DISORDERS OF SALIVARY
GLANDS
DR. NADA KHALIL
DISORDER OF SALIVARY GLANDS
•
ANATOMY : SALIVARY
GLANDS ARE
1.
2 PAROTID GL.
2.
2 SUBMANDIBULAR GL.
3.
2 SUBLINGUAL GL.
4.
> 400 MINOR SALIVARY GL.
DISORDER OF MINOR SALIVARY GL
COMMON ABNORMALITIES OF MINOR SALIVARY GLANDS :
1.EXTRAVASATION CYST .
2.MINOR GLAND TUMORS .
CYSTS
• EXTRAVASATION CYST :
.MOST COMMON SALIVARY GL. DISORDER.
.CYST ARISE AS A RESULT OF
TRAUMA
TO THE OVERLYING
MUCOSA.
.USUALLY AFFECT GL. IN THE
LOWER LIP.
.IT IS PAINLESS SWELLING USUALLY TRANSLUCENT .
.SOME RESOLVE SPONTANEOUSLY ,OTHER NEED SURGICAL
EXCISION.
.RECURRENCE IS RARE.
TUMORS OF MINOR SALIVARY GL
• ARE HISTOLOGICALLY IDENTICAL TO THOSE OF MAJOR GL.
• UNLIKE TO MAJOR GL. 90% OF MINOR SALIVARY GL. TUMOUR ARE
MALIGNANT.
• IT MAY OCCUR ANY WHERE IN UPPER AERODIGESTIVE TRACT .
• COMMON SITES ARE: UPPER LIP, PALATE & RETROMOLAR REGIONS .
• ARISE IN SUBMUCOSAL SEROMUCOUS GL.
•
BENIGN MINOR SAL. GL. TUMOUR
:
.PAINLESS, FIRM, SLOW GROWING, OVERLYING MUCOSAL ULCERATION
IS VERY RARE.
.TREAT.:EXCISION WITH OVERLYING MUCOSA WITH PRIMARY CLOSURE
OF THE DEFECT.
•
MALIGNANT MINOR SALIVARY GL. TUMOUR
:
.FIRMER CONSISTENCY, UNDER SUBSEQUENT NECROSIS .
.OVERLYING MUCOSA PRODUCE VARIED DISCOLORATION FROM PINK TO
BLUE OR BLACK.
.TREATMENT OF TUMOUR IN PALATE BY WIDE EXCISION WHICH MAY
INVOLVE LOW LEVEL OR TOTAL MAXILLECTOMY .
SUBLINGUAL GL.
•
ANATOMY
.THEY ARE PAIRED SET OF SMALL SALIVARY GL.
.BETWEEN MANDIBLE & GENIOGLOSSUS.
.LYING IN THE ANT. PART OF FLOOR OF MOUTH.
.EACH GL. HAS NUMEROUS EXCRETORY DUCTS WHICH OPEN EITHER
DIRECTLY INTO THE ORAL CAVITY OR INDIRECTLY VIA DUCTS THAT DRAIN
INTO SUBMANDIBULAR DUCT.
.NO CAPSULE.
.INNERVATION:
• SUPERIOR CERVICAL GANGLION (SYMP).
• SUBMANDIBULAR GANGLION (PARA).
.ARTERY/VEIN: SUBLINGUAL BRANCH OF LINGUAL & SUBMENTAL BRANCH
OF FACIAL A.
.LYMPHATICS: SUBMANDIBULAR NODES.
DISORDERS OF SUBLINGUAL GL.
• PROBLEMS ARE RARE.
• CYSTS :
.DEVELOPE IN THE FLOOR OF MOUTH.
.IT IS EITHER DUE TO OBSTRUCTION OF MINOR
SALIVARY GL.
OR FROM SUBLINGUAL GL.
.
PLUNGING RANULA
• .IT IS RARE FORM OF MUCOUS RETENTION CYST THAT CAN ARISE
FROM BOTH SUBLINGUAL & SUBMANDIBULAR SALIVARY
GL.
•
IT IS PAINLESS,SOFT FLUCTUANT, TRANSLUCENT
SWELLING.THAT TAKES THE APPEARANCE OF “
FROG’S BELLY
”
• RESOLVE SPONTANEOUSLY, SOME REQUIRES EXCISION OF CYST
& THE AFFECTED SUBLINGUAL GL., WHILE DRAINAGE RESULT
IN RECURRENCE OF THE CYST.
• APPROACH TO SURGICAL EXCISION IS USUALLY CERVICAL, BUT
SOME SMALL RANULAE
CAN BE EXCISED TRNSORAL WITH OR
WITHOUT MARSUPIALIZATION OF THE CYST.
SUB LINGUAL GL. DISORDER (CONT’D)
•
TUMOURS
:
.IT IS EXTREMELY RARE.
.PRESENT AS HARD OR FIRM PAINLESS SWELLING
IN
THE FLOOR OF MOUTH.
. 90% OF THESE TUMOURS ARE MALIGNANT.
.REQUIRE WIDE EXCISION INVOLVING
NECK
DISSECTION.
SUBMANDIBULAR GL.
ANATOMY :
• THEY ARE TWO BELOW MANDIBLE ON EITHER SIDE.
• DIVIDED INTO LARGE SUPERFICIAL & SMALLER DEEP LOBES.
• SURROUNDED BY WELL DEFINED CAPSULE DERIVED FROM CERVICAL
FASCIA.
• IT DRAINS INTO THE ANT. FLOOR OF MOUTH.
SUBMANDIBULAR GL.(CONT’D)
•
INNERVATION
• SUPERIOR CERVICAL GANGLION (SYMP)
• SUBMANDIBULAR GANGLION (PARA)
•
ARTERY
: SUBMENTAL BRANCH OF FACIAL A.
•
VEIN
: ANTERIOR FACIAL VEIN WHICH IS IMPORTANT
RELATION.
•
LYMPHATICS
: DEEP CERVICAL AND JUGULAR CHAINS
• FACIAL ARTERY NODES
SUBMANDIBULAR GL
IMPORTANT ANATOMICAL
RELATIONS OF SUBMANDIBULAR
GL.
• LINGUAL N.
• HYPOGLOSSAL N.
• ANT. FACIAL VEIN .
• FACIAL A.
• MARGINAL MANDIBULAR BRANCH OF FACIAL N.
DEVELOPMENTAL DISORDERS OF
SUBMANDIBULAR GL.
1.
CONGENITAL ABSENCE
.
2.
DUCT ATRESIA
:PRESENTATION WITHIN 2-3 DAYS OF
LIFE .AS SUBMANDIBULAR SWELLING ON THE
AFFECTED SIDE, ASSOCIATED WITH RETENTION
CYST.
3.
ABERRANT SALIVARY GL. TISSUE
:THIS FORMED AS BONE
CYST ,ASYMPTOMATIC, WELL DEMARCATED &
RADIOLUCENCY OF THE ANGLE OF MANDIBLE, NO
TREATMENT IS REQUIRED.
INFLAMMATORY DISORDERS OF SUBMANDUBULAR
GL.
• IT IS EITHER ACUTE, CHRONIC OR ACUTE ON CHRONIC.
•
ACUTE SUBMANDIBULAR SIALADENITIS
1.VIRAL
:
. MUMPS VIRUS (PARAMYXOVIRUS) ,IT USUALLY PRODUCE PAROTITIS, BUT
SUBMANDIBULAR GL. OCCASIONALY INVOLVED.
.THERE IS PAINFUL TENDER SWELLEN GL.
2.BACTERIAL :
.IT IS MORE COMMON THAN VIRAL ONE IN SUBMANDIBULAR GL.
.GL. HAS POOR CAPACITY FOR RECOVERY FOLLOWING INFECTION DESPITE
CONTROL OF SYMPTOM WITH ANTIBIOTICS SO THE GL. FREQUENTLY BECOME C
HRONICALLY INFLAMMED & REQUIRE FORMAL EXCISION.
CHRONIC SUBMANDIBULAR
SIALADENITIS
•
OBSTRUCTION & TRAUMA
.STONE IS THE MOST COMMON CAUSE OF OBSTRUCTION.
.80% OF ALL SALIVARY STONES OCCUR IN SUBMAND.
GL.(DUE TO HIGH
MUCINOUN CONTENT WITH HIGH
VISCOSITY).
.80% OF THESE STONES ARE RADIOPAQUE.
.
SYMPTOMES
:
-ACUTE PAINFUL SWELLING IN SUBMAND. REGION
PRECIPITATING BY
EATING.
-
COMPLETE OBSTRUCTION
:WHEN THE STONE IMPACTED
AT THE
OPENING OF THE DUCT SWELLING OCCUR
RAPIDLY & RESOLVE
SPONTANEOUSLY OVER 1 TO 2
HOURS AFTER MEAL.
-
PARTIAL OBSTRUCTION
:IT HAPPENS WHEN THE STONE
LIES IN WITH
THE HILUM OF THE GL.OR WITHIN THE
DUCT IN THE FLOOR OF MOUTH.
CHRONIC
SUBMANDIBULAR
SIALADENITIS
(CONT’D)
•
CLINICAL EXAMINATION
: ENLARGED, FIRM SUBMANDIBULAR GL.,
TENDER ON BIMANUAL EXAM., PUS MAY BE VISIBLE DRAINING
FROM SUBLINGUAL PAPILLA.
•
MANAGEMENT
:
-IF THE STONE IS DISTAL TO LINGUAL N. THE DUCT CAN BE LAID
OPEN & LEFT.
-IF IT IS PROXIMAL ,THE GL. SHOULD BE APPROACHED FROM
OUTSIDE THE MOUTH & THE STONE WITH THE GL. REMOVED AFTER
LIGATION OF THE DUCT DISTALLY.
• POORLY FITTED DENTURES MAY CAUSE A STRICTURE.
SUBMANDIBULAR GL. EXCISION
•
INDICATIONS
1.SIALADENITIS
2.STONES PROXIMAL TO LINGUAL N.
3.SALIVARY TUMOURS.
•
OPERATION INCLUDES:
1.INCISION &EXPOSURE OF THE GL.
2.GL. MOBILIZATION.
3DISSECTION OF DEEP LOBE & IDENTIFICATION
OF LINGUAL N.
4.WOUND CLOSURE.
COMPLICATIONS OF SUBMANDIBULAR
GL. EXCISION
• HAEMATOMA
• WOUND INFECTION.
• MARGINAL MANDIBULAR NERVE INJ.
• LINGUAL N. INJ.
• HYPOGLOSSAL N. INJ.
• TRANSECTION OF NERVE TO MYLOHYOID MUSCLE.
PRODUCING SUBMENTAL SKIN ANAESTHESIA.
TUMOURS OF THE SUBMANDIBULAR GL.
• IT IS UNCOMMON.
• PRESENTATION USUALLY SLOW-GROWING PAINLESS SWELLING
WITHIN SUBMAND. TRIANGLE EVEN MALIGNANT TUMOR.
• 50% ARE BENIGN.
• BENIGN TUMOR CAN BE PAINFUL, SO PAIN IS NOT RELIABLE
INDICATION OF MALIGNANCY ,(THIS MAY BE DUE TO CAPSULE
DISTENTION OR OUTFLOW OBSTRUCTION).
• SOMETIMES IN CLINICAL EXAMINATION CANNOT BE DIFFERENTIATED
FROM SUBMAND. LYMPHADENOPATHY.
TUMOURS OF THE SUBMANDIBULAR
GL.(CONT’D)
•
CLINICAL FEATURES OF MALIGNANT SALIVARY TUMORS:
1.FASCIAL N. WEAKNESS.
2.RAPID ENLARGEMENT OF SWELLING.
3.INDURATION OR ULCERATION OF OVERLYING SKIN.
4.CERVICAL NODE ENLARGEMENT.
TUMOURS OF THE SUBMANDIBULAR
GL.(CONT’D)
•
INVESTIGATION:
1. CT & MRI
ARE THE MOST HELPFUL IMAGING TECHNIQUES, GIVE
IDEA ABOUT THE MASS :
-INTRINSIC TO THE GL. OR NOT.
-ITS BORDER.
-INVASSIVENESS.
-RELATIONSHIP WITH OTHER ANATOMICAL STRUCTURES WHICH
IS HELPFUL IN PLANNING OF SURGERY
2. FNA IS SAFE
, BUT RARELY ALTER THE MANAGEMENT.
NB: OPEN SURGICAL BIOPSY IS CONTRAINDICATED
BECAUSE POSSIBILITY OF SEEDING TUMOR INTO
SURROUNDING TISSUE PLANE.
TUMOURS OF THE SUBMANDIBULAR
GL.(CONT’D)
• MANAGEMENTS:
AS WITH ALL SALIVARY GLANDS THE GOAL OF
SURGICAL
PROCEDURE
IS EXCISION OF TUMOR WITH A CUFF OF NORMAL
TISSUE.
PAROTID GL. ANATOMY
•
STRUCTURES WITHIN THE GL.:
1.BRANCHES OF FASCIAL N.
2.TERMINAL BR. OF EXT. CAROTID A. WHICH DIVIDED INTO; MAXILLARY
& SUPERFICIAL TEMPORAL AA.
3.RETROMANDIBULAR VEIN.
4.INTRAPAROTID LYMPH NODES.
•
STRUCTURES DEEP TO GL.;
1.MASTOID PROCESS.
2.STERNOMASTOID.
3.POST. BELLY OF DIAGASTRIC.
4.STYLOID PROCESS.
5.TMJ
6.STYLOPHARYNGEUS & STYLOGLOSSUS.
PAROTID GLAND ANATOMY
PAROTID GLAND ANATOMY
DEVELOPMENTAL ABNORMALITIES
• AGENESIS.
• DUCT ATRESIA.
• CONGENITAL FISTULA.
ALL ARE EXTREMELY RARE
!!
COMMON CAUSES OF PAROTID GL.
SWELLING
•
MUMPS
• ACUTE ASCENDING
BACTERIAL SIALADENITIS
IN DEHYDRATED ELDERLY
PATIENT.
•
ACUTE BACTERIAL PAROTITIS.
•
OBSTRUCTIVE PAROTITIS.
INFLAMMATORY DISORDERS
• VIRAL INF.:
.MUMPS
IS THE MOST COMMON OF ACUTE PAINFUL PAROTID
SWELLING.
.PREDOMINANTLY AFFECT CHILDREN.
.CLINICAL FEATURES:
1.PRODROMAL PERIOD OF 1 TO 2 DAYS.
2.FEVER, NAUSEA, HEADACHE.
3. LATER THERE WILL BE PAIN & SWELLING OF ONE OR BOTH GL.S
4.PAIN MAY BE VERY SEVER & EXACERBATED BY EATING &
DRINKING.
5.SYMPTOMS RESOLVE WITHIN 5-10 DAYS.
•
DIAGNOSIS
OF MUMPS:
DEPEND ON HISTORY & CLINICAL EXAM.
•
TREATMENT
: SYMPTOMATIC; FLUID & ANTIPYRETIC.
•
COMPLICATION
:
• ORCHITIS, OOPHORITIS, PANCREATITIS, MENINGOENCEPHALITIS, SENSORY
NEURAL DEAFNESS.
OBSTRUCTIVE PAROTITIS
•
PAPILLARY OBST
.:
-IT IS LESS COMMON THAN OBST. SUBMAND. SIALADENITIS.
-CAN BE CAUSED BY TRAUMA TO THE PAROTID PAPILLA EITHER BY
OVER EXTENDED DENTURE OR FRACTURE UPPER MOLAR TEETH.
-SUBSEQUENT INFLAMMATION & OEDEMA OBSTRUCT SALIV.
FLOW. PARTICULARLY AT MEALTIMES.
- CLINICAL PRESENTATION: PATIENT FEELS RAPID ONSET PAIN &
SWELLING, IF UNTREATED PROGRESSIVE SCARRING & FIBROSIS
AROUND DUCT PAPILLA LEADING TO PERMENANT STENOSI, IN
SUCH CONDITION SYMPTOMS UNLIKLY TO RESOLVE UNLESS
PAPILLOTOMY
OBSTRUCTIVE PAROTITIS (CONT’D)
•
STONE FORMATION
:
-MUCH MORE RARE THAN SUBMANDIBULAR.
-USUALLY RADIOLUCENT.
-SIALOGRAPHY IS NEEDED TO IDENTIFY THEM.
-REMOVED SURGICALLY
TUMORS OF PAROTID GL.
• MOST COMMON IS PLEOMORPHIC ADENOMA(80-90%).
• MOST ARISE IN THE SUPERFICIAL LOBE.
• LOW-GRADE MALIGNANT TUMOR CANNOT BE
DISTINGUISH FROM BENIGN NEOPLASM .
• HIGH-GRADE TUMOR GROW RAPIDLY ARE USUALLY
PAINFUL & OFTEN HAVE LYMPH NODES INVOLV. AT
PRESENTATION.
• CT & MRI ARE USEFUL.
• FNA IS BETTER THAN OPEN BIOPSY .
• TUMORS SHOULD BE EXCISED NOT ENUCLEATED.
INVESTIGATION OF SAL. GL. TUMORS
• CT & MRI ARE THE MOST USEFUL TECHNIQUES.
• FNA.
OPEN SURGICAL BIOPSY IS CONTRAINDICATED
TREATMENT OF PAROTID TUMOR
• ALL SPACE OCCUPYING LESION OF SUPERFICIAL LOBE OF PAROTID
GL. SHOULD BE MANAGED WITH SUPERFICIAL PAROTIDECTOMY.
• OPERATIONS: SUPERFICIAL & RADICAL PAROTIDECTOMY.
COMPLICATION OF PAROTID GL.
SURGERY
1. HEMATOMA FORMATION.
2. INFECTION.
3. TEMPORARY FACIAL N. WEAKNESS.
4. PERMANENT FACIAL N. WEAKNESS DUE TO NERVE
TRANSACTION.
5. SIALOCELE.
6. FACIAL NUMBNESS.
7. PERMANENT NUMBNESS OF EAR LOBE DUE TO GR.
AURICULAR N. TRANSACTION.
8. PERMANENT FACIAL N. WEAKNESS AFTER RADICAL
PAROTIDECTOMY.
9. FREY’S SYNDROME.
FREY’S SYNDROME
• CALLED GUSTATORY SWEATING.
• CONSIDER AS UNIVERSAL SEQUEL FOLLOWING
PAROTIDECTOMY.
• RESULT FROM DAMAGE OF THE INNERVATIONS OF
SALIVARY GL.DURING DISSECTION IN WHICH THERE IS
INAPPROPRIATE REGENERATION OF PARASYMP.
AUTONOMIC NERVES WHICH THUS STIMULATE THE
SWEAT GL. OF OVERLYING SKIN.
• CLINICAL FEATURES:SWEATING & ERYTHEMA OVER
REGION OF GL. DUE TO AUTONOMIC STIMULATION
OF SALIVATION BY SMELL .
FREY’S SYND.(CONT’D)
•
PREVENTION
:
1.
STERNOMASTOID FLAP
2.
TEMPORALIS FACIAL FLAP.
3.
INSERTION OF ARTIFICIAL MEMBRANE BETWEEN
SKIN & PAROTID GL. BED.
•
MANAGEMENT
:
1.
ANTIPERSPIRANT.
2.
DENERVATION BY TYMPANIC NEURECTOMY.
3.
INJ. OF BOTULINIUM TOXIN INTO AFFECTED SKIN.
GRANULOMATOUS SIALADENITIS
• MYCOBACTERIAL INFECTION.
• CAT SCRATCH DISEASE.
• TOXOPLASMOSIS.
• SARCOIDOSIS.
SIALADENOSIS
•
IT IS NON-INFLAMMATORY SWELLING AFFECTING
PAROTID GL. AND ASSOCIATED WITH SYSTEMIC
DISEASES :
1.
DM.
2.
ALCOHOLISM.
3.
OTHER ENDOCRINE DISEASE.
4.
PREGNANCY.
5.
DRUGS.
6.
IDIOPATHIC.
THANK YOU