SALIVARY GLAND DISEASEit protein rich hypotonic solution. Salivary gland disease •Most common...
Transcript of SALIVARY GLAND DISEASEit protein rich hypotonic solution. Salivary gland disease •Most common...
SALIVARY GLAND & ITS DISEASE
INTRODUCTION CLASSIFICATION
• Major salivary glands
• Minor salivary glands
Major Salivary Glands
a. Parotid gland
▪ Purely serous in adult and predominately serous in newborn.
▪ 25% contribution to saliva
▪ Secreted through Stensen’s duct
▪ Orifice visible in buccal mucosa adjacent to maxillarymolar.
Submandibular gland
Predominately serous
Contribute 60% to the salivary secretion
Secretion through Wharton’s Duct opening either side of lingual frenum
Sublingual gland
Predominately mucous
Contribute 5% to the salivary secretion
Secretion through multiple small independent duct or may empty directly into the Wharton’s Duct
Minor salivary gland
1. Labial (superior and Inferior), lips
Mixed (predominately mucous)
2. Buccal – cheek, Mixed (predominately mucous)
3. Glossopalatine – anterior faucial pillar, glossopalatine
fold- purely mucous
4. Palatine : hard and soft palate, uvula- purely mucous
5. Lingual
(anterior tongue )- mixed predominately mucous
Circumvillate papillae( Von Ebner’s Gland) purely serous
Posterior – mucous
• At rest minor salivary gland may produce half of the
salivary secretion of the oral cavity.
• On stimulation it produces only 10-20% of salivary
secretion.
• Saliva is highly complex mixture of water, organic and non
organic components.
• The basic anatomic structure of salivary gland are acinar
and ductal cell.
• Acinar cells are the secretory end piece of the gland,
secreting the fluid component of the saliva.
• Primary saliva secreted from acinar component is a
isotonic solution with serum.
• Extensive resorption of sodium and chloride and
secretion of potassium within the ductal system makes
it protein rich hypotonic solution.
Salivary gland disease
• Most common presenting symptom is
Xerostomia
• Second most common symptoms is
Swelling.
• Xerostomia not always results from salivary gland
hypo function
• 25% of older patient suffer from xerostomia….??
Causes of Xerostomia
▪ Developmental Origin
➢ Salivary gland aplasia
▪ Water/Metabolite loss
➢ Impaired fluid intake
➢ Hemorrhage
➢ Vomiting /diarrhea
▪ Iatrogenic Factor
➢ Medication (antihistamine, decongestant, anti depression, antipsychotic, sedative and anxiolytic)
➢ Radiation therapy to head and neck
➢ chemotherapy
▪ Systemic Disease➢ Sjogren Syndrome
➢ Diabetes Mellitus
➢ Diabetes Insipidus
➢ Sarcoidosis
➢ HIV
➢ Hepatitis C infection
➢ Graft versus host disease
➢ Psychogenic Disorder
▪ Local Factors
➢Decreased medication
➢Smoking and
➢Mouth breathing
Clinical Features of Xerostomia
▪ Signs of mucosal dryness
▪ Lips appears cracked, peeled and atrophied
▪ Buccal mucosa appear corrugated and pale
▪ Tongue appear smooth and reddened.
▪ Marked increase in carious lesion and erosion
(pattern??)
▪ Angular cheilitis and erythematous candidiasis
History and Clinical examination
Drug history
History of systemic disease/ radiotherapy
dryness of eye, skin , joint pain etc.
Difficulty in mastication and swallowing correlated
with decreased secreatory capacity of gland.
Oral pain and intolerance to spicy and coarse food
• Lipstick sign
Lipstick or shed epithelial cells on the labial
mucosa on maxillary anterior teeth.
• Tongue blade sign
Hold the tongue blade against the buccal mucosa
for few seconds if it stick to the mucosa the
sign is positive.
➢Decrease salivary flow on stimulation of gland.
➢Thick ropy saliva/scanty saliva instead of watery clear
and copious saliva indicates
Chronically reduced function
➢Cloudy exudate may indicates
Bacterial function
Treatment of xerostomia
▪ Difficult and unsatisfactory
• Frequent sipping of water
• Use of artificial saliva
• Use of sialogogue like Pilocarpine
Side Effects
Excessive sweating
Increased heart rate and blood pressure
Palpation of salivary gland
• Usually painless without any palpable mass
• Swelling occurs due to
• inflammation,
• infection or
• neoplastic growth.
If painful it indicates
Infection or acute inflammation
▪ Recurrent swelling or swelling with pain or without painmust be confirmed.
▪ Relation of swelling with food must be asked
▪ Tumor will present as painless solitary swelling
▪ Most commonly at the tail region
▪ Facial nerve paralysis must be confirmed or rule
out with parotid gland swelling
▪ Ulceration of overlying skin may indicates
malignancy
Investigations for salivary gland diseases
Saliva Collection
➢ Salivary flow rate provides important information
regarding the gland function
Whole saliva
• Mixed fluid content of the oral cavity
Methods of collection
▪ Draining
▪ Suction
▪ Spitting
▪ Absorbent
Spitting Method
• Ask patient to collect saliva in the mouth and
spit in pre weighted tube .
• Patient must be advised to spit once in 60
seconds for 5 to 15 minutes
Absorbent Method
• Pre weighted gauze sponge kept in the patient
mouth for set period of time.
Collection of Stimulated Saliva
▪ Ask the patient to chew on unflavored gum base or
inert material such as paraffin ( 60 times in a minute)
▪ Individual parotid gland saliva collection is performed
by using Carlson-Crittenden collectors
▪ From submandibular or sublingual gland using
aspirating device or alginate held collector called
segregator
▪ For general assessment of salivary gland function ,
un-stimulated whole saliva collection is the
recommended method of collection
What is the normal range of salivary secretion ??
Minimum value of un-stimulated salivary flow
0.1ml/min
Minimum value of stimulated salivary flow 0.7
ml/min
Sialochemistry
Saliva contains more than 60 constituents
Composition will change in many pathological condition
Saliva is also being used for screening of drug abuse,
estimation of viral infection, blood alcohol and hormone.
Imaging of salivary glandWhy do we need imaging??
▪ Most of the salivary gland diseases are having overlapping
signs
Imaging is needed to ascertain-
➢ Location of lesion whether it is intra glandular or extra
glandular
➢ Nature of the lesion whether it is inflammatory or
infectious or a mass.
Methods of imaging for salivary gland
Plain Radiography
Sialography
Ultra sonography
Radionuclide imaging
MRI
CT
Sialoscopy
Positron emission computed tomography
PLAIN FILM RADIOGRAPHY• Plain film radiography is a fundamental part of
examination of major salivary glands.
• It may provide sufficient information to preclude the
use of more sophisticated and expensive imaging
technique.
• It is useful when clinical impression supported by a
compatible history suggest the presence of sialolith or
any dystrophic calcification.
• Both extra oral and intra oral images should be taken to
demonstrate the entire region gland
Imaging of submandibular gland
Intraoral View
• Occlusal radiograph
Extra oral View
• Panoramic radiograph
• Lateral oblique radiograph
Imaging of parotid gland
Intra oral view
• Intra oral view of cheek
Extra oral view
• Panoramic view
• Lateral oblique view
• PA View of skull with cheek puffed out
Cross sectional mandibular occlusal projection
• It helps in imaging sialolith in the anterior 2/3 of
submandibular duct.
• For this projection patient should be positioned in a
semi recline position with head tilted back.
• Anterior border should be approximately 1 cm beyond
the mandibular central incisor.
• The central beam should be directed through the centre
of film and perpendicular to it.
Over the shoulder occlusal projection
• This projection is indicated to demonstrate the
sialolith in the posterior part of Wharton’s duct.
• In this projection, directing cone is placed over the
shoulder of the patient and centre beam is directed in
an anterior direction through the angle of the mandible
with the patient’s head tilted to the unaffected side and
rotated back.
Panoramic projection
• It is helpful in demonstrating sialolith present in the
posterior part of Wharton’s duct or intra glandular
sialolith in the submandibular gland.
Lateral oblique projection
➢ It is helpful in demonstrating sialolith in the
submandibular gland.
➢To project sialolith in the submandibular gland the
projection is need to be modified by opening the
mouth, extending the chin, and depressing the tongue
with the index finger. This improves the image of
sialolith by moving it inferior to the mandibular
border.
Intra oral view of cheek
• Parotid sialolith is more difficult to demonstrate as
compared to submandibular sialolith as a result of
tortuous course of stensen duct around the anterior
border of mandilble.
• As a rule, only sialolith anterior to the masseter muscle
can be imaged on intra oral film.
• To demonstrate sialolith in the anterior portion of the
parotid gland an occlusal film should be placed inside
the cheek over the parotid papilla. Central beam should
be directed perpendicular to the cheek and also
perpendicular to the film.
Posterior anterior skull projection with cheek puffed out
• PA Skull view with cheek puffed out may move theimage of sialolith free of bone rendering it visible onthe projected image. This technique may alsodemonstrate intra glandular sialolith that may beobscured during sialography.
• It is helpful in demonstrating sialolith in the distalportion of Stenson duct. It may also demonstrate intraglandular sialolith.
Limitation
• 20% of the sialolith of submnadibular gland
and 40% of that parotid gland are not well
calcified, so not visible on the plain films.
• Inflammatory changes in the ductal system or
in gland cannot be visualised using plain films.
Sialography• Sialography can be defined as the radiographic
demonstration of the major salivary glands by
introducing a radiopaque contrast medium into their
ductal system.
• It is an invasive procedure but the only imaging
modality for examining the fine anatomy of the
salivary gland ductal system.
• Sialography was first introduced in the year of 1902.
In 1925 Barsony first time introduced in vivo
sialography. Rubin and Holt in 1957 divided the
sialography into filling and emptying phase.
Conventional Sialography• It is the sialographic imaging technique that uses plain
radiograph for imaging gland and its ductal system.
Indication
• To detect or confirm small parotid or submandibulargland sialolith or foreign bodies.
• Evaluation of the extent of irreversible damage presentas a result of infection.
• Differentiation of disease such as chronic sialadenitis,Sjogren’s syndrome and sialosis.
• Evaluation of fistulae, strictures, diverticula,
communicating cyst and ductal trauma
• Rarely, as a dilating procedure for mild ductal
stenosis.
Equipments used
• Sialographic cannules
• Lacrimal dialators
• 5-10 ml of syringe
• Contrast media
• Secretogogue
CONTRAST MEDIA
• Contrast media suitable for sialography are all iodine
based. Contrast media that can be used for
sialography are of two types -
• Fat soluble or oil based contrast media
• Aqueous or water soluble
Oil based contrast media
• Densely radiopaque, thus show good contrast.
• High viscosity, thus slow excretion from the gland
Disadvantage
• Extravasated contrast media may remain in the soft
tissue for many months, and may produce a foreign
body reaction.
• Granuloma formation has been reported with the use
of ethidol following extravasation.
• High viscosity means considerable pressure needed to
introduce the contrast media, calculi may be forced
down the main duct.
Aqueous or water soluble mediaAdvantage
• Low viscosity, thus easily introduced.
• Easily and rapidly removed from the gland
• Easily absorbed and excreted if extravasated.
• No foreign body reaction or granuloma formation has been reported.
Disadvantage
• Less radiopaque, thus show reduced contrast.
• Excretion from the gland is very rapid unless used in a closed system.
The procedure is divided into three phases
• The preoperative phase
• The filling phase
• The emptying phase
Preoperative phase
This involves taking of scout or survey radiographs
• To look for, any radiopaque obstruction.
• To assess the position of shadows cast by normal anatomical
structures that may overlie the gland, such as the hyoid bone.
• To assess the exposure factor.
Filling phase
• Once the scout radiograph has been obtained, the
relevant duct orifice need to be located and
cannulated.
• If difficult to locate the ductal orifice gland can be
milked gently to locate the ductal opening.
• Once it is located it should be cannulate to introduce
contrast media.
• Once the contrast medium is introduced the filling
phase radiograph has been taken, ideally at least two
different views at right angle to each other.
For submandibular gland
• lateral mandibular view
• lateral oblique view
For parotid gland
• lateral oblique
• anterio posterior view should be taken.
The normal sialographic appearance of salivary gland
Parotid gland
Tree in winter appearance.
Submandibular gland
Bush in winter appearance
Bush in winter appearance of submandibular gland (normal sialographic appearance)
Normal radiographic appearance of parotid gland tree in winter appearance
Emptying Phase
• The cannula is removed and the patient allowed rinsing
out.
• Gland should be allowed to empty without any
stimulation and post evacuation radiograph should be
taken to assure complete evacuation.
• If post evacuation radiograph shows presence of
contrast media, use of lemon juice will be helpful in
complete evacuation of gland and ductal system.
Indication
Sialolith
• Indicated for those conditions not detected by plain
radiography.
• On sialograph the ductal system will appear dilated
proximal to obstruction.
• Contrast media may flow around small radiolucent
sialolith and the radiolucent sialolith and the
radiolucent sialolith will appear as a ‘Ductal filling
defect’
Bacterial sialidenitis
Mild dilation of terminal duct and sac like acini
Ductal sialadenitis
• Dilatation of the ductal system is a prominent
sialographic presentation of ductal sialadenitis.
• If interstitial fibrosis develops, it is apparent in
sialograms as a ‘sausage- string appearance’ of the
main duct and its major branches produced by
alternate stricture and dilation.
sausage- string appearance
Autoimmune Sialadenitis
• It represents a group of disorders that affect the salivary
gland and share auto sensitivity.
• Sialography is helpful in diagnosing and staging of
autoimmune disorder.
Early stage
• This stage is characterised by punctate(<1 mm),
globular(1-2mm) collection of contrast agent evenly
distributed throughout the gland.
• At this stage main gland appears normal, but
intraglandular ducts may be narrowed or not even
evident.
• Retention of the contrast medium even after
administration of sialogog, indicates extraductal
pooling.
Cavitary Stage
• As the disease progress, the collection of contrast
agent increases in the size (>2mm) and becomes
irregular in shape.
• This pool of contrast agent is known as cavitary stage.
• They are fewer in numbers and irregular in shape and
shows uneven distribution.
EARLY STAGE
ADVANCED STAGE
Tumours
• Benign tumour will appear as a space occupying
lesion on sialograph with smooth displacement of
main gland and its branches.
• Malignant tumour will show distortion in the ductal
system.
SPACE OCCUPYING LESION
Variants of saliography imaging technique
▪ Panoramic Sialography
▪ Fluoroscopic Sialography
▪ Digital Sialography
▪ CT Sialography
▪ MRI Sialography
▪ Cone Beam Computed Sialography
Contraindication
• Acute infection.
• Known sensitivity to iodine containing compound.
• Immediately anticipated thyroid function test.
ULTRASONOGRPHYIt is a technique based on sound waves that acquire image on real
time and without the use of ionizing radiation.
Diagnostic ultrasongraphy use vibratory frequencies in the range
of 1-20 MHz.
CLINICAL IMPLICATION OF ULTRASONOGRAPHY IN
SALIVARY GLAND IMAGING
Being paired superficial structures, the parotid and submandibular
glands are suitable for high resolution ultrasound examination.
The ultrasound examination can be easily combined with fine
needle aspiration cytology (FNAC) further enhancing its ability to
differentiate between benign and malignant lesions.
Diagnosis of different pathological condition of
salivary gland using ultrasound
▪ Sialolithiasis
➢ For the detection of salivary calculi, ultrasound is the
investigation of choice, with a sensitivity of 94%, specificity
of 100% and an accuracy of 96%
➢ Intra-glandular ductal dilatation and an intra-ductal echogenic
filling defect casting posterior acoustic shadowing are the
hallmark ultrasound features of sialolithiasis.
➢ Complications of calculi, including sialocele and abscess, can
be easily identified with ultrasound.
Ultrasonography of left parotid gland showing 5 mm.
of calculi in Stenson duct
Acute bacterial infection
▪ The acutely inflamed gland is enlarged and hypoechoic
on ultrasound. The parenchyma may have a
heterogeneous pattern attributable to the presence of
micro-abscesses, localized duct dilatation or retention
cysts
Chronic inflammatory sialadenitis (Sjogren’s syndrome)
▪ The role of ultrasound is to confirm or exclude
salivary gland involvement and to look for
lymphomatous change in the cervical lymph nodes
▪ Early stage the salivary glands may be normal or show
diffuse enlargement with normal echogenicity.
▪ Late features
➢ A heterogeneous echopattern with multiple round hypoechoic areas
within the parenchyma, sometimes containing frank cystic changes In
long-standing disease, the involved glands appear small and atrophic with
a hypoechoic echotexture or may have a reticular pattern.
Chronic sclerosing sialadenitis (Kuttner tumor)
➢ The most typical ultrasound appearance is a diffuse cirrhotic-like pattern:
bilateral diffuse involvement with multiple hypoechoic lesions against a
heterogeneous background resembling a cirrhotic liver.
Well defined margin in cystic lesion Well defined solid mass in parotidgland
cirrhotic-like’ echo pattern
Ultrasound-guided core needle biopsy for salivarygland lesions
▪ Ultrasound guided core needle biopsy (US-CNB) isrelatively recently described technique in the salivarygland which has been well tolerated and has demonstrateda high degree of diagnostic accuracy
INDICATION
• US-CNB has potential advantages over FNAC, particularlyin the typing and grading of lymphoma and carcinoma andin improved differentiation of reactive nodal hyperplasiafrom lymphoma.
• The use of US-CNB may help to reduce the need forsurgical biopsy and facilitate prompt appropriatemanagement.
ADVANTAGE
• Non invasive technique
• Inexpensive
• No radiation exposure
• Provide real time image during the procedure.
LIMITATION
• Don’t provide information about the deep lobe of
parotid gland.
• Imaging of malignant tumour is not very precise.
• Deeper tissue invasion can’t be detected.
COMPUTED TOMOGRAPHY
• CT scanning involves a combination of two different
fields (x-ray technology and computers).
• Greater attenuation of x-ray by dense structure such as
bone is represented by increasing “whiteness” on gray
scale image. Whereas soft tissue structure attenuate to
lesser degree are more “black”
• Scanning should be done in various planes like coronal
or axial plane.
Clinical implication of computed tomography inimaging salivary gland diseases
▪ Proximity of salivary gland to vital structures likefacial nerve, retromandibular vein, carotid artery ordeep lymph nodes can be identified on computedtomography
▪ Main indication of use of CT imaging of salivarygland is presence of mass in salivary gland orsuspected sialolith in gland that gone undiagnosed byplain radiography or ultrasonography.
▪ The sensitivity of CT over plain radiography indiagnosing sialolith is ten times higher.
▪ CT attenuation of masses is helpful in differentiating
benign cyst from solid mass and lipoma from other
neoplasm.
▪ Administration of contrast material is helpful because cysts
usually enhance on their periphery, whereas pleomorphic
adenomas enhance solidly.
▪ It also provides definition of cystic walls, making it
possible to distinguish fluid filled mass from abscess.
▪ Osseous erosions and sclerosis are better visualized by CT
• Does not help in predicting histologic diagnosis since
most malignant and non malignant solid masses have
similar CT attenuation.
• Radiation exposure to patient that much higher than the
plain radiography
• Administration of iodine containing contrast media for
contrast enhancement may cause allergic reaction to
patient.
• Potential scatter from dental restoration.
• Expensive procedure
CLINICAL IMPLICATION OF MRI IN DIAGNOSIS OF SALVARY GLAND DISEASES
▪ It has become the imaging modality of choice for
preoperative evaluation of salivary gland tumours
because of its ability to provide multiplanar image.
▪ MRI may be used as the first (and only) technique to
evaluate a neoplasm of the major salivary glands, if
clinicians are highly confident that the process in the
gland is neoplastic and not obstructive or
inflammatory.
• Virtually all parotid lesions are well visualized on T1-
weighted MR images because of the hyperintense
(fatty) background of the gland.
• The T1-weighted image gives an excellent
assessment of the margin of the tumour, its deep
extent, and its pattern of infiltration.
• T2-weighted MR imaging has been shown to be a
reasonably reliable (73%) predictor of whether a
salivary gland tumor is benign or malignant.
Hyperintense mass on T2-weighted images is benign
and a mass of low to intermediate signal intensity is
malignant.
ADVANTAGES
• Facial nerve is the critical structure when operating on theparotid gland. Pre operative assessment of salivary glandtumour using MRI may be helpful to surgeon indetermining the treatment modality because of itsexcellent ability to differentiate soft tissue
• T2-weighted MRI is reasonably reliable predictor ofwhether a salivary gland tumor is benign or malignant.
• No radiation exposure to patient.
• No intravenous contrast media are required routinely.
• Minimal artefacts from dental restoration reported.
DISADVANTAGE
• Not reliable in detecting calculi or any osseous
changes.
• Patient with pacemaker or implant can’t undergo MRI.
• Patient who is claustrophobic MRI is contraindicated
SCINTIGRAPHY• A salivary gland scan or scintigraphy is a nuclear medicine
test that examines the uptake and secretion in the salivary
glands of a radioactively labelled marker substance.
• The pattern of uptake and secretion shows if these glands
are functioning normally.
INDICATION
• When sialography is contraindicated
• When it is difficult to cannulate major duct
• When there is a need of quantification of function of gland.
• To assess injury to parenchymal tissue of gland, following
head and neck radiotherapy.
Imaging Study Indications Comments
Plain films Calculus disease Limited value; may differentiate salivary gland disease from
bony abnormality
Sialography Sjogrensyndrome, chronic
inflammatory conditionsBest means of imaging ductal system; of limited value other
than in evaluating the ductal system
CT Chronic inflammatory
conditions and complications,
intrinsic and extrinsic masses,
calculus disease
Excellent anatomic detail for intrinsic and extrinsic salivary
gland
tumours; best means of identifying calculi or calcification
MRI Chronic inflammatory
conditions and complications,
intrinsic and extrinsic masses
Excellent anatomic detail in tumour evaluation; may be better
than CT
for parapharyngeal space and intracranial extensions
Ultrasonography Abscess, cyst, intrinsic salivary
neoplasm
Best means of determining solid vs. cystic lesions, but limited
nasopharyngeal detail
Radionuclide imaging Warthin Tumour Sodium pertechnetate Tc 99m taken up by benign neoplasms;
gallium
67 citrate and bone-scanning agents occasionally useful for
Malignancies
Diseases of Salivary Gland
• Functional disorder
• Obstructive disorder
• Non – neoplastic disorder
• Neoplastic disorder
Functional disorder
• Sialorrhea
Neurological disorder
Mercury poisoning
• Xerostomia
Post surgical
Mumps , Sjogren Syndrome, post radiation
Functional disorder
• Mucocele
Secondary to trauma
70% occur on lower lip
Excisional biopsy is the cure
Ranula
Sublingual salivary gland
Removal of sublingual gland
Mucoele• Mucus is a exclusive secretary product of the
accessory minor salivary gland and the most
prominent product of the sublingual gland.
• Mechanism for mucus cavity development is
extravasations or retention.
▪ Secondary to trauma
▪ 70% occur in lower lip
• Extravasation Type: leakage of fluid from the duct or acini in the surrounding tissue.
• Retention Type: narrowed ductal opening that can not be adequately accommodate the exit of the saliva produced, leading to the ductaldilation and surface swelling.
• Lacks a true epithelial linining
• Excision with removal of associated salivary gland
Ranula
• Its a term used for mucoceles that occur in the floorof the mouth.
• The name is derived form the word rana, because theswelling may resemble the translucent underbelly ofthe frog
• Presents as a blue dome shaped swelling in the floorof mouth (FOM). They tend to be larger thanmucocele & can fill the floor of the mouith & elevatetongue. Located lateral to the midline, helping todistinguish it from a midline dermoid cyst.
• Treatment of Ranula
Marsupialization ( de roofing ) excessive recurrence rate
of 60-90%
Sublingual gland removal via intraoral approach
Obstructive SG Disorders
Sialolithiasis /stone Sialolithiasis
• Results in a mechanical obstuction of the salivary duct
• It is the major cause of unilateral diffuse parotid or
submandibular gland swelling.
• Exact etiology is not known
• Obstuct the flow of saliva from the gland.
• Hyperclacemia,
• Xerostomia
• Smoking etc.
• Anatomy of duct
• Components of saliva Upwarding route.
• Mucus protein
• Longer duct
• Calcium content and Curve duct n
Reasons sialolithiasis may occur more often in the Sub
mandibular gland
• Saliva is more alkaline
• Higher concentration of calcium and phosphate in
the saliva
• Higher mucus content
• Longer curved duct
• Anti-gravity flow
Obstruction Phenomenon
Acute ductal obstruction may occur at meal time when
saliva producing is at its maximum, the resultant
swelling is sudden and can be painful.
Gradually reduction of the swelling can result but it
recurs repeatedly when flow is stimulated. This
process may continue until complete obstruction
and/or infection occurs.
Traditional treatment
Intraoral route Sialolithotomy
Sialadenectomy via external approach
Gland excision indicated for very posterior stones
Acute Suppurative Parotitis –
History
▪ Sudden onset of erythematous swelling of the pre/postauricular areas extend into the angle of the mandible.
▪ Male above 60 affected more than female
▪ Staphylococcus aureus is the most causative organismhence it is colonizes around ductal orifice thusdecrease salivary flow
• Clinical Presentation
▪ Rapid onset of the preauricular swelling
▪ Erythema
▪ Pain
▪ Palpation ( milking ) of the involved gland will reveal
no flow or elicit a thick , purulent discharge from the
orifice of the duct
• Parotitis is generally a clinical diagnosis
• If no response to antibiotics in 48 hrs can perform MRI,
CT or ultrasound to exclude abscess formation
• Among salivary gland neoplasms,
• 80% arise in the parotid glands,
• 10-15% arise in the submandibular glands,
• and the remainder occur in the sublingual and minor
salivary glands
• The most common tumor of the parotid gland is
the pleomorphic adenoma, which represents
about 60% of all parotid neoplasms .
• Almost half of submandibular gland neoplasms
and the majority of sublingual and minor
salivary gland tumors are malignant.
• Salivary gland neoplasms are rare in children.
• Most tumors (65%) are benign, with hemangiomas being
the most common, followed by pleomorphic adenomas.
• In children, 35% of salivary gland neoplasms are
malignant.
• Mucoepidermoid carcinoma is the most common salivary
gland malignancy in children.
• The majority of patients with salivary gland neoplasms
present with a slowly enlarging painless mass.
• Parotid neoplasms most commonly occur in the tail of
the gland.
• Submandibular neoplasms often present with diffuse
enlargement of the gland, while sublingual tumors
will produce a palpable fullness in the floor of the
mouth.
• Minor salivary gland tumors will have a varied
presentation depending on the site of origin. Painless
masses on the palate or floor of mouth are the most
common presentation of minor salivary neoplasm.
Clinical presentation
➢ Painful swelling (60%)
➢Painless swelling (30%)
➢ Pain only (12%)
➢Sometimes described as recurrent salivary colic
and spasmodic pains upon eating.
Clinical History
• History of swellings / change over time?
• Trismus?
• Pain?
• Variation with meals?
• Bilateral?
• Dry mouth? Dry eyes?
• Recent exposure to sick contacts (mumps)?
• Radiation history?
• Current medications?
Inspection
Asymmetry (glands, face, neck)
Diffuse or focal enlargement
Erythema extra-orally
Trismus
Medial displacement of structures intraorally?
Examine external auditory canal (EAC)
Palpation
➢ Palpate for cervical lymphadenopathy
➢Bimanual palpation of floor of mouth in a posterior
to anterior direction
➢ Have patient close mouth slightly & relax oral
musculature to aid in detection
➢Examine for duct purulence
➢ Bimanual palpation of the gland (firm or
spongy/elastic).
TNM STAGING
• The TNM system is the most widely usedcancer staging system.
• In the TNM system:
• The T refers to the size and extent of the main tumor.The main tumor is usually called the primary tumor
• The N refers to the number of nearby lymph nodes thathave cancer.
• The M refers to whether the cancer has metastasizedThis means that the cancer has spread from the primarytumor to other parts of the body.
•
Primary tumor (T)
• TX: Main tumor cannot be measured.
• T0: Main tumor cannot be found.
• T1, T2, T3, T4: Refers to the size and/or extent of the
main tumor. The higher the number after the T, the
larger the tumor or the more it has grown into nearby
tissues. T's may be further divided to provide more
detail, such as T3a and T3b.
Regional lymph nodes (N)
• NX: Cancer in nearby lymph nodes cannot be
measured.
• N0: There is no cancer in nearby lymph nodes.
• N1, N2, N3: Refers to the number and location of
lymph nodes that contain cancer. The higher the
number after the N, the more lymph nodes that
contain cancer.
Distant metastasis(M)
• MX: Metastasis cannot be measured.
• M0: Cancer has not spread to other parts of the body.
• M1: Cancer has spread to other parts of the body.
TNM Classification for Cancer of Major Salivary Glands
Primary tumor (T)• Primary tumor cannot be assessed• No evidence of primary tumor• Carcinoma in situ• Tumor ≤2 cm in greatest dimension without extraparenchymal
extension*• Tumor >2 cm but not more than 4 cm in greatest dimension without
extraparenchymal extension*• Tumor >4 cm and/or tumor having extraparenchymal extension*• Moderately advanced or very advanced disease• Moderately advanced disease• Tumor invades the skin, mandible, ear canal, and/or facial nerve• Very advanced disease• Tumor invades skull base and/or pterygoid plates and/or encases
carotid artery
Regional lymph nodes (N)
▪ NX- Regional nodes cannot be assessed
▪ N0- No regional lymph node metastasis
▪ N1- Metastasis in a single ipsilateral lymph node ≤ 3
cm in greatest dimension and ENE (-)
N2- Metastasis in a single ipsilateral lymph node > 3 cm
but not more than 6 cm in greatest dimension and ENE
(-);
• or metastases in multiple ipsilateral lymph nodes, none
> 6 cm in greatest dimension and ENE (-);
• or in bilateral or contralateral lymph nodes, none > 6 cm
in greatest dimension and ENE (-)
• N2a- Metastasis in a single ipsilateral lymph node
> 3 cm but not more than 6 cm in greatest
dimension and ENE (-)
• N2b- Metastasis in multiple ipsilateral lymph
nodes, none > 6 cm in greatest dimension and ENE
(-)
• N2c- Metastasis in bilateral or contralateral lymph
nodes, none > 6 cm in greatest dimension and ENE
(-)
• N3- Metastasis in a lymph node > 6 cm in greatest
dimension and ENE (-); or metastasis in any node(s)
with clinically overt ENE (+)
• N3a- Metastasis in a lymph node > 6 cm in greatest
dimension and ENE (-)
• N3b- Metastasis in any node(s) with clinically overt
ENE (+)
• . Prognostic stage groupsStage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M
T0–T3 N1 M0
IVA T4a N0–N1 M0
T0–T4a N2 M0
IVB T Any N3 M0
T4b N Any M0
IVC T Any N Any M1
•
TNM STAGING OF ORAL CANCER