Salivary Gland Disease Flashcards
Investigations in salivary gland dz
Plain films - detect stone/foreign body
USG - detect mass or stone
CT/MRI - to assess extend size location of mass; mri allows neural involvment assessment
Sialogram - using contrast agent injected into ductal system to see its morphology and anatomy for any obstruction, strictures, sialectasia
Core needle biopsy - ct/usg guided to give definite histopath dx
Sialendoscopy - diagnostic / therapeutic
Scintigraphy - assessment of function of parenchyma using radioisotope technetium 99
Causes of xerostomia
Inflammatory - infection hep b,c, HIV, GVHD
Neoplasia - benign or malignant
Drugs - antihpt, tca antidepressant, narcotics, benzodiazepines, anticholinergic, beta blockers, antihistamines, diuretics
Iatrogenic - local factors - smoking, mouth breathing
Congenital - aplasia
Autoimmune - sjogrens, sarcoidosis, amyloidosis
Trauma - obstructive
Endocrine - DM, DI
Whats the sequalae of xerostomia?
Sialedenitis
Sialolithiasis
Presentation of sialadenitis
Pain at the affected salivary gland on eating Swelling Erythematous Fever Purulent discharge
Imaging required for sialadenitis
Plain radiograph - opg, occlusal to rule out sialolithiasis
Sialography - to assess the ductal system and see sialectasis proximal to any obstruction
Chronic sialadenitis will show sausaging - due to scarring and stricture of ductal system.
Ct/mri - to rule out neoplasm
Diff dx of sialadenitis
Sialolithiasis
Salivary gland neoplasia
Investigations of sialadenitis
- Imaging
- C&S if pus present
- Bloods (cbc - increase neutrophils, raised esr)
Initial management of sialadenitis
Hydration Antibiotics Analgesias Steroids Sialogogues I&d if abscess present Glandular massage
If unresolved with initial therapy, whats the next tx?
Minimally invasive
- sialendoscope with ductal irrigation +/- ductal stenting if stricture is present
Invasive (if still recur, persist, with destruction of gland parenchyma)
- surgical removal of gland
When do you do removal of salivary gland? whats the indication?
Sialolithiasis ( 3 conditions)
- stone severely impacted at hilar region of submandibular gland
- intraparenchymal calculi
- calculi beyond the muscles (mylohyoid for submandibular, masseter for parotid)
Salivary neoplasm
Recurrent persistent sialadenitis
Whats the presentation of obstructive salivary gland dz
Mealtime syndrome
What is mealtime syndrome
A collection of symptoms occurring due to increase salivary flow during or when meal is anticipated, but unable to be secreted due to obstruction, leading to gland capsule distension and swelling.
How does mealtime syndrome presents with
Acute recurrent pain and swelling during or when meal is anticipated, and subsides after meal.
Where does stone commonly occur in submandibular gland?
- At hilar region of submandibular gland where it wraps around the mylohyoid muscle
- Intraparenchymal
- Terminal end of the duct
Why is submandibular gland most common to have sialolithiasis
- Long tortous submandibular duct
- Antigravity flow of the submandibular gland saliva
- Mucinous saliva
Where does stone commonly occur in parotid gland?
Intraparenchymal
Posterior part of gland where it wraps around mandible
What is gland preserving tx
- Transoral removal of anterior floor of mouth stone (sialalithotomy/direct ductal incision) with or without sialadochoplasty (neo-ostium of duct - reported to reduce ductal stenosis)
- Sialendoscopy with basket retrieval of stone
- ESW Lithotripsy
- Transoral removal of stone at hilar region
How do you perform stone removal at the distal end of the duct
Ligation of duct at the proximal end of the stone to prevent retrograde movement of the stone
Locating ductal opening with lacrimal probe
Direct ductal incision
Massaging the stone out through the incision
Ductal opening to be left open (risk of stenosis) or resutured to the mucosa (sialadochoplasty - creation of neo-ostium; reduces risk of stenosis)
What is Freys syndrome
ATN injury
Inappropriate re innervation of the parasympathetic fibers of trigeminal nerve (CN V) that carries parasympathetic fibers to the parotid gland leading to gustatory sweating when parasympathetic parotid is stimulated.
Causing sweating/flushing at the distribution of ATN when salivary gland stimulated
+ve starch iodine test (face is painted with iodine, and starch. And areas with sweat will turn blue)
How do you remove submandibular gland
Transcutaneous submandibular incision - skin, sc, platysma, fascia/capsule of gland
Capsule of gland incised
Dissection of gland subcapsular
Oral and cervical portion of gland - cervical part is quite straight fwd, no vital structures superficial to mylohyoid
Deep and medial to post belly of digastric is facial artery and hypoglossal nerve
Front-to-back dissection of salivary gland from mylohyoid muscle
Once the cervical portion freed, to excise the oral portion
Immediate deep to mylohyoid ms is lingual, hypoglossal nerve and ranine vein
Mylohyoid is freed and retracted anteriorly
Oral portion of gland, duct, ganglion, lingual nerve, hypoglossal nerve is seen
Finger dissection in plane between SMG and fascia covering XIIn and ranine veins
Divide the submandibular duct
Freeing the gland from the posterior belly of digastric
Complications of submandibular gland excision
Bleeding from facial or lingual artery
Nerve injury (MMB of facial nerve, Hypoglossal nerve, lingual nerve)
Submandibular scar
Complication of parotid gland excision
Facial nerve injury - temporary 30%, permanent 1-3%
Freys syndrome - ATN injury - iodine starch test
Sialocele
Salivary fistula
Other gen risks - bleeding from ECA, internal maxillary artery, hematoma, scar
How to manage ranula?
Deroofing and marsupialization
Excision of simple ranula
Excision of sublingual gland
Excision of plunging ranula through transcutaneous - including sublingual excision
Controversy to deroofing of the ranula
Rarely successful
Scarring on floor of mouth
Damage to ducts draining the sublingual gland
Tx options for sialolithiasis?
Conservative - hydration, sialagogues, muscarinic agonists, glamdular massage
Gland preserving tx
Gland excision
- total submandibular gland excision
- superficial parotidectomy
What are gland preserving procedures
Transoral stone removal - direct duct incision
Lithotripsy
Endoscopic removal
