Diseases of the Salivary Glands

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Talk about the anatomy of a salivary gland.

3 major salivary glands: parotid, submandibular, sublingual. Minor salivary glands: 750-1000 glands located submucosally from lips -> trachea, others in aerodigestive tract: paranasal sinus, hypopharynx, larynx, trachea. Duct-acinus unit (pyramid shape surrounding lumen) Duct: 3 types of specialized epithelia cells involved in modification/excretion of saliva - 1) Acini contain cells that secrete mucous/serous fluid. 2) Smooth/myoepithelial cells surround these secretory acinar cells. BECAUSE of the cellular complexity of this unit --> leads to possibility for different malignant variants of carcinoma! 2 large ducts - Cheek (stenson's duct), Sublingual (wharton's duct)

What's the physiology of a salivary gland?

Saliva - moistens food, buffers acid, mucins protects mucosa, prevents dental caries, provides inorganic ions for enamel formation, immunity! (2/3 of salivary flow = unstimulated is from submandibular gland. 2/3 stimulated = parotid duct)

What are the common etiologies of an acute inflammatory disease of the salivary glands?

Viral and Bacterial

What are the types of viral diseases? (acute inflammatory disease)

Mumps, Coxsackie virus A (spring, young kids), echo viruses, influenza A, lymphocytic choriomeningitis, HIV, Cytomegalovirus (in newborns- may lead to mental/physical retardation, causes: jaundice, hematomegaly, thrombrocytopenic purpura!

What are the types of viral diseases? Measles

1) Mumps- cause: contagious systemic myxovirus, incubates 14-21 days, SSX: SHE'S FMM. Sour liquids =painful, headache, erythema stenson's duct orifice, swelling of parotid (uni/bi) (not usually felt at all), fever, malaise, myalgia. Complications: sensorineural deafness, encephalitis, orchitis/oophoritis can lead to sterility. Tx: supportive, symptomatic. Prevention: vaccine!

What's the etiology of Acute Suppurativa Sialentitis? (b)

1) Stasis (nothing's flowing) secondary to obstruction. 2) Decreased salivary flow or production. 3) Dehydration. 4) Poor oral hygiene

Parotiditis (b)

Who? Post-op pt, esp after GI surgery, elderly. Etiology? Exposure to HOSPITAL FLORA!, dehydrated pt, pt isn't eating which is a stimulatory/detergent effect (that's lost!), Calculi/duct stricture. Organisms: Staph aureus - most common in the parotid. SSx: SUDDEN onset of DIFFUSE enlargement of the involved gland, induration, tenderness, pain. 2) PURULENT SALIVA @ at the duct orifice -> massage the gland (warn them that it might hurt!). DX: culture/gram stain. TX: antibiotics, massage gland, dilation of duct (done with probe, stone? might pop out), warm compress, lemon drops!, hydration, improved oral hygiene/nutrition. (will feel better in 24-48 hr, if non responsive SURGERY DRAINAGE...mortality from septicemia ~20% +due to associated disease

Chronic Inflammatory Disorder Chronic Sialadenitis aka Chronic Sialadenitis Parotid

Etiology: lowered secretion rate/stasis, MOST common in PAROTID GLAND, damage from recurrent acute infection/childhood, (ductal ectasia, sialectasis, progressive acinar, destruction, w/lymphocytic infiltrate ((might be scarring over time!)), recurrent stones, changes in saliva chemically result. SSX: history of painful recurrent parotid enlargement aggrv by eating, >gland size, massage can produce scanty saliva at orifice, PERMANENT XEROSTOMIA (dry mouth) 80%. TX: treat the treatable (stone stricture, (same as acute-massage, lemon drops, abx). Bebe aggresive: periodic ductal dilation, ligation of the duct, total gland irradiation, excise the gland!

What can Chronic recurrent Parotiditis lead to?

Benign Lymphepithelial lesion! >F, in recurrent- usually an asymptomatic enlargement (unless infected, treat, otherwise no tx!)

How is Parotiditis different in children?

(infant - 12 yo) > M!!! Sudden onset unilateral or bilateral parotid swelling, NO OBVIOUS CAUSE, clinically not ill- salivary chemistries are altered in the adult form. SSX: mild pain, no xerostomia, may go away at puberty. --> FOLLOW UP CLOSELY! Can develop carcinoma, lymphocytic lymphoma involving extra salivary sites.

Autoimmune Disease Sjogren's Syndrome

WBCs replace/invade the glands function. Etiology: collagen vascular disorder, 90% FEMALES!. SSX: KGX: keratoconjunctivitis sicca, gland enlargement (bilateral par, lacr, submand), xerostomia

Primary tuberculosis.

UNCOMMON - TB of the salivary gland, mostly parotid (focus your attention on any infected tonsils or teeth!), DX: Acid-Fast salivary stain, fine needle aspiration (cytology), TX: treat acute TB, if resistant, excise the gland!

Describe actinomycosis and sarcoidosis.

A: occurs in salivary, Tx: i&d, long term antibiotics. S: unknown etiology, SSx: uveitis, parotid enlargement, facial paralysis (transient), f&n, night sweats, swelling might last for months or years, involve other glands as well, TX- symptomatic/supportive, steroids - good in acute phase. Be careful uveitis can lead to glaucoma!!!

Sialolithiasis: CALCULI! How can I lookatchu?

80% are in the SUBMANDIBULAR GLAND! (radio-opaque) <20% parotid (radiolucent)...minor salivary gland uncommon to have stones - upper lip and buccal mucosa. USE CT IMAGE TO SEE! (parotid) Plain X-ray for a submanidbular stone. Facts: Usually only 1, multiple gland-mid-men

What's the only condition that causes calculi? What is calculi?

GOUT! (only systemic condition to cause uric acid calculi). Well Marian, calculi are calcium phosphates w/small amounts of Mg, Am, Carbonate

Etiology of Sialolithiasis

1) Calculus formation - nidus (origination) of material allowing precipitation of salts coupled w/stasis. 2) Submandibular duct is MORE susceptible because saliva = >alkaline, >Ca and [PO3], duct longer, antigravity flow

What are the SSX of calculi?

1) may be palpable in duct, 2) GLAND IS ENLARGED, and tender, 3) massage of the gland DECREASES the flow of cloudy/mucopurulent saliva

Tx of calculi?

1) Acute infection should be treated. 2) Location at or near the orifice of duct removed transorally. 3) If it's within the hilum of the gland- excise the gland!. 4) Recurrence is rare ~18%

Describe ductal stenosis!!

Etiology: trauma, neoplasm, chronic inflammatory process. SSx: PAINFUL Swollen gland-neoplasm is usually palpable. Tx: dilation or gland excision

What are the types of cystic lesions?

1) Ranula- mucocele-mucus retention cyst of the floor of mouth. 2) Mucocele + retention cysts= common on the lips, buccal mucosa, ventral portion of the tongue Types: circumscribed obstruction + cystic dilation of the sublingual gland/submandibular duct. 2) Plunging-extravastion of saliva into tissues of the floor of the mouth

What are the SSX and TX of a cystic lesion?

Cystic sub mucosal mass in the floor of the mouth, may SHRINK periodically w/discharge of contents into mouth. Tx: circumscribed cyst excised w/gland, plunging ranula extends from floor of mouth into the neck.

Congenital Cyst

Most true cysts, occur in the parotid - 2-5% of lesions. Type of congenital cyst = dermoid cyst (keratinizing squamous epithelium w/associated skin appendages. Tx: complete removal of cysts and preservation of the facial nerve

Branchial cyst

1st arch branchial cleft cyst <1% of all branchial cleft anomalies, present as cysts/draining sinuses preauricular area. Type 1 cysts: track deep into parotid along the External Auditory Canal. Type 2 cysts: track deep into the parotid and are intimately involved w/the facial nerve. Tx: excision

What if I have trauma?

-Pentrating injury to the parotid gland, may involve the duct/facial nerve, inspect directly! If no duct identified, pass the probe transorally w/in the wound. Compress to find the orifice. if transected, end to end anastomose over a polyurethan catheter suture in place to the buccal mucosa. Laceration to the parenchyma? manage conservatively! Hematoma can be drained! Salivary cutaneous fistula can develop therefore use repeated aspiration/pressure dressings - it will heal in 1-2 weeks! (submandibular/sublingual are the least common ductal injuries, since the mandible protects them!)

What is Sialadenosis: assymetry?

It's a non-specific term that describes a non-inflammatory non-neoplastic enlargement of a salivary gland, parotid usually, elderly submandibular commonly. Etiology: own mechanism. Signs: gland enlargement=asymptomatic, bilateral parotid swelling can occur, bilateral submandibular gland swelling (SEEN IN ELDERLY!), fatty hypertrophy in fatties, malnutrition - common, pellegra, alcoholic cirrhosis (parotid 30-80%), DM, Beri beri (vit C def), anorexic, bulima, kwashiokor, hypovitaminosis A, celiac disease, bacillary dysentery (ANY CHRONIC DISEASE THAT INTERFERES W/THE ABSORPTION OF NUTRIENTS Tx: treat the underlying disease and the parotid should go back to normal!

Other disorders of the salivary gland

Pneumparotitis (increased intrabuccal pressure), Cherlitis glandularis (enlargement of labial salivary gland, secretes clear sticky mucus), Kussmaul's Disease (duct becomes fibrous and duct becomes visible in the orifice), Drug induced salivary gland enlargement (iodine, heavy metals, isopropternol, phenothiazine), Necrotizing Sialometaplasia (cryptogenic origin - some related to injury tho, mucosal ulceration commonly of hard palate but can occur in any salivary tissue

Parotid Gland neoplasm

~Parotid = largest volume of salivary tissue, 20% tumors here are malignant!, SUBMANDIBULAR + MINOR SALIVARY GLAND TUMORS = increasingly % of malignancy!!. Chances of malignancy: 1:4-parotid, 1:1-submandibular, 4:1- sublingual. MINOR SALIVARY GLAND TUMOR IS FAR MORE WORRISOME!! OMG OMG!

What are the risk factors of getting a parotid gland neoplasm?

Non-race related. 1) clustering of lymphepitheliomas (undifferentiated squamous c.c of the major salivary glands - eskimo's have it). 2) Woodworkers inhale wood dust - could develop sinonasal adenocarcinoma. 3) Carcinogenic role of alcohol + tobacco (more obvious in head/neck cancers...not really salivary gland cancer!

What are the common presentations of the major salivary gland?

DAPHNES: dysphasia, aspiration, painless mass, hoarseness, nasal obstruction, epistaxis, sinusitis. RESPIRATORY DIFFICULTY

What are the uncommon presentations of the major/minor glands?

Soft palate bulge, cranial nerve weakness!

What are the clinical presentations of the minor salivary glands?

CAPED: CSF fluid leak-(when sino nasal mass grows), anosmia (loss of smell), proptosis, epiphoria (overproduction of tears), diplopia (double vision) or visual compromise!

SO you've got a parotid tumor...

55-60 yo, asymmetric (4-8 mo), pleomorphic adenoma may present w/sudden change in s.s.. PE: fixation to other surr. structures, pain/no pain, superficial lobe in 90%, trismus (locked jaw), parapharyngeal space mass 5%, regional motor or sensory cranial nerve deficit, facial nerve paralysis, ulceration of surr. soft tissue, APPARENT cervical lymph nodes (10-15%)

What's the most common salivary gland carcinoma of the head/neck?

1) mucoepidermoid carcinoma (MOST COMMON) - low-intermediate-high grade

SSx of Submandibular gland malignancies

Clinically, 50-60 yo, >M. SSX: asymptomatic mass, pain in 6-7% of pts, sX LAST 6 MONTHS, AND THEN tumor for >5 years, usually low grade mucoepidermoid carcinoma/malignant mixed tumors, Skin attachment ~ 28%, local tumors invasion includes nerves (may lose sensation of tongue!) CERVICAL LYMPH NODE METASTASIS IS CLINICALLY APPARENT, 14-16% OF THE TIME!

Sublingual malignancies

45% asymptomatic floor of mouth swelling, 20% identified by dentist, 15% already experiencing pain! Sx: PAIN, impaired denture, tongue sensory loss.

Where are the tumor sites?

They're located in anatomically concealed locations like the nose, paranasal sinus, upper pharynx. They grow considerably b4 causing symptoms that lead to Dx...most tumors involve the oral cavity, COMMON IN THE HARD PALATE!!!!!.

What are the SSX?

pain and ulceration = unusual, nasal cavity/paranasal sinus = epistaxis, nasal obstruction, chronic sinusitis, facial pain, and swelling. Most MOBILE hard palate are not, duration of Sx: 6 months, 30% have Sx > year before diagnosis

How do you diagnose cancer?

1) FNA Bx: fine needle aspiration biopsy - done immediately by cytologist, DO IT FIRST!. 2) Imaging - CT scan or MRI w/+w/out contrast PET/CT.

How do you stage the cancer?

1) classify the primary tumor, size, extraparenchymal extension. 2) Lymph node involvement. 3) Distant metastasis

When do you refer?

Cytologist MD (to biopsy), medical oncologist, radiation oncologist, maxillofacial surgeon (for removal), team approach, head and neck surgeon

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