salivary gland disorders final
TRANSCRIPT
Presented By :- Dr Jayesh
PG Student
Dept Or Oral And Maxillofaical Surgery
SALIVARY GLAND DISORDERS AND SALIVARY GLAND DISORDERS AND DIAGNOSISDIAGNOSIS
Anatomy and physiologyClassification
Diagnostic modalitiesSalivary gland diseasesSalivary gland tumors
ConclusionReferences
ANATOMY
PAROTID GLAND
Parotid gland
PAROTID CAPSULE
PAROTID DUCT
BLOOD SUPPLY
Nerve supply:
Lymphatic drainage:
Parotid lymph nodes:
ANATOMY
SUBMANDIBULAR GLAND
Submandibular duct:
i
BLOOD SUPPLY AND LYMPHATIC DRAINAGE
ANATOMY
Nerve supply:It is supplied by branches 'from the submandibular ganglion. These branches convey: (a) Secretomotor fibres: (b) sensory fibres from the lingual nerve. and (c)vasomotor sympathetic fibres 'from the plexus on the facial artery.
Smallest of the 3 salivary glands,lies above the mylohyoid,below the mucosa of floor of the mouth medial to sublingual fossa of the mandible,lateral to the genioglossus.
About 15 ducts emerge from the gland most of them directly open into floor of mouth.the acinar ducts are called Bartholin’s ducts and in most instances coalesce to form 8to 20 ducts of rivinus.
SUBLINGUAL SALIVARY GLAND:
Serous cells: produce a thin watery secretion
Mucous cells: produce a more viscous secretion
Parotid: serous
Submandibular: mucous & serous
Sublingual: mucous
Physiologic control of the SG is almost entirely by the autonomic nervous system; parasympathetic effects predominate.
If parasympathetic innervation is interrupted, glandular atrophy occurs.
Normal saliva is 99.5% water
Normal daily production is 1-1.5L
PHYSIOLOGY
Keeps the mouth moist-lubricates food and mouth during chewing, swallowing and phonationRenders food substances soluble-thus aiding in taste sensation
Digestion of starch in the diet is first by œ-amylase ptyalin in the saliva
Noxious substances increase the salivary secretion there by help in diluting the noxious stimuli
Bicarbonate & protein contribute to the buffering power of saliva-restores physiologic pH of the oral cavity
FUNCTIONS OF SALIVA
May be used as a diagnostic tool in monitoring physiologic disorders and systemic hormone & drug
levels.
Protective & Anti bacterial Functions:Salivary mucins (glycosaminoglycans) coating the oral
mucosa protect against the harmful effects of noxious stimuli, Microbial toxins & minor trauma. This coat
traps the microbes and transfers them to the stomach where the acidic Ph of the gastric juice degrades
them. Lysozyme-an enzyme that has little effect on the normal flora inhibits the noncommensals by
combining with IgA immunoglobulin and lyses the bacteria.
Thiocynate dependent factors –the presence of which increases the chances of oral malignancy is increased with decrease in saliva
as seen in smokers and tobacco chewers. Green’s factor-Anticariogenic, presence is now questioned
Lactoferrin-binds with the available iron and does not allow it to enter bacterial metabolism.
Antifungal property-by a histidine rich peptide-inhibits candidal growth.
A . Developmental Congenital aplasiaCongenital hypoplasiaAtresia Aberance or ectopic gland Accessory duct Congenital fistulaB.InflammatoryAcute and chronicStaphylococcal,streptococcus,actinomycosis,tuberculosis.Viral infectionMumps ,CMV,para-influenza.
CLASSIFICATION OF SALIVARY GLAND DISORDER
C .Obstructive Sialolithiasis Mucocele Ranula D .Autoimmune Sjogrens syndromeBenign lymphoepithelial lesionE .Neoplasms F .Others Sialadenosis Necrotizing sialometaplasiaFrey’s syndrome
Plain film radiographs. Sialography. Flow rate studies. Sialoendoscopy. Sialochemistry. FNAC. Salivary gland biopsy. Computed tomography. Radioisotope imaging. Magnetic resonance imagingScintigraphy.
DIAGNOSTIC MODALITIES
COMMONLY USED RADIOGRAPHIC PROJECTIONS
Parotid gland •OPG•Oblique lateral•Rotated PA or AP•Intra oral view of cheek
Submandibular gland
•OPG•Oblique lateral•Lower 90degree occlusal to show duct •Lower oblique occlusal to show gland•True lateral skull with tongue depressed
Sialography can be defined as the radiographic demonstration of the major salivary glands by introducing a radiographic contrast medium into their ductal system.The procedure is divided into three phases:
Preoperative phase
The filling phase
The emptying phase
SIALOGRAPHY
To determine the presence or position of calculi or other blockages.
To assess extent of ductal and glandular destruction secondary to an obstruction.
To determine the extent of glandular breakdown and as a crude assesment of function in cases of dry mouth.to determine the location ,size,nature and origin of a swelling or mass.
INDICATIONS:
Allergy to compounds containing iodine.
Acute inflammation or infection.
When calculus is close to the duct opening,as injection of the contrast medium may push the calculus back down the main duct where it may be inaccessible.
CONTRAINDICATIONS:
Involves taking preoperative radiographs before the introduction of contrast medium
To note the position and presence of any radiopaque obstruction
To assess the position of shadows cast by normal anatomical structures that may overlie the gland,such as the hyoid bone.
To assess the exposure factors.
PREOPERATIVE PHASE
Having obtained the films,the relevant duct orifice need to be found,probed and dilatedand then cannulated.
Three main techniques for introducing contrast medium are:Simple injection technique
Hydrostatic technique
Continous infusion pressure monitored technique
Oil based or aqueous contrast medium is introduced using gentle hand pressure until patient experiences tightness or discomfort in the gland,about 0.7ml for parotid gland,0.5mlfor Submandibular gland. Hydrostatic technique:
Aqueous contrast media is allowed to flow freely into the gland under the force of the gravity until patient experiences discomfort.Continuous infusion monitored technique:A constant flow rate is adopted and the ductal pressure is monitored through out the procedure
Ionic aqueous solutions including:
Iothalamate
Metrizoate.
Oil based solutions:
Iodized oil eg.lipiodol
Water insoluble organic iodine compounds eg.pantopaque.
Most commonly used are aqueous solutions.
CONTRAST MEDIA:
The cannula is removed and the patient is allowed to rinse out. The use of lemon juice at this stage to aid excretion of contrast medium is advocated but is seldom
necessary.
EMPTYING PHASE
Parotid gland:
The main duct is of even diameter1-2mm and should be filled completely and uniformly.
Tree in winter appearance.
Submandibular gland:
The main duct is of even diameter 3-4mm .
Bush in winter appearance.
NORMAL SIALOGRAPHIC APPEARANCES
These are used to investigate salivary gland function . Comparative flow rates of saliva from major salivary glands are measured over a known time period .Indications: Dry mouth Poor saliva flow Excess salivation
FLOW RATE STUDIES
Advantages :Ionizing radiation is not usedSimple to performProvides information on salivary gland function
Disadvantages:No indication of nature of underlying diseaseTime consuming
It is a specialized procedure that uses a small video camera (endoscope) with light at the end of a flexible cannula; which is introduced into the ductal orifice . The endoscope can be used diagnostically and therapeutically.It has demonstrated strictures in the ductal system , as well as mucous plugs and calcifications.May also be used to dilate small strictures and flush clear small mucous plugs .Specialized devices such as balloon catheters may be used to dilate sites of ductal constriction.
SIALOENDOSCOPY
An examination of the electrolyte composition of the saliva of each gland may indicate a variety of disorders.
Principally the concentration of sodium and potassium,which normally change with salivary flow rate are measured .
Certain changes in the relative concentrations of these electrolytes are seen in specific disorders.
SIALOCHEMISTRY
This procedure has a high accuracy rate for distinguishing between benign and malignant lesions in the superficial locations.
Performed using a syringe with a 20guage or smaller needle.
FINE NEEDLE ASPIRATION BIOPSY
Either incisional or excisional can be used to diagnose a tumor of one of the major salivary gland.
But is usually performed as an aid in the diagnosis of sjogrens syndrome .
The lower lip labial salivary gland biopsy has been shown to demonstrate certain histopathological changes.Around 10 minor salivary glands are removed for
histopathological examination.
SALIVARY GLAND BIOPSY
Indications:Discrete swellings both extrinsic and intrinsic to the
salivary glands.Advantages:
Provides accurate localization of masses especially in the deep lobe of the parotid.
The nature of the lesion can often be determined.Images can be enhanced by using contrast media,either in the ductal system or more commonly intravenously .
COMPUTED TOMOGRAPHY
Disadvantages:Provides no indication of salivary gland function.
Small calculi may not be detected.Risks associated with intravenous contrast media.
Indications:Dry mouth due to salivary gland diseases such as sjogrens syndrome.To assess salivary gland function.Advantages:Allows bilateral comparison and images all four major salivary glands at the same time.Computer analysis of results is possible.Can be performed in cases of acute infection
RADIOISOTOPE IMAGING
Disadvantages:
Provides no indication of salivary gland anatomy or ductal architecture.
Relatively high radiation dose to the whole body.
Images are not diseases specific.
Indications:Discrete swellings both extrinsic and intrinsic to the salivary glands.Advantages:Ionizing radiation is not used.Provides excellent soft tissue detail,readily enables differentiation between normal and abnormal.Accurate location of massesImages in all planes and facial nerve is usually identifiable.
MAGNETIC RESONANCE IMAGING
Scintigraphy is the only method available that can provide qualitative and quantitative functional assessments of the major salivary glands
The isotopes used for salivary gland is Technetium-99m pertechnetate
Technetium-99m about 5 mCi is injected intravenously into antecubital vein. The activity is at 1st, 20th, and 40th min]. Twenty minutes after the injection, vitamin C chewable tablet was given to stimulate the secretion and continued until the end
of the study period (40 min)
SCINTIGRAPHY
Sialosis: Non neoplastic and noninflammatory enlargement of salivary glandsSialadenitis: Inflammation of salivary glandsSialodochitis: Inflammation of salivary ductXerostomia: Salivary production < 0.2ml\ minSialolithiasis: Calculi / stone in duct or glandSialactesis: Atrophy of total / part of salivary glandPtyalism : Excessive secretion of saliva > 4 ml / min
TERMINOLOGIES
Xerostomia is salivary production less than 0.2ml / min.
XEROSTOMIA (PTYALISM / DRY MOUTH
SYNDROME)
Factors affecting salivary center: Emotional disturbance like stress,strain.
Depression.Hysteria.Neurosis.
Factors affecting ANS:EncephalitisBrain tumor
Neurological operationFactors affecting salivary gland:
DevelopmentalInflammatory
Atrophy of glandSjogren’s syndromeMickuliz’s disease
Alteration in fluid and electrolyte balance:DehydrationDiarrhea Vomiting Diuresis
Diabetes insipidusLiver cirrhosis
Drugs:AnticholinergicsAntideppresants Antihistamines Antipsychotics
SympathommimeticsSedatives Steroids
Chemotherapeutic agents MalnutritionRadiationToxemia
Chronic alcoholismHabits(smoking,betul nut chewing)
MANAGEMENT:
Use of water or gels
Lozenges / sour candies
Non fermentable carbohydrates
Saliva stimulating agents
Glycerol
Lemon juice
Oral hygiene
Chewing gums (Fluorides)
Hexidine mouth washes
Artificial saliva (lacks mucus)
Causes:Acute inflammation oral mucosa.
During eruption of teeth in infants.Mental retardation.
Parkinsonism.Epilepsy .
Schizophrenia.Acrodynia.Rabies.
Psychosis .Neurosis.
Drugs like sialogogues.
SIALORRHOEA (PTYALISM)
Mucous extravasation phenomenon
mucous escape reaction
Common lesion of oral cavity involving salivary glands and ducts
Result from traumatic severance of salivary duct by biting lips or cheek, pinching the lips by extractions forceps thus leading to spillage of mucin into surrounding tissues
Lack epithelial lining, they are not true cysts
MUCOCELE
Most common on lower lip and usually found laterally to midline
Less common sites include buccal mucosa, anterior ventral tongue and floor of the mouth
Increased predilection in children and young adults, possibly because of higher incidence of trauma
Appear as raised dome shaped vesicle ranging in size from 1to 2mm to several centimeters
May lie fairly deep in the tissue or be exceptionally superficial and thus depending on the location will
present a variable clinical appearance
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
Superficial lesions present a bluish transluscent cast the blue color imparted by spilled mucin below the mucosal surface
Treatmennt is excision Excision with strict removal of any projecting peripheral salivary glands
Avoid injury to other glands during primary wound closure
Form of mucocele that specifically occurs in floor of the mouthDerived from the latin word rana meaning meaning frog,because the swelling may
resemble a frogs transluscent bellyMost common source of mucin spillage is sublingual gland, may also arise from
submandibular duct or from minor salivary glands in floor of mouthMostly located laterally to midline
RANULA
Develops as a slowly enlarging painless mass in the floor of mouth
A rare suprahyoid type termed plunging or cervical ranula occurs due to herniation of spilled mucin through the
mylohyoid muscle producing swelling in the neck Treatment is removal of sublingual gland or marsipulization Entails removal of roof of the lesion potentially allowing the sublingual gland ducts to reestablish communication with the
oral cavity.Most authors emphasize removal of offending gland is the
most important consideration in preventing recurrence.
CLINICAL FEATURES
Sialocyst or mucous duct cystEpithelium lined cyst arising from salivary gland tissues
Commonly observed in adult age groupCan arise in both major and minor salivary glands.
Parotid gland is the most commonly involved presenting as slowly growing asymptomatic swelling.
Conservative surgical excicion is the treatment of choice for isolated cysts.
SALIVARY DUCT CYST
Also called sicca syndromeTriad of keratoconjunctivitis sicca, xerostomia and
rheumatoid arthritis.Primary sjogrens syndrome present only with dry eyes
and dry mouth.Secondary sjogrens syndrome present with systemic
lupus erythematosus ,polyarteritis nodosa,rheumatoid arthritis and scleroderma.
Etiology;Combination of factors like
genetic,hormonal,infectious and immunologic have been suggested.
SJOGREN SYNDROME
Predominantly in women over 40yrs of age.Male to female ratio is 1:10. 90% cases occur in women
Dryness of mouth and eyes as a result of hypo function of salivary and lacrymal glands,burning sensation of oral
mucosaClassic monograph on the disease published in 1933 by
Sjögren, a Swedish ophthalmologist
CLINICAL FEATURES
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 finiding is lacrimation of 5mm or less.
Approximately 85% specific & sensitive
Diagnosis: 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
SialolithiasisMucous retention/extravasation
OBSTRUCTIVESALIVARY GLAND
DISORDERS
Sialolithiasis results in a mechanical obstruction of the salivary duct
Is the major cause of unilateral diffuse parotid or submandibular gland swelling.
OBSTRUCTIVE SG DISORDERS: 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.
Acute ductal obstruction may occur at meal time when saliva producing is at its maximum, the resultant swelling 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.
Etiology :Water hardness ↑likelihoodHypercalcemia
Xerostomic medsTobacco smoking, positive correlation
Smoking has an increased cytotoxic effect on saliva, decreases PMN phagocytic ability and reduces salivary proteins
Organic; often predominate in the center
Glycoproteins
Mucopolysaccarides
Bacteria!
Cellular debris
Inorganic; often in the periphery
Calcium carbonates & calcium phosphates in the form of hydroxyapatite
STONE COMPOSITION
Saliva more alkaline
Higher concentration of calcium and phosphate in the saliva
Higher mucus content
Longer duct
Anti-gravity flow
REASONS SIALOLITHIASIS MAY OCCUR MORE OFTEN IN THE
SMG
Painful swelling (60%)
Painless swelling (30%)
Pain only (12%)
Sometimes described as recurrent salivary
colic and spasmodic pains upon eating
CLINICAL PRESENTATION
History of swellings / change over time?Trismus?
Pain?Variation with meals?
Bilateral?Dry mouth? Dry eyes?
Recent exposure to sick contacts (mumps)?Radiation history?
Current medications?
CLINICAL HISTORY
Asymmetry (glands, face, neck)
Diffuse or focal enlargement
Erythema extra-orally
Trismus
Medial displacement of structures intraorally?
Examine external auditory canal (EAC)
Cranial nerve testing
INSPECTION
Palpate for cervical lymphadenopathyBimanual palpation of floor of mouth in a posterior to anterior direction
Have patient close mouth slightly & relax oral musculature to aid in detection
Examine for duct purulence
Bimanual palpation of the gland (firm or spongy/elastic).
PALPATION
Effective for intraductal stones, while….
intraglandular, radiolucent or
small stones may be missed.
DIAGNOSTICS: PLAIN OCCLUSAL FILM
CT Scan:
large stones or small CT slices done
also used for inflammatory disorders
Ultrasound:
operator dependent, can detect small stones (>2mm), inexpensive, non-invasive
DIAGNOSTIC APPROACHES
Consists of opacification of the ducts by a retrograde injection of a water-soluble dye.
Provides image of stones and duct morphological structure
May be therapeutic, but success of therapeutic sialography never documented
DIAGNOSTIC APPROACHES: SIALOGRAPHY
Disadvantages:
irradiation dose
pain with procedure
poss.perforation
infection dye reaction
push stone further
contraindicated in active infection.
Allows complete exploration of the ductal system, direct visualization of duct pathology
Success rate of >95%2
Disadvantage: technically challenging, trauma could result in stenosis, perforation
DIAGNOSTIC APPROACH: DIAGNOSTIC SIALENDOSCOPY
If patients DO defer treatment, they need to know:
Stones will likely enlarge over time
Seek treatment early if infection develops
Salivary gland massage and hyper-hydration when symptoms develop.
SIALOLITHIASIS TREATMENT
DiagnosisDigital manipulation:
Gland – firm and largerProduces flow of saliva – visual inspection of fluidLocation of hard calcific stone along ductal course
Yellowish colour of calcific deposit seen through distended and thin mucous membrane
Sialography
SIALOLITH
Acute bacterial sialdenitis
Chronic bacterial sialdenitis
Viral infections
SALIVARY GLAND INFECTIONS
Sialadenitis represents inflammation mainly involving the acinoparenchyma of the gland.
SIALADENITIS
Acute infection more often affects the major glands than the minor glands1
SIALADENITIS
1. Retrograde contamination of the salivary ducts and parenchymal tissues by bacteria inhabiting the oral cavity.
2. Stasis of salivary flow through the ducts and parenchyma promotes acute suppurative infection.
PATHOGENESIS
More common in parotid gland. Suppurative parotitis, surgical parotitis, post-operative parotitis, surgical mumps,
and pyogenic parotitis. The etiologic factor most associated with this entity is the retrograde infection
from the mouth. 20% cases are bilateral7
ACUTE SUPPURATIVE
The composition of parotid secretions differs from those in other major glands.
Parotid is primarily serous, the others have a greater proportion of mucinous material.
PREDILECTION FOR PAROTIDSALIVARY COMPOSITION
Mucoid saliva contains elements that protect against bacterial infection including lysozymes & IgA antibodies
(therefore, parotid has ↓ bacteriostatic activity)
Mucins contain sialic acid which agglutinates bacteria and prevents its adherence to host tissue.
Specific glycoproteins in mucins bind epithelial cells competitively inhibiting bacterial attachment to these cells.
SALIVARY COMPOSITION
Minor role in formation of infections
Stensen’s duct lies adjacent to the maxillary mandibular molars and Wharton’s near the tongue.
It is thought that the mobility of the tongue may prevent salivary stasis in the area of Wharton's that may reduce the rate of infections in SMG.
PAROTID PREDILECTIONANATOMIC FACTORS
Systemic dehydration (salivary stasis)Chronic disease and/or immunocompromise
Liver failure
Renal failure
DM, hypothyroid
Malnutrition
HIV
Sjögren’s syndrome
RISK FACTORS FOR SIALADENITIS
Neoplasms (pressure occlusion of duct)Sialectasis (salivary duct dilation) increases the risk for retrograde contamination.
Is associated with cystic fibrosis and pneumoparotitisExtremes of age
Poor oral hygieneCalculi, duct stricture
RISK FACTORS CONTINUED…
Mumps classically designates a viral parotitis caused by the paramyxovirus
However, a broad range of viral pathogens have been identified as causes of AVI of the salivary glands.
Derived from the Danish word “mompen”
Means mumbling, the name given to describe the characteristic muffled speech that patients demonstrate because of glandular inflammation and trismus.
As opposed to bacterial sialadenitis, viral infections of the salivary glands are SYSTEMIC from the onset!
MUMPS
Mumps is a non-suppurative acute sialadenitisIs endemic Communicable diseaseEnters through upper respiratory tract2-3 week incubation after exposure (the virus multiplies in the URI or parotid gland)3-5day viremiaThen localizes to biologically active tissues like salivary glands, germinal tissues and the CNS.
Classic mumps syndrome is caused by paramyxovirus, an RNA virus
Others can cause acute viral parotitis:Coxsackie A & B, ECHO virus, cytomegalovirus and adenovirus
Clinical presentation
VIROLOGY
30% experience prodromal symptoms prior to development of parotitisHeadache, misaligns, anorexia, malaiseOnset of salivary gland involvement is heralded by ear ache, gland pain, dysphagia and trismus
Glandular swelling (tense, firm) Parotid gland involved frequently, SMG & SLG can also be affected.
May displace ispilateral pinna75% cases involve bilateral parotids, may not begin bilaterally (within 1-5 days
may become bilateral)….25% unilateralLow grade fever
PHYSICAL EXAM
Leukocytopenia, with relative lymphocytosis
Increased serum amylase (normal by 2- 3 week of disease)
Viral serology essential to confirm:
Complement fixing antibodies appear following exposure to the virus.
DIAGNOSTIC EVALUATION
Orchitis, testicular atrophy and sterility in approximately 20% of young men Oophoritis in 5% femalesAseptic meningitis in 10%
Pancreatitis in 5%Sensorineural hearing loss <5%
Usually permanent
80% cases are unilateral .
COMPLICATIONS
ADENOMAS
Pleomorphic Adenoma
Myoepithelioma
Basal cell Adenoma
Warthins Tumor
(Adenolymphoma)
Oncocytoma
Sebaceous adenoma
Ductal Papilloma
Carcinoma s
Acinic cell carcinoma
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Basal cell carcinoma
Sebaceous carcinoma
Salivary duct carcinoma
Myoepithelial carcinoma
Squamous cell carcinoma
WHO CLASSIFICATION
OF SALIVARY GLAND TUMORS
(1992)
Non Epithelial TumoursMalignant Lymphomas
Secondary TumoursUnclassified TumoursTumours like lesions
SialadenosisOncocytosis
Necrotizing SialometaplasiaBenign Lymphoepithelial Lesions
Salivary gland cysts
Diverse histopathology
Relatively uncommon
2% of head and neck neoplasm's
Distribution
Parotid: 80% overall; 80% benign
Submandibular: 15% overall; 50% benign
Sublingual/Minor: 5% overall; 40% benign
SALIVARY GLAND NEOPLASMS
Most common of all salivary gland neoplasms
70% of parotid tumors
50% of submandibular tumors
45% of minor salivary gland tumors
6% of sublingual tumors
4th-6th decades
F:M = 3-4:1
PLEOMORPHIC ADENOMA
Slow-growing, painless massParotid: 90% in superficial lobe, most in tail of gland
Minor salivary gland: lateral palate, sub mucosal mass
Gross pathologySmooth
Well-demarcated
Solid
Cystic changes
Myxoid stroma
Histology
Mixture of epithelial, myopeithelial and stromal components
Epithelial cells: nests, sheets, ducts, trabeculae
Stroma: myxoid, chrondroid, fibroid, osteoid
No true capsule
Tumor pseudopods
Papillary cystadenoma lymomatosum
6-10% of parotid neoplasms
Older, Caucasian, males
10% bilateral or multicentric
3% with associated neoplasms
Presentation: slow-growing, painless mass
WARTHIN’S TUMOR
Gross pathologyEncapsulated
Smooth/lobulated surface
Cystic spaces of variable size, with viscous fluid, shaggy
epithelium
Solid areas with white nodules representing lymphoid follicles
Most common salivary gland malignancy
5-9% of salivary neoplasms
Parotid 45-70% of cases
Palate 18%
3rd-8th decades, peak in 5th decade
F>M
Caucasian > African American
MUCOEPIDERMOID CARCINOMA
Presentation
Low-grade: slow growing, painless mass
High-grade: rapidly enlarging, +/- pain
**Minor salivary glands: may be mistaken for benign or inflammatory process
Hemangioma
Papilloma
Tori
Gross pathologyWell-circumscribed to partially encapsulated to unencapsulated
Solid tumor with cystic spaces
Overall 2nd most common malignancyMost common in submandibular, sublingual and minor salivary glands
M = F5th decade
Presentation
Asymptomatic enlarging mass
Pain, paresthesias, facial weakness/paralysis
ADENOID CYSTIC CARCINOMA
Gross pathologyWell-circumscribed
Solid, rarely with cystic spaces
infiltrative
2nd most common parotid and pediatric malignancy
5th decade
F>M
Bilateral parotid disease in 3%
Presentation
Solitary, slow-growing, often painless mass
ACINIC CELL CARCINOMA
Gross pathology
Well-demarcated
Most often homogeneous
Rare5th to 8th decades
F > MParotid and minor
salivary glandsPresentation:
Enlarging mass
25% with pain or facial weakness
ADENOCARCINOMA
Carcinoma ex-pleomorphic adenoma
Carcinoma developing in the epithelial component of preexisting pleomorphic adenoma
Carcinosarcoma
True malignant mixed tumor—carcinomatous and sarcomatous components
Metastatic mixed tumor
Metastatic deposits of otherwise typical pleomorphic adenoma
MALIGNANT MIXED TUMORS
2-4% of all salivary gland neoplasms4-6% of mixed tumors
6th-8th decadesParotid > submandibular > palate
Risk of malignant degeneration1.5% in first 5 years
9.5% after 15 years
PresentationLongstanding painless mass that undergoes sudden enlargement
CARCINOMA EX-PLEOMORPHIC ADENOMA
Gross pathology
Poorly circumscribed
Infiltrative
Hemorrhage and necrosis
Rare: <.05% of salivary gland neoplasms6th decade
M = FParotid
History of previously excised pleomorphic adenoma, recurrent pleomorphic adenoma or recurring pleomorphic treated with XRT
Presentation
CARCINOSARCOMA
Gross pathology
Poorly circumscribed
Infiltrative
Cystic areas
Hemorrhage, necrosis
Calcification
1.6% of salivary gland neoplasms
7th-8th decades
M:F = 2:1
MUST RULE OUT:
High-grade mucoepidermoid carcinoma
Metastatic SCCA to intraglandular nodes
Direct extension of SCCA
SQUAMOUS CELL CARCINOMA
Gross pathology
Unencapsulated
Ulcerated
fixed
Frey syndrome (gustatory sweating) is now considered an universal sequel following parotidectomy surgery
It results from of the innervation of the salivary gland during dissection in which there is inappropriate regeneration of
parasympathetic autonomic nerve fibres which thus stimulate the sweat glands of the overlying skin.
The clinical features of Frey syndrome include sweating and erythema over the region of the parotid glands surgical bed as a
consequence of autonomic stimulation of salivation by the smell or taste of food.
The symptoms are entirely variable and are clinically demonstrated by a starch iodine test.
FREY’S SYNDROME
Starch iodine test:
Involves painting the affected area with iodine which is allowed to dry before applying dry starch, which turns blue on exposure to iodine in the presence of
sweat. Sweating is stimulated by salivary stimulation .
FREY’S SYNDROME
Management:Antiperspirants,usually astringents such as alumium
chloride.Denervation by tympanic neurectomy
The injection of Botulinum toxin into the affected skinThe last remains the most modern, effective method,
which can be performed on an out-patient basis.
FREY’S SYNDROME
Human anatomy vol.3 –B.D.Chaurasia 4th edn. Textbook of oral pathology –ShafferTextbook of oral medicine –Burkett
Principles of surgery –PetersonOral and maxillofacial surgery clinics of North America
REFERENCES
