W5 - Salivary Gland Disorders - Thomson Flashcards
What are the 4 salivary glands
- Parotid
- Submandibular
- Sublingual
- Minor salivary glands
What type of saliva does the parotid, submandibular and sublingual glands produce, respectively?
Parotid - Serous
Submd - Mixed (10% mucinous)
Subling - Mixed (10% serous)
Where does the majority of saliva come from? (glands)
Submandibular (75%)
Parotid (25%)
Sublingual (5%)
Problems that salivary hypofunction / xerostomia cause (5)
Difficulty chewing and swallowing
Erythematous & atrophic oral mucosa
Lobulation & depapillation of tongue
Caries
Oral candidiasis / angular cheilitis
Primary causes of xerostomia (salivary gland pathology) (6)
Aplasia (missing gland) Excision / irradiation Infection / obstruction Sjogrens HIV Cystic Fibrosis
Secondary causes of xerostomia (4)
Anxiety
Neurological
Drug therapy
Fluid / electrolyte imbalance
What type of drugs cause xerostomia? (5)
antihistamines
antidepressants
antipsychotics
anti-cholinergics
diuretics
How can salivary gland diseases be classified (2)
Neoplastic
non neoplastic
Reasons for non-neoplastic salivary gland disease (7)
Developmental Obstructive Inflammation Ischaemic Trauma Infection Autoimmune
4 classifications of salivary disease clinical presentation + examples
- Acute inflammatory swellings (acute sialadenitis)
- Recurrent swellings (sialolith)
- Persistent diffuse enlargement (sjogrens)
- Nodular enlargement (neoplasm, cyst, lymph node)
Synonym for sialolith
Salivary calculi
4 reasons for recurrent swelling of salivary gland
- Salivary calculi
- Papillary obstruction
- Duct Stricture
- Punctate sialectasis
What is acute sialadenitis? 3 types?
Infection causing acute inflammatory swelling
- Viral (mumps)
- Suppurative
- Granulomatous
3 reasons for persistent diffuse enlargement of salivary glands
Sjogrens syndrome
Sialosis
Sarcoidosis
What is sjogrens syndrome?
Chronic multisystem autoimmune exocrinopathy
- affects middle aged / elderly females
2 types of sjogrens syndrome
Primary “Sicca syndrome” - salivary and lacrimal glands affected
Secondary - salivary/lacrimal glands, + connective tissue/autoimmune disease
- Rheumatoid arthritis, Systemic lupus erythematous
Features of sjogrens syndrome (4)
Persistent xerostomia - dry mouth, caries, depapillated tongue, etc.
Persistent xeropthalmia - dry eyes
Salivary and lacrimal gland enlargement
Parotitis - swollen parotid
Investigations / tests for sjogrens (5)
Unstimulated SFR - <1.5mL in 15 min
Sialography imaging
Labial gland biopsy
Schirmer test - tear production <5 mm / 5 min
Blood test - Rheumatoid factor, Anti-Ro, Anti-La antibodies
What is this
Sialography test for investigating sjogrens syndrome
What dangerous thing can histopathology show about sjogren syndrome?
Lymphocyte infiltration within intra-glanular septa, acinar atrophy and destruction -> risk of LYMPHOMA
Management of sjogrens syndrome
Keep in mind that salivary gland damage is irreversible -> focus on symptomatic relief
Biotene
Caries control
Management of infection and candidiasis
Regular parotid gland examination
Visits with opthamology and rheumatology
Benign vs malignant salivary gland tumour symptoms
Benign: slowly enlarging, symptomless lump
Malignant: Rapid enlargement Pain Ulceration Bone destruction Trismus Facial paralysis
Pt says this has been growing slowly. Feels no pain
Benign salivary gland tumour
Pt says this has grown quickly, is painful, difficulty opening mouth
Malignant submandibular salivary gland tumour
3 types of benign salivary gland tumour
Pleomorphic salivary adenoma
Adenoma
Adenolymphoma aka Warthin’s tumour
5 examples of malignant salivary gland tumours
Mucoepidermoid carcinoma Acinic cell carinoma Adenoid cystic carcinoma Adenocarcinoma Carcinoma
What is the most common salivary gland tumour
75% Parotid (80% of these are benign)
15% Submandibular (60% benign)
10% Minor salivary glands (40% benign)
Features of pleomorphic salivary adenoma
“Mixed tumour” that makes up the majority of salivary gland tumours
- Arising from duct epithelium or myoepithelial cells
- Incomplete capsule with ductal, fibrous, elastic and cartilage tissue
- Rubbery, lobulated swellings that slowly grow
- Squamous metaplasia and keratin foci
- Occasionally turns malignant
Pleomorphic salivary adenoma (PSA)
Features of adenoid cystic carcinoma (4)
- Slow growing malignant tumour
- Late metastases
- Bony invasion and infiltration along nerve sheaths
- Cribiform “swiss cheese” histological appearance
Adenoid cystic carcinoma
- bony invasion and infiltration along nerve sheaths
“Swisscheese” cribiform histological appearance
How to investigate sus salivary glands (8)
- Clinical exam / palpation
- Salivary flow rate
- Radiography
- Ultrasound
- Sialography
- CT / MR scan
- Scintiscanning
- Sialadenoscopy
salivary gland pathology
- stone, tumour
salivary gland pathology
6 types of salivary gland surgery
- Removal of calculi
- Ductal repositioning
- Excision of sublingual gland
- Excision of submandibular gland
- Parotidectomy (superficial, total)
- Excision of minor salivary gland lesions / tumours
What important structures run through the parotid (5)
- Facial nerve
- Auriculotemporal nerve
- External carotid
- Retromandiular vein
- Stylomandibular ligament
“Snowstorm appearance”
- Sjorgrens syndrome
S & S
Sialography
Interruptions / holes in line (radiopaque dye) indicate presence of calculi
What are MR scans useful for?
Soft tissue evaluation
- not as good for bone
How does salivary gland scintiscanning work?
Demonstrates uptake and distribution of isotope
- Assess salivary gland function
- Demonstrates tumour formation
What is likely the cause of recurrent swelling during meal times
Sialolith
What sizes of sialolith can be removed by sialendoscopy? (3)
3-4mm - endoscopy
5-7mm - laser / lithotripsy
> 8mm - combined technique
Ranula
- fluid collection / cyst under the tongue
What is the problem with sublingual gland cyst surgery / ranula removal
Will also need to remove sublingual gland in addition to ranula
- If you just remove the cyst, will likely return
What nerves can be affected by submandibular gland pathology
Hypoglossal nerve - motor supply to muscles of tongue
Lingual nerve
Submandibular gland swelling
Sebaceous cyst / epidermoid cyst
- Connected to skin
- NOT in submandibular gland triangle thus cannot be submandibular swelling/pathology
Why do we cut here? (dotted line)
Avoids the marginal mandibular branch of the facial nerve
What is this and what went wrong
Mandibular branch of facial weakness
- Surgeon did not cut two finger widths below md, knicked the nerve
Should have cut like this pic
What does the auriculotemporal nerve innervate
TMJ and skin of ear lobe
- runs through parotid
Facial nerve palsy
What is freys syndrome
When auriculotemporal nerve is injured due to trauma from surgery near parotid
Every time the patient salivates, sweat is also produced on the surface
Lump in the upper lip vs lower lip consideration
Be very wary - could be malignant tumour if in upper lip
38 min
Lower lip lump more likely to be benign tumour
Mucocele or benign minor salivary gland tumour
Palatal swelling showing signs of potentially malignant tumour
Adenoid cystic carcinoma
“swiss cheese histologic appearance”
- malignant
in this picture, dentist had extracted tooth bc they thought swelling was abscess. after the tooth healed the palatal swelling became ulcerated
“swiss cheese appearance” of adenoid cystic carcinoma
- malignant
“swiss cheese appearance” of adenoid cystic carcinoma
- malignant
