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Salivary Gland Disorders and Tumours

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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 Salivary gland disorders and tumours: List of Salivary gland disorders and tumours Viral sialadenitis (mumps) Bacterial sialadenitis Sialosis (sialadenosis) Sialolithiasis Mucocele Acute Necotising Sialometaplasia Tumours: Pleomorphic adenoma Warthins Tumour Mucoepidermoid carcinoma Adenoid cystic carcinoma Acinic cell carcinoma Low-grade polymorphic adenoma Sjogren's syndrome Xerostomia Sialorrhea ReviseDental.com Key words: Sialosis non-pathogenic, non-neoplastic increase in salivary gland size Sialodenitis ductal infection Sialolithiasis duct obstruction Sialectasis cystic widening of the duct Sialorrhea excessive salivation/drooling (1) Acute Viral Sialadenitis Aetiology and epidemiology Common in the childhood disease Mumps caused by the RNA virus Parmyxovirus Typically affects the parotid gland 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, fever 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 Trismus 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 neoplasms 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 mouth) 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 Saliva 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, periodontal disease 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 cerebral palsy 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 Lymphoma 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 lip, buccal mucosa or ventral surface of the tongue Mucoceles encompass both retention and extravasation cysts Epithelial lined are called retention cysts Non-epithelial lined cysts are called an extravasation cyst 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 ranula 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 sublingual gland tumours are malignant Salivary gland tumours of the tongue
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