S2 - Salivary Gland Disorders

Question 1

What are the salivary glands? (4)

Answer 1

1. parotid
2. submandibular
3. sublingual
4. minor salivary glands

Question 2

Where are the major salivary glands located

Answer 2

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

Question 3

Some diff diagnoses for swelling around angle of md? What might be a clinical clue differentiation?

Answer 3

• ameloblastoma arising from body of md
• parotid tumour

parotid swellings tend to raise the lobe of the ear

Question 4

2 differential diagnoses for swelling in angle of mandible. What may be an important clinical clue?

Answer 4

• ameloblastoma arising from body of md
• parotid gland tumour

parotid swellings tend to lift the lobe of the ear

Question 5

Position of parotid (stensen’s) duct and accessory lobe of the parotid gland?

Answer 5

accessory lobe sits along the parotid duct which runs through buccinator and opens opposite upper 2nd m

Question 6

Where would tumours of the accessory parotid duct present?

Answer 6

more on the cheek

in MRI scan - accessory lobe mass within what would normally be buccinator

Question 7

Describe submandibular gland anatomy

Answer 7

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)

Question 8

Histology of salivary gland types

Answer 8

parotid - mainly serous

submd - mixed, mainly serous

sublingual - mixed, mainly mucous

Question 9

Where are minor salivary glands located?

Answer 9

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

Question 10

How much saliva produced per day. Resting vs stimulated SFR

Answer 10

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)

Question 11

Which of the 3 major salivary glands produce most to least saliva

Answer 11

1. submd (75%)
2. parotid (25%)
3. sublingual (5%)

Question 12

What is xerostomia. What are some clinical features.

Answer 12

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

Question 13

Name some causes of xerostomia (2 categories)

Answer 13

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

Question 14

Categories of drugs that may induce xerostomia

Answer 14

• antihistamines
• antidepressants
• antipsychotics
• anti-cholinergic drugs
• diuretics (some antihypertensives)
• narcotics (opioids)

Question 15

2 main categories of salivary gland disease

Answer 15

neoplastic
non-neoplastic

Question 16

Types of neoplastic and non-neoplastic salivary gland disease.

Answer 16

Question 17

What is sialosis

Answer 17

non-neoplastic, non-inflammatory enlargement and lack of function of salivary glands - can be in pts with eating disorders, HIV or diabetes

Question 18

Name some acute inflammatory swellings(3) Describe characteristics

Answer 18

• *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

Question 19

Name causes of recurrent salivary gland swellings (4) Describe character

Answer 19

• 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

Question 20

Causes of papillary obstruction, where is it most common. What can it lead to

Answer 20

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

Question 21

What are salivary calculi aka sialolith. Which gland(s) is it found in. What is the aetiology and what does it lead to

Answer 21

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

Question 22

What is recurrent punctate sialectasis in child

Answer 22

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)

Question 23

Appearance of punctate sialectasis in sialograph

Answer 23

snow-storm appearance

Question 24

Causes of persistent diffuse enlargement (aka swelling) (3) Describe character.

Answer 24

• 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)

Question 25

Causes of nodular enlargement (aka lump) (3)

Answer 25

* 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

Question 26

What is Sjogren's Syndrome and 2 types.

Answer 26

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)

Question 27

Symptoms of Sjogren's Syndrome (4)

Answer 27

1. persistent xerostomia (dry mouth, frequent intake of water, dry red atrophic wrinkled mucosa, depapillated, lobulated tongue, cervical caries) 2. persistent xerophthalmia (dry, gritty eyes, keratoconjuctivitis sicca, freq use of tear substitues) 3. salivary and lacrimal gland enlargement 4. parotitis (parotid infection) (main symptoms: dry mouth, dry eyes, RA) pictures show lacrimal gland enlargement (uncommon), bilateral parotid gland swelling (more common)

Question 28

What may another condition confused for bilateral parotid swelling

Answer 28

masseter hypertrophy due to TMD | (feel w fingers to distinguish)

Question 29

Investigations for Sjogren's Syndrome

Answer 29

1. unstimulated total SFR \<1.5ml in 15min 2. imaging: sialography will show punctate sialectasis snow storm appearance 3. labial gland biopsy (of swellings?) 4. blood tests - increased ESR, Anti-Ro and Anti- La Antinuclear antibodies, Rheumatoid Factor 5. Schimer test - blotting paper test for tear production \<5mm/5min

Question 30

What would be seen histologically in labial gland biopsy. Why is it important to detect early?

Answer 30

**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)

Question 31

Management of Sjogren's Syndrome

Answer 31

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

Question 32

Describe typical character of benign vs malignant salivary gland tumours

Answer 32

benign - slow growing, symptomless lump malignant - rapid enlargement, pain, bone destruction, trismus, facial paralysis (invade nerves), ulceration

Question 33

Common types of benign salivary gland tumours (3)

Answer 33

* Pleomorphic salivary adenoma (PSA) * Warthin's tumour (adenolymphona -not a lymphoma/malignant) * Adenoma

Question 34

Types of malignant salivary gland tumours

Answer 34

* mucoepidermoid carcinoma * acinic cell carcinoma * adenoid cystic carcinoma * adenocarcinoma * carcinoma ex PSA (malignant change of PSA - look for the signs)

Question 35

Where do the most salivary gland tumours occur and what proportion are benign/malignant)

Answer 35

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

Question 36

What is pleomorphic salivary adenoma

Answer 36

‘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

Question 37

Risk of removing PSA in parotid

Answer 37

damage to facial nerve

Question 38

What is adenoid cystic carcinoma?

Answer 38

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

Question 39

What are the 4 typical presentations of salivary gland swellings, and what are some causes of each of these?

Answer 39

1. Acute inflammatory swellings - acute sialadenitis * Viral - mumps * Suppurative * Granulomatous 2. 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 3. Peristent diffuse swellings * Sjogren's syndrome * sialosis * sarcoidosis 4. Nodular enlargement * Lymph nodes * cysts * Neoplasm

Question 40

Types of enlargements

Answer 40

1. acute inflammatory swellings (acute sialadenitis - viral, suppurative, granulomatous) 2. recurrent swellings (salivary calculi, papillary obstruction, duct stricture, punctate sialectasis) 3. persistent diffuse enlargement (Sjogrens, Sarcoidosis, Sialosis) 4. nodular enlargement (neoplasm, LN, cyst)