salivary glands, anatomy, pathology, management.pptx

salivary glands, anatomy, pathology, management.pptx

• 1.
  Salivary Glands
• 2.
  • There arethree pairs of salivary glands— • parotid, • submandibular and • sublingual. • In addition to these, there are multiple minor salivary glands located in the cheek mucosa, lips, palate, base of the tongue, etc.
• 3.
  Parotid Gland (Para—around, otis—ear) •It is the largest of the salivary gland, Parotid gland is present on the lateral aspect of the face, divided by the facial nerve into superficial lobe and deep lobe. • Parts of the Parotid Gland • • Superficial part (80%)—lies over the posterior part of the ramus of mandible. • • Deep part (20%)—lies behind the mandible and medial pterygoid muscle; in relation to mastoid and styloid process.
• 5.
  • Parotid (Stensen’s)duct is 2-3 mm in diameter, 5 cm in length, begins behind the angle of the mandible, passes through the buccinator muscle and opens in the mucosa of the cheek opposite the upper 2nd molar tooth. • Facial Nerve • After emerging from stylomastoid foramen, it hooks around the condyle of mandible, enters the substance of parotid and divides into 2 major branches, zygomaticotemporal and cervicofacial. Facial nerve along with retromandibular vein is present in this plane. This plane is called fasciovenous plane of Patey
• 9.
  • Submandibular SalivaryGland • It is a ‘J’ shaped salivary gland situated in the anterior part of the digastric triangle. • Submandibular (Wharton’s) duct (5 cm), emerges from the anterior end of the deep part of the gland, enters the floor of the mouth, on the summit of papilla beside the frenulum of the tongue.
• 10.
  • Minor SalivaryGlands • There are around 450 minor salivary glands which are distributed in lips, cheeks, palate and floor of the mouth. • They contribute to 10% of total salivary volume. • Sublingual glands are minor salivary glands one on each side; located in the anterior aspect of the floor of the mouth in relation to mucosa, mylohyoid muscle, body of the mandible near menta symphysis. Gland drains directly into mucosa or through a duct which drains into submandibular duct. This duct is called as Bartholin duct.
• 11.
  ACUTE PAROTITIS • Acuteinflammation of the parotid can occur due to bacterial or non-bacterial causes. It can be unilateral or bilateral. • Causes: • Viral- • Mumps parotitis: Mumps1 is an acute generalised viral disease with painful enlargement of salivary glands, chiefly the parotids. The virus belongs to Paramyxoviridae family and only one serotype is known. The disease spreads from a human reservoir by direct contact, airborne droplets or fomites contaminated by saliva and possibly by urine.
• 12.
  • Bacterial :Usually ascending infection, Staphylococcus aureus. • Post-irradiation : Reduction in the salivary juice • Post-operative : Due to dehydration • Clinical features • Patient who is recovering in the postoperative period may complain of pain and swelling in the parotid region. Presence of severe pain, very sick, toxic look and high grade fever with chills and rigors, indicates parotid abscess. Diffuse brawny swelling is characteristic. • If the abscess is not drained, it is likely to rupture into the external auditory canal. • The opening of the parotid duct may be inflamed and on gentle compression of the parotid gland, pus can be seen coming out of the parotid duct.
• 13.
  • Treatment • Conservativeline of management is indicated in a stage of cellulitis with no evidence of abscess. • Maintaining good hydration of the patient in the postoperative period. • Improvement in the oral hygiene—mouth washes with potassium permanganate (KMnO4) solution. • Appropriate antibiotics against staphylococci, such as cloxacillin, along with metronidazole is given to treat anaerobic infections. • It takes about 3–5 days for the inflammation to settle down. • Surgical treatment is indicated when there is pus
• 14.
  SALIVARY CALCULUS ANDSIALADENITIS • • 80% Submandibular. • • 80% Radio-opaque. • • It is commonly calcium phosphate and calcium carbonate stones. • • Calculi are more common in submandibular gland, because the gland secretion is viscous, contains more calcium and also, its drainage is nondependent, causing stasis. • • Secretion from parotid is serous, contains less calcium and so stones are not common.
• 16.
  • Presentation • Acutefeatures: • • Pain, swelling, tenderness is seen in submandibular region and floor of the mouth. • • Duct is inflamed and swollen. • Features in chronic cases (chronic sialadenitis): • • Pain is more during mastication due to stimulation. • (Salivary colic which can be induced by meals, lemon juice, etc). • • Salivary secretion is more during mastication causing increase in gland size. • • Firm, tender swelling is palpable bidigitally. • • When stone is in the duct, it is palpable in the floor of the mouth as a tender swelling with features of inflammation in the duct. Pus exudes through the duct orifice. (Irritation of the lingual nerve, which is in very close proximity to submandibular salivary duct, causes referred pain tongue – lingual colic). • • In submandibular salivary gland, often the stones are multiple, with chronic inflammation of gland (sialadenitis).
• 17.
  • Investigations • •Intra oral X-ray (dental occlusion films) to see radiopaque stones. • • FNAC of the gland to rule out other pathology. • • Total count and ESR in acute phase. • Treatment • • If the stone is in the duct, removal of the stone is done intraorally, by making an incision in the duct. Incised duct is not sutured as it may result in stricture. • • If stone is in the gland, excision of submandibular gland is done.
• 19.
  SALIVARY GLAND TUMOURS
• 20.
  • Eighty percent salivary neoplasms are in the parotids of which 80% are benign. 80% of these are pleomorphic adenomas. • • Fifteen per cent of salivary tumours are in the submandibular salivary gland, of which 50% are benign. 95% of these are pleomorphic adenomas.
• 21.
  PLEOMORPHIC ADENOMA (Mixed salivarytumour) • Commonest of the salivary gland tumour. • • It is 80% common. • • More common in parotids (80%). • • It is mesenchymal, myoepithelial and duct reserve cell origin. • It is called as dumb bell tumour. • Clinical Features • • Raised ear lobule • • Cannot be moved above the zygomatic bone— curtain sign • • Deviation of uvula and pharyngeal wall towards midline in case of deep lobe tumour • • Facial nerve, masseter, skin, lymph node and bone involvement eventually occurs in case of malignancy.
• 22.
  • Present asa single painless, smooth, firm lobulated, mobile swelling in front of the parotid with positive curtain sign (As the deep fascia is attached above to the zygomatic bone, it acts as a curtain, not allowing the parotid swelling to move above that level. Any swelling superficial to the deep fascia will move above the zygomatic bone.). • • Obliteration of retromandibular groove is common. • The ear lobule is lifted. • • When deep lobe is involved, swelling is commonly located in the lateral wall of pharynx, posterior pillar and over the soft palate—10%. • • Facial nerve is not involved.
• 24.
  • Long-standing pleomorphicadenoma may turn into carcinoma (carcinoma in ex. pleomorphic adenoma). Its features are: • • Recent increase in size • • Pain and nodularity • • Involvement of skin, ulceration • • Involvement of masseter • • Involvement of facial nerve—Lower facial nerve • palsy—(Difficulty in closing eyelid, difficulty in • blowing and clenching teeth) • • Involvement of neck lymph node
• 25.
  • Investigations • •FNAC is very important and diagnostic. • • CT scan to know the status of deep lobe, local extension and spread. • • MRI is better method. • Treatment: • • Surgery—First line treatment. • • If only superficial lobe is involved, then superficial • parotidectomy is done wherein parotid superficial to • facial nerve is removed. • • If both lobes are involved, then total conservative • parotidectomy is done by retaining facial nerve. Treatment of malignant pleomorphic adenoma • Radical parotidectomy refers to removal of both lobes, facial nerve, • parotid duct, fibres of masseter, buccinator, pterygoids and radical block • dissection of the neck. If facial nerve is not involved it should be • preserved to avoid morbidity. Advanced tumours with fixed nodes in the • neck may require radiotherapy.
• 26.
  ADENOLYMPHOMA (Warthin’s Tumour,Papillary Cystadenoma Lymphomatosum) • Adenolymphoma is not a lymphoma. It is a misnomer . • It is a benign parotid tumour and next common to pleomorphic adenoma. • Clinical features • Middle aged or elderly males are commonly affected—usually they are • smokers. • Can be bilateral, in some cases (10%). • It has smooth surface, round border with soft, cystic consistency • Classically, situated at the lower pole of parotid elevating the ear lobule. • May be multicentric • This tumour affects only parotid gland. (Very, very rarely, other glands • may be affected.) • Treatment: • It has got a well-defined capsule. Hence, enucleation can be done.
• 27.
  • Adenoid CysticCarcinoma • It is a highly malignant tumour consisting of cords of dark staining cells with cystic spaces containing mucin. It also consists of myoepithelial cells and duct epithelium. • Even though slow growing, it spreads along the perineural tissue, may invade periosteum or medullary bone at a distance. This bone resorption results in bony tenderness. • These tumours have high incidence of distant metastasis but in general they display indolent growth. Skip lesions are common as it spreads along • the nerve tissue, which leads to treatment failure. • Local infiltration, lymphatic and blood spread and local recurrence are • important features. • It is hard and fixed and can produce anaesthesia of the skin overlying • the tumour. • Early cases are treated by radical parotidectomy with block dissection of • the neck. However, many cases present late to the hospital. Thus, • palliative radiotherapy is given to reduce pain and to arrest the progress of • the disease.
• 28.
  MALIGNANT PAROTID TUMOURS •Rapidly growing neoplasm • Change in consistency (the tumour tends to be hard) • Fixity to underlying muscle such as masseter as in parotid tumours • Fixity to mandible as in parotid or submandibular tumour • Involvement of facial nerve as in 80% of cases of malignant parotid tumours • Resorption of adjacent bone such as mastoid, tenderness as in adenoid cystic carcinoma. • Significant hard nodes in the neck. • They are treated by radical sialadenectomy with radical block dissection of the neck. Radiotherapy is used as a palliative treatment.
• 29.
  FREY’S SYNDROME—GUSTATORY SWEATING •It occurs after surgery for parotid tumours, surgery in the region of temporomandibular joint, or due to injury to the parotid gland. Injury to the auriculotemporal nerve can occur at a site where it turns around the neck of the mandible. The injury is manifested at a later date (2–3 months). • Because of the injury, post-ganglionic parasympathetic fibers from otic ganglion are united with sympathetic fibres of superior cervical ganglion which supplies the vessels and sweat glands over the skin overlying parotid region. • As a result of this, whenever the act of chewing or mastication is started, there is increased sweating and hyperaesthesia in the region supplied by auriculotemporal nerve (cutaneous branch of mandibular division of trigeminal nerve).
• 30.
  • Treatment • Reassurance •Aluminium chloride—antiperspirant which is a useful astringent • Denervation by tympanic neurectomy • Latest treatment includes injection of botulinum toxin into the affected skin.
• 31.
  SJÖGREN’S SYNDROME • Itis an autoimmune disease causing progressive destruction of salivary and lacrimal glands, leading to keratoconjuctivitis sicca (dry eyes), and xerostomia (dry mouth). • Types • 1. Primary. • 2. Secondary. • Primary Sjogren’s Syndrome: • • Severe dry mouth. • • Severe dry eyes. • • Widespread dysfunction of exocrine glands. • • Incidence of developing lymphomas is high. • • There is no association of connective tissue disorders.
• 32.
  • Secondary Sjogren’sSyndrome: • • Dry mouth. • • Dry eyes. • • With association of connective tissue disorders like • – Primary biliary cirrhosis (near 100%). • - SLE (30%). • - Rheumatoid arthritis (RA) (15%). • Clinical Features: • • It is common in middle aged females who present with dry eyes, dry mouth, enlarged parotids and enlarged lacrimal glands. • • Often they are tender. • • Superadded infections of the mouth, Candida albicans is common.
• 33.
  • Investigations • 1.Autoantibody estimation—rheumatoid factor, antinuclear factor, salivary duct antibody. • 2. Sialography. • 3. Estimation of salivary flow. • 4. Slit lamp test of eyes. • 5. Schirmer test – to detect lack of lacrimal secretion. • 6. FNAC of parotids and lacrimal glands. • 7. 99Technetium pertechnetate scan for gland function. • Treatment: It is conservative. • 1. Artificial tears. • 2. Artificial saliva. • 3. Frequent drinking of water. • 4. Treat the cause.