disorder of salivary glands are a major problem in oral cavity

1. Presented By :- Dr Jayesh
PG Student
Dept Or Oral And Maxillofaical Surgery
SALIVARY GLAND DISORDERS ANDSALIVARY GLAND DISORDERS AND
DIAGNOSISDIAGNOSIS

2. Anatomy and physiology
Classification
Diagnostic modalities
Salivary gland diseases
Salivary gland tumors
Conclusion
References

3. ANATOMY

4. PAROTID GLAND

5. Parotid gland
PAROTID CAPSULE

6. PAROTID DUCT

7. BLOOD SUPPLY

8. Nerve supply:

9. Lymphatic drainage:
Parotid lymph nodes:

10. ANATOMY

11. SUBMANDIBULAR GLAND

12. Submandibular duct:
i

13. BLOOD SUPPLY AND LYMPHATIC
DRAINAGE

14. ANATOMY

15. Nerve supply:
It is supplied by branches 'from the submandibular ganglion. These
branches convey: (a) Secretomotor fibres: (b) sensory fibres from the
lingual nerve. and (c)vasomotor sympathetic fibres 'from the plexus on the
facial artery.

16. Smallest of the 3 salivary glands,lies above the mylohyoid,below the mucosa of
floor of the mouth medial to sublingual fossa of the mandible,lateral to the
genioglossus.
About 15 ducts emerge from the gland most of them directly open into floor of
mouth.the acinar ducts are called Bartholin’s ducts and in most instances coalesce
to form 8to 20 ducts of rivinus.
SUBLINGUAL SALIVARY GLAND:

17. Serous cells: produce a thin watery secretion
Mucous cells: produce a more viscous secretion
Parotid: serous
Submandibular: mucous & serous
Sublingual: mucous

18. Physiologic control of the SG is almost entirely by the autonomic nervous
system; parasympathetic effects predominate.
If parasympathetic innervation is interrupted, glandular atrophy occurs.
Normal saliva is 99.5% water
Normal daily production is 1-1.5L
PHYSIOLOGY

19. Keeps the mouth moist-lubricates food and mouth during chewing,
swallowing and phonation
Renders food substances soluble-thus aiding in taste sensation
Digestion of starch in the diet is first by œ-amylase
ptyalin in the saliva
Noxious substances increase the salivary secretion
there by help in diluting the noxious stimuli
Bicarbonate & protein contribute to the buffering
power of saliva-restores physiologic pH of the oral cavity
FUNCTIONS OF SALIVA

20. May be used as a diagnostic tool in monitoring
physiologic disorders and systemic hormone & drug
levels.
Protective & Anti bacterial Functions:
Salivary mucins (glycosaminoglycans) coating the oral
mucosa protect against the harmful effects of noxious
stimuli, Microbial toxins & minor trauma. This coat
traps the microbes and transfers them to the stomach
where the acidic Ph of the gastric juice degrades
them.
Lysozyme-an enzyme that has little effect on the
normal flora inhibits the noncommensals by
combining with IgA immunoglobulin and lyses the
bacteria.

21. Thiocynate dependent factors –the presence of which increases the
chances of oral malignancy is increased with decrease in saliva
as seen in smokers and tobacco chewers.
Green’s factor-Anticariogenic, presence is now questioned
Lactoferrin-binds with the available iron and does not
allow it to enter bacterial metabolism.
Antifungal property-by a histidine rich peptide-inhibits
candidal growth.

22. A . Developmental
Congenital aplasia
Congenital hypoplasia
Atresia
Aberance or ectopic gland
Accessory duct
Congenital fistula
B.Inflammatory
Acute and chronic
Staphylococcal,streptococcus,actinomycosis,tuberculosis.
Viral infection
Mumps ,CMV,para-influenza.
CLASSIFICATION OF SALIVARY
GLAND DISORDER

23. C .Obstructive
Sialolithiasis
Mucocele
Ranula
D .Autoimmune
Sjogrens syndrome
Benign lymphoepithelial lesion
E .Neoplasms
F .Others
Sialadenosis
Necrotizing sialometaplasia
Frey’s syndrome

24.  Plain film radiographs.
 Sialography.
 Flow rate studies.
 Sialoendoscopy.
 Sialochemistry.
 FNAC.
 Salivary gland biopsy.
 Computed tomography.
 Radioisotope imaging.
 Magnetic resonance imaging
Scintigraphy.
DIAGNOSTIC
MODALITIES

25. COMMONLY USED
RADIOGRAPHIC PROJECTIONS
Parotid gland •OPG
•Oblique lateral
•Rotated PA or AP
•Intra oral view of cheek
Submandibular
gland
•OPG
•Oblique lateral
•Lower 90degree occlusal to show duct
•Lower oblique occlusal to show gland
•True lateral skull with tongue depressed

26. Sialography can be defined as the radiographic
demonstration of the major salivary glands by introducing
a radiographic contrast medium into their ductal system.
The procedure is divided into three phases:
Preoperative phase
The filling phase
The emptying phase
SIALOGRAPHY

27. To determine the presence or position of calculi or other
blockages.
To assess extent of ductal and glandular destruction secondary
to an obstruction.
To determine the extent of glandular breakdown and as a crude
assesment of function in cases of dry mouth.to determine the
location ,size,nature and origin of a swelling or mass.
INDICATIONS:

28. Allergy to compounds containing iodine.
Acute inflammation or infection.
When calculus is close to the duct opening,as injection of the
contrast medium may push the calculus back down the main duct
where it may be inaccessible.
CONTRAINDICATIONS:

29. Involves taking preoperative radiographs before the introduction of
contrast medium
To note the position and presence of any radiopaque
obstruction
To assess the position of shadows cast by normal anatomical
structures that may overlie the gland,such as the hyoid
bone.
To assess the exposure factors.
PREOPERATIVE PHASE

30. Having obtained the films,the relevant duct orifice need to
be found,probed and dilatedand then cannulated.
Three main techniques for introducing contrast medium
are:
Simple injection technique
Hydrostatic technique
Continous infusion pressure monitored technique

32. Oil based or aqueous contrast medium is introduced using
gentle hand pressure until patient experiences tightness or
discomfort in the gland,about 0.7ml for parotid gland,0.5mlfor
Submandibular gland.
Hydrostatic technique:
Aqueous contrast media is allowed to flow freely into the
gland under the force of the gravity until patient experiences
discomfort.
Continuous infusion monitored technique:
A constant flow rate is adopted and the ductal pressure is
monitored through out the procedure

33. Ionic aqueous solutions including:
Iothalamate
Metrizoate.
Oil based solutions:
Iodized oil eg.lipiodol
Water insoluble organic iodine compounds eg.pantopaque.
Most commonly used are aqueous solutions.
CONTRAST MEDIA:

34. The cannula is removed and the patient is allowed to rinse out. The use of lemon
juice at this stage to aid excretion of contrast medium is advocated but is seldom
necessary.
EMPTYING PHASE

35. Parotid gland:
The main duct is of even diameter1-2mm and should be filled completely and uniformly.
Tree in winter appearance.
Submandibular gland:
The main duct is of even diameter 3-4mm .
Bush in winter appearance.
NORMAL SIALOGRAPHIC
APPEARANCES

36. These are used to investigate salivary gland function . Comparative flow rates of
saliva from major salivary glands are measured over a known time period .
Indications:
 Dry mouth
 Poor saliva flow
 Excess salivation
FLOW RATE STUDIES

37. Advantages :
Ionizing radiation is not used
Simple to perform
Provides information on salivary gland function
Disadvantages:
No indication of nature of underlying disease
Time consuming

38. It is a specialized procedure that uses a small video
camera (endoscope) with light at the end of a flexible
cannula; which is introduced into the ductal orifice .
The endoscope can be used diagnostically and
therapeutically.
It has demonstrated strictures in the ductal system ,
as well as mucous plugs and calcifications.
May also be used to dilate small strictures and flush
clear small mucous plugs .
Specialized devices such as balloon catheters may be
used to dilate sites of ductal constriction.
SIALOENDOSCOPY

39. An examination of the electrolyte composition of the
saliva of each gland may indicate a variety of disorders.
Principally the concentration of sodium and
potassium,which normally change with salivary flow rate
are measured .
Certain changes in the relative concentrations of these
electrolytes are seen in specific disorders.
SIALOCHEMISTRY

40. This procedure has a high accuracy rate for distinguishing between benign and
malignant lesions in the superficial locations.
Performed using a syringe with a 20guage or smaller needle.
FINE NEEDLE ASPIRATION
BIOPSY

41. Either incisional or excisional can be used to diagnose a
tumor of one of the major salivary gland.
But is usually performed as an aid in the diagnosis of
sjogrens syndrome .
The lower lip labial salivary gland biopsy has been shown
to demonstrate certain histopathological changes.
Around 10 minor salivary glands are removed for
histopathological examination.
SALIVARY GLAND BIOPSY

42. Indications:
Discrete swellings both extrinsic and intrinsic to the
salivary glands.
Advantages:
Provides accurate localization of masses especially in the
deep lobe of the parotid.
The nature of the lesion can often be determined.
Images can be enhanced by using contrast media,either
in the ductal system or more commonly intravenously .
COMPUTED TOMOGRAPHY

43. Disadvantages:
Provides no indication of salivary gland function.
Small calculi may not be detected.
Risks associated with intravenous contrast media.

44. Indications:
Dry mouth due to salivary
gland diseases such as
sjogrens syndrome.
To assess salivary gland
function.
Advantages:
Allows bilateral
comparison and images all
four major salivary glands at
the same time.
Computer analysis of
results is possible.
Can be performed in cases
of acute infection
RADIOISOTOPE IMAGING

45. Disadvantages:
Provides no indication of salivary gland anatomy or ductal architecture.
Relatively high radiation dose to the whole body.
Images are not diseases specific.

46. Indications:
Discrete swellings both extrinsic and
intrinsic to the salivary glands.
Advantages:
Ionizing radiation is not used.
Provides excellent soft tissue
detail,readily enables differentiation
between normal and abnormal.
Accurate location of masses
Images in all planes and facial nerve
is usually identifiable.
MAGNETIC RESONANCE
IMAGING

47. Scintigraphy is the only method available that can provide qualitative and
quantitative functional assessments of the major salivary glands
The isotopes used for salivary gland is Technetium-99m pertechnetate
Technetium-99m about 5 mCi is injected intravenously into antecubital vein. The
activity is at 1st
, 20th
, and 40th
min]. Twenty minutes after the injection, vitamin C
chewable tablet was given to stimulate the secretion and continued until the end
of the study period (40 min)
SCINTIGRAPHY

48. Sialosis: Non neoplastic and noninflammatory
enlargement of salivary glands
Sialadenitis: Inflammation of salivary glands
Sialodochitis: Inflammation of salivary duct
Xerostomia: Salivary production < 0.2ml min
Sialolithiasis: Calculi / stone in duct or gland
Sialactesis: Atrophy of total / part of salivary gland
Ptyalism : Excessive secretion of saliva > 4 ml / min
TERMINOLOGIES

49. Xerostomia is salivary production less than 0.2ml / min.
XEROSTOMIA
(PTYALISM / DRY MOUTH
SYNDROME)

50. Factors affecting salivary center:
 Emotional disturbance like stress,strain.
Depression.
Hysteria.
Neurosis.
Factors affecting ANS:
Encephalitis
Brain tumor
Neurological operation
Factors affecting salivary gland:
Developmental
Inflammatory
Atrophy of gland
Sjogren’s syndrome
Mickuliz’s disease

51. Alteration in fluid and electrolyte balance:
Dehydration
Diarrhea
Vomiting
Diuresis
Diabetes insipidus
Liver cirrhosis
Drugs:
Anticholinergics
Antideppresants
Antihistamines
Antipsychotics
Sympathommimetics
Sedatives
Steroids
Chemotherapeutic agents
Malnutrition
Radiation
Toxemia
Chronic alcoholism
Habits(smoking,betul nut chewing)

52. MANAGEMENT:
Use of water or gels
Lozenges / sour candies
Non fermentable carbohydrates
Saliva stimulating agents
Glycerol
Lemon juice
Oral hygiene
Chewing gums (Fluorides)
Hexidine mouth washes
Artificial saliva (lacks mucus)

53. Causes:
Acute inflammation oral mucosa.
During eruption of teeth in infants.
Mental retardation.
Parkinsonism.
Epilepsy .
Schizophrenia.
Acrodynia.
Rabies.
Psychosis .
Neurosis.
Drugs like sialogogues.
SIALORRHOEA (PTYALISM)

54. Mucous extravasation phenomenon
mucous escape reaction
Common lesion of oral cavity involving
salivary glands and ducts
Result from traumatic severance of
salivary duct by biting lips or cheek,
pinching the lips by extractions forceps
thus leading to spillage of mucin into
surrounding tissues
Lack epithelial lining, they are not true
cysts
MUCOCELE

55. Most common on lower lip and usually found laterally to
midline
Less common sites include buccal mucosa, anterior
ventral tongue and floor of the mouth
Increased predilection in children and young adults,
possibly because of higher incidence of trauma
Appear as raised dome shaped vesicle ranging in size
from 1to 2mm to several centimeters
May lie fairly deep in the tissue or be exceptionally
superficial and thus depending on the location will
present a variable clinical appearance

56. Extravasation is the leakage of fluid from the ducts or
acini into the surrounding tissue.
Extra: outside, vasa: vessel
Retention: narrowed ductal opening that cannot
adequately accommodate the exit of saliva produced,
leading to ductal dilation and surface swelling. Less
common phenomenon

57. Superficial lesions present a bluish transluscent cast the blue color imparted by
spilled mucin below the mucosal surface
Treatmennt is excision Excision with strict removal of any projecting peripheral
salivary glands
Avoid injury to other glands during primary wound closure

59. Form of mucocele that specifically occurs in floor of the mouth
Derived from the latin word rana meaningmeaning frog,because the swelling may
resemble a frogs transluscent belly
Most common source of mucin spillage is sublingual gland, may also arise from
submandibular duct or from minor salivary glands in floor of mouth
Mostly located laterally to midline
RANULA

60. Develops as a slowly enlarging painless mass in the floor of
mouth
A rare suprahyoid type termed plunging or cervical ranula
occurs due to herniation of spilled mucin through the
mylohyoid muscle producing swelling in the neck
Treatment is removal of sublingual gland or marsipulization
Entails removal of roof of the lesion potentially allowing the
sublingual gland ducts to reestablish communication with the
oral cavity.
Most authors emphasize removal of offending gland is the
most important consideration in preventing recurrence.
CLINICAL FEATURES

62. Sialocyst or mucous duct cyst
Epithelium lined cyst arising from salivary gland tissues
Commonly observed in adult age group
Can arise in both major and minor salivary glands.
Parotid gland is the most commonly involved presenting
as slowly growing asymptomatic swelling.
Conservative surgical excicion is the treatment of choice
for isolated cysts.
SALIVARY DUCT CYST

63. Also called sicca syndrome
Triad of keratoconjunctivitis sicca, xerostomia and
rheumatoid arthritis.
Primary sjogrens syndrome present only with dry eyes
and dry mouth.
Secondary sjogrens syndrome present with systemic
lupus erythematosus ,polyarteritis nodosa,rheumatoid
arthritis and scleroderma.
Etiology;
Combination of factors like
genetic,hormonal,infectious and immunologic have
been suggested.
SJOGREN SYNDROME

65. Predominantly in women over 40yrs of age.
Male to female ratio is 1:10.
90% cases occur in women
Dryness of mouth and eyes as a result of hypo function of
salivary and lacrymal glands,burning sensation of oral
mucosa
Classic monograph on the disease published in 1933 by
Sjögren, a Swedish ophthalmologist
CLINICAL FEATURES

66. Keratoconjuntivitis sicca: diminished tear production
caused by lymphocytic cell replacement of the
lacrimal gland parenchyma.
Evaluate with Schirmer test. Two 5 x 35mm strips of
red litmus paper placed in inferior fornix, left for 5
minutes. A positive finiding is lacrimation of 5mm or
less.
Approximately 85% specific & sensitive

67. Diagnosis:
Single 1.5 to 2cm horizantal incision labial mucosa.
Not in midline, fewer glands there.
Include 5+ glands for identification
Glands assessed semi-quantitatively to determine the number of foci of
lymphocytes per 4mm2
/gland

68. Sialolithiasis
Mucous retention/extravasation
OBSTRUCTIVE
SALIVARY GLAND
DISORDERS

69. Sialolithiasis results in a mechanical obstruction of the salivary duct
Is the major cause of unilateral diffuse parotid or submandibular gland swelling.
OBSTRUCTIVE SG DISORDERS:
SIALOLITHIASIS

70. The exact pathogenesis of sialolithiasis remains unknown.
Thought to form via….
an initial organic nidus that progressively
grows by deposition of layers of inorganic and
organic substances.
May eventually obstruct flow of saliva from the gland to the oral cavity.

71. Acute ductal obstruction may occur at meal time when saliva
producing is at its maximum, the resultant swelling sudden and can be
painful.
• Gradually reduction of the swelling can
result but it recurs repeatedly when flow is
stimulated.
• This process may continue until complete
obstruction and/or infection occurs.

72. Etiology :
Water hardness ↑likelihoodHypercalcemia
Xerostomic meds
Tobacco smoking, positive correlation
Smoking has an increased cytotoxic effect on saliva, decreases PMN phagocytic
ability and reduces salivary proteins

73. Organic; often predominate in the center
Glycoproteins
Mucopolysaccarides
Bacteria!
Cellular debris
Inorganic; often in the periphery
Calcium carbonates & calcium phosphates in the form of hydroxyapatite
STONE COMPOSITION

74. Saliva more alkaline
Higher concentration of calcium and phosphate in the saliva
Higher mucus content
Longer duct
Anti-gravity flow
REASONS SIALOLITHIASIS MAY
OCCUR MORE OFTEN IN THE
SMG

75. Painful swelling (60%)
Painless swelling (30%)
Pain only (12%)
Sometimes described as recurrent salivary
colic and spasmodic pains upon eating
CLINICAL PRESENTATION

76. History of swellings / change over time?
Trismus?
Pain?
Variation with meals?
Bilateral?
Dry mouth? Dry eyes?
Recent exposure to sick contacts (mumps)?
Radiation history?
Current medications?
CLINICAL HISTORY

77. Asymmetry (glands, face, neck)
Diffuse or focal enlargement
Erythema extra-orally
Trismus
Medial displacement of structures intraorally?
Examine external auditory canal (EAC)
Cranial nerve testing
INSPECTION

78. Palpate for cervical lymphadenopathy
Bimanual palpation of floor of mouth in a posterior to anterior direction
Have patient close mouth slightly & relax oral musculature to aid in detection
Examine for duct purulence
Bimanual palpation of the gland (firm or spongy/elastic).
PALPATION

79. Effective for intraductal stones,
while….
intraglandular, radiolucent or
small stones may be missed.
DIAGNOSTICS: PLAIN OCCLUSAL
FILM

80. CT Scan:
large stones or small CT slices done
also used for inflammatory disorders
Ultrasound:
operator dependent, can detect small stones (>2mm), inexpensive, non-invasive
DIAGNOSTIC APPROACHES

81. Consists of opacification of the ducts by a retrograde injection of a water-soluble
dye.
Provides image of stones and duct morphological structure
May be therapeutic, but success of therapeutic sialography never documented
DIAGNOSTIC APPROACHES:
SIALOGRAPHY

82. Disadvantages:
irradiation dose
pain with procedure
poss.perforation
infection dye reaction
push stone further
contraindicated in active infection.

83. Allows complete exploration of the ductal system, direct
visualization of duct pathology
Success rate of >95%2
Disadvantage: technically challenging, trauma could result in
stenosis, perforation
DIAGNOSTIC APPROACH:
DIAGNOSTIC SIALENDOSCOPY

84. If patients DO defer treatment, they need to know:
Stones will likely enlarge over time
Seek treatment early if infection develops
Salivary gland massage and hyper-hydration when symptoms develop.
SIALOLITHIASIS TREATMENT

85. Diagnosis
Digital manipulation:
Gland – firm and larger
Produces flow of saliva – visual inspection of fluid
Location of hard calcific stone along ductal course
Yellowish colour of calcific deposit seen through distended and thin
mucous membrane
 Sialography

86. SIALOLITH

87. Acute bacterial sialdenitis
Chronic bacterial sialdenitis
Viral infections
SALIVARY GLAND INFECTIONS

88. Sialadenitis represents inflammation mainly involving the acinoparenchyma of
the gland.
SIALADENITIS

89. Acute infection more often affects the
major glands than the minor glands1
SIALADENITIS

90. 1. Retrograde contamination of the salivary ducts and parenchymal tissues by
bacteria inhabiting the oral cavity.
2. Stasis of salivary flow through the ducts and parenchyma promotes acute
suppurative infection.
PATHOGENESIS

91. More common in parotid gland.
Suppurative parotitis, surgical parotitis, post-operative parotitis, surgical mumps,
and pyogenic parotitis.
The etiologic factor most associated with this entity is the retrograde infection
from the mouth.
20% cases are bilateral7
ACUTE SUPPURATIVE

92. The composition of parotid secretions differs from
those in other major glands.
Parotid is primarily serous, the others have a
greater proportion of mucinous material.
PREDILECTION FOR PAROTID
SALIVARY COMPOSITION

93. Mucoid saliva contains elements that protect against
bacterial infection including lysozymes & IgA antibodies
(therefore, parotid has ↓ bacteriostatic activity)
Mucins contain sialic acid which agglutinates bacteria and
prevents its adherence to host tissue.
Specific glycoproteins in mucins bind epithelial cells
competitively inhibiting bacterial attachment to these cells.
SALIVARY COMPOSITION

94. Minor role in formation of infections
Stensen’s duct lies adjacent to the maxillary mandibular molars and Wharton’s
near the tongue.
It is thought that the mobility of the tongue may prevent salivary stasis in the area of
Wharton's that may reduce the rate of infections in SMG.
PAROTID PREDILECTION
ANATOMIC FACTORS

95. Systemic dehydration (salivary stasis)
Chronic disease and/or immunocompromise
Liver failure
Renal failure
DM, hypothyroid
Malnutrition
HIV
Sjögren’s syndrome
RISK FACTORS FOR SIALADENITIS

96. Neoplasms (pressure occlusion of duct)
Sialectasis (salivary duct dilation) increases the risk for retrograde contamination.
Is associated with cystic fibrosis and pneumoparotitis
Extremes of age
Poor oral hygiene
Calculi, duct stricture
RISK FACTORS CONTINUED…

97. Mumps classically designates a viral parotitis caused by the paramyxovirus
However, a broad range of viral pathogens have been identified as causes of AVI
of the salivary glands.
Derived from the Danish word “mompen”
Means mumbling, the name given to describe the characteristic muffled speech
that patients demonstrate because of glandular inflammation and trismus.
As opposed to bacterial sialadenitis, viral infections of the salivary glands are
SYSTEMIC from the onset!
MUMPS

99. Mumps is a non-suppurative acute sialadenitis
Is endemic Communicable disease
Enters through upper respiratory tract
2-3 week incubation after exposure (the virus multiplies in the
URI or parotid gland)
3-5day viremia
Then localizes to biologically active tissues like salivary glands,
germinal tissues and the CNS.

100. Classic mumps syndrome is caused by paramyxovirus, an
RNA virus
Others can cause acute viral parotitis:
Coxsackie A & B, ECHO virus, cytomegalovirus and adenovirus
Clinical presentation
VIROLOGY
30% experience prodromal symptoms prior to development of parotitis
Headache, misaligns, anorexia, malaise
Onset of salivary gland involvement is heralded by ear ache, gland pain,
dysphagia and trismus

101. Glandular swelling (tense, firm) Parotid gland involved frequently, SMG & SLG
can also be affected.
May displace ispilateral pinna
75% cases involve bilateral parotids, may not begin bilaterally (within 1-5 days
may become bilateral)….25% unilateral
Low grade fever
PHYSICAL EXAM

102. Leukocytopenia, with relative lymphocytosis
Increased serum amylase (normal by 2- 3 week of disease)
Viral serology essential to confirm:
Complement fixing antibodies appear following exposure to the virus.
DIAGNOSTIC EVALUATION

103. Orchitis, testicular atrophy and sterility in approximately 20% of young men
Oophoritis in 5% females
Aseptic meningitis in 10%
Pancreatitis in 5%
Sensorineural hearing loss <5%
Usually permanent
80% cases are unilateral .
COMPLICATIONS

104. ADENOMAS
Pleomorphic Adenoma
Myoepithelioma
Basal cell Adenoma
Warthins Tumor
(Adenolymphoma)
Oncocytoma
Sebaceous adenoma
Ductal Papilloma
Carcinoma s
Acinic cell carcinoma
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Basal cell carcinoma
Sebaceous carcinoma
Salivary duct carcinoma
Myoepithelial carcinoma
Squamous cell carcinoma
WHO
CLASSIFICATION
OF SALIVARY
GLAND TUMORS
(1992)

105. Non Epithelial Tumours
Malignant Lymphomas
Secondary Tumours
Unclassified Tumours
Tumours like lesions
Sialadenosis
Oncocytosis
Necrotizing Sialometaplasia
Benign Lymphoepithelial Lesions
Salivary gland cysts

106. Diverse histopathology
Relatively uncommon
2% of head and neck neoplasm's
Distribution
Parotid: 80% overall; 80% benign
Submandibular: 15% overall; 50% benign
Sublingual/Minor: 5% overall; 40% benign
SALIVARY GLAND NEOPLASMS

107. Most common of all salivary gland neoplasms
70% of parotid tumors
50% of submandibular tumors
45% of minor salivary gland tumors
6% of sublingual tumors
4th
-6th
decades
F:M = 3-4:1
PLEOMORPHIC ADENOMA

108. Slow-growing, painless mass
Parotid: 90% in superficial
lobe, most in tail of gland
Minor salivary gland: lateral
palate, sub mucosal mass
Gross pathology
Smooth
Well-demarcated
Solid
Cystic changes
Myxoid stroma

109. Histology
Mixture of epithelial, myopeithelial
and stromal components
Epithelial cells: nests, sheets, ducts,
trabeculae
Stroma: myxoid, chrondroid, fibroid,
osteoid
No true capsule
Tumor pseudopods

110. Papillary cystadenoma lymomatosum
6-10% of parotid neoplasms
Older, Caucasian, males
10% bilateral or multicentric
3% with associated neoplasms
Presentation: slow-growing, painless mass
WARTHIN’S TUMOR

111. Gross pathology
Encapsulated
Smooth/lobulated surface
Cystic spaces of variable size,
with viscous fluid, shaggy
epithelium
Solid areas with white nodules
representing lymphoid follicles

112. Most common salivary gland malignancy
5-9% of salivary neoplasms
Parotid 45-70% of cases
Palate 18%
3rd
-8th
decades, peak in 5th
decade
F>M
Caucasian > African American
MUCOEPIDERMOID CARCINOMA

113. Presentation
Low-grade: slow growing, painless mass
High-grade: rapidly enlarging, +/- pain
**Minor salivary glands: may be mistaken for benign or inflammatory process
Hemangioma
Papilloma
Tori

114. Gross pathology
Well-circumscribed to partially
encapsulated to unencapsulated
Solid tumor with cystic spaces

115. Overall 2nd
most common malignancy
Most common in submandibular, sublingual and minor salivary glands
M = F
5th
decade
Presentation
Asymptomatic enlarging mass
Pain, paresthesias, facial weakness/paralysis
ADENOID CYSTIC CARCINOMA

116. Gross pathology
Well-circumscribed
Solid, rarely with cystic spaces
infiltrative

117. 2nd
most common parotid and pediatric malignancy
5th
decade
F>M
Bilateral parotid disease in 3%
Presentation
Solitary, slow-growing, often painless mass
ACINIC CELL CARCINOMA

118. Gross pathology
Well-demarcated
Most often homogeneous

119. Rare
5th
to 8th
decades
F > M
Parotid and minor
salivary glands
Presentation:
Enlarging mass
25% with pain or facial weakness
ADENOCARCINOMA

120. Carcinoma ex-pleomorphic adenoma
Carcinoma developing in the epithelial component of preexisting pleomorphic adenoma
Carcinosarcoma
True malignant mixed tumor—carcinomatous and sarcomatous components
Metastatic mixed tumor
Metastatic deposits of otherwise typical pleomorphic adenoma
MALIGNANT MIXED TUMORS

121. 2-4% of all salivary gland neoplasms
4-6% of mixed tumors
6th
-8th
decades
Parotid > submandibular > palate
Risk of malignant degeneration
1.5% in first 5 years
9.5% after 15 years
Presentation
Longstanding painless mass that undergoes sudden enlargement
CARCINOMA EX-PLEOMORPHIC
ADENOMA

122. Gross pathology
Poorly circumscribed
Infiltrative
Hemorrhage and necrosis

123. Rare: <.05% of salivary gland neoplasms
6th
decade
M = F
Parotid
History of previously excised pleomorphic adenoma, recurrent pleomorphic
adenoma or recurring pleomorphic treated with XRT
Presentation
CARCINOSARCOMA

124. Gross pathology
Poorly circumscribed
Infiltrative
Cystic areas
Hemorrhage, necrosis
Calcification

125. 1.6% of salivary gland neoplasms
7th
-8th
decades
M:F = 2:1
MUST RULE OUT:
High-grade mucoepidermoid carcinoma
Metastatic SCCA to intraglandular nodes
Direct extension of SCCA
SQUAMOUS CELL CARCINOMA

126. Gross pathology
Unencapsulated
Ulcerated
fixed

127. Frey syndrome (gustatory sweating) is now considered an universal
sequel following parotidectomy surgery
It results from of the innervation of the salivary gland during
dissection in which there is inappropriate regeneration of
parasympathetic autonomic nerve fibres which thus stimulate the
sweat glands of the overlying skin.
The clinical features of Frey syndrome include sweating and
erythema over the region of the parotid glands surgical bed as a
consequence of autonomic stimulation of salivation by the smell or
taste of food.
The symptoms are entirely variable and are clinically demonstrated
by a starch iodine test.
FREY’S SYNDROME

128. Starch iodine test:
Involves painting the affected area with iodine which is allowed to dry before
applying dry starch, which turns blue on exposure to iodine in the presence of
sweat. Sweating is stimulated by salivary stimulation .
FREY’S SYNDROME

129. Management:
Antiperspirants,usually astringents such as alumium
chloride.
Denervation by tympanic neurectomy
The injection of Botulinum toxin into the affected skin
The last remains the most modern, effective method,
which can be performed on an out-patient basis.
FREY’S SYNDROME

130. Human anatomy vol.3 –B.D.Chaurasia 4th
edn.
Textbook of oral pathology –Shaffer
Textbook of oral medicine –Burkett
Principles of surgery –Peterson
Oral and maxillofacial surgery clinics of North America
REFERENCES