DIAGNOSIS AND

MANAGEMENT OF
SAIVARY GLAND
DISORDERS
DR.TAHERA AYEUB
ASISSTANT PROFESSOR
ORAL AND MAXILLOFACIAL SURGERY
DEPARTMENT

EMBRIOLOGY ANATOMY AND

PHYSIOLOGY
Divided into two groups
minor glands
major glands
-Develop from embryonic oral cavity as
buds of epithelium that extend into
underlying mesenchymal tissues
-epithelium in growth branch to form a
primitive dental system-canalized to
provide for drainage of salivary secretion

 Development begin
-minor salivary gland-fortieth day in
utero
-major salivary gland-thirty fifth day
in utero
-secretory cell around the ductal
system-7th
or 8th
month in utero

SALIVARY GLAND
RADIOLOGY

TO IDENTIFY SALIVARY STONES(CALCULI)

80% TO 85% stones are radiopaque
Visible radiographically
Mandibular occlusal film is use for detecting
sublingual and sub mandibular gland calculi in the
floor of the mouth
Panoramic radiograph reveal stones in the
parotid gland and posteriorly located
submandibular gland
Periapical radiograph can show calculi in each
salivary gland and minor salivary gland

PAROTID GLAND
Largest salivary gland
Lie superficial to the posterior aspect of
masseter muscle and assending ramus of
mandible
Peripheral portion extend to the mastoid
process along the anterior border of the
sternocleidomastoid muscle
Around the posterior border of the
mandible into the pterogomandibular space

 seventh cranial (facial) nerve divide the

parotid gland into
-superficial lobe
-deep lobe
Coursing anteriorly from their exit at the
stylomastoid foramen to the innervate the
muscle of expression
Small ducts from various regions of the
gland coalesce at the anterosuperior
aspect of the parotid to form stensen's
duct
Stensen's duct 1 to3mm in diameter and
6cm in length

 At the anterior edge of the masseter

Stensens duct turns medial and
passes through the fibers of the
buccinators muscle
The duct opens into the oral cavity
through buccal mucosa adjacent to
maxillary 1st and 2nd molar tooth
Gland receive innervation from ninth
cranial (glossopharyngeal)nerve with
auriculotemporal nerve from the otic
ganglion

SUBMANDIBULAR GLANDS
Located in the submandibular triangle of the
neck
Which is formed by anterior and posterior belly
of digastrics muscles and inferior border of the
mandible
Poster-superior portion of the gland curves
upward around the posterior border of the
mylohyoid muscle
Give rise to the major duct of the
submandibular gland known as Wharton's duct

 Duct passes forward along the

superior surface of the mylohyoid
muscle in the sublingual space
,adjacent to the lingual nerve
Lingual nerve loops under wartan,s
duct from lateral to medial in the
posterior floor of the mouth
Duct is 5cm in length
Diameter of lumen is 2 to 4 mm
Wharton's duct open into the floor of
the mouth with a punctum

 Punctum located close to the incisors

at the most anterior aspect at the
lingual frenum and the floor of the
mouth

SUBLINGUAL GLANDS
Lie on the superior surface of the mylohyoid
muscle, in the sublingual space
Are separated from oral cavity by a thin
layer of oral mucosa
Acinar ducts of the sublingual glands are
bartholins duct in most instance coalesce to
form 8 to 20 ducts of rivinus
Short and small in diameter
open directly into the floor of the mouth on
a crest of mucosa known as plica
sublingualis

 Or they open indirectly through

connection to the submandibular
duct and then into the oral cavity
with wharton's duct
Submandibular and sublingual glands
are innervated by the facial nerve
through the submandibular ganglion
with the chorda tympani nerve.

FUNCTIONS OF SALIVA
Provide lubrication for speech and
mastication
To produce enzymes for digestion
To produce compounds with
antibacterial properties
Produce 1000 to 1500 saliva per day
with the highest flow rates occurring
during meals

Daily saliva production by salivary

glands

Submandibular gland
Parotid gland
Sublingual gland
Minor glands

70%
25%
3% to 4%
trace

Diagnostic modalities
HISTORY AND CLINICAL EXAMINATION
-In most cases patient will guide the doctor
to the diagnosis by relating the events that
have occurred in association with the
presenting complaint
Must perform a thorough evaluation for
diagnosis
Many instances diagnosis can be
determined without further diagnostic
evaluation

 Occasionally the clinician may find it

necessary to use any of several
diagnostic modalities
- salivary gland radiology
- salivary gland
endoscopy(sialoendoscopy)
- sialochemistry
- fine-needle aspiration biopsy
- salivary gland biopsy

SALIVARY GLAND
RADIOLOGY
PLAIN FILM RADIOGRAPHS
- in the assessment of salivary gland
disease is to identify salivary
stones(calculi)
- 80% to 85% stones are radio
opaque
- mandibular occlusal film is most
useful for submandibular and
sublingual gland calculi in the
anterior floor of the mouth

SIALOGRPHY
Indications
in the detection of radio opaque
stones
In the assessment of the extent of
destruction of salivary duct or gland
as a result of
-obstructive , inflammatory,
traumatic and neoplastic diseases

COMPUTER TOMOGRAPHY
For the assessment of mass lesions
of the salivary glands
Less invasive than sialography
Does not require the use of contrast
material
Demonstrate salivary gland calculi
Especially submandibular stones that
are located posteriorly in the duct or
in the substance of the gland itself

Magnetic resonance
imaging(MRI)
Superior to CT scanning in
delineating the soft tissue detail of
salivary gland lesions
Specifically tumors , with no radiation
exposure to the patient

ULTRASONOGRAPHY
Simple , noninvasive imaging
modality
Poor detail resolution
Role is in the assessment of
superficial structures
To determine whether a mass lesion
is solid or cyst(fluid-filled) in nature

SALIVARY SCINTIGRAPHY
(RADIOGRAPHIC ISOTOPE SCANNING)
Use of nuclear imaging in the form of
radioactive isotope scanning
Allows a thorough evaluation of the salivary
gland parenchyma
Presence of mass lesions
Function of the gland itself
Demonstrate increased uptake of radioactive
isotope in an acutely inflamed gland
Decrease uptake in chronically inflamed gland
Presence of a mass lesion(benign or
malignant)

SALIVARY GLAND
ENDOSCOPY(SIALOENDOSCOPY)
Minimally invasive modalities of diagnosis and treatment
Applied to the major salivary glands
Is a specialized procedure that uses a small video
camera(endoscope)
With a light at the end of a flexible canula
Introduced into the ductal orifice
Can be used diagnostically and therapeutically
Used to dilate small strictures
Flush clear small mucous plugs in the salivary gland ducts
Specialized devices such as small balloon catheters used to
dilate sites of ductal constriction
Small baskets may be used to retrieve stones in the ductal
system

SIALOCHEMISTRY
An examination of the electrolyte
composition of the saliva of each gland
May indicate a variety of salivary gland
disorders
Concentration of sodium and potassium
change with salivary flow rate
Elevated sodium concentration with
decreased potassium concentration may
indicate an inflammatory sialadenitis

FINE NEEDLE ASPIRATION

BIOPSY
Use in the diagnosis of salivary gland
tumors'
Has a high accuracy rate for
distinguishing between benign and
malignant lesion in the superficial
location
Is performed using a syringe with
a20-guage or smaller needle

PROCEDURE
local anesthesia
Needle is advanced into the mass lesion
The plunger is activated to create a vacuum in the
syringe
The needle is moved back and forth throughout
the mass with pressure maintained on the plunger
The pressure is then released the needle is
withdrawn
The cellular material and fluid is expelled onto a
slide and fixed on histologic examination

SALIVARY GLAND BIOPSY

Either incisional excisional biopsy can be used
to diagnosed tumor of one of the major salivary
glands
The lower lip labial salivary gland biopsy has
been shown to demonstrate certain
characteristic histopathology changes that are
seen in the major glands in ss
The procedure is performed using local
anesthesia
Approximately 10 minor salivary glands are
removed for histological examination

OBSTRUCTIVE SALIVARY GLAND

DISEASE

Sialolithiasis
formation of stones or calculi may
occur throughout the body
Including gallbladder, urinary tract
and salivary glands
Common in men
Age between 30 and 50
Multiple stone formation in 25% of
patients

 The pathogenesis of salivary calculi

progresses through a series of stages
beginning with an abnormality in calcium
metabolism and salt precipitation
Formation of a nidus that subsequently
becomes layered with organic and
inorganic material,to form a calcified
mass
Submandibular gland involve 85%
Concentration of calcium is about twice
as abundant in submandibular saliva as in
parotid saliva

 Alkaline Ph of submandibular saliva may further

support stone formation
Wharton,s duct is longes salivary duct has a
greater distance to travel before being emptied
into the oral cavity
The punctum of submandibular gland is smaller
-provide potential areas of stasis of salivary flow
or obstruction
-precipitated material mucous and cellular
debris are more easily trapped in the tortuous
and submandibular duct
Obstruction occurs at meal time because
salivary production maximum

SIALOLITHIASIS FOR GENERAL

DENTIST
Classic signs and symptoms of
sialolithiasis
- exacerbation of pain and swelling
at mealtimes
- check for flow from wahrton,s
duct
- check for tenderness of
submandibular
gland
- Palpate for stone in floor of mouth
- check mandibular occlusal

MANAGEMENT

the management of
submandinbular gland calculi
depends on
- the duration of symptoms
- the number of repeated episodes
- the size of the stone
- the location of the stone

SIALODOCHOPLASTY
(revision of the salivary duct)
An incision made floor of the mouth
Expose the duct and stone
A longitudinal incision is then made
in the duct ,the stone is retrieved
The ductal lining is sutured to the
mucosa of the floor of the mouth
Saliva will then flow out the revised
duct

 In many instances of repeated stone

formation
The submandibular gland and the
stone should be removed by an extra
oral approach

Counciling of the patient

Patients are encourage to maintain
ample salivary flow by using salivary
stimulants
- citrus fruits
- flavored candies
- glycerin swabs

EXTRACORPOREAL SHOCK WAVE

LITHOTRIPSY
Successful in treating small salivary
gland stones
This technology uses transcutaneous
electromagnetic waves to break the
calculus into small calcified debris
particles
Flushed from the ductal system by
the normal flow of saliva

 This procedure is limited by

- the size of stone(usually less than
3mm)
- the number of stones(usually less
than three)
- the location of the
stone(intraglandular stones may be
less amenable to ecswl)

MUCOUS RETENTION
AND EXTRAVASATION
PHENOMENA

 MUCOCELE
what is mucocele?
. Salivary duct, especially those of the
minor salivary glands ,are occasionally
traumatized commonly by lip biting, and
severed beneath the surface mucosa.
. Subsequently saliva production may
then extravsate beneath the surface
mucosa into the soft tissues
. Over time ,secretions accumulate within
the tissues and produce a pseudocyst that
contains thick viscous saliva common in
mucosa of upper lip known as mucoceles

 second common site is buccal

mucosa
Mucocele formation results in an
elevated,thinned, stretched overlying
mucosa that appears as a vesicle
filled with a clear or blue-gray
mucus.
The patient frequently relates a
history of the lesion filling with fluid,
rupture of the fluid collection, and
refilling of these lesion
Mostly mucocele formation regress

 Persistent or recurrent lesions

treatment consist of exicision of the
mucocele and associated minor
salivary glands
Recurrence rates may be as high as
15% to 30% after surgical removal

 RANULA
Ranulas results from either mucous
retention in the sublingual gland
ductal system or mucous
extravasation as a result of ductal
disruption
Most common lesion of sublingual
gland
Two types of ranulas are
- simple ranula
- plunging ranula

First recurrence of ranula

Third recurrance of ranula

Fifth recurrance of ranula

 Simple ranula is confined to the area occupied

by the sublingual gland in the sublingual space,
superior to the mylohyoid muscle
Plunging ranula occures when the lesion
extends beyond the level of the mylohyoid
muscle into the submandibular space
- plunging ranula has the potential to extend
into the neck and compromise the airway,
resulting in medical emergency
Ranulas may reach a larger size than mucoceles
because their overlying mucosa is thicker and
because trauma that would cause their rupture
is less likely in the floor of the mouth

Treatment of ranula
Is marsupilization
In which a portion of the oral mucosa of
the floor of the mouth is excised along
with the superior wall of the ranula
The ranula wall is sutured to the oral
mucosa of the floor of the mouth and
allowed to heal by secondary intention
The preferred treatment for recurrent or
persistant ranulas is excision or the
ranula and sublingual gland

SALIVARY GLAND
INFECTIONS
Related to obstructive disease, especially in
submandibular gland
Cause of acute suppurative sialadenitis of the parotid
gland usually involves a change in fluid balance that
is likely to occur in patients who are
-elderly
-debilitated
-malnourished
-dehydrated
-plagued with chronic illness
In these cases , gland infections are usually bilateral

 Mean age of infection is is 60 years

Organisms including aerobic and
anaerobic , bacteria, viruses , fungal
organisms and mycho bacteria
In most cases mixed bacterial flora is
responsible for sialadenitis
The most common organism implicated
in salivary gland infection is
staphylococcus aureus
This organism normally colonizes around
ductal orifices

Clinical characteristics of acute

bacterial salivary gland infections
Is rapid onset of swelling in the pre
auricular(parotid gland)or
submandibular regions
Associated erythema and pain
On palpation gland will reveal no flow
or elicit a thick purulent discharge
from the orifice of the duct

TREATMENT 0F BACTERIAL SALIVARY

GLAND INFECTIONS
Includes symptomatic and supportive care
Including IV fluid hydration, antibiotics ,and
analgesics
Initial empiric antibiotics should be aimed at
the most likely causative organism s. aureus
Should include a cephalosporin or anti
staphylococcal semi synthetic penicillin
Culture and sensitivity studies of purulent
material should be obtained to aid in selecting
the most appropriate antibiotic for each patient

 In most cases, surgery consist of

incision and drainage
Untreated infection may progress
rapidly and can cause
-respiratory obstruction
-septicemia and eventually death
In recurrent infections , excision of
the gland may be indicated

Viral parotitis or mumps

Is an acute ,non suppurative
communicable disease
Occurred in epidemics during winter
and spring
Viral infections are not the result of
obstructive disease
Not require different treatment ,not
including antibiotics

 Mumps is characterized by a painful ,non

erythematous swelling of one or both parotid
glands
Begins 2 to 3 weeks after exposure to the
virus
Common in children between ages 6 and 8
Signs and symptoms
pain
swelling
fever
chills
headache
Usually resolves in 5 to 12 days after its onset

 Supportive and symptomatic care for

-fever
-headache
-malaise with antipyretics
-analgesics
-adequate hydration treats viral partitas
Complications in 20% of young males
-meningitis
-pancreatitis
-nephritis
-orchitis
-testicular atrophy

NECROTIZING
SIALOMETAPLASIA
Is a reactive nonneoplastic inflammatory process
that usually affects the minor salivary glands of
the palate
Unclear origin but is thought to be secondary to
vascular infarction of the salivary gland lobules
Potential causes of diminished blood flow to the
affected area including
trauma, local anesthetic injection
smoking, diabetes mellitus, vascular disease
pressure from denture prosthesis
Age range is 23 and 66 years

 Lesions usually 1 to 4 cm large

Painless or painful
Deeply ulcerated areas lateral to the palatal midline
and near the junction of the hard and soft palate
Unilateral or bilateral involvement may occur
Patient may report a prodromal flulike illness before
the onset of the ulceration
It resembles a malignant carcinoma(squamous cell
or mucoepdermoid carcinoma)
The ulceration of necrotizing sialometaplasia usually
heal spontaneously within 6 to 10 weeks after their
onset
No surgical management

SJOGRENS SYNDROME
Is a multisystem disease process with a
variable presentation
Two types of ss are
1- primary ss or sicca syndrome
. Charecterized by xerostomia(dry mouth)
. Keratocunjuctivitis sicca(dry eyes)
2- secondary ss
. Composed of primary ss and an
associated connective tissue most commonly
rheumatoid arthritis

 Cause of ss is unknown
There appears to be a strong autoimmune
influence
The first symptoms to appear are
arthritic complaints
followed by occular symptoms
late in the disease proses
Salivary gland symptoms
Xerostomia results from a decreased
function of both the major and minor
salivary glands

DIAGNOSIS

By the patient complaints complaints

By immunological laboratory tests
By using salivary flow rate studies
Sialography
Labial minor Salivary gland biopsy

Treatment
SYMPTAMATIC
- artificial tears for dry eyes
- salivary substitute for dry eyes
MWDICATION
- pilocarpine(salagen)
- biotene products to stimulate
salivary flow from the remaining
functional salivary gland tissue

TRAUMATIC SALIVARY GLAND

INJURIES
Occur in close proximity to one of the major
salivary glands or ducts
Due to trauma, fractures,
Repair may include ductal anastomoses
In which the proximal and distal portions of
the duct are identified
A plastic or metal catheter is placed as a
stent
The duct is sutured over the stent
Catheter leave for 10 to 14 days for
epithelialization of the duct

 Trauma involve the major salivary

glands include infection-facial
paralysis-cutaneous salivary gland
fistula sialocele formation and duct
obstruction as a result of scar
formation-evantually glandular
atrophy-require surgical removal

NEOPLASTIC SALIVARY GLAND

DISORDERS
Salivary gland tumor distribution
Major salivary gland
parotid glands
85% to 90%
submandibular gland 5% to 10%
sublingual gland
rare
Minor salivary gland
palatal
55%
lips
15%
remainder
rare

BENIGN SALIVARY GLAND

TUMORS
pleomorphic adenoma or benign
mixed tumor
warthin,s tumor or papillary
cytadenoma lymphomatosum
Monomorphic adenoma

Pleomorphic adenoma

Most common salivary gland tumor

Occurrence age is 45 years
Male to female ratio 3:2
In major glands parotid gland is involved 80%
Minor glands intraoral sit is the palate
Slow growing painless masses
Histopathology shows two types of cell
1- ductal epithelial cell
2-myoepithelial cell

 Treatment
- complete surgical excision with
a margin of normal uninvolved tissue
- parotid lesion-removal of
involved lobe along with tumor
- recurrene is possible in rare
cases
- small risk 5% of malignant
transformation

Warthans tumor or papillary

cystadenomatosum
Affect the parotid gland
Specifically the tail of the parotid
gland
Peak incidence is sixth decade of life
Male to female ratio 7:1
Slow growing soft and painless mass
Caused by entraped salivary
epithelial rests within developing
lymph nodees

 Histopathology
epithelial component in a papillary
pattern
Slymphoid component with
germinal centers
Treatment
surgical excision
Recurrence is rare

Malignant salivary gland

tumors
Mucoepidermoid carcinoma
Polymorphous low grade
adenocarcinoma
Adenoid cystic carcinoma

Mucoepidermoid carcinoma
most common malignant salivary
gland tumor
10% major gland tumor(mostly
parotid)
20% minor gland tumors(mostly
palate)
Mean age is 45 years
Male to female ratio is 3:2
Clinical presentation submucosal
mass-painful or ulcerated

 Histopathology show three cell types

-mucous cells
-epidermoid cells
-intermediate (clear) cells

 Treatment
- low grade lesion wide surgical
removal with margins of uninvolved
normal tissue
-95% 5-year survival rate
-high grade lesions require more
aggressive
surgical removal with
margins
-local radiation therapy
- less than 40% 5-year survival rate

Polymorphous low-grade
adenocarcinoma
Second most common malignant
tumor
Most common sit is the junction of
hard and soft palate
Mean age 56-year
Male to female ratio is 3:1
Slow growing asymptomatic masses
May be ulcertaed

Polymorphous low grade

adenocarcinoma

 Histopathology shows many cell

shapes and patterns(polymorphous)
Patient experienced an infiltrative
proliferation of ductal epithelial cells
in an indian file pattern
Invasion of surrounding nerves
Treatment-WIDE SURGICAL EXCISION
Recurrence rate is 14%

ADENOID CYSTIC
CARCINOMA
Third most common intraoral salivary
gland malignancy
Mean age 53 years
Male to female ratio 3:2
50% in parotid gland
50% occur in minor salivary gland
Slow growing nonulcerated masses
Associated chronic dull pain

 Parotid lesion may result in facial

paralysis as a result of facial nerve
involvment
Histopathology infiltrative
proliferation of basaloid cells
arranged in a cribriform (swiss
cheese) pattern
Treatment
- wide surgical excision
- in some cases radiation therapy
- Prognosis is poor

Necrotizing sialometaplasia