Saliva

Question 1

Parotid

Answer 1

Preauricular
Serous
Cont. 20-40% saliva

Question 2

Submandibular

Answer 2

Submandibular location
Mucous and serious
60-70% saliva

Question 3

Sublingual

Answer 3

FOM, under tongue
Mucous secretion
10% saliva

Question 4

Minor salivary glands

Answer 4

Everywhere but mainly lips, palate, cheeks, tongue
800+ total
Mucus except one exception
Exception - serous glands of von Ebner
5-10% saliva

Question 5

Stafnes bone cavity

Answer 5

Non-neoplastic developmental anomaly
Unilocular, corticated well-defined radiolucency at angle of mandible under ID canal
Thought to be pathological cystic lesion
Now know is normal salivary tissue pushing on mandible making dent - appearing as lucency on rad

Question 6

Sialedenitis

Answer 6

Acute - bacterial (acute, recurrent - adults/kid), viral

Chronic - bacterial, post-irradiation, Sjogren’s

Question 7

Acute parotitis

Answer 7

Ascending infection
oral bacteria - S. aureus
Acute swelling, pain
Pus exudes from ducts
Usually 2^ to dry mouth - radiotherapy, Sjogrens, drug-induced

Question 8

Recurrent parotitis - adults

Answer 8

40-60
F > M
Unilateral
Recurrent ascending infections
Secondary to xerostomia
Xerostomia due to: irradiation, drug-induced, Sjogren’s

Question 9

Recurrent parotisis of childhood

Answer 9

4m - 15 years
M = F
No obvious cause
Bilateral parotid swellings
Sudden onset
Periods of quiescence
Days - weeks duration
NOT suppuration but may be other signs of infection - pain, fever, redness
Sialography shows punctate sialectasis - ‘snowstorm’ appearance
Gradual destruction of acinar elements - reduced salivary flow
Non specific histology but shows dilation of salivary ducts with fibrosis replacing salivary tissue
Lots of lymphocytes extending into epithelium and around ducts

Question 10

Acute viral sialedenitis: mumps
Complications

Answer 10

Epidemic parotitis
Mumps virus - paramyxovirus
Rare - <1000 cases/year
Mainly in children
Very painful, malaise, fever
Acute bilateral parotid swelling
Incubation period - 2-3 weeks. Droplet or direct spread
Self limiting - 10-14 days
May spread to other glands/organs

Complications:
Orchitis - 30%
Meningitis - 10%
Oophoritis - 5%
Pancreatitis - 5%
Cranial nerve palsies
VIII nerve deafness

Question 11

Chronic sailodenitis is usually….

Answer 11

…..secondary to duct obstruction due to calculi

Question 12

Salivary caliculi

Answer 12

Accumulation of calcium and phosphate salts which deposit in salivary ducts or gland
Usually unilateral
M>F
Submandibular - 80% due to: saliva being pushed upwards against gravity in mouth and tortious course of gland
Parotid 20%, minor glands 1-15%
Calculus - concentric circles of calcium salts deposited around cellular debris and mucous
When obs by calculus occurs, get saliva retention and inflammation of gland = swelling and fibrosis, then continued fibrosis and loss of function

Question 13

Radiation sialodenitis

Answer 13

Doses >20Gy
High risk of permanent damage >30Gy
Severe damage >50Gy
Serous acini most sensitive
Inflammation and fibrosis of glands
Loss of function
Important consideration in cancer pt’s

Question 14

Eg’s of obstruction and trauma

Answer 14

Salivary caliculi
Mucous cysts (mucoceles)
Necrotising sialometaplasia

Question 15

Mucous extravasation cyst

Answer 15

85% mucoceles
Younger age - 20-30
Lower lip commonest site - 50%
Rupture of ducts, saliva spills out into surrounding CT - forming cyst like area lined by granulation and fibrous tissue

Histology:
Lumen filled with mucous
Macrophages filled with mucous
Lining of inflamed, compressed granulation tissue

Question 16

Mucous retention cyst

Answer 16

15% mucoceles
Older age range - 40-60
Buccal mucosa, FoM
Due to blocked duct but with NO rupture
Blockage of duct leads to dilation and expansion of duct epithelium

Histology:
Mucous in lumen
Lining of ductal epithelium
Cyst wall of fibrous tissue with glands

Question 17

Ranula

Answer 17

Floor of mouth
Usually extravasation cysts
Mainly sublingual
Usually children
Painless swellings
Rupture and recur
2-3cm

Question 18

Necrotising sialometaplasia

Answer 18

Presents as indurated, ulcerated swelling
Usually on palate
Often biopsied as malignant
But is acc benign inflammatory disease
Heals spontaneously after 4-8 weeks

Histology:
Squamous metaplasia of salivary ducts - islands of squamous epithelium deep in CT’s BUT
Also see necrosis of acini with ‘ghosts’ of normal structures

Question 19

Classification of salivary gland tumours WHO 2017

Answer 19

Benign

• Pleomorphic adenoma
• Warthin tumour
• Cystadenoma
• Basal cell adenoma
• Canalicular adenoma

Malignant

• Mucoepidermoid carcinoma
• Acinic cell carcinoma
• Polymorphous adenocarcinoma
• Adenoid cystic carcinoma
• Carcinoma ex pleomorphic adenoma

Question 20

Pleomorphic adenoma

Answer 20

Most common salivary gland tumour

Parotid most common, then palate

Age 30-60

M=F

Benign

May recur

Question 21

Pleomorphic adenoma histology

Answer 21

Mixed (pleomorphic) pattern

Islands and strands of epithelium

Encapsulated

Usually lobulated

Myxoid, mucoid or chondroid stroma

Duct like structures

Typical appearance: duct like structured w/inner and outer layer. Pink secretions inside

Occasionally, tumours are solid - made up of lots of cells with no stroma

Myoepithelial cells surrounding duct-like structures - fried egg appearance

Question 22

Warthin tumour + histology

Answer 22

10% of benign salivary gland tumours

Always in parotid gland

Male:female 60:40

Associated with smokers

Sometimes bilateral or multifocal

Completely benign

Histology: irregular cysts, lined by oncocytic duct epithelium, stroma composed of lymphoid tissue

Question 23

Mucoepidermoid carcinoma + histology

Answer 23

Most common malignant salivary tumour

Parotid most common site

Also palate, cheek, retromolar

Seen occasionally in children

15% metastasise

Histology:

Mixture of mucous and epidermoid cells (squamous cells)

Lesions usually multicystic

High grade lesions may be solid with few mucous cells

Occasional lesions have many clear cells

Question 24

Adenoid cyStic carcinoma + histology

Answer 24

Second most common salivary malignancy

Infiltrative tumour - no capsule

Parotid most common

Cheeks, palate, Sinuses

Highly malignant

75% pt’s die within 20 years

Metastasis via blood stream and nerve invasion

Histology:

Non-encapsulated

Characteristic multicystic/cribriform pattern - ‘Swiss-cheese’

Infiltrates widely - through bone, blood vessels, along nerves

Question 25

Polymorphous adenocarcinoma

Answer 25

Only intra-orally Palate 70%, lips, cheek 30% 3rd most common I/o malignancy \>50 years Variable histological pattern - lobules, ductal structures, cribriform areas, papillary cystic pattern, single cell filing Perineural infiltration typically Infiltrative growth Bland, monotonous cytology Often **misdiagnosed** on incisional biopsies as **pleomorphic adenoma** or **adenoid cystic carcinoma -** need great care with small palatal biopsies Survival \>90% at 5 years Metastases 10-15% Similar to mucoepidermoid Unpreditable - lesions with papillary cystic pattern and cytological atypia may have worse prognosis

Question 26

Acinic cell carcinoma

Answer 26

5% salivary malignancies mostly parotid 10% recurrence, 15% metastasise Variable histological appearance - solid, microcystic, papillary cystic, follicular Lymphoid tissue and germinal centres common

Question 27

Carcinoma ex pleomorphic adenoma

Answer 27

10% pleomorphic adenomas may become malignant Usually long standing or recurring lesions Elderly - 60+ History of **long term slow growing lesions** with **recent increase in size**

Question 28

Sjogren's and clinical features

Answer 28

Sjogren's - autoimmune disorder characterised by lymphocyte mediated destruction of the exocrine glands resulting in dry eyes and dry mouth Primary - dry eyes and mouth Secondary - dry eyes and mouth +/- CT disease e.g. RA, SLE Clinical features: 90% female Middle age Oral symptoms - dry mucosa, lobulated tongue, candidosis, caries Dry eyes - keratoconjunctivitis Parotid swelling in 20%

Question 29

Pathology of Sjogren's + histology

Answer 29

Lymphatic infiltrates in salivary glands In minor glands - lymphocytic sialedenitis In major glands - lymphoepithelial lesion in 3-5% cases, these lesions may progress to lymphoma HISTOLOGY: Gland replaced by lymphocytes Acini disappear, but ducts proliferate to form epithelial islands Epithelial island infiltrated by lymphocytes - ‘lymphoepithelial lesion'

Question 30

Imaging - dry mouth

Answer 30

Ultrasound if suspect Sjogrens. Can be followed by sialography if necessary Sjogren's is the only cause of dry mouth that can be identified on imaging - disease process destroys the gland parenchyma, producing a typical pattern of changes on imaging Blobs and dots of xray contrast within gland US - normal parotid tissue replaced with black spaces = inflammation

Question 31

Imaging - obstructive sialedenitis

Answer 31

Calculi most common in submandibular, strictures more common in parotid. Obstruction of sublingual rare Imaging - plain film rads then sialography. For submandibular obstruction - lower true occlusal (90degrees) and posterior oblique film + possibly sectional OP For parotid obstruction, AP extra oral film plus small dental film inside cheek useful Sialography - injecting iodinated contrast along submandibular or parotid ducts. The iodine in the contrast makes it densely radiopaque, stones less dense to appear radiolucent

Question 32

Txt of submandibular caliculi

Answer 32

If visible in anterior ⅓rd of duct - surgical excision under LA - intra-orally If small, mobile and anterior to mylohyoid bend - basket removal If beyond mylohyoid bend, or too large for basket, surgical excision - extra orally

Question 33

Basket removal + complications

Answer 33

Intra-ductal technique done under LA Helical wire basket placed (closed) into duct opening. Advanced past calculus then opened. Calculus snared into helical basket and advanced to duct opening Small incision - papillotomy to release calculus. No sutures as would cause stenosis Complications: Pain and swelling expected post-procedure Failure to retrieve stone Basket stuck in duct - stone may be adhered to duct wall, needs to be mobile on sialogram Persisting symptoms even after removal

Question 34

Treatment of parotid obstruction

Answer 34

**Strictures:** balloon dilation if in the extra-glandular duct (most common). Articaine and iodinated dye passed down parotid to identify stricture site and give topical anaesthesia. Submucosal buccal lidocaine also injected along course of duct Dilation of parotid papilla using lacrimal probe. Angioplasty 2-3mm balloon inserted (uninflated) and advanced to stricture site with x-ray guidance. Balloon inflated - 15psi 90 secs, may need 2-3x inflations In some cases, stricture may be too tight to pass balloon, even when fine wire guide used. Despite LA, inflating balloon is uncomfortable. Some will not dilate, even after several inflations ⅓rd dilated parotid strictures will restenose within 2 years and need repeating **Stones:** if visible at duct opening - simple surgical excision If in the extra-glandular duct, anterior to posterior border of ramus and small and mobile - basket retrieval as per submand If in gland parenchyma or too large, lithotripsy (sound waves to break up) or superficial parotidectomy