SPECIFIC DISEASES AND DISORDERS OF THE SALIVARY GLANDS

Salivary Gland Diseases

Developmental

Obstructive

Inflammatory

Cystic

Neoplastic

Developmental Disturbances of The Salivary Glands

Aplasia (agenesis), atresia.

Aberrancy. (Latent bone cyst)

Salivary Gland Aplasia

Congenital absence of major salivary glands Cl. Presentation (Xerostomia, Mucositis, Glossitis,Caries)

Sialometry (flow rate) < 0.1 ml/min (unstimulated)< 0.5 ml/min (stimulated)

Scintigraphy

Diagnostic Approaches :

A part of the submand. SG lies within a well-defined depression on the lingual posterior surface of the mandible.It is an aberrant SGSite

Recognition of the defect should preclude any treatment or surgical exploration.

Latent bone(Staphne’s) cyst

Obstructive Salivary Gland Disorders

Causes of obstruction include

Salivary calculi (Sialolithiasis)

Strictures or kinks of the duct wall

Oedema or fibrosis of the papilla

Pressure on the duct due to an adjacent mass

Invasion of the duct by a malignant neoplasm.

Mucous retention/extravasation

♦ The main cause of obstructive salivary diseases

Obstructive Salivary Gland Disorders

Sialolithiasis

Sialolith are calcified and organic matter that form within the duct system of the major salivary glands.

Sialolithiasis

• The exact etiology and pathogenesis of salivary calculi is unknown.

• The calculi are believed to arise from the deposition of ca ++ salt around a nidus of debris within the duct lumen, these debris include bacteria, ductal epith cells, or foreign bodies.

30% of salivary diseases

Most of SMG calculi are radio-opaque & solitary

Most of parotid calculi are radiolucent & multiple

Minor salivary glands (buccal mucosa or upper lip) → firm nodule.

Sialolithiasis: Incidence

submandibular83%

parotid10%

sublingual7%

• The submandibular gland is the most common site of involvement, and 80 - 90% of sialoliths occur in this gland. ….. Why?

• Higher concentration of calcium and phosphate• Torturous course of the Wharton’s duct• The dependent position of the submandibular

glands, which leave them prone to stasis. (Anti-gravity flow)

Sialolithiasis: Incidence

Sialolithiasis: Clinical presentation

May be asymptomatic for a long time.History of pain and/or swelling of the concerned gland during eating followed by gradual reduction between meals.The degree of symptoms is dependent on the extent of salivary duct obstruction and the presence of secondary infection.Complete obstruction causes constant pain and swellingAn examination of the soft tissue surrounding the duct may show a severe inflammatory reaction.

Sialolithiasis: Clinical presentation

Palpation along the pathway of the duct may confirm the presence of a stone.

The involved gland is usually enlarged and tender. Stasis of the saliva may lead to infection, ductal stricture, and ductal dilatation fibrosis, and gland atrophy.

A uniformly firm gland suggests a hypo- or non-functional gland

No salivary flow or purulent discharge.

Signs of systemic infection may be present.

Diagnostic AidsRadiographic examination is often necessary since the stone may not be accessible to bimanual palpation.

The recommended view for radiography of sialoliths

50% of parotid gland sialoliths and 20% of submandibular gland sialoliths are poorly calcified. This is clinically significant because such sialoliths are not radiographically detectable.Calcified phleboliths and lymph nodes can be easily mistaken radiographically for sialoliths. Sialography can aid in differentiating these lesions.

Diagnostic Aids

Type, site & size of stones Associated inflammatory disorders Assess the gland function →

longstanding recurrent swelling

Objectives Diagnostic modalities

Plain films, CT, MRI, ultrasound ,sialography, sialoscopy

Sialolithiasis: Treatment Effective treatment of the sialolith depends

on the location of the stone and on its effect on gland function.

Stones in the Anterior Duct Stones in the Posterior Duct Stones in the Hilum or Gland

Removal of the stone:♦ Conservative management by:

Milking the gland Shock-wave Lithotripsy (external and

intraductal)Interventional sialendoscopy

♦ Surgical removal (Sialolithotomy)

Gland excision (Sialadenectomy)

Sialolithiasis Treatment Modalities

♦ Stone may be removed by spontaneous exfoliation on stimulation of salivation to flush the stone out of the duct.

♦ Indication: Small, mobile stone at or just behinde

the duct orifice Stone causing partial obstruction

♦ Procedures

♦Hydration♦Application of moist warm heat ♦Gland massage♦The use of sialogogues♦Infection → antibiotic

Conservative Management

Sialolithiasis: Treatment

♦ Stone may be removed by manipulation

♦ Indication: Small, mobile stone at or just

behinde the duct orifice♦ Procedures

Open the duct with the aid of lacrimal probes and dilators.

By gentle probing, the stone can be identified, milked forward, grasped and removed.

The gland is then milked to remove any other debris in the more posterior portion of the duct

Conservative Management

Sialolithiasis: Treatment

Extraglandular removal of the stone

(sialolithotomy), intraoral approach.

Intraglandular removal of the gland

Intraoral approach (sublingual gL.)

Extraoral approach (Parotid,

submand. gL.)

Surgical Treatment

Extraglandular stone• Stones in the Anterior

Duct

located in the distal third of the submandibular duct √

• Stones in the Posterior Duct

TRANSORAL REMOVAL

Indication

Surgical Removal of Sialolith from Duct of Submandibular Gland

Surgical Removal of Sialolith from Ant.Duct of Submandibular Gland

rubber tube

o The wound held open

o The incised duct is closed over silastic catheter

Surgical Removal of Sialolith from Ant.Duct of Submandibular Gland

Surgical Removal of Sialolith from Post.Duct of Submandibular Gland

guidewire

Lingual n

Wharton’s duct

Lingual n Wharton’s duct

Surgical removal of a submandibular duct stone at the hilum

Gland Excision (Sialadenectomy)

Indication Very posterior stones Intra-glandular stones Irreversible parenchymal damage

• Stones in the Terminal Duct

• Stones in the Posterior Duct

• Stones in the hilum or gland

Surgical Removal of Parotid Gland Stones

Surgical Removal of Sialolith from Duct of Parotid Gland

Parotid duct meatotomy

Sialolithotomy when the stone is at or just behind the duct orifice

Meatotomy: An incision made to enlarge a meatus

Surgical removal of a stone in the Terminal parotid duct

Surgical removal of a posterior parotid duct stone

Gland Excision

Parotidectomy

Modern treatment of obstructive salivary diseases

Shock-wave Lithotripsy

Interventional sialendoscopy

Sialoendoscopy

Minigrasping forceps

← Sialendoscope

Sialostent basket retrieving

It allows removal the stone while preserving the gland.

Laser fragmentation and extraction of debris using a wire basket through a minimal incision of Wharton’s papilla is followed by a complete clearance of the duct.

Shock-wave lithotripsy

Shock-waves → fragmenting salivary stones → flushing out from the salivary duct system

Types External lithotripsy; results

were poor specifically in patients with large calculi

External lithotripter

Interventional sialendoscopy with intraductal laser fragmentation and basket extraction of calculi (success rate 80%)

Endoscopically Intracorporeal Electrohydraulic Lithotripsy

Sialendoscope

Electrohydraulic lithotripter, Autolith, and a probe which can be inserted into the working channel of the sialendoscope.

Endoscopically Intracorporeal Electrohydraulic Lithotripsy

Sialolith at the hilus