sialolithiasis Acute ductal obstruction may occur at meal time when saliva producing is at its maximum, the resultant swelling is sudden and can be painful. Gradually reduction of the swelling can result but it recurs repeatedly when flow is stimulated. This process may continue until complete obstruction and/or infection occurs.

23 Etiology Hypercalcemia…in rats only Xerostomic meds Tobacco smoking
Smoking has an increased cytotoxic effect on saliva, decreases PMN phagocytic ability and reduces salivary proteins Gout is the only systemic disease known to cause salivary calculi and these are composed of uric acid.

24 Stone Composition Organic; often predominate in the center
Glycoproteins Mucopolysaccharides Bacterial products Cellular debris Inorganic; often in the periphery Calcium carbonates & calcium phosphates in the form of hydroxyapatite

25 Parotid (PG) vs. Submandibular Gland (SMG)….
Most authorities agree obstructive phenomemnon such as mucous plugs and sialoliths are most commonly found in the SMG Escudier et al Lustmann et al Rice

26 Reasons sialolithiasis may occur more often in the SMG
Saliva more alkaline Higher concentration of calcium and phosphate in the saliva Higher mucus content Longer duct Anti-gravity flow

27 Clinical presentation
Painful swelling (60%) Painless swelling (30%) Sometimes described as recurrent salivary colic and spasmodic pain upon eating

28 Diagnostics: Plain occlusal film
Effective for intraductal stones, while…. intraglandular, radiolucent or small stones may be missed.

29 DIAGNOSIS: Radiographic examination Plain film radiography Sialography Sialendoscopy Ultrasonography CT imaging

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33 Mucocele Mucoceles, exclusive of the irritation fibroma, are most common of the benign soft tissue masses in the oral cavity. Muco: mucus , coele: cavity. Consist of a circumscribed cavity in the connective tissue and submucosa producing an obvious elevation in the mucosa When in the oral floor, they are called ranula.

34 Etiology and pathogenesis
Obstruction of minor sg duct Traumatic severance of duct Chronic partial obstruction Salivary calculus Classification Extravasation mucocele Retention mucocele

35 Mucocele 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

36 C/F Accessory glands lower lip Birth to ninth decade Dome shaped mucosal swelling 1 or 2 mm to several cms Children, young adult

37 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.

38 H/P Lack of epi lining Mucous laden tissue defect Infiltraion of infl cells Adj sg may be atrophic or show interstitial fibrosis

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40 Ranula 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.

41 Ranula 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.

42 Ranula Presents as a blue dome shaped swelling in the floor of mouth.
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.

43 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.

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

45 AUTOIMMUNE DISEASES: Keratoconjunctivits sicca Xerostomia
SJOGERNS SYNDROME HENRIK SJOGREN : 1933 CLINICAL TRIAD : Keratoconjunctivits sicca Xerostomia Rheumatoid arthritis

46 Primary Sjogren’s syndrome (Sicca complex)
Dry mouth and dry eyes Secondary Sjogren’s syndrome Systemic lupus erythematosus, polyarteritis nodosa, polymyositis, scleroderma

47 Etiology Genetic Hormonal Infectious Immunologic – antisalivary duct antibody Combinations of factors

48 C/F: Usually in females over 40yrs Children & young adults may be affected F:M– 10:1 Dryness of eyes and mouth Painful, burning sensation of oral mucosa Lymphadenopathy is more common in primary form

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51 Salivary gland function test
Diagnosis : History & Exam Investigations: Opthalmologic test Salivary gland function test Connective tissue disorder test Opthalmologic test: Schirmer’s test Break up time test (BUT) Rose Bengal Dye test

52 Salivary gland function test:
Salivary flow rate Salivary gland biopsy Scintigraphy & Sialography Connective tissue disorder test: +ve antisalivary antibody +ve rheumatoid factor

53 Lab finding Polyclonal hyperglobulinemia Antisalivary duct antibodies, rheumatoid factor and antinuclear antibodies. An increased sedimentation rate Radiography formation of punctate cavity defect which are filled with radio-opaque contrast media Cherry blossom or branchless fruit laden tree appearance

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55 H/P Intense lymphocytic infiltration of the gland replacing all acinar structures although the lobular architecture is preserved. Proliferation of ductal epithelium and myoepithelium to form 'epimyoepithelial islands'. An atrophy of the glands sequential to the lymphocytic infiltration.

56 Treatment: Symptomatic treatment Salivary substitutes Ocular lubricants Complication– Development of lymphomas

57 Mikulicz’s disease Condition characterized by an abnormal enlargement of the SG and lacrimal glands Johan Mikuliczs in 1888 Etiology Autoimmune Viral genetic

58 Mikulicz disease If the cause is unknown Mikulicz’s syndrome If enlargement of the glands are associated with known dieseases – tuberculosis, sarcoidosis or lymphoma

59 C/F Often affects females Middle age Occurs with SS Sudden onset of xerostomia, difficulty in swallowing Tooth decay Eyes - Enlarged lacrimal glands , decreased lacrimation Fever

60 H/P Variable replacement of the parenchyma, particularly acini, by lymphocytic infiltrate, but the lobular architecture is retained • Infiltrate composed mainly of small lymphocytes and germinal centers may or may not be present

61 Embedded within the infiltrate are varying numbers of residual ducts and epimyoepithelial islands
• Epimyoepithelial islands consist of round to irregularly shaped groups of epithelial cells or branching duct-like structures

62 Treatment: Symptomatic

63 FUNCTIONAL DISORDERS XEROSTOMIA SIALORRHEA

64 XEROSTOMIA Risk factors: Developmental : Salivary gland aplasia
Iatrogenic : Medications Radiation therapy Water metabolite loss: Impaired fluid intake Vomiting /diarrohea

65 XEROSTOMIA Local factors : Smoking Mouth breathing Systemic diseases :
Sjogerns syndrome Diabetes mellitus Sarcoidosis & HIV

66 XEROSTOMIA Causes; Depression / chronic anxiety Dehydration Drugs
Diseases

67 XEROSTOMIA Diagnosis : Clinical features : Dry mucosa
Residual saliva : thick and ropey PT c/o diff in mastication & swallowing Diagnosis : Diseases : Oral candidiasis radiation induced caries History Clinical examination Investigations

68 XEROSTOMIA MANAGEMENT Preventive therapy Symptomatic treatment
Local or topical salivary stimulation Systemic salivary stimulation

69 XEROSTOMIA Treatment : Hydration Discontinue the drugs Symptomatic :
Artificial saliva Chewing gums Sialogogues: pilocarpine

70 SIALORRHEA Risk factors: Medications Ill fitting dentures
Excess saliva production Risk factors: Medications Ill fitting dentures Rabies clinical sign Heavy metal poisoning New complete dentures Local irritations Mentally retarded pts Gastrointestinal reflux disease

71 SIALORRHEA Diagnosis : Past medical history
Clinical features : Constant soiling of clothes Diagnosis : Past medical history Diagnostic tests – salivary flow rate .

72 SIALORRHEA Treatment: Medications : Antihistamine Anti cholinergics
Injection : BOTULINUM TOXIN- PAROTID Surgical intervention: salivary gland excision (permanent relief) salivary duct ligation

73 Sialoadenosis Non neoplastic non infl enlargement of parotid gland
Bilaterally and may manisfest recurrence or pain or both Assos with systemic d/o; this forms the basis for classification Hormonal sex hormone diabetic thyroid adreno cortical d/o Neurohormonal peripheral central Dysenymatic Hepatogenic Pancreotogenic Nephrogenic dysprotienimic Malnutrional sialadenois Drug induced sialoadenosis

74  Left submandibular sialogram demonstrates “leafless-tree” pattern (arrow) with compression of finer ducts suggestive of sialadenosis

75 Salivary gland cyst Cystic neoplasm 2 to 5 percent of parotid gland
Rare in other major glands 3 types Lympho epi cyst Salivary duct cyst , two types acquired and congenital Dysgenic cyst

76 Clinical features Parotid gland ,unilateral painless swellings with no involvement of facial nerve and no fixation to the overlying skin. Patients are over 40 years of age. cm with an average size of approximately 1-3 cms .

77 H/P Unilocular cysts are lined by single or multilayered cuboidal or columnar epithelium. Mucus containing goblet cells and areas of Oncocytic differentiation may be seen. Completely or partially lined by squamous epithelium. Lymphocytic infiltration in the cyst wall.

78 Chronic sclerosing sialadenitis of SMG
Benign inflammatory condition of the submandibular gland that mimics a malignant neoplasm clinically because of presentation as a hard mass. H/P preserved lobular architecture, thickening of interlobular septa by sclerotic tissue, dense lymphoplasmacytic infiltrate, preservation of ducts with periductal fibrosis, and variable loss of acini

79 References Salivary gland Pathlogy. Irving Dardick
Surgical Pathology of salivary glands. Gary L. Ellis Textbook of Oral Pathology. Shafer 6th edition Oral and Maxillofacial pathology. Neville, 3rd edition Essentials of oral medicine and oral pathology. Cawson, 7th edition.

80 Thank you


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