Dr.

Saleh Al Salamah

Diseases of the SALIVARY GLAND:

1. 2. 3. 4. 5. Introduction Evaluation of Salivary Disease Inflammatory Diseases Salivary Gland Stones (Sialolithiasis) Salivary Retentions Cysts and Mucous Cysts Salivary Fistulas and Sialoceles Salivary Gland Tumors Rare Autoimmune Diseases Salivary Diseases in Childhood

6. 7. 8. 9.

INTRODUCTION There are Major and Minor groups of Salivary Glands:

a) Major groups of salivary glands which are consists three major glands, the parotid, submandular and sublingual glands. The parotid produces mucous secretions. The parotid and sub- mandular glands each drain into the mouth in a single long duct. Where as the sublingual glands drain via many small ducts.

b) Minor groups of salivary glands may be found in the lips, cheeks, tongue, floor of the mouth, palate, larynx, trachea and tonsils and lacrymal gland. And all are liable to undergo the same pathological change as the major groups.

FUNCTIONS:
The Salivary glands secrets saliva which contains the enzyme amylase (protein of molecular wt. 50,000. Containing calcium which splits starch and glycogen into maltose) all the secretory activity is regulated mainly by parasympathetic nerves.

The total salivary secretion is between 1,000 ml 1,500 ml daily and is almost all the result of stimulation.

Deficiency
Deficiency of the saliva cause dry mouth (xerostormia)

eg: Dehydration, Sjogrens syndrome, atropine which blocks the action of parasympathetic nerves on the glands.

Evaluation of the SALIVARY GLANDS Diseases:

a. History: Age, pain, swelling, duration etc..

b.

Clinical Examination: (Position (site), colour,

temperature, tenderness, shape, surface. composition, relation, lymphatic drainage.

c. Investigations:

Edge,

I. Blood (CBC), Hb, Urea and Electrolytes, Blood

Sugar etc.. II. Constituents of saliva in inflammatory diseases. The sodium increased while the phosphate level is decreased. The albumin usually very low but increased in Sjogrens diseases, also antibodies can be demonstrated. Contd.

III. Radiology: a) Plain X-ray (20% of salivary calculi are non-opaque to Xrays) b) Sialogram
Radiology is helpful in the diagnosis of;

Calculi Degree of glandular damage in obstruction Duct strictures Duct fistulas and sialoceles Contd.

IV. V.

Ultrasound distinguishes solid from the rare cyst and sialocales.

tumour

Radio Isotopes: Tc 99 warthins tumours may take up more of the isotopes and appear as (hot) lesion. Carcinoma take up very little and appear cold. CAT scanning has definite place in the assessment of deep parotid tumours.

VI.

Inflammatory diseases of the salivary glands:

Acute

bacterial sialadenitis sialadenitis sialadenitis

Chronic

Recurrent

Mumps
Post

operative usually parotid diseases

Autoimmune

Acute Bacterial Sialadenitis:

This condition is now uncommon almost always occurring in elderly or debilitated patients with poor oral hygiene. Dehydrations and reduced salivary flow encourage ascending infection. The parotid gland is usually involved the result is painful, unilateral swelling accompanied by trismus, pyrexia and tachycardia.

On Examination: The parotid gland is tender and diffusely enlarged and purulent discharge can be seen oozing (or can be milked) from the parotid duct orifice (Stensen duct). TREATMENT:

a. Parenteral antibiotics.
b. If parotid abscess has already formed surgical drainage should be performed.

CHRONIC SIALADENITIS

Prolonged obstruction of major salivary gland by ductal calculus causes chronic inflammation of the gland. The glandular secretory element, progressively atrophy and are replaced by fibrous and adipose tissues.

Chronic Sialadenitis (contd)

The ducts system becomes fibrotic and infiltrated by inflammatory cells. dilated, chronic

Chronic Sialadenitis and salivary calculi usually involved the submandibular gland. The submandibular gland swollen and there may be purulent discharge from the duct. The swelling is made worse by taking food.
TREATMENT: by removing the duct obstruction. Antibiotics may be necessary.

RECURRENT SIALADENITIS

Uncommon condition may occur at any age.

which

Usually affects the parotid glands are subject to recurrent attacks of pain and swelling caused by combination of obstruction and infection of the glands.

RECURRENT SIALADENITIS
(contd)

There may be an associated dilatation of the duct system and alveoli of the glands with terminal sacculation (Sialectasis) associated with strictures of the duct or stones. These changes best demonstrated by performing Sialogram.

RECURRENT SIALADENITIS

Treatment:
a. Antibiotics with careful attention to oral hygiene. b. Associated strictures is treated with dilatation. c. If stones present these must be removed. b. Intractable causes may required surgical removal of the gland.

MUMPS
Viral infectious disease attack the parotid gland mainly incubation period (17-21days) which is usually bilateral usually occur in children. Fever, painful swelling and difficulty in mastication.

MUMPS
(contd)

* *

Mumps is interest to the Surgeon for the following reasons: Occasional cause of acute orchitis especially when mumps occurs in adolescent or young adults pain and swelling in the testicle occur 7-10 days after the onset of parotid and may lead to testicular atrophy.

TREATMENT: by rest and sedation.

POST OPERATIVE PAROTITIS

* Ascending infection of the parotid gland via its duct may occur after major surgical procedures.

Aetiological factors include dental sepsis, dehydration. The presence of nasogastric tube for prolonged period and poor oral hygiene.
Clinically there is swelling and pain in one or both parotid gland and there may be discharge from the duct.

POST OPERATIVE PAROTITIS TREATMENT: (Rare nowadays) However :

a. Prophylaxis important and elimination of the above etiological factors. b. Patient must be kept fully hydrated the flow encourage suckling, sweets or chewing gums. c. Antibiotic therapy. d. Occasionally surgical drainage required.

SALIVARY GLAND STONES (SIALOLITHIASIS)

I. Parotid calculus is rare and difficult to diagnose since the stone is so small that it cannot be demonstrated by radiography and sialography is usually necessary.

II. Submandibular calculus: very common being more than 50 times than parotid this is due to:

SALIVARY GLAND STONES (SIALOLITHIASIS)

a. The secretion of the gland is thick and viscid as compared to watery secretion of the parotid. The upward course of the submandibular duct does not provide adequate drainage. The duct orifice lies in the floor of the mouth where foreign bodies may lodge into it and provide nucleus for stone formation.

b.

c.

PATHOLOGY:

The stones may be singly or multiple and may lie in the gland, duct or both. They contain high proportion of calcium. The gland often enlarged and inflammed as chronic irritation and obstruction by the stone.

* Investigation: Plain X-Ray will demonstrate most calculi.

Sialography.

SALIVARY GLAND STONES (SIALOLITHIASIS)

Clinical Features:
Patient complaint recurrent attacks of pain and swelling in the region of the gland during meals.

Occasionally present with acute or chronic bacterial infection (Sialadenitis). On Examination: * The gland is enlarged and firm and tender .

If the stone lies in the duct it can be felt or even seen in the floor of the mouth.

Salivary Retention Cysts:

Large retention cysts sometimes develop in the floor of the mouth. They reach several centimeters in diameter and are known as Ranulae. RANULAE: Typically appear as blue-grey dome like swelling beneath the tongue in the floor of the mouth. They are more common seen in neonates and children.

It may burst spontaneously discharging it content and collapsing.

They are painless and can recurr.
TREATMENT: Marsupialisations with de-roofing the cyst so that it opens into the floor of the mouth.

Note: They are painless and can recur

SALIVARY MUCOUS CYSTS:

They are arising from minor mucous secreting gland in the lower lip. They sometimes spontaneously disappear but excision is the treatment.

SALIVARY FISTULAS: Submandular fistulas uncommon (rare) and always arises in the gland
TREATMENT: by excision of the gland

PAROTID FISTULA:
May follow penetrating wound or incision of parotid abscess. It may arise from the main duct or from the ductules within the gland
TREATMENT:
a.

Sialography is performed to establish the exact site or origin of the fistula

Fistula of the gland may be X-ray therapy to the gland. Fistula of the duct treated by anastomosis (construction). If fail superficial parotidectomy.

b.
c.

SALIVARY GLAND TUMORS:

Tumors of the salivary glands are commonest in the parotid much less common in the submandular gland and very rare in the sublingual and minor salivary glands. They are difficult to classify as benign and malignant since all of them tend to recur after removal.

Classification:
I. Benign:
a) Mixed salivary tumor or pleomorphic adenoma b) Adenolymphoma or warthins tumor c) Oncocytoma d) Monomorphic adenoma

II. Malignant:
a) Primary carcinoma b) Secondary carcinoma direct invasion from skin or from secondarily involved lymph nodes

The most common benign neoplasms of salivary glands. Most pleomorphic present in middle age but may occur at any age and equally in either sex.

PLEOMORPHIC ADENOMA

It usually remains benign for many years but unless adequately removed it tend to recur and to turn malignant.
Clinically: a) Slow growing painless lump mostly in parotid and some in submandular and few in the minor glands. b) Mobile with well defined edge and smooth or lobulated surface. Definitive diagnosis can only be made histologically after excision
Treatment surgical removal (superficial parotidectomy)

ADENOLYMPHOMA (Warthins Tumor)

Benign tumor less than 10% of salivary tumor. It occur in parotid glands only between the ages 40-60 years male strong predominance. They are sometimes bilateral.

Clinically:

The tumor present as painless cystic swelling

Treatment: Surgical removal (superficial parotidectomy)

Malignant Salivary Tumors:

The malignat tumors are 1. Mucoepidermoid Carcinoma 2. Adeno Cystic Carcinoma 3. Adeno Carcinoma 4. Squamous Cell Carcinoma 5. Carcinoma in Pleomorphic Adenoma (Malignant Mixed Tumor) 6. Acinic Cell Tumor 7. Malignant Lymphoma 8. Anoplastic Carcinoma

Clinical Features:

Affects elderly people and common in parotid with equal sex distribution.

The tumor forms rapidly growing hard swelling with ill defined edges and nodular surface.
Soon becomes fixed with pain-facial palsy, and lymph nodes enlargement but distant metastasis are rare.

TREATMENT:
1. Operable Tumors:
a) Radical parotidectomy combined with block dissection of the cervical lymph node. b) Post-operative radiotherapy c) When the tumor arises in the other site of salivary tissues wide local excision is performed with block dissection of lymph node.

2. Non operative tumor with infiltration to the skull and pharynx. Radiotherapy can be given.

Complication of Parotidectomy:
1) Damage to facial nerve causes facial palsy or damage to its branches 2) Salivary fistula
3) Freys syndrome

Autoimmune salivary gland disorder or disease:

There are two syndromes of slow, progressive, painless enlargement of salivary glands.

Biopsy reveals the swelling is caused by replacement of glandular tissues by lymphoid tissue and fibrosis.

MICKULICZs SYNDROME
1) 2) 3) Symmetrical enlargement of salivary glands Enlargement of the lachrymal glands Dry mouth

SJOGRENs SYNDROME All the above conditions plus;

Dry eyes
Generalized arthritis

Salivary diseases in childhood:

1) Mumps: Viral sialaidenitis both parotid become painful and swollen and accompanied by general malaise and subsided in few days. 2) Recurrent swellings of the parotid: Due to obstruction of one or both parotid ducts. Symptomatic treatment and reassurance of the parents. There is no place for surgery.

3) Tumors: The commonest tumor in infants is haemangioma found in 2-3 years old child. The tumor nearly undergo natural resolution.
4) Lymphangiomas: They have tendency to enlarged and infection. The treatment partial resection.