SALIVARY GLAND DISEASES Yrd Do Dr Rasim Ylmazer

SALIVARY GLAND DISEASES Yrd. Doç. Dr. Rasim Yılmazer

Learning goal and objectives of the lesson Learning goal of the lesson: The learner should know the main clinical features and investigation of salivary gland disorders Learning objectives of the lesson the learner will be able to: n identify the most common etiologies of salivary masses based on history and physical exam n develop a clear concinse algorithm for use of diagnostic tests evaluation of salivary masses n describe available therapeutic options for malignant salivary gland masses n Understand how to approach the patient with “ a lump in the parotis or submandibular gland. Skill objectives of the lesson the learner will be able to take a directed history and perform a physical exam on a patient with salivary gland masses.

Introduction n n Salivary gland is any cell or organ discharging a secretion into oral cavity Major (paired) n n Parotid (Stensen’s duct) Submandibular (wharton’s duct Sublingual Minor n Those in tongue, palatine tonsil, palate, lips and cheeks

Nonneoplastic Diseases of the Salivary Glands

n Mumps Most common viral disorder of salivary glands n Peak age 4 -6 n Prodrome period is 2 -3 weeks n 1 or both parotid glandes can be involved n Contagious from approximately 6 days before the onset of symptoms until about 9 days after symptoms start n Diagnosis: diagnosed on clinical grounds n Serum amylase is often elevated n

Mumps

n n Complications: deafness, pancreatitis, meningitis, encephalitis, orchitis or epididymitis, Oophoritis (inflammation of ovaries) Deafness generally unilateral rarely bilateral Profound (91 d. B or more) sensorineural hearing loss Acute unilateral deafness occurs in about 0. 005% of cases

n n n No specific treatment Paracetamol for pain relief Warm saltwater gargles, soft foods, and extra fluids may also help relieve symptoms Self-limiting, and general outcome is good Most common preventative measure against mumps is a vaccination with a mumps vaccine

n Other Viruses CMV, Coxsackievirus A, Echovirus, Influenza A, Lymphocytic choriomeningitis Virus n Treatment: symptomatic for all viral diseases n

n Acute bacterial parotitis most often caused by a bacterial infection of Staphylococcus aureus but may be caused by any commensal bacteria n Peak age 50’s-60’s n 30 -40% in post-op patients; most commonly gastrointestinal procedures n

Presentation: sudden, diffuse enlargement with associated induration and tenderness. Massage produces purulent saliva n 20% of cases bilateral n Treatment: hydration, improved oral hygiene, repeated massage of gland, IV antibiotics, warm compresses, sialogogues n If no significant improvement in 24 -48 h, then proceed to incision & drainage OR imageguided needle aspiration n

n Chronic Nonspecific Sialadenitis Most commonly parotid n Usually from permanent damage during acute infection; occasionally from recurrent parotitis of childhood n

n Recurrent Parotitis of Childhood n n n More common in males; peak age 5 -7 ¾ give role of Mumps; heredity plays no role Presentation: Usually unilateral; when bilateral, one side worse Severe pain, fever, malaise during attacks Recurs 55% of cases resolve with puberty 25% no improvement with puberty

n Sarcoidosis Parotid enlargement is a classic feature of sarcoidosis, but clinically apparent parotid involvement occurs in less than 10% of patients. n Bilateral involvement is the rule. n The gland is usually not tender, but firm and smooth. n Xerostomia can occur n Other exocrine glands are affected only rarely n

n Sjogren’s Syndrome: Sjögren syndrome also known as "Sicca syndrome" n Systemic autoimmune disease in which immune cells attack and destroy the exocrine glands that produce tears and saliva n Chronic, slowly progressive, benign; 2 nd most common autoimmune disease behind Rheumatoid arthritis n

n Although Sjögren's occurs in all age groups in both women and men n Nine out of ten Sjögren's patients are women n Average of onset is after menopause in women

Presentation Other exocrine gland involvement: dry nose, dry throat, xerotrachea, esophageal mucosal atrophy, atrophic gastritis, subclinical pancreatitis, vaginal dryness n 1/3 = fatigue, low grade fever, myalgias/arthralgias n Extraglandular involvement in ¼: Lungs, kidneys, vasculitis, nervous system n

Associated risks n Increased risk of 1) Non. Hodgkin’s Lymphoma 2) Multiple Myeloma

n Sialolithiasis n Formation of stones in the salivary glands n 80% submandibular gland, 20% parotid n Only 1 stone in ¾ cases n Presentation: recurrent swelling, pain worse with eating n Complications: sialadenitis, ductal ectasia, and stricture

Diagnosis is usually made by characteristic history and physical examination n Diagnosis can be confirmed by x-ray (80% of salivary gland calculi are visible on x-ray), or by sialogram or ultrasound. n 90% of submandibular stones radioopaque; 90% of parotid stones radiolucent n Treatment: Endoscopic excision, If near duct orifice transoral removal of stone with marsupialization, gland excision n

n Cysts Mucous cysts: minor salivary glands n Mucocel 2 -5% of all parotid lesions n Congenital: dermoid cysts, ductal cysts, 1 st arch branchial cleft cysts n Acquired: trauma, parotitis, calculi, neoplasms n

Neoplastic Diseases of the Salivary Glands

Salivary Gland Neoplasms n Benign Neoplasms n n n Pleomorphic Adenoma Warthin’s Tumor Oncocytoma Monomorphic Adenomas Myoepithelioma n Malignant Neoplasms n n n n Mucoepidermoid Carcinoma Adenoid Cystic Carcinoma Acinic Cell Carcinoma Adenocarcinoma Malignant Mixed Tumor Squamous Cell Carcinoma Clear Cell Carcinoma Epithelial-Myoepithelial Carcinoma

Salivary Gland Neoplasms n n Diverse histopathology Relatively uncommon n n 2% of head and neck neoplasms Distribution Parotid: 80% overall; 80% benign n Submandibular: 15% overall; 50% benign n Sublingual/Minor: 5% overall; 40% benign n

Pleomorphic Adenoma n Most common of all salivary gland neoplasms 70% of parotid tumors n 50% of submandibular tumors n 45% of minor salivary gland tumors n 6% of sublingual tumors n n n 4 th-6 th decades F: M = 3 -4: 1

Pleomorphic Adenoma n n n Slow-growing, painless mass Parotid: 90% in superficial lobe, most in tail of gland Minor salivary gland: lateral palate, submucosal mass

Pleomorphic Adenoma n Treatment: complete surgical excision Parotidectomy with facial nerve preservation n Submandibular gland excision n Wide local excision of minor salivary gland n n Avoid enucleation and tumor spill

Pleomorphic Adenoma n Gross pathology n n n Smooth Well-demarcated Solid Cystic changes Myxoid stroma

Warthin’s Tumor n n n Papillary cystadenoma lymphomatosum 6 -10% of parotid neoplasms Older, caucasian, males 10% bilateral or multicentric 3% with associated neoplasms Presentation: slow-growing, painless mass

Oncocytoma n n n Rare: 2. 3% of benign salivary tumors 6 th decade M: F = 1: 1 Parotid: 78% Submandibular gland: 9% Minor salivary glands: palate, buccal mucosa, tongue

Monomorphic Adenomas n n n Basal cell, canalicular, sebaceous, glycogenrich, clear cell Basal cell is most common: 1. 8% of benign epithelial salivary gland neoplasms 6 th decade M: F = approximately 1: 1 Caucasian > African American Most common in parotid

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

Mucoepidermoid Carcinoma n Presentation n Low-grade: slow growing, painless mass n High-grade: rapidly enlarging, +/- pain

Mucoepidermoid Carcinoma n Gross pathology n n Well-circumscribed to partially encapsulated to unencapsulated Solid tumor with cystic spaces

Adenoid Cystic Carcinoma n n n Overall 2 nd most common malignancy Most common in submandibular, sublingual and minor salivary glands M=F 5 th decade Presentation n Asymptomatic enlarging mass n Pain, paresthesias, facial weakness/paralysis

Acinic Cell Carcinoma n n n 2 nd most common parotid and pediatric malignancy 5 th decade F>M Bilateral parotid disease in 3% Presentation n Solitary, slow-growing, often painless mass

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

Malignant Mixed Tumors n n n Carcinoma ex-pleomorphic adenoma n Carcinoma developing in the epithelial component of preexisting pleomorphic adenoma Carcinosarcoma n True malignant mixed tumor—carcinomatous and sarcomatous components Metastatic mixed tumor n Metastatic deposits of otherwise typical pleomorphic adenoma

Squamous Cell Carcinoma n Gross pathology n n n Unencapsulated Ulcerated fixed