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Salivary Glands DisordersDR-KALAF RASHEED

Anatomical Considerations
Two submandibular Two Parotid Two sublingual > 400 minor salivary glands

Minor salivary glands

These lie just under mucosa. Distributed over lips, cheeks, palate, floor of mouth & retro-molar area. Also appear in upper aerodigestive tract Contribute 10% of total salivary volume.

Sublingual Salivary glands

This is the smallest of the major salivary glands. The almond shaped gland lies just deep to the floor of mouth mucosa between the mandible & Genioglossus muscle. It is bounded inferiorly by the Mylohyoid muscle drain directly by numerous duct to oral cavity or indirectly to submandibular duct It lacks a single dominant duct. Instead, it is drained by approximately 10 small ducts (the Ducts of Rivinus)

Submandibular Gland

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.

Submandibular Gland…… Wharton’s duct empties into the intraoral cavity lateral to the lingual frenulum on the anterior floor of mouthdeep lobe lies over hypoglossal muscle related to lingual nerve and inferior to he hypoglossal nerveenclosed by capsule ,


Parotid Gland
The parotid gland represents the largest salivary glandThe following lists the boundaries of the parotid compartment:•Superior border – Zygoma•Posterior border – External Auditory Canal•Inferior border – Styloid Process, Styloid Process musculature, Internal Carotid Artery, Jugular Veins•Anterior border – a diagonal line drawn from the Zygomatic root to the EAC

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

Parotid Gland…… 80% of the gland overlies the Masseter and mandible. The remaining 20% of the gland (the retromandibular portion This portion of the gland lies in the Prestyloid Compartment of the Parapharyngeal space


Parotid Gland…… Stensen’s duct arises from the anterior border of the Parotid and parallels the Zygomatic arch, 1.5 cm inferior to the inferior margin of the arch. It runs superficial to the masseter muscle, then turns medially 90 degrees to pierce the Buccinator muscle at the level of the second maxillary molar where it opens onto the oral cavity.

Parotid Gland…… Cranial Nerve VII divides it into 2 surgical zones (the superficial and deep lobes). After exiting the foramen, it turns laterally to enter the gland at its posterior margin. The nerve then branches at the Pes Anserinus (goose’s foot) approximately 1.3 cm from the stylomastoid foramen. The nerve then gives rise to 2 divisions:1)Temperofacial (upper)2)Cervicofacial (lower)

Parotid Gland…… Followed by 5 terminal branches: 1)Temporal 2)Zygomatic 3)Buccal 4)Marginal Mandibular 5)Cervical

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

Functions of saliva include the following:

It has a cleansing action on the teeth It moistens and lubricates food during mastication and swallowing It dissolves certain molecules so that food can be tasted It begins the chemical digestion of starches through the action of amylase, which breaks down polysaccharides into disaccharides. The saliva from the parotid gland is a rather thin, watery fluid, but the saliva from the sublingual and the submandibular glands contains mucus and is much thicker.


Disorders of minor salivary Glands
Extravasation Cysts Follow trauma MSG with in lower lip Visible painful swelling Some resolve spontaneously or require surgery

Disorders of minor salivary Glands

MSG tumours are rare but 90% are malignant Common sites include Upper lip, Palate, Retromolar regions, Rare sites are nose/PNS/Pharynx

Disorders of minor salivary Glands

Benign tumours present as painless slow growing swellings, overlying ulceration is rare. Malignant tumours overlying mucosa have varied discolouration from pink to blue to black Malignant tumours have firmer consistency and have ulceration at later stage very rarely a muco-epidemoid cyst can present as an intraosseous tumor of mandible

Disorders of minor salivary Glands treatment

Benign tumors of palate < 1cm in size are removed by excisional biopsy When size larger than 1 cm prior incisional biopsy is done Malignant tumors are managed by excision which may involve low-level or total maxillectomy and immediate reconstruction

Disorders of sublingual salivary Glands

Problems are rare Minor mucous retention cysts Plunging ranula is a retention cyst that tunnels deep Nearly all tumours are malignant

cyst

Common sublingual disorder
a-due to obstruction of the duct b-extrvasation of mucous forming term ranula it is translucent swelling appearance of a frog belly (ranula)

Plunging ranula

Rare form of retention cyst May arise from SM/SL SG Mucous collects around gland Penetrates Mylohyoid muscle to enter neck Soft painless fluctuant dumb-bell shaped swelling Surgical excision via neck

Disorders of sublingual salivary Glands

Tumours are rare 90% are malignant Wide excision and simultaneous neck dissection

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 angle of mandible 3- asymptomatic 4- radiolucent 5- no treatment

Predisposing factors for inflammation

1-oral hygiene2-obstructionOrganisms, Why is pain markedAbscess –ve fluctuation

Disorders of submandibular salivary Glands

Acute sialadenitis Viral (Mumps) Bacterial secondary to infection More Common Secondary to obstruction Poor capacity to recover Despite control with Abx chronicity follows and requires surgical excision

Chronic Sialadenitis

Commonly due to obstruction following stone formation 80% salivary stones occur in SMSG High mucous content Acute painful swelling rapidly precipitated by eating & resolves within 1-2 hours Enlarged bimanually palpable SMG Marsuplisation/Excision


Tumors of Submandibular Salivary Glands
Uncommon, slow growing, painless Only 50% are benign Even malignant tumours can be slow growing Pain is not a reliable feature Investigations: CT/MRI FNAC No open biopsy

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

Management

Small & encased within capsule intracapsular excisionLarge benign tumors– suprahyoid excision Malignant tumours require concomitant neck dissection

Disorders of parotid Glands

Common causes of parotid swelling: Mumps Acute bacterial sialadenitis in dehydrated elderly patients Acute bacterial parotitis Obstructive parotitis: causes swelling at meal time

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

Developmental disorder

Agenesis, duct atresia, congental fistula

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



Parotid Tumours
Most Common is pleomorphic adenoma (80-90%) Low grade Tumors like acinic cell carcinoma are not distinguishable from benign High grade Tumours grow rapidly, are often painful and have nodal metastasis CT/MRI are useful FNAC better than open biopsy Tx should be excised & not enucleated

Classification of salivary gland 

Common examplel
Sub-group
type
Pleomoric adenoma adenolymphoma
Pleomoric monomorphic
1-adenoma

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 Parotid Tumours

AdenomaPleomorphicMonomorphic (Warthin’s Tumour)CarcinomaLow grade (Acinic cell/Adenoid cystic)High grade (Adenocarcinoma/SCC)

Management

Superficial parotidectomy most common procedure Radical parotidectomy is performed for patients clear histological evidence of high grade malignancy

Complication of parotid gland surgery 

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

Sjogren Syndrome

Autoimmune condition causing progressive degeneration of salivary and lachrymal glands The oral aspects of primary Sjogren's syndrome consist of mucosal atrophy (80% to 95%), salivary gland enlargement approximately 30 %), The oral manifestations may include xerostomia with or without salivary gland enlargement, candidiasis, dental caries and taste dysfunction.

Investigations

Sialometry Sialography Scintigraphy a radioactive tracer is given by vein that is subsequently taken up by the salivary glands and gradually eliminated within the salivary fluid Sialochemistry Ultrasonogram Labial or minor salivary gland biopsy

Management

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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