SALIVARY GLAND DISEASES omr Introduction Classification of salivary

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SALIVARY GLAND DISEASES omr

SALIVARY GLAND DISEASES omr

Introduction

Introduction

Classification of salivary glands: Ø Ø Ø According to size. u Major : -

Classification of salivary glands: Ø Ø Ø According to size. u Major : - Parotid / Submandibular /Sublingual u Minor : - Lingual / buccal / labial / palatine / glossopalatine According to nature of secretion. u Serous : - Parotid u Mucous : - Sublingual / minor u Mixed : - Submandibular / minor According to location of the opening of duct. u Into vestibule : - Parotid / minor u Into oral cavity proper : - Submandibular / Sublingual / minor

Embryology u 6 th-8 th Weeks of Gestation u Parotid u. First to develop

Embryology u 6 th-8 th Weeks of Gestation u Parotid u. First to develop u. Last to become encapsulated u Autonomic Nervous System Crucial

Embryology

Embryology

Anatomy: Parotid Gland u Wedge shaped with 5 processes u 3 Superficial u 2

Anatomy: Parotid Gland u Wedge shaped with 5 processes u 3 Superficial u 2 Deep u Parotid Compartment u Superior – Zygoma u Posterior – EAC u Inferior – Styloid, ICA, Jugular Veins

Anatomy: Parotid Gland u 80% overlies Masseter & Mandible u 20% Retromandibular u Stylomandibular

Anatomy: Parotid Gland u 80% overlies Masseter & Mandible u 20% Retromandibular u Stylomandibular Tunnel, Isthmus of Parotid u Tail of Parotid

Anatomy: Parotid Gland u. Parapharyngeal u. Prestyloid Space Compartment u. Poststyloid Compartment (Paragangliomas)

Anatomy: Parotid Gland u. Parapharyngeal u. Prestyloid Space Compartment u. Poststyloid Compartment (Paragangliomas)

Anatomy: Parotid Gland u Stensen’s u. Arises u 1. 5 from anterior border cm

Anatomy: Parotid Gland u Stensen’s u. Arises u 1. 5 from anterior border cm inferior to Zygomatic arch u. Pierces u 4 -6 u 5 Duct Buccinator at 2 nd Molar cm in length mm in diameter

Anatomy: Parotid Gland u Parotid Capsule u. Superficial layer Deep Cervical Fascia u. Superficial

Anatomy: Parotid Gland u Parotid Capsule u. Superficial layer Deep Cervical Fascia u. Superficial u. Deep layer

Anatomy: Parotid Gland u CN VII u 2 Surgical zones u 3 Motor branches

Anatomy: Parotid Gland u CN VII u 2 Surgical zones u 3 Motor branches immediately u Pes Anserinus – 1. 3 cm u Temperofacial u Cervicofacial u 5 Division Terminal branches

Anatomy: Parotid Gland

Anatomy: Parotid Gland

Anatomy: Parotid Gland u Localization of CN VII u Tragal pointer u Tympanomastoid suture

Anatomy: Parotid Gland u Localization of CN VII u Tragal pointer u Tympanomastoid suture u Posterior belly Digastric u Styloid process u Retrograde dissection u Mastoidectomy

Anatomy: Parotid Gland u Great Auricular nerve u Auriculotemporal nerve u Superficial Temporal vessels

Anatomy: Parotid Gland u Great Auricular nerve u Auriculotemporal nerve u Superficial Temporal vessels u Frey’s Syndrome

Anatomy: Parotid Gland u Neural u VII, compartment Great Auricular, Auriculotemporal u Venous compartment

Anatomy: Parotid Gland u Neural u VII, compartment Great Auricular, Auriculotemporal u Venous compartment u Retromandibular u Arterial vein compartment u Superficial Temporal/Transverse Facial

Anatomy: Parotid Gland u Lymphatics u Paraparotid u Superficial & Intraparotid nodes & Deep

Anatomy: Parotid Gland u Lymphatics u Paraparotid u Superficial & Intraparotid nodes & Deep Cervical nodes

Anatomy: Submandibular Gland u The ‘Submaxilla’ u Submandibular Triangle u Mylohyoid ‘C’ u Marginal

Anatomy: Submandibular Gland u The ‘Submaxilla’ u Submandibular Triangle u Mylohyoid ‘C’ u Marginal Mandibular branch u Capsule from superficial layer of Deep Cervical fascia

Anatomy: Submandibular Gland u Wharton’s duct u Exits medial surface u Between Mylohyoid &

Anatomy: Submandibular Gland u Wharton’s duct u Exits medial surface u Between Mylohyoid & Hyoglossus u 5 cm in length u Lingual nerve & CN XII

Anatomy: Submandibular Gland

Anatomy: Submandibular Gland

Anatomy: Submandibular Gland u Innervation u Superior Cervical Ganglion (symp) u Submandibular Ganglion (para)

Anatomy: Submandibular Gland u Innervation u Superior Cervical Ganglion (symp) u Submandibular Ganglion (para) u Artery: Submental branch of Facial a. u Vein: Anterior Facial vn. u Lymphatics: Deep Cervical and Jugular chains u Facial artery nodes

Anatomy: Sublingual Gland u Between Mandible & Genioglossus u No capsule u Ducts of

Anatomy: Sublingual Gland u Between Mandible & Genioglossus u No capsule u Ducts of Rivinus +/- Bartholin’s duct u Sialogram not possible u Innervation: Same as Submandibular u Artery/Vein: Sublingual branch of Lingual & Submental branch of Facial u Lymphatics: Submandibular nodes

Anatomy: Sublingual Gland

Anatomy: Sublingual Gland

Anatomy: Minor Salivary Glands u 600 -1, 000 u Simple ducts u Buccal, Labial,

Anatomy: Minor Salivary Glands u 600 -1, 000 u Simple ducts u Buccal, Labial, Palatal, Lingual u Tumor sites: Palate, upper lip, cheek u Lingual & Palatine nn.

INVESTIGATIONS: 1. IMAGING u Radiography u Sialography u CT scan u MRI u Ultrasound

INVESTIGATIONS: 1. IMAGING u Radiography u Sialography u CT scan u MRI u Ultrasound Contd. .

2. PATHOLOGY u Aspiration cytology & biopsy for definitive diagnosis u Frozen section u

2. PATHOLOGY u Aspiration cytology & biopsy for definitive diagnosis u Frozen section u Histochemistry u Immunohistochemistry u Electron microscophy Contd. .

3. FUNCTIONAL TESTS u Flow rates & sialochemistry 4. TESTS FOR RELATED / CONTRIBUTORY

3. FUNCTIONAL TESTS u Flow rates & sialochemistry 4. TESTS FOR RELATED / CONTRIBUTORY SYSTEMIC DISEASE u Bacteriology u Haematology u Autoantibody studies Contd. .

Imaging u CT – Inflammatory u MR – Tumor u Children: U/S & MR

Imaging u CT – Inflammatory u MR – Tumor u Children: U/S & MR u NO sialogram during active infection u Parotid is fatty

Microanatomy u The Secretory Unit u Acinus (serous, mucous, mixed) u Myoepithelial cells u

Microanatomy u The Secretory Unit u Acinus (serous, mucous, mixed) u Myoepithelial cells u Intercalated duct u Striated duct u Excretory duct

Microanatomy u Striated & Intercalated ducts well developed in serous, NOT mucous glands u

Microanatomy u Striated & Intercalated ducts well developed in serous, NOT mucous glands u Striated duct: HCO 3 into, Cl from lumen u Intercalated duct: K into lumen, Na from lumen, producing hypotonic fluid u Excretory ducts do NOT modify saliva

Microanatomy

Microanatomy

Microanatomy u The Bicellular Theory u Intercalated duct u Excretory duct u The Multicellular

Microanatomy u The Bicellular Theory u Intercalated duct u Excretory duct u The Multicellular Theory

Microanatomy u Parotid: serous & fatty u Submandibular: mixed serous u Sublingual: mixed mucous

Microanatomy u Parotid: serous & fatty u Submandibular: mixed serous u Sublingual: mixed mucous u Stroma: Plasma cells

Microanatomy

Microanatomy

Microanatomy

Microanatomy

Saliva u 600 to 700 ml (upto 1. 5 L) per 24 hours. u

Saliva u 600 to 700 ml (upto 1. 5 L) per 24 hours. u PH is 6. 7 (6. 2 – 7. 6) u Contribution of various glands: u. Parotid: - 60 – 65% u. Submandibular: - 20 – 30% u. Sublingual: - 2 – 5% u. Minor glands: - 6 – 7%

Composition of saliva: u Water : - 94. 0 – 99. 5% u Solids

Composition of saliva: u Water : - 94. 0 – 99. 5% u Solids : - 6. 0% (unstimulated), 0. 5% (stimulated) u organic constituents: -urea, uric acid, glucose, aminoacid, lactate, fatty acids, proteins like amylase, peroxidase, lysosyme, Ig. A, Ig. M, Ig. G. u inorganic constituents: - Ca, Mg, F, HCO 3, K, Na, Cl, NH 4. u gases: - CO 2, N 2, O 2. u constituents from oral cavity: desquamative epithelial cells, bacteria.

Function of Saliva u. Inhibition of dental caries u. Water balance u. Lubrication u.

Function of Saliva u. Inhibition of dental caries u. Water balance u. Lubrication u. Taste action of food u. Buffering u. Hygienic action u Digestion (Amylase, Lipase) u Antibacterial (Lysozyme, Ig. A, Peroxidase, FLOW) u Mineralization u Protective Pellicle

Factors influencing salivary secretion: u. Taste and smell u. Mechanical stimulation of oral mucosa

Factors influencing salivary secretion: u. Taste and smell u. Mechanical stimulation of oral mucosa and gingiva u. Mastication of food u. Chemical irritation of oral mucosa & stomach u. Distension / irritation of oesophagus u. Pregnancy

Causes of salivary gland dysfunction: u. Drugs (anticholinergic, antihistamine, antihypertensive) u. Radiation theraphy u.

Causes of salivary gland dysfunction: u. Drugs (anticholinergic, antihistamine, antihypertensive) u. Radiation theraphy u. Oncologic chemotheraphy u. Psychological u. Systemic factors diseases u. Malnutrition and neoplasms

Clinical features: u Commonly present as an asymptomatic mass u Pain – infection/ hemorrhage/

Clinical features: u Commonly present as an asymptomatic mass u Pain – infection/ hemorrhage/ infected cyst u Malignant lesions are also symtomless unless involves the nerves u Nasal obstruction – tumor involves paranasal sinuses / nose u Xerostomia

Salivary hypofunction u. Candidiasis u. Lichen Planus u. Burning Mouth u. Aphthous u. Dental

Salivary hypofunction u. Candidiasis u. Lichen Planus u. Burning Mouth u. Aphthous u. Dental ulcers caries u. Xerostomia reliable not

XEROSTOMIA u Causes; u. Depression / chronic anxiety u. Dehydration u. Drugs u. Diseases

XEROSTOMIA u Causes; u. Depression / chronic anxiety u. Dehydration u. Drugs u. Diseases

XEROSTOMIA u Clinical features; u. Dry mouth u. Salivary u. Rapid froath adhering to

XEROSTOMIA u Clinical features; u. Dry mouth u. Salivary u. Rapid froath adhering to mucosa dental decay u. Adherence u. Soreness of food debris to teeth / halitosis

XEROSTOMIA u MANAGEMENT u. Preventive theraphy u. Symptomatic treatment u. Local or topical salivary

XEROSTOMIA u MANAGEMENT u. Preventive theraphy u. Symptomatic treatment u. Local or topical salivary stimulation u. Systemic salivary stimulation

Effects of Aging u Total salivary flow independent of age u Acinar cells degenerate

Effects of Aging u Total salivary flow independent of age u Acinar cells degenerate with age u Submandibular gland more sensitive to metabolic/physiologic change u Unstimulated salivary flow more greatly affected by physiologic changes

CLASSIFICATION OF DISEASES u DEVELOPMENTAL u APLASIA / HYPOPLASIA u ACCESSORY SALIVARY DUCTS u

CLASSIFICATION OF DISEASES u DEVELOPMENTAL u APLASIA / HYPOPLASIA u ACCESSORY SALIVARY DUCTS u DIVERTICULI u DARIER’S DISEASE u ACQUIRED u REACTIVE LESIONS u INFECTIONS u METABOLIC CONDITIONS u ASSOCIATED IMMUNE DEFECTS u NEOPLASMS

NEOPLASMS BENIGN u. Pleomorphic adenoma u. Monomorphic adenoma u. Ductal papilloma MALIGNANT u Mucoepidermoid

NEOPLASMS BENIGN u. Pleomorphic adenoma u. Monomorphic adenoma u. Ductal papilloma MALIGNANT u Mucoepidermoid carcinoma u Adenoid cystic carcinoma u Acinic cell carcinoma u Salivary duct carcinoma u Squamus cell carcinoma u Basal cell adenocarcinoma u Adenocarcinoma