ORAL SURG salivary gland disease Flashcards
where do you find minor salivary glands and roughly how many are there?
500-100 all over mouth except gingivae and anterior hard palate
what type of glands are the minor salivary glands?
mostly mucous
what pathology is found of the minor salivary glands?
most common=mucus extravasation cyst
benign/ malignant tumours
treatment for mucous extravasation cyst?
excision with overlying mucosa and underlying glandular tissue
general treatment for benign/ malignant minor salivary gland tumours?
excision with a margin of normal tissue
name the 3 major salivary glands
parotid glands
submandibular glands
sublingual glands
how are all 3 major salivary glands palpated?
parotid + subman = EO
sublingual = IO
when do the major salivary glands produce saliva?
when thinking about eating
when eating
when smelling food
what predisposes major salivary glands to infection?
their period of status when no saliva passing down the duct - bacteria from mouth can enter the duct and will therefore not be flushed out
what is the largest paired major salivary gland?
parotid
what are the parotid glands enclosed by and where are they located?
fascia located anterior to the ear behind the ramus of the mandible
what is the name of the main excretory duct of the parotid gland and where is it located?
Stenson’s duct
opens opposite the second maxillary molar
what type of saliva do the parotid glands excrete?
mixed seromucous
predominantly serous
what should you palpate for the parotid glands?
palpate masseter and parotid duct when pt clenches teeth
what muscle do the parotid glands overlap?
masseter muscle
where does the tail of the parotid extend?
down the angle of the mandible
what are the 2 parts of the parotid gland and where do they sit?
superficial (4/5) - sits above the facial nerve
deep lobe (1/5) - sits below the facial nerve
ala of the parotid - sits behind angle of mandible
accessory lobe - sits above the duct
what vasculature runs through the parotid? include nerves
facial nerve
terminal branch of external carotid artery
superficial temporal artery
maxillary artery
greater auricular nerve
where are the submandibular glands located?
in the submandibular triangles
what are the submandibular glands encapsulated by?
cervical fascia and stylohyoid ligament
where do the submandibular glands drain via?
Whartons duct in FOM
what type of saliva do the submandibular glands excrete?
mixed seromucous
what do you palpate for the submandibular glands?
deep lobe - palpate IO (posterior FOM at posterior margin of mylohyoid)
superficial lobe - under the chin EO
what anatomy surrounds the submandibular glands?
anterior and posterior head of digastric muscle
stylohyoid muscle and ligament (posteriorly)
facial artery and vein
marginal branch of facial nerve
lingual nerve
where are the sublingual glands located and what covers them?
FOM
covered by mucosa
where do the sublingual glands drain via?
Ravinis ducts on the plica sublingularis
or
Bartholin’s duct
what type of saliva do the sublingual glands secrete?
mucous
list common pathology of the major salivary glands/
inflammatory disorders:
- viral (mumps, coxsackie, CMV, HIV)
- bacterial (TB, sarcoid)
- radiation induced
obstruction/ trauma
neoplasms
autoimmune/ degenerative (Sjorgens syndrome)
what is the clinical name for mumps and describe it?
paramyxovirus
causes sialadenitis
- most common viral pathology
- bilateral enlargement of parotid glands
- disease of childhood but can affect adults (severe symptoms)
- self limiting
what is CMV?
Cytomegalovirus
causes sialadenitis
- affects babies or very old/ immunocompromised pts (severe symptoms)
- most primary infections are asymptomatic
what is sialadenitis?
inflammation of the salivary glands
differential diagnosis of a unilateral facial swelling?
mumps
odontogenic infection
what is the treatment for viral sialadenitis?
self limiting - no meds
what is the treatment for bacterial sialadenitis?
abx if systemically unwell - first line
what is the treatment for facial swelling caused by odontogenic infection?
eliminate focus of infection by creating a path of least resistance
extirpate pulp or XLA
why cant you incise and drain an inflamed salivary gland?
major glands are encapsulated - only way to drain is through the duct
what are the 2 presentations of sialadenitis?
acute or chronic
*often presents as acute but can become chronic
what is the local cause of sialadenitis?
secondary to stasis
- gland not functioning
- pt starving/ fasting
- obstruction of duct (mucus plug, stone)
what are systemic causes of sialadenitis?
immunosuppression
immune based
medication
dehydration
irradiation
what is the acute management sialadenitis/
antibiotics
fluids
sialogogues
analgesics
what can be used as a sialagogue?
lemon juice
chewing gum
when would you incise and drain a case of sialadenitis?
if there is abscess formation
when would you surgically treat a case of sialadentitis?
if chronic symptoms present
what gland is more commonly affected by sialadenitis?
submandibular
what do sialagogues do?
encourage drainage of the glands by saliva stimulation
what is a symptom which well differentiates sialadenitis and odontogenic infection?
prandial symptoms - symptoms associated with meal times
if the gland is partially obstructed
if a pt presents with extreme facial swelling what do you do and why?
refer quickly for intravenous abx
risk of retrograde spread and cavernous sinus thrombosis
what may be damaged when draining an area of inflammation in the pre auricular area?
the facial nerve
when there is a submandibular swelling, what may be inflammed?
the gland or any of the 3 nodes
with a gland swelling, what is a sign of chronic infection?
the overlying skin is not inflamed
what disease should be considered when asymmetry involving the subman triangle?
lymphoma
what would you do if a pt presents with asymmetry involving the subman triangle?
refer for ultrasound or MRI (this determines whether submandibular gland infection or lymph node involvement)
first line investigation - FNA under ultrasound
what may cause obstruction/ trauma to salivary glands?
sialolithiasis (salivary gland stones)
stasis of saliva
mucus plug or duct stricture (caused by trauma)
how does sialolithiasis occur?
organic nidus (mucous) containing calcium and phosphate ions out of solution from saliva causes it to enlarge
what type of pts and glands does sialolithiasis affect?
pts older than 20
submandibular 80%
parotid 19%
describe the presentation of obstructive sialadenitis?
- recurrent episodes of transient prandial salivary gland swelling
- no symptoms between attacks as saliva escapes from gland
- the bigger the stone becomes the more severe the symptoms
- complete obstruction causes stasis of saliva and allows commensals from the oral cavity to enter the gland, causing persistent pain
describe the presentation of acute sialadenitis secondary to obstruction (sialolithiasis)?
increasing painful swelling of 24-72 hour duration
oral discharge of pus when massaged
systemic manifestations
there is a small sialith in the left submandibular gland orifice. what is the treatment?
encourage the use of sialagogues to flush the stone forward
if cannot, remove stone by cutting the opening large enough
what are the 2 presentations of a submandibular sialolith?
intraductal
intraglandular
what radiographs would you take to view a submandibular sialolith?
intraductal - occlusal view of FOM
intraglandular - DPT
why is the submandibular gland more commonly affected by sialalothiasis?
its duct is long
gland is more alkaline so the calcium and phosphate ions come out of solution quicker
does removal of a gland lead to dry mouth?
no
there is such a large physiological reserve of saliva
how are submandibular gland stones removed?
intraductal - under LA
intraglandular - surgery along with the gland
*always advise there may be future episodes
when removing an intraductal sialolith in FOM where must sutures be placed and why?
pass suture behind the stone to prevent it moving back into the gland when trying to retrieve it
at what size does a sialolith have to be surgically removed?
if the stone is 1/3 larger than diameter of the duct (it wont spontaneously shed)
what is basket retrieval of stones?
less invasive technique using endoscope
only works for small stones
*not available in Scotland
describe the process of removing a submandibular duct sialolith?
- identify the outline of the stone under mucosa (yellow colour)
- pass a suture behind and infront of the stone to immobilise
- incise through firm swelling, cut through mucosa and roof of the duct
- take out the stone
- flush with saline
- remove traction sutures
- leave open or stich open with non resorbable sutures
what is lithotrypsy?
a machine which produces ultrasonic waves that break down saliva stones into smaller components which can be shed
*used in Kings college in London
what are the 2 types of mucocoeles and where do you find them?
mucus retention cyst - sublingual gland
mucus extravasation cyst - lip
what is a ranula?
a large mucus retention cyst in the FOM
what is the treatment for a ranula?
marsupialisation - create an opening for the gland to discharge
what gland would ascending infections not present in?
sublingual gland
what is sialometaplasia?
traumatic inflammatory condition which affects minor salivary glands of the palate
how may sialometaplasia present?
between junction of H+S palate
keratotic
red dots (inflamed minor salivary duct orifices)
often presents with pain
treatment for sialometaplasia?
review - if doesnt resolve within 2-3 weeks, biopsy
describe a salivary gland tumour?
localised salivary enlargement
tend to be solid and more discrete
what type of glands are more common for tumours?
major glands
90% parotid (80% benign)
50% subman
25% sublingual
where do you tend to find salivary gland tumours?
55% palate
20% upper lip
investigations for a pleomorphic adenoma?
incisional biopsy and CBCT to determine whether bony erosion/ invasion
what SG pathology has intermittent swelling?
transient obstructive sialadenitis
what SG pathology has persistent swelling?
complete obstructive sialadenitis
what SG pathology presents with unilateral but diffuse swelling?
obstructive or viral sialadenitis
what SG pathology presents with unilateral but localised swelling?
tumour
what SG pathology presents with bilateral localised swelling?
Warthons tumour
what SG pathology presents with bilateral diffuse swelling?
Sjogrens or sialadenosis
what SG pathology presents with prandial pain?
obstructive sialiadenitis
what SG pathology may present with persistent pain?
Sjorgens
what SG pathology presents with pain involving a particular branch of nerve/ facial palsy?
neoplasm
what is sialorrhea?
excess salivation
symptom of an inability to clear saliva due to a neuromuscular reason
what SG pathology presents with pain in the tongue?
lingual nerve tumour
what does viscous saliva imply?
autoimmne problems
what gland is most commonly affected by tumour (benign)?
parotid
what is the most common type of tumour found most commonly in parotid glands?
pleomorphic adenoma
why do you never incise major gland tumours?
it may cause seeding of the surrounding tissue
list types of investigations which can be used for salivary gland disease?
radiographs
sialography (injected dye)
FNA
CT/MRI
scintigraphy
labial gland biopsy
blood tests
why is ultrasound used to investigate salivary gland pathology?
outlines the size, position and consistency of the lesion
why would you take a CT to investigate salivary gland disease?
if worried about bone invasion
what is scintography?
checks the function of the gland (rarely use)
why would you use a labial gland biopsy?
to confirm diagnosis of Sjogren’s (along with serology)
describe FNA?
vacuum within a syringe
contents are aspirated
semi fluid = cystic
blood = vascular
what are indications for surgery for salivary gland disease?
chronic pain/ symptoms - refractory
repeated acute on chronic sialadenitis
- excise sialolith from submandibular duct
- remove gland
- ranula (marsupialise/ complete removal)
benign/ malignant tumours +/- nerve reconstruction
what symptom is a result of facial nerve damage?
weakness of corner of mouth and drooping
what symptom is a result of lingual nerve damage?
numbness in the lateral aspect of the tongue
what are the post op complications of removal of submandibular gland?
pain, swelling, bruising
scar (initially visible but hidden in crease of neck)
numbness of tongue
weakness of lower lip
weakness of tongue movement
what symptom is a result of damage to mandibular branch of facial nerve?
weakness of lower lip
what does damage to the hypoglossal nerve cause?
weakness of tongue
what are the 4 types of parotid surgery?
extracapsular dissection
lobar resection
superficial parotidectomy (4/5 parotid gland)
total parotidectomy (only if deep lobe tumour)
what is the treatment of choice for sjogrens?
superficial parotidectomy
what is the treatment of choice for a parotid tail tumour?
extracapsular dissection/ superficial lobar resection
treatment for pleomorphic adenoma?
superficial parotidectomy
treatment of choice for malignant parotid tumour?
take out as much of the tumour and facial nerve associated - total parotidectomy under ultrasound guidance
what are the post op complications of parotid gland surgery?
pain, swelling, bruising
facial nerve injury - weakness of muscles of facial expression
gustatory sweating (Freys syndrome)
numbness around ear lobe
salivary fistula
infection
recurrence of tumour
how may gustatory sweating occur post parotid surgery?
parasympathetic innervation of salivary gland cross reacts with the sympathetic innervation of the vasculature in the area
what is gustatory sweating?
when you think about food, you sweat
how may numbness around ear lobe occur post parotid surgery?
if the auriculotemporal nerve damaged (usually permanent)
why may a fistula occur post parotid surgery?
with a superficial parotidectomy - the deep lobe will continue to produce saliva
