CHAPTER:SALIVARY GLANDS

NON-NEOPLASTIC LESIONS

TOPIC:ACUTE SUPPURATIVE
SIALADENITIS

Acute suppurative sialadenitis may

involve parotid or submandibular gland.
Parotid is a ected more due to less
bacteriostatic activity of saliva of parotid
gland, than saliva of submandibular
gland which has more glycoprotein
contents.

Q.WHAT ARE THE PREDISPOSING

CONDITIONS?
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These usually are calculi, strictures, poor
orodental hygeine, dehydration and
immune de ciency and postoperatively,
Staphylococcus is the usual organism.

Q.WHAT ARE THE CLINICAL

FEATURES?
Pain, body aches, fever, swelling of the
gland and trismus. On examination, duct
of the gland appears in amed and
purulent secretions can be expressed

Fig:swelling of parotid gland

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Q.WHAT IS THE TREATMENT?
• Antibiotics
• Anti-in ammatory drugs and
analgesics
• Orodental hygeine

TOPIC:CHRONIC SIALADENITIS

Chronic infection of salivary glands can

lead to rm, mild enlargement of the
gland with repeated acute infections. It
is also seen more in parotid gland
followed by submandibular gland. There
occurs progressive glandular destruction
leading to changes in the chemistry of
saliva.
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Q.WHAT ARE THE CLINICAL
FEATURES?
History of recurrent, mildly painful
enlargement of gland. Massage of gland
produces scanty secretions at the
opening of the duct.Xerostomia may
develop.

Q.WHAT ARE THE INVESTIGATIONS

PERFORMED?
1. Sialography̶a study of ductal system
of salivary glands by injecting contrast
media (Meglumine diatrizoate) to
show calculi, foreign bodies stricture,
salivary stulas, volume of gland, size of
tumor and SjÖgren s syndrome.
‒ Sialography may be conventional,
secretory, interventional or hydrostatic
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type, computed tomography (CT)
sialography, digital substraction
sialography.
Various Appearances in Sialography

FIG:sialography picture showing

obstruction of salivary gland duct.
(google)

• Inchronic Sialadenitis̶Sausageor
string appearance.
• In large sialolith̶Pruned tree like
appearance.
• In Sjögren s syndrome̶Fruit laden
tree like.
 • Benign tumors̶Ball in hand
appearance
• Normal gland̶Double comb
appearance.
2. CT scan
3. Fine needle aspiration cytology
(FNAC)
4. Color Doppler sonography̶non-
invasive technique to evaluate vascular
anatomy.
5. Positron emission tomography̶helps
to di erentiate benign from malignant
lesions.

Q.WHAT IS THE TREATMENT?

• Treatment of the cause such as
stone or stricture of the duct.
• If there is no cause, conservative
treatment should be given in the form of
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antibiotics, massage of the gland and
sialogogues.
• If it fails, ductal dilation, ligation of
duct or total gland excision may be
done. Tympanic neurectomy may also
help.

TOPIC:MUMPS

Mumps is also called viral parotitis and is

usually seen in children up to 12 to 15
years of age. It spreads by droplet
infection and its incubation period is 15
to 20 days.

Q.WHAT ARE THENCLINICAL

FEATURES?
Fever, malaise, tender and di use
enlargement of gland.

Fig:enlarged salivary galnd in case of

mumps. (Google)

Q.WHAT ARE THE INVESTIGATIONS

DONE?
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 Diagnosis is made on clinical basis serum
amylase is raised in 90 percent cases.
Titers of mumps S and V antibodies is
raised.

Q.WHAT IS THE TREATMENT?

Complete bedrest, antibiotics, anti-
in ammatory drugs and
vitamins.Prevention may be done by
giving MMR (measles, mumps
and rubella) vaccination at 15 months of
age.

Q.WHAT ARE THE COMPLICATIONS?

• Unilateral sensorineural hearing loss
(SNHL) due to labyrinthitis
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• Viremia causing orchitis,
pancreatitis, meningitis, and
encephalitis.

TOPIC:SJÖGREN S SYNDROME (SICCA

SYNDROME)

• Sjögren s syndrome it was described

by Hadden in 1883
• Sjögren was a Swedish
ophthalmologist
• It is characterized by swelling of the
salivary gland with xerostomia and
xerophthalmia
• It is thought to be an autoimmune
disorder a ecting exocrine glands of the
body
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 • In35percent cases,major salivary
glandsmaybe involved.
• In 90 percent cases, women are
a ected.

Q.WHAT ARE THE TYPES?

They are of two types

-Primary type: In which there is

involvement of only exocrine glands
causing dryness of mouth and eyes.
Lymphoma may develop in primary type.

-Secondary type: In which in addition to

the symptoms of primary type there is
rheumatoid arthritis or systemic lupus
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erythematosus (SLE) or primary biliary
cirrhosisAssociated symptoms with
primary type may be:

• Pneumonitis
• Raynaud s phenomenon
• Dryness of skin and caries teeth
• Achlorhydria
• Hepatosplenomegaly
• Myositis, pancreatitis and nephritis
• Dryness of genitals
• Lymphadenopathy.
 Fig:clinical features of Sjögren s
syndrome
(Google)

Q.WHAT ARE THE INVESTIGATIONS

PERFORMED?
1. Biopsy shows periductal lymphocytic
in ltration. Preferred site for biopsy is
minor sublabial gland (lower lip).
2. Raised erythrocyte sedimentation
rate (ESR).
3. Rheumatoid factor may be positive.
4. Antinuclear antibodies may be
present.
5. Elevated antigens Sjögren s
syndrome antigen A (SS-A)and
Sjögren s syndrome antigen B (SS-B).

Q.WHAT IS THE TREATMENT?

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• Symptomatic treatment in the form
of arti cial saliva,arti cial tears and use
of sialogogues to stimulate saliva
formation such as eating raw apples
daily and sugar-free sour candies
• Orodental hygeine should be
maintained
• Use of immunosuppressant drugs
such as methotrexate,helps in the
prevention of development of
subsequent malignancy.

TOPIC:SIALOLITHIASIS

Calculi occur in the duct of

submandibular gland in 80 percent
cases and 20 percent in parotid gland.
They are formed when calcium
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phosphates are deposited around the
debris and mucus.

Q.WHAT ARE THE CLINICAL

FEATURES?
There is painful swelling of the gland due
to obstruction to ow of saliva.
Examination shows a calculus in the duct
of the gland con rmed by plain X-ray
with occlusive bite taken ondental X-
rays plate. Sialography may con rm the
radiolucent stone.

Q.WHAT IS THE TREATMENT?

Excision of the calculus under local
anesthesia if it is in the duct and if
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 present in the gland, gland may also be
sacri ced.

SALIVARY GLAND TUMORS

BENIGN TUMORS

TOPIC:PLEOMORPHIC ADENOMA

Pleomorphic adenoma is also called

mixed parotid tumor. It is the most
common benign tumor and may a ect
major
and minor salivary glands. It is very slow
growing, benign pathology seen more in
females between 30 and 50 years.
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These are called mixed tumors due to
presence of epithelial and mesenchymal
tissues.

Fig:clinical features of pleomorphic

adenoma

Q.WHAT ARE THE CLINICAL FEATURES

OF PLEOMORPHIC ADENOMA?
Patients present with rm, lobulated
mass of submandibular or parotid gland
or of the minor salivary glands of oral
cavity. Malignant change is very rare.

Q.WHAT IS THE TREATMENT OF

PLEOMORPHIC ADENOMA?
Excision of the tumor is done and
enucleation is avoided as there may be
recurrence.

TOPIC:Warthin s Tumor

Hilderbrand described this tumor in

1895, but Warthin of Michigan in 1929
described two cases of papillary
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cystadenoma. It is seen in elderly, obese
males and may be soft, cystic or rm in
the parotid gland.
Histologically, there are epithelial cells
with lymphoid tissue.
Treatment consists of wide excision.

TOPIC:MALIGNANT TUMORS

These are more commonly seen in

parotid gland and can be:
• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
(cylindroma)
• Squamous cell carcinoma
• Sarcomas.
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Q.WHAT ARE THE CLINICAL
FEATURES?
Sudden rapid increase in the size of
growth, which becomes painful and may
fungate or give secondary deposits into
lymph nodes. Facial nerve may be
involved.
Staging of malignancy is on the
American Joint Committee on Cancer
(AJCC) (1988) lines as usual.

Q.WHAT IS THE TREATMENTOF

MALIGNANT TUMOURS OF SALIVARY
GLAND?
Total excision of parotid gland with block
dissection of neck
followed by radiotherapy.
In advanced cases, palliative treatment
in the form of
radiotherapy or chemotherapy is given
TOPIC:PAROTIDECTOMY

Procedure
• Parotidectomy may be super cial
parotidectomy as in benign tumors and
total parotidectomy in malignant tumors
• Incision begins at preauricular region
going below lobulein the skin crease on
to the neck.
• Skin ap is raised upwards and
downwards
• Stylomastoid region is exposed to
locate the trunk of facialnerve, cartilage
pointer being a reliable landmark here
beside styloid process and mastoid
process
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• Super cial lobe of parotid is then
exteriorized by blunt dissection keeping
in mind branches of facial nerve
• Posterior facial vein branches will be
seen deep tomarginal mandibular nerve
• Parotid duct is ligated as far forward
as possible
• If deep lobe has to be removed
branches of facial nerve are separated
and deep lobe is mobilized from its
attachments by blunt dissection
• Perfect hemostasis is achieved and
dressing done.

Fig:Types of incision in parotidectomy

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(Google)

Complications
• Facial nerve palsy or weakness
• Gustatory sweating (Frey s
syndrome)
• Sialocele or salivary stulas.
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MCQ

1. Benign tumors of super cal lobe of

parotid gland takes a very long time to
project outwards because
a.The external surface of the parotid
gland is covered by tough parotid fascia
b.Slow rate of tumor growth
c.The styloid process stops the
progression of tumor
d. Ramus of the mandible stops tumor
progression

2. During sleep salivary secretion is

maintained by
a.Sublingual gland only
b.Submandibular gland only
c.Parotid gland only
d.Submandibular and sublingual salivary
glands
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3. Acini of parotid glands are formed by
a.Mucinous cells
b.Serous cells
c.Seromucinous cells
d.Cloudy cells

4. The parotid gland is divided into

super cial and deep portions by:
a.Cartilagenous portion of external
auditory canal
b.Facial nerve branches
c.Mandible
d.Internal maxillary artery

5. Sublingual salivary gland is situated

a.Under the palatopharyngeous muscle
b.Posterior to the mylohyoid muscle
c.Below the mylohyoid muscle
d.Above the mylohyoid
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6. Technitium pertechnetate scans are
useful in the diagnosis of
a.Monomorphic adenoma
b.Warthin's tumor
c.Sialadinitis
d.Pleomorphic adenoma

7. Multiple cystic lesions inside both the

parotid glands in a patient should alert
the clinician for a possible diagnosis of
a.Measles infection
b.Mumps
c.HIV infection
d.Malignancy

8. Warthin's tumor is commonly seen in

a.Submandibular salivary gland
b.Accessory salivary gland
c.Sublingual salivary gland
d.Parotid gland

9. Parotid duct is known as

a.Finely's duct
b.Stenson's duct
c.Wharton's duct
d.Stylle's duct

10. Calcium content of saliva is low in

a.Submandibular salivary gland
secretions
b.Parotid secretions
c.Accessory salivary gland secretions
d.Sublingual salivary gland secretions

11. Submandibular salivary gland

swelling is di erentiated from
submandibular lymphadenitis clinically by
a.Bidigital palpation
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b.Presence of transillumination in
submandibular salivary gland
c.Movement during swallowing
d.Palpation from behind the patient

1. a 2. d 3.b 4.b 5.d 6.b 7.c 8.d 9.b 10.b

11.a
CLINICAL QUESTION
Q.A 43 YEAR OLD MALE PATIENT
PRESESNTED TO THE OPD WITH
COMPLAINT OF SWELLING OVER THE
LEFT CHEEK WHICH IS VERY
SLOWHROWING
ON EXAMINATION SWELLING IS FIRM
AND LOBULATED
Q.WHAT IS THE DIAGNOSIS
Q.WHAT ARE THE CLINICAL FEATURE?
Q.WHAT IS THE TREATMENT?

ANS:PLEOMORPHIC ADENOMA
HINT:SWELLING OR MASS OVER
PAROTID REGION WHICH IS FIRM AND
LOBULATED
Q.A MALE PATIENT WHO IS A KNOWN
CASE OF RHEUMATOID ARTHRITIS
PRESENTED TO THE OPD WITH CHIEF
COMPLAINT OF DRYNESS OF BOTH
MOUTH AND EARS
ON INVESTIGATING THE CASE THERE
IS ELEVATED SS-A ANTIGEN
Q.WHAT IS THE DIAGNOSIS?
Q.WHAT ARE THE CLINICAL
FEATURES?
Q.WHAT ARE THE INVESTIGATIONS
PERFORMED?
Q.WHAT IS THE TREATMENT?

ANS:SJÖGREN S SYNDROME
HINT:DRYNRSS OF MOUTH AND EARS
ALONG WITHELEVATED SS-A ANTIGEN
LEVELS