S O F

EA SE
DI S

Dr. Saleh Al Salamah

Diseases of the
SALIVARY GLAND:
1. Introduction
2. Evaluation of Salivary Disease
3. Inflammatory Diseases
4. Salivary Gland Stones (Sialolithiasis)
5. Salivary Retentions Cysts and Mucous
Cysts
6. Salivary Fistulas and Sialoceles
7. Salivary Gland Tumors
8. Rare Autoimmune Diseases
9. Salivary Diseases in Childhood
 INTRODUCTION

There are Major and Minor groups of

Salivary Glands:
a) Major groups of salivary glands which
are consists three major glands, the
parotid, submandular and sublingual
glands. The parotid produces mucous
secretions. The parotid and sub-
mandular glands each drain into the
mouth in a single long duct. Where as
the sublingual glands drain via many
small ducts.
 b) Minor groups of salivary glands
may be found in the lips, cheeks,
tongue, floor of the mouth, palate,
larynx, trachea and tonsils and
lacrymal gland. And all are liable to
undergo the same pathological
change as the major groups.
 FUNCTIONS:
The Salivary glands secrets saliva
which contains the enzyme amylase
(protein of molecular wt. 50,000.
Containing calcium which splits
starch and glycogen into maltose) all
the secretory activity is regulated
mainly by parasympathetic nerves.

The total salivary secretion is between 1,000

ml – 1,500 ml daily and is almost all the result
of stimulation.
Deficiency

Deficiency of the saliva cause dry

mouth (xerostormia)

eg: Dehydration, Sjogren’s syndrome,

atropine which blocks the action of
parasympathetic nerves on the glands.
 Evaluation of the
SALIVARY GLANDS Diseases:
a. History: Age, pain, swelling, duration etc..
b. Clinical Examination: (Position (site), colour,
temperature, tenderness, shape, surface. Edge,
composition, relation, lymphatic drainage.
c. Investigations:
I. Blood (CBC), Hb, Urea and Electrolytes, Blood
Sugar etc..
II. Constituents of saliva in inflammatory diseases.
The sodium increased while the phosphate
level is decreased. The albumin usually very low
but increased in Sjogren’s diseases, also
antibodies can be demonstrated.
Contd….
III. Radiology:
a) Plain X-ray (20% of salivary
calculi are non-opaque to X-rays)
b) Sialogram
Radiology is helpful in the diagnosis of;
Calculi
Degree of glandular damage in
obstruction
Duct strictures
Duct fistulas and sialoceles
Contd….
IV. Ultrasound distinguishes solid tumour
from the rare cyst and sialocales.
V. Radio Isotopes: Tc 99 warthins tumours
may take up more of the isotopes and
appear as (hot) lesion. Carcinoma take
up very little and appear cold.
VI. CAT scanning has definite place in the
assessment of deep parotid tumours.
Inflammatory diseases of the salivary
glands:
 Acute bacterial sialadenitis
 Chronic sialadenitis
 Recurrent sialadenitis
 Mumps

 Post operative usually parotid

 Autoimmune diseases
 Acute Bacterial Sialadenitis:
 This condition is now uncommon
almost always occurring in elderly or
debilitated patients with poor oral
hygiene.

 Dehydrations and reduced salivary

flow encourage ascending infection.

 The parotid gland is usually involved

the result is painful, unilateral swelling
accompanied by trismus, pyrexia and
tachycardia.
On Examination:
The parotid gland is tender and diffusely
enlarged and purulent discharge can be
seen oozing (or can be milked) from the
parotid duct orifice (Stensen duct).

TREATMENT:
a. Parenteral antibiotics.

b. If parotid abscess has already

formed surgical drainage should be
performed.
 CHRONIC SIALADENITIS

 Prolonged obstruction of major

salivary gland by ductal calculus
causes chronic inflammation of the
gland.

 The glandular secretory element,

progressively atrophy and are
replaced by fibrous and adipose
tissues.
 Chronic Sialadenitis (cont’d)
(cont’d)

 The ducts system becomes dilated,

fibrotic and infiltrated by chronic
inflammatory cells.
Chronic Sialadenitis and salivary calculi
usually involved the submandibular gland.
The submandibular gland swollen and there
may be purulent discharge from the duct. The
swelling is made worse by taking food.
TREATMENT: by removing the duct obstruction.
Antibiotics may be necessary.
 RECURRENT SIALADENITIS

 Uncommon condition which may

occur at any age.
Usually affects the parotid glands are
subject to recurrent attacks of pain and
swelling caused by combination of
obstruction and infection of the glands.
 RECURRENT SIALADENITIS
(cont’d)

 There may be an associated dilatation

of the duct system and alveoli of the
glands with terminal sacculation
(Sialectasis) associated with strictures
of the duct or stones. These changes
best demonstrated by performing
Sialogram.
 RECURRENT SIALADENITIS

Treatment:
a. Antibiotics with careful attention to oral
hygiene.
b. Associated strictures is treated with
dilatation.
c. If stones present these must be removed.
b. Intractable causes may required surgical
removal of the gland.
 MUMPS

Viral infectious disease attack the

parotid gland mainly incubation
period (17-21days) which is
usually bilateral usually occur in
children. Fever, painful swelling
and difficulty in mastication.
 MUMPS
(cont’d)

* Mumps is interest to the Surgeon for

the following reasons:
* Occasional cause of acute orchitis
especially when mumps occurs in
adolescent or young adults pain and
swelling in the testicle occur 7-10 days
after the onset of parotid and may lead to
testicular atrophy.
TREATMENT: by rest and sedation.
 POST OPERATIVE PAROTITIS

* Ascending infection of the parotid gland

via its duct may occur after major surgical
procedures.
Aetiological factors include dental sepsis,
dehydration.
The presence of nasogastric tube for
prolonged period and poor oral hygiene.
 Clinically there is swelling and pain in one or
both parotid gland and there may be discharge
from the duct.
 POST OPERATIVE PAROTITIS
TREATMENT: (Rare nowadays) However :
a. Prophylaxis important and elimination of
the above etiological factors.
b. Patient must be kept fully hydrated the
flow encourage suckling, sweets or
chewing gums.
c. Antibiotic therapy.
d. Occasionally surgical drainage required.
 SALIVARY GLAND STONES
(SIALOLITHIASIS)

I. Parotid calculus is rare and difficult to

diagnose since the stone is so small
that it cannot be demonstrated by
radiography and sialography is usually
necessary.
II. Submandibular calculus: very
common being more than 50 times than
parotid this is due to:
 SALIVARY GLAND STONES
(SIALOLITHIASIS)
a. The secretion of the gland is thick and
viscid as compared to watery secretion
of the parotid.
b. The upward course of the
submandibular duct does not provide
adequate drainage.
c. The duct orifice lies in the floor of the
mouth where foreign bodies may lodge
into it and provide nucleus for stone
formation.
 PATHOLOGY:
 The stones may be singly or multiple
and may lie in the gland, duct or both.
 They contain high proportion of calcium.
 The gland often enlarged and inflammed
as chronic irritation and obstruction by
the stone.
* Investigation:
 Plain X-Ray will demonstrate most calculi.
 Sialography.
 SALIVARY GLAND STONES
(SIALOLITHIASIS)
Clinical Features:
Patient complaint recurrent attacks of pain and
swelling in the region of the gland during meals.
 Occasionally present with acute or chronic
bacterial infection (Sialadenitis).
 On Examination:
* The gland is enlarged and firm and tender .
* If the stone lies in the duct it can be felt or
even seen in the floor of the mouth.
 Salivary Retention Cysts:
Large retention cysts sometimes develop in the floor of the
mouth. They reach several centimeters in diameter and are
known as ‘Ranulae’.
RANULAE: Typically appear as blue-grey dome like
swelling beneath the tongue in the floor of the mouth.
They are more common seen in neonates and children.
It may burst spontaneously discharging it content and
collapsing.
They are painless and can recurr.
TREATMENT: Marsupialisations with de-roofing
the cyst so that it opens into the floor of the
mouth.

Note: They are painless and can recur

SALIVARY MUCOUS CYSTS:

They are arising from minor

mucous secreting gland in the
lower lip. They sometimes
spontaneously disappear but
excision is the treatment.
 SALIVARY FISTULAS:

Submandular fistulas uncommon

(rare) and always arises in the
gland

TREATMENT: by excision of the gland

 PAROTID FISTULA:
May follow penetrating wound or
incision of parotid abscess.
It may arise from the main duct or from the
ductules within the gland
TREATMENT: Sialography is performed to
establish the exact site or origin of the fistula
a. Fistula of the gland may be X-ray therapy to the gland.
b. Fistula of the duct treated by anastomosis
(construction).
c. If fail superficial parotidectomy.
SALIVARY GLAND TUMORS:

Tumors of the salivary glands are commonest

in the parotid much less common in the
submandular gland and very rare in the
sublingual and minor salivary glands. They
are difficult to classify as benign and
malignant since all of them tend to recur after
removal.
 Classification:
I. Benign:
a) Mixed salivary tumor or pleomorphic
adenoma
b) Adenolymphoma or warthin’s tumor
c) Oncocytoma
d) Monomorphic adenoma

II. Malignant:
a) Primary carcinoma
b) Secondary carcinoma – direct invasion
from skin or from secondarily involved lymph nodes
 PLEOMORPHIC ADENOMA
The most common benign neoplasms of salivary
glands. Most pleomorphic present in middle age
but may occur at any age and equally in either
sex.
It usually remains benign for many years but unless adequately
removed it tend to recur and to turn malignant.
Clinically:
a) Slow growing painless lump mostly in parotid and
some in submandular and few in the minor glands.
b) Mobile with well defined edge and smooth or
lobulated surface.
Definitive diagnosis can only be made histologically after
excision
Treatment surgical removal (superficial parotidectomy)
ADENOLYMPHOMA (Warthin’s Tumor)

Benign tumor less than 10% of

salivary tumor. It occur in parotid
glands only between the ages 40-60
years male strong predominance.
They are sometimes bilateral.
Clinically: The tumor present as painless
cystic swelling
Treatment: Surgical removal (superficial
parotidectomy)
 Malignant Salivary Tumors:

The malignat tumors are –

1. Mucoepidermoid Carcinoma
2. Adeno Cystic Carcinoma
3. Adeno Carcinoma
4. Squamous Cell Carcinoma
5. Carcinoma in Pleomorphic Adenoma
(Malignant Mixed Tumor)
6. Acinic Cell Tumor
7. Malignant Lymphoma
8. Anoplastic Carcinoma
 Clinical Features:
 Affects elderly people and common in
parotid with equal sex distribution.

 The tumor forms rapidly growing hard

swelling with ill defined edges and nodular
surface.

 Soon becomes fixed with pain-facial palsy,

and lymph nodes enlargement but distant
metastasis are rare.
 TREATMENT:

1. Operable Tumors:
a) Radical parotidectomy combined with block dissection
of the cervical lymph node.
b) Post-operative radiotherapy
c) When the tumor arises in the other site of
salivary tissues wide local excision is performed with
block dissection of lymph node.
2. Non operative tumor with infiltration
to the skull and pharynx.
Radiotherapy can be given.
Complication of Parotidectomy:

1) Damage to facial nerve causes

facial palsy or damage to its
branches
2) Salivary fistula
3) Frey’s syndrome
Autoimmune salivary gland disorder
or disease:

There are two syndromes of slow,

progressive, painless enlargement
of salivary glands.

Biopsy reveals the swelling is caused by

replacement of glandular tissues by lymphoid
tissue and fibrosis.
 MICKULICZ’s SYNDROME

1) Symmetrical enlargement of salivary

glands
2) Enlargement of the lachrymal glands

3) Dry mouth
 SJOGREN’s SYNDROME

All the above conditions plus;

Dry eyes
Generalized arthritis
Salivary diseases in childhood:

1) Mumps: Viral sialaidenitis both parotid

become painful and swollen and accompanied by
general malaise and subsided in few days.

2) Recurrent swellings of the parotid:

Due to obstruction of one or both parotid
ducts. Symptomatic treatment and reassurance
of the parents. There is no place for surgery.
3) Tumors: The commonest tumor in infants
is haemangioma found in 2-3 years old child.
The tumor nearly undergo natural resolution.

4) Lymphangiomas: They have tendency

to enlarged and infection. The treatment
partial resection.