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Salivary Glands Flashcards

1
Q

Functions of saliva

A 
Tissue coating
Buffering
Digestion
Dental protection
Lubrication and viscoelasticity
Anti bacterial/fungal/viral
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2
Q

Sialosis

A

Non pathogenic, non neoplastic increase in salivary gland size

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3
Q

Sialadenitis

A

Ductal infection

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4
Q

Sialolithiasis

A

Duct obstruction

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5
Q

Sialectasis

A

Cystic dilatation of duct

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6
Q

Sialorrhoea

A

Excessive salivation/ drooling

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7
Q

What virus is acute viral sialadenitis often caused by?

A

Mumps

RNA virus paramyxovirus

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8
Q

Acute viral sialadenitis presentation

A 
Usually parotid (rarely SM)
Pain
Usually bilateral enlargement
Skin over unaffected 
Malaise, fever, headache
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9
Q

Acute viral sialadenitis spread

A

Droplet/direct contact

2-3 wks IP

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10
Q

Acute viral sialadenitis extrasalivary manifestations

A

Ochitis
Oophoritis
Pancreatitis

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11
Q

Acute viral sialadenitis histology

A

Accumulation of neutrophils and fluid in lumen of ductal structures

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12
Q

Management of acute viral sialadenitis

A

Clinical diagnosis
Fluid and pain meds
Second attack possible
Vaccination

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13
Q

Pathogenesis of acute bacterial sialadenitis

A

Retrograde contamination of salivary ducts and parenchymal tissues
- reduced flow can predispose pt - bacteria enter against flow
Stasis of flow caused by hypersalivation, dehydration, med induced hyposalivation, obstruction, strictures, adhesions, sialolithiasis

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14
Q

acute bacterial sialadenitis underlying causes

A 
ALWAYS
Dehydration and flow reduction 
Flow obstruction
DM
Immunosuppression
Abnormal anatomy

Most commonly affects : hospital inpts, elderly, H and N radio pts, SS pts, pre-existing salivary conditions

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15
Q

acute bacterial sialadenitis bacteria

A

S pyogenes, s aureus, prevotella spp

Rarely mycobacteria

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16
Q

acute bacterial sialadenitis presentation

A 
Painful and tender enlargement of one gland 
Pus discharge duct
Reddening of overlying skin
Trismus 
Pyrexia
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17
Q

acute bacterial sialadenitis histology

A

Acinar destruction with neutrophil infiltrates and bacterial presence

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18
Q

acute bacterial sialadenitis diagnosis

A

Clinical

Needle aspirate pus sample

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19
Q

acute bacterial sialadenitis tx

A

Antibiotics and analgesia
Fluids
Good OH
may need IV drainage

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20
Q

acute bacterial sialadenitis pathophysiology

A

Duct ectasia
Mucous metaplasia of ductal epithelium
Periductal fibrosis
Fusion of lobules

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21
Q

Chronic sialadenitis

A

Low grade bacterial invasion
Relapsing/radiation/sclerosing
Can develop after acute sialadenitis or calculi formation

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22
Q

Chronic sialadenitis clinical

A

Recurrent attacks of pain and swelling

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23
Q

Chronic sialadenitis histology

A

Atrophy of serous acini during chronic obstructions

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24
Q

Chronic sialadenitis diagnosis

A

Clinical and history

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25
Chronic sialadenitis tx
Surgical excision
26
Chronic recurrent parotitis
Most common form of chronic sialadenitis ?aetiology - semisolid material - coagulated albumin - as a result of gland inflammation, obstructs duct network, swelling
27
Chronic recurrent parotitis ages
Children 4m-15yrs | Adults 40-60 years
28
Chronic recurrent parotitis clinically
``` Sudden onset parotid swelling Usually unilateral Varying discomfort Overlying skin normal/slightly reddish, low-grade fever Swelling 24-48 hrs, 1-2wks, months Followed by clear periods weeks-years Periodic as duct cleared by muscles/sialogogues Viscous and milky secretion (rarely pus) ```
29
Chronic recurrent parotitis tx
Short term steroids | Ductal clearance from ppt serum proteins
30
What is the most common benign minor SG lesion?
Mucocele
31
Main cause of mucocele
Mechanical trauma on discharge duct
32
Extravasation mucocele
Pseudocysts (no epithelial lining) Mechanical trauma to excretory duct - transaction/rupture Extravasation of mucin into CT - triggers inflammatory and granular reaction to contain Extravasation Common minor SGs L lip, buccal mucosa and RM area
33
Retention mucocele
Lined by ductal epithelium , cystic dilatation Often elderly Due to duct obstruction- sialolith/periductal strictures/invasive tumour Narrowing of ductal opening - reduced flow, subsequent distal distension - mucosal swelling Common U lip, HP, FOM, MS
34
ranula
variant of mucocele on FOM which usually arises in body of SL gland and occ inducts of Rivini/Wharton's duct if extends through mylohyoid plunging ranula
35
mucocele most common sites
lip | FOM
36
mucocele clinical presentation
``` surface smooth (can be rough/ulcerated) colour: red/whitish/bluish/translucent usually asymptomatic fluctuant - rupture and release mucous - salty taste often hx of trauma usually bulging mass (can be polypoid/blister) usually 0-2cm most <30yrs, M ```
37
U lip mucocele
beware - likely a pathological lesion
38
mucocele diagnosis
hx and exam | US: cystic masses, sometimes contain fibrillar processes produced by FBs
39
mucocele recurrence
esp if traumatic habit persists | RFs - younger pt, ventral tongue
40
mucocele histology
``` vascular GT surrounding a mucus pool foam cells macrophage lined cavity severed duct if trauma cystic cavity ```
41
mucocele tx
``` usually surgical - surgery - complete excision/marsupialisation/dissection - cryosurgery - CO2 laser - electrocautery non-surgical - IL injection of sclerosing agent - IL steroid injection can resolve spontaneously ```
42
sialolith formation
small deposits of Ca etc that form on bacteria, mucus or epithelial cells, can block saliva flow and cause gland to swell
43
where are most sialoliths and why?
80% SMG 2x as much Ca as parotid, quite alkaline and mucous tortous and uphill path
44
predisposing factors for sialolithiasis
``` cause unknown age radio H+N mouth injuries/trauma meds affecting saliva production SS kidney problems not drinking enough water ```
45
sialolithiasis clinical presentation
unilateral SG swelling painful intermittent worst pain periprandial (flow) gout link? usually asymptomatic whilst forming, can sometimes disappear affected gland can get infected - suppurative sialadenitis
46
sialolithiasis histology
dilated ducts with calculi chronic inflammatory cells calcified structure metaplasia from columnar to SSE of lining - chronic irritation from stone
47
sialolithiasis diagnosis
hx attempt to palpate calculus radiograph (not always obvious - referral?) sialography CT - check for other causes of obstruction
48
sialolithiasis tx
``` conservative - moist heat and gentle massage - hydration - sialogogues e.g. lemon drops - try to remove it if in proximity of exit - NSAIDs - ABs if infection surgery lithotripsy sialendoscopy duct dilatation surgical removal of gland: recurrent stones/irreversible damage to gland ```
49
other gland obstruction
``` recurrent parotitis - HIV - duct stenosis - bacterial infection chronic obstructive sialadenitis - usually caused by sialalithiasis - can be post-op ```
50
sialosis
non-inflammatory, non-neoplastic, chronic, diffuse enlargement of major SGs (usually parotid, occ SM, rarely minor) painless/((tender)) bilateral can be reactive mechanism e.g. EDs/alcoholism clinical diagnosis no tx
51
sialosis histology
hypertrophy (increase in cell size) of serous acini | oedema of interstitial CT
52
xerostomia
subjective feeling of oral dryness, may/may not be accompanied by hyposalivation
53
hyposalivation
objective reduction in salivary flow and production
54
causes of xerostomia
``` dehydration psychological neurological dysfct disease e.g. SS medications radio SG tumour SG trauma nutritional deficiencies and/or EDs ```
55
meds which cause dry mouth
``` tricyclics B-blockers antipsychotics antihistamines atropine diuretics cytotoxics antimuscarinic cholinergic drugs ```
56
radiation
critical dose limits for parotid and SM tissue 40Gy, most regimens exceed this declines during tx fct deterioration in secretion up to several months after, concomitant with progressive, irreversible changes of the SG tissue with no significant recovery in gland fct
57
oral manifestations of xerostomia
``` difficulties: speaking, sleeping, tasting, chewing, swallowing caries - incisal edge and cervical PDD oral infections - fungal - candida, angular cheilitis - bacterial - staph - SG infections atrophic lesions - depapillated tongue traumatic lesions reduced denture retention halitosis bad taste frothy saliva ```
58
clinical evaluation of SG fct - history
systemic/local diseases trauma meds list
59
clinical evaluation of SG fct - symptom Qs
sip liquids to aid swallowing dry foods? does mouth feel dry when eating? diff swallowing any foods? amount of saliva seem too little/much/don't notice = common complaints but don't reliably predict SG hypofct additional symptoms - speaking and eating difficulties - taste disturbances - halitosis, oral discomfort, intolerance of acidic/spicy
60
clinical evaluation of SG fct - physical exam
EO: major SGs, LNs IO: STs, periodontium, dentition
61
challacombe scale oral dryness - about
additive score 1-10 symptoms will not necessarily progress in the order shown, but summated scores indicate likely pt needs monitor symptom progression/regression
62
challacombe scale oral dryness - mild
1 - mirror sticks to buccal mucosa 2 - mirror sticks to tongue 3 - saliva frothy = mild, may not need tx, SF gum, hydration, routine monitoring
63
challacombe scale oral dryness - mod
4 - no saliva pooling in FOM 5 - tongue mild depapillation 6 - altered gingival architecture i.e. smooth = mod, SF gum/simple sialogogues, substitutes, F investigate if reasons not clear monitor regularly - decay and S+S
64
challacombe scale oral dryness - severe
``` 7 - glassy appearance esp palate 8 - tongue lobulated/fissured 9 - cervical caries (>2 teeth) 10 - debris on palate or sticking to teeth = severe, saliva substitutes and topical F identify cause, exclude SS refer monitor, specialist input if worsening ```
65
xerostomia measurements and lab tests
``` measure salivary output - UWSF, SWSF - ductal flow of major SGs sialochemical analyses serum lab studies - CBC with differential - AI markers - serum immunoglobulins - ESR ```
66
xerostomia imaging
``` US: superficial sonoelastography: (postradiation) CT: tumours *MRI: tumours scintigraphy: fct - assess SG dysfct PET: high cellular activity areas sign of tumour sialography radiograph ```
67
salivary biopsy
``` FNA major SG minor labial SG - ≥5 minor glands SS: focus score ≥1 per 4mm2 (focus score - ≥50 mononucleate cells per 4mm2) ```
68
pilocarpine SEs
``` vision changes hiccups bradycardia hypotension bronchoconstriction hyperhidrosis nausea, vomiting, diarrhoea cutaneous vasodilation increased urinary freq ```
69
xerostomia therapy
water tx cause if possible: hydration, modify drugs, control diseases relief/substitutes - oralbalance gustatory and tactile sialogogues - SF acidic sweets, lemon pastilles, SF gum pharmacologic sialogogues - cevimeline (US only), pilocarpine (cholinergic), betanechol chloride
70
pilocarpine dose
5mg daily, up to 30mg
71
pilocarpine contraindications
``` iritis and narrow-angle glaucoma CV disease chronic pulmonary disease inc uncontrolled asthma pts taking B-adrenergic blockers active gastric ulcers ```
72
hypersalivation/sialorrhea
increased saliva flow drooling (salivary incontinence) not usually associated with increased production of saliva - upset in coordinated control mechanism of orofacial and palato-lingual musculature leading to excessive pooling of saliva in anterior mouth - unintentional loss of saliva from mouth
73
drooling common causes
reduced swallowing - NM diseases: CP, Parkinsons, stroke - anatomic abnormalities: macroglossia, ortho problems (incompetent lips, AOB), surgical defects following major HandN resection, TMJ ankylosis)
74
causes of hypersalivation
irritating oral disease (ulceration, infection, trauma) med SEs (clozapine, risperidone, nitrazepam, bethanecol) GORD ENT diseases - can have oesophageal aetiologies - obstructive, inflammatory
75
hypersalivation causes - medications
parasympathomimetic drugs causing an increase of salivary flow rate, low viscosity directly working - arecoline, bethanechol, cevimeline, methacholine, muscarine, pilocarpine indirectly working - cisapride, neostigmine, nizatidine, physostigmine
76
clinical features of drooling
repeated perioral cutaneous alterations aspiration-related resp and pulmonary complications altered speech and swallowing social and psychological consequences
77
assessment of drooling - freq
dry - never drools occ drooling - not every day freq - drooling every day constant - constant drooling
78
assessment of drooling - severity
``` dry - never drools mild - only lips wet mod - lips and chin wet severe - clothing soiled profuse - hands and tray moist and wet ```
79
drooling therapy
``` oral motor training speech therapy behaviour therapy drugs - antihistamines - glycopyrrolate (tablets) - scopolamine (patch) - Botox A - good in Parkinsons surgery radio others - photocoagulation of salivary ducts - tongue acupuncture ```
80
drooling surgical tx
``` reduce flow/redirect flow to location more advantageous to promote swallowing SMG excision SM duct re-routing parotid duct re-routing parotid duct ligation transtympanic neurectomy ```
81
acute necrotising sialometaplasia about and predisposing factors
trauma induced smokers benign ulcerative lesion (resembles a SCC) small vessel infarct
82
acute necrotising sialometaplasia pathophysiology
ischaemic necrosis of minor SGs lack of blood supply leads to death of the tissue and infarction of the SGs vascular damage of palatine vessels
83
acute necrotising sialometaplasia clinically
typically HP/SP jct surface slough necrotic tissue initially red tender swelling then central ulcer when overlying mucosa breaks down anaesthesia can be associated to affected area
84
acute necrotising sialometaplasia histology
hyperplasia metaplasia of ducts necrosis of salivary acini
85
acute necrotising sialometaplasia diagnosis
usually biopsy to ensure not SCC
86
acute necrotising sialometaplasia management
self-resolving within 6-10wks | antiseptic MW to tx ulceration
87
SG neoplasms - locations with high risk of malignancy
SL gland | tongue
88
what % of SG neoplasms are benign?
80%
89
what % of SG neoplasms are parotid gland?
80% and 80% in superficial lobe
90
SG neoplasms - clinically
asymptomatic swelling and eversion of ear lobes no xerostomia malignant - can be pain/ulcerate/facial palsy
91
SG neoplasms management
surgical excision +/- radio
92
Frey's syndrome
if parotid gland tumour excision risk of damage to facial nerve - Frey's syndrome 'gustatory sweating' - damaged nerve fibres regrow to supply the sweat glands of the skin - when hungry you sweat
93
SG neoplasms - indication of malignant change
rapid growth pain fixation to deep tissues facial palsy
94
which area is most affected by minor SG neoplasms?
palate
95
usual benign locations of minor SG neoplasms
lip buccal palatal
96
usual malignant locations of minor SG neoplasms
tongue FOM RM pad
97
benign epithelial tumours
pleomorphic adenoma Wharthin tumour oncocytoma
98
malignant epithelial tumours
mucoepidermoid carcinoma adenoid cystic carcinoma acinic cell carcinoma
99
order of incidence of SG neoplasms
``` pleomorphic adenoma Warthin's tumour adenoid cystic carcinoma mucoepidermoid carcinoma acinic cell carcinoma ```
100
what is the most common SG tumour?
pleomorphic adenoma
101
pleomorphic adenoma - site
parotid 90% then SM and minor palate (fixed mass)
102
pleomorphic adenoma - clinical
``` solitary, painless, slow-growing unilateral swelling not fixed to underlying tissues skin overlying normal but can give bluish appearance most parotid affect superficial lobe ```
103
pleomorphic adenoma - histology
epithelial component: ducts or cystic structures myoepithelial cells: angled, fusiform or rounded cells stroma: CT, myxoid, chondroid, chondromyxoid, hyaline, fibrous usually encapsulated with fibrous tissue (non/poorly encapsulated related to recurrence)
104
pleomorphic adenoma - tx
surgery
105
pleomorphic adenoma - outcome
can recur | risk of malignant transformation (3-13%)
106
Warthin's tumour - location
almost exclusively parotid and superficial lobe, can be bilateral (5-14%) - 2.3% SM - ext rare in minor
107
Warthin's tumour - usual age
>40yrs
108
Warthin's tumour - clinical
painless, slow-growing, round/oval mass | sometimes fluctuant swelling
109
Warthin's tumour - histology
epithelial tissue, cystic formations dense lymphoid tissue stroma - can get germinal centres in this well defined CT capsule
110
Warthin's tumour - tx
surgery (/monitor)
111
Warthin's tumour - outcome
low recurrence rate | 1% malignant transformation of epithelial component
112
oncocytoma - incidence
rare <1%
113
oncocytoma - location
mostly parotid rare minor rarer SMG
114
oncocytoma - clinical
painless, slow-growing, non-tender, firm, lobulated and mobile mass occ pain/facial nerve paralysis
115
oncocytoma - histology
monotonous, polygonal, eosinophilic (oncocytic) epithelial cells round uniform nucleus low nucleus-cytoplasm ratio
116
oncocytoma - outcome
v low malignant potential SMG best prognosis recurrence 20% - insufficient surgery and occult multinodularity
117
oncocytoma - tx
surgery
118
what is the most common major SG malignant tumour?
mucoepidermoid carcinoma
119
what is the most common minor SG malignant tumour?
adenoid cystic carcinoma
120
mucoepidermoid carcinoma - site
50% parotid, but can affect any
121
mucoepidermoid carcinoma - minor
most common on palate, rubbery/soft mass, may stimulate a mucocele/vascular tumour also RM area
122
mucoepidermoid carcinoma - clinical
swelling, pain, ulcer, infiltration, discolouration, facial paralysis
123
mucoepidermoid carcinoma - histology
mucin secreting cells intermediate cells epidermoid cells slow growth and can infiltrate surrounding tissues
124
mucoepidermoid carcinoma - freq spread
perineural spread | 40% show high-grade metastasis
125
mucoepidermoid carcinoma - tx
surgery and radio
126
mucoepidermoid carcinoma - outcome
high grade poorer survival
127
adenoid cystic carcinoma - site
most common minor SG malignancy - often palate | can present in major
128
adenoid cystic carcinoma - clinical
asymptomatic mass, can get ulcer pain/cranial neuropathies - early and freq perineural invasion - parotid - facial n palsy slow growing locally invasive metastasises - cervical LNs, lung, liver, bone haematogenous spread - to lungs most common which is unusual for a carcinoma
129
adenoid cystic carcinoma - histology
``` swiss cheese no capsule cribiform pattern most common tubular type best prognosis solid type least common - most aggressive and higher distant metastases ```
130
adenoid cystic carcinoma - tx
surgery and radio | poor prognosis - local recurrence - hard to determine clinically how far tumour has spread
131
acinic cell carcinoma - location
parotid >80%, can be bilateral
132
acinic cell carcinoma - clinical
``` slowly enlarging mass, few symptoms occ involves nerves/regional nodes usually solitary, encapsulated, soft, grey-white invasive slow growth, good prognosis ```
133
acinic cell carcinoma - histology
``` serous acinar cell differentiation - microcystic, solid, papillary cystic, follicular clear/vacuolated cells intercalated duct-like cells non-specific glandular cells ```
134
acinic cell carcinoma - tx
surgery
135
polymorphous low-grade adenoma
rare most common palate M>F slow growing
136
which malignant tumours ten to have a slow growth pattern?
adenoid cystic carcinoma low-grade MEC acinic cell carcinoma
137
prognostic factors for malignant SG tumour prognosis
``` age stage histology grading lympho-vascular invasion FN paralysis cervical node involvement neural spread + surgical margins site gene mutations ```
138
diagnosis of SG tumours - clinical S+S
``` rapid growth rate pain facial nerve involvement neck nodes complete/partial parapharyngeal or palatal fullness trismus skin ulceration fistulas = but be suspicious of every painless swelling of a SG ```
139
diagnosis of SG tumours
``` clinical S+S US MRI pathology TNM staging ```
140
diagnosis of SG tumours - US
cheap, safe, accuracy 90%
141
diagnosis of SG tumours - MRI
interface of tumour and tissue for surgical planning
142
diagnosis of SG tumours - pathology
open biopsy not usually recommended due to risk of seeding if small masses in minor SGs (palate, tongue) - punch biopsy US guided FNA cytology
143
tx of SG tumours
surgery post-op radio recommended in selected pts chemo only suitable for individual clinical use as palliative for unresectable disease, pts not amenable to radio, pts with metastatic disease
144
TNM staging for SG tumours
Tx - T4b Nx - N3 M0 - M1
145
parotid gland
serous | stensen duct
146
SMG
mixed | wharton duct
147
SL gland
mucous
148
aplasia
congenital absence of ≥ SGs | ectodermal dysplasia
149
duct atresia
failure of a duct to canalise | can result in salivary retention cysts
150
HIV
parotid enlargement in up to 10% pts
151
CF
causes plugging of acinar ducts with precipitated secretions | essentially microscopic sialoliths
152
sarcoidosis
collections of granulomas | can occur in any organ but often affect SGs causing large masses and facial palsy
153
gland infiltration
``` amyloidosis - build up of amyloid protein fibrils - lymphoepithelial cysts haemachromatosis - causes xerostomia ```
154
cancer tx that affects SGs
radio GvHD anti-neoplastic drugs (chemo) radioiodine
155
why are salivary tissues sensitive to radio?
due to their highly differentiated and specialised state | - not because of high mitotic figures
156
radio and saliva
reduced quantity and quality of saliva saliva usually reproduced after 4-8wks of finishing tx - but can be thick, viscous and bad tasting fibrosis of salivary tissue - end arteritis
157
GvHD and saliva
mainly haematopoietic SC pts | results in SS
158
chemo and saliva
reduced secretion | early apoptosis of SG cells
159
radioiodine and saliva
reduction of gland fct | increased lymphocytic infiltrate
160
saliva substitutes
glandosane saliva orthana biotene
161
sugar substitutes
xylitol mannitol sorbitol
162
salivary proteins
IgA PRPs mucins histatin
163
salivary enzymes
lipase lysozyme amylase
164
what is Warthin's tumour thought to originate from?
remnants of salivary duct epithelium trapped in LNs during embryogenesis
165
parotid neoplasms
80% of all tumours | 15% malignant
166
SM neoplasms
10% of all tumours | 30% malignant
167
SL neoplasms
0.5% of all tumours | 80% malignant
168
minor neoplasms
10% of all tumours | 45% malignant
169
SS investigations
``` dry eyes - subjective dry eyes - objective dry mouth - subjective dry mouth - objective autoAB findings histopathology American european consensus group revised international criteria 4 or more positive criteria (must inc 5 and/or 6) ```
170
SS minor gland histology
focal lymphocytic sialadenitis - collections of 50+ lymphocytes, one or more collections /4mm2 acinar loss fibrosis
171
SS major gland histology
lymphocytic infiltration atrophy of acini ductal epithelium shows hyperplasia which eventually occludes ducts - myoepithelial islands

Oral medicine (14 decks)

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