3. Salivary Gland Disorders/Disease
What is a sialendoscopy?
is an image-guided technique for the evaluation and treatment of patients with obstructive disease of the salivary glands. no incision, go through lumen of duct
parotid gland excretory duct ?
parotid/stenson's duct - duct emerges anterior from gland, superficial to masseter muscle, and pierces buccinator - duct orifices id by small papilla located close to max second molar
adenoid cystic carcinoma
perineural spread - spreads along the nerve - rapidly growing swelling affecting palate
Chronic sialadenitis is associated with?
periodic swelling and pain.
Ranula - CT scan
plunging/cervical ranula that produce swelling in nect (dissect mylohyoid) speech can be difficult, pts may be concerned about eating, if ruptured, will likely refill again
What is a punctum?
prevents retrograde flow of fluid. (one way barrier)
What is sialography?
radiographic examination of the salivary glands usually involves the injection of a small amount of contrast medium into the salivary duct of a single gland, followed by routine X-ray projections. resulting image is called a sialogram
One of the more common causes of sialadenitis?
recent surgery
How do you treat ranula?
removal of the sublingual gland. Marsupialization may sometimes be used, where the intra-oral lesion is opened to the oral cavity with the aim of allowing the sublingual gland to re-establish connection with the oral cavity
if you suspect a salivary gland tumor, what should you do?
send to OS MRI or CBCT fine needle aspiration biopsy make treatment plan
Sialolithiasis: variation in stone sizes
small stones can be massaged out larger stones need to be retrieved or cut out if multiple stones, can remove entire gland to facilitate good fx of other glands
Salivary Gland Disorders/Disease
some can impede the salivary glands from functioning properly while other salivary gland disorders/disease may affect one's overall health.
what causes a ranula?
usually severance of the sublingual gland duct although severance of the submandibular duct may also be the cause Blockage of the duct with a salivary gland stone (sialolith) may produce a ranula which is a true mucous cyst
Ranula - Surgical removal of Sublingual gland
very superficial, be careful of whartons duct and lingual nerve
what is the name of the ducts for the following major salivary glands? Parotid submandibular sublingual
Parotid = stenson's duct submandibular = wharton's duct sublingual = bartholins ducts
what is the largest of the salivary glands and is predominantly serous with few scattered mucous acini?
Parotid Gland
What are mucocele caused by?
traumatic severance of the salivary gland excretory duct. Extravasation of fluid from rupture salivary excretory duct (blue dome shape lesion). - Encapsulated and consists of mucin.
Functional disorders/disease Xerostomia (Decrease in saliva flow)
- Mumps - Sarcoidosis - Sjoegrens syndrome - Lupus - Post-irradiation treatment
Salivary Gland Disorder Bacterial Sialdenitis Acute/Suppurative
- Parotid (Parotitis) > SMG (Sialadenitis) - Adults > children - Pain, swelling, +/- fevers - Staph. Aureus or MRSA(Parotid gland), - Strep. Pneumonia, - Strep. Viridans (Submandibular Gland)
Salivary Gland Disorder Bacterial Sialdenitis Chronic/Non-Suppurative
- Parotid > SMG - Adults > children Pain, swelling, +/- fevers Staph. Aureus, Strep. Pneumonia, Strep. Viridans
Sialolithiasis - Imaging options
- Plain films (radiopaque stones, well calcified) - occlusal radiographs - CT Scan = gold standard - Ultrasound (stone must larger than 2mm to be seen) - Sialography - MRI
Functional disorders/disease Sialorrhea (Increase in saliva flow)
- Psychosis - Mental retardation - Certain neurological diseases - Rabies - Mercury poisoning
Sialolithiasis - Clinical Exam
- Salivary flow evaluation - Stones in the terminal ducts can usually be palpated. - Palpation of stone in the submandibular duct - Palpation of the submandibular gland - Determine expression of pus from duct (positive or negative) bimanual palpation
what nerve is related to parotid gland?
facial nerve embedded within superficial and deep lobes of parotid gland
mucoepidermoid carcinoma
histopathological classification - high grade (most aggressive) - intermediate grade - low grade (least aggressive)
Surgical Management of Submandibular Gland Sialolithiasis A patient with multiple salivary gland stones and chronic recurrent infection of the salivary gland has:
increased risk of significant damage) to the salivary gland. In this situation, the salivary gland needs to be surgically removed.
What is a sialdentitis?
inflammation of gland or duct. Inflammation of the salivary glands can arise from various infectious and non-infectious causes: - Obstruction - Bacterial infection (acute vs chronic) --- Most bacterial infections arise as a result of ductal obstruction or decreased salivary flow - Viral (HIV, Mumps) --- secondary bacterial infection after viral - Sarcoidosis - Sjogrens syndrome - Tumor - Irradiation - Malnutrition
what gland Produces most stimulated saliva?
parotid
Salivary Gland Disorders/Diseases classifications
- Functional disorders/disease - Neoplastic disorders/disease - Obstructive disorders/disease - Infectious disorders/disease
Acute/Suppurative Sialadenitis clinical signs
- Indurated/swelling - Erythema - Pain - +/- fever - + infection - +/- obstruction The overlying skin may be erythematous and the patient may have low-grade fever, trismus and purulent discharge from parotid duct.
Submandibular Gland - Anatomy
- It is a large salivary gland composed of a mixture of serous and mucous acini. - Located in Submandibular triangle bordered by inferior border of mandible and ant/post digastric muscle, deep to mylohyoid muscle submand gland wraps around posterior portion of the mylohyoid where it becomes warthons duct lateral to the lingual freneum
Mucocele: Clinical Features
- bluish, dome-shaped swellings if superficial - normal color if deep in the tissues. They may be slightly painful due to an accompanying acute inflammatory reaction.
Malignant Salivary Gland Tumors
1. Mucoepidermoid tumor (Most common Salivary gland Malignancy) 2. Adenoid cystic carcinoma 3. Acinic cell tumor (A form of adenocarcinoma) 4. Squamous cell carcinoma
Benign Salivary Gland Tumors
1. Pleomorphic adenoma (Most Common and often recurrent) 2. Warthin's tumor (adenolymphoma) (seldom recurrent 3. Canalicular adenoma
Obstructive Disorders of Salivary Gland
1. sialolithiasis - mechanical usually unilateral diffuse glandular swelling 2. mucous retention and extravastion - mucocele - ranula
Ranula: Clinical Features
A ranula is the term used for mucoceles that occur in the floor of the mouth. They appear as dome-shaped, fluctuant swellings unless they are deep in the tissue. Typically, they are lateral to the midline. "plunging" or cervical ranulas dissect through the mylohyoid muscle to produce swelling in the neck
what type of saliva does each gland produce? parotid submandibular sublingual
parotid - Serous = watery submandibular - serous > mucous sublingual mucous
What are ducts of the sublingual glands called?
Bartholins ducts - very small, unable to clinically examine like stensons and whartons ducts - consist of 8-20 smaller ducts called ducts of rivinus empties into floor or mouth near the punctum of Whartons ducts or on a crest of sublingual mucosa called plica sublingualis called plica sublingualis or directly into Whartons duct
where is the parotid glad located?
Below/anterior EAC (External Acoustic Meatus) Posterior to mandibular ramus and anterior to mastoid process or temporal bone ends just inferior to angle of mandible
What are the risk factors of sialolithiasis?
Dehydration, diuretics, anti-cholinergics, trauma, smoking, surgery, etc The blockage of the duct and resultant inflammation can cause significant damage to the gland.
Sialolithiasis: Etiology
Etiology is unknown, Deposition of calcium salts around a nidus of debris in the duct lumen occurs but the exact cause of this is unknown. salivary calculi/stones - composition largely of calcium phosphate and hydroxyapatite
if a pt has a swollen parotid gland and their earlobes are raised bilaterally, what can this be a sign of?
MUMPS
Salivary Calculi/ Stones (Sialolithiasis)
Mechanical obstruction usually causes unilateral diffuse glandular swelling - typically forms along duct - common in submandibular duct (whartons)
Obstructive Disorders Mucocele -
Mucus Extravasation Phenomenon
if pt has an acute infection, should you do surgery to remove the gland?
NO, because borders of gland are altered.
Mucocele: Treatment, Prognosis and Significance
Occasionally, mucoceles will rupture spontaneously and heal without treatment. Surgical excision, if needed, is the treatment of choice. Removal of the adjacent minor salivary gland helps prevent recurrence The prognosis is excellent, although occasional mucoceles will recur, necessitating re-excision, especially if the feeding glands are not removed.
Transoral Sialolithotomy with Sialodochoplasty
Performed with stone is palpable within distal segment or anterior region of whartons duct in submandibular gland Stone can be removed transorally if in the duct and easily palpable lingual nerve block - incision on duct to open and expose salivary gland stone - keep duct open to avoid stenosis
Sialolithiasis: Treatment Options Non Surgical Options:
Small sialoliths can sometimes be removed by gentle message, sialagogues, moist heat, or increased fluid intake. - hydration - sialogogues - NSAIDs - +/- abx
Plunging Ranula
Soft painless fluctant mass Plunging ranulas extend through the facial plans, usually posterior to the mylohyoid muscle into the neck, and present as cervical masses.
What are the treatment for a plunging ranula?
Surgical removal of sublingual gland, submandibular gland or both
Sialendoscopy
The duct of the gland is dilated to allow passage of the sialendoscope The sialendoscope is a tiny lighted scope, about 1.5 millimeters wide, that is attached to a camera and has a channel for microinstruments.
Sialolithiasis: Treatment Options Other Treatment Options
Transoral Sialolithotomy with Sialodochoplasty (Surgical incision of a salivary duct to remove a calculus) Sialendoscopy - if bigger stone, can go through lumen of duct and remove Surgical removal of salivary gland - if there are multiple stones, inflammation, repeat infections, fibrotic
Submandibular Gland Excretory duct:
Wharton's duct. - exit on the sides of the lingual frenum Wharton duct adjacent to: - lingual nerve - ultimately drains into punctum within the sublingual caruncles on either side of lingual frenum
Sialolithiasis - Clinical Features
Young and middle-aged adults are most frequently affected - Patients frequently present with episodic pain and swelling particularly around mealtime. - Sometimes painless swelling
What is a ranula?
a translucent blue, dome shaped, fluctuant swelling in the tissues of the floor of the mouth. - Consist of mucin from rupture salivary gland Obstruction disorder usually involves the Sublingual gland Usually asymptomatic with exception to elevation in floor of mouth
what is a CONTRA-indication for sialography?
acute infection - can be used to see if there is a narrowing structure
functions of salivary glands
aids in mastication deglutition immunity speech tasting etc
Acute sialadenitis is treated by?
antibiotic therapy and rehydration (Fluids), heat , salivary stimulants to stimulate salivary flow. Surgical drainage may be required if abscesses occur. - Incision and drainage - Culture pus if pt has acute swelling, do I&D
facial nerve and parotid gland
be careful not to damage the facial nerve - nerve stimulator used to trace the nerve superficial parotid gland removal may be done if stenson's duct tumor or pleomorphic adenoma facial nerve paralysis - likely due to malignant process (benign process would likely be slow growing and facial nerve fx intact)
canalicular adenoma
benign - associated with upper lip ddx: fibroma (most common in this area) excisional biopsy
Mucoceles typically appear as
bluish, dome-shaped swellings if superficial or of normal color if deep in the tissues.
Ranula is common in who?
children
chronic sialadenitis is treated by?
depends upon the severity and duration of the condition. surgical removal if significant inflammatory destruction of the salivary gland (Chronic sialadenitis)
what are salivary gland disorders/disease caused by?
due to salivary gland stones, infection, cysts and tumors.
What is the sialendscope used for?
examine the inside of the gland, which is magnified on a monitor in the operating room. A wire basket is passed through and tightened around the stones for removal. The duct can then be further examined and flushed if needed.
Where is the sublingual salivary gland located?
lies beneath the mucous membrane of the floor of the mouth close to the midline. almond-shaped mucous-secreting gland.
how to evaluate saliva flow of parotid gland>
massage and try to milk the saliva, indicates good fx of salivary gland, compare both sides. if compromised salivary flow or pus, red flag
Pleomorphic Adenoma
most common and often recurrent - benign parotid gland (superficial lobe), mixed tumor extensions can be left behind, multifocal seeding. make sure incision is wide enough
Malignant Salivary Gland Tumors characteristics
not encapsulated, spread, rapidly growing - motor nerve fx of facial nerve, sensory fx of GP can be altered
Where is the sublingual gland located?
on superior surface of mylohyoid muscle and separated from oral cavity by thin later of mucosa layers from superficial to deep: oral cavity thin oral mucosa sublingual gland mylohyoid muscle
Where are muccoceles most common?
on the lower lip (70% occur in lower lip) and buccal mucosa. most common in children and adolescents rarely occur in upper lip common oral lesion
warthin's tumor
papillary cystadenomaism - benign - seen in smokers superficial lobe of parotid gland tx: remove superficial lobe of parotid gland
What is the smallest major salivary gland?
sublingual salivary gland
What salivary gland stones occur most often in?
submandibular gland ducts (92%) - whartons duct is loopy and likely to have a stone form parotid gland (6%) rare in sublingual gland most stones are solitary - likely feel something at the floor of the mouth
Submandibular gland divided into:
superficial and deep lobes separated by mylohyoid muscle
submandibular gland superficial lobe: deep lobe:
superficial lobe: in submandibular space deep lobe: in the sublingual space where it can be palpated intraorally.
Acute bacterial sialadenitis is most common in?
the parotid where it produces a painful swelling.
What is Sialolithiasis?
the presence of stones or calculi in the salivary glands or ducts, is a relatively common condition.
