S2 - Salivary Gland Disorders Flashcards
What are the salivary glands? (4)
- parotid
- submandibular
- sublingual
- minor salivary glands
Where are the major salivary glands located
parotid - between posterior border of md and ear, facial nerve seperates superficial and deep lobes
submd- in submd triangle, HUGS mylohyoid muscle
sublingual - in fom
Some diff diagnoses for swelling around angle of md? What might be a clinical clue differentiation?
- ameloblastoma arising from body of md
- parotid tumour
parotid swellings tend to raise the lobe of the ear
2 differential diagnoses for swelling in angle of mandible. What may be an important clinical clue?
- ameloblastoma arising from body of md
- parotid gland tumour
parotid swellings tend to lift the lobe of the ear
Position of parotid (stensen’s) duct and accessory lobe of the parotid gland?
accessory lobe sits along the parotid duct which runs through buccinator and opens opposite upper 2nd m
Where would tumours of the accessory parotid duct present?
more on the cheek
in MRI scan - accessory lobe mass within what would normally be buccinator
Describe submandibular gland anatomy
lie in posterior part of the submd triangle, wraps/hugs around mylohyoid muscle which seperates the superficial and deep (in back of mouth) part
whartons duct runs over the submd AND sublingual gland and opens in the anterior fom (sublingual papilla)
Histology of salivary gland types
parotid - mainly serous
submd - mixed, mainly serous
sublingual - mixed, mainly mucous
Where are minor salivary glands located?
there are 100s
- particularly in palatal vault (in areas not tightly bound down to gingival mucoperiosteum and median palatal raphe
- mixed mucous serous in tongue and inner lips
How much saliva produced per day. Resting vs stimulated SFR
1-1.5L /day
resting SFR 0.25ml/min, stimulated SFR 1ml/min (eating, preparing food, thinking abt food etc - might be important for pain hx)
Which of the 3 major salivary glands produce most to least saliva
- submd (75%)
- parotid (25%)
- sublingual (5%)
What is xerostomia. What are some clinical features.
a chronic debilitating conditio
= subjective sensation of dry mouth
- difficulty chewing and swallowing
- erythematous, atrophic, cracked, dry oral mucosa (mirror sticks)
- lobulation & depapillation of tongue
- females/elderly
- risk of oral candidiasis/angular cheilitis
- increased risk of dental caries (smooth surface) & perio
- risk of secondary infections
Name some causes of xerostomia (2 categories)
primary (salivary gland pathology):
- aplasia (missing)
- excision/irradiation
- infection/obstruction
- Sjogren’s syndrome
- Sarcoid (growth of granulomas)
- HIV
- cystic fibrosis
- primary biliary cirrhosis (destroyed)
secondary (to systemic disease):
- fluid/electrolyte imbalance
- neurological
- anxiety
- drug therapy
Categories of drugs that may induce xerostomia
- antihistamines
- antidepressants
- antipsychotics
- anti-cholinergic drugs
- diuretics (some antihypertensives)
- narcotics (opioids)
2 main categories of salivary gland disease
neoplastic
non-neoplastic
Types of neoplastic and non-neoplastic salivary gland disease.
What is sialosis
non-neoplastic, non-inflammatory enlargement and lack of function of salivary glands - can be in pts with eating disorders, HIV or diabetes
Name some acute inflammatory swellings(3) Describe characteristics
- *acute sialadenitis** (infection):
- viral (e.g. mumps - Paramyxoviridae, usually bilateral and lifts earlobe, also painful testicles and ovaries)
- suppurative (bacterial infection if dehydrated - no flow, when sick or surgical etc)
- granulomatous
-> hours or days, painful
Name causes of recurrent salivary gland swellings (4) Describe character
- salivary calculi
- papillary obstruction (damage to opening of duct) can be: 1. acute, ulcerative or 2. chronic, fibrosis
- duct stricture (scarring - long term problem)
- punctate sialectasis (ballooning damage of acini)
they last a few hours then goes down, brought on by saliva stimulation - eating, thinking abt, cooking etc
Causes of papillary obstruction, where is it most common. What can it lead to
repeated trauma - can be due to sharp tooth or prosthesis, most common in Stensen’s duct (Parotid)
ultimately can lead to duct stricture (scarring) and long term problem
What are salivary calculi aka sialolith. Which gland(s) is it found in. What is the aetiology and what does it lead to
calcified stones, can arise in any of the saliva glands but submd duct is particular prone
Unclear aetiology - possible relation to calculus formation
leads to obstruction of duct
What is recurrent punctate sialectasis in child
ballooning damage of the acini structure of glands
may be unusual iatrogenic condition or children who develop recurrent mumps infection (since not necessarily from paramyxoviridae, can also be from Coxsackie etc)
Appearance of punctate sialectasis in sialograph
snow-storm appearance
Causes of persistent diffuse enlargement (aka swelling) (3) Describe character.
- Sjogren’s syndrome
- Sialosis (non-inflam, non-neoplastic - eating disorders, HIV or diabetes)
- Sarcoidosis (infiltration of proteins and granulomas into tissues)
affects whole gland (diffuse), doesnt go down and up, stays up (persistent)
Causes of nodular enlargement (aka lump) (3)
- neoplasm (tumour)
- lymph node
- cyst
e.g. nodule just under ear lobe or around angle of md, DD - parotid tumour, parotid lymph node, skin cyst
What is Sjogren’s Syndrome and 2 types.
chronic multisystem autoimmune exocrinopathy
or simply, long term condition affecting multiple systems - body reacting against exocrine glands (salivary, lacrimal etc)
Primary (Sicca) - salivary + lacrimal glands
Secondary: Sicca + generalised connective tissue/autoimmune disease → Rheumatoid Arthritis (vast majority), Systemic Lupus Erythematosus (not uncommon)
Symptoms of Sjogren’s Syndrome (4)
- persistent xerostomia (dry mouth, frequent intake of water, dry red atrophic wrinkled mucosa, depapillated, lobulated tongue, cervical caries)
- persistent xerophthalmia (dry, gritty eyes, keratoconjuctivitis sicca, freq use of tear substitues)
- salivary and lacrimal gland enlargement
- parotitis (parotid infection)
(main symptoms: dry mouth, dry eyes, RA)
pictures show lacrimal gland enlargement (uncommon), bilateral parotid gland swelling (more common)
What may another condition confused for bilateral parotid swelling
masseter hypertrophy due to TMD
(feel w fingers to distinguish)
Investigations for Sjogren’s Syndrome
- unstimulated total SFR <1.5ml in 15min
- imaging: sialography will show punctate sialectasis snow storm appearance
- labial gland biopsy (of swellings?)
- blood tests - increased ESR, Anti-Ro and Anti- La Antinuclear antibodies, Rheumatoid Factor
- Schimer test - blotting paper test for tear production <5mm/5min
What would be seen histologically in labial gland biopsy. Why is it important to detect early?
focal lymphocytic infiltrate (blue cells) destroying and replacing salivary acini
as a result of this infilitration of lymphocytes there is a risk over-time of lymphoma (check that there is no nodular, rubbery hard lump within the swelling)
Management of Sjogren’s Syndrome
salivary gland damage is irreversible but mainly about symptomatic relief
- saliva stimulants - Pilocarpine (muscarinine parasympathomimetic, can have other parasymethetic side effects - sweating, increased HR, dizziness)
- artificial saliva substitutes (but only work as long as they are in the mouth)
- caries prevention/tx
- management of oral infection & candidiasis
- regular parotid gland examination (check for rubbery, hard swellings! lymphomas)
- opthalmology
- rheumatology
Describe typical character of benign vs malignant salivary gland tumours
benign - slow growing, symptomless lump
malignant - rapid enlargement, pain, bone destruction, trismus, facial paralysis (invade nerves), ulceration
Common types of benign salivary gland tumours (3)
- Pleomorphic salivary adenoma (PSA)
- Warthin’s tumour (adenolymphona -not a lymphoma/malignant)
- Adenoma
Types of malignant salivary gland tumours
- mucoepidermoid carcinoma
- acinic cell carcinoma
- adenoid cystic carcinoma
- adenocarcinoma
- carcinoma ex PSA (malignant change of PSA - look for the signs)
Where do the most salivary gland tumours occur and what proportion are benign/malignant)
75% parotid (80% mostly benign, 80% of these PSA) - ⅔s of each
15% submandibular (60% benign, 95% PSA)
10% minor salivary gland (60% MALIGNANT)
as they get smaller, more risk of malignancy
What is pleomorphic salivary adenoma
‘mixed tumour’ arising from duct epithelium and myoepithelial cells (epithelial cells that line the duct and muscle epithelial cells that squeeze saliva out)
incomplete capsule with ductal, fibrous, myxoid, elastic, cartilage tissue
squamous metaplasia & keratin foci
smooth, rubbery, nodular, lobulated swellings, slowly grow to great size
occasionally undergo malignant change
Risk of removing PSA in parotid
damage to facial nerve
What is adenoid cystic carcinoma?
common salivary gland cancer
slow growing malignant tumour with late metastases in the lungs
histology: characteristic cribriform ‘swiss cheese’ appearance
has particular predilection to bony invasion and infiltration along nerve sheath
What are the 4 typical presentations of salivary gland swellings, and what are some causes of each of these?
- Acute inflammatory swellings - acute sialadenitis
- Viral - mumps
- Suppurative
- Granulomatous
- Recurrent swellings
- sialoliths → salivary calculi stuck in salivary duct, causing pain especially when salivary flow is initiated
- Papillary obstruction
- duct stricture (scar tissue formation) → eg. due to trauma from occlusion
- Punctate sialectasis
- Peristent diffuse swellings
- Sjogren’s syndrome
- sialosis
- sarcoidosis
- Nodular enlargement
- Lymph nodes
- cysts
- Neoplasm
Types of enlargements
- acute inflammatory swellings (acute sialadenitis - viral, suppurative, granulomatous)
- recurrent swellings (salivary calculi, papillary obstruction, duct stricture, punctate sialectasis)
- persistent diffuse enlargement (Sjogrens, Sarcoidosis, Sialosis)
- nodular enlargement (neoplasm, LN, cyst)