Non-neoplastic and Neoplastic Mucocele

Lesions of Salivary Glands

Very common
Rupture of duct pillage of mucin (extravasation)
Dr. Ioannis G. Koutlas Frequent trauma history
Division of Oral Pathology Classification:
Extravasation, retention, oncocytic type
Retention a separate type = true salivary gland cysts
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Mucocele
Dome-shaped
Blue or normal color depending on the depth
Children
Fluctuant or occasionally firm
History of rupture and rebuilding
Lower lip, buccal mucosa, ventral tongue, FOM
Superficial mucoceles
Soft palate, retromolar mucosa, buccal mucosa
Multiple; associated with other lesions
Ranula
Sublingual, submandibular, minor glands FOM
Plunging: below the mylohyoid muscle

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 Mucocele

Histology
Spilled mucin
Macrophages
Chronic inflammation of salivary glands
Treatment
May not be needed
Surgical excision and histopathologic evaluation

Salivary duct cyst

Epithelium-lined cavity
Mucus retention phenomenon
Adults
Slow-growing
Floor of mouth, buccal mucosa, lips (upper lip)
Conservative surgical excision

Sialolithiasis (Salivary stones) Sialolithiasis (Salivary stones)

If superficial, palpable hard tissue

Deposition of calcium salts around a nidus
Panoramic, periapical radiographs may show opacity
Submandibular gland Can be multiple; DD: tuberculosis
Tortuous duct, thicker saliva
Sialography needed occasionally
Less frequently parotid
Treatment
Upper lip
Milking of stone
Most common in young and middle-aged adults Surgical removal
Lithotripsy

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 Sialadenitis
Viral: Mumps
Other viruses
Bacterial: Retrograde spread of bacteria throughout the ductal
system
Surgical mumps
After surgery NPO patients, staph. aureus or other
Non-infectious agent: Sjgren syndrome, sarcoidosis, radiation tx
Parotid, frequently bilateral
Swelling, pain, erythematous skin, low-grade fever, trismus

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 Sialadenitis

Submandibular gland: Kttner tumor

Autoimmune pancreatitis
Minor gland
Subacute necrotizing sialadenitis
Palate
Young adults
Crowded conditions
Self-limiting
Chronic sclerosing sialadenitis

Sialorrhea
Sialorrhea
Recurrent aphthous stomatitis
Patients with GERD Treatment
Heavy metal poisoning Anticholinergic agents
Cerebral pulsy, mental retardation Surgical relocation of salivary ducts
Medications: cholinergic agonists, lithium Submandibular gland excision, parotid gland ligation
Surgery: mandibulectomy Section of chorda tympani
Idiopathic paroxysmal sialorrhea
~ 5 minutes
Prodrome of nausea or epigastric pain

Xerostomia Xerostomia

Salivary gland aplasia Reduction of salivary flow

Very rare; part of syndromes Saliva appears ropey or foamy
Impaired fluid intake
Gloves stick on the mouth
Vomiting, diarrhea, hemorrhage
Difficulty in mastication or swallowing
Medications, radiation treatment
Measurement of resting or stimulated salivary flow
Sjgren syndrome, diabetes, sarcoidosis, HIV, GVHD,
psychogenic disorders Prevalence of candidiasis
Decreased mastication, smoking, mouth breathing Cervical caries

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 Xerostomia Benign lymphoepithelial lesion

Treatment Mikulicz disease vs. Mikulicz syndrome

Oral hygiene products that contain enzymes B9 lymphoepithelial lesion vs. lymphoid infiltrates
Medication-related: act appropriately Bilateral enlargement of parotids and lacrimal glands
Medications featuring intense lymphocytic infiltrate
Pilocarpine: parasympatheticomimetic agonist, 5-10 mg TID or QID Sjgren syndrome
Cevimeline HCl: acetylocholine derivative Epimyoepithelial islands
Both medications contraindicated if patient have narrow-angle MALToma
glaucoma
Lymphoepithelial carcinoma

Sjgren syndrome Sjgren syndrome

Chronic systemic autoimmune disease
Keratoconjunctivitis sicca and xerostomia: 1 Sjgren San Diego criteria for 1 Sjgren
Xerophthalmia
+ other autoimmune disease: 2 Sjgren
Xerostomia
Unknown cause; EBV or human T lymphotrophic virus
Serologic evidence of systemic autoimmunity
Non-hereditary but genetic influence
Elevated rheumatoid factor
Mostly women Elevated antinuclear abs
Rheumatoid arthritis Presence of anti-SS-A or anti-SS-B
15% of pts with rheumatoid arthritis have also SS
30% of pts with lupus may develop SS

Sjgren syndrome Sjgren syndrome

Treatment
San Diego criteria for 2 Sjgren Supportive
Primary plus Artificial tears and saliva
Clinical features for rheumatoid arthritis, lupus, polymyositis, Protective eyewear
scleroderma or biliary cirrhosis Meticulous oral hygiene
Increased risk for lymphoma

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 Revised Criteria
Exclusion Criteria
New International Criteria
Ocular symptoms Radiation tx
Oral symptoms Hepatitis C
Ocular signs
Schirmer test, rose Bengal score
AIDS
Lip biopsy (!) Lymphoma
`Salivary gland involvement Sarcoidosis
Salivary flow
Parotid sialography
GVHD
Salivary scintigraphy Anticholinergic medications
Autoantibodies (!)

Sialadenosis (Sialosis) Necrotizing Sialometaplasia

Non-inflammatory disorder
Uncommon, locally destructive
Salivary gland enlargement
Cause: Ischemia that leads to infarction
Parotids
Posterior palate and soft palate
Causes
Major glands can be affected
Endocrine: diabetes, acromegaly, hypothyroidism, pregnancy
Nutritional: malnutrition, alcoholism, anorexia nervosa, Unilateral (most frequently) or bilateral
bulimia Adults 2M:F
Neurogenic medications: antihypertensive, psychotropic,
symphathomimetic

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 Necrotizing Sialometaplasia Necrotizing Sialometaplasia

Course
CAN LOOK BOTH CLINICALLY AND
Initially no ulcerated swelling with pain or paresthesia
MICROSCOPICALLY LIKE SQUAMOUS CELL
In 2-3 weeks necrosis occurs and an ulcer is formed
CARCINOMA OR MUCOEPIDERMOID
1-5 cm
CARCINOMA
Pain subsides
Rarely destruction of bone

Salivary gland tumors Salivary gland tumors

1.
THE TEN Benign salivary gland tumors are more
COMMANDMENTS frequent than malignant.

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 Salivary gland tumors Salivary gland tumors
2. 3.
Benign tumors occur more frequently in the fourth and Malignant tumors are more frequent in the minor than
fifth decades of life, and malignant tumors are most major salivary glands.
common in the sixth decade.

Salivary gland tumors Salivary gland tumors

4. 5.
Clinical signs such as pain, hemorrhage, ulcerations, The parotid and the minor salivary glands of the palate
and necrosis characterize malignant salivary gland are the sites of predilection for all varieties of benign
neoplasms. and malignant salivary gland tumors.

Salivary gland tumors Salivary gland tumors

6. 7.
The upper lip is far more frequently (10 times) affected Pleomorphic adenoma is the most common epithelial
than the lower lip. tumor of major and minor salivary glands. In minor
glands the most common malignant tumor in the U.S. is
mucoepidermoid carcinoma.

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 Salivary gland tumors Salivary gland tumors
8. 9.
Mucoepidermoid carcinoma is the most common Pleomorphic adenoma, although benign, can
malignant salivary gland tumor in childhood and occasionally recur due to frequent treatment difficulties
adolescence. (i.e. enucleation, seeding of neoplastic cells,
preservation of facial nerve).

Salivary gland tumors

10.
Perineural invasion is a common finding in adenoid
cystic carcinoma and polymorphous low grade
adenocarcinoma. In other malignant salivary gland
tumors it is less frequent.

Pleomorphic adenoma
Slow growing, 30-50 years, females >? males,
superficial lobe of the parotid more often, sometimes as
a mass of the lateral pharyngeal wall or soft palate.
Well circumscribed, presence of capsule in major
(parotid), infiltration of capsule, cellular
component=parenchyma: ductal cells and myoepithelial
cells, stroma shows myxoid, chondroid and occasionally
bone formation; other elements may be present .
Preservation of the facial nerve, for deep lobe most often
total parotidectomy, malignant transformation.

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10
 Papillary cystadenoma
lymphomatosum (Warthin's tumor)

Second most common benign parotid tumor,

smokers 8x more often, tail of the parotid,
bilateral tumors that are metachronous, used to
be male predilection but not anymore.
Histology explains name

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 Other Adenomas
Canalicular adenoma: almost exclusively in the
minor glands, upper lip; mistaken for mucocele,
F>M
Basal cell adenoma: Primarily of the parotid.
Oncocytoma: Primarily the parotid, cells have
mitochondria.
Ductal papillomas

Mucoepidermoid carcinoma
Carcinoma vs. tumor.
Most common malignant tumor, it is the most
common malignant salivary gland tumor in
children, lower lip, intraosseous examples (most
common intraosseous salivary gland tumor).
Histology explains name

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 Acinic cell carcinoma
Low grade malignancy
Most common location is the parotid, buccal
mucosa, lips and palate

Adenoid cystic carcinoma

a.k.a. cylindroma.

Half of them occur in the minor salivary glands, palate; relatively

rare in the parotid, most common malignancy of submandibular
gland, pain, facial nerve paralysis.

Cribriform pattern, tubular pattern and solid variant,

perineural invasion (also seen in polymorphous low grade
adenoca), distant metastasis (lungs. bones).

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 Polymorphous low-grade adenocarcinoma
(PLGA)

Misdiagnosed in the past

One of the more common salivary gland
malignancies.
Exclusively of the minor salivary glands, most
often site is the palate, 2/3 in females.
Many patterns, perineural invasion.

Mesenchymal tumors
Juvenile hemangioma or cellular hemangioma
(hemangioendothelioma) is the most frequent
tumor of the parotid in children.
Lymphomas (remember Sjgren syndrome)
Sialoblastoma: congenital tumor

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