NON SPECIFIC DISEASE OF PAROTID

Babak Saedi.MD

Tehran university of Medical

sciences

Imam Khomeini Hospital

ANATOMY & PHYSIOLOGYParotid

• Serous

Sublingual• Mucous

Submandibular• Mixed

Minor salivary glands

Controlled by sympathetic & parasympathetic

SALIVARY GLAND LESSIONSSALIVARY GLAND LESSIONS

Non-Neoplastic DiseaseNon-Neoplastic Disease Benign TumorsBenign Tumors Malignant TumorsMalignant Tumors

Acute & ChronicNon-AutoimmuneAcute & Chronic

Non-Autoimmune

AutoimmuneSialadenitis

AutoimmuneSialadenitis

NecrotizingSialametaplasia

NecrotizingSialametaplasia

SialadenosisSialadenosis

SalivaryLymphoepithelial

Cysts

SalivaryLymphoepithelial

Cysts

PleomorphicAdenomas

PleomorphicAdenomas

Basal Cell AdenomasBasal Cell Adenomas

MyoepitheliomasMyoepitheliomas

Warthin’s TumorWarthin’s Tumor

Oncocytoma and Oncocytosis

Oncocytoma and Oncocytosis

Sclerosing Polycystic Adenosis

Sclerosing Polycystic Adenosis

Adenoid Cystic Carcinoma

Adenoid Cystic Carcinoma

MucoepidermoidCarcinoma

MucoepidermoidCarcinoma

SIALADENOSIS

Non-specific term used to describe a non-

inflammatory non-neoplastic enlargement of a

salivary gland, usually the parotid.

May be called sialosis

The enlargement is generally asymptomatic

Mechanism is unknown in many cases.

SIALADENOSIS (SIALOSIS)

Parotid glands most commonly.

Probably due to abnormalities of neurosecretory control.

SIALADENOSIS (SIALOSIS)

Cause maybe due to:a. Nutritional (Alcoholism, Cirrhosis, Kwashiorkor

and Pellagrab. Endocrine (Diabetes, Thyroid diasease, Gonadal

dysfunction)c. Neurochemical (Vegetative state, Lead, Mercury,

Iodine, Thiouracil)

RELATED TO…

a. Metabolic “endocrine sialendosis”

b. Nutritional “nutritional mumps” a. Obesity: secondary to fatty hypertrophyb. Malnutrition: acinar hypertrhophyc. Any condition that interferes with the absorption

of nutrients (celiac dz, uremia, chronic pancreatitis, etc)

RELATED TO…

a. Alcoholic cirrhosis: likely based on protein

deficiency & resultant acinar hypertrophy

b. Drug induced: iodine mumps

e. HIV

SIALADENOSIS (SIALOSIS)

Histopathology:

1. Hypertrophy of serous acinar cells to about

twice their normal size.

2. Cytoplasm is densely packed with secretory

granules.

ALLERGIC SIALADENITIS Caused by drugs or allergens

Clinical presentation:1. Acute salivary gland enlargement2. Itching over the gland3. With/without rash

Treatment• Self-limiting• Avoid allergen• hydration

SALIVARY GLAND

O B S T R U C T I V ES A L I VA R Y G L A N D D I S O R D E R S

 

Sialolithiasis

Mucous

retention/extravasation

MUCOCELE9

Mucus is the exclusive secretory product of the

accessory minor salivary glands and the most

prominent product of the sublingual gland.

The mechanism for mucus cavity development is

extravasation or retention

MUCOCELES & RANULA

Etiology• Trauma extravasation labial mucosa• Obstruction retention palate & floor of mouth

Clinical appearance

Ranula• extravasation / retention in floor of mouth• Obstruction of Sublingual salivary gland duct• Usually unilateral

MUCOCELEMucoceles, exclusive of the irritation fibroma, are most

common of the benign soft tissue masses in the oral

cavity.

Muco: mucus , coele: cavity.

When in the oral floor, they are

called ranula.

MUCOCELE9

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

MUCOCELE Consist of a circumscribed cavity in the connective tissue and

submucosa producing an obvious elevation in the mucosa

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.

RANULA9

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.

RANULA9

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.

RANULA

Presents as a blue dome shaped swelling

in the floor of mouth (FOM).

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.

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.

TREATMENT OF MUCOCELES 9

IN LIP OR BUCCAL MUCOSA

Excision with strict removal of any projecting peripheral

salivary glands

Avoid injury to other glands during primary wound closure

RANULA TREATMENT9

Marsupialization has fallen into disfavor due to the

excessive recurrence rate of 60-90%

Sublingual gland removal via intraoral approach

SALIVARY GLAND

IMMUNOLOGIC D ISEAS E S JÖ GREN’S SY ND RO ME 7

Most common immunologic disorder associated with salivary

gland disease.

Characterized by a lymphocyte-mediated destruction of the

exocrine glands leading to xerostomia and keratoconjunctivitis

sicca

SJÖGREN’S SYNDROME7

90% cases occur in women

Average age of onset is 50y

Classic monograph on thediease published in 1933

by Sjögren, a Swedish ophthalmologist

SJOGREN’S SYNDROME SJOGREN’S SYNDROME

All the above conditions plus;

Dry eyes

Generalized arthritis

All the above conditions plus;

Dry eyes

Generalized arthritis

PRIMARY SS - CLINICAL PICTURE

Mostly parotid gland is affected

Persistent / intermittent gland enlargement

bilateral, non-tender, firm, and diffuse swelling

saliva and altered saliva composition

Check of any recent changes to the character of the glands (nodularity)

• significantly increased risk of developing B-cell lymphoma

Keratoconjunctivitis sicca

SECONDARY SS - CLINICAL PICTURE

Dryness of the skin & pruritis

Dry and persistent cough

>50% have arthralgia with or without

arthritis

Dysphagia, nausea, dyspepsia, and

epigastric pain

Peripheral & cranial neuropathy

SJÖGREN SYNDROME - DIAGNOSIS

Different diagnostic criteria

1. Objective measurement of decreased

salivary & lacrimal gland function

2. +ve autoimmune serologies

3. Minor salivary gland biopsy• Lymphocytic infiltration

4. Silagoraphy is also useful

SJÖGREN’S SYNDROME

Keratoconjuntivitis sicca: diminished tear production

caused by lymphocytic cell replacement of the

lacrimal gland parenchyma.

Evaluate with Schirmer test. Two 5 x 35mm strips of

red litmus paper placed in inferior fornix, left for 5

minutes. A positive finding is lacrimation

of 5mm or less.

Approximately 85% specific & sensitive

SJÖGREN’S LIP BIOPSY15

Biopsy of SG mainly used to aid in the

diagnosis

Can also be helpful to confirm

sarcoidosis

SJÖGREN’S LIP BIOPSY15

Single 1.5 to 2cm horizantal incision

labial mucosa.

Not in midline, fewer glands there.

Include 5+ glands for identification

Glands assessed semi-quantitatively to

determine the number of foci of

lymphocytes per 4mm2/gland

SJÖGREN SYNDROME - TREATMENT

Symptomatic

Systemic cholinergic (Pilocarpine)

• 5mg TID/QID (should not exceed 30mg/day)

Follow up

SJÖGREN’S TREATMENT15

Avoid xerostomic meds if possible

Avoid alcohol, tobacco (accentuates xerostomia)

Sialogogue (eg:pilocarpine) use is limited by

other cholinergic effects like bradycardia &

lacrimation

Sugar free gum or diabetic confectionary

Salivary substitutes/sprays

MICKULICZ’S SYNDROME MICKULICZ’S SYNDROME

1) Symmetrical enlargement of salivary

glands

2) Enlargement of the lachrymal glands

3) Dry mouth

1) Symmetrical enlargement of salivary

glands

2) Enlargement of the lachrymal glands

3) Dry mouth

RADIATION INDUCED PATHOLOGY

Permanent salivary damage caused by doses 50Gy

Radioactive iodine for thyroid cancer treatment has

similar but less severe effect

Clinical presentation1. Salivary gland dysfunction signs & symptoms2. Osteonecrosis3. Increased risk of tumors affecting radiated tissues

MANAGEMENT STEPS FOR PATIENTS WITH RADIATION-

INDUCED XEROSTOMIA

RADIATION INJURY7

Low dose radiation (1000cGy) to a salivary gland

causes an acute tender and painful swelling within

24hrs.

Serous cells are especially sensitive and exhibit

marked degranulation and disruption.

Continued irradiation leads to complete

destruction of the serous acini and subsequent

atrophy of the gland7.

Similar to the thyroid, salivary neoplasm are

increased in incidence after radiation exposure7.

GRANULOMATOUS DISEASE 7

Primary Tuberculosis of the salivary glands:• Uncommon, usually unilateral, parotid most common

affected• Believed to arise from spread of a focus of infection

in tonsils

Secondary TB may also involve the salivary glands

but tends to involve the SMG and is associated with

active pulmonary TB.

6- GRANULOMATOUS CONDITIONS

1. Tuberculosis• Granulation tissue formation in salivary gland

1. Xerostomia2. Salivary gland enlargement

2. Sarcoidosis• Granulomas (T lymphocytes) affecting several organs

• Lungs• Skin• Eyes• Parotid glands

• Severity and duration of disease varies• Mild improvement noticed with steroid therapy

GRANULOMATOUS CONDITIONS

1. Tuberculosis• Granulation tissue formation in salivary gland

1. Xerostomia2. Salivary gland enlargement

2. Sarcoidosis• Granulomas (T lymphocytes) affecting several organs

• Lungs• Skin• Eyes• Parotid glands

• Severity and duration of disease varies• Mild improvement noticed with steroid therapy

GRANULOMATOUS DISEASE 7

Sarcoidosis: a systemic disease characterized by noncaseating granulomas in multiple organ systems

Clinically, SG involvement in 6% cases

Heerfordts’s disease is a particular form of sarcoid characterized by uveitis, parotid enlargement and facial paralysis. Usually seen in 20-30’s. Facial paralysis transient.

GRANULOMATOUS DISEASE 7

Cat Scratch Disease:Does not involve the salivary glands directly, but involves the periparotid and submandibular triangle lymph nodes May involve SG by contiguous spread.Bacteria is Bartonella Henselae(G-R)

Also, toxoplasmosis and actinomycosis.

CYSTS7

True cysts of the parotid account for 2-5% of all parotid lesions May be acquired or congenital Type 1 Branchial arch cysts are a duplication anomaly of the membranous external auditory canal (EAC)Type 2 cysts are a duplication anomaly of the membranous and cartilaginous EAC

CYSTS

Acquired cysts include:Mucus extravasation vs. retentionTraumaticBenign epithelial lesionsHIVAssociation with tumors

• Pleomorphic adenoma• Adenoid Cystic Carcinoma• Mucoepidermoid Carcinoma• Warthin’s Tumor

OTHER: PNEUMOPAROTITIS

In the absence of gas-producing bacterial parotitis, gas in the parotid duct or gland is assumed to be due to the reflux of pressurized air from the mouth into Stensen’s duct.May occur with episodes of increased intrabuccal pressure

• Glass blowers, trumpet playersAka: pneumosialadenitis, wind parotitis, pneumatocele glandulae parotis

PNEUMOPAROTITIS8

Crepitation, on palpation of the gland

Swelling may resolve in minutes to hours, in some

cases, days.

US and CT show air in the duct and gland

Consider antibiotics to prevent superimposed

infection

NECROTIZING SIALOMETAPLASIA

Benign self-limiting reactive inflammatory disorder

Etiology• Unknown• Trauma (LA)

Clinical presentation• Red nodule• Deep ulcer with rolled margin• Necrosis• Moderate dull pain• 6-8 weeks

Treatment

OTHER: NECROTIZING SIALOMETAPLASIA

Cryptogenic origin, possibly a reaction to ischemia

or injury

Manifests as mucosal ulceration, most commonly

found on hard palate.

May have prodrome of swelling or feeling of

“fullness” in some.

Pain is not a common complaint

NECROTIZING SIALOMETAPLASIA

Self limiting lesion, heals by secondary

intention over 6-8 weeks

Histologically may be mistaken for SCC

IMPORTANCE OF SALIVA

Oral hygiene

Taste acuity

Mastication

Deglutition

Digestion

Voice acuity

Speech articulation

XEROSTOMIA

22 – 26% of total population Occurs most common among elderly Associated with immunotherapy,

radiotherapy Treatment

1. Stringent oral and dental care2. Radiation therapy protectants3. Gene therapy4. Pharmacologic options

DIAGNOSTIC APPROACH1- EVALUATION OF DRY MOUTH

Symptoms of salivary gland dysfunction

1. Dryness of all oral mucosal surfaces

2. Difficulty chewing, speaking

3. Increased sensitivity to spicy food

4. Increased caries activity

D I A G N O S T I C A P P R O A C H2 - PAST & PRESENT MEDICAL HISTORY

Radiotherapy

Dryness at other body sites (eye, nose, skin) Medication

• Tricyclic antidepressant• Antihypertensive• Antihistamines• Decongestants

DIAGNOSTIC APPROACH3- CLINICAL EXAMINATION

Intra-Oral examination• Notice signs of salivary gland dysfunction

• Red depapillated tongue• Oral mucosa adhere to mirror• Lipstick/food debris on anterior teeth• Candidaiasis• Increase caries & erosion

• If could detect mass• Any mucosal ulcerations over the mass• Milking of saliva

DIAGNOSTIC APPROACH3- CLINICAL EXAMINATION

Extra-Oral examination

• Palpate cervical lymph nodes

• Palpate the gland

• Slightly rubbery

• Painless unless infected/inflamed

• Check motor function of facial nerve

DIAGNOSTIC APPROACH4- SALIVA COLLECTION

Different methods to determine salivary flow rate

Salivary flow rate fluctuate

Abnormal low salivary flow rate• Unstimulated whole saliva flow rate <0.1ml/min

• Stimulated whole saliva flow rate <1.0ml/min

TREATMENT OF XEROSTOMIA

1. Preventive therapy1. Florid rinses & gel2. Oral hygiene

2. Symptomatic treatment1. Water 2. Artificial saliva• Avoid products containing sugar, alcohol

3. Salivary stimulation1. Local / topical stimulation

1. Chewing (flavoured)2. Systemic stimulation (sialogogues)

1. Pilocrpine HCl

FREY’S SYNDROMEEtiologies:1. Trauma to parotid regions

a. Parotidectomyb. Penetrating traumac. Closed mandibular fractures

2. Trauma to cervical sympathetic chain3. Diabetic neuropathy4. Aberrant regeneration location

a. CP angleb. Middle earc. OTIC Ganglions

TREATMENT OF FREYS SYNDROME

1. External radiotherapy

2. Local or systemic applications of

anticholinergic drugs

3. Section of some portion of efferent arc

4. Interposition of subcutaneous barrier

5. Botox injection

SIALORRHEACauses:1. Change in oral perception

1. Neurologic changes (CVA, Parkinson’s)2. Extensive oral surgical procedure

2. Decrease swallowing

Treatment:3. Speech pathologist4. Xerostimia inducing drugs (antihistamine)5. Botulinum toxins (Botox injection)6. Surgery

A G E C H A N G E S I N S A L I VA RY G L A N D S

Reduction in weight of parotid and submandibular glands related to atrophy of secretory tissue & replacement by fibrofatty tissue.

Similar changes in labial minor glands.

Oncocytic change in ductal epithelium.

Reduction in flow rate in submandibular gland.

REFERENCES

1. McQuone, SJ: Acute viral and bacterial infections of the salivary glands. Oto

Clinics North America, 32:793,1999

2. Marchal F, Dulguerov P. Sialolithiasis Management. Arch Oto, 129:951,

2003

3. Escudier MP, McGurk M. Symptomatic sialodenitiis and sialolithiasis in the

english population:an estimate of the cost of hospital treatment. Br Dent J.

1999;186:463

4. Lustmann J, Regev E, Melamed Y. Sialolithiasis: a survey on 245 patients

and a review of the literature. Int J Oral Maxillofacial. 1990; 19, 135

5. Crabtree GM, Yartington CT. Submandibular gland excision. Laryngoscope.

1988;98:1044

Sialadenitis

Treatment:• The first step is to make sure about fluid balance. •Patient needs to receive fluids intravenously •Antibiotics to destroy the bacteria. •Sugarless sour candies or gum is recommend ,they can stimulate the glands to produce more saliva. •If the infection is not improving, surgery may be needed to open and drain the gland.

Prevention:Always drink plenty of fluids. This is especially important after surgery, during illness or in elderly people