Transcript 09. Acute and chronic sialodenitis

Salivary glands pathology.
Acute and chronic sialodenitis:
etiology, classification, clinic,
diagnosis, prevention. Treatment,
prevention of complications. Salivastone disease: etiology, pathogenesis,
clinical features, differential diagnosis,
treatment, complications and their
prevention.
Mucocele VS Mucus Retention Cyst
VS Salivary Duct Cyst
Mucocele: Prognosis and
Significance
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The prognosis is excellent, although occasional
mucoceles will recur, necessitating re-excision,
especially if the feeding glands are not removed.
Ranula: Clinical Features
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A ranula is the term used for mucoceles that occur in
the floor of the mouth.
The term ranula is derived from the Latin word for
frog.
They appear as dome-shaped, fluctuant swellings unless
they are deep in the tissue.
Typically, they are lateral to the midline.
“Plunging” or cervical ranulas dissect through the
myohyoid muscle to produce swelling in the neck.
Sialolithiasis: Clinical Features
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Salivary gland stones occur most often in the
submandibular gland ducts but they may also
occur in the minor glands particularly of the
upper lip and buccal mucosa.
Young and middle-aged adults are most
frequently affected.
Patients frequently present with episodic pain
and swelling particularly around mealtime.
Sialolithiasis: Clinical Features
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Stones in the terminal ducts can usually be
palpated.
If the sialolith is well calcified, it may appear on
radiograph as a radipaque mass.
Minor gland stones are often asymptomatic.
Sialolithiasis: Cause, Treatment and
Significance
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Deposition of calcium salts around a nidus of debris in
the duct lumen occurs but the exact cause of this is
unknown.
The blockage of the duct and resultant inflammation
can cause significant damage to the gland.
Small sialoliths can sometimes be removed by gentle
message, sialagogues, moist heat, or increased fluid
intake. Larger stones are removed surgically.
Stones in minor glands/ducts are best treated by
surgical removal including the associated gland.
Sialadenitis
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Inflammation of the salivary glands can arise
from various infectious and non-infectious
causes.
The most common viral infection is mumps.
Most bacterial infections arise as a result of
ductal obstruction or decreased salivary flow.
One of the more common causes of sialadenitis
is recent surgery.
Sialadenitis: Clinical Features
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Acute bacterial sialadenitis is most common in the
parotid where it produces a painful swelling. The
overlying skin may be erythematous and the patient
may have low-grade fever, trismus and purulent
discharge.
Chronic sialadenitis is associated with periodic swelling
and pain.
Subacute necrotizing sialadenitis is more common in
young (males?) adults. The lesion usually involves the
minor glands of the hard or soft palate. It appears as a
painful nodule, which does not ulcerate or slough like
necrotizing sialometaplasia.
Sialadenitis: Cause
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The inflammation of the glands can arise for various
causes as noted previously. While mumps is the most
common viral cause, other viruses such as Coxsackie A,
ECHO, choriomeningitis, parainfluenza and
cytomegalovirus may be the cause.
The most common cause of acute bacterial sialadenitis
is Staphylococcus aureus but streptococci and a host of
other bacteria have been implicated at different times.
Medications that can induce xerostomia can predispose
the patient to infection.
Non-infectious causes include Sjögren syndrome,
radiation therapy, sarcoidosis and some allergens.
Sialadenitis: Treatment, Prognosis
and Significance
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Acute sialadenitis is treated by antibiotic therapy and
rehydration to stimulate salivary flow.
Surgical drainage may be required if abscesses occur.
Management of chronic sialadenitis depends upon the
severity and duration of the condition.
Subacute necrotizing sialadenitis is self-limiting and
usually resolves in 2 weeks.
Significant inflammatory destruction of the salivary
gland can occur requiring its surgical removal.
Xerostomia: Clinical Features
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Xerostomia, dry mouth, is more common in
females and the elderly.
With decreased salivary flow, the saliva becomes
foamy or thick and “ropey”. There is a lack of
polling of saliva in the floor or the mouth and
the mucosa appears dry.
The dorsal tongue is often fissured with atrophy
of the filiform papilla.
Sjögren Syndrome: Clinical Features
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Sjögren syndrome is a chronic, systemic
autoimmune disorder that principally involves
the salivary and lacrimal glands.
It predominantly affects middle-aged and older
adults with 80-90 % of them being women.
The principal oral symptom is xerostomia.
A third to a half of all patients have diffuse, firm
enlargement of the major salivary glands, usually
bilaterally.
Sialadenosis (Sialosis): Clinical
Features
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Sialadenosis is a non-inflammatory disorder
characterized by salivary gland enlargement,
most common of the parotid.
Most cases present as a slowly developing,
painless swelling of the parotids.
Most cases present with bilateral involvement.
Decreased salivary secretion may occur.
Sialography demonstrates a “leafless tree”
pattern.
Salivary Gland Tumors
Pleomorphic Adenoma (Benign
Mixed Tumor): Introduction
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This tumor is easily the most common salivary
neoplasm.
Pleomorphic adenomas are derived from a
mixture of ductal and myoepithelial elements.
This mixture gives rise to a remarkable diversity
of microscopic appearances both among
different pleomorphic adenomas and within any
one tumor.
Pleomorphic Adenoma (Benign
Mixed Tumor): Introduction
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Neither the term pleomorphic nor mixed are
entirely accurate in describing this neoplasm.
The basic pattern of the neoplasm is highly
variable but rarely are individual cells actually
pleomorphic.
Pleomorphic Adenoma (Benign
Mixed Tumor): Introduction
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Although the tumor often has prominent mesenchymal
appearing “stroma”, it is not truly a mixed neoplasm
that is derived from more than one germ layer. These
“stromal” changes are believed to be produced by the
myoepithelial cells.
Occasionally, salivary tumors are seen that are
composed almost entirely of myoepithelial cells with no
ductal elements. These tumors are called
myoepitheliomas.
Pleomorphic Adenoma: Clinical
Features
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As indicated, this lesion is the most common salivary
gland neoplasm representing from 53-77% of all
parotid tumors, 44-68 % of submandibular tumors and
from 38-43 % of all minor gland tumors.
Benign mixed tumors are most commonly diagnosed
between the ages of 30-50 years and there is a slight
female gender predilection.
They typically appear as slow growing, painless masses.
Pleomorphic Adenoma: Clinical
Features
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In the parotid, they occur more commonly in the
superficial lobe and initially the lesion is movable.
Intraorally, they are most common in the palate
(posterior-lateral) followed by the upper lip and buccal
mucosa.
The intraoral lesion is typically smooth-surfaced, domeshaped and non-ulcerated (if traumatized the
pleomorphic adenoma can be ulcerated).
In the hard palate, pleomorphic adenomas will be nonmobile due to the mucosa being tightly bound to the
underlying bone.
Pleomorphic Adenoma: Cause,
Treatment, Prognosis & Significance
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The cause of this tumor is unknown.
Pleomorphic adenomas are best treated by surgical
excision.
With adequate surgery, there is a 95 % cure rate.
With inadequate surgery, multifocal seeding occurs. In
such cases multiple recurrences are not unusual.
Malignant transformation is a potential complication
but the rate is < 5 % of all cases. Transformation
typically occurs many years (10-15) after the tumor is
originally recognized.
Warthin Tumor: Cause, Treatment,
Prognosis and Significance
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The cause is unknown. Some authors have suggested it
results from heterotopic salivary gland tissue occurring
within the parotid lymph nodal tissue. Smokers are said
to have an eightfold greater risk than non-smokers.
Treatment consists of surgical removal and there is a 612 % recurrence rate.
Since some tumors are multicentric in nature, is it a
recurrence or a proliferation of another nodule.
Malignant Warthin tumors do occur but these are
exceedingly rare.
Polymorphous Low-Grade
Adenocarcinoma: Clinical Features
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This malignant salivary gland neoplasm occurs almost
exclusively in the minor salivary glands, where it is one
of the more common malignancies.
Sixty percent of the cases occur on the hard or soft
palates following in frequency by the upper lip and
buccal mucosa.
Most commonly occurs in older adults (6-8th decades)
and there is a female gender predilection ( two thirds of
cases).
Most commonly presents as a slow-growing mass
occasionally accompanied by bleeding or discomfort.
Polymorphous Low-Grade
Adenocarcinoma:Cause & Treatment
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The cause of this tumor is unknown.
Treatment consists of wide surgical excision
sometimes including resection of the underlying
bone.
It is a low-grade malignancy which uncommonly
metastizes.
Radical neck surgery is usually unwarranted.
Polymorphous Low-Grade
Adenocarcinoma: Prognosis
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Eighty percent of the patients are tumor free after
treatment and most of the rest are controlled with reexcision.
Death due to the tumor is rare.
Perineural invasion, like adenoid cystic carcinoma,
occurs frequently and does not appear to affect
prognosis if it occurs.
This tumor must be differentiated from adenoid cystic
carcinoma.
The histopathology of this tumor is deceptively
uniform and can be mistaken for a benign lesion.
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