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Salivary Gland Disorders and Tumours

Salivary Gland Disorders and Tumours

Salivary gland disorders and tumours

Sumamry This lesson is one we all tend to avoid because most of them sound the same! Hopefully this lesson will help you with clarification.

Introduction to disorders and tumours:

List of Salivary gland disorders and tumours

Viral () Bacterial sialadenitis Sialosis (sialadenosis) Mucocele Acute Necotising Sialometaplasia Tumours: Warthins Tumour Low-grade polymorphic adenoma Sjogren's syndrome Sialorrhea ReviseDental.com

Key words:

Sialosis non-pathogenic, non-neoplastic increase in salivary gland size Sialodenitis ductal infection Sialolithiasis duct obstruction cystic widening of the duct Sialorrhea excessive salivation/ (1)

Acute Viral Sialadenitis

Aetiology and epidemiology Common in the childhood disease Mumps caused by the RNA virus Parmyxovirus Typically affects the Spread by droplet spread or direct contact 2-3 week incubation period precedes the clinical symptoms Can cause extrasalivary manifestations such as Orchitis Oophoritis Pancreatitis Clinical features Painful Typically bilateral enlargement of parotid glands Skin over the glands is not affected which distinguishes from bacterial sialodenitis Malaise, and headaches Histopathology Accumulation of neutrophils and fluid in the lumen of the ductal structures Diagnosis Made on clinical presentation Management FluidsReviseDental.com and medication for pain management Can prevent through immunisation Mumps, Measles and Rubella (MMR) vaccine Acute Bacterial Sialadenitis

Aetiology and epidemiology Most commonly affects: Hospital in-patients Head & neck radiotherapy patients Sjogren's patients Patients with pre-existing salivary conditions eg calculi Streptococci pyogenes, Staphylococcus aureus, and Hemophilus specie typically responsible Bacteria are able to enter the ducts against the salivary flow Decreased salivary flow can predispose patient to Chronic sialadenitis Pathophysiology Duct ectasia, mucous metaplasia of ductal epithelium, periductal fibrosis and fusion of lobules Clinical features Painful and tender enlargement of one gland Purulent discharge from the duct orifice Reddening of the overlying skin Pyrexia Histopathology Acinar destruction with neutrophil infiltrates and bacterial prescence Diagnosis Made on clinical presentation Pus can be sent for cultures Management Fluids and medication for pain management Antibiotics Flucloxacillin if the patient is not allergic to penicillin IV drainage may be required

ReviseDental.com Chronic Sialadenitis

Aetiology and epidemiology Low grade bacteria invasion Can be subdivided into relapsing, radiation, sclerosing Pathophysiology Can develop after acute sialadenitis or calculi formation Clinical features Recurrent attacks of pain and swelling Histology Atrophy of serous acini during chronic obstructions Diagnosis Made on clinical presentation and history Management Surgical excision

Sialolithiasis

Aetiology and epidemiology Refers to a salivary duct obstruction M:F 2:1 Pathophysiology Typically caused by calculus in the submandibular duct Salivary stone forms due to the calcium deposits on bacteria, mucus or epithelial cells Other causes include and mucus plugs Clinical features Unilateral salivary gland swelling Painful Intermittent Appearing before and after mealtimes Histopathology Dilated ducts with calculi Diagnosis Thorough history Attempt to palpate the calculus Radiographs can reveal calculus obstruction however not always obvious so referral to a specialist can be necessary Sialography CanReviseDental.com check for other cause of obstructions using CT Management Duct dilation Small stones can be milked out Lithotripsy This is when ultrasonic shock waves are used to break down the calculus. Similar to Ultrasonic handpieces we use to remove dental calculus! Surgical removal of the obstruction Submandibular Duct obstruction from a calculi stone

Sialosis

Aetiology and epidemiology Non-inflammatory and non-neoplastic enlargement of the salivary glands Can be a reactive mechanism ReviseDental.comEg Eating disorders or Alcoholism Clinical features Bilateral, painless swelling Histopathology Hypertrophy (increase in cell size) of the serous acini, and oedema of the interstitial connective tissue Diagnosis Made on clinical presentation Management No treatment required Xerostomia (dry )

Aetiology and epidemiology Dry mouth can have a number of causes Medication Common drugs include antidepressants and antihypertensives Irradiation Radiation exposure to kill tumours causes damage and fibrosis to salivary glands within the radiation field Diseases which affect salivary glands Sjogren's, Cystic fibrosis and Sarcoidosis Dehydration Psychogenic Clinical features can be referred to as 'frothy' Unpleasant taste Difficulty eating dry foods such as crackers Mucosal dryness – the mirror may stick to the mucosa The tongue is red, lobulated and shows varied depapillation Management Pilocarpine a cholinergic drug used which stimulates salivation Sugar-free sweets and chewing gum This will stimulate saliva flow Saliva substitutes can be prescribed in the DPF in various forms including sprays, pastilles and gels Note: Some are only available to patients whom have had radiotherapy or Sicca syndrome Dental Implications More susceptible to dental decay, fungal infection, and salivary gland infections LessReviseDental.com denture retention

Sialorrhea - Excess salivation or drooling

Aetiology and epidemiology Common in neurologically impaired children and adults with neuro-muscular difficulties Eg children with Eg adults with parkinsons disease Pathophysiology Common when foreign bodies are in the mouth such as new dentures Can occur when painful lesions manifest including ulcers In some cases caused due to poor neuromuscular coordination leading to difficulty in saliva swallowing Clinical features Drooling Diagnosis Made on clinical presentation and through complaints Management Atropinics are recommended however the side effects make it unfavourable Antihistamines Surgically rerouting the gland duct opening more posteriorly

Sjogren's Syndrome

Aetiology and epidemiology Second most common connective tissue disorder (CTD) after Rheumatoid Arthritis F:M 9:1 and middle aged is the typical onset Divided into primary and secondary Sjogren's Primary Sjogren's is when there is no associated CTD also known as Sicca syndrome Secondary Sjogren's is when there is an associated CTD such as Rheumatoid arthritis, or Systemic Lupus Erythematous Pathophysiology Lymphocyte-mediated destruction of lacrimal, salivary and other exocrine glands Clinical features Dry eyes DryReviseDental.com mouth Difficulty in talking and swallowing Taste changes Oral discomfort, especially in denture wearing patients Swelling of the parotid glands is found in a third of patients Histopathology Focal lymphocytic infiltrate Polyclonal B cell proliferation Diagnosis Antibody profile Biopsy of labial salivary glands Sialometry <0.5ml per minute Sialography Management Pilocarpine Salivary substitutes Saliva substitutes can be prescribed in the DPF in various forms including sprays, pastilles and gals Note: Some are only available to patients who have Sicca syndrome Eye drops Excess of fluids Dental implication Xerostomia leads to an increased risk of Acute/chronic Sialadenitis Dental caries Candida infections Increased risk of due to the proliferation of the B cells

Mucocele

Aetiology + Epidemiology An accumulation of mucus in the salivary duct or connective tissue Commonly found on the lower , buccal mucosa or ventral surface of the tongue Mucoceles encompass both retention and extravasation Epithelial lined are called retention cysts Non-epithelial lined cysts are called an extravasation More likely to affect male adults/children Pathophysiology Usually caused by trauma to a minor salivary gland This causes the build-up of mucus and leads to a cystic appearance Clinical Features: Bluish, translucent, fluctuant painless swellings Rupture easily to release mucus which can taste salty HighReviseDental.com recurrence rate Called a if located on the floor or the mouth Called a plunging ranula if they then extend through mylohyoid ALWAYS BE AWARE OF THE UPPER LIP MUCOCELE - Likely to be more pathological Histology: Granulation tissue surrounding a mucous pool Severed duct typically due to trauma Management: Can resolve spontaneously Excision Cryosurgery Mucocele on the lower labial mucosa

ReviseDental.com Ranula

Acute Necrotising Sialometaplasia

AetiologyReviseDental.com + Epidemiology Trauma induced Benign ulcerative lesion More likely to affect smokers Resembles a SCC Pathophysiology Ischemic necrosis of minor salivary glands This means the lack of blood supply leads to death of the tissue and infarction of the salivary glands Clinical Features: Typically, in the hard tissue and soft tissue junction Initially red tender swelling, however a central ulcer forms when the overlying mucosa breaks down Anaesthesia can be associated to the affected area Diagnosis Biopsy is typically required to ensure it is not a SCC Management: Self-resolving within 6-10 weeks Can recommend the use of an antiseptic mouthwash to treat the ulceration

Salivary Gland Tumours

For all Neoplasms:

Location Most tumours are malignant Salivary gland tumours of the tongue are typically malignant eg Adenoid Cystic Carcinoma Aetiology 80% Benign 80% in the Parotid Gland 80% superficial lobe Clinical Features: Asymptomatic swelling and eversion of the ear lobes No ReviseDental.comxerostomia Malignant tumours can be painful and ulcerate, or lead to facial palsy Management: Surgical excision of the tumour Can be followed by radiotherapy Dental Implications if excision of from the Parotid gland: During excision risk of damage to the Risk of Frey's syndrome This is known as ‘gustatory sweating’ as when the nerve fibres from the parotid are damaged during , they can regrow to supply the sweat glands of the skin Hence when you are hungry, you sweat! Warnings: Indication of malignant change can be indicated by Rapid growth Pain Fixation to deep tissues Facial palsy

Benign

Pleomorphic Adenoma

Aetiology + Epidemiology Most common Painless rubbery nodules Pathophysiology Slow growing Can transform to malignant Clinical Features: Typically present as a unilateral swelling of the parotid Can affect minor salivary glands of the Not fixed to underlying tissues Skin overlying appears normal however intraorally can give a blueish appearance Histology: Mixed tumour with ductal and myoepithelial cells (sheets) suspended in connective tissue such as loose myxoid tissue Usually encapsulated with fibrous tissue Management: ExcisionReviseDental.com and monitor

Warthin’s Tumour (adenolymphoma)

Aetiology + Epidemiology Only found in the parotid gland and can be bilateral Second most common type of salivary gland neoplasm Smoking is the risk factor Pathophysiology Can undergo cystic change

Malignant

Adenoid Cystic Carcinoma

Aetiology + Epidemiology Can present in major and minor salivary glands Characterised by the Swiss Cheese histological appearance Pathophysiology Slow growing Locally invasive Infiltrates perineurally and metastasises Poor prognosis Clinical Features Firm and painless swelling most commonly in the palate Can show areas of ulceration superficially If found in the parotid, can cause facial nerve palsy Diagnosis Biopsy required ReviseDental.com

Mucoepidermoid Carcinoma

Aetiology + Epidemiology Most common malignant salivary gland tumour 50% found in the parotid gland however all glands can be affected Pathophysiology Slow growth and can infiltrate surrounding tissues Perineural spread 40% show high glade

Acinic Cell Carcinoma

Aetiology + Epidemiology Very rare Most commonly in the parotid gland and can be bilateral Pathophysiology Invasive Slowly growth Good prognosis

Polymorphous Low-Grade Adenoma

Aetiology + Epidemiology Rare Most commonly found on the palate More commonly affects males Pathophysiology Slow growing ReviseDental.com

Conclusion There are several different salivary disorders and tumours and it is important to be able to differentiate between them in order to treat appropriately.

Third Party Links References

Specific references: ¹Farlex, Medical Dictionary. The Free Dictionary Accessed May 1st, 2020. Other references: Lewis M, Jordan R. . Milton: Taylor & Francis Group; 2012. Lewis MA, Lamey PJ. Oral Medicine in Primary Dental Care. Springer; 2019 Jun 21. Odell EW. Cawson's Essentials of Oral Pathology and Oral Medicine E-Book. Elsevier Health Sciences; 2017 May 2. Scully C, Porter S. Orofacial disease: update for the dental clinical team: 8. Salivary complaints. Dental update. 1999 Oct 2;26(8):357-65. These textbooks can be found here: BDA ebooks: Endodontics

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