SALIVARY GLAND & ITS DISEASE

INTRODUCTION CLASSIFICATION

• Major salivary glands

• Minor salivary glands

Major Salivary Glands

a. Parotid gland

▪ Purely serous in adult and predominately serous in newborn.

▪ 25% contribution to saliva

▪ Secreted through Stensen’s duct

▪ Orifice visible in buccal mucosa adjacent to maxillarymolar.

Submandibular gland

Predominately serous

Contribute 60% to the salivary secretion

Secretion through Wharton’s Duct opening either side of lingual frenum

Sublingual gland

Predominately mucous

Contribute 5% to the salivary secretion

Secretion through multiple small independent duct or may empty directly into the Wharton’s Duct

Minor salivary gland

1. Labial (superior and Inferior), lips

Mixed (predominately mucous)

2. Buccal – cheek, Mixed (predominately mucous)

3. Glossopalatine – anterior faucial pillar, glossopalatine

fold- purely mucous

4. Palatine : hard and soft palate, uvula- purely mucous

5. Lingual

(anterior tongue )- mixed predominately mucous

Circumvillate papillae( Von Ebner’s Gland) purely serous

Posterior – mucous

• At rest minor salivary gland may produce half of the

salivary secretion of the oral cavity.

• On stimulation it produces only 10-20% of salivary

secretion.

• Saliva is highly complex mixture of water, organic and non

organic components.

• The basic anatomic structure of salivary gland are acinar

and ductal cell.

• Acinar cells are the secretory end piece of the gland,

secreting the fluid component of the saliva.

• Primary saliva secreted from acinar component is a

isotonic solution with serum.

• Extensive resorption of sodium and chloride and

secretion of potassium within the ductal system makes

it protein rich hypotonic solution.

Salivary gland disease

• Most common presenting symptom is

Xerostomia

• Second most common symptoms is

Swelling.

• Xerostomia not always results from salivary gland

hypo function

• 25% of older patient suffer from xerostomia….??

Causes of Xerostomia

▪ Developmental Origin

➢ Salivary gland aplasia

▪ Water/Metabolite loss

➢ Impaired fluid intake

➢ Hemorrhage

➢ Vomiting /diarrhea

▪ Iatrogenic Factor

➢ Medication (antihistamine, decongestant, anti depression, antipsychotic, sedative and anxiolytic)

➢ Radiation therapy to head and neck

➢ chemotherapy

▪ Systemic Disease➢ Sjogren Syndrome

➢ Diabetes Mellitus

➢ Diabetes Insipidus

➢ Sarcoidosis

➢ HIV

➢ Hepatitis C infection

➢ Graft versus host disease

➢ Psychogenic Disorder

▪ Local Factors

➢Decreased medication

➢Smoking and

➢Mouth breathing

Clinical Features of Xerostomia

▪ Signs of mucosal dryness

▪ Lips appears cracked, peeled and atrophied

▪ Buccal mucosa appear corrugated and pale

▪ Tongue appear smooth and reddened.

▪ Marked increase in carious lesion and erosion

(pattern??)

▪ Angular cheilitis and erythematous candidiasis

History and Clinical examination

Drug history

History of systemic disease/ radiotherapy

dryness of eye, skin , joint pain etc.

Difficulty in mastication and swallowing correlated

with decreased secreatory capacity of gland.

Oral pain and intolerance to spicy and coarse food

• Lipstick sign

Lipstick or shed epithelial cells on the labial

mucosa on maxillary anterior teeth.

• Tongue blade sign

Hold the tongue blade against the buccal mucosa

for few seconds if it stick to the mucosa the

sign is positive.

➢Decrease salivary flow on stimulation of gland.

➢Thick ropy saliva/scanty saliva instead of watery clear

and copious saliva indicates

Chronically reduced function

➢Cloudy exudate may indicates

Bacterial function

Treatment of xerostomia

▪ Difficult and unsatisfactory

• Frequent sipping of water

• Use of artificial saliva

• Use of sialogogue like Pilocarpine

Side Effects

Excessive sweating

Increased heart rate and blood pressure

Palpation of salivary gland

• Usually painless without any palpable mass

• Swelling occurs due to

• inflammation,

• infection or

• neoplastic growth.

If painful it indicates

Infection or acute inflammation

▪ Recurrent swelling or swelling with pain or without painmust be confirmed.

▪ Relation of swelling with food must be asked

▪ Tumor will present as painless solitary swelling

▪ Most commonly at the tail region

▪ Facial nerve paralysis must be confirmed or rule

out with parotid gland swelling

▪ Ulceration of overlying skin may indicates

malignancy

Investigations for salivary gland diseases

Saliva Collection

➢ Salivary flow rate provides important information

regarding the gland function

Whole saliva

• Mixed fluid content of the oral cavity

Methods of collection

▪ Draining

▪ Suction

▪ Spitting

▪ Absorbent

Spitting Method

• Ask patient to collect saliva in the mouth and

spit in pre weighted tube .

• Patient must be advised to spit once in 60

seconds for 5 to 15 minutes

Absorbent Method

• Pre weighted gauze sponge kept in the patient

mouth for set period of time.

Collection of Stimulated Saliva

▪ Ask the patient to chew on unflavored gum base or

inert material such as paraffin ( 60 times in a minute)

▪ Individual parotid gland saliva collection is performed

by using Carlson-Crittenden collectors

▪ From submandibular or sublingual gland using

aspirating device or alginate held collector called

segregator

▪ For general assessment of salivary gland function ,

un-stimulated whole saliva collection is the

recommended method of collection

What is the normal range of salivary secretion ??

Minimum value of un-stimulated salivary flow

0.1ml/min

Minimum value of stimulated salivary flow 0.7

ml/min

Sialochemistry

Saliva contains more than 60 constituents

Composition will change in many pathological condition

Saliva is also being used for screening of drug abuse,

estimation of viral infection, blood alcohol and hormone.

Imaging of salivary glandWhy do we need imaging??

▪ Most of the salivary gland diseases are having overlapping

signs

Imaging is needed to ascertain-

➢ Location of lesion whether it is intra glandular or extra

glandular

➢ Nature of the lesion whether it is inflammatory or

infectious or a mass.

Methods of imaging for salivary gland

Plain Radiography

Sialography

Ultra sonography

Radionuclide imaging

MRI

CT

Sialoscopy

Positron emission computed tomography

PLAIN FILM RADIOGRAPHY• Plain film radiography is a fundamental part of

examination of major salivary glands.

• It may provide sufficient information to preclude the

use of more sophisticated and expensive imaging

technique.

• It is useful when clinical impression supported by a

compatible history suggest the presence of sialolith or

any dystrophic calcification.

• Both extra oral and intra oral images should be taken to

demonstrate the entire region gland

Imaging of submandibular gland

Intraoral View

• Occlusal radiograph

Extra oral View

• Panoramic radiograph

• Lateral oblique radiograph

Imaging of parotid gland

Intra oral view

• Intra oral view of cheek

Extra oral view

• Panoramic view

• Lateral oblique view

• PA View of skull with cheek puffed out

Cross sectional mandibular occlusal projection

• It helps in imaging sialolith in the anterior 2/3 of

submandibular duct.

• For this projection patient should be positioned in a

semi recline position with head tilted back.

• Anterior border should be approximately 1 cm beyond

the mandibular central incisor.

• The central beam should be directed through the centre

of film and perpendicular to it.

Over the shoulder occlusal projection

• This projection is indicated to demonstrate the

sialolith in the posterior part of Wharton’s duct.

• In this projection, directing cone is placed over the

shoulder of the patient and centre beam is directed in

an anterior direction through the angle of the mandible

with the patient’s head tilted to the unaffected side and

rotated back.

Panoramic projection

• It is helpful in demonstrating sialolith present in the

posterior part of Wharton’s duct or intra glandular

sialolith in the submandibular gland.

Lateral oblique projection

➢ It is helpful in demonstrating sialolith in the

submandibular gland.

➢To project sialolith in the submandibular gland the

projection is need to be modified by opening the

mouth, extending the chin, and depressing the tongue

with the index finger. This improves the image of

sialolith by moving it inferior to the mandibular

border.

Intra oral view of cheek

• Parotid sialolith is more difficult to demonstrate as

compared to submandibular sialolith as a result of

tortuous course of stensen duct around the anterior

border of mandilble.

• As a rule, only sialolith anterior to the masseter muscle

can be imaged on intra oral film.

• To demonstrate sialolith in the anterior portion of the

parotid gland an occlusal film should be placed inside

the cheek over the parotid papilla. Central beam should

be directed perpendicular to the cheek and also

perpendicular to the film.

Posterior anterior skull projection with cheek puffed out

• PA Skull view with cheek puffed out may move theimage of sialolith free of bone rendering it visible onthe projected image. This technique may alsodemonstrate intra glandular sialolith that may beobscured during sialography.

• It is helpful in demonstrating sialolith in the distalportion of Stenson duct. It may also demonstrate intraglandular sialolith.

Limitation

• 20% of the sialolith of submnadibular gland

and 40% of that parotid gland are not well

calcified, so not visible on the plain films.

• Inflammatory changes in the ductal system or

in gland cannot be visualised using plain films.

Sialography• Sialography can be defined as the radiographic

demonstration of the major salivary glands by

introducing a radiopaque contrast medium into their

ductal system.

• It is an invasive procedure but the only imaging

modality for examining the fine anatomy of the

salivary gland ductal system.

• Sialography was first introduced in the year of 1902.

In 1925 Barsony first time introduced in vivo

sialography. Rubin and Holt in 1957 divided the

sialography into filling and emptying phase.

Conventional Sialography• It is the sialographic imaging technique that uses plain

radiograph for imaging gland and its ductal system.

Indication

• To detect or confirm small parotid or submandibulargland sialolith or foreign bodies.

• Evaluation of the extent of irreversible damage presentas a result of infection.

• Differentiation of disease such as chronic sialadenitis,Sjogren’s syndrome and sialosis.

• Evaluation of fistulae, strictures, diverticula,

communicating cyst and ductal trauma

• Rarely, as a dilating procedure for mild ductal

stenosis.

Equipments used

• Sialographic cannules

• Lacrimal dialators

• 5-10 ml of syringe

• Contrast media

• Secretogogue

CONTRAST MEDIA

• Contrast media suitable for sialography are all iodine

based. Contrast media that can be used for

sialography are of two types -

• Fat soluble or oil based contrast media

• Aqueous or water soluble

Oil based contrast media

• Densely radiopaque, thus show good contrast.

• High viscosity, thus slow excretion from the gland

Disadvantage

• Extravasated contrast media may remain in the soft

tissue for many months, and may produce a foreign

body reaction.

• Granuloma formation has been reported with the use

of ethidol following extravasation.

• High viscosity means considerable pressure needed to

introduce the contrast media, calculi may be forced

down the main duct.

Aqueous or water soluble mediaAdvantage

• Low viscosity, thus easily introduced.

• Easily and rapidly removed from the gland

• Easily absorbed and excreted if extravasated.

• No foreign body reaction or granuloma formation has been reported.

Disadvantage

• Less radiopaque, thus show reduced contrast.

• Excretion from the gland is very rapid unless used in a closed system.

The procedure is divided into three phases

• The preoperative phase

• The filling phase

• The emptying phase

Preoperative phase

This involves taking of scout or survey radiographs

• To look for, 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 factor.

Filling phase

• Once the scout radiograph has been obtained, the

relevant duct orifice need to be located and

cannulated.

• If difficult to locate the ductal orifice gland can be

milked gently to locate the ductal opening.

• Once it is located it should be cannulate to introduce

contrast media.

• Once the contrast medium is introduced the filling

phase radiograph has been taken, ideally at least two

different views at right angle to each other.

For submandibular gland

• lateral mandibular view

• lateral oblique view

For parotid gland

• lateral oblique

• anterio posterior view should be taken.

The normal sialographic appearance of salivary gland

Parotid gland

Tree in winter appearance.

Submandibular gland

Bush in winter appearance

Bush in winter appearance of submandibular gland (normal sialographic appearance)

Normal radiographic appearance of parotid gland tree in winter appearance

Emptying Phase

• The cannula is removed and the patient allowed rinsing

out.

• Gland should be allowed to empty without any

stimulation and post evacuation radiograph should be

taken to assure complete evacuation.

• If post evacuation radiograph shows presence of

contrast media, use of lemon juice will be helpful in

complete evacuation of gland and ductal system.

Indication

Sialolith

• Indicated for those conditions not detected by plain

radiography.

• On sialograph the ductal system will appear dilated

proximal to obstruction.

• Contrast media may flow around small radiolucent

sialolith and the radiolucent sialolith and the

radiolucent sialolith will appear as a ‘Ductal filling

defect’

Bacterial sialidenitis

Mild dilation of terminal duct and sac like acini

Ductal sialadenitis

• Dilatation of the ductal system is a prominent

sialographic presentation of ductal sialadenitis.

• If interstitial fibrosis develops, it is apparent in

sialograms as a ‘sausage- string appearance’ of the

main duct and its major branches produced by

alternate stricture and dilation.

sausage- string appearance

Autoimmune Sialadenitis

• It represents a group of disorders that affect the salivary

gland and share auto sensitivity.

• Sialography is helpful in diagnosing and staging of

autoimmune disorder.

Early stage

• This stage is characterised by punctate(<1 mm),

globular(1-2mm) collection of contrast agent evenly

distributed throughout the gland.

• At this stage main gland appears normal, but

intraglandular ducts may be narrowed or not even

evident.

• Retention of the contrast medium even after

administration of sialogog, indicates extraductal

pooling.

Cavitary Stage

• As the disease progress, the collection of contrast

agent increases in the size (>2mm) and becomes

irregular in shape.

• This pool of contrast agent is known as cavitary stage.

• They are fewer in numbers and irregular in shape and

shows uneven distribution.

EARLY STAGE

ADVANCED STAGE

Tumours

• Benign tumour will appear as a space occupying

lesion on sialograph with smooth displacement of

main gland and its branches.

• Malignant tumour will show distortion in the ductal

system.

SPACE OCCUPYING LESION

Variants of saliography imaging technique

▪ Panoramic Sialography

▪ Fluoroscopic Sialography

▪ Digital Sialography

▪ CT Sialography

▪ MRI Sialography

▪ Cone Beam Computed Sialography

Contraindication

• Acute infection.

• Known sensitivity to iodine containing compound.

• Immediately anticipated thyroid function test.

ULTRASONOGRPHYIt is a technique based on sound waves that acquire image on real

time and without the use of ionizing radiation.

Diagnostic ultrasongraphy use vibratory frequencies in the range

of 1-20 MHz.

CLINICAL IMPLICATION OF ULTRASONOGRAPHY IN

SALIVARY GLAND IMAGING

Being paired superficial structures, the parotid and submandibular

glands are suitable for high resolution ultrasound examination.

The ultrasound examination can be easily combined with fine

needle aspiration cytology (FNAC) further enhancing its ability to

differentiate between benign and malignant lesions.

Diagnosis of different pathological condition of

salivary gland using ultrasound

▪ Sialolithiasis

➢ For the detection of salivary calculi, ultrasound is the

investigation of choice, with a sensitivity of 94%, specificity

of 100% and an accuracy of 96%

➢ Intra-glandular ductal dilatation and an intra-ductal echogenic

filling defect casting posterior acoustic shadowing are the

hallmark ultrasound features of sialolithiasis.

➢ Complications of calculi, including sialocele and abscess, can

be easily identified with ultrasound.

Ultrasonography of left parotid gland showing 5 mm.

of calculi in Stenson duct

Acute bacterial infection

▪ The acutely inflamed gland is enlarged and hypoechoic

on ultrasound. The parenchyma may have a

heterogeneous pattern attributable to the presence of

micro-abscesses, localized duct dilatation or retention

cysts

Chronic inflammatory sialadenitis (Sjogren’s syndrome)

▪ The role of ultrasound is to confirm or exclude

salivary gland involvement and to look for

lymphomatous change in the cervical lymph nodes

▪ Early stage the salivary glands may be normal or show

diffuse enlargement with normal echogenicity.

▪ Late features

➢ A heterogeneous echopattern with multiple round hypoechoic areas

within the parenchyma, sometimes containing frank cystic changes In

long-standing disease, the involved glands appear small and atrophic with

a hypoechoic echotexture or may have a reticular pattern.

Chronic sclerosing sialadenitis (Kuttner tumor)

➢ The most typical ultrasound appearance is a diffuse cirrhotic-like pattern:

bilateral diffuse involvement with multiple hypoechoic lesions against a

heterogeneous background resembling a cirrhotic liver.

Well defined margin in cystic lesion Well defined solid mass in parotidgland

cirrhotic-like’ echo pattern

Ultrasound-guided core needle biopsy for salivarygland lesions

▪ Ultrasound guided core needle biopsy (US-CNB) isrelatively recently described technique in the salivarygland which has been well tolerated and has demonstrateda high degree of diagnostic accuracy

INDICATION

• US-CNB has potential advantages over FNAC, particularlyin the typing and grading of lymphoma and carcinoma andin improved differentiation of reactive nodal hyperplasiafrom lymphoma.

• The use of US-CNB may help to reduce the need forsurgical biopsy and facilitate prompt appropriatemanagement.

ADVANTAGE

• Non invasive technique

• Inexpensive

• No radiation exposure

• Provide real time image during the procedure.

LIMITATION

• Don’t provide information about the deep lobe of

parotid gland.

• Imaging of malignant tumour is not very precise.

• Deeper tissue invasion can’t be detected.

COMPUTED TOMOGRAPHY

• CT scanning involves a combination of two different

fields (x-ray technology and computers).

• Greater attenuation of x-ray by dense structure such as

bone is represented by increasing “whiteness” on gray

scale image. Whereas soft tissue structure attenuate to

lesser degree are more “black”

• Scanning should be done in various planes like coronal

or axial plane.

Clinical implication of computed tomography inimaging salivary gland diseases

▪ Proximity of salivary gland to vital structures likefacial nerve, retromandibular vein, carotid artery ordeep lymph nodes can be identified on computedtomography

▪ Main indication of use of CT imaging of salivarygland is presence of mass in salivary gland orsuspected sialolith in gland that gone undiagnosed byplain radiography or ultrasonography.

▪ The sensitivity of CT over plain radiography indiagnosing sialolith is ten times higher.

▪ CT attenuation of masses is helpful in differentiating

benign cyst from solid mass and lipoma from other

neoplasm.

▪ Administration of contrast material is helpful because cysts

usually enhance on their periphery, whereas pleomorphic

adenomas enhance solidly.

▪ It also provides definition of cystic walls, making it

possible to distinguish fluid filled mass from abscess.

▪ Osseous erosions and sclerosis are better visualized by CT

• Does not help in predicting histologic diagnosis since

most malignant and non malignant solid masses have

similar CT attenuation.

• Radiation exposure to patient that much higher than the

plain radiography

• Administration of iodine containing contrast media for

contrast enhancement may cause allergic reaction to

patient.

• Potential scatter from dental restoration.

• Expensive procedure

CLINICAL IMPLICATION OF MRI IN DIAGNOSIS OF SALVARY GLAND DISEASES

▪ It has become the imaging modality of choice for

preoperative evaluation of salivary gland tumours

because of its ability to provide multiplanar image.

▪ MRI may be used as the first (and only) technique to

evaluate a neoplasm of the major salivary glands, if

clinicians are highly confident that the process in the

gland is neoplastic and not obstructive or

inflammatory.

• Virtually all parotid lesions are well visualized on T1-

weighted MR images because of the hyperintense

(fatty) background of the gland.

• The T1-weighted image gives an excellent

assessment of the margin of the tumour, its deep

extent, and its pattern of infiltration.

• T2-weighted MR imaging has been shown to be a

reasonably reliable (73%) predictor of whether a

salivary gland tumor is benign or malignant.

Hyperintense mass on T2-weighted images is benign

and a mass of low to intermediate signal intensity is

malignant.

ADVANTAGES

• Facial nerve is the critical structure when operating on theparotid gland. Pre operative assessment of salivary glandtumour using MRI may be helpful to surgeon indetermining the treatment modality because of itsexcellent ability to differentiate soft tissue

• T2-weighted MRI is reasonably reliable predictor ofwhether a salivary gland tumor is benign or malignant.

• No radiation exposure to patient.

• No intravenous contrast media are required routinely.

• Minimal artefacts from dental restoration reported.

DISADVANTAGE

• Not reliable in detecting calculi or any osseous

changes.

• Patient with pacemaker or implant can’t undergo MRI.

• Patient who is claustrophobic MRI is contraindicated

SCINTIGRAPHY• A salivary gland scan or scintigraphy is a nuclear medicine

test that examines the uptake and secretion in the salivary

glands of a radioactively labelled marker substance.

• The pattern of uptake and secretion shows if these glands

are functioning normally.

INDICATION

• When sialography is contraindicated

• When it is difficult to cannulate major duct

• When there is a need of quantification of function of gland.

• To assess injury to parenchymal tissue of gland, following

head and neck radiotherapy.

Imaging Study Indications Comments

Plain films Calculus disease Limited value; may differentiate salivary gland disease from

bony abnormality

Sialography Sjogrensyndrome, chronic

inflammatory conditionsBest means of imaging ductal system; of limited value other

than in evaluating the ductal system

CT Chronic inflammatory

conditions and complications,

intrinsic and extrinsic masses,

calculus disease

Excellent anatomic detail for intrinsic and extrinsic salivary

gland

tumours; best means of identifying calculi or calcification

MRI Chronic inflammatory

conditions and complications,

intrinsic and extrinsic masses

Excellent anatomic detail in tumour evaluation; may be better

than CT

for parapharyngeal space and intracranial extensions

Ultrasonography Abscess, cyst, intrinsic salivary

neoplasm

Best means of determining solid vs. cystic lesions, but limited

nasopharyngeal detail

Radionuclide imaging Warthin Tumour Sodium pertechnetate Tc 99m taken up by benign neoplasms;

gallium

67 citrate and bone-scanning agents occasionally useful for

Malignancies

Diseases of Salivary Gland

• Functional disorder

• Obstructive disorder

• Non – neoplastic disorder

• Neoplastic disorder

Functional disorder

• Sialorrhea

Neurological disorder

Mercury poisoning

• Xerostomia

Post surgical

Mumps , Sjogren Syndrome, post radiation

Functional disorder

• Mucocele

Secondary to trauma

70% occur on lower lip

Excisional biopsy is the cure

Ranula

Sublingual salivary gland

Removal of sublingual gland

Mucoele• Mucus is a exclusive secretary product of the

accessory minor salivary gland and the most

prominent product of the sublingual gland.

• Mechanism for mucus cavity development is

extravasations or retention.

▪ Secondary to trauma

▪ 70% occur in lower lip

• Extravasation Type: leakage of fluid from the duct or acini in the surrounding tissue.

• Retention Type: narrowed ductal opening that can not be adequately accommodate the exit of the saliva produced, leading to the ductaldilation and surface swelling.

• Lacks a true epithelial linining

• Excision with removal of associated salivary gland

Ranula

• Its a term used for mucoceles that occur in the floorof the mouth.

• The name is derived form the word rana, because theswelling may resemble the translucent underbelly ofthe frog

• Presents as a blue dome shaped swelling in the floorof mouth (FOM). They tend to be larger thanmucocele & can fill the floor of the mouith & elevatetongue. Located lateral to the midline, helping todistinguish it from a midline dermoid cyst.

• Treatment of Ranula

Marsupialization ( de roofing ) excessive recurrence rate

of 60-90%

Sublingual gland removal via intraoral approach

Obstructive SG Disorders

Sialolithiasis /stone Sialolithiasis

• Results in a mechanical obstuction of the salivary duct

• It is the major cause of unilateral diffuse parotid or

submandibular gland swelling.

• Exact etiology is not known

• Obstuct the flow of saliva from the gland.

• Hyperclacemia,

• Xerostomia

• Smoking etc.

• Anatomy of duct

• Components of saliva Upwarding route.

• Mucus protein

• Longer duct

• Calcium content and Curve duct n

Reasons sialolithiasis may occur more often in the Sub

mandibular gland

• Saliva is more alkaline

• Higher concentration of calcium and phosphate in

the saliva

• Higher mucus content

• Longer curved duct

• Anti-gravity flow

Obstruction Phenomenon

Acute ductal obstruction may occur at meal time when

saliva producing is at its maximum, the resultant

swelling is 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.

Traditional treatment

Intraoral route Sialolithotomy

Sialadenectomy via external approach

Gland excision indicated for very posterior stones

Acute Suppurative Parotitis –

History

▪ Sudden onset of erythematous swelling of the pre/postauricular areas extend into the angle of the mandible.

▪ Male above 60 affected more than female

▪ Staphylococcus aureus is the most causative organismhence it is colonizes around ductal orifice thusdecrease salivary flow

• Clinical Presentation

▪ Rapid onset of the preauricular swelling

▪ Erythema

▪ Pain

▪ Palpation ( milking ) of the involved gland will reveal

no flow or elicit a thick , purulent discharge from the

orifice of the duct

• Parotitis is generally a clinical diagnosis

• If no response to antibiotics in 48 hrs can perform MRI,

CT or ultrasound to exclude abscess formation

• Among salivary gland neoplasms,

• 80% arise in the parotid glands,

• 10-15% arise in the submandibular glands,

• and the remainder occur in the sublingual and minor

salivary glands

• The most common tumor of the parotid gland is

the pleomorphic adenoma, which represents

about 60% of all parotid neoplasms .

• Almost half of submandibular gland neoplasms

and the majority of sublingual and minor

salivary gland tumors are malignant.

• Salivary gland neoplasms are rare in children.

• Most tumors (65%) are benign, with hemangiomas being

the most common, followed by pleomorphic adenomas.

• In children, 35% of salivary gland neoplasms are

malignant.

• Mucoepidermoid carcinoma is the most common salivary

gland malignancy in children.

• The majority of patients with salivary gland neoplasms

present with a slowly enlarging painless mass.

• Parotid neoplasms most commonly occur in the tail of

the gland.

• Submandibular neoplasms often present with diffuse

enlargement of the gland, while sublingual tumors

will produce a palpable fullness in the floor of the

mouth.

• Minor salivary gland tumors will have a varied

presentation depending on the site of origin. Painless

masses on the palate or floor of mouth are the most

common presentation of minor salivary neoplasm.

Clinical presentation

➢ Painful swelling (60%)

➢Painless swelling (30%)

➢ Pain only (12%)

➢Sometimes described as recurrent salivary colic

and spasmodic pains upon eating.

Clinical History

• 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?

Inspection

Asymmetry (glands, face, neck)

Diffuse or focal enlargement

Erythema extra-orally

Trismus

Medial displacement of structures intraorally?

Examine external auditory canal (EAC)

Palpation

➢ Palpate for cervical lymphadenopathy

➢Bimanual 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).

TNM STAGING

• The TNM system is the most widely usedcancer staging system.

• In the TNM system:

• The T refers to the size and extent of the main tumor.The main tumor is usually called the primary tumor

• The N refers to the number of nearby lymph nodes thathave cancer.

• The M refers to whether the cancer has metastasizedThis means that the cancer has spread from the primarytumor to other parts of the body.

•

Primary tumor (T)

• TX: Main tumor cannot be measured.

• T0: Main tumor cannot be found.

• T1, T2, T3, T4: Refers to the size and/or extent of the

main tumor. The higher the number after the T, the

larger the tumor or the more it has grown into nearby

tissues. T's may be further divided to provide more

detail, such as T3a and T3b.

Regional lymph nodes (N)

• NX: Cancer in nearby lymph nodes cannot be

measured.

• N0: There is no cancer in nearby lymph nodes.

• N1, N2, N3: Refers to the number and location of

lymph nodes that contain cancer. The higher the

number after the N, the more lymph nodes that

contain cancer.

Distant metastasis(M)

• MX: Metastasis cannot be measured.

• M0: Cancer has not spread to other parts of the body.

• M1: Cancer has spread to other parts of the body.

TNM Classification for Cancer of Major Salivary Glands

Primary tumor (T)• Primary tumor cannot be assessed• No evidence of primary tumor• Carcinoma in situ• Tumor ≤2 cm in greatest dimension without extraparenchymal

extension*• Tumor >2 cm but not more than 4 cm in greatest dimension without

extraparenchymal extension*• Tumor >4 cm and/or tumor having extraparenchymal extension*• Moderately advanced or very advanced disease• Moderately advanced disease• Tumor invades the skin, mandible, ear canal, and/or facial nerve• Very advanced disease• Tumor invades skull base and/or pterygoid plates and/or encases

carotid artery

Regional lymph nodes (N)

▪ NX- Regional nodes cannot be assessed

▪ N0- No regional lymph node metastasis

▪ N1- Metastasis in a single ipsilateral lymph node ≤ 3

cm in greatest dimension and ENE (-)

N2- Metastasis in a single ipsilateral lymph node > 3 cm

but not more than 6 cm in greatest dimension and ENE

(-);

• or metastases in multiple ipsilateral lymph nodes, none

> 6 cm in greatest dimension and ENE (-);

• or in bilateral or contralateral lymph nodes, none > 6 cm

in greatest dimension and ENE (-)

• N2a- Metastasis in a single ipsilateral lymph node

> 3 cm but not more than 6 cm in greatest

dimension and ENE (-)

• N2b- Metastasis in multiple ipsilateral lymph

nodes, none > 6 cm in greatest dimension and ENE

(-)

• N2c- Metastasis in bilateral or contralateral lymph

nodes, none > 6 cm in greatest dimension and ENE

(-)

• N3- Metastasis in a lymph node > 6 cm in greatest

dimension and ENE (-); or metastasis in any node(s)

with clinically overt ENE (+)

• N3a- Metastasis in a lymph node > 6 cm in greatest

dimension and ENE (-)

• N3b- Metastasis in any node(s) with clinically overt

ENE (+)

• . Prognostic stage groupsStage T N M

0 Tis N0 M0

I T1 N0 M0

II T2 N0 M0

III T3 N0 M

T0–T3 N1 M0

IVA T4a N0–N1 M0

T0–T4a N2 M0

IVB T Any N3 M0

T4b N Any M0

IVC T Any N Any M1

•

TNM STAGING OF ORAL CANCER