script 14 -salivary gland disorders 1

8/3/2019 Script 14 -Salivary Gland Disorders 1

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salivary gland disease

We will start with new chapter today which is salivary gland diseases.

arelandsajor salivaryWe have major salivary gland and minor salivary glands. The(parotid, submandibular, sublingual gland) so we have three major salivary glands, the

of themucosaof glands in thenumerous, multiple, hundredsareinor salivary glandsoral cavity.

Location of the minor salivary gland:

1- Soft palate, lips, buccal mucosa, ventral of the tongue, lateral border of the tongue,

floor of the mouth.

We dont find minor salivary gland in:

1- Dorsum of the tongue (ant 2/3 only because we have von ebner gland in the post

1/3).

2- Gingiva.

3- Anterior hard palate.

gland:he major salivary1-The parotid gland is serous acini , the cell which produce saliva is serous acini , look at

picture below and notice these cells that contain blue granules .

(Parotid gland)


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, but we can find moreixture of mucous and serous aciniis asubmandibularTheserous than mucous .look at the picture below and notice the mucous acini cytoplasmcontaining a lot of bale color mucous acini so they will appear as empty cell .

(Submandibular gland)

But here the mucous isixture of mucous and serous acini.The sublingual gland ismore, so this will lead to produce different type of saliva. Look at picture below and

notice it has more mucous cell.

(Sublingual gland)

.ucous aciniThe minor salivary gland all of it is

(Minor salivary gland)


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Developmental Anomalies of salivary gland

, so Aplasia means the absence of theajor SG: the absence of one or moreplasia-1salivary gland from birth especially parotid gland.

anomalies.may be associated with otherplasia of parotid gland.so itsandibulofacial dysostosis , aplasia of lacrimal glands, hemifacial microsomia-

associated with the decrease of the size of the cells , face, mouth , lacrimal gland .

. So aplasia for the gland itselfor SG ductsathe absence of one or moretresia-2and atresia for the duct.

this mean normal tissue but in up normal location ,:issueeterotopic salivary gland-3we said before that the salivary gland tissue can enter the lingual surface of the

tafnesand we called itelow the IV canalmandible in concavity there especiallyidiopathic bone cavity.

theseommonelativelymuscle isasseterwithin cheek orarotid tissueccessory-4tissues may be affected by any disease or tumor affect the parotid gland.

Infection of the salivary glandSialadenitis is inflammation of a salivary gland. This inflammation could be happenby bacteria or virus or irradiation .

Sialadenitis.ecurrenthronic,cute,we havenfectionacterial

Acute Sialadenitis:the bacteria reacharotid gland,especially affected the,nfectionncommonIts

thats mean the bacteria will go up throughscending infectionthe gland throughthe gland, the salivary flow may be reduced. we know that when the salivary


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secretion decrease the wash out will decrease this make the bacteria to go up to the

gland .

The bacteria that may cause the acute Sialadenitis are Staphylococcus aureus,Streptococcus pyogenes.The causes:

theflow ,salivarymay reduce thejgren syndromeReduced salivary flow like-1drug with xerostomia as a side effect, so anything reduce the salivary flow will make

the patient more opportunistic to get acute bacterial Sialadenitis.

2-Used to be a common postoperative complication in debilitated, dehydrated

patients following abdominal surgery.

3-Immunocompromized patients.

4- Acute exacerbation of chronic Sialadenitis, usually submandibular gland.

5- Irradiation to the area where the salivary gland locate may decrease the salivary

flow and lead to acute Sialadenitis.

The clinical feature:Rapid onset, swelling of involved gland, Pain, fever, malaise, Pus may be expressedfrom duct.look at the picture below and notice the redness in the area where the

parotid gland locate.

(Acute bacterial Sialadenitis)

Now we will move to:

:acterial Sialadenitishronic


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(salivaryassociated with duct obstruction,specific-nonglands, it is usuallyIn major

infection is associated with ductThisgrade ascending infection.-lowcalculi) &

obstruction so there is no complete wash out of the duct make the bacteria can

ascend through the duct to affect the gland.

Usually submandibular have possibility to be affected with chronic Sialadenitis

more than parotidbecause saliva in the submandibular is more than the parotid

according to the gravity which make the saliva more.. that make the calcium

deposits..Surrounded by protein core forming the stone. So the submandibular

gland most likely to have stones which obstruct the gland.

2-Disorder of secretion & decreased salivary flow may also predispose to it.

eatures:linical1- Usually unilateral stones, sometimes it can be multiple unilateral stones.

2-Recurrent, tender swelling of affected gland related to obstruction.

3-Duct orifice may appear inflamed and red.

. So we can see theischargeurulent or saltyIn acute exacerbations there may be-4.in acute Sialadenitis and acute exacerbationspus

(Chronic bacterial Sialadenitis with unilateral stones)

Histopathology:- varying degrees of ductal dilatation.

.yperplastic ductal epithelium-- Periductal fibros : collagen bundle forming around the duct replacing the acini.

- Acinar atrophy & replacement by fibrous tissue.


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- Chronic inflammatory infiltration.

So when we compare with normal it will have well-defined acini mixed with fat and

the fat increase with age .

(Look at the picture above and notice the dilatation, the ductal hyperplastic and

).lack dots is lymphocytes infiltrate in the ductthe atrophy of the duct Progressive chronic inflammation of submandibular gland may result in almost

complete replacement of parenchyma by fibrous tissue, which may be mistaken for a

tumor (chronic sclerosing Sialadenitis)

Sialography : is the injection of the salivary gland with certain material will give usa feature of ductal dilatation because the injected material will accumulate in the

duct make it not straight but it will give us dilatation appearance. with dilatation

we may have a features of glandular tissue obstruction and duct obstruction.

Parotitisecurrentalculi or ductdue to predisposing factor such ashildren or adultThis may occur in

may alsoup normal immune response,is decrease salivary flowwhichbstructionplay a role in recurrent parotitis and in children there is a congenital obstruction in

the duct not stenosis it's congenital.

:ossible etiology of childhood typeAbnormally low secretion rate.*

Immaturity of immune response.*

Congenital abnormalities of ductal system.*

Clinical features :1-Unilateral or bilateral.

2-Recurrent painful swelling of parotid.


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3-Pus may be expressed from orifice.

4-Often resolves spontaneously by early adulthood.

damage to main duct, predisposing torreversibleRepeated infection may cause-5duct obstruction and further episodes in adult life.this is important feature becausethe recurrent infection may be deformed the duct and make it predisposing to duct

obstruction either by itself or by allowing deposition of minerals around it , thiscondition may not improved in the adult life.... so the recurrent infection will change

the morphology of the duct.

This is all about bacterial Sialadenitis of the salivary gland.

Now we will move tohe salivary glandialadenitis ofral

sumpAn acute, contagious infection which often occurs in minor epidemics

, its the most common cause of the parotidaramyxovirusacaused byWhichis the common of all salivary gland diseases.enlargement and the mump

:linical features1. Most common in childhood.

.roplet spreadandirect contact with infected saliva2. Transmitted by.weeksf 23. Incubation period

4. Prodromal symptoms of fever & malaise.

5- The patient may have the virus in saliva 2- 3 days before the symptoms, we dont

know that the patient is infected but the virus is in saliva.

6- After healing the symptoms, the patient still have the virus for 6 days, Thats

mean the patient can still contagious the virus to surrounding.

7- Sudden onset of painful swelling of one or more salivary glands, mostly theparotid gland (70%), if the patient starts with one side it will go to other side.


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arelyinvolvement of submandibular and sublingual glands, butOccasional-8without parotid also.

9- Enlargement gradually subsides over a week.

10- If the virus go to other organ like the testis it will induce complication like.20% of affected adult malesespecially ininflammation of the testis )rchitis

Child with mumps

The Diagnosis is usually clinical look at the picture above, but can be confirmed by

detection of IgM antibodies after 2 weeks and by rise in serum titer to mumps virusantigens within the 1st week.

That meanand recurrent infection is rare.astingongImmunity after an attack inthe patient will not have the virus again ... now a days we have vaccine against

mumps.

Cytomegalic Inclusion DiseaseIn general if the healthy person infected by cytomegalic virus he will not have aclinical infection so the virus will go and latent in ductal epithelium and other

organ.

mmunocompromisedandeonatesinevere disseminated diseasecan causeBut itSo the CMV will affect severalnfected patients.transplant and HIVhosts e.g

organs like thekidneys, liver, lungs, brain, & other organs and cause severeinfection.


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and this virus have 2 stages of primaryerpesvirus groupmember of theCMV is aand secondary infection, Most primary infections are asymptomatic.. But when the

infection get reactivated later on life if the patient have HIV or

immunocompromised secondary infection will be improved.

Histopathology:Salivary gland involvement is usually an incidental histological finding.

In normal case (dont have HIV or immuncompromised ) but infected with CMV wehave inclusion of the epithelium cells.. Large, doubly contoured owl-eye inclusion

bodies within nucleus very big surrounding by clear area or cytoplasm of duct cells

of parotid gland ,, we see the inclusion in the nucleus or cytoplasm .

ut it may involve several organwe have the same inclusion bcasetedisseminIn,mean the inclusion may attack the liver, lung etc Look at the picture below and

notice the owl-eye inclusion

)ytomegalic Inclusion

Postirradiation SialadenitisDirect correlation between dose of irradiation and severity of damage it could

produce destruction of the acini so it will destruct everything,, some case with time

we may have some improvement thats depend in the dose and acini damaged by

the irradiation.. In general serous acini are more sensitive than mucous acini .hereandibrous replacement of damaged aciniothe damage is irreversible lead

quamous metaplasia of ducts.


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SarcoidosisThe etiology is unknown may be bacterial or viral.. We have deposition of

granulomas.. The granulomas contain microphages and multi-nucleated giant cell..If

u remember the TB we have granulomas with caseating but in the sarcoidosis we

have formation of granulomas that are non- caseatinggranulomas.May affect parotid and minor salivary glands.

Parotid involvement presents as persistent, often painless enlargement.

wheneerfordt syndromeMay be associated with involvement of lacrimal glands inwe have involvement of lacrimal and salivary glands.

Sarcoidosis is a separated disease may affect the gingiva and lymph node and other

organ but in salivary gland the sarcoidosis is non-caseating granulomasrenteithoutbutranulomas with bale colorLook at the picture and notice the

.aseation

(Sarcoidosis with non-caseation granulomas)

Sialadenitis of Minor GlandsMinor salivary gland is less likely to have Sialadenitis; it could be due to trauma that

comes from the friction of the denture causing irritation of the minor salivary gland.

Calculi through the minor salivary gland is rare the inflammation of the minor may be

diagnostic of the diseases affect the major salivary gland. Because it easier for us to

take biopsy from the lower labial mucosa (minor gland) than to take it from the parotid(major gland), this is advantage for us because the patient will get the biopsy from the


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minor gland not major gland, for example sarcoidosis & Sjgren syndrome will affectmajor gland and minor Most frequently seen in association with:

cysts.xtravasationMucous-1soft palatean in the smoker due to heat in thewhich me:icotinic stomatitis-2

,heat will inflame minor salivary gland ,this disease is not due to bacteria or virus its

due to heat in the oral cavity, This term is used mainly in soft palatal lesions.

Histopathology:Its the same as major salivary gland Sialadenitis

- Varying degrees of ductal dilatation.

- Hyperplastic ductal epithelium.

- Periductal fibrosis.

- Acinar atrophy & replacement by fibrous tissue, the acini will be replaced by

when there is inflammation.hronic fibrousing Sialadenitisitstissue;fibrous- Chronic inflammatory infiltration.

(Sialadenitis of minor salivary gland)

Very rarely may affect labial mucosa present with multiple mucosal swellings(stomatitishronic suppurationassociated with cystic dilatation of ducts and

glandularis).


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When we make eversion of the labial mucosa u will find a multiple swelling in addition

stomatitscolor due to excreting pus this is calledthe orifice of the duct will be white inglandularis.

ofof a chronic formcute exacerbation, probably as anipsMost commonly on theSialadenitis associated with obstruction or reduction in salivary flow (cheilitis

glandularis).

when we makelips)its a rare case in lower lip (chelitis refer to:landularisheilitisexamination we will find the minor salivary gland large and fibrouses.

Obstructive & Traumatic Lesions1-Salivary calculi (sialoliths) : mainly in submandibular salivary gland 79-80 % ofinvolve case ,calcium and mineral precipitate in a nidus ( core ) the core is protein or

dried mucous, some time the saliva itself dried and make a core for calcium and mineral

.

The submandibular gland is the most affected gland followed by Parotid gland, while

only 2% affect sublingual or minor glands.

Usually unilateral, although may be multiple in same gland.

Salivary Calculi (Sialoliths)Look at the picture above and notice this yellowish stone may be at the orifice of the

duct or alongside the duct.


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Clinical features:1-When symptomatic, they cause pain & sudden enlargement of affected gland, like

submandibular gland, especially at meal times when secretion of saliva is stimulated;

here because the gland is obstructed the saliva will accumulate in a gland and causesudden enlargement.

2-Reduction in flow predisposes to ascending infection & chronic Sialadenitis.

.adiographsalpation and onCalculi may be detected by-3

Here we have occlusal radiograph we can detect the mineralized tissue easily because

it differ from the other soft tissue.

:eatureistopathologyThought to form by gradual deposition of calcium salts around an initial organic nidus

which may consist of altered salivary mucins with desquamated cells andmicroorganisms. There will be chronic infection and ductal dilatation etc.

Necrotizing SialometaplasiaA relatively uncommon disorder. The patient will have an ulcer in center of the palate

and redness which start as an elevation and its take about 3 month (10-12 weeks) which

make the patient think he has cancer for example sqamuous cell carcinoma.

May be mistaken clinically and histologically for malignant disease.

Most frequent on hard palate in middle-aged patients, especially males.

most widelyleading to infarction of salivary lobules isschemiaEtiology unknown, butaccepted theory.In some patients there may be history of trauma, including local anesthetic injection

because it contain vasoconstrictor will decrease blood supply to the gland and causeischemia.


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Histopathology:1-Lobular necrosis: I can't see the boundaries of each cell it's all like one acini look at

the picture below its look like a one cell and it's have the lobular pattern (lobular

.quamous cell carcinomait fromdifferentiatethis is important feature to),necrosis2-Squamous metaplasia of ducts & acini. Changing from columnar cells to squamous

cells and sometimes its look as Epithelium Island.

3-Mucous extravasation.

4-Inflammatory cell infiltration.

5-Overlying palatal mucosa shows pseudoepitheliomatous hyperplasia, some time

the surface epithelium causing something called pseudoepitheliomatous becauseit's have severe hyperplasia .. Nowadays pseudoepitheliomatous called

Pseudocarcinomatous hyperplasis because its look like carcinoma.6-Features may be mistaken for SCC or mucoepidermoid carcinoma.

)ecrotizing Sialometaplasia

Sjgren SyndromeA chronic autoimmune disease, the salivary gland are involved, mainly the parotid

gland and the lacrimal gland, but it can associated with other chronic disease like

Rheumatoid arthritis and its Characterized by lymphocytic infiltration and acinardestruction of lacrimal and salivary glands.


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Classified into:when the salivary gland and lacrimal gland:Primary Sjgren or sicca syndrome1

r primaryiccaled itany connective tissue disease we calithoutinvolved onlysyndrome like dry mouth (xerostomia) and dry eyes (xerophthalmia orkeratoconjunctivitis sicca)

gland and lacrimal glandsalivarywhen the:econdary Sjgren syndrome2.involved with another CT disease like xerostomia (dry mouth ), xerophthalmia

rheumatoidsuallyan autoimmune CT disease,( decrease in the tears ) , witharthritis.

that may be associated include:ther autoimmune diseases1-Systemic lupus erythematosus.2-Systemic sclerosis.3-Primary biliary cirrhosis.4-Mixed CT disease.

Clinical Features :


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The clinical features are wide spectrum, may involved glandular tissue like dryness inthe skin, nasal secretion etc And non-glandular tissue like joint, skin, liver, renal we can

take look in the table above.

The diagnosis of depend on mainly in six criteria :Ocular symptoms: the symptoms what the patient tell the doctor.*

*Ocular signs: the signs what the doctor notice on the patient.

Oral symptoms.*

*Salivary gland function: u will know how to measure the salivary gland function in

ur 5th year 3la 5er wo slameh .

*Labial salivary gland histology: we said that minor salivary gland diseases are

helpful in the diagnoses the major gland diseases.

Ro and La autoantibodies*

.o we need 4 to 6 criteria to diagnose Sjgren Syndromeaged females (9:1 F:M ratio).ffects middleredominantly

be associated with:erostomia mayDifficulty in swallowing & speaking*

Increased fluid intake.*

*disturbances of taste.

*soreness & redness of mucosa associated with candidosis.

*rapidly progressive caries.

*acute bacterial Sialadenitis.

*The mucosa will be sticky and glaze so the patient can't talk some times.


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(Sjgren Syndrome)*Keratoconjuctivitis sicca manifests as:

Dryness of eyes, conjunctivitis, gritty, burning sensation

* Salivary gland enlargement is variable, some patient will give u history of

enlargement about 30% and 15% present with enlargement, so the enlargement

may not be helpful in the diagnosis.

(Enlargement in salivary gland predominant in parotid gland)

Look at this swelling its happen due to attack of the gland with lymphocyte mainly T

cells lymphocytes, it will attack the acini and surround the duct and give

enlargement of the gland.


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*Lacrimal gland enlargement is uncommon.*Although clinical involvement of minor salivary glands is uncommon, they are often

involved microscopically.

:esistopathological Featu

Major gland : * Lymphocytic infiltration, initially around intralobular ducts, eventually replacingthe whole affected lobules.

* 20% B cells, 80% T cells, mostly T-helper: although it mostly T cells the patient

more prone to have B cells lymphoma .MALT lymphoma it's not aggressive it's havebetter properties than other type of lymphoma .

* Acinar atrophy.

)n major glandjgren Syndrome: Histopathological Features

Proliferation of duct epithelium to form epimyoepithelial islands.*

lyoepithelial sialadenitis or benign lymphoepitheliaThe appearance is described as*it's not only,epithelial islandsthedue to=Epithelialymphocytes ..Lympho =.esion

present in Sjgren syndrome , it's not a good indication of this syndrome.

If its lymphoma it.nlike lymphoma, the infiltrate does not cross interlobular CT septawill cross the interlobular septa.


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Minor glands:then it will, initially around intralobular ductsocal collections of lymphoid cells

spread to the acini .

The dr talked about a case inhe number of foci reflects the severity of the disease.the hospital is questionable to has Sjgren syndrome, the patient had four location

of more than 70 lymphocytes surrounding the intralobular duct so it was helpful to

us in diagnosis the case.

(Sjgren syndrome in minor salivary gland )

Sjgren Syndrome InvestigationsMinor salivary gland biopsy.*

*Estimation of parotid salivary flow rates usually reduced.

*Sialography: shows sialectasia (snowstorm pattern, cherry tree in blossom

appearance).

Serological findings: anti-Ro, anti-La.*

The antibody present in the blood in case of Sjgren syndrome is anti Ro (also calledSSA Sjgren syndrome A) and anti-La (also called SSb Sjgren syndrome B ) the anti-Roare more common to present in the serum of the affected patient compared to anti-LAor SSb , and both of them are more common in primary more than secondary .


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Etiology & Pathogenesis

Strong evidence that it is autoimmune.*

*Genetic factors thought to be important in increasing susceptibility to external

factors which trigger the disease.

Occurs with increased frequency in patients with certain HLA class II MHC genes.*

*Several viruses, especially EBV have been suggested as potential trigger factors.

*Immunological mechanisms leading to destruction of glandular tissue probably

involve mainly T cells and their cytokines.

Pathogenic significance of the range of circulating auto antibodies is uncertain.*

Finally

Risk of B cell lymphoma developing in affected gland 44 times that of general

population and the percent will reach 6% to have B cell lymphoma.

Duty completed

Forgive me for any mistakes

Done by: Mohmmad Ahmad

This work, is dedicated to the beating heart of the batchshhadehmar AbuAnd to Jiana azam , Sara kazkaz ,Mohmmad rafayah ( al jineral in 2009 batch )

Fahed salman, Mo3taz al sardi,Hazim abo alzeek , Musap al Rawi ,Mohanad al

rawash ,Abdullah hamdan ,Ali wattad, Anas hamid , Mohmmad tawalbeh and to all

my friend ..

script 14 -salivary gland disorders 1

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