Salivary gland disease Flashcards
(154 cards)
1
Q
List the major salivary glands
A
Parotid
Submandibular
Sublingual
2
Q
List the basic functions of saliva
A
- Microorganisms - antifungal, antivital and antibacterial
- Food - mastication, bolus formation, taste and digestion
- teeth - lubrication, remineralisation, buffering, protection against demin
3
Q
How does saliva protect the oral cavity?
A
- Lubricates and cleanses the mouth and teeth
- Controls oral PH to allow buffering of bicarbonate
- Limits oral pathogen growth via lysosomes and IgA
- Remineralisation of teeth
4
Q
What ph level does the saliva maintain in the mouth?
A
6.2-7.4
5
Q
What is the rest (unstimulated) flow of saliva
A
500ml (or up to 1 litre) a day
this is around 0.35ml/min
6
Q
What is the contribution of rest flow from the salivary glands?
A
Submandibular 70%
Parotid 20%
Sublingual 5%
Minor 5%
7
Q
What is the stimulated flow rate? Which gland is responsible?
A
2ml/min
Parotid gland increases secretion by 5x
8
Q
What is the dinural flow rate?
A
Around 0.1ml/min
Lowest flow rate is around 3am
9
Q
List the differential diagnosis for salivary gland diseases
A
Infection - bacterial (staph, TB, actinomycosis), viral (mumps, HIV, CMV)
Cysts - mucocoles or ranulas
Tumours - benign or malignant
Systemic conditions - sialadenosis, sarcoidosis, HIV, autoimmune
Obstruction - calculi or strictures
10
Q
What are some presenting signs of an obstruction?
A
Intermittent, meal time related swelling or pain
11
Q
What are presenting signs of sialadenitis
A
Intermittent non-meal related swelling
12
Q
List the imaging techniques used for salivary gland disease
A
Sialography Ultrasound Plain films CT and CT sialography MR sialography Endoscopy
13
Q
Advantages of ultrasound as an ix for salivary gland disease
A
- Quick, non-invasive, cheap, good compliance, doesn’t use contrast media or radiation, high resolution
- First line ix
14
Q
When are plain films indicated?
A
Ix for calculi as 20-40% of parotid and 60-80% of submandibular stones are radiopaque
15
Q
Indications for sialography
Contraindications for sialography
A
Obstruction, sialdenitis, sjogrens
CI - allergy to iodine, acute infection of gland, caulcus at the ostium of the duct
16
Q
Technique for sialography
A
Radiopaque medium is introduced into the ducts to demonstrate anatomy
17
Q
What types of radiopaque materials are used in sialography
A
Water based (urographic) Oil based - NOT USED AS LESS SAFE
18
Q
What is the best ix for salivary stones and why?
A
CT and CT sialography as it is 10x more sensitive for calcification than plain films (100% sensitivity)
19
Q
Tx options for salivary stones
A
- Extracorporeal or intracorporeal shockwave lithotripsy
- Stone retrival
- Dissolution
- Conservative surgery
20
Q
Tx options for strictures
A
Baloon duct dilation
21
Q
Indications for basket removal
A
- Mobile stone
- No stricture distal to the stone
- Stone <50% width of the duct
- Basket can pass the stone
22
Q
Complications of salivary gland surgery
A
Nerve damage Facial scarring Post op infection Salivary fistula Frey's syndrome
23
Q
What is the risk of nerve damage in salivary gland surgery
A
Parotid - 20-60% temporary, 1-7% risk of permanent damage to the facial nerve
SM gland - marginal mandibular nerve palsy or lingual nerve palsy
24
Q
Tx options for parotid surgery
A
- Partial superficial parotidectomy
- Capsular dissection
25
What is Frey's syndrome?
Complication of surgery occuring near the parotid gland, characterised by swelling at meal times and flushing of the face
26
What are the acinar cells?
Clusters of cells acting as the basic secretory unit of the salivary glands. They can be serous or mucous
27
What are the myoepithelial cells
Cells in the glandular epithelium around the acinar cells, which control luminal functions e.g. flow of fluid
28
Define: sialosis
Non-pathogenic, non-neoplastic increase in salivary gland size
29
Define: sialodenitis
Ductal infection
30
Define sialolithiasis
Duct obstruction
31
Define sialectasis
Cystic widening of the duct
32
Define sialorrhea
Excessive salivation or drooling
33
Aetiology of salivary gland tumours
- Ionising radiaition
- Occupational risks - rubber or car manufacturing, woodworking
- Little is known
- SMOKING AND ALCOHOL PLAY NO ROLE
34
Pathophysiology of salivary gland tumours
Unknown for most, except in the case of chromosomal translocations
35
How do chromosomal translocations occur
Non-disjunction at mitosis - there is mutations in the DNA repair genes and random breaks (double-strand break or reciprocal T)
36
Examples of salivary gland tumours caused by chromosomal translocations
- Pleomorphic adenoma
- Adenoid cystic carcinoma
- Mucoepidermoid carcinoma
- Secretory carcinoma
37
Presentation of salivary gland tumours
- All ages affected, but risk increases with age
- Lump in gland or mucosal at an intraoral site e.g. palate
- If malignant - there will be signs e.g. pain, ulceration, bone invasion, rapid growth, nerve signs
38
Where are malignant and benign salivary gland tumours more likely to occur?
Malignant - in minor salivary glands
| Benign - in major salivary glands
39
Which salivary gland tumours are benign?
- Pleomorphic adenoma
| - Warthin's tumour
40
Which salivary gland tumours are malignant?
- Mucoepidermoid carcinoma
- Polymorphous adenocarcinoma
- Acinic cell carcinoma
- Adenoid cystic carcinoma
41
List the features of benign salivary gland tumours
- Slow growing
- Well differentiated and encapsulated
- Soft or rubbery consistency
- Do not ulcerate
- No associated nerve signs
- Non-invasive and non-metastatic
- CO aesthetics or pressure
42
List the features of malignant salivary gland tumours
- Slow or rapid growth
- Non-capsulated
- Can be hard and indurated
- Progressively increase in size
- May be ulcerated
- Can mets
- Signs of malignancy (pain, impaired function, neurological signs)
- imaging shows an irregular pattern of destruction or invasion
43
What is the most common salivary neoplasm?
Pleomorphic salivary adenoma - around 75% of parotid tumours
44
List the features of pleomorphic salivary adenomas
- Arise from duct epithelium or myoepithelial cells
- Encapsulated
- Painless and slow growing
45
Ix for pleomorphic salivary adnoma
- Sialography showing 'ball-in-hand'
- Histology showing incomplete capsule, ducts, sheets or dark-staining epithelial cells, squamous metaplasia or foci of keratin
46
How is pleomorphic salivary adenoma diagnosed?
Via FNA
47
Tx of pleomorphic salivary adenoma
Wide excision
48
Recurrence risk of pleomorphic salivary adnoma
High risk due to difficulty removing entire tumour due to proximity to facial nerve
Risk is reduced by removing the gland with the tumour
49
Describe the features of Warthin's tumour
Almost always in the paortid
Mobile, firm to fluctant
Enlcueated
May be single or multiple
50
Histology of Warthin's tumour
Tall, eosinophillic columnar cells forming a folded layer covering lymphoid tissues
51
Tx to Warthin's tumour
tends to respond to enucleation
52
What is the most common malignant salivary neoplasm
Mucoepidermoid carcinoma (3-9% of all salivary gland neoplasm)
53
Describe the features of mucoepidermoid cecinomas
Most in minor salivary glands (esp palate)
| Can be high or low grade
54
Tx of mucoepidermoid carcinoma
Wide excision with risk of reucrrence
55
Describe the features of acinic cell carcinoma
Rare (1% of all salivary gland tumours)
Low to intermediate grade salivary neoplasm with serous granules
Often arises in the parotid
Invasive and sometimes mets
56
Histology for acinic cell carcinoma
Uniform pattern of large cells with granular basophilic cytoplasm
Round holes gives a lace appearance
57
Describe the features of adenoid cystic carcinoma
Arise in major or minor glands
Initial presentation often nerve palsy or 'funny feeling'
Slow growth but highly INFILTRATIVE along nerve sheaths
58
Prognosis for adenoid cystic carcinoma
Very poor 15 year diagnosis due to late presentation (due to slow growth)
59
Tx for adenoid cystic carcinoma
Wide excision, often combined with radiotherapy at the earliest possible stage
60
Histological appearance of adenoid cystic carcinoma
Round groups of darkly stained cells with multiple clear spaces (looks like swiss cheese)
61
What is a carcinoma ex pleomorphic adenoma?
A carcinoma arising from pre-existing pleomorphic adenoma
62
Prognosis for carcinoma ex pleomorphic adenoma
Poor if it breaches the capsule (specifically extracapsular invasion>8mm) due to high infiltrative and metastatic spread
63
Describe polymorphous adenocarcinoma
Variable grades but often low grade in the minor glands (palate)
Local recurrence occurs, but it rarely mets
Can spread along nerve sheaths
Good prognosis
64
What is an example of a non-epithelial tumour affecting the salivary glands
Lymphoma
65
Where do lymphomas affecting the salivary gland arise?
- In the lymph nodes within the gland (high-grade-B-cell lymphoma or Hodgkins) or in the gland parenchyma (MALT lymphoma)
66
What are the tumour-like salivary swellings to be aware of?
Necrotising sialometaplasia
| Sialadenosis
67
what is necrotising sialometaplasia
Affects minor glands in the palate, often in males and smokers, painless but ulcerated swelling 1-2cm resembling a carcinoma
68
What is sialadenosis
Non-neoplastic, non-inflammatory enlargement of the salivary glands (most often parotids) caused by alcoholism, diabetes, endocrine disturbances, pregnancy, drugs, bulimia
69
What are the non-neoplastic salivary gland diseases
```
Calculi
strictures
Fistula
Mucoceles and cysts (including ranulas)
Sialadenitis
Xerostomia
Sjogreans disease
```
70
What is the most common cause of salivary gland swelling
Calculi (sialolithiasis) - this is when a stone forms in the duct
71
Epidemiology for calculi
Adults, males 2:1
80% in SM, 6% in P and 2% in sl
Unilateral
72
Presenting signs and symptoms for calculi
Asymptomatic
There may be pain at mealtimes, when the stone passes forward to the orifice or if it becomes infected
it does not cause dry mouth!!!
73
Ix for calculi
Plain film radiographs - however not all stones are radiopaque
Sialography
74
Pathology of calculi
Deposition of calcium salts around organic material
Tend to have a rough lining which may cause squamous metaplasia of the duct lining or inflammation and fibrosis of the duct due to microbial flora
75
Tx of calculi
- Identify stone and damage to the duct
- if far forward - push it out the orifice
- If distally placed - intervention using conservative approach (basket removal or lithotripsy)
- Conventional removal
- Excision if extensive damage to the duct
76
Aetiology of duct strictures
Chronic trauma leading to fibrosis e.g. clasps, faulty restorations, sharp teeth
77
Ix for strictures
Sialography will show narrowing of the duct or papilla and the dilation distal to the pathology
78
tx of strictures
Depends on site of obstruction - dilation or excision may be required
79
What is the most common cyst found in the salivary glands
Extravastatoin mucocele of the minor glands
80
Difference between extravastation and retention cysts?
Extravastations have no epithelial lining (not true cysts)
| Retention cysts have an epithelial lining
81
Aetiology of mucoceles
Damage to the duct or mucous gland e.g. trauma to the lip
82
Pathology of mucoceles
Saliva leaks from the damaged duct into the superficial tissue, causing inflam response
Pools of saliva coalesce around the liquid by compressed connective tissue
83
Describe the presentation of mucoceles
- Common on lower lip on young patients or BM on older patients
- Superficial lesion around 1cm dia
- Round fleshy swelling at first, then it becomes hemispherical, fluctuant and blusish
84
What is a ranula?
An uncommon salivary cyst found at the floor of the mouth (arise from sublingual or submandibular salivary glands
85
How to distinguish between mucocele and retention cyst?
Histological examination
86
Tx for mucoceles and cysts
- re-establish duct continuity via cryotherapy, sutures, decompression
- If small and superficial - excise with underlying gland
87
Tx for ranulas
Marsupialisation and removal of associate gland to prevent recurrence
88
What is a plunging ranula
Form when a rapidly growing simple ranula bursts
89
Presentation of acute sialdenitis due to mumps
- Painful swelling of the parotids +/- other glands
| - systemic symptoms - malaise, fever, headache
90
What is the most common cause of acute sialdenitis
Mumps
91
Presentation of supparative parotitis
- Uni or bilateral painful parotid glands with swelling, redness, tenderness, malaise and fever
- Enlargement of region lymphs
- Pus exudate from parotid ducts
92
Aetiology of supparative parotitis
- Staph aureus, streptococci and anaerobes
| - Usually seen in patients with severe xerostomia (sjogrens) or a complication of tricyclic antidepressants
93
Tx for supparative parotitis
Flucloxacillin
94
Presentation of chronic sialadenitis
- Asymptomatic or with intermittent low-grade painful swelling of the gland
- Often unilateral
95
Aetiology of chronic sialdenitis
Complication of duct obstruction
96
Histology of chronic sialdenitis
Duct containing mucin and neutrophils surrounded by a layer of fibrosis with severe acinar atrophy
Lymphocytic infiltration and squamous metaplasia of the duct epithelium
97
What is Kuttner's tumour (chronic sclerosing sialadenitis)
Chronic inflammatory disease of the salivary glands characterised by progressive fibrosis, dilated ducts with dense lymphocyte infiltration and acinar atrophy
98
What is allergic/eosinophilic sialdentisis (sialadenitis fibrinosa)
Rare salivary condition usually found in Japan in atopic patients, characterised by strings of thick saliva in dilated ducts with increase esosinophils
99
Define: dry mouth
Condition of decreased flow of saliva, caused by failure of the salivary glands to function as normal, or a sensation of dry mouth occurring even though the salivary glands function as normal
100
Define: hyposalivation
OBJECTIVE dryness of the mouth
101
Define: xerostomia
Subjective complaint of dryness
102
What may be a presenting complaint for dry mouth?
- Dryness
- Difficulty eating dry food
- Unpleasant taste in the mouth
103
Aetiology of subjective xerostomia (false xerostomia)
- Mouth breathing
- Night dryness
- Psychological and psychogenic
104
Aetiology of objective (true) xerostomia
- Drugs
- Psychogenic (anxiety)
- Dehydration - diabetes, cardiac or renal failure, low fluid intake or fluid loss
- Gland or nerve damage - sjogrens, irradiation or cytotoxic drugs
- Hypoplasia or aplasia of the glands
105
List the types of drugs responsible for xerostomia
- Anticholinergics - antiparkinsons, tricyclic antidep, antihistamines, phenothiazines
- Sympathomimetics - amphetamines, decongestants
- Centrally acting - L DOPA, lithium, optiates and benzos
- Dehydration - diuretics, alcohol and coffee
106
List the mechanisms by which drugs cause xerostomia
- Directly acting on glands
- Acting on sympathetic nerves and ganglia
- Acting on parasympathetic nerves and ganglia
- Cause dehydration
107
which drugs do not cause xerostomia?
- Beta blockers
| - Smoking
108
Describe the influence of the parasympathetic nervous system on salivary flow
- Responsible for secretory function
| - If the PSNS is blocked, the gland will atrophy (this is why drugs act on the PSNS to increase salivary flow)
109
Describe the influence of the sympathetic nervous system on salivary flow
Responsible for protein secretion
| If SNS is blocked, there is little effect on the glands
110
What are the clinical features of xerostomia?
- Mirror or fingers sticking to mucosa
- Sticky, stringy or frothy saliva
- Matte mucosa
- Difficulty swallowing and speaking
- Oral discomfort
- Reduced denture retention or tolerance
111
What are some indirect complications of xerostomia?
- Bad taste
- Caries
- Candida
- Erythematous gingiva
- Sialadenitis
- Lobulation of dorsal tongue or increased fissuring
- Mucosal atrophy or lateral tongue depapillation
112
Management sequence of dry mouth
- History and examination
- Special IX
- True or false - diagnosis
- Specific treatment
- Assess risk of complications and plan prevention
113
History of xerostomia that leads to a 'true' diagnosis
- Prolonged and unremitting dryness
114
What factors should you consider in your history and examination phase for xerostomia?
```
Smoking and drug history
History of radiotherapy
History of autoimmune disease
Mouth breathing
Bad taste in the mouth
Other dryness e.g. eyes
```
115
List the special ix for xerostomia
- Salivary flow rate
- Saliva sample for candida and pathogens
- Referral for sjogrens testing - lacrimal, serology, ultrasound and biopsy
116
What salivary flow rates will indicate reduced flow?
- Whole unstimulated flow is <0.2ml/min over 10mins (2ml over 10 mins)
- Stimulated parotid flow is <0.4ml/min (4ml) from a single glad on stimulation with citric acid twice in 10 mins
117
Tx options for dry mouth
- Ensure hydration throughout the day
- Avoiding drying drugs
- Use of flow stimulants
- Treat mucosal soreness and denture difficulty symptomatically
- Monitor for complications - caries, candida
118
Define: Sjogrens syndrome
Relatively common, multisystem, chronic autoimmune disease which is characterised by mononuclear infiltration of salivary and lacrimal glands, progressive glandular atrophy and loss of function.
119
What is primary and secondary sjogrens
Primary - sjogrens alone
| Secondary - sjogrens alongise another connective tissue disease
120
Epidemiology of sjogrens
Females > males (9:1)
| Usually occurs in middle age (1st peak in mid 30s then postmenopausal)
121
Aetiology of sjogrens
Unknown - likely to have genetic susceptibility triggered by environmental factors
122
Describe the pathology of sjogrens
- Glands become infiltrated by activated B cells (hyperactive b cells)
- B cells collect around ducts and destroy acinar cells
- Late stages are characterised by glandular atrophy and destruction of ducts
123
What autoantibodies are markers for sjogrens
- Antinuclear factor ANF
- Ro (SSA) and La (SSB)
- Rheumatoid factor RF
- Gastric parietal cell antibody
- Anti-thyroid antibody
- Anti-salivary duct antibody
124
Ocular features of sjogrens
- Failure of tear formation
- Drying of conjunctiva - C/O dry gritty eyes
- Burning soreness
- Eyelids adherent in the AM
- Keratoconjunctivitis sicca
125
Oral signs of sjogrens
- Signs of xerostomia (mirror sticking, matte mucosa, fissuring of the tongue)
- Loss of function - hard to eat, speak
- Recurring infection (candida and possibly angular cheilitis)
126
Extraoral signs of sjogrens
- Swelling of parotids (may be historical) - however it is rarely painful
- Dry skin, vagina, oesophagus, lungs
- Raynaud's
- Vasculitis
- Fatigue, myalgia and arthalgia
- Memory loss
127
What type of sjogrens is more severe?
Primary sjogrens
128
What other autoimmune conditions are associated with sjogrens
Rheumatoid arthritis (10-50%)
Systemic lupus erythematous (30%)
Scleroderma
129
Diagnostic testing for sjogrens
- Salivary flow rate
- Lacrimal function
- Antibody screening
- Labial salivary gland bipsy
- Sialography
130
How many diagnostic factors are required for a diagnosis of Sjogrens to be made?
4/6 of the symptoms in the criteria are met
131
What is the criteria for a sjogrens diagnosis
1. Autoantibody and/or positive minor gland biopsy
PLUS 2 or 3 of:
- Ocular symptoms >3months
- Oral symptoms >3 months +/- gland swelling
- Ocular signs - Schrimers, scintigraphy, reduced flow
132
List the histological appearance in sjogrens
- Periductal lymphocytic infiltrte
- Expansion of infiltrate
- Atrophy of acinar cells
- Ductal hyperplasia forming epimyoepithelial islands
- Formation of lymphoepithelial lesion
133
Management of sjogrens
- Reassurance
- Multidisciplinary care
- Dry mouth - sipping water, saliva substitutes
- Caries risk prevention
- Antifungals when required
134
What are the types of saliva substitutes available
- Sprays, lozenges, gels, pastilles
| - Pilocarpine to stimulate flow
135
What does MALT stand for
Mucosa associated lymphoid tissue
136
What are the characteristics of MALT lymphomas
Low grade
Indolent behaviour
Good prognosis
137
Why is the risk of MALT lymphomas high with sjogrens disease?
- B cell proliferation is continually occuring - eventually a clone may escape control of division and form a lymphoma
138
Where do MALT lymphomas arise?
In the affected parotid gland and may remain localised for many years
139
Where do MALT lymphomas spread?
Local lymph nodes or other MALT sites around the body
140
What is the lifetime risk of MALT lymphoma for someone with sjogrens
5%
141
When should you suspect MALT lymphoma?
Patient with sjogrens with swollen glands until proven otherwise
142
Risk factors for MALT lymphoma
- Parotid enlargement esp if sudden
- Lymph node involvement
- Vasculitits
- Neutropenia
- Low CD4 count
- Systemic symptoms - night sweats, fever
143
Diagnosis of MALT lymphoma
Biopsy from lower pole of the gland (prevent damage to facial nerve)
144
Tx of MALT lymphoma
- Radiotherapy, chemotherapy and surgery are all options
145
What is IgG4 sclerosing disease
Multiorgan immune mediated condition with many presentations - but all are a primarily fibrotic mass
146
what salivary gland complication is seen in IgG4 sclerosing disease?
Sialadenitit of major and minor glands: including: Kuttner's tumour and Mikuliczs disease
147
What is Mikuliczs disease?
Disorder characterised by enlarged lacrimal and parotid glands due to infiltration with lymphocytes
148
What salivary gland symptoms are seen with HIV?
- Swollen parotids - usually gradual and uni or bilateral, painful and disfiguring
- Xerostomia with no obvious cause
- Dry eyes and arthalgia
149
What salivary gland symptoms are seen with Sarcoidosis?
- Uni or bilateral parotid gland swelling +/- facial palsy (Heerfordt's syndrome)
150
What is sarcoidosis?
Inflammatory, multi-organ disease, characterised by formation of granulomas commonly affecting the lumps and lymph glands
151
What is ptyalism
Excess salivation
152
Why is true ptyalism an uncommon complaint?
Excess saliva can be readily swallowed
153
Aetiology of false ptyalism
Psychogenic
Bells palsy
Parkinsons
Stroke
154
Aetiology of true ptyalism
- Oral infections or wounds
- Dental procedures
- Oral appliance e.g. new dentures or retainer
- Systemic - nausea or acid reflux
- Iodine
- Heavy metal poisoning
