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Oral Disease - Soft tissue > Salivary gland disease > Flashcards

Salivary gland disease Flashcards

1
Q

List the major salivary glands

A

Parotid
Submandibular
Sublingual

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2
Q

List the basic functions of saliva

A
  • Microorganisms - antifungal, antivital and antibacterial
  • Food - mastication, bolus formation, taste and digestion
  • teeth - lubrication, remineralisation, buffering, protection against demin
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3
Q

How does saliva protect the oral cavity?

A
  • Lubricates and cleanses the mouth and teeth
  • Controls oral PH to allow buffering of bicarbonate
  • Limits oral pathogen growth via lysosomes and IgA
  • Remineralisation of teeth
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4
Q

What ph level does the saliva maintain in the mouth?

A

6.2-7.4

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5
Q

What is the rest (unstimulated) flow of saliva

A

500ml (or up to 1 litre) a day

this is around 0.35ml/min

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6
Q

What is the contribution of rest flow from the salivary glands?

A

Submandibular 70%
Parotid 20%
Sublingual 5%
Minor 5%

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7
Q

What is the stimulated flow rate? Which gland is responsible?

A

2ml/min

Parotid gland increases secretion by 5x

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8
Q

What is the dinural flow rate?

A

Around 0.1ml/min

Lowest flow rate is around 3am

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9
Q

List the differential diagnosis for salivary gland diseases

A

Infection - bacterial (staph, TB, actinomycosis), viral (mumps, HIV, CMV)
Cysts - mucocoles or ranulas
Tumours - benign or malignant
Systemic conditions - sialadenosis, sarcoidosis, HIV, autoimmune
Obstruction - calculi or strictures

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10
Q

What are some presenting signs of an obstruction?

A

Intermittent, meal time related swelling or pain

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11
Q

What are presenting signs of sialadenitis

A

Intermittent non-meal related swelling

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12
Q

List the imaging techniques used for salivary gland disease

A 
Sialography 
Ultrasound 
Plain films 
CT and CT sialography 
MR sialography 
Endoscopy
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13
Q

Advantages of ultrasound as an ix for salivary gland disease

A
  • Quick, non-invasive, cheap, good compliance, doesn’t use contrast media or radiation, high resolution
  • First line ix
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14
Q

When are plain films indicated?

A

Ix for calculi as 20-40% of parotid and 60-80% of submandibular stones are radiopaque

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15
Q

Indications for sialography

Contraindications for sialography

A

Obstruction, sialdenitis, sjogrens

CI - allergy to iodine, acute infection of gland, caulcus at the ostium of the duct

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16
Q

Technique for sialography

A

Radiopaque medium is introduced into the ducts to demonstrate anatomy

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17
Q

What types of radiopaque materials are used in sialography

A 
Water based (urographic) 
Oil based - NOT USED AS LESS SAFE
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18
Q

What is the best ix for salivary stones and why?

A

CT and CT sialography as it is 10x more sensitive for calcification than plain films (100% sensitivity)

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19
Q

Tx options for salivary stones

A
  • Extracorporeal or intracorporeal shockwave lithotripsy
  • Stone retrival
  • Dissolution
  • Conservative surgery
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20
Q

Tx options for strictures

A

Baloon duct dilation

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21
Q

Indications for basket removal

A
  • Mobile stone
  • No stricture distal to the stone
  • Stone <50% width of the duct
  • Basket can pass the stone
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22
Q

Complications of salivary gland surgery

A 
Nerve damage 
Facial scarring 
Post op infection 
Salivary fistula 
Frey's syndrome
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23
Q

What is the risk of nerve damage in salivary gland surgery

A

Parotid - 20-60% temporary, 1-7% risk of permanent damage to the facial nerve
SM gland - marginal mandibular nerve palsy or lingual nerve palsy

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24
Q

Tx options for parotid surgery

A
  • Partial superficial parotidectomy

- Capsular dissection

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25
Q

What is Frey’s syndrome?

A

Complication of surgery occuring near the parotid gland, characterised by swelling at meal times and flushing of the face

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26
Q

What are the acinar cells?

A

Clusters of cells acting as the basic secretory unit of the salivary glands. They can be serous or mucous

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27
Q

What are the myoepithelial cells

A

Cells in the glandular epithelium around the acinar cells, which control luminal functions e.g. flow of fluid

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28
Q

Define: sialosis

A

Non-pathogenic, non-neoplastic increase in salivary gland size

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29
Q

Define: sialodenitis

A

Ductal infection

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30
Q

Define sialolithiasis

A

Duct obstruction

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31
Q

Define sialectasis

A

Cystic widening of the duct

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32
Q

Define sialorrhea

A

Excessive salivation or drooling

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33
Q

Aetiology of salivary gland tumours

A
  • Ionising radiaition
  • Occupational risks - rubber or car manufacturing, woodworking
  • Little is known
  • SMOKING AND ALCOHOL PLAY NO ROLE
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34
Q

Pathophysiology of salivary gland tumours

A

Unknown for most, except in the case of chromosomal translocations

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35
Q

How do chromosomal translocations occur

A

Non-disjunction at mitosis - there is mutations in the DNA repair genes and random breaks (double-strand break or reciprocal T)

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36
Q

Examples of salivary gland tumours caused by chromosomal translocations

A
  • Pleomorphic adenoma
  • Adenoid cystic carcinoma
  • Mucoepidermoid carcinoma
  • Secretory carcinoma
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37
Q

Presentation of salivary gland tumours

A
  • All ages affected, but risk increases with age
  • Lump in gland or mucosal at an intraoral site e.g. palate
  • If malignant - there will be signs e.g. pain, ulceration, bone invasion, rapid growth, nerve signs
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38
Q

Where are malignant and benign salivary gland tumours more likely to occur?

A

Malignant - in minor salivary glands

Benign - in major salivary glands

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39
Q

Which salivary gland tumours are benign?

A
  • Pleomorphic adenoma

- Warthin’s tumour

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40
Q

Which salivary gland tumours are malignant?

A
  • Mucoepidermoid carcinoma
  • Polymorphous adenocarcinoma
  • Acinic cell carcinoma
  • Adenoid cystic carcinoma
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41
Q

List the features of benign salivary gland tumours

A
  • Slow growing
  • Well differentiated and encapsulated
  • Soft or rubbery consistency
  • Do not ulcerate
  • No associated nerve signs
  • Non-invasive and non-metastatic
  • CO aesthetics or pressure
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42
Q

List the features of malignant salivary gland tumours

A
  • Slow or rapid growth
  • Non-capsulated
  • Can be hard and indurated
  • Progressively increase in size
  • May be ulcerated
  • Can mets
  • Signs of malignancy (pain, impaired function, neurological signs)
  • imaging shows an irregular pattern of destruction or invasion
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43
Q

What is the most common salivary neoplasm?

A

Pleomorphic salivary adenoma - around 75% of parotid tumours

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44
Q

List the features of pleomorphic salivary adenomas

A
  • Arise from duct epithelium or myoepithelial cells
  • Encapsulated
  • Painless and slow growing
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45
Q

Ix for pleomorphic salivary adnoma

A
  • Sialography showing ‘ball-in-hand’
  • Histology showing incomplete capsule, ducts, sheets or dark-staining epithelial cells, squamous metaplasia or foci of keratin
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46
Q

How is pleomorphic salivary adenoma diagnosed?

A

Via FNA

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47
Q

Tx of pleomorphic salivary adenoma

A

Wide excision

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48
Q

Recurrence risk of pleomorphic salivary adnoma

A

High risk due to difficulty removing entire tumour due to proximity to facial nerve
Risk is reduced by removing the gland with the tumour

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49
Q

Describe the features of Warthin’s tumour

A

Almost always in the paortid
Mobile, firm to fluctant
Enlcueated
May be single or multiple

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50
Q

Histology of Warthin’s tumour

A

Tall, eosinophillic columnar cells forming a folded layer covering lymphoid tissues

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51
Q

Tx to Warthin’s tumour

A

tends to respond to enucleation

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52
Q

What is the most common malignant salivary neoplasm

A

Mucoepidermoid carcinoma (3-9% of all salivary gland neoplasm)

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53
Q

Describe the features of mucoepidermoid cecinomas

A

Most in minor salivary glands (esp palate)

Can be high or low grade

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54
Q

Tx of mucoepidermoid carcinoma

A

Wide excision with risk of reucrrence

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55
Q

Describe the features of acinic cell carcinoma

A

Rare (1% of all salivary gland tumours)
Low to intermediate grade salivary neoplasm with serous granules
Often arises in the parotid
Invasive and sometimes mets

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56
Q

Histology for acinic cell carcinoma

A

Uniform pattern of large cells with granular basophilic cytoplasm
Round holes gives a lace appearance

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57
Q

Describe the features of adenoid cystic carcinoma

A

Arise in major or minor glands
Initial presentation often nerve palsy or ‘funny feeling’
Slow growth but highly INFILTRATIVE along nerve sheaths

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58
Q

Prognosis for adenoid cystic carcinoma

A

Very poor 15 year diagnosis due to late presentation (due to slow growth)

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59
Q

Tx for adenoid cystic carcinoma

A

Wide excision, often combined with radiotherapy at the earliest possible stage

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60
Q

Histological appearance of adenoid cystic carcinoma

A

Round groups of darkly stained cells with multiple clear spaces (looks like swiss cheese)

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61
Q

What is a carcinoma ex pleomorphic adenoma?

A

A carcinoma arising from pre-existing pleomorphic adenoma

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62
Q

Prognosis for carcinoma ex pleomorphic adenoma

A

Poor if it breaches the capsule (specifically extracapsular invasion>8mm) due to high infiltrative and metastatic spread

63
Q

Describe polymorphous adenocarcinoma

A

Variable grades but often low grade in the minor glands (palate)
Local recurrence occurs, but it rarely mets
Can spread along nerve sheaths
Good prognosis

64
Q

What is an example of a non-epithelial tumour affecting the salivary glands

65
Q

Where do lymphomas affecting the salivary gland arise?

A
  • In the lymph nodes within the gland (high-grade-B-cell lymphoma or Hodgkins) or in the gland parenchyma (MALT lymphoma)
66
Q

What are the tumour-like salivary swellings to be aware of?

A

Necrotising sialometaplasia

Sialadenosis

67
Q

what is necrotising sialometaplasia

A

Affects minor glands in the palate, often in males and smokers, painless but ulcerated swelling 1-2cm resembling a carcinoma

68
Q

What is sialadenosis

A

Non-neoplastic, non-inflammatory enlargement of the salivary glands (most often parotids) caused by alcoholism, diabetes, endocrine disturbances, pregnancy, drugs, bulimia

69
Q

What are the non-neoplastic salivary gland diseases

A 
Calculi 
strictures
Fistula 
Mucoceles and cysts (including ranulas) 
Sialadenitis 
Xerostomia 
Sjogreans disease
70
Q

What is the most common cause of salivary gland swelling

A

Calculi (sialolithiasis) - this is when a stone forms in the duct

71
Q

Epidemiology for calculi

A

Adults, males 2:1
80% in SM, 6% in P and 2% in sl
Unilateral

72
Q

Presenting signs and symptoms for calculi

A

Asymptomatic
There may be pain at mealtimes, when the stone passes forward to the orifice or if it becomes infected
it does not cause dry mouth!!!

73
Q

Ix for calculi

A

Plain film radiographs - however not all stones are radiopaque
Sialography

74
Q

Pathology of calculi

A

Deposition of calcium salts around organic material
Tend to have a rough lining which may cause squamous metaplasia of the duct lining or inflammation and fibrosis of the duct due to microbial flora

75
Q

Tx of calculi

A
  • Identify stone and damage to the duct
  • if far forward - push it out the orifice
  • If distally placed - intervention using conservative approach (basket removal or lithotripsy)
  • Conventional removal
  • Excision if extensive damage to the duct
76
Q

Aetiology of duct strictures

A

Chronic trauma leading to fibrosis e.g. clasps, faulty restorations, sharp teeth

77
Q

Ix for strictures

A

Sialography will show narrowing of the duct or papilla and the dilation distal to the pathology

78
Q

tx of strictures

A

Depends on site of obstruction - dilation or excision may be required

79
Q

What is the most common cyst found in the salivary glands

A

Extravastatoin mucocele of the minor glands

80
Q

Difference between extravastation and retention cysts?

A

Extravastations have no epithelial lining (not true cysts)

Retention cysts have an epithelial lining

81
Q

Aetiology of mucoceles

A

Damage to the duct or mucous gland e.g. trauma to the lip

82
Q

Pathology of mucoceles

A

Saliva leaks from the damaged duct into the superficial tissue, causing inflam response
Pools of saliva coalesce around the liquid by compressed connective tissue

83
Q

Describe the presentation of mucoceles

A
  • Common on lower lip on young patients or BM on older patients
  • Superficial lesion around 1cm dia
  • Round fleshy swelling at first, then it becomes hemispherical, fluctuant and blusish
84
Q

What is a ranula?

A

An uncommon salivary cyst found at the floor of the mouth (arise from sublingual or submandibular salivary glands

85
Q

How to distinguish between mucocele and retention cyst?

A

Histological examination

86
Q

Tx for mucoceles and cysts

A
  • re-establish duct continuity via cryotherapy, sutures, decompression
  • If small and superficial - excise with underlying gland
87
Q

Tx for ranulas

A

Marsupialisation and removal of associate gland to prevent recurrence

88
Q

What is a plunging ranula

A

Form when a rapidly growing simple ranula bursts

89
Q

Presentation of acute sialdenitis due to mumps

A
  • Painful swelling of the parotids +/- other glands

- systemic symptoms - malaise, fever, headache

90
Q

What is the most common cause of acute sialdenitis

91
Q

Presentation of supparative parotitis

A
  • Uni or bilateral painful parotid glands with swelling, redness, tenderness, malaise and fever
  • Enlargement of region lymphs
  • Pus exudate from parotid ducts
92
Q

Aetiology of supparative parotitis

A
  • Staph aureus, streptococci and anaerobes

- Usually seen in patients with severe xerostomia (sjogrens) or a complication of tricyclic antidepressants

93
Q

Tx for supparative parotitis

A

Flucloxacillin

94
Q

Presentation of chronic sialadenitis

A
  • Asymptomatic or with intermittent low-grade painful swelling of the gland
  • Often unilateral
95
Q

Aetiology of chronic sialdenitis

A

Complication of duct obstruction

96
Q

Histology of chronic sialdenitis

A

Duct containing mucin and neutrophils surrounded by a layer of fibrosis with severe acinar atrophy
Lymphocytic infiltration and squamous metaplasia of the duct epithelium

97
Q

What is Kuttner’s tumour (chronic sclerosing sialadenitis)

A

Chronic inflammatory disease of the salivary glands characterised by progressive fibrosis, dilated ducts with dense lymphocyte infiltration and acinar atrophy

98
Q

What is allergic/eosinophilic sialdentisis (sialadenitis fibrinosa)

A

Rare salivary condition usually found in Japan in atopic patients, characterised by strings of thick saliva in dilated ducts with increase esosinophils

99
Q

Define: dry mouth

A

Condition of decreased flow of saliva, caused by failure of the salivary glands to function as normal, or a sensation of dry mouth occurring even though the salivary glands function as normal

100
Q

Define: hyposalivation

A

OBJECTIVE dryness of the mouth

101
Q

Define: xerostomia

A

Subjective complaint of dryness

102
Q

What may be a presenting complaint for dry mouth?

A
  • Dryness
  • Difficulty eating dry food
  • Unpleasant taste in the mouth
103
Q

Aetiology of subjective xerostomia (false xerostomia)

A
  • Mouth breathing
  • Night dryness
  • Psychological and psychogenic
104
Q

Aetiology of objective (true) xerostomia

A
  • Drugs
  • Psychogenic (anxiety)
  • Dehydration - diabetes, cardiac or renal failure, low fluid intake or fluid loss
  • Gland or nerve damage - sjogrens, irradiation or cytotoxic drugs
  • Hypoplasia or aplasia of the glands
105
Q

List the types of drugs responsible for xerostomia

A
  • Anticholinergics - antiparkinsons, tricyclic antidep, antihistamines, phenothiazines
  • Sympathomimetics - amphetamines, decongestants
  • Centrally acting - L DOPA, lithium, optiates and benzos
  • Dehydration - diuretics, alcohol and coffee
106
Q

List the mechanisms by which drugs cause xerostomia

A
  • Directly acting on glands
  • Acting on sympathetic nerves and ganglia
  • Acting on parasympathetic nerves and ganglia
  • Cause dehydration
107
Q

which drugs do not cause xerostomia?

A
  • Beta blockers

- Smoking

108
Q

Describe the influence of the parasympathetic nervous system on salivary flow

A
  • Responsible for secretory function

- If the PSNS is blocked, the gland will atrophy (this is why drugs act on the PSNS to increase salivary flow)

109
Q

Describe the influence of the sympathetic nervous system on salivary flow

A

Responsible for protein secretion

If SNS is blocked, there is little effect on the glands

110
Q

What are the clinical features of xerostomia?

A
  • Mirror or fingers sticking to mucosa
  • Sticky, stringy or frothy saliva
  • Matte mucosa
  • Difficulty swallowing and speaking
  • Oral discomfort
  • Reduced denture retention or tolerance
111
Q

What are some indirect complications of xerostomia?

A
  • Bad taste
  • Caries
  • Candida
  • Erythematous gingiva
  • Sialadenitis
  • Lobulation of dorsal tongue or increased fissuring
  • Mucosal atrophy or lateral tongue depapillation
112
Q

Management sequence of dry mouth

A
  • History and examination
  • Special IX
  • True or false - diagnosis
  • Specific treatment
  • Assess risk of complications and plan prevention
113
Q

History of xerostomia that leads to a ‘true’ diagnosis

A
  • Prolonged and unremitting dryness
114
Q

What factors should you consider in your history and examination phase for xerostomia?

A 
Smoking and drug history 
History of radiotherapy 
History of autoimmune disease 
Mouth breathing 
Bad taste in the mouth 
Other dryness e.g. eyes
115
Q

List the special ix for xerostomia

A
  • Salivary flow rate
  • Saliva sample for candida and pathogens
  • Referral for sjogrens testing - lacrimal, serology, ultrasound and biopsy
116
Q

What salivary flow rates will indicate reduced flow?

A
  • Whole unstimulated flow is <0.2ml/min over 10mins (2ml over 10 mins)
  • Stimulated parotid flow is <0.4ml/min (4ml) from a single glad on stimulation with citric acid twice in 10 mins
117
Q

Tx options for dry mouth

A
  • Ensure hydration throughout the day
  • Avoiding drying drugs
  • Use of flow stimulants
  • Treat mucosal soreness and denture difficulty symptomatically
  • Monitor for complications - caries, candida
118
Q

Define: Sjogrens syndrome

A

Relatively common, multisystem, chronic autoimmune disease which is characterised by mononuclear infiltration of salivary and lacrimal glands, progressive glandular atrophy and loss of function.

119
Q

What is primary and secondary sjogrens

A

Primary - sjogrens alone

Secondary - sjogrens alongise another connective tissue disease

120
Q

Epidemiology of sjogrens

A

Females > males (9:1)

Usually occurs in middle age (1st peak in mid 30s then postmenopausal)

121
Q

Aetiology of sjogrens

A

Unknown - likely to have genetic susceptibility triggered by environmental factors

122
Q

Describe the pathology of sjogrens

A
  • Glands become infiltrated by activated B cells (hyperactive b cells)
  • B cells collect around ducts and destroy acinar cells
  • Late stages are characterised by glandular atrophy and destruction of ducts
123
Q

What autoantibodies are markers for sjogrens

A
  • Antinuclear factor ANF
  • Ro (SSA) and La (SSB)
  • Rheumatoid factor RF
  • Gastric parietal cell antibody
  • Anti-thyroid antibody
  • Anti-salivary duct antibody
124
Q

Ocular features of sjogrens

A
  • Failure of tear formation
  • Drying of conjunctiva - C/O dry gritty eyes
  • Burning soreness
  • Eyelids adherent in the AM
  • Keratoconjunctivitis sicca
125
Q

Oral signs of sjogrens

A
  • Signs of xerostomia (mirror sticking, matte mucosa, fissuring of the tongue)
  • Loss of function - hard to eat, speak
  • Recurring infection (candida and possibly angular cheilitis)
126
Q

Extraoral signs of sjogrens

A
  • Swelling of parotids (may be historical) - however it is rarely painful
  • Dry skin, vagina, oesophagus, lungs
  • Raynaud’s
  • Vasculitis
  • Fatigue, myalgia and arthalgia
  • Memory loss
127
Q

What type of sjogrens is more severe?

A

Primary sjogrens

128
Q

What other autoimmune conditions are associated with sjogrens

A

Rheumatoid arthritis (10-50%)
Systemic lupus erythematous (30%)
Scleroderma

129
Q

Diagnostic testing for sjogrens

A
  • Salivary flow rate
  • Lacrimal function
  • Antibody screening
  • Labial salivary gland bipsy
  • Sialography
130
Q

How many diagnostic factors are required for a diagnosis of Sjogrens to be made?

A

4/6 of the symptoms in the criteria are met

131
Q

What is the criteria for a sjogrens diagnosis

A
  1. Autoantibody and/or positive minor gland biopsy
    PLUS 2 or 3 of:
    - Ocular symptoms >3months
    - Oral symptoms >3 months +/- gland swelling
    - Ocular signs - Schrimers, scintigraphy, reduced flow
132
Q

List the histological appearance in sjogrens

A
  • Periductal lymphocytic infiltrte
  • Expansion of infiltrate
  • Atrophy of acinar cells
  • Ductal hyperplasia forming epimyoepithelial islands
  • Formation of lymphoepithelial lesion
133
Q

Management of sjogrens

A
  • Reassurance
  • Multidisciplinary care
  • Dry mouth - sipping water, saliva substitutes
  • Caries risk prevention
  • Antifungals when required
134
Q

What are the types of saliva substitutes available

A
  • Sprays, lozenges, gels, pastilles

- Pilocarpine to stimulate flow

135
Q

What does MALT stand for

A

Mucosa associated lymphoid tissue

136
Q

What are the characteristics of MALT lymphomas

A

Low grade
Indolent behaviour
Good prognosis

137
Q

Why is the risk of MALT lymphomas high with sjogrens disease?

A
  • B cell proliferation is continually occuring - eventually a clone may escape control of division and form a lymphoma
138
Q

Where do MALT lymphomas arise?

A

In the affected parotid gland and may remain localised for many years

139
Q

Where do MALT lymphomas spread?

A

Local lymph nodes or other MALT sites around the body

140
Q

What is the lifetime risk of MALT lymphoma for someone with sjogrens

141
Q

When should you suspect MALT lymphoma?

A

Patient with sjogrens with swollen glands until proven otherwise

142
Q

Risk factors for MALT lymphoma

A
  • Parotid enlargement esp if sudden
  • Lymph node involvement
  • Vasculitits
  • Neutropenia
  • Low CD4 count
  • Systemic symptoms - night sweats, fever
143
Q

Diagnosis of MALT lymphoma

A

Biopsy from lower pole of the gland (prevent damage to facial nerve)

144
Q

Tx of MALT lymphoma

A
  • Radiotherapy, chemotherapy and surgery are all options
145
Q

What is IgG4 sclerosing disease

A

Multiorgan immune mediated condition with many presentations - but all are a primarily fibrotic mass

146
Q

what salivary gland complication is seen in IgG4 sclerosing disease?

A

Sialadenitit of major and minor glands: including: Kuttner’s tumour and Mikuliczs disease

147
Q

What is Mikuliczs disease?

A

Disorder characterised by enlarged lacrimal and parotid glands due to infiltration with lymphocytes

148
Q

What salivary gland symptoms are seen with HIV?

A
  • Swollen parotids - usually gradual and uni or bilateral, painful and disfiguring
  • Xerostomia with no obvious cause
  • Dry eyes and arthalgia
149
Q

What salivary gland symptoms are seen with Sarcoidosis?

A
  • Uni or bilateral parotid gland swelling +/- facial palsy (Heerfordt’s syndrome)
150
Q

What is sarcoidosis?

A

Inflammatory, multi-organ disease, characterised by formation of granulomas commonly affecting the lumps and lymph glands

151
Q

What is ptyalism

A

Excess salivation

152
Q

Why is true ptyalism an uncommon complaint?

A

Excess saliva can be readily swallowed

153
Q

Aetiology of false ptyalism

A

Psychogenic
Bells palsy
Parkinsons
Stroke

154
Q

Aetiology of true ptyalism

A
  • Oral infections or wounds
  • Dental procedures
  • Oral appliance e.g. new dentures or retainer
  • Systemic - nausea or acid reflux
  • Iodine
  • Heavy metal poisoning

Oral Disease - Soft tissue (12 decks)

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