11: Salivary Gland Pathology Flashcards
What is a rare inflammatory condition of minor glands causing lower lip swelling and subsequent eversion caused by hypertrophy and inflammation? What group is it most common in?
Cheilitis Glandularis; middle- to older-aged men
What are the 3 levels of Cheilitis Glandularis?
Simple, Superficial Supurative (Baeltz’s Disease), Deep supurative
Superficial supurative Cheilitis Glandularis and Deep Supurative Cheilitis Glandularis have what involvement and symptoms?
Bacterial involvement w/ inflammation, swelling, suppuration, ulceration
What specifically is inflamed and dilated in cheilitis glandularis? What does this cause?
The openings of the minor glands; Pressure on the glands may produce mucopurulent secretions
What is tx of persistent cheilitis glandularis?
Vermillionectomy
What are about 1/3 of cheilitis glandularis ass’d with? What is commonly the specific cause?
Squamous cell carcinoma; changes in actin
If I say excess salivation, you think:
Sialorrhea
What are episodes of excess salivation for 2-5 min associated with prodrome of nausea and epigastric pain?
Idiopathic Paroxysmal Sialorrhea
T/F. Patients with sialorrhea have excess saliva.
F. Not an overproduction, but lack of neuromuscular control of saliva.
What three patient populations may have sialorrhea?
Mentally retarded, those with neuromuscular disorders (e.g. CP), or those with surgical resection of the mandible
What are four treatments for sialorrhea?
Anticholinergics, Transdermal scopolamine, Surgery if muscular involvement, GERD meds if a factor
What are the first, second, and third leading causes of Xerostomia? What are seven other causes?
Drugs; anxiety/emotions, fluid/electrolyte deficiency, Xray/BMT/Chemo, Autoimmunity, Aging, Smoking and Mouth Breaking (General: iatrogenic, developmental, H20 imbalance, systemic disease, or local factors)
What’s the drug rule for xerostomia?
If it’s an anti drug (e.g. antidepressant) it causes xerostomia (also beta blockers and Gerd)
What are five consequences of xerostomia?
Thirst, Caries, Thick mucus, Microfloral shift and sleep may be affected
What are three “drug” tx for xerostomia? Other tx (6)?
Pilocarpaine (5mg tabs), Biotene or Prevident 5000; sip water frequently, avoid alcohol (mouthwash), humidify sleeping area, lubricate lips, fluoride supplementation, change meds, etc.
What infection is seen with Xerostomia?
Candidiasis and cervical/root caries
This is a cause of Xerostomia that is normally a unilateral swelling of the parotid gland.
Benign lymphoepithelial lesion
Although pilocarpaine helps xerostomia, when is it contraindicated?
Narrow-angle glaucoma
What is the chronic, systemic autoimmune disease that principally involves the salivary and lacrimal glands resulting in xerostomia, xeropthalmia (dry eyes)?
Sjogrens
What is dry eyes and dry mouth without another autoimmune disorder called?
Sicca (primary Sjogrens)
What is xeropthalmia of Sjogren Syndrome called?
Keratoconjunctivitis sicca
Secondary Sjogren Syndrome means? What is typically the other autoimmunity? Predilection?
There’s another autoimmune component involved; rheumatoid arthritis; middle-aged females
Symptoms associated with Sjogren syndrome (or any xerostomia) (7)?
Red tender oral mucosa, Angular cheilitis, Candidiasis, Cervical Decay, Difficulty swallowing, Altered taste, Retrograde bacterial sialadenitis
Sialographic appearance of Sjogren’s?
Fruit-laiden branchless tree: punctate sialectasia and lack of normal aborization of ductal system
What is the tear test for Sjogren Syndrome?
Schirmer test (<5mm tears for 5 min = Keratoconjuctivitis sicca)
What are two histopathologic aspects of Sjogren’s Syndrome?
Lympocytic infiltrate and epimyoepithelial islands; lymphocytes replace glands except for ducts (which become the epimyoepithelial islands)
What are four treatments for Sjogren’s?
Supportive; eye and mouth lubrication
Oral hygiene products that contain lactoperoxidase, lysozymge & lactoferrin (biotene and oral balance)
Fluoride applications (prevident)
Sialogogues (pilocarpine and cevimeline)
What is the noninflammatory disorder characterized by salivary gland enlargement, especially parotid, usually do to some underlying systemic problem?
Sialadenosis/Sialosis
What are three general causes of sialadenosis? Four specific causes?
Neurogenic, endocrine, or nutritional; Diabetes Mellitus, general malnutrition, alcoholism & bulimia
What actually goes wrong in sialadenosis?
Deregulation of autonomic innervation of salivary acini with excessive accumulation of secretory granules (enlargement)
What is a locally destructive inflammatory condition of salivary glands caused by ischemia that leads to local infarction? What is the main problem?
Necrotizing sialometaplasia; it mimics a malignant process clinically and microscopically
What are six predisposing factors of necrotizing sialometaplasia?
Trauma, Injections, Ill-fitting dentures, URI, adjacent tumors, previous surgery
What are two ways to differentiate Necrotizing Sialometaplasia from Oral Cancer?
Location and cleaner borders around the lesion (cancer has ragged borders)/glands are present but simply an outline
Where is necrotizing sialometaplasia typically found?
Unilaterally on the palate salivary glands (squamous cell carcinoma rarely found there)
What demographic typically has necrotizing sialometaplasia?
Mid 40-year old males
Tx for necrotizing sialometaplasia?
Biopsy and no treatment, will resolve in 5-6 weeks
What is the course of necrotizing sialometaplasia?
Initially: non-ulcerated swelling (may have pain or parathesia);
2-3 weeks: necrotic tissue will slough w/ crater like ulcer (1-5cm); heals 5-6 weeks
Most common:
- Benign salivary gland tumor (neoplasm)
- Location for salivary gland tumor
- Intraoral location of salivary gland tumor
- Pleimorphic adenoma
- Parotid
- Palate
What is the benign vs. malignant percentages for salivary gland tumors based on location?
Parotid: 80% benign, 20% malignant Submand/palatal/Buccal: 50/50
Sublingual: 20% Benign, 80% malignant
Upper lip glands: 80% benign, 20% malignant
Lower lip glands: 20% benign, 80% malignant
What is the most common malignancy in the parotid?
Mucoepidermoid carcinoma
Where is the most common location for the pleimorphic adenoma? What age group?
Superficial lobe of the parotid with swelling over ramus in front of ear; 30-50yo
In what five locations are the mucoepidermoid carcinoma the most salivary gland tumor?
Parotid, Lower lip, retromolar pad, floor of mouth or tongue
What are the three most common extra oral places of the pleimorphic adenoma? Intraoral?
- Parotid, submandibular gland, minor glands
2. Palate, upper lip, and buccal mucosa
What are three characteristics of pleimorphic adenoma? What is rare with PA?
Painless, slow growing, firm mass that becomes less mobile with growth; facial palsy and pain are rare
What is the radiographic character of pleimorphic adenoma?
Well-circumscribed border and encapsulated (malignancy would have irregular border and more moth-eaten)
T/F. Xerostomia is a function of age.
F. Age does not affect xerostomia so much as when we age, we take more medications (and GERD) which typically have drying effects
What are intraoral clinical findings of pleimorphic adenoma? What places have immobile and mobile lesions?
Posterior lateral aspect of palate- presents as smooth surface dome shaped mass; immobile=hard palate and mobile=lip and buccal mucosa
What is the treatment of pleimorphic adenoma?
Surgical excision cures most (95%);
Tumor that is exclusive to parotid gland?
Warthin Tumor
Who is most common to get Warthin Tumor?
Males (8x), 50-60 yo, and smokers
Where is a warthin tumor never found? In parotid, where specifically found?
Minor salivary glands; tail of parotid near angle of mandible
What is the histology associated with the Warthin Tumor?
Double row of oncocytes with adjacent lymphoid stroma; ductal epithelium
What are four characteristics of warthin tumor? How do you tx?
Slow-growing, painless, nodular mass; firm or fluctuant to palpation; conservative excision
What is a monomorphic adenoma found almost exclusively in the minor glands of the upper lip?
Canalicular adenoma
How do you diagnose Sjogren’s?
Take a high-powered field and look at the number of periductal lymphocytic clusters; more than +2 clusters may indicate Sjogren’s
What are two types of monomorphic adenomas?
Canalicular and basal cell adenomas
Treatment for monomorphic adenoma?
Surgical excision
Difference between a Warthin tumor and an Oncocytoma (benign salivary gland tumor in 8th decade)?
No lymphoid stroma around the double row of oncocytes
What is the histopathology of canalicular adenoma?
Monomorphic, single layered cords of columnar or cuboidal epithelium w/ basophilic epithelium
What will half of the tumors we see be?
Pleimorphic adenoma- will have many stromal elements b/c trying to make ducts (ductal and myoepithelial)
Where are most basal cell adenoma found? How tx?
Parotid (75%) and then upper lip; surgical excision
What is a benign salivary gland tumor composed of large epithelial cells known as oncocytes?
Oncocytoma
How do tori and salivary glands differ?
Tori are on midline and are bony; salivary glands are off the midline and will be firm (not hard)
Why do oncocytes swell?
Excessive accumulation of mitochondria
What is the most common salivary gland tumor carcinoma in children?
Mucoepidermoid carcinoma
What are the most and second most common site for the mucoepidermoid carcinoma?
- Parotid and 2. Minor glands of palate
If there is an elevated lesion on the palate that is not tooth related, what is it until proven otherwise?
Salivary gland tumor
What does the grading of mucoepidermoid cells depend upon (3)? Specify for low.
Cyst formation, degree of cellular atypia, and relative number of mucous, epidermoid and intermediate cells; cyst formed, minimal atypia, and more mucous-producing cells
How do monomorphic and pleimorphic adenomas differ?
Mono=just ductal (no stromal tissues found)
What is the histology of mucoepidermoid carcinoma?
Mucous-producing and epidermoid cells
Mucoepidermoid carcinoma is the salivary gland tumor that most commonly…
Goes into bone
Low vs. high grade mucoepidermoid carcinoma tx?
Low: surgical resection with modest margin of surrounding normal tissue w/ good prognosis
High: more resection and possible radiation with a more guarded prognosis.
What is a slow growing mass with pain early in the swelling? Why pain?
Adenoid cystic carcinoma; perineural invasion
What are the classical histology and clinic feature of adenoid cystic carcinoma?
Swiss cheese or cylindrical look and perineural invasion
What is the surgical consideration of adenoid cystic carcinoma?
Relentless, hard to get rid of, doesn’t kill you quickly. Surgery w/ adjunct radiation
Where does adenoid cystic carcinoma metastasize to?
Lungs and bones
What are the three most common malignant salivary gland tumors?
Mucoepidermoid carcinoma, adenoid cystic carcinoma and low grade carcinoma
What are two malignant salivary gland tumors we should be able to ID histologically?
Mucoepidermoid (mucous/epidermoid cells) and adenoid cystic carcinoma (swiss-cheese look)
How is Polymorphous Low Grade Adenocarcinoma like Adenoid Cystic Carcinoma?
both have perineural invasion, but polymorphous low grade adenocarcinoma perineural invasion does not affect prognosis (low-grade’s pt will not die from it)
What is tx for polymorphous low-grade adenocarcinoma?
Wide surgical resection with good prognosis
What is the third most common malignant salivary gland tumor and is exclusive to the minor salivary glands?
Polymorphous low-grade adenocarcinoma; minor salivary glands infers it is more common on palate
What does polymorphous histologically look like?
“Streaming pattern”
What is also know as cylindroma?
Adenoid cystic carcinoma
What are demographics of adenoid cystic carcinoma?
Middle-aged adults
Most common:
- Gland tumor w/ highest rate of malignancy?
- Tumor of upper lip?
- Malignant salivary gland neoplasm?
- Sublingual
- Canalicular adenoma
- Mucoepidermoid carcinoma
