Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU

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Salivary gland diseases

Dr. Yanming Liu Dept. Oral Maxillofacial
Surgery 2nd Affiliated Hospital, ZJU
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Section 1 Clinical anatomy

• Submucosal minor salivary glands labial, buccal,
  palatal, lingual
• Three paired major salivary glands
• Parotid gl.
• Submandibular gl.
• Sublingual gl.

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Parotid gland

• largest
• almost entirely serous
• between ramus of the mandible, mastoid process,
  external acoustic meatus, SCM muscle,
• Pyramidal in shape
• Superficial and deep lobes by facial nerve and
  branches
• Stensons duct, its opening opposite 2nd upper
  molar
• Adjacent structures facial n., external carotid
  a., retromandibular v.

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Submandibular glands

• Submandibular gl.
• Intermediate in size
• A seromucous (predominantly serous) gland
• Superficial and deep parts
• Hooked in shape
• Whartons duct, its opening sublingual papilla
• Adjacent structures facial artery/vein, marginal
  mandibular branch of facial n., lymph nodes,
  lingual and hypoglossal n.

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Sublingual glands

• Sublingual gl.
• Smallest
• seromucous, but predominantly mucous
• above mylohyoid m., the sublingual fossa
• Adjacent structures lingual and hypoglossal n.
  deep lingual a./v.
• Open direct to the oral cavity or through
  Whartons duct

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Physiology of salivary glands

• Functions of Saliva
• lubricates food
• moistens oral mucosa
• digestive enzymes
• antimicrobial agents, e.g. immunoglobulin A (IgA)
  
• Xerostomia may result in periodontal inflammation
  and dental caries

• Data about saliva
• 0.5 L saliva / day
• 0.3 mL/min when unstimulated,
• 1.52 mL/min when stimulated
• Unstimulated state parotid gl. contributes 20,
  submandibular gl. 65, other 15.
• When stimulated, parotid contribution rises to
  50.

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Section 2 Investigations
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Investigations

• History taking swelling, pain, mass, nerve
  functions, etc.
• Clinical examination
• bimanual palpation
• comparing bilateral glands
• Auxiliary examination
• Radiology (plate radiography, CT, MR, PET/CT)
• Ultrasound
• Biopsy
• Sialometry

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Symptoms and their indication
Symptom Suggestion
Slowing developing swelling or mass tumor
Immediate swelling at meal, then slowly subsiding Obstruction by calculus
Pain and swelling, perhaps with bad taste Infection
Dry mouth Sjogrens syndrome
Facial nerve palsy with a mass in parotid gland Malignant tumor?
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Sialometry

• Method volume of saliva dribble over 5 minutes
  at the unstimulated condition
• Normal saliva flow rate 0.3-0.4ml/min
• Clinically significant xerostomia lt0.1ml/min

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Clinical situation and auxiliary test option
Clinical situation Selection
Calculus present? Plain radio. Ultras.
Obstruction in the duct system? Sialography
a mass present? Ultrasound, CT, MR
Abnormal gland function? Radioisotope imaging
Evaluation of salivary function Labial minor gland biopsy
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Biopsy in salivary gland disease
Clinical situation Selection
Evaluation of overall salivary function Labial minor gland biopsy
Tumor of major glands No incisional biopsy!!! Fine needle aspiration biopsy Frozen section
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Section 3 salivary gland diseases
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3.1 obstructive salivary disorders

• Caused by narrowing or total obstruction of
  ductal system
• Typical symptoms pain and immediate swelling of
  the affected gland just before meal, or having
  meal, or maybe thinking about meal, which then
  slowly subside after meal.
• Occasionally accompanied by a bad taste,
  indicating associated sialadenitis.

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3.1 obstructive salivary disorders

• Three types
• Extraductal obstruction, e.g. neoplasia
• duct wall thickening, caused by trauma or
  fibrosis
• intraductal obstruction (most common type) ,
  caused by calculi (sialoliths), 80 in
  submandibular gland

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3.1 obstructive salivary disorders

• Why do intraductal obstruction and sialolithiasis
  happen more often in submandibular gl. (80) than
  parotid gl.?

Submandibular gl. Parotid gl.
Mucoserous saliva Almost serous saliva
Containing more calcium salt Less calcium salt
Saliva flows upwards, against gravity Nearly horizontally
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3.1 obstructive salivary disorders

• Treatment options of intraductal obstruction by
  sialoliths
• Antibiotic and anti-inflammatory treatment
• Remove sialolith by marsupialization of the duct,
  when sialolith is close to the whartons papilla.
• Remove sialolith with the assistance of
  sialendoscopy
• Remove the submandibular gland and the sialolith
  when it is close to the gland, especially with
  fibrosis of the gland.

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3.1 obstructive salivary disorders
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3.1 obstructive salivary disorders
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3.1 obstructive salivary disorders
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3.2 acute viral sialadenitis

• Also named mumps, acute contagious infection,
  caused by paramyxovirus through direct contact
  with infected saliva
• Incubation period of 2-3 weeks
• Fever, malaise
• Sudden and painful swelling of one or both
  parotid gl. (occasionally submandibular gl.)
• clear salivary secretion
• Occasionally involvement of central nerve system
  and gonads (orchitis), in rare case resulting in
  dysgenesis
• Lifelong immunity
• Rising hemodiastase and urinary amylase in some
  cases
• Treatment bedrest, massive water drinking, fluid
  infusion, antiviral treatment, etc.
• Avoiding the infected patients to contact with
  susceptible population

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3.3 acute bacterial sialadenitis

• Principally involving parotid gl. (parotitis)
• Etiological factors
• Local reduced salivary flow leading to bacteria
  in the ductal system mainly by staphylococcus
  aureus
• Systemic other chronic diseases or large
  surgical operation, leading to poor systemic
  conditions fluid and electrolyte imbalance
• Often unilateral parotid gl., pain and swelling
• Red and swelling of duct opening, mucopurulent
  discharge
• fever, erythema of skin
• Treatment principles
• supporting therapy bedrest water drinking or
  fluid infusion, correction of electrolyte
  imbalance
• antibiotic therapy mouthrinse
• Incision and abscess discharge when pitting edema
  and tenderness, or when getting pus by needle
  aspiration or confirmed by ultrasound

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3.3 chronic bacterial sialadenitis

• Caused by low-grade bacterial invasion, often
  follows chronic obstructive disease
• Submandibular gland most commonly involved
• Symptom recurrent and painful swelling
  associated with eating and drinking
• Salty and bad taste
• Mucopurulent discharge
• Can be transformed into acute sialadenitis
• Treatment removal of sialolith, mouthwash,
  removal of gland when fibrosis

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3.4 radiation sialadenitis

• History of radiotherapy for head and neck cancers
• Acinar damage and fibrous replacement
• Low saliva secretion, leading to dental caries
  and mucositis
• Prevention shielding the salivary glands when
  radiotherapy
• Treatment of xerostomia (dry mouth)

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3.5 Sjögrens syndrome

• Autoimmune chronic inflammatory disease involving
  salivary and lacrimal glands
• Characterised by polyclonal B-cell proliferation
• Continuous destruction of glandular parenchyma
  and lymphocytic infiltration
• Classification
• primary Sjögrens syndrome
• secondary Sjögrens syndrome

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3.5 Sjögrens syndrome

• Primary Sjögrens syndrome
• Xerostomia (dry mouth) and xerophthalmia (dry
  eyes) (and nasal, vaginal, skin ... dryness)
• Secondary Sjögrens syndrome
• Xerostomia (dry mouth) and/or xerophthalmia (dry
  eyes)
• an autoimmune connective tissue disease
  (Rheumatoid disease, renal tubular acidois...)

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3.5 Sjögrens syndrome

• Clinical features
• Mostly involving middle-aged females
• Symptoms of xerostomia including glazed oral
  mucosa lobulated beefy-red tongue difficulty in
  eating dry foods, swallowing, speaking, etc.
• Parotid gland enlargement, occasional acute
  infection
• Symptoms of xerophthalmia

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3.5 Sjögrens syndrome

• Valuable tests in aiding in diagnosis
• Sialometry (salivary flow rate measurement)
• Schirmer test (lacrimal flow measurement)
• Detection of autoantibodies against SS-A, SS-B,
  RF (rheumatoid factor), etc.
• Labial gland biopsy infiltration of lymphocytes
  around intralobular ducts, resulting in focal
  lymphocytic sialadenitis

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3.5 Sjögrens syndrome

• Management
• Multidisciplinary team
• Management of xerostomia
• Salivary stimulants (sugar-free gum,
  pilocarpine) if residual salivary function
  remains
• Saliva substitutes
• Prevention of caries and periodontal disease

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3.6 salivary gland tumors

• 3 of human tumors
• Mostly arising in the parotid gland (80), in
  which 90 are benign
• Higher relative proportion of malignant tumors in
  submandibular (40), sublingual (90), palatal
  and other minor glands (60)

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3.6 salivary gland tumors

• Common benign salivary gland tumors
• Pleomorphic adenoma
• Wharthins adenoma
• Common malignant salivary gland tumors
• Adenoid cystic carcinoma
• Mucoepidermoid carcinoma

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3.6.1 Pleomorphic adenoma

• Benign
• Accounting for 80-90 of all salivary tumors
• Slow-growing, painless nodule, soft or firm in
  texture, moveable, well-circumscribed
• Varied size ( several cm to 20 cm) and duration
  ( several months to decades)
• Rare involving facial nerve
• Low potentiality of canceration

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3.6.1 Pleomorphic adenoma

• Also termed mixed tumor
• Characteristic cellular and stromal elements
• Celluar element ductal epithelial and
  myoepithelial cells
• Stromal element myxoid (muscle-like) tissue or
  chondroid (cartilage-like) tissue
• Tumor islands may exist beyond capsule
• Management excision biopsy of tumor together
  with a margin of normal tissue

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3.6.2 Wharthins tumour

• Also termed adenolymphoma
• benign
• Predominantly in older men and exclusively in
  parotid
• Discrete nodule, smooth, soft in texture, mostly
  lt3cm in diameter
• Etiologically related to smoking
• Can be multiple nodules and in bilateral parotids
• Characteristical pathological feature a
  papillary cystic structure composed of double
  layered ductal cells and a lymphoid stroma

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3.6.2 Wharthins tumour

• Management tumor excision, when multiple nodules
  present, excision the surrounding glandular
  tissue as well

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3.6.3 adenoid cystic carcinoma

• Middle-aged or elderly patients
• Frequently in palatal minor gland and parotid
• Slow growing, tendency to invade and spread along
  nerve, leading to pain, palsy or paraesthesia
• Histopathologically Swiss-cheese-like structure
  due to microcysts filled by basement membrane
  material
• Infiltrative, metastasis
• Poor long-term prognosis
• Treatment surgery with adjuvant radiotherapy
  involved nerve has to be sacrificed

Perineural invasion
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3.6.4 mucoepidermoid carcinoma

• Younger and Middle-aged patients
• Histopathologically both mucous and squamous
  differentiation
• Painless slow-growing nodule blue cyst
• Treatment
• high differentiation surgery, preserving nerve
• low differentiation surgery with radiotherapy

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3.6.5 salivary gland cysts

• Blue, fluctuant swellings, with a relapsing
  history
• Mucous extravasation mucocele
• Tearing of the duct due to trauma, leading to
  leakage of saliva into the connective tissue
• No epithelium lining
• Major type, mainly in low labial mucosa, buccal
  mucosa, sublingual gland (ranula)
• Mucous retention mucocele
• Duct expansion, leading to cyst with epithelium
  lining
• Mostly in upper labial mucosa

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3.6.5 salivary gland cysts

• Treatment removal of cyst as well as the minor
  gland or sublingual gland

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A case of giant cancerized pleomorphic tumor

• Slow growth of the tumor for 34 years, painful
  recently

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A case of giant cancerized pleomorphic tumor

• Slow growth of the tumor for 34 years, painful
  recently

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A case of giant cancerized pleomorphic tumor
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A case of giant cancerized pleomorphic tumor
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A case of giant cancerized pleomorphic tumor