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2013-01-09 17:28:40
salivary christensen osd4

osd4 opath4 salivary lesions
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  1. Salivary Gland Aplasia
    • • Rare developmental anomaly that can affect 1+ major salivary glands.
    • • May be associated with a syndrome.
  2. Mucocele
    • • Common lesion of the oral mucosa that results from rupture of a salivary gland duct and spillage of mucin into the surrounding soft tissues.
    • o Spillage is the result of local trauma.
    • • Not a true cyst b/c it lacks an epithelial lining.
    • • Clinical Features
    • o Typically appear as dome-shaped mucosal swellings that can vary in size.
    • o Do not occur on upper lip
    • • Histo
    • o Mucin-filled cyst like cavity beneath the mucosal surface.
    • o Spilled mucin is associated with granulation tissue containing foamy histiocytes.
    • • Tx and Prognosis
    • o Short-lived lesions that rupture and heal by themselves.
    • o Some are chronic, and require surgical excision.
    • • To minimize risk of recurrence, the surgeon should remove any adjacent minor salivary glands that may be feeding into the lesion when the area is excised.
  3. Ranula
    • • Mucoceles that occur in the floor of the mouth.
    • • Source of mucin spillage is usually from the sublingual gland, but may also arise from the Submandibular duct or from minor salivary glands in the floor of the mouth.
    • • Larger ranulas arise from the body of the sublingual gland; smaller lesions can develop along the sublingual plica from the superficial ducts of Rivini.
    • • Clinical Features
    • o Usually appears as a blue, dome-shaped fluctuant swelling in the floor of the mouth.
    • • Deeper lesions may be normal in color.
    • o Plunging/Cervical Ranula – unusual clinical variant that occurs when the spilled mucin dissects through the mylohyoid muscle and produces swelling within the neck.
    • • Histo
    • o Similar to that of a mucocele
    • • Tx and Prognosis
    • o Removal of the feeding sublingual gland/marsupialization [removal of the roof of the intraoral lesion, which can be successful for small, superficial ranulas associated w/ the ducts of Rivini].
    • o Marsupialization is unsuccessful for larger ranulas developing from the body of the sublingual gland.
  4. Salivary Duct Cyst
    • • Epithelium-lined cavity that arises from salivary gland tissue.
    • • True developmental cyst that is lined by epithelium that is separate from the adjacent normal salivary ducts.
    • • Cause is uncertain.
    • • Cystlike dilatation of salivary ducts may develop 2ndary to ductal obstruction, which creates increased intraluminal pressure.
    • • Clinical Features
    • o Usually occur in adults and can arise within either the major or minor salivary glands.
    • • Histo
    • o Cystic cavity lined by thin cuboidal epithelium. Adjacent to the cyst is an excretory salivary gland duct lined by columnar epithelium.
    • o Oncocytic salivary ductal ectasia – dilated duct is lined by columnar eosinophilic oncocytes that exhibit papillary folds into the ductal lumen. May develop 2ndary to ductal obstruction.
    • • Tx and Prognosis
    • o Isolated salivary duct cysts are treated by conservative surgical excision.
  5. Sialolithiasis
    • • Calcified structures that develop w/in the salivary ductal system.
    • • Arise from deposition of calcium salts around a nidus of debris w/in the duct lumen.
    • o Debris: mucus, bacteria, ductal epithelial cells, or foreign bodies.
    • • Formation can be promoted by chronic sialadenitis and partial obstruction.
    • • Development not related to any systemic derangement in calcium and phosphorus metabolism.
    • • Clinical Features
    • o Most often develop w/in the ductal system of the Submandibular gland [parotid gland is less frequent]
    • • Duct is long, tortuous, and goes in an upward direction.
    • • Duct also has thicker, mucoid secretions
    • o Sialoliths can form w/in the minor salivary glands, most often within the glands of the upper lip or buccal mucosa.
    • o Can occur at any age, but most common in young and middle-aged adults.
    • o Major gland sialoliths most frequently cause episodic pain or swelling of the affected gland, especially when eating.
    • o Sialoliths typically appear as radiopaque masses on radiographic examination, but not all stones are visible on standard radiographs.
    • o Minor gland sialoliths are asymptomatic but may produce local swelling tenderness of the affected gland. Small radiopacity may be seen with a soft tissue radiograph.
    • • Histo
    • o Intraductal calcified mass showing concentric laminations.
    • o The duct exhibits squamous metaplasia.
    • • Tx and Prognosis
    • o Small sialoliths of the major glands can be treated by gentle massage in order to milk the stone toward the duct opening.
    • o Sialologues – drugs that stimulate salivary flow
    • o Other methods: moist heat, increased fluid intake.
    • o Larger sialoliths need to be removed surgically.
    • o If significant inflammatory damage has occurred w/in the feeding gland, then the gland may need to be removed.
    • o Minor salivary stones are best treated by surgical removal, including the associated gland.
    • o Shock wave lithotripsy, salivary gland endoscopy, and radiologically guided basket retrieval are newer techniques that have been shown to be effective in the removal of sialoliths from the major glands. Low morbidity and may preclude the necessity of gland removal.
  6. Sialadenitis
    • • Inflammation of the salivary glands; can arise from various infectious and noninfectious causes.
    • • Most common viral infection: mumps
    • o Other viruses: Coxsackie A, ECHO, choriomeningitis, parainfluenza, cytomegalovirus
    • • Most bacterial infections arise as a result of ductal obstruction or decreased salivary flow, allowing retrograde spread of bacteria throughout the ductal system.
    • • Blockage of the duct can be caused by sialoliths, congenital strictures, or compression by an adjacent tumor.
    • • Decreased flow can result from dehydration, debilitation, or medications that inhibit secretions.
    • • More common cause: recent surgery [abdominal surgery], after which an acute parotitis [surgical mumps] may arise b/c the patient has been kept w/out food or fluids and has received atropine during the surgical procedure.
    • • Other meds that produce xerostomia as a side effect can also predispose patients to such an infection.
    • • Most cases of acute bacterial sialadenitis are caused by Staph aureus, but strep or others can do it too.
    • • Noninfectious causes: Sjogren syndrome, sarcoidosis, radiation therapy, allergens.
    • • Clinical Features
    • o Tender swelling of the Submandibular gland
    • • Histo
    • o Chronic inflammatory infiltrate w/ associated acinar atrophy, ductal dilatation, and fibrosis.
    • • Tx and Prognosis
    • o Appropriate antibiotic therapy and rehydration of the patient to stimulate salivary flow.
    • o Surgical drainage may be needed if there is abscess formation.
    • o Spread of infection and sepsis may cause death.
    • o Management of chronic sialadenitis depends on the severity of the condition and ranges from conservative therapy to surgical intervention.
    • o Initial management often includes: antibiotics, analgesics, sialagogues, and glandular massage.
  7. Sialorrhea
    • • Aka excessive salivation
    • • Uncommon condition that has various causes: local irritations [aphthous ulcers, ill-fitting dentures], gastroesophageal reflux disease [episodic hypersecretion of saliva], rabies, heavy metal poisoning, medications [antipsychotics, cholinergic agonists].
    • • Can be a problem for: mentally retarded pts, pts who have surgical resection of mandible, pts w/ various neurologic disorders such as cerebral palsy, Parkinson’s disease, or amyotrophic lateral sclerosis.
    • o In these cases, there is drooling caused by poor neuromuscular control.
  8. Xerostomia
    • • Subjective sensation of a dry mouth; frequently associated w/ salivary gland Hypofunction.
    • • Causes:
    • o Developmental – salivary gland aplasia
    • o Water/metabolite loss
    • • Impaired fluid intake
    • • Hemorrhage
    • • Vomiting/diarrhea
    • o Iatrogenic origin
    • • Medications
    • • Radiation therapy to the head and neck
    • • Chemotherapy
    • o Systemic diseases
    • • Sjogren syndrome
    • • Diabetes
    • • Sarcoidosis
    • • HIV infection
    • • Hep C infection
    • • Graft vs Host disease
    • • Psychogenic disorders
    • o Local factors
    • • Decreased mastication
    • • Smoking
    • • Mouth breathing
    • • Xerostomia in older adults is more likely to be a result of other factors (besides age) like medications.
    • o More than 500 drugs produce xerostomia
    • o More drugs you take, more likely to produce xerostomia
    • • Clinical Features
    • o Reduction in salivary secretions, and the residual saliva is foamy or thick and ropey.
    • o Mucosa appears dry, and exam gloves stick to the mucosal surfaces.
    • o Dorsal tongue is fissured w/ atrophy of the filiform papillae.
    • o Patient may complain of difficulty w/ mastication and swallowing; food may adhere to the oral membranes during eating.
    • o Increased prevalence of oral candidiasis in pts w/ xerostomia b/c of the reduction in the cleansing and antimicrobial activity normally provided by saliva.
    • o Also these pts are more prone to dental decay, especially cervical and root caries.
    • • Radiation-induced caries – should be xerostomia-related caries
    • • Tx and Prognosis
    • o Difficult and unsatisfactory.
    • o Artificial saliva, continuous sips of water throughout the day.
    • o Sugarless candy can be used to stimulate salivary flow.
    • o Use of oral hygiene products that contain lactoperoxidase, lysozymes, and lactoferrin.
    • o Sialogogue – systemic pilocarpine, cevimeline hydrochloride
    • • Side effects: excess sweating, increased heart rate and blood pressure
    • o Frequent dental visits are recommended b/c of increased risk of dental caries.
  9. • Oral hygiene products that contain lactoperoxidase, lysozymes, and lactoferrin
    • • Sialagogue meds – pilocarpine and cevimeline
    • o Pts w/ Sjogrens have increased risk for lymphoma, up to 40x higher.
    • • Tumors may arise within salivary glands or within lymph nodes.
  10. Sialadenosis (Sialosis)
    • • Unusual noninflammatory disorder characterized by salivary gland enlargement, particularly involving the parotid glands.
    • • Frequently associated w/ underlying systemic problem – endocrine, nutritional, or neurogenic in origin.
    • o Diabetes mellitus, general malnutrition, alcoholism, bulimia.
    • o Problems result in dysregulation of the autonomic innervations of the salivary acini, causing an aberrant intracellular secretory cycle.
    • o Leads to excessive accumulation of secretory granules, w/ marked enlargement of acinar cells.
    • • Clinical Features
    • o Enlargement of the parotid and Submandibular glands 2ndary to alcoholism.
    • • Histo
    • o Hypertrophy of acinar cells, sometimes 2-3x greater than normal size
    • • Tx and Prognosis
    • o Clinical management is unsatisfactory b/c it is closely related to the control of the underlying cause.
  11. Necrotizing Sailometaplasia
    • • Uncommon, locally destructive inflammatory condition of the salivary glands.
    • • Uncertain cause; believed to be result of ischemia of the salivary tissue that leads to local infarction.
    • • Mimics a malignant process, both clinically and microscopically.
    • • Clinical Features
    • o Most frequently develops in the palatal salivary glands – mostly in posterior palate.
    • o Can cause crater-like defect of the posterior palate.
    • • Histo
    • o Necrotic mucous acini and adjacent ductal squamous metaplasia.
    • o Ulceration and pseudoepitheliomatous hyperplasia of the overlying epithelium
    • • Tx and Prognosis
    • o Biopsy is indicated to rule out the possibility of malignant disease.
    • o Once dx has been established, no specific tx is indicated or necessary.
    • o Lesion typically resolves on its own accord, w/ an avg healing time of 5-6 weeks.
  12. Salivary Gland Tumors
    • • General Considerations
    • o Constitute an important area in the field of oral and maxillofacial pathology.
    • o Not common, but not rare.
    • o 2/3 – ¾ of all salivary tumors occur in the Parotid Gland, and 2/3-3/4 of these tumors are benign.
    • o Pleomorphic adenoma is overwhelmingly the most common tumor.
    • • Accounts for 40% of all cases.
    • o Sublingual gland tumors have a very high malignancy rate, higher than in parotid gland.
    • o Minor glands have a 50% malignancy rate.
    • o Mucoepidermoid carcinoma and adenoid cystic carcinoma generally have been considered the 2 most common malignancies, although polymorphous low-grade adenocarcinoma is also becoming recognized as one of the more common minor gland tumors.
  13. • Pleomorphic Adenoma
    • o Most common, most important salivary gland tumor.
    • o Derived from a mixture of ductal and myoepithelial elements.
    • o Basic tumor pattern is highly variable.
    • o Not truly a mixed neoplasm that is derived from more than one germ layer.
    • o Clinical Features
    • • Appears as a painless, slowly growing firm mass. Pt may be aware of the lesion for many months or years before seeking a diagnosis.
    • • Most adenomas of the parotid gland occur in the superficial lobe and present as a swelling overlying the mandibular ramus in front of the ear.
    • • If neglected, the lesion can grow to grotesque proportions.
    • o Histo
    • • Typically a well-circumscribed, encapsulated tumor.
    • • Composed of a mixture of glandular epithelium and myoepithelial cells w/in a mesenchyme-like background.
    • • Ratio of epithelial elements and the mesenchyme-like component is highly variable among different tumors.
    • • Epithelium often forms ducts and cystic structures or may occur as islands or sheets of cells.
    • • Keratinizing squamous cells and mucus producing cells can be seen.
    • • Myoepithelial cells often make up a large percentage of the tumor cells and have a variable morphology, sometimes appearing angular or spindled.
    • • Highly characteristic “stromal” changes are believed to be produced by the myoepithelial cells.
    • • Extensive accumulation of mucoid material may occur between the tumor cells, resulting in a myxomatous [full of mucus] background.
    • • Vacuolar degeneration of cells in these areas can produce a chondroid appearance.
    • • In many tumors, the stroma exhibits areas of an eosinophilic, hyalinized change.
    • • At times, fat and osteoid is also seen.
    • o Tx and Prognosis
    • • Best treated by surgical excision.
    • • W/ adequate surgery, the prognosis is excellent, with a cure rate of 95%+.
    • • Malignant degeneration is a potential complication, resulting in a carcinoma ex pleomorphic adenoma.
    • • Risk of malignant transformation is probably small, but it may occur in as many as 5% of all cases.
  14. • Oncocytoma
    • o Benign salivary gland tumor composed of large epithelial cells known as oncocytes.
    • • Onco – to swell
    • o The swollen granular cytoplasm of oncocytes is due to excessive accumulation of mitochondria.
    • • Focal oncocytic metaplasia of salivary ductal and acinar cells is common in older patients.
    • o Rare neoplasm, respresenting approximately 1% of all salivary tumors.
    • o Histo
    • • Large, eosinophilic oncocytes
    • o Tx and Prognosis
    • • Best treated by surgical excision.
    • • Prognosis after removal is good, with a low rate of recurrence.
  15. • Oncocytosis
    • o Transformation of ductal and acinar cells to oncocytes.
    • o This disease refers to both the proliferation and the accumulation of oncocytes w/in salivary gland tissue.
    • o May mimic a tumor, both clinically and microscopically, but it also is considered to be a metaplastic process rather than a neoplastic one.
    • o Histo
    • • Focal nodular collections of oncocytes w/in the salivary gland tissue.
    • • Enlarged cells are polyhedral and demonstrate abundant granular, eosinophilic cytoplasm as a result of the proliferation of mitochondria.
    • • Multifocal nature of this proliferation may be confused w/ that of a metastatic tumor, especially when the oncocytes are clear in appearance.
    • o Tx and Prognosis
    • • Benign condition that is discovered only on incidental finding.
    • • No further treatment is necessary, prognosis is excellent.
  16. • Papillary Cystadenoma Lymphomatosum [Warthin Tumor]
    • o Benign neoplasm that occurs exclusively in the parotid gland.
    • o Both the epithelial and lymphoid components of the tumor are polyclonal; this suggests that the lesion may not represent a true neoplasm but would be better classified as a tumor-like process.
    • o Pathogenesis
    • • Arise from heterotopic salivary gland tissue found w/in parotid lymph nodes.
    • • Develop from a proliferation of salivary gland ductal epithelium that is associated w/ 2ndary formation of lymphoid tissue.
    • • Strong association between smoking and this tumor [8x risk if pt is a smoker].
    • o Clinical Features
    • • Usually appears as a slowly growing painless, nodular mass of the parotid gland.
    • • May be firm or fluctuant to palpation. Most frequently occurs in the tail of the parotid near the angle of the mandible and may be noted for many months before the pt seeks a Dx.
    • • Tumor tends to occur bilaterally – not simultaneously, however.
    • • Associated w/ cigarette smoking.
    • o Histo
    • • Papillary cystadenoma lymphomatosum
    • • Papillary cystic tumor w/ lymphoid stroma
    • o Tx and Prognosis
    • • Surgical removal
  17. • Monomorphic Adenoma
    o Describes a group of benign salivary gland tumors demonstrating a more uniform histopathologic pattern than the common pleomorphic adenoma.
  18. • Canalicular Adenoma
    • o Uncommon tumor that occurs almost exclusively in the minor salivary glands.
    • o Clinical Features
    • • Striking predilection for the upper lip.
    • • Occurs in older pts.
    • • Appears as a slowly growing, painless mass that usually ranges in size.
    • o Histo
    • • Uniform columnar cells forming canal-like ductal structures
    • o Tx and Prognosis
    • • Local surgical excision. Recurrence is uncommon [usually only multifocal cases]
  19. • Basal Cell Adenoma
    • o Benign salivary tumor that derives its name from the basaloid appearance of the tumor cells.
    • o Clinical
    • • Primarily a tumor of the parotid gland.
    • o Histo
    • • Usually encapsulate or well circumscribed
    • o Tx and Prog
    • • Tx is similar to that of pleomorphic adenoma and consists of complete surgical removal.
  20. • Mucoepidermoid Carcinoma
    • o One of most common salivary gland malignancies. Highly varied biologic potential.
    • o Clinical
    • • Most common malignant salivary gland neoplasms.
    • • Occurs fairly evenly over a wide age range.
    • • Most common malignant salivary gland tumor in children.
    • • Most common in the parotid gland and usually appears as an asymptomatic swelling.
    • • Minor salivary glands = 2nd most common site.
    • • Typically appear as asymptomatic swellings, which are sometimes fluctuant and have a blue or red color that can be mistaken clinically for a mucocele.
    • o Histo
    • • Composed of a mixture of mucus-producing cells and squamous [epidermoid] cells.
    • • The mucous cells vary in shape but contain abundant foamy cytoplasm that stains positively w/ mucin stains.
    • • Epidermoid cells are characterized by squamoid features, often demonstrating a polygonal shape, intercellular bridges, and keratinization.
    • • Intermediate cell is typically present and is a progenitor of both the mucous and epidermoid cells.
    • • Vary in appearance from small, basaloid cells to slightly larger ovoid cells w/ scant, pale eosinophilic cytoplasm.
    • • Grading
    • • Based on:
    • o Amount of cyst formation
    • o Degree of cytologic atypia
    • o Relative numbers of mucous, epidermoid, and intermediate cells
    • • Low Grade – prominent cyst formation, minimal cellular atypia, relatively high proportion of mucous cells.
    • • Intermediate grade – features that fall between those of high and low grade neoplasms.
    • • High grade – consist of solid islands of squamous and intermediate cells, which can demonstrate considerable pleomorphism and mitotic activity.
    • o Tx and Prognosis
    • • Depends on the grade and stage of the tumor.
    • • Low grade = good prognosis.
    • • Intermediate = slightly worse
    • • High grade = bad, 30-54% survival rate
    • • If in minor salivary glands, then has better prognosis, b/c they are mostly low to intermed grade.
  21. • Intraosseous Mucoepidermoid Carcinoma
    • o Salivary gland tumor that arises centrally within the jaws.
    • o Pathogenesis
    • • May arise from ectopic salivary gland tissue that was developmentally entrapped within the jaws.
    • • May arise from glands of the sinus lining.
    • • Most likely: odontogenic epithelium.
    • • Mucus-producing cells are common in odontogenic cyst linings, especially dentigerous cysts.
  22. • Acinic Cell Adenocarcinoma
    • o Salivary gland malignancy w/ cells that show serous acinar differentiation.
    • o Many of these tumors act in a nonaggressive fashion, and they are associated with a good prognosis.
    • o Formerly called acinic cell tumor.
  23. • Malignant Mixed Tumors
    • o Represent malignant counterparts to the benign mixed tumor or pleomorphic adenoma
    • o Most common: carcinoma ex pleomorphic adenoma
    • • Characterized by malignant transformation of the epithelial component of a previously benign pleomorphic adenoma.
    • o Histo
    • • Sheets of plasmacytoid myoepithelial cells w/in a myxoid background
    • • Malignant portion of a tumor shows epithelial cells w/ pleomorphic nuclei
  24. • Adenoid Cystic Carcinoma
    • o One of the more common and best-recognized salivary malignancies.
    • o Clinical
    • • Can occur in any salivary gland site, but most develop w/in minor salivary glands.
    • • Other tumors are found mostly in the parotid and Submandibular glands, w/ a fairly even distribution between these 2 sites.
    • o Histo
    • • Highly characteristic feature – tendency to show perineural invasion
    • • Probably corresponds to the common clinical finding of pain in these patients.
    • • Sometimes the cells appear to have a swirling arrangement around nerve bundles.
    • • Perineural invasion is not pathognomonic for adenoid cystic carcinoma.
    • • Also may be seen in other salivary malignancies, especially polymorphous low grade adenocarcinomas.
    • o Tx and Prognosis
    • • Prone to late recurrence and metastasis.
    • • Survival rate decreases steadily with time.
    • • Death usually results from local recurrence or distant metastases.
    • • Tumors of the palate or maxillary sinus eventually may invade upward to the base of the brain.
    • • Metastasis most frequently involves the lungs and bones.
  25. • Polymorphous Low-Grade Adenocarcinoma
    • o Most recently recognized type of salivary malignancy.
    • o One of the more common minor salivary gland malignancies.
    • o Clinical
    • • Almost exclusively a tumor of the minor salivary glands.
    • o Histo
    • • Cribriform arrangement of uniform tumor cells w/ pale-staining nuclei
    • • Pale-staining cells that infiltrate as single-file cords
    • • Perineural invasion occurs
    • o Tx and Prognosis
    • • Wide surgical excision, sometimes including resection of the underlying bone.
    • • Metastasis to regional lymph nodes is relatively uncommon, occurring in just under 10% of patients.
    • • Distant metastasis is rare.