Salivary glands
How can a salivary fistula present?
internal fistula - no symptoms external parotid fistula = troublesome, persistent, cause injury to the cheek, infection becomes superimposed, leakage of saliva prevents healing
How is MALT in SS diagnosed?
- very difficult for early diagnosis - suspect all cases with swollen glands - boppsy - clonality by PCR or immunohistochemistry W
What tests would be conducted for suspected SS?
parotid flow rates minor gland biopsy US/sialography/technetium scintigraphy blood tests - FBP, ESR, immunoglobulin levels autoantibody screen, antinuclear SSA and SSB lacrimal flow - schirmer test
When is ultrasound indicated?
salivary gland lumps salivary gland obstruction
What is a salivary calculi
stone formation in the salivary gland or duct
What can cause stricture of a duct?
CAused by fibrosis from ulceration and inflammation round a calculus or scarring following inadequate surgery
What features need to considered when examining and considering SS?
- MH - mouth dry, mirror or finger stick? - dry smooth, glazed or matt mucosa - is tongue red, fissured, lobulated? - palpate salivary glands, submandibular glands bimanually and milk saliva - caries? - dry eyes - signs of connective tissue disorders?
what is the treatment for ptyalism
- anticholinergic drugs - speech therapy - redirect salivary duct or excise submandibular glands - section off chord tympani but may lose some taste
What is the likely aetiology of sjogren's syndrome?
- autoimmune disorder = failure of immune control - loss of tolerance - glands infiltrated by activated b cells - lymphocytes collect around ducts and destroy acinar cells - mechanism unclear - systemic polyclonal B cell hyper reactivity - raised ESR - autoantibodies - ANF, Ro and La, gastric patietal cell antibody, anti-thyroid antibody, pancreatic, collagen, organ and non-organ specific, anti-saliary duct
What is sialorrhoea or ptyalism?
excess salivation
What salivary sample features would indicate SS?
flow rate <0.2ml/min/10min - candida - cloudiness
what are the clinical features of mumps?
headache malaise fever tense, painful tender swelling of parotid Diagnosed through history, make sure to not mistake it for dental infection
What are the features of ultrasound for use in salivary gland investigation?
- 1st one used for salivary glands - quick, simple, non-invasive, inexpensive - good patient compliance - no contrast - no IR - high resolution multi planar imaging - colour doppler for vascularity - Guides FNA or core biopsy
What are the features of a carcinoma arising from a pleomorphic adenoma?
- 4% of salivary tumours - arises from luminal cells of ductal structures - prognosis depends on whether the neoplasm has breached the capsule of the original adenoma or extended more than 5mm beyond it, when the prognosis is poor - clinically = sudden spurt in growth or development of pain and facial palsy
What are the clinical features of pleomorphic adenomas?
- commonest benign salivary neoplasm - mainly in parotid, most common in minor glands - found in posterior hard palate, FOM, upper lip - a benign slow growing neoplasm with potential for recurrence and malignant transformation - rubbery lobulated swelling - may appear bluish - mobile
What is suppurative parotiditis caused by? What are the clinical features?
- deblitiating patients, after op, from xerostomia, from dehydration - bacterial cause - staphylococcus aureus Causes intense acute inflammatory infiltrate extending along and dilates the ducts. Inflammation extends in to the periductal tissues Left too long = abscess forms = varying degree of acinar destruction pain in one or both parotid, swelling, redness, tenderness and increasing malaise and fever - regional lymph nodes are enlarge, pus exudes or can be expressed from the parotid duct
What treatment options are available for those with SS (10)?
- explain and reassure - hydration 1-1.5L water per day - preserve remaining flow - avoid drying drugs - stimulate flow by safe means - stimulate flow by pilocarpine (sweating nausea, vomitting, diarrheoa, constipation, dizziness, headache, dyspepsia, vasodilation, AV block, tachycardia, hypotension, confusion, tremors - prevent complications - diet analysis and fluoride - symptomatic treatment i.e. denture soreness - replace saliva - hypromellose and fums, polyox, saliva orthana - monitor for caries TW, ascending infecton and lymphoma
What are the minimally invasive treatment options for stones
- extracorporeal shockwave lithotripsy - intracorporeal shockwave lithotripsy - stone retrieval - radiologically or endoscopicaly guided - dissolution of stones SubyG - conservative surgery
What is the pathology of a salivary duct calculi?
- formed by deposition of calcium salts around a nidus of organic material - roughness can cause duct lining metaplasia - microflora can grow on surface of = inflammation and fibrosis around duct
Name some conditions that may present sialadenitis
- inflammation of salivary gland Mumps )paramyxovirus - suppurative parotitis
what are the functions of saliva
- lubricating - control pH 6.2-7.4 - limits oral pathogen growth (lysozymes, IgA and reduces oral odour) - Remineralise tooth surface - calcium - aids mastication - enzymes, lubricates, dissolves
What are the clinical features of a patient with a salivary calculi?
- mainly adults - unilateral - pain with smell or taste of food stimulates secretion - infection, pain, swelling of the gland - may be no symptoms until stone passes forward
What are the clinical features of a dry mouth?
- mirror or fingers stick to mucosa - difficulty swallowing and speaking, general oral discomfort, reduced denture retention/tolerance - secondary effects= increased caries, candidiasis, toothwear (rare in comparison to caries but does occur) - risk of ascending infection to salivary gland (non-specific sialadenitis) - if severe, lobulation of dorsum of tongue, mucosal atrophy whole unstimulated flow reduced below 0.2 ml per min over 10 mins (total 2mls) parotid flow reduced to less than 0.4 ml / min / single parotid gland stimulated X2 with citric acid over 10 minutes (4 mls total)
What are the clinical features of a muocele?
- often on lower lip, buccal mucosa of FOM - superfuicial - up to 1cm in diameter - early stage = round fleshy swelling, later they become obviously cystic, hemispherical, fluctuant and bluish - can't distinguish it from a retention cyst
What are the features of a mucoepidermoid carcinoma?
- one of most common salivary carcinomas - range of structure and behaviour from low grade to highly malignant - present in minor salivary glands - sometimes present in bone
What are the features of an adenoid cystic carcinoma?
- one of most common salivary gland carcinomas - slow growing - highly infiltrative malignant neoplasm - along nerve sheath - short term prognosis good, long term bad
What are the features of sialadenosis?
- persistant bilateral parotid swelling - acinar secretory cells become enlarged - aetiology = endocrine, metabolic, neurogenic - autonomic neuropathy is secondary to all aetiological factors - accumulation of secretory granules that causes the secretory cells to ENLARGE because of a lack of support from functionally insufficient myoepithelial cells.
What are the features of a lymphoepithelial sialadenitis?
- persistant bilateral parotid swelling - most common in SS - may prelude to a lowe grade MALT lymphoma - epithelial component rarely may become a carcinoma - lymphoepithelial islands produced by infiltration of lymphocytes between ductal cells and hyperplasia of ductal cells
What can cause false ptyalism?
- psychiatric - head down posture in disabled \ - poor neuromuscular control- parkinsons, bells palsy, muscle wasting disease
what are the causes of true xerostomia?
- psychogenic - anxiety - drugs -dehydration shock = diabetes mellitus / diabetes insipidus / cardiac and renal failure / diuretic drugs /low fluid intake - gland / nerve damage = Sjögren's and sicca syndromes/ Irradiation and cytotoxic drugs/ Neurological damage - rare causes: hypoplasia / aplasia of glands vitamin A deficiency
What are the predisposing factors for MALT?
- purpura - anaemia, leukopenia, lymphopenia - reduced CD4 count - parotid gland swelling - hyper gammaglobulinaemia - hypocomplementemia (C3 and C4)
When are plain films indicated?
- radiopaque salivary calculi
What is the risk of MALT lymphoma in SS?
- relative risk of lymphoma is x44, greater increased in SS - starts in parotid gland - salivary glands contain plasma cells of MALT system and in SS there are additional lymphocytes of the disease
What is seen in the histology of a carcinoma arising from a pleomorphic adenoma?
- resemble adenocarcinoma - mitoses - highly infiltrative in local tissues
What is the pathology of a mucocele?
- saliva leaks from a damaged duct in to superficial surrounding tissues excites and inflammatory reaction - pools of saliva gradually coalesce to form a rounded collection without epithelial lining - less frequent the duct may become obstructed but less severly damaged so that saliva does not escape into the surrounding tissues = retention cyst formation
What are the histological appearances of pt with sjogren's syndrome?
- similar in major and minor glands - periductal infiltrate of lymphocytes in many small lobules, these enlarge - acinar atrophy - complete replacement by lymphocytes - in parotid, ducts become hyper plastic - epimyoepithelial islands develop, infiltrated by lymphocytes
What is the treatment of a mucocele?
- small superficial = excise with underlying gland
What is the histology of an adenoid cystic carcinoma?
- swiss cheese appearance - rounded groups of small darkly staining cells of almost uniform size, surrounding multiple small clear spaces - two types of epithelial cells = polyhedral cells completely or partially enclosing BM often with few mitoses // luminal cells surrounding occasional true lumina containing PAS positive secretory glycoprotein - no capsule - perineural infiltration common
What are the histological features of a mucoepidermoud carcinoma?
- two types of cells = large pale mucous-secreting cells surrounded by epidermoud squamous cells - low grade often arranged around cysts - no well defined capsule
What is a ranula?
- uncommon type of salivary cyst arising from sublingual or submandibular gland
What are the clinical features of a ranula?
- unilateral - 2-3cm in diametere - extend across the whole of FOM - soft - fluctuant - bluish - painless - can interfere with speech or mastication
What are the histological features of pleomorphic adenomas?
-capsule never complete - ducts- two or more layers of cells> two types of cells - luminal cells - oesinophilic = secrete PAS secretory glycoprotein - peripheral abluminal cells undergo separation and stromalisation with the secretion of proteoglycan and collagen to form the stroma that is myxoid and chondroid - sheets or strands of dark staining epithelial cells - squamous metaplasia and foci of keratin - fibrous and elastic tissue - myxoid (mucus-like) tissue - mitoses seldome present - cartilage sometimes calcified
IMAGING AND INTERVENTION IN SALIVARY GLAND DISEASE
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SALIVARY GLAND NEOPLASM
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XEROSTOMIA SJORGREN'S SYNDROME
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How much saliva is produced everyday?
500ml
What is a salivary fistula?
A communication between the duct system of a gland with the skin or mucous membrane
What is a mucocele?
A mucus filled cyst (though it isn't a true cyst as it does not have an epithelial lining)
How are salivary gland neoplasms classified?
Adenomas - pleomorphic adenoma Carcinoma - carcinoma ex pleomorphic adenoma/ adenoid cystic carcinoma/ mucoepidermal carcinoma Nonepithelial tumours MALT lymphoma secondary malignancies unclassifiable tumours neoplasmlike conditions - lymphoepithelial sialadenitis/ sialadenosis
What is MALT lymphoma
B cell proliferation in mucosa associated lymphoid tissue that is faster than usual and cells last longer
What is the treatment of an pleomorphic adenoma?
Excision
What can be the consequences of trauma to the parotid papilla?
Fibrosis which result in stricture formation
What is the treatment of supparative parotiditis?
Flucloxacillin, but only after pus has been obtained for culture and sensivity testing
What are the main salivary gland diseases?
Infection (sialadenitis) - bacterial= staph, TB, actinomycosis, Viral = mumps, CMV, HIV -SALIVARY CYSTS - mucocele and ranula -SALIVARY TUMOUR - benign or malignant - SYSTEMIC RELATED - sialosis (sialadenosis, sarcoid, lymphoma, HIV, autoimmune - SALIVARY OBSTRUCTION - salivary calculi, salivary duct strictures
What is sialography? What is used for it and when is it indicated?
Introduction of radiopaque contrast material into salivary ducts used to demonstrate duct anatomy contrast media - water based or oil based - water based = urographin, is opaque - safer absorbed by tissues - OIL based - not commonly used as it remains in tissue afterwards INDICATIONS - Obstruction, sjogren's, sialadenitis
What can cause true ptyalism?
Local irritation/reflex - ulcers, AUG, dentures - lithium, cholinergic drugs - waterbrash, and idiopathic paroxysmal sialorrhoea - heavy metal poisoning - rabies -
What is tuburculous sialadenitis?
Myobacterial parotiditis - feature of advanced AIDS - chronic inflammatory swelling - detection of non-caseating granulomas and identification of Mtuberculosis
What is a stricture?
Narrowing of a duct or opening
What are the complications following salivary gland surgery
Nerve damage - parotid gland = facial nerve palsy:temporary/permanent // Submandibular - marginal mandibular nerve palsy Facial scarring post-operative infection salivary fistula Frey's syndrome
What features need to be evaluated in the ultrasound of a salivary gland ?
Parenchymal echogenicity Parenchymal pattern salivary gland involved? hypoechoic foci - individual lesions which stand out as larger than small foci scattered through the particular affected gland parenchyma
What is the management of salivary calculi?
Rx to see where it is - far forward = milked forward and manipulated - above doesn't work/placed distally = start from the most conservative option first - Lithotripsy = ultrasonic wave applied extra orally = fracture calculi = pass out orifice -Basket technique = stones in duct but not in gland =fine wire manipulated down the duct and around the stone - Surgical - if above fails, LA - incision made along the line of duct. Temporary suture behind duct to stop it slipping back - if calculi in gland =excision
What is SOX syndrome?
Sialadenitis Osteoarthritis Xerostomia
What are the differentiating presentations of various salivary disease causes?
TUMOUR = persistent localised swelling in a gland SJOGRENS SYNDROME, SIALADENITIS, SIALOSIS = persistent diffuse swelling affecting whole glands SIALODENITIS - intermittent non meal related swelling OBSTRUCTION - meal time related swelling
What can cause strictures of the papilla?
Trauma = projecting clasp, faulty restoration, sharp edges of broken tooth
What are the various forms of imaging that can be used for investigation?
Ultrasound plain fims sialography CT and CT sialography MR and MR sialography MR spectropscopy Scintigraphy and PET Endoscopy
What is sjogren's syndrome?
a syndrome consisting of dry eyes and dry mouth ± connective tissue disorder an autoimmune sialadenitis which may effect all exocrine glands subsequently subdivided into primary: dry eyes and mouth secondary: with connective tissue disease
What are the contraindications for sialography?
allergy to iodine acute infection of gland calculus at osmium of duct
what drugs may be associated with xerostomia?
anti Parkinsonian drugs and L Dopa antihistamines atropine like drugs clonidine and ganglion blockers, aldomet, many antihypertensives but not b blockers lithium monoamine oxidase inhibitors tricyclic antidepressants amphetamines opiate based analgesics all diuretics smoking drugs of abuse
What is chronic sialadenitis?
complication of duct obstruction -unilateral - asymptomatic - intermittent painful swelling of gland - varying degree of destruction of acini, duct dilation and a scattered chronic inflammatory cellular infiltrate - interstitail fibrosis - squamous metaplasia
What is dry mouth?
decreased saliva flow caused by failure of the salivary glands to function as normal OR a sensation of dry mouth that occurs even though th salivary glands function as normal
What are the clinical features of sjogren's syndrome?
dry eyes,= anterior conjunctiva becomes dried, leads to keratoconjunctivitis sicca dry gritty eyes, burning soreness, eyelids adherent in morning, cannot cry dry mouth other exocrine glands = dry vagina, skin, oesophagus (leads to dysphagia), lung (leads to infections) connective tissue disease = commonest is rheumatoid arthritis (50% Sjögren's patients have RA, and mild Sjögren's is found in 20% patients with RA), also polyarteritis nodosa, systemic systemic lupus erythematosus, autoimmune diabetes and thyroiditis, scleroderma, primary biliary cirrhosis, etc Raynaud's phenomenon, erythema nodosum other associated signs = gland swelling, usually parotid, in only 10% patients, commoner in primary may also detect lacrimal gland swelling recurrent ascending bacterial sialadenitis due to reduced flow increased risk of lymphoma, x44 over normal population, usually B cell
What is sicca?
dryness features in sjogrens
What is the treatment of a ranula?
marsupialisation + removal of related gland
What is false xerostomia?
mouth breathing psychological
what is hypo salivation?
objective dryness
What tests should be conducted for suspected SS if the glands are swollen?
palpate nodes temp culture parotid duct saliva imaging consider biopsy of major gland
What is the treatment for strictures of papilla or duct?
papilla may be excised duct lining sutured to mucosa on other side Duct may be dilated with bougies
What is xerostomia
subjective dry mouth
What is the treatment for a salivary fistula?
surgical repair - difficult, damage to facial nerve
What is a parotid papilla?
the bump on the buccal mucosa where the parotid duct opens