Pathology of Salivary Glands
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Transcript of Pathology of Salivary Glands
PATHOLOGY OF SALIVARY GLANDS
MAJOR SALIVARY GLANDS
Parotid: so-called watery serous saliva rich in amylase, proline-rich proteins Stenson’s duct
Submandibular gland: more mucinous Wharton’s duct
Sublingual: viscous saliva ducts of Rivinus; duct of Bartholin
3
MINOR SALIVARY GLANDS
Minor salivary glands are not found within gingiva and anterior part of the hard palate
Serous minor glands=von Ebner below the sulci of the circumvallate and folliate papillae of the tongue
Glands of Blandin-Nuhn: ventral tongue Palatine, glossopalatine glands are pure
mucus Weber glands
Embryology
6
• The major salivary glands develop from the 6th-8th weeks of gestation as outpouchings of oral ectoderm into the surrounding mesenchyme.
• The parotid develops first, growing posteriorly as the facial nerve advances anteriorly; eventually, the fully developed parotid surrounds VII.
• However, the Parotid is the last to become encapsulated, after the lymphatics develop, resulting in its unique anatomy with entrapment of lymphatics in the parenchyma of the gland
Structural elements of the salivary gland unit.
pleomorphic adenomas originate from the intercalated duct cells and myoepithelial cells
oncocytic tumors originate from the striated duct cells
acinous cell tumors originate from the acinar cells,
Mucoepidermoid tumors and squamous cell carcinomas develop in the excretory duct cells
9
• Salivary epithelial cells are often included within these lymph nodes, leading to development of Warthin’s tumors and Lymphoepithelial cysts within the Parotid gland.
• The other major salivary glands do NOT have intraparenchymal lymph nodes.
Normal Histology
Mucous cells
Production, storage, and secretion of proteinaceous material; smaller enzymatic component-more carbohydrates-->mucins=more prominent Golgi-less prominent (conspicuous) rough endoplasmic reticulum, mitochondria-less interdigitations
Serous cells
Seromucus cells=secrete also polysaccharides They have all the features of a cell specialized
for the synthesis, storage, and secretion of protein Rough endoplasmic reticulum (ribosomal sites--
>cisternae) Prominent Golgi-->carbohydrate moieties are added
Secretory granules-->exocytosis
Serous cells
The secretory process is continuous but cyclic
There are complex foldings of cytoplasmic membrane
The junctional complex consists of: Tight junctions (zonula occludens)--
>fusion of outer cell layer Intermediate junction (zonula
adherens)-->intercellular communication
Desmosomes-->firm adhesion
Myoepithelial cells
One, two or even three myoepithelial cells in each salivary and piece body
Four to eight processes Desmosomes between
myoepithelial cells and secretory cells
Myofilaments frequently aggregated to form dark bodies along the course of the process
Myoepithelial cells
The myoepithelial cells of the intercalated ducts are more spindled-shaped and fewer processes
Ultrastructurally very similar to that of smooth muscle cells
Functions of myoepithelial cells Support secretory cells Contract and widen the diameter of the
intercalated ducts Contraction may aid in the rupture of acinar
cells of epithelial origin
Formation and Secretion of Saliva Primary saliva
Serous and mucous cells Intercalated ducts
Modified saliva Striated and terminal ducts End product is hypotonic
Macromolecular component
Synthesis of proteins RER, Golgi apparatus Ribosomes RER
posttranslational modification (N- & O-linked glycosylation) Golgi apparatus Secretory granules
Exocytosis Endocytosis of the granule
membrane
Fluid and Electrolytes
Parasympathetic innervationBinding of acetylcholine to
muscarinic receptors Activation of phospholipase IP3
release of Ca2+ opening of channels K+, Cl- Na+ in
K+ and Cl- in Also another electrolyte transport
mechanism through HCO3-Noepinephrine via alpha-adrenergic
receptors Substance P activates the Ca2+
Functions
Protection lubricant (glycoprotein) barrier against noxious stimuli; microbial toxins and minor traumas
washing non-adherent and acellular debris
formation of salivary pellicle▪ calcium-binding proteins: tooth protection; plaque
Functions
Buffering (phosphate ions and bicarbonate) bacteria require specific pH conditions
plaque microorganisms produce acids from sugars
Functions
Digestion
neutralizes esophageal contents
dilutes gastric chyme forms food bolus brakes starch
Functions
Tissue repair bleeding time of oral tissues shorter than other tissues
resulting clot less solid than normal
remineralization
Functions
Taste solubilizing of food substances that can
be sensed by receptors trophic effect on receptors
Function of Saliva
30
At least 8 major functions of saliva have been identified:
1) Moistens oral mucosa. Mucin layer is the most important nonimmune defense mechanism in the oral cavity.
2) Moistens dry food and cools hot food. 3) A medium for dissolved foods to stimulate the taste buds. 4) Buffers oral cavity contents due to high concentration of
bicarbonate ions. 5) Digestion. Alpha-amylase, contained in saliva, breaks 1-4
glycoside bonds, while lingual lipase helps break down fats. 6) Controls bacterial flora of the oral cavity. 7) Mineralization of new teeth and repair of precarious enamel
lesions. Saliva is high in calcium and phosphate. 8) Protects the teeth. This signifies a saliva protein coat on the
teeth which contains antibacterial compounds. Thus, salivary hypofunction results in dental caries.
The intraoral complications of salivary hypofunction
31
• 1) Candidiasis • 2) Oral Lichen Planus (usually painful) • 3) Burning Mouth Syndrome (normal appearing
oral mucosa with a subjective sensation of burning)
• 4) Recurrent aphthous ulcers • 5) Dental caries. • The best way to evaluate salivary function is to
measure the salivary flow rate in stimulated (e.g., by using a parasympathomimetic as pilocarpine) and unstimulated states. Xerostomia is NOT a reliable indicator of salivary hypofunction.
• There is a hierarchy of sensory stimuli such that swallow>mastication>taste>smell>sight>thought.
• Stimulation results in an increase in total salivary flow from 0.3 cc/min to >1 cc/min. The salivary response is directly related to a subject’s state of hunger
The Parotid Gland
32
• The largest salivary gland• Lies wedge-shaped between the mandible and
sternomastoid and over both• Relations: • Above: external auditory meats and temporo-
mandibular joint• Below: post belly digastric• Anteriorly: mandible and masseter• Medially: styloid process and its muscles
Structures at the Angle of the Mandible
33
• Medial relations of the parotid: the styloid process and its muscles separate the gland from the
• internal jugular vein• Internal carotid artery• The last four cranial nerves• Lateral wall of the pharynx
Relations of the Parotid
34
Parotid Bed
36
Deep relations of Parotid
37
Fascia
38
• The parotid is enclosed in a split in the investing fascia
• The parotid lymph nodes lie both on and below the parotid gland
• Antero-inferiorly, the fascia is thickened to form the stylomandibular ligament; the only structure that separates the parotid from the submandibular glands
The Facial Nerve
39
• The parotid gland is divided into superficial and deep lobes by three structures traversing the gland:
• The Facial Nerve• The retromandibular vein (post facial)
formed by the superficial temporal and maxillary
• The external carotid artery dividing at the neck of the mandible into the superficial temporal and maxillary
Relation of the Facial Nerve and Parotid
40
• The parotid develops in the crotch formed by the 2 divisions of the facial nerve
• As it enlarges it overlaps the nerve trunks, the superficial and deep parts fuse and the nerve becomes buried within the gland
• It is not a sandwich
Facial Nerve
41
The Facial Nerve
42
• Emerges from the stylomastoid foramen• Winds laterally to the styloid process• Surgical Exposure• In the inverted V between the bony external
auditory meatus and the mastoid process• Just beyond the point the nerve dives into the post
aspect of the parotid and bifurcates almost immediately into its two main divisions
Branches of the Facial N
43
• The nerve then gives rise to 2 divisions: • 1) Temperofacial (upper) • 2) Cervicofacial (lower)
• Followed by 5 terminal branches: • 1) Temporal • 2) Zygomatic • 3) Buccal • 4) Marginal Mandibular • 5) Cervical
Nerve Injury
44
• Clinical examination of the Parotid should include examination of the Facial nerve
• Malignant tumors of the parotid may involve VII and cause facial palsy, while benign tumors never affect VII
• During Superficial Parotidectomy, the nerve is exposed posteriorly in the space bet the bony canal of external auditory meatus and the mastoid process
• It is then traced anteriorly into the gland to excise the gland superficial to nerve branches
The Parotid Duct
45
• Stensen’s duct is 5 cm long.• Arises from the anterior part of the gland and
runs over the masseter one finger below the zygomatic arch to pierce the buccinator and open opposite the second upper molar tooth
Parotid Duct orifice
46
• Clinical examination of the parotid gland should include examination of the duct orifice opposite the upper 2nd molar for signs of inflammation, and palpated for stone
• Parotid Sialogram is performed by injecting a contrast through a canula placed in the orifice of the duct
47
Submandibular Gland
48
• Large superficial lobe and a small deep lobe, that connect around the mylohyoid
• Superficial lobe lies at the angle of the Jaw, wedged bet the mandible and mylohyoid and overlapping the digastric
49
Superficial and Deep Relations
50
• Superficially: The skin, the platysma, the capsule (deep fascia), the cervical branch of Facial Nerve, and the Facial Vein
• Deeply: the deep aspect lies against the mylohyoid for the most part. But posteriorly lies on the hyoglossus and comes in contact with the lingual and hypoglossal nerves.
• Both nerves lie on the hyoglossus as they pass forward to the tongue
The facial Artery
51
• Posterior • Arches over its superior aspect to reach
inferior border of the mandible and then ascends on to the face in front of the masseter
Facial artery52
The Submandibular Duct
53
• Arises from the deep part of the gland, runs forward to open at the side of the frenulum linguae
• Lies beneath the mucosa of the floor of the mouth along the side of the tongue
• Lingual nerve loops around the duct, double-crossing it, by passing from lateral beneath, then medial
• The sublingual salivary gland is also medial to the duct.
Clinical Applications
54
• Submandibular LN are adherent to the gland and partly between it and the mandible
• Differentiating bet submandibular LN and Salivary gland:
• The salivary gland can be palpated bimanually as it extends into the floor of the mouth.
• The Lymph Nodes are only felt below the mandible. • LN may be multiple and a space separates them
from the mandible
Clinical Applications
55
• A stone in the submandibular duct can be felt bimanually in the floor of the mouth and can be seen if large
• The presence of LN adherent to the gland makes removal of the gland part of block neck dissection
Autonomic Innervations
56
• Parasympathetic Stimulation results in abundant, watery saliva with a decrease in [amylase] in saliva and an increase in [amylase] in the serum. Acetylcholine is the active neurotransmitter, binding at muscarinic receptors in the salivary glands. The parasympathetic nervous system is the primary instigator of salivary secretion.
• Parasympathetic Interruption to salivary glands results in atrophy, while sympathetic interruption doesn’t cause a significant change.
• It was once thought that the sympathetic nervous system antagonizes the parasympathetic nervous system, but this is now known not to be true
Autonomic Innervation
57
• In the case of the parotid, parasympathetic fibers originate from CN IX
• In the case of the Submandibular and Sublingual glands, the parasympathetic fibers originate in CN VII
Sympathetic Innervation
58
• Stimulation by the sympathetic nervous system results in a scant, viscous saliva rich in solutes with an increase in [amylase] in the saliva and no change in [amylase] in the serum.
• For all of the salivary glands, these fibers originate in the Superior Cervical ganglion and travel with arteries to reach the glands:
• 1) External Carotid artery for the Parotid • 2) Lingual artery for the Submandibular, and • 3) Facial artery in the case of the Sublingual.
History• Determine if solitary parotid or moregeneralized salivary gland involvement• Progression of enlargement• Inciting factors for enlargement• Nature and duration of symptoms• Pain: character, severity, frequency
Associated Symptoms- Head and Neck- Systemic• Review of Systems• Medications• Past Medical History• Social History (eg. alcohol use)• Family History
Physical Examination• Complete Head and Neck Exam• Inspection / Palpation of Salivary Glands- enlargement (unilateral/bilateral)- consistency- tenderness- mobility• Differentiate diffuse gland enlargement fromdiscrete mass or anatomic anomaly
BIMANUAL PALPATION OF SUBMANDIBULAR GLAND
Parotid gland:Inspect the pre- and infra-auricular region, observing for symmetry.Palpate the parotid gland.Lacrimal gland:Have the patient close their eyes and observe the upper and outer aspect of the upper lid.The lid is normally smooth and symmetrical.Gently retract the upper lid and have the patient gaze to the opposite side.The lacrimal gland is located under the lid near the outer angle.Submandibular gland:Observe the submandibular region.Tilt the patient's head forward and gently roll your fingers over the inner surface of the mandible.
Physical Examination• Oral Cavity-Moisture level-Dentition status-Salivary duct outputamountcharacter-Palpate for sialoliths, masses• Salivary duct probing
LABORATORY
Chemical analysis of saliva Anti-SS-A, anti-SS-B, and rheumatoid
factor may be present in autoimmune diseases. Saliva may be cultured, which is helpful, and it may be analyzed chemically, which is rarely helpful.
Most laboratories cannot perform useful tests on saliva. Dental researchers had hopes for several decades that analysis of saliva would be of diagnostic importance. Saliva has such wide variations in composition that analysis has produced little of diagnostic value.
Laboratory Studies• HIV test• Angiotensin converting enzyme (Sarcoid)• Autoantibodies (Sjogren’s)- Rheumatoid factor- Antinuclear antibodies- Anti-SSA, Anti-SSB• Antineutrophil cytoplasmic antibody;ANCA(Wegener’s)• Hormone levels (eg. TSH)
EXPLORATORI METHODS
1. X-rays without preparation. Plainfilm The views of the salivary glands are
taken full face and profile of the parotid, or the submandibular gland, depending on the pathology. A 3/4 x-ray view of the submandibular gland is preferred.
These different x-rays can show not only radio opaque stones in the salivary glands, but also old calcifications in a lymph node.
2. Regular occlusal x-rays of the floor of the mouth. These occlusal views are helpful in revealing an opaque stone in the submandibular gland, or in the duct.The procedure entails actually putting film in the mouth to obtain an x-ray image.Regular occlusal X-rays can only be made at the sub-mandibular and sub-lingual glands levels. They either entail the positioning of an occlusal image source in an orthogonal position in relation to the mouth's floor, or scanning the ray to obtain a view of the forward sub-mandibular gland.This results in the visualisation of calcification in the glandular area. These are most frequently stones but may also be calcified lymph node
(a-d) Transverse CT scans of ductal and glandular calcifications.
SIALOGRAPHY 3. Sialography Technique A cannula is introduced into the parotid or
submandibular ducts and is used to inject contrast enhancing products (eg Lipiodol) to outline the ramifications of the ductal systems of these glands, showing their patterns and calibers. This examination can be performed on everyone, including children over the age of 4. The injection should be of no more than 0.5 to 1 cc, and injected very slowly. This examination is painless if done smoothly. The only contraindication is an allergic reaction to iodine.It must be know in such cases, pre-medication with corticosteroïds will permit the examination.
Results Basically, sialography is prescribed each time
there is a suspicion of an inflammatory syndrome, especially if there is the possibility of a lithiasis,in order to visualize the exact caliber of the duct and the position of the stone, as opposed to calcification within a lymph node.
Conventional sialography.
Yousem D M et al. Radiology 2000;216:19-29
©2000 by Radiological Society of North America
IMAGING
CT scanning and MRI with gadolinium enhancement These studies may be used to
determine the size, shape, and some qualities of neoplasms or swelling within the gland.
Either method reliably differentiates between solid masses, cystic lesions, and diffuse involvement of the gland.
(a-d) Transverse CT scans of ductal and glandular calcifications.
Submandibular calculi visualized at MR imaging.
Simple ranula.
(a-d) Transverse CT scans of ductal and glandular calcifications.
Glandular calcifications in a patient with sarcoidosis.
Yousem D M et al. Radiology 2000;216:19-29
©2000 by Radiological Society of North America
BIOPSY
Incisional biopsy -Under local anesthesia, a biopsy of the tail of the gland may be obtained by an experienced surgeon without injury to the facial nerve. Fine-needle aspiration biopsy frequently is
diagnostic for tumors and may be helpful to identify cell types and to obtain material for cultures when the clinical picture suggests infection. Excisional biopsy of a labial minor salivary gland may be diagnostic when the clinical picture suggests Sjögren syndrome.
The Most Common Tumors
87
• Histologically, salivary gland tumors are the most heterogenous group of tumors of any tissue in the body
• Of salivary gland neoplasms, >50% are benign• Approximately 70% to 80% of all salivary gland
neoplasms originate in the parotid• The palate is the most common site of minor
salivary gland tumors• The frequency of malignant lesions varies by site.
PLUNGING RANULA
RANULA
Pleomorphic Adenoma
Pleomorphic Adenoma
Submandibular pleomorphic adenoma.
Yousem D M et al. Radiology 2000;216:19-29
©2000 by Radiological Society of North America
SUBMAXILLECTOMY
Warthin's Tumor
Warthin's tumor (benign papillary cystadenoma lymphomatosum)
the second most common benign tumor of the parotid gland
It accounts for 2-10% of all parotid gland tumors
Bilateral in 10% of the cases
may contain mucoid brown fluid in FNA
Bilateral Warthin tumors.
Yousem D M et al. Radiology 2000;216:19-29
©2000 by Radiological Society of North America
Monomorphic Adenoma Similar to Pleomorphic Adenoma except no
mesenchymal stromal component Predominantly an epithelial component
More common in minor salivary glands (upper lip)
12% bilateral Rare malignant potential Types:
Basal Cell Adenoma Canicular Adenoma Myoepithelioma Adenoma Clear Cell Adenoma Membranous Adenoma Glycogen-Rich Adenoma
Malignant Tumors
99
• Approximately 20-25% of parotid, 35-40% of submandibular tumors, 50% of palate tumors, and > 90% of sublingual gland tumors are malignant
• The most common benign salivary tumor is pleomorphic adenoma, comprising 50% of all salivary tumors and 65% of parotid gland tumors
• The most common malignant salivary tumor is the mucoepidermoid carcinoma, comprising 10% of all salivary gland neoplasms and 35% of malignant salivary gland neoplasms, occurring most often in the parotid gland.
Salivary Gland Tumors
PAROTID CANCER
Mucoepidermoid Carcinoma
MECs contain two major elements:
mucin-producing cells and epithelial cells of the epidermoid variety
(Epidermoid and Mucinous components).
MEC is divided into low-grade (well differentiated).
High-grade (poorly differentiated).
Acinic Cell Carcinoma
This lesion is characterized by a benign histomorphologic picture but by occasional malignant behavior.
These lesions are treated by surgical excision
Bilateral involvement occurs in 3% of patients, making acinic cell carcinoma the second-most common neoplasm, after Warthin’s tumor, to exhibit bilateral presentation.
Adenoid Cystic Carcinoma
Adenoid cystic carcinoma with Swiss cheese pattern.
It is the second-most common malignant tumor of the salivary glands.
ACC is the most common malignant tumor found in the submandibular, sublingual, and minor salivary glands.
Mucoepidermoid Carcinoma
Mucoepidermoid carcinoma (MEC) is the most common malignant tumor of the parotid gland and the second-most common malignancy (adenoid cystic carcinoma is more common) of the submandibular and minor salivary glands.
Stained +ve by musicarmine. MECs constitute approximately 35%
of salivary gland malignancy, and 80% to 90% of MECs occur in the parotid gland.
Hodgkin's Lymphoma Hodgkin's
disease involving the parotid gland.
Note the Reed-Sternberg cell. (Fine needle aspiration, Pap, 630x)
PARTIAL PAROTIDECTOMY
Inflammatory EnlargementAcute Sialadenitis• Viral• Bacterial• Radiation• MedicationChronic Sialadenitis• Obstructive• Granulomatous• Autoimmune• HIV-associated
Sialadentitis
What is Sialadentitis? Simply inflammation of the salivary
glands Can be due to a number of factors
including: Mumps infection Coxackie Virus Parainfluenza Systemic Disease
Sialadentitis: Etiology
May be infectious: May be caused by bacterial or viral infections
May be non-infectious: May be caused by systemic disease such as
Sjogren’s or Sarcoidosis or even by radiation therapy
May be Post-Surgical: Called “Surgical Mumps” Pt kept without fluids and given atropine
causes xerostomia predisposing to inflammation
May be Pharmacological: Drugs causing xerostomia
May be architectural: Block of the salivary gland due to a stone
SIALOLITHIASIS
Sialolithiasis • Recurrent painful parotid gland swelling• Episodes of acute bacterial sialadenitis• Abscess formation• Chronic sialadenitis• Gland atrophy
Submandibular calculi visualized at MR imaging.
Yousem D M et al. Radiology 2000;216:19-29
©2000 by Radiological Society of North America
(a-d) Transverse CT scans of ductal and glandular calcifications.
Parotitis
Definition: Inflammation of the Parotid Gland
May be infectious or non-infectious Common Causes:
Mumps Sjogren’s Syndrome Bacterial infection of parotid gland
usually Staph. aureus Blocked salivary duct Stone in salivary duct
Parotitis
Definition: Inflammation of the Parotid Gland
May be infectious or non-infectious Common Causes:
Mumps Sjogren’s Syndrome Bacterial infection of parotid gland
usually Staph. aureus Blocked salivary duct Stone in salivary duct
Mumps: Clinical Features
Transmitted via airborne droplet Mainly effects the parotid gland Mainly effects children between
the ages of 5-18 Has a 2-3 week incubation period Clinically:
Will see rapid swelling of the parotids bilaterally
Acute pain when salivating
Mumps (Viral endemic parotitis) Mumps is an acute sialadenitis
which caused by an RNA virus This RNA virus is the
“paramxovirus” Other virus which can cause
salivary infections are: Cytomegalovirus Coxsackieviruses Echovirus
Mumps (Viral endemic parotitis)TREATMENT: There no effective antiviral therapy
available for the treatment of mumps.
Analgesics and antipyretics are given to control pain and fever
Liquid diet with vitamins should be considered
There should be complete bed rest.
Bacterial Saladenitis
Bacterial saladinitis usually occurs after surgery most commonly abdominal surgery.
The possible reason may be temporary lack of ductal flow which can develop while atropine sulphate is administered while delivering general anesthesia which allows ascending infections and thus pyogenic bacteria can inhibit the ducts.
Due to this there is pain and swelling . Purulent exudate can be expressed
from the orifice of the duct.
Clinical Features- continued When looking at the patient:
The ear lobe is elevated due to glandular enlargement
There may be a purulent discharge from the parotid duct but it is clear and unremarkable
Blood Work: As the acini become infected the salivary
amylase leaks into the interstitium and is absorbed in the blood stream raising the serum amylase levels
Acute right-sided parotitis.
Yousem D M et al. Radiology 2000;216:19-29
©2000 by Radiological Society of North America
Overall Treatment for Parotitis Acute:
Antibiotics Rehydration stimulating salivary flow Possible IND
Chronic: Eliminate causative agent:
Get rid of salivary stone/ other blockage Warm Compresses Sialogogues Possible surgical resection Ligation of the duct in hopes of atrophy
Radiation Sialadenitis• Inflammatory process due to radiation effecton gland parenchyma, dose-related injury• Serous glands and acini most susceptible• External beam radiation• Radioactive iodine• Painful, tender glands; swelling; xerostomia• Chronic injury can result• Some benefit with sialendoscopy
Chronic Sialadenitis• Non-granulomatous chronic inflammatory condition• Etiology may be unclear by history- primary obstruction / secondary infection- primary infection / secondary obstruction• Recurrent painful gland enlargement common- exacerbation with eating• Relief of duct obstruction, sialogogues,glandular massage, warm heat• Gland resection for medical therapy failure
Sjogren’s Syndrome
Sjogren’s Syndrome It is a group of autoimmune conditions
with a marked predilection for woman, it has an intense T lymphocyte – mediated autoimmune process in salivary and the lacrimal glands as on of its most prominent component
Sjogren’s syndrome exhibits T cells infiltration and replaces the glandular parenchyma
Sjogren’s Syndrome
Sjogren’s Syndrome: objective evidence of
keratoconjunctivitis sicca characteristic pathologic features of
the salivary glands 2 out of 3 of:
recurrent chronic idiopathic salivary gland swelling
unexplained xerostomia connective tissue disease
Sjogren's Syndrome: Age of Onset The frequency distributions of ages at onset of symptoms
& at diagnosis of primary Sjogren's syndrome
0
5
10
15
20
25
30
35
40
45
1-10 11-2021-3031-4041-5051-6061-7071-80
81-90
AGE
% O
F P
AT
IEN
TS
At diagnosisAt diagnosisOnset Onset
Sjogren’s Syndrome: Clinically Subjective and Objective Findings: Subjective:
Xerostomia Salivary Gland Enlargement
Objective: Stomatitis Oral Ulcers Cracked, “crocodile skin” tongue Carious Teeth Parotid Gland Enlargement Certain Tests can be done
“Crocodile Skin” Tongue, Carious Teeth
Tests and Studies: Serology
Autoantibodies % positiveRheumatoid factors (Igs) 80
Cryoglobulins (type II)
30
Ro/SSA 60La/SSB 30a-fodrin 95
Tests and Studies: Scintigraphy Scintigraphy (Nuclear Medicine) administer
radioactive substance in order to show the physiology and state of the biological process:
Scintigraphy diagnosis
NormalModerate
involvementMarked
involvement
Degree of xerostomia
None Mild Severe
Salivary flow rate (ml/5-min/gland)
1.60 0.42 0.00
Tests and Studies: Schirmer’s Test A test of whether the eye has enough tears to
keep moist Procedure:
Piece of filter paper inserted for several minutes (usually 5) and moisture recorded
<5 ml in 5 minutes is characteristic of Sjogren’s Syndrome
Tests and Studies: Salivary Gland Biopsy
A lip biopsy, if positive for Sjogren’s will show lymphocytes clusters and glandular destruction due to inflammation
Tests and Studies: Salivary Gland Biopsy
A lip biopsy, if positive for Sjogren’s will show lymphocytes clusters and glandular destruction due to inflammation
Pathophysiology: Continued
Multifactorial disease SS is sometimes called autoimmune
epithelitis in which there is apoptosis of epithelial cells leading to degradation products and leading to antinuclear autoantigens to the immune system
Molecules within the TNF family play a big role in the polyclonal activation of B Cells. This, in turn leads to autoantibodies
There is known inhibition of healthy glands and/or the muscarinic receptors (via antibodies) and also abnormal function of aquaporins leading to poor function of remaining healthy glandular structure
There is prolonged/permanent activation of autoreactive B cells favoring oncogenic activity and possible development of B Lymphoma
Pathological
Sjogren’s Syndrome: Systemic Manifestations
Systemic manifestations Frequency (%)
Arthralgia/arthritis 60Raynaud’s phenomenon 30Purpura/Vasculitis 15 (1)Lung involvement(increased liver enzymes)
10 (25)
Kidney involvement(Interstitial Nephritis/Glomerulonephritis)
8 (25)
Liver involvement 5Muscle involvement 1
Skopouli et al., Semin Arthritis Rheum. 2000, 29:296
Sjogren’s Syndrome: Treatment To Treat Xerostomia:
Glandular Stimulation/Replacement Salivary Substitutes Dx and treatment of candidiasis Meticulous oral hygeine for prevention of
caries To Treat Xerophthalmia:
Stimulation for tears: Cyclosporin A Pilocarpine Cimeviline
Treatment: Continued
Treatment for Salivary Gland Enlargement: Local moist heat Antibiotic Therapy NSAIDs Rule out a Lymphoma
Treatment for Peripheral Symptoms: Methotrexate Cyclosporin A Infliximab Hydroxychloroquine Corticosteroids
SARCOIDOSIS –HEERFORD SDR
Sarcoidosis• Systemic granulomatous disease, unclear etiology• < 1/3 patients - painless salivary gland swelling• Nontender and multinodular glands; xerostomia• ACE elevation (50-80%)• Most patients have pulmonary involvement• CXR- hilar nodes, adenopathy, parenchymalinfiltrates• Noncaseating granulomas on histopathology• Treatment supportive; steroids in select patients
HIV-Associated Cystic Sialadenitis• Bilateral parotid multicystic enlargement• Lymphocytic (T cell) infiltration of gland• Persistent, nonprogressive• May be mildly painful• Enlarged adenoids, cervical nodes common• Diagnosis largely clinical• Positive HIV test• Must exclude lymphoma or other neoplasm
Non-Inflammatory EnlargementAcute Enlargement• Neoplasm• Miscellaneous:TraumaPneumoparotitisAnesthesia/EndoscopyChronic Enlargement• Obesity• Sialadenosis- Endocrine- Nutritional- Medication- Idiopathic• Amyloidosis
Sialadenosis (Sialosis)• Non-inflammatory, non-neoplastic glandparenchyma enlargement• Bilateral parotid enlargement most common• Can be recurrent or persistent• Wide variety of systemic conditions causative• Unifying factor - neuropathic alteration of theautonomic innervation of salivary acini (Batsakis)• Diagnosis primarily clinical, exclusion of others• Complete metabolic and endocrine evaluation
Sialadenosis - Etiologies• Endocrine Disorders- Diabetes Mellitus (1/4)- Hypothyroidism• Alcoholism (autonomic neuropathy)• Nutritional Disorders- Bulimia (1/3)- Deficiency conditioneg. protein (alcoholism)vitamin (niacin, thiamine, vit. A)
Sialadenosis - Etiologies• Medications- Direct effect on glandeg. iodine compounds- Drug side-effect (adrenergic, cholinergic)eg. antihypertensives (guanethidine)antiemetics (phenothiazine)antiepileptics (phenobarbital)bronchodilators (isoproterenol)• Idiopathic - diagnosis of exclusion
SIALADENOSIS - Treatment• Correct underlying disorder
• Pilocarpine - Bulimia• Consider parotidectomy only forunacceptable cosmetic deformityunresponsive to medical therapy