Salivary Gland Diseases PDF

Department Name Salivary gland diseases Prof Dr. Rehab Fawzi Kasem Head of Oral Pathology Department and Vice Dean of Environment Affairs Development and Community Services Salivary gland diseases ‫رؤﯾﺔ ورﺳﺎﻟﺔ اﻟﻛﻠﯾﺔ‬ Vision “Shaping the future of Dentistry through exce...

Department Name Salivary gland diseases Prof Dr. Rehab Fawzi Kasem Head of Oral Pathology Department and Vice Dean of Environment Affairs Development and Community Services Salivary gland diseases ‫رؤﯾﺔ ورﺳﺎﻟﺔ اﻟﻛﻠﯾﺔ‬ Vision “Shaping the future of Dentistry through excellence in Dental Education, innovative Research, patient-centered care, and health promotion Internationally”. ‫اﻟرؤﯾﺔ‬ ‫ﺗﺷﻛﯾل ﻣﺳﺗﻘﺑل طب اﻻﺳﻧﺎن ﻣن ﺧﻼل اﻟﺗﻣﯾز ﻓﻲ اﻟﺗﻌﻠﯾم اﻟطﺑﻲ واﻷﺑﺣﺎث اﻟﻣﺑﺗﻛرة واﻟرﻋﺎﯾﺔ اﻟﺻﺣﯾﺔ اﻟﺗﻲ‬.‫ﺗرﺗﻛز ﺣول اﻟﻣرﯾض وﺗﻌزﯾز اﻟﺻﺣﺔ ﻋﺎﻟﻣﯾﺎ‬ Mission: “Provide learner-focused dental education, cutting-edge scientific research, patient-centered care, and community engagement all within a positive organizational culture”. :‫اﻟرﺳﺎﻟﺔ‬ ‫ﺗوﻓﯾر ﺗﻌﻠﯾم طب اﻻﺳﻧﺎن اﻟذي ﯾرﺗﻛز ﻋﻠﻲ اﻟﻣﺗﻌﻠم واﻟﺑﺣث اﻟﻌﻠﻣﻲ اﻟﻣﺗطور واﻟرﻋﺎﯾﺔ‬ ‫ ﻛل ذﻟك ﻓﻲ اطﺎر ﺛﻘﺎﻓﺔ ﺗﻧظﯾﻣﯾﺔ‬,‫اﻟﺻﺣﯾﺔ اﻟﻣرﺗﻛزة ﻋﻠﻲ اﻟﻣرﯾض واﻟﻣﺷﺎرﻛﺔ اﻟﻣﺟﺗﻣﻌﯾﺔ‬ ‫إﯾﺟﺎﺑﯾﺔ‬ Core Values: Leadership. Excellence. Innovation. Collaboration. Respect. Integrity :‫اﻟﻘﯾم اﻟﺟوھرﯾﺔ‬ ‫ اﻟﻧزاھﺔ‬.‫ اﻻﺣﺗرام‬.‫ اﻟﺗﻌﺎون‬.‫ اﻻﺑﺗﻛﺎر‬.‫ اﻟﺗﻔوق‬.‫اﻟﻘﯾﺎدة‬ Classification of salivary gland diseases (Parotid swellings) III - OBSTRUCTIVE: I-DEVELOPMENTAL: Sialolithiasis Aplasia. IV - CYSTIC: Atresia 1. Mucous Extravasation cyst Abberancy. 2. Mucous Retention cyst II-INFECTIOUS: 3. Ranula A. Bacterial: V - AUTOIMMUNE: ( Degenerative Disease of 1. Non-Specific: Salivary Glands ) 1. Acute suppurative (post operative) parotitis. Sjogren's syndrome 2. Chronic Sialadenitis. VI - NEOPLASTIC: 3. Recurrent Sialadenitis. A. Benign: 2. Specific: 1. Pleomorphic adenoma a. Tuberculosis 3. Papillary cystadenoma Lymphomatosum b. Actinomycosis B. Malignant: B.Viral: 2. Adenoid cystic carcinoma Mumps 3. Mucoepidermoid carcinoma Acute Suppurative Parotitis (Post Operative) A middle age male patient subjected to abdominal operation , Post operatively he manifested apinful swelling of the parotid gland, uplifting of the ear lobe, The overlying skin is reddened, edema may involve the cheek, and neck, By digital pressure, pus may be expressed from the duct of the gland. Lab investigation revealed Increased sedimentation rate (ESR) and leukocytosis. Patient also suffers malaise, headache and low grade fever Etiology As a sequela to abdominal operations, mainly due to postoperative dehydration (which cause secondary Xerostomia) and poor oral hygiene. Debility Drugs that cause xerostomia Bacterial infections affects mainly parotid glands due to Staphylococcus-streptococci,pneumococci. The organisms reach the gland from the oral cavity through the duct. Treatment 1. Antibiotics 2. Proper oral hygiene. 3. Proper maintenance of fluid and electrolyte balance. CHRONIC SIALADENITIS A middle age male patient suffers pain and unilaterak swelling in parotid gland (submandibular gland). The pain subsided within a few days but the swelling persisted for weeks or even months. Clinical examination revealed a solid mass within the gland duct (obstructed duct). Microscopic examination revealed periductal chronic inflammatory cell infiltration, hyperplasia of ductal epithelium and fibrosis leading to disappearance and atrophy of the acini. Nonspecific chronic sialadenitis reveals dilatation of ducts, interstitial infiltration of lymphocytes and fibrosis. Recurrent parotitis A middle age male patient have good oral hygiene and suffers swelling often starts at a mealtime and may persist from half an hour to several days. The swelling is firm and smooth but not hot. There is a feeling of tension and pain at meal time. Patient manifests Xerostomia during an attack. It is a form of chronic sialadenitis with acute exacerbation Mumps , Epidemic parotitis A 15 years old male suffers pain and swelling started in one parotid gland, after one or two days the both glands manifests both pain and swelling. The swollen area is tender and painful. it is slowly subsides within (7) days. Ear lobe is pushed upwards and outwards. Redness and swelling about the opening of Stensen's duct. Red rash on the trunk. the patient suffers headache, malaise and fever. A virus culture is done by swabbing the inside of the cheek or throat. The swab collects mucus and cells and is sent to a lab to be tested for the pathogen. Salivary analysis also took place. Etiology It is an acute, contagious viral disease. Caused by RNA virus paramyxovirus. The infection occurs by droplet infection. After infection the virus becomes blood-borne to many tissues, among which the salivary and other glands are most susceptible. Lifelong immunity usually follows clinical or subclinical infection although second infections have been documented. Diagnosis of Mumps: 1-Swelling of parotid first the swelling is unilateral then cecomes bilateral 2-Virus culture….cytology 3-Saliva analysis 4-Virus can be isolated from cereprospinal fluid in cases of menegitis 5-Virus can be isolated from any body fluid even tears Anyone who is diagnosed with mumps should be excluded from school or childcare, and should minimize contact with others during the contagious period, which is 9 days after his or her glands begin to swell. Complications of mumps 1. Meningitis 2. Orchitis (Testicular inflammation)🡪Infertility Rarely occurs in young age, but is common in adults. The affected testis becomes swollen and tender. 3. Pancreatitis presented by Epigastric pain, vomiting; fever and chills. 4. Myocarditis 🡪(myocardium) Pericardial pain and fatigue. 5. Deafness, arthritis, & optic neuritis.  Department Name Salivary gland disaeases Prof. Dr. Rehab Fawzi Head of the Oral Pathology Department  Sialolithiasis(salivary calculus) A young age male patient suffers palpable tender swelling in the floor of mouth. Occlosal radiograph reveals well circumscribed small radiopacity. Histologically, intraductal mass consists of concentric laminations of calcium salts around a nidus of micro-organisms, foreign bodies or desquamated epithelial cells. Calcium phposphate or carbonate are the major inorganic components. Mucopolysaccharides, cholesterol and uric acid are the major organic compounds. -Salivary stone mainly affects submandibular gland since has tortous irregular course and viscous secretion Complications: chronic sialadenitis Mucous retention cyst Macroscopically, this mass does not exceed 1cm in length.  SJOGREN'S SYNDROME Middle age female suffers from, decreased salivary and lacrimal function, keratoconjunctivitis, dryness with burning and sandy sensation of the eyes and photophopia. redness, Lacrimal gland enlargement. Also patient manifests dryness of the nose ,pharynx and skin with scaling and pruritus. Patient suffers group of oral manifestations which are chronic salivary gland enlargement, bilateral, intermittent or persistent, difficulty in swallowing mastication & speech, abnormalities in taste, soreness and ulceration of the oral mucosa, which appears dry, smooth and glazed. patient’s tongue is red with atrophy of the papillae and deep fissures. Plaque accumulates with progressive dental caries and tooth erosion, Patient show arthritis also. Histopathological examination of the minor or major salivary gland show lymphocytic infiltration of the gland, acinar degeneration, ductal dilatation, ductal hyperplasia and presence of epimyoepithelial islands.  Cherry blossom or branchless fruit laden tree Radiographic examination(sialography) reveals Snow flake appearence Pathogenesis Autoimmune disease :a condition in which an individual's primary defense mechanism is directed against his own tissues producing circulating antibodies that affect specific tissues and organs such as: skin, joints and medium sized blood vessels but may have: Environmental, genetic and hormonal contributors which seem to be involved in the pathogenesis of the disease. ❖ Environmental risk factors, possibly including chronic viral infections such as the Epstein–Barr virus, cytomegalovirus, hepatitis C virus, human herpes virus 6, coxsackie virus and several retroviruses ❖ The genetic background of Sjögren's syndrome patients is an active area of research. The illness is sometimes found in other family members. It is also found more commonly in families that have members with other autoimmune illnesses, such as systemic lupus erythematosus, autoimmune thyroid disease, type I diabetes, etc.  Classified into: Primary SS (pSS) isolated disorder. In pSS, decreased exocrine gland function leads to the ‘sicca complex’, a combination of dry eyes (xerophthalmia) and dry mouth (xerostomia) Secondary SS (sSS) is associated with other rheumatic conditions, of which the most common is rheumatoid arthritis or other autoimmune disease as systemic lupus erytherematosus (SLE)  Diagnosis 1-Careful clinical examination and history (xerostomia and salivary swelling) 2-Stimulated parotid salivary flow rates are measured a spit test – you spit as much saliva as you can into a cup over a five-minute period and the amount is then measured or weighed Normal salivary flow is between 1 & 2 ml per minute but may be reduced to less than 0.5 ml/mm. 3-Salivary gland biopsy 4-Sialography 5-Ophthalmological Examination Persistant forign body sensation, burning sensation and absence of tears harmless coloured drops being placed in your eyes to make the layer of tears easier to see for a short time. Your doctor then looks at your eyes using a special microscope with a light. 6-Serological examination (blood tests for autoantibody screeining) Antinuclear antibody Antisalivary duct antibody Anti-thyroid factor Rhematoid factor Antinuclear antibodies) Anti-Ro/Anti-SSA Antibodies Anti-Ro/SSA and anti-La/SSB antibodies are ANAs that have been detected with high frequency in patients with SLE and in patients with Sjogren's syndrome. Anti SS-A/RO and anti SS-B/La are autoantibodies against ribonucleoprotein. Anti-SS-B/La is more specific for Sjogren’s syndrome in primary form. Treatment: Only symptomatic treatment by : 1- artificial tears 2- artificial saliva 3. caries Control using topical fluorides and Suggest sugar-free gum 4. maintain good oral hygiene using Chlorhexidine rinses to reduce plaque formation.  Complications 1- Lymphoma people with Sjögren's syndrome are about five times more likely to get non-Hodgkin lymphoma than those who don't have the condition, but the chances of getting it are still small. 2-Pseudo-lymphoma (wide involvement of lymph nodes)  Department Name Benign salivary gland neoplasms Prof Dr Rehab Fawzi Head of Oral Pathology Department  VI. SALIVARY GLAND NEOPLASMS Classification of Salivary Gland Neoplasms I. Benign 1. Pleomorphic adenoma ('mixed tumor'). 2. Papillary cystadenoma lymphomatosum (Warthin's tumor). II. Malignant 1. Adenoid cystic carcinoma 2. Mucoepidermoid carcinoma  Malignant Benign Same Middle age –elderly Age Same ♀>♂ Sex Except: Warthin’s tumor 45% of minor salivary 85% of parotid Site gland tumors tumors  Malignant Benign Painful Painless Irregular mass Nodule Rapidly growing slowly-growing Increase in size rapidly by time Small in size Sometimes firm consistency Soft or rubbery consistency ulceration of the mucosal Overlying mucosa or skin are surface and invade bone intact with same color & texture as surrounding Except: if subjected to trauma Fixed to overlying mucosa & Movable underlying structure Except: neoplasms of palate facial nerve paralysis if affect No associated nerve signs  Malignant Benign Fixed to overlying mucosa Movable Clinically & underlying structure Except: neoplasms of palate Because of tightly bound nature of the hard palate mucosa, tumors in this location are not movable Paresthesia (sensory No associated nerve nerves, V) and facial nerve signs paralysis (motor nerves, VII) if affect parotid Non capsulated Capsulated Histology  Pleomorphic Adenoma A middle age female patient suffers freely movable unilateral painless, soft tissue swelling in the parotid region, no ulceration, no hemorrhage, no facial paralysis. Grossly, the lesion is encapsulated and of variable consistency.  Microscopic examination reveals lesion surrounded by fibrous capsule of variable thickness, completeness and density. The lesion shows multiple duct like structures, masses of epithelial cells.  zones show network appearance consists of cells with small cell body and long cytoplasmic processes in a fibrillary basophilic matrix, other zones show rounded or oval cells surrounded by thick homgenous pink matrix Myxoid Chondroid matrix matrix  Histogenesis of Pleomorphic Adenoma pleomorphic adenomas arise from the intercalated ducts. Both epithelial and myoepithelial cells participate in their formation. These cells are responsible for the development of variable histological features of this neoplasm. Benign mixed tumor, it is the most common salivary neoplasm. It has variable histological features. Myxoid Matrix Epithelial cells Duct like structures  myxochondroid matrices give the mesenchyme-like elements. Signs of malignant transformation into malignant pleomorphic adenoma 1-Rapid growth 2-Ulceration 3-Hemorrhage 4-Pain 5-Facial paralysis  Papillary Cystadenoma Lymphomatosum (Warthin's Tumor) An adult male suffers painless, movable swellingin the parotid region. Grossly, cut section show papillary cystic spaces. Microscpic examination reveals multiple cytic spaces lined with 2layers of cells , the basal layer is cuboidal cells and the luminal cells are columnar cells with granular eosinophilic cytoplasm and show apical striations. In between the columnar cells present the goblet cells which are mucous secreting cells. The cystic spaces contain mucin. The cystic spaces surrounded by diffuse T and B lymphocytes. Germinal centers also present  Germinal centre Irregular cystic spaces Double layered epithelial lining Non-neoplatic lymphocytes Mucin in cystic cavity Granular cells have eosinophilic granular cytoplasm. Granules are giant mitochondria. Granular cells are oncocytes  Histogenesis: During embryonic life; late encapsulation of parotid gland will lead to entrapment of some epithelial salivary tissue within the surrounding small lymph nodes.  The presence of such salivary elements in lymph nodes adjacent to the parotid gland, as well as the presence of lymphoid tissue within the parotid gland, is thought to be responsible for the more frequent occurrence of adenolymphomas in the parotid area, and the absence of such tumors in the submandibular and sublingual glands. Warthin’s tumour originates from stiated ducts of the part of the parotid gland ectopically present within the adjacent lymph node. Oncocytes An oncocyte is an epithelial cell characterized by an excessive number of mitochondria, resulting in an abundant acidophilic, granular cytoplasm. By E/M granules are giant mitochondria.  Goblet cells: among the epithelial cells lining the interlobular and intralobular ducts of all salivary glands there is a variable number of irregularly dispersed mucin secreting cells called goblet cells. The existence of these cells explains the occurrence of a mucinous growth in the almost exclusively serous parotid gland whose acini do not produce mucin  Department Name Malignant salivary gland neoplasms Prof.Dr.Rehab Fawzi Head of Oral Pathology Department  Muco-epidermoid Carcinoma A middle age female patient has palatal ulcer. The ulcer shows hemorrhage and by palpation it reveals fixed base. Grossly, the lesion is non encapsulated, cut section may be cystic and contains clear mucoid materisl, other sections may be solid and shows grayish white areas. Microscopic examination shows cystic spaces lined with mucous secreting cells. Some of these cystic spaces show a combination of mucous secreting cells and epidermoid cell (squamous cells)show nuclear hyperchromatisn and other nuclear changes.Masses of mucous secreting cells as well as masses of epidermoid cells can be detected with in the neoplasm. Histogenesis of mucoepidermoid carcinoma: This neoplasm arises from the epithelium of excretory ducts. they may thus contain cuboidal and flattened epithelial cells( epidermoid cells of squamous differentiation) as well as mucin-secreting cells and myoepithelial cells.  Low grade mucoepidermoid carcinoma High grade MEC A higher magnification Adenoid Cystic Carcinoma A middle age male patient has painful palatal ulcer. Hemorrage can be detected. Palpation of ulcer reveals fixed base. Grossly, neoplasm is not encapsulated and cut section my show solid grey areas together with cystic areas. Microscopic examination shows tubular and duct like structures lines with uniform monotonous darkly stained cells called basaloid cells. Solid masses of theses cells can be detected in other fields. Multiple cystic spaces also can seen reflects Swiss cheese appearance or sieve like appearance. Clusters of basaloid cells can be detected surrounding nerve fibers and invading perineural lymphatic spaces. Basaloid cells Patterns of adenoid cystic carcinoma 1)Tubular/trabecular Tubular pattern Trabecular pattern Condensation of stroma 2)Cribriform pattern Swiss cheese” or sievelike appearence 3)Solid pattern Increased cellular pleomrphism and mitotic figures  Histogenesis Adenoid cystic carcinoma arises from intercalated ducts. They have a special tendency to invade and spread along perineural lymphatic spaces, and this probably accounts for the frequent complaints of pain and tenderness associated with this neoplasm, as well as spreading to areas far from their anticipated destination (regional lymph nodes) and the spontaneous paralysis of the facial nerve when it occurs in the parotid gland as neoplasm invades nerves. The tumour is commonly recurrent and has a greater tendency to haematogenous dissemination than other salivary gland tumours. Adenoid cystic carcinoma showing perineural invasion  The percentages of each pattern form the basis of the grading system Grade I tumors contain only the tubular or cribriform growth pattern, grade II tumors contain cribriform or tubular growth with less than 30% solid component, and grade III tumors contain more than 30% solid component. The presence of a solid component has been a consistent predictor of poor prognosis.