Salivary glands Sheet #22 Done by : Farah Al khouly



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Salivary glands

Sheet #22

Done by : Farah Al khouly

*Saliva has an important role in :



  1. reminalization

  2. buffering capacity

  3. antimicrobial activity (it contains enzymes and IgA )

  4. it has a role in digestion (it contains lipase )

  5. water balance

*There is difference between resting salivary flow and stimulated salivary flow :

- resting salivary flow : mainly it comes from submandibular

- stimulated salivary flow : it comes from parotid and sublingual

* salivary flow varies during the day ; it decreases at night and increases during eating and throughout the day . On average it is 0.5-1 liter/day .

*There are 3 pairs of salivary glands :

1- parotid : mainly serous secretion

2-sublingual : mucus secretion

3- submandibular : mixed

*note : the dr said that we have to revise the anatomy of each salivary gland since we took them before :p

- last time we talked about examination of salivary glands : palpation , inspection, sialometry , sialography , MRI , CT scan

- also last time we talked about sialometry : assessment of some chemicals in the saliva .

Now lets start with the Diseases of salivary glands :



  • sialadinitis

  • sialosis

  • necrotizing sialometaplasia

*Lets start with Sialadinitis :

- Its an inflammation of salivary gland

- could be infective ( due to bacteria or virus ) or non infective ( due to radiotherapy or allergic rxn)

- mainly it affects major salivary glands, and could affect minor salivary glands

- example of non infective sialadinitis : necotinic stomatitis >> due to smoking


  1. Bacterial sialadinitis :

  • Common

  • Its secondary to a predisposing factor (for example; anything lead to xerostomia make the patient succiptable to sialdinitis . Also patients who have calculus and stones in their ducts are susceptible to sialadinitis . That’s why sialadinitis in submandibular gland is mostly secondary to stones because this gland is so susceptible to stones . Whereas in parotid , xerostomia is the most common cause of sialidinitis )

  • Features : acute sudden onset swelling , pain and swelling in the skin overlying the gland which will be erythrematous , pus discharge from the duct (this is a distinctive feature for bacterial siladinitis , and it could appear in viral sialadinitis if there was a secondary bacterial infection )

  • Treatment :

First treat the acute phase >> give antibiotic and hydrate the patient and use anything that increase the salivary secretion ,

Then treat the predisposing factors .



  • In case of sever recurrent sialadinitis ; do incision for the gland after the resolution of acute phase

  • The preferred antibiotis that’s used : flucloxacillin ( the dr asked why its preferred? ).



  1. Allergic sialadinitis :

  • Has the same clinical presentation of bacterial sialdinitis

  • Its rare

*Sialadinosis ( sialosis) :

- bilateral swelling of s.g

- its not inflammatory and not neoplastic

- could affect any salivary gland

- unknown mechanism

- its associated with : alcohol consumption, diabetes, sarcoidosis , females who have anorexia nervosa , also associated with some drugs for example anti rheumatic drugs .

- management : take proper detailed history from the patient , and search for any systemic disease that could lead to sialosis , that’s why do some tests :

- liver function test ( because liver diseases and cirrhosis could cause sialosis)

-asses the blood glucose level

-growth hormone level

-CBC

Sialosis has no treatment , so What we can do is only knowing the cause of it .



*Necrotizing sialometaplasia :

- it “looks like” malignancy

- the patient will have non healing ulcer at the palate and will stay for a long time ( these are features of benign changes in the salivary gland , however they look like malignancy features )

- its called necrotizing due to presence of features of necrosis in the biopsy

-its called sialometaplasia because there will be changes in the epi cells ( from columnar or cuboidal to squamous cells )

-it has unknown cause , but it maybe caused by trauma

- the patient will come with ulcerated mass at the palate with variable degrees of pain ( painful or painless) , and as we said it will have the same features of malignancy >> deep and stay for a long time , and sometimes its mistaken with cancer in the pathology (since there will be psudoepithilumatous hyperplasia and necrosis in the biopsy)

-its self limiting , and as we said benign . So all what we can do is reassurance and follow up only .



*Sarcoidosis:

-it’s a granulomatous disorder , it could affect the salivary glands

- lead to enlargement and xerostomia in the s.g

*Heerfordt’s syndrome :

-facial palsy + uveitis + salivary gland enlargement



*HIV:

-associated with xerostomia, salivary gland enlargement and multicystic lesions in the salivary gland.



**Salivary gland tumors :

  • Could be benign : slowly growing , has firm consistancy , painless and not ulcerated

  • Or could be malignant : rapidly growing , ulcerated , numbness , paresthesia

  • There are 3 main tumors we must keep them in mind : pleomorphic adenoma (the most common s.g tumor ) , mucoepidermoid carcinoma and adenoid cystic carcinoma ( they are the most common malignant s.g tumors )

  • As we took before minor salivary glands has a high malignancy, and sublingual and submandibular glands are more susceptible to malignant transformation than parotid

*Xerostomia :

- its oral dryness

- the patient could have normal salivary flow rate (not necessarily to have hyposalivation )

- its caused by :

1- sensory disorders such as : stress and anxiety

2-some diseases such as : sjogren syndrome ( there will be a replacement of salivary glands with lymphocytes)

3- some drugs

4- systemic factors : chronic renal failure , endocrine diseases “Diabetes” , radiation of head and neck , hyperthyroidism patients who took radioactive iodine , aging



(( the most common factors are drugs and stress))

  • Example of drugs that could lead to xerostomia : antidepressants , antihistamines , antiepileptic drugs , antihypertensive drugs .

{All these drugs will affect the parasympathetic innervation }

Or there are other drugs that increase the secretion of fluids , such as duiritics .



  • Management :

1-It include taking a proper history ( whether the amount of saliva is within the normal range or reduced , because if it was within the normal range and the patient have xerostomia >> we must think of functional causes such as stress and anxiety )

2-We must ask the pt some questions to determine the severity of xerostomia : how frequent does he need to drink water ? or if he cant eat biscuits without drinking tea , or ask him if he has difficulty in swallowing or eating or wearing the denture .

3-Notice the symptoms :

Some patients may complain from burning sensation due to xerostomia or abnormal taste and halitosis .

Some patients may have cracked lips and soreness at the corner of the mouth.

4- Notice the signs :

Dry mucosa ( noticed by putting the mirror or the suction or cotton rolls at the mucosa >> they will stick )

Candidiosis

Thick frothy saliva

High index of caries and periodontal disease

Swelling in s.g



  • Note : there are some patients that could have hyposalivation without having xerostomia, however they will have at least signs of increased risk of caries and periodontal disease.

  • After taking proper history and defining the signs and symptoms we must do the proper manegmant :

*fluoride rinse/ gel

*oral hygiene instructions

*educating the patient about xerostomia

*symptomatic treatment>> the patient will come to you holding a bottle of water or juice

*artificial saliva ( not acceptable by patients)

*encourage the patient to decrease sugary food and alcohol (some mouth washes contain alcohol , they must be avoided because alcohol lead to dehydration and dryness )

*olive oil is very beneficial because it replaces the lubricant effect of the saliva

*if the patient has candida give him antifungal agents

*drugs that stimulate salivary secretion, such as pilocarpine (pilocarpine increases the secretion of saliva , bleeding , rhinorrhea , so its dose must be adjusted according to the severity of xerostomia )

*Sjogren syndrome :

- autoimmune disease

- destruct all the exocrine glands including the salivary glands

- primary (comes alone ) and secondary (associated with other autoimmune diseases or connective tissue diseases such as : such as scleroderma , rheumatoid arthritis )

- more in old females

- must ask the patient if he has dryness in the eyes in association with mouth dryness

- ask the patient if there is fatigue and weakness

- its very important to diagnose sjogren syndrome as soon as possible because these patients have a high risk of lymphoma , so its advisable to do ultrasound for these patients every year to be able to detect the lymphoma at its early stage .

- diagnostic criteria :

1-signs : dry eyes , dry skin , redness in eyes , itchy skin , cough , joint pain , dysphagia, nausea ,gastric pain , peripheral or cranial neuropathy

2-occular symptoms : dry eyes (diagnosed by schirmer test )

3-oral symptoms : dry mouth , recurrent s.g swelling , they need liquid to swell dry food ( when salivary flow rate < 1.5 ml/min , or if he have abnormal parotid sialography , or abnormal radio isotopes )

4-labial salivary gland biopsy : it shows us if there is lymphocytic sialadinitis ( patients will have +ve SSA and/or SSB “auto antibodies” ).

** To diagnose sjogren syndrome the patient must have >> +ve histopathology and +ve auto antibodies out of the 4 criterias ,, or any 3 of the 4 objective criterias (which are signs and symptoms and histopathology and auto antibodies ).



  • Management : steroids , prevent caries and any complication of xerostomia , pilocarpine (cholinergic drug that increase salivary secreation) , follow up(for the risk of lymphoma).

*Sialorrhea (hypersalivation) :

- common in young children

- its not necessarily to be associated with increase in saliva , maybe the problem is that the patient cant swallow saliva normally .

- its common in : patients who wear dentures / in patients who have ulcerative lesions /cerebral palsy patients (cant control the muscles of lips so they will have drooling of saliva)/ Parkinson disease patients / in infants (decrease swallowing ) / in patients who have neuromuscular disease .



- Treatment :

By knowing its cause > ulcer , palsy …..

Drugs that lead to xerostomia with limited side effects , such as antihistamine drugs . or we can use stronger drugs >> sympathomemitic drugs

Botox can be used >> its used in cerebral palsy patients who have sialorrhea , by injecting it in the salivary gland so it will decrease salivary secretion

Speech therapy >> educate the patient to have more competent lips and more control on the muscles of the mouth (its beneficial in patients who have neuromuscular diseases such as Parkinson )

*Sialolythiasis :

- stones in s.g

- mostly in submandibular glands due to the shape of its duct and its content of high percentage of calcium .

- clinical features : intermittent swelling during eating ( upon stimulation) , and due to accumulation of saliva in the duct the patient may have infection ( bacterial sialadinitis )

- Treatment : removal of stone . But if the s.g is fibrosed and had recurrent infection then we remove the whole gland

Sometimes the stone will be at the orifice > its so easy to remove the stone by tweezers in this case

Or sometimes the stone will be removed alone

** the dr showed a case : a child has bilateral swelling of submandubular gland with fever and erythema > the diagnosis is sialadinosis due to mumps (mumps mostly happen in parotid gland but could happen it submandibular gland )

Its charectarized by no pus discharge , and mostly affects children but also could affect the immunosupressed adults

It has vaccine : MMR

** if the patient have recurrent swelling think of stone , but if he has persistent swelling think of tumor .

*To diagnose salivary stone : do sialograghy >> inject radiopaque material in the duct and take xray then you will see obstruction due to stone or stricture or mucus plug (called obstructive sialadinitis) .



**NOTES :

  • Xerostomia lead to fissuring appearance of the tongue due to dryness ( not fissured tongue! )

  • Pleomorphic adenoma could have malignant transformation tendency >> carcinoma ex pleomorphic adenoma

GOOD LUCK :D


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