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Intra-ductal causes of obstruction:
- Stenosis of duct papilla
- Retention cysts
Extra-ductal causes of obstruction:
Tx of mucocele?
- Delicate excision. Elliptical incision.
- Release the cyst and remove the gland.
- Other glands seen in the wound should also be removed, as they will become blocked by scar tissue and give rise to new cysts.
- Primary closure
Tx of Ranula?
- More difficult, FOM
- Damage to submandib duct and lingual nerve.
- Often may need to excise sublingual gland as part of procedure.
Which glands are salivary calculi most commonly assoc with?
- 80% SUBMANDIB
- 6% Parotid
- Subling and minor 2%
Why more calculi in subman?
- Bend in duct around mylohyoid muscle
- Serous and mucous secretion - viscous nature
- Length of duct - elongated
Where in submandib gland are they located?
- 85% are within DUCT no gland
- 35% are found at the bend of the duct
- 15% hilum or gland proper
How to take a history of salivary disease?
- Presence of pain, swelling, altered flow, bad taste
- Periodicity and duration of swelling is often great assistance in getting Dx
- palpate - help determine presence and nature
- Bimanual palpation
- Check swelling, tenderness, presence of fixation, ulceration, local nerve involvement
Classic symptom of salivary calculi?
Pain when smell or taste of food stimulates salivary stimulation.
What can duct obstruction lead to?
Scarring, Infection, swelling of gland
How do calculi form?
Calcium slats deposited around a nidus of organic material
Are all calculi radio-opaque?
- 40% of parotid are NOT
- 20% of subman are NOT (therefore most are!)
What can help you view calculi?
- Sialography -
- might see it on a DPT
- Lower occlusal (subman)
- Postero-anterior view for Parotid
What can sialography show?
- INVASIVE. Using canula, put contrast medium into a duct orifice
- Outlines duct architecture
- Filling defects
- Dilatation (proximal to obstruction)
- Emptying of the contrast med from gland allows assessment of gland function
Sialography, what will a normal Subman and parotid look like?
- Submandibular - bush in winter
- Parotid - tree in winter
U/S is can confirm presence of?
- Glandular swelling
- Abnormal gland structure
- Tumour vs obstructive damage
When is biopsy useful?
SS or other CT disorders suspected, where histopatho is necessary
What is papillary stenosis?
- more commonly affects parotid papilla following trauma from dentures/sharp cusps.
- Tx - sliting the duct from its orifice for a short distance along its length and suturing margins to the surrounding mucosa
Can you get papillary stenosis in the submandib duct?
Possibly, where a salivary calculus causes chronic ulceration near the orifice.
How to treat strictures?
- Dilate using balloon dilation
- If this fails, the stoppage is bypasses by surgery to bring the duct into the mouth proximal to the obstruction.
- Parotid strictures may require duct reconstruction using mucosal graft.
How can stones be removed (submandib)
- If acute infection, first line Tx = antibiotic therapy.
- Stone in anterior two-thirds may be removed under LA
- incision made parallel to the duct in the FOM
- Stone accurately localised by palpation
- Suture passed deep to the duct and posterior to the stone and tied tight to p/vent sialolith moving backwards towards gland
- Assistant should push up the FOM from below to improve access.
- Blunt dissection to identify the calculus
- Incision and removal of stone.
Do you leave all incisions open?
- Small incisions are left open
- Large ones may be partially closed
- Stimulation of saliva flow is important to keep the new opening patent
What about stones at the posterior part of submandib duct?
- More difficult
- Careful dissection, LINGUAL NERVE crosses the duct in this region
- If in gland and causing symptoms -excise gland
- Complication - scarring, lingual paraesthesia
Why are parotid calculi generally harder?
- Often multiple
- Poorly calcified and not easily seen on Rads
- Can be removed intraoral approach if in Duct
- But course of duct through buccinators makes it difficult
Can you leave parotid gland stones alone?
- Yes, if producing minor symptoms, and are lodged in the gland, leave untreated.
- Others - may need to excise part of gland.
What other techniques are used to get stones out?
- Basket retrieval
- Lithotripsy- shockwave therapy to break stone
Predisposing factors for acute sialadenitis?
- Exacerbation of chronic
Symptoms acute sialadenitis?
- Parotid more common.
- Swollen gland, tender, painful
- Inflammes parotid papilla, rarely pus from parotid
- Submand pus discharge from duct, FOM swollen, red
- Lymph maybe - raised upper deep cervical if parotid
What other condit must you exclude with acute sialadenitis?
What organism causes acute sialadenitis?
- Staphylococus infection
- Strep viridans
Sialadenitis in the submandibular gland is usually assoc with?
- Or stricture of duct
If severe gland infection, what should you do?
- Admit to hosp
- Vigorous AB
- incision and drainage if necc
- complication - salivary fistula
Chronic sialadenitis is due to?
Prolonged obstruction to salivary flow
What will you see on the sialography of chronic sialadenitis?
Sialectasis - tree in summer! - Leakage of contrast through acini walls
Histopatho of Chronic sialadenitis?
- Chronic inflamm process (lymphocytes and plasma cells)
- Acinar atrophy
- Duct dilatation
Complication of chronic inflamm in submandib gland?
- Kuttner Tumour.
- Progressive destruction - almost complete replacement of the parenchyma by FIBROUS tissue
- Producing a firm mass.
Three nerves that can be damaged in submandibular surgery?
- 2.MARGINAL MANDIBULAR
Name some granulomatous processes that can cause parotid enlargement - including infections:
Sarcoidosis of the parotid gland will present as?
- Persistent, painless enlargement
- Generalised LN enlargement
If combined with uveitis, and facial palsy, sarcoidosis of CNs and Parotid and lacrimal glands?
Mumps - which virus causes it?
Mumps - is it uni/bilateral?
Symptoms of Mumps?
- Bilat parotid swelling
- Low grade fever
- High grade fever suggests metastatic orchitis or meningitis
How long does Mumps last?
- Course done by 2 weeks.
- Recurrence is rare
What other organs can be involved?
- Orchitis - 25% MALES testicular swelling, pain
- Meningitis - very serious and severe. Can get encephalitis
What could an ulcer on the palate suggest?
- Necrotising sialometaplasia
- Adenoid cystic carcinoma
- Mucoepidermoid carcinoma
- Non-hodgkin lymphoma (but tend not to ulcerate, but be fleshy mass)
Tx of necrotising sialometaplasia?
- Biopsy to exclude malig
- Heals in 4-10 weeks spontaneously
- Unknown Ax
- Pseudoepitheliomatous hyperplasia, and squamous metaplasia of ducts
Why may HIV pts get bilat parotid enlargement?
- Lymphoepithelial cysts in parotid glans.
- Not caused by bacteria
- May present like SS, but without Autoantibodies
- Can develop lymphoma
What is Sialosis?
Non-inflamm, non-neoplastic persistant bilateral swelling of salivary glands (parotid mainly)
Ax of sialosis?
- Unknown, but may be assoc with:
- Hormonal disturbances - preg, diabetes, hypothyroid
- Malnutrition - alcoholics, bulimia
- Drugs - iodine, antihypertensive
Clinical fts of sialosis?
- Persistent bilat swelling
- Look like hamster
- Increase saliva K+
- Flow is normal
- Sialography normal
Histopath of sialosis?
- HyperTROPHY of acinar cells
- Fatty replacement (adipocytes lager than acinar cells) if long-standing.
Bulimia, what would you see on their fingers?
Salivary gland neoplasms, are they common?
Yes! 2nd most common neoplasm of the mouth after SCC.
Where are most salivary neoplasms usually found?
- Parotid 73%
- Subman - 11
- Subling - 0.4
- Minor - 14
Even though neoplasms are rare in subling and minor, are they more likely to be MALIGNANT?
- YES. 86% of Sublin neoplasms are malignana
- 46% of minor saliv gland neoplasms are malignant
- 37% subman
Parotid gland neoplasms, how many are malignant?
Less. Only 15%
Describe the clinical fts of Benign neoplasm in salivary glands:
- Slow growing
- Rubbery consistency, soft
- Parotid mainly
- No ulceration
- No assoc nerve signs
Describe the clinical fts of Malignant salivary neoplasm?
- Can be fast growing and painful
- Sometimes hard consistency
- 45% are from minor salivary glands
- can ulcerate and invade bone
- CN palsy possible
Which nerves might you get paraesthesia from if malignant involvement?
- esp with adenoid cystic carcinoma
Most common benign tumour?
4 fts of pleomorphic adenoma?
- characterised by its �mixed� (pleomorphic) appearance
- Fibrous capsule
- Painless firm mass
- Superficial parotid, but can get I/O in palate.
Investigation of pleomorphic adenoma
- If parotid - FNA (incisional Bx contraindicated because of tendency to seed and recur in insicion scar)
- Palatal mass - Deep incisional biopsy
Diff Dx of pleomorphic adenoma in parotid?
- Warthins tumour
- Basal cell adenoma
- Mucoepidermoid c.
- Adenoid cystic c.
- Acinic cell c.
- Non-salivary - lymphoma, haemangioma, lipoma, lymphoma
Diff dx of pleomorphic in palate?
- Adenoid cystic
Can pleomorphic have malignant transformation?
- Yes. Only 5-10%.
- Will recur if not completely removed
- (recurrence depends on lack of capsule, satellite nodule, intracapsular invasion, spilt in tumour)
What tumour might you get in upper lip?
- Canalicular Adenoma 90% of them are in upper lip
- It is benign
What is the most common Minor salivary gland malignancy?
- Adenoid cystic carcinoma
- e.g in palate,
- But can occur in parotid
What is relevant in terms of the behaviour of an Adenoid cystic tumour?
- extensive local invasion
- peri and intra neural spread
- lymph node involvement
- metastases to lung, bone, brain
Are major glands biopsied?
- Not usually.
- FNA used instead. Provides diagnostic cytology specimens without risk of tumour seeding or salivary fistulae.
How does FNA work?
- Aseptic technique.
- Wide-bore needle 18-20 gauge
- Lesion aspirated and cellular contents deposited onto a glass slide and fixed immediately
- Histological exam.
Use of MRI?
- if Tumour in salivary gland
- Can see relationship of parotid lesion to the facial nerve
- Can see defined benign tumour capsules or irregular malignant tumour margins
- Tumour STAGING
How to treat Benign tumours?
- Local exicision
- Wide excision of a pleomorphic adenoma should include tumour outgrowths outside the capsule
- Pvent recurrence
Tx Malignant tumours?
- Extensive resection
- Try to preserve facial nerve, but may have to be sacrificed
Is radiotherapy used in salivary gland tumour?
Not often, because of the relatively slow growth rate and resultant radioresistance of salivary gland cancers.
Removal of submandib gland involves:
- Skin crease incision about 5cm in neck, about 2cm below border of mandible, to avoid mandibular branch of facial nerve.
- Divide platysma and fascia.
- Facial vessels are detected and ligated
- Ligate facial artery on posterior aspect of gland.
- Superiorly lingual nerve may be embedded in capsule
Complications of subman surgery?
- lingual nerve damage
- Hypoglossal (rare)
- Marginal mandib of facial
- Duct damage
Superficial parotidectomy involves:
- Sigmoid, periauricular incision
- Extends from temporal region to below ear lobe, around angle, into skin crease in neck 2cm below border.
- Facial skin flap raised
- Identify facial nerve
- Avoid rupturing the tumour capsule.
Complications of parotid surgery?
- Damage to facial nerve
- Frey�s syndrome
- damage to retromandibular vein - haematoma
- numbness of ear - Greater auricular nerve V3
What is Frey's syndrome?
- Damage to auriculotemporal V3
- Abberant reactivation of secretomotor fibres from auriculotemporal nerve to sweat glands in skin
- Pt sweats when salivating.
Management of Frey's?
Botox, anticholinergic drug, surgical resection of nerve