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Salivary gland diseases

Salivary gland diseases. Dr. Yanming Liu Dept. Oral & Maxillofacial Surgery 2nd Affiliated Hospital, ZJU. Section 1: Clinical anatomy. Submucosal minor salivary glands: labial, buccal, palatal, lingual Three paired major salivary glands: Parotid gl. Submandibular gl. Sublingual gl.

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Salivary gland diseases

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  1. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Salivary gland diseases Dr. Yanming Liu Dept. Oral & Maxillofacial Surgery 2nd Affiliated Hospital, ZJU

  2. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Section 1: Clinical anatomy • Submucosal minor salivary glands: labial, buccal, palatal, lingual • Three paired major salivary glands: • Parotid gl. • Submandibular gl. • Sublingual gl.

  3. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Parotid gland • largest • almost entirely serous • between ramus of the mandible, mastoid process, external acoustic meatus, SCM muscle, • Pyramidal in shape • Superficial and deep lobes by facial nerve and branches • Stenson’s duct, its opening opposite 2nd upper molar • Adjacent structures: facial n., external carotid a., retromandibular v.

  4. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Submandibular glands • Submandibular gl.: • Intermediate in size • A seromucous (predominantly serous) gland • Superficial and deep parts • Hooked in shape • Wharton’s duct, its opening: sublingual papilla • Adjacent structures: facial artery/vein, marginal mandibular branch of facial n., lymph nodes, lingual and hypoglossal n.

  5. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Sublingual glands • Sublingual gl.: • Smallest • seromucous, but predominantly mucous • above mylohyoid m., the sublingual fossa • Adjacent structures: lingual and hypoglossal n.; deep lingual a./v. • Open direct to the oral cavity or through Wharton’s duct

  6. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Physiology of salivary glands • Data about saliva • 0.5 L saliva / day • 0.3 mL/min when unstimulated, • 1.5–2 mL/min when stimulated • Unstimulated state: parotid gl. contributes 20%, submandibular gl. 65%, other 15%. • When stimulated, parotid contribution rises to 50%. • Functions of Saliva • lubricates food • moistens oral mucosa • digestive enzymes • antimicrobial agents, e.g. immunoglobulin A (IgA) • Xerostomia may result in periodontal inflammation and dental caries

  7. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Section 2: Investigations

  8. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Investigations • History taking: swelling, pain, mass, nerve functions, etc. • Clinical examination: • bimanual palpation; • comparing bilateral glands • Auxiliary examination: • Radiology (plate radiography, CT, MR, PET/CT) • Ultrasound • Biopsy • Sialometry

  9. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Symptoms and their indication

  10. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Sialometry • Method: volume of saliva dribble over 5 minutes at the unstimulated condition • Normal saliva flow rate: 0.3-0.4ml/min • Clinically significant xerostomia: <0.1ml/min

  11. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Clinical situation and auxiliary test option

  12. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Biopsy in salivary gland disease

  13. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Section 3: salivary gland diseases

  14. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders • Caused by narrowing or total obstruction of ductal system • Typical symptoms: pain and immediate swelling of the affected gland just before meal, or having meal, or maybe thinking about meal, which then slowly subside after meal. • Occasionally accompanied by a bad taste, indicating associated sialadenitis.

  15. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders Three types: • Extraductal obstruction, e.g. neoplasia • duct wall thickening, caused by trauma or fibrosis • intraductal obstruction (most common type) , caused by calculi (sialoliths), 80% in submandibular gland

  16. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders Why do intraductal obstruction and sialolithiasis happen more often in submandibular gl. (80%) than parotid gl.?

  17. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders Treatment options of intraductal obstruction by sialoliths: • Antibiotic and anti-inflammatory treatment • Remove sialolith by marsupialization of the duct, when sialolith is close to the wharton’s papilla. • Remove sialolith with the assistance of sialendoscopy • Remove the submandibular gland and the sialolith when it is close to the gland, especially with fibrosis of the gland.

  18. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders

  19. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders

  20. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders

  21. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.2 acute viral sialadenitis • Also named mumps, acute contagious infection, caused by paramyxovirus through direct contact with infected saliva • Incubation period of 2-3 weeks • Fever, malaise • Sudden and painful swellingof one or both parotid gl. (occasionally submandibular gl.) • clear salivary secretion • Occasionally involvement of central nerve system and gonads (orchitis), in rare case resulting in dysgenesis • Lifelong immunity • Rising hemodiastase and urinary amylase in some cases • Treatment: bedrest, massive water drinking, fluid infusion, antiviral treatment, etc. • Avoiding the infected patients to contact with susceptible population

  22. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.3 acute bacterial sialadenitis • Principally involving parotid gl. (parotitis) • Etiological factors: • Local: reduced salivary flow leading to bacteria in the ductal system; mainly by staphylococcus aureus • Systemic: other chronic diseases or large surgical operation, leading to poor systemic conditions; fluid and electrolyte imbalance • Often unilateral parotid gl., pain and swelling • Red and swelling of duct opening, mucopurulent discharge • fever, erythema of skin • Treatment principles: • supporting therapy: bedrest; water drinking or fluid infusion, correction of electrolyte imbalance • antibiotic therapy; mouthrinse • Incision and abscess discharge when pitting edema and tenderness, or when getting pus by needle aspiration or confirmed by ultrasound

  23. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.3 chronic bacterial sialadenitis • Caused by low-grade bacterial invasion, often follows chronic obstructive disease • Submandibular gland most commonly involved • Symptom: recurrent and painful swelling associated with eating and drinking • Salty and bad taste • Mucopurulent discharge • Can be transformed into acute sialadenitis • Treatment: removal of sialolith, mouthwash, removal of gland when fibrosis

  24. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.4 radiation sialadenitis • History of radiotherapy for head and neck cancers • Acinar damage and fibrous replacement • Low saliva secretion, leading to dental caries and mucositis • Prevention: shielding the salivary glands when radiotherapy • Treatment of xerostomia (dry mouth)

  25. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome • Autoimmune chronic inflammatory disease involving salivary and lacrimal glands • Characterised by polyclonal B-cell proliferation • Continuous destruction of glandular parenchyma and lymphocytic infiltration • Classification: • primary Sjögren’s syndrome • secondary Sjögren’s syndrome

  26. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome • Primary Sjögren’s syndrome • Xerostomia (dry mouth) and xerophthalmia (dry eyes) (and nasal, vaginal, skin ... dryness) • Secondary Sjögren’s syndrome • Xerostomia (dry mouth) and/or xerophthalmia (dry eyes) • an autoimmune connective tissue disease (Rheumatoid disease, renal tubular acidois...)

  27. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome • Clinical features • Mostly involving middle-aged females • Symptoms of xerostomia including: glazed oral mucosa; lobulated beefy-red tongue; difficulty in eating dry foods, swallowing, speaking, etc. • Parotid gland enlargement, occasional acute infection • Symptoms of xerophthalmia

  28. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome • Valuable tests in aiding in diagnosis • Sialometry (salivary flow rate measurement) • Schirmer test (lacrimal flow measurement) • Detection of autoantibodies against SS-A, SS-B, RF (rheumatoid factor), etc. • Labial gland biopsy: infiltration of lymphocytes around intralobular ducts, resulting in focal lymphocytic sialadenitis

  29. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome • Management • Multidisciplinary team • Management of xerostomia Salivary stimulants (sugar-free gum, pilocarpine) if residual salivary function remains Saliva substitutes Prevention of caries and periodontal disease

  30. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6 salivary gland tumors • 3% of human tumors • Mostly arising in the parotid gland (80%), in which 90% are benign • Higher relative proportion of malignant tumors in submandibular (40%), sublingual (90%), palatal and other minor glands (60%)

  31. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6 salivary gland tumors • Common benign salivary gland tumors • Pleomorphic adenoma • Wharthin’s adenoma • Common malignant salivary gland tumors • Adenoid cystic carcinoma • Mucoepidermoid carcinoma

  32. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6.1 Pleomorphic adenoma • Benign • Accounting for 80-90% of all salivary tumors • Slow-growing, painless nodule, soft or firm in texture, moveable, well-circumscribed • Varied size ( several cm to ~20 cm) and duration ( several months to decades) • Rare involving facial nerve • Low potentiality of canceration

  33. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6.1 Pleomorphic adenoma • Also termed “ mixed tumor” • Characteristic cellular and stromal elements • Celluar element: ductal epithelial and myoepithelial cells • Stromal element: myxoid (muscle-like) tissue or chondroid (cartilage-like) tissue • Tumor islands may exist beyond capsule • Management: excision biopsy of tumor together with a margin of normal tissue

  34. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6.2 Wharthin’stumour • Also termed “adenolymphoma” • benign • Predominantly in older men and exclusively in parotid • Discrete nodule, smooth, soft in texture, mostly <3cm in diameter • Etiologically related to smoking • Can be multiple nodules and in bilateral parotids • Characteristical pathological feature: a papillary cystic structure composed of double layered ductal cells and a lymphoid stroma

  35. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6.2 Wharthin’stumour • Management: tumor excision, when multiple nodules present, excision the surrounding glandular tissue as well

  36. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6.3 adenoid cystic carcinoma • Middle-aged or elderly patients • Frequently in palatal minor gland and parotid • Slow growing, tendency to invade and spread along nerve, leading to pain, palsy or paraesthesia • Histopathologically “Swiss-cheese”-like structure due to microcysts filled by basement membrane material • Infiltrative, metastasis • Poor long-term prognosis • Treatment: surgery with adjuvant radiotherapy; involved nerve has to be sacrificed Perineural invasion

  37. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6.4 mucoepidermoid carcinoma • Younger and Middle-aged patients • Histopathologically both mucous and squamous differentiation • Painless slow-growing nodule; blue “cyst” • Treatment: • high differentiation: surgery, preserving nerve • low differentiation: surgery with radiotherapy

  38. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6.5 salivary gland cysts • Blue, fluctuant swellings, with a relapsing history • Mucous extravasation mucocele • Tearing of the duct due to trauma, leading to leakage of saliva into the connective tissue; • No epithelium lining; • Major type, mainly in low labial mucosa, buccal mucosa, sublingual gland (ranula) • Mucous retention mucocele • Duct expansion, leading to cyst with epithelium lining • Mostly in upper labial mucosa

  39. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6.5 salivary gland cysts Treatment: removal of cyst as well as the minor gland or sublingual gland

  40. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor Slow growth of the tumor for 34 years, painful recently

  41. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor Slow growth of the tumor for 34 years, painful recently

  42. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor

  43. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor

  44. 浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor

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