SEMINAR ON DISORDERS OF SALIVARY

GLANDS.

CLASSIFICATION OF SALIVARY GLAND DISORDERS

A) Developmental disorders AberrancyAplasia & HypoplasiaHyperplasiaAtresiaAccessory ductsDiverticuliCongenital fistula

B) Functional disordersSialorrhoeaXerostomia

C) Obstructive disordersSialolithiasisMucus plugStricture & stenosisForeign bodiesExtra ductal causes

D) Cyst MucoceleRanula

E) Asymptomatic enlargementSialosisAllergicAssociated with malnutrition and alcoholism

F) InfectionViral BacterialMycotic

G) Autoimmune disordersSjogren’s syndromeMikulicz’s diseaseUveoparotid feverRecurrent non specific parotitis

Developmental anomalies Aberrant salivary glands

An aberrant or ectopic is salivary gland tissue that develops at a site where it is not normally found.

Clinical featuresSite – cervical region near the parotid gland or body of mandible.

Posterior to first molarClinical significance

Site for development of retention cyst or neoplasm

Aplasia & hypoplasia It is congenitally absence of salivary gland.

Aplasia occurs in combination with congenital anomalies.Hypoplasia in patient with Melkersen Rosenthal syndrome.

Clinical featuresOne or group of glands missing unilaterally or bilaterally.XerostomiaDental cariesEarly loss of teethDry & smooth oral mucosaCracking & Fissuring at corner of mouth.

Management Good oral hygiene.

HyperplasiaCause- Hormonal

MetabolicClinical features

Site minor salivary glands of palate.Asymptomatic when surface firm,sessile & normal in color.

Management Excision for microscopic examination.

Accesory ductsMost common developmental anomoli.

Site- superior and anterior to normal stenson’s duct orifice.

Atresia Congenital occlusion or absence of one

or two major salivary gland ducts. Site- submandibular duct in floor of mouth. Causes severe xerostomia.

Diverticuli Small pouches or outpocketing of ductal system of one of the major salivary glands.

Congenital fistula Sinus tract form either in crease behind the pinna or in front of tragus.

Management Complete surgical excision of sinus tract.

Functional disorders

Sialorrhoea or ptyalism It is increase salivary secretion. Stimulation of parasympathetic causes

profuse secretion of watery saliva.

Etiology Drugs like sialogogues Local factors ANUG,erythema multiforme Systemic like paralysis Misc. like metal poisoning

Clinical features Drooling from mouth Lip chapping Infection from constant exposure to saliva Cheek scarring.

Management Oral motor draining Biofeed Removal of local factors Anti cholinergic drugs (atropine sulphate

0.4 mg in adults .01 mg / kg in children upto 0.4

Surgery

Xerostomia Dryness of mouth.

EtiologyRadiation inducedDrug induced Nutritional

Clinical featuresIncrease thirst Difficulty in speech, swallowing & eating dry foodBurning sensationBlurred visionFissuring of tongue.

Management Preventive therapy Symptomatic treatment Topical salivary stimulation Systemic salivary stimulation

Bromhexiene 8mg T.D.S. adult 4mg B.D. children

Dry leathery tongue

Obstructive disordersSialolithiasis Salivary gland stone or salivary gland calculus within major &

minor salivary gland.

Clinical featuresSite Submandibular 83%

Parotid 10% Sublingual 7%

Severe painSwelling during mealsPus from duct orificeInflammatory reaction to surrounding soft tissueOverlying mucosa may ulcerate along calculus to extend into oral floorRadiographically almost radio opaque, oval shape & with multiple layers of calcification, smooth borders.

ManagementManual manipulation of stone within duct.If in submandibular duct then incision is made directly over it.If in gland then excision is doneAntibiotics if acute infection is present.

Mucus plugIncompletely mineralized sialolithes.

Hard mass

Minor salivary gland sialolith

Strictures & stenosisEtiology

IrritationAcute traumaTumour

Types Papillary obstructionDuct obstruction

Management Saline rinses Salivary gland massageDuctoplasty

Foreign Bodies Tooth brush bristles Tooth picks Spikes of wheat Finger nails

Extraductal causes Muscle pressure Tumors Enlarged lymph nodes Denture flanges associated with the primary salivary duct.

Cysts of salivary gland

MucoceleSwelling caused by pooling of saliva at site of injured minor salivary gland.

TypesMucous extravasation cystMucous retention cyst

Clinical featuresSite inner aspect of lower lip, palate, cheek,tongue,floor of mouth.Painless swelling which is frequently recurrent develops at meal time and drains simultaneously at intervals.Shape round or oval & smooth.Consistency soft or hard depend upon tension of fluid.

Blue pigmented nodule Exophytic lesion

Superficial vesicle like Nodule

Management Complete excision of cyst under L.A.Injection steroid & cryosurgery.

Ranula It is used for the mucoceles occurring in the floor of the mouth in association with ducts of sub mandibular or sub lingual glands

TypesSuperficialPlunging

Clinical featuresSite – floor of mouth on side of frenulumUnilateral bluish swellingShape – spherical or dome shaped only top visible

Fluctuation & Transillumination – positive brilliantly translucentOn aspiration – sticky clear fluid Slowly enlarging swelling on side of floor of big ranula may cause difficulty in speech or eating.

Plunging ranula when intra buccal ranula has cervical prolongation it is called deep or plunging ranula. It is located along post border of mylohyoid muscles in submandibular region.

Management

Surgical excision including portion of surrounding tissue. Partial excision & marsupilization.

Blue pigmented swelling

Plunging Ranula Ranula

Viral InfectionsMumps Contagious viral infection caused by para myxo virus

Clinical features Unilateral & bilateral swelling of salivary gland Fever, malaise, anorexia. Tender & pain on eating sore food Involved gland continues to enlarge for 2-3 days & comes back to normal.

Complication oophritis, orchitis, meningitis, encephalitis.Management

Self limitingMMR vaccineSystemic corticosteroids

Unilateral Bilateral Parotid enlargement

Bacterial InfectionAcute bacterial sialadenitis (acute supprative parotitis)CausesStaph aureusStaph viridans

Clinical featuresSite- unilateral involvement of parotidFeverPain at angle of jawElevation of ear lobuleCervical lymphadenopathy

ManagementOral hygieneSoft dietI.V. fluidsParentral antibodies active against pencillin resistence staphylococcusSurgical drainage of affected gland

Acute bacterial sialadenitis

Mycotic InfectionsActinomycosis Cause

A.IsraliaeTypes

Primary ascending canalicular inflammation. Infection penetrates from mouth into gland and affects it entirely.Secondary when transferred to gland from tissue surrounding, non tender, non fluctuant indurated lesion with formation of multiple fistulae with discharge of sulphur granules.

Autoimmune Disorders Sjorgen’s syndrome

Chronic inflammatory disease that predominantly affects salivary, lacrimal & other exocrine glandsIt was first described by HENNIK SJOGREN in 1933.

Types primary – dry eyes, dry mouth. secondary – dry eyes , dry mouth ,

collagen disorders usually rheumatoid arthritis & SLE.

Dry & Fissured Tongue

Benign Lymphoepithelial Lesion

Clinical FeaturesMiddle aged and female are commonly infectedXerostomiaSoreness and difficulty in controlling denturesPus from ductDifficulty in eating and unpleasant tasteUnilateral and bilateral enlargement of parotid glandFrothy salivaSevere dental cariesDepapillation of tongueDry eyesVaginal drynessConnective tissue disorderEnlargement of lymph nodes

Radiographic FindingsSnow storm appearanceIn some cases cherry blossom appearance

MANAGEMENT SYMTOMATIC TREATMENT

Occular lubricant- artificial tears coating methyl celluloseSaliva substituteOral hygieneSurgery for enlargement of glands

MIKULICZ’S DISEASE Symmetric or bilateral chronic painless enlargement of lacrimal or salivary gland has inflammatory characteristics.

Clinical Features Women in middle and later lifeSite- unilateral or bilateral enlargement of parotid or submandibular glandFeverUpper respiratory tract infectionOccasional painXerostomiaDiffuse poorly outline and enlargement of gland

ManagementSurgical excision

InvestigationsNon-invasive investigations

RadiographsComputerized TomographyUltrasound scanningMagnetic resonance imagingSingle Photon emission Computed Tomography

Invasive InvestigationsBiopsyFine needle Aspiration cytology

Sialography

SIALOGRAPHY“It is a specialized radiographic view of salivary gland taken by introduction of soluble contrast material into the ductal system.” The radiographs are called Sialographs.

IndicationsDetection of sialoliths, calculus, foreign bodies.Evaluation of extend of irreversible ductal damage.Detection/diagnosis of recurrent swelling & inflammatory process.

Evaluation of diverticula's, strictures and fistulae.Tumor location & size.Selection of a site for biopsy.Outline the plane of facial nerve.Residual stone/tumor, fistulae & stenosis.

ContraindicationsAcute infection of salivary gland.Allergic reaction to any radio opaque material to be used.Thyroid disorders.

PhasesFilling phaseEmptying phaseParenchyma phase

Agents usedContrast mediaX-ray filmContrast media (Ideal requisites)

Physiologic properties similar to saliva.Miscibility with saliva.Absence of systemic/local toxicity.Low surface tension & low viscosity.Easy elimination.

Types of contrast mediaWater soluble - HyopaqueFat soluble - Lipidol

Sialographic appearanceNormalCalculusInflammation/blockage (Sialadenitis)Strictures Sjogren’s syndrome Tumors

Large calcified stone

Sialadenitis

Sjogren’s syndrome

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