Stomatolog y

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9.4 Sialoses

Sialoses are a group of diseases characterized by recurring or chronic swelling of large salivary glands (especially the parotid gland - parotidomegaly). Chronic changes affect also small lip glands in about 80% of cases. Sialoses can be divided according to their etiology into the following types:

sialoses of mostly allergic origin (Sjögren-Gougerot-Houwers’ syndrome, Mikulicz’s disease, Mikulicz’s syndrome, Heerford’s syndrome),

sialoses of a hormonal origin (swelling of salivary glands during diabetes mellitus - Charvát’s sign)

neurogenous sialoses (originating from a damage to n. auriculotemporalis during an injury of the parotid gland or after parotitis abscedens)

deficiency sialoses (after a long-term vitamin deficiency during a starvation, so called Terezin sign, Kwashiorkor’s syndrome).

A histological picture is characterized by atrophy of the gland’s acini and huge lymphocytic infiltrates. Upon reduction of the functional parenchyma of a salivary gland, secretion of saliva is lowered (hyposialia or even xerostomia) which allows for an ascendental infection of the gland. Sialoses are marked by a chronic course, local and overall signs and a typical sialographic findings.

Sjögren’s syndrome is marked by various extents of hyposialia as well as reduction of secretion of lacrimal glands and nasal mucosa glands, decreased secretion of synovial fluid, and glands of the alimentary tract mucosa. Patients report dry mouth, difficulties to swallow, pain in joints, digestion problems and dry conjunctivas. Etiology emphasizes an immunopathological origin and hormonal imbalance, since this disease appears at women during a menopause. Therapy is symptomatic and not very successful due to chronic nature and progression of the disorder. Salivary secretion is enhanced by application of pilocarpine and syntostigmine. Lacrysin (methylcellulose) eye drops are recommended at a dry conjunctivitis. It is also recommended to drink the “Karlovarský Mlýnský pramen” mineral water, half a liter a day or more.

Mikulicz’s disease is manifested, similarly as the above described condition, by gradual swelling of the parotid, submaxillar and small salivary glands, and also enlargement of lacrimal glands. The swelling is semi-rigid, not painful, and can extend into a large size. Histological finding shows primarily lymphocytic infiltration and formation of follicles (the benign lymphocytic lymphoma). If the salivary secretion is reduced, the disease may get complicated by an ascendant inflammation of a salivary gland. Therapy by an X-ray irradiation or ligation of a salivary gland ducts show positive results.

Mikulicz’s syndrome has the same clinical picture as the above disease, but the etiology is known. The causes of swelling of salivary or lacrimal glands may be lymphatic system disorders, such as lymphatic leukemia, lymphogranuloma, lymphosarcoma, benign lymphogranuloma, tuberculosis or metastases of a carcinoma.

Heerford’s syndrome is characterized by a non-painful swelling of the parotids, affliction of the uveal tract (uveitis, iridocyclitis), sometimes fevers (febris uveoparotidea) and paralysis of the facial nerve. The disease has a good prognosis. Therapy should be conducted by an ophthalmologist, since ocular complications may arise (synechia at the uveal tract, glaucoma).

9.5 Sialolithiasis

Sialolithiasis is a disease during which concrements (sialoliths) are formed inside the ducts or parenchyma of salivary glands thus slowing down or disabling flow of saliva. The disease affects the submandibular salivary gland (about 90% of cases) more often than the parotids or sublingual gland. Salivary stones originate from changed mucin of the saliva, by precipitation of salts around a core formed in the duct by a foreign object, cluster of epithelial cells and leukocytes, at the time of salivary glands inflammations. Stones may have rounded or spindled shapes. Clinical manifestations of sialolithiasis are repeated swelling of the gland area which appear especially before a meal when salivation increases and a stone prevents the saliva to pass freely inside the mouth. The saliva retention may result in an ascendant transfer of infection and occurrence of a secondary sialodenitis.

Upon long-term illnesses and repeated infections, the gland may become fibrously modified (sialodenitis fibroproductiva). Sialolithiasis therapy is surgical and lies at a salivary stone removal from the duct after discission of its wall. If a stone is positioned intra-parenchymatously at the submandibular salivary gland, an extirpation of the whole gland from the extra-oral side is indicated.

9.6 Tumors of Salivary Glands

Salivary gland tumors may appear at any age, however, they occur mainly during the fourth to sixth decennium. Clinical manifestations include a slow, non-painful growth and gradual deformations of the face. Tumors can be found most often in the parotid gland (90%), submandibular gland (about 9%) and rarely in the sublingual salivary gland or small salivary glands.

Classification of salivary glands tumors

  1. Epithelial tumors

    1. Adenomas

      1. Pleomorphic adenoma

      2. Monomorphic adenoma

        1. Adenolymphoma

        2. Oxyphil adenoma

        3. Other types

    2. Mucoepidermoid tumor

    3. Acinocellular tumor

    4. Carcinomas

      1. Adenoid cystic carcinoma

      2. Adenocarcinoma

      3. Epidermoid carcinoma

      4. Non-differentiated carcinoma

      5. Carcinom in the pleomorphic adenoma

  2. Non-epithelial tumors

  3. Non-classified tumors

  4. Tumor-like states

      1. Benign lymphoepithelial lesion

      2. Sialoses

      3. Oncocytoses

According to the old classification, tumors can be divided into the following classes:

  1. Sialomas: true tumors that originate from epithelial cells of acini or ducts. Here belong all types of adenomas, mucoepidermoid and acinocellular tumors and carcinomas.

  2. Synsialomas: originate from the salivary glands interstitial tissue. This class includes non-epithelial and some of non-classified tumors.

  3. Parasialomas: all types of tumors of epithelial and mesenchymal types that grow in the proximity of salivary glands.

Therapy for salivary gland tumors is mainly surgical in cases of benign neoplasms. In cases of malignant tumors, a combined therapy including surgery, radiotherapy and chemotherapy is indicated. The submandibular salivary gland containing a tumor is extirpated as a whole. The extent of a surgery at the parotid gland is determined by a pre-operational histological examination. The surgery includes either partial or total parotidectomy, while the maximum effort is paid to preserving the facial nerve. A diagnostic excision of a tumor for pre-operational examinations is not recommended in cases of salivary gland tumors due to possibility of a tumor dispersal.

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