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Salivary Gland Disorders. Salivary Gland Disorders ENT for the PA-C. Andrew Golde MD,CM FRCSC FACS Advanced Ear, Nose and Throat Associates Atlanta, GA February 2011. Classification of Salivary Disorders. Infections Systemic disorders Trauma Medication side-effects Neoplasms.

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Salivary Gland Disorders

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Salivary gland disorders l.jpg

Salivary Gland Disorders


Salivary gland disorders ent for the pa c l.jpg

Salivary Gland DisordersENT for the PA-C

Andrew Golde MD,CM FRCSC FACS

Advanced Ear, Nose and Throat Associates

Atlanta, GA

February 2011


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Classification of Salivary Disorders

  • Infections

  • Systemic disorders

  • Trauma

  • Medication side-effects

  • Neoplasms


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Salivary Gland Anatomy

  • Major salivary glands

    • Parotid (2)

    • Submandibular (2)

    • Sublingual (2)

  • Minor salivary glands (5000)


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    Salivary Gland Physiology

    • Autonomic control

      • Parasympathetic ---> secretion (Ach)

      • Sympathetic ---> composition (adrenergic)

    • Complex composition

      • Electrolytes, urea, ammonia, glucose, cholesterol, fatty acids, lipids, amino acids, proteins (albumin, globulin, enzymes, glycoproteins, polypeptides including kallikrein, epidermal growth factor, renin, glucagon, angiotensin II, erythropoetin, gastrin, somatostatin)


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    Functions of Saliva

    • Lubricant

      • Aid swallowing, mechanical cleaning

  • Digestion

    • Enzymatic cleavage - amylase

  • Mediation of taste

  • Excretion

    • Blood group proteins, mediators, viruses

  • Defense

    • Antibodies, mucosal integrity


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    Saliva Production

    • Max rate 1 ml/min/gm of tissue

    • High blood flow (10x equal mass muscle)

    • Distribution

      • Parotid 75% low viscosity

      • Submandib20% medium

      • Minor5% high


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    Take Home Message

    • Three categories of problems

      • 1. Altered saliva production

      • 2. Painless swelling of saliva glands

      • 3. Painful swelling of saliva glands


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    Disorders of Altered Physiology

    • Increased or decreased stimulation

      • Medication, neurogenic, hormonal

  • Obstruction of secretion

    • Sialadenitis, sialolithiasis

  • Change of composition

    • Cystic fibrosis

    • Nutrition

  • Parenchymal damage

    • Irradiation, Sjogren’s syndrome, cystic fibrosis


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    Sialadenosis

    • Recurrent painless swelling (parotid)

    • Etiology

      • Endocrine disorders (diabetes)

      • Malnutrition (protein, ETOH, vitamin)

      • Autonomic dysfunction

  • Treatment

    • Correct underlying causes

    • Reassurance


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    Sialolithiasis

    • Formation of salivary stones

    • Submandibular (92%) > Parotid (6%) > Minor (2%)

      • High mucin content, Alkaline pH, high concentration organic matter and Ca and salts

      • Anatomy of Wharton’s duct

  • One of most common causes of salivary dysfunction


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    Sialolithiasis

    • Etiology

      • Enhanced in presence of stasis of salivary flow

      • Genetic predisposition (kidney stones, gout)

      • Mineralization of a mucoid gel

  • Clinical Presentation

    • Asymptomatic

    • Recurrent swelling associated with eating

    • Spitting out stones

    • Sialadenitis (infection)


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    Sialolithiasis

    • Management

      • Hydration

      • Massage (Post --->Ant) + heat

      • Anti-inflamatories

      • Antibiotics if infected

      • Removal of stones

      • Sialendoscopy

      • Surgical excision of affected gland


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    Disorders of Decreased Saliva

    • Irradiation

    • Sjogren’s syndrome

    • Cystic fibrosis

    • Anti-cholinergic side effects of meds


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    Irradiation of Salivary Glands

    • Conventional XRT for head and neck tumors 6000-7000cGy over 6-7 weeks

    • 50% function lost after 1000 cGy

    • 90-100% loss after complete course of XRT

    • Xerostomia can last for several years

      • Loss of taste

      • Increased incidence dental carries

      • Altered nutritional status

      • Loss of appetite


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    Irradiation of Salivary Glands

    • Protective strategies

      • IMRT (Intensity modulated radiation therapy)

      • Lower total doses (Canada vs US)

      • Amifostine

        • Free oxygen radical scavenger

        • Difficult to tolerate

  • Treatment

    • Supportive - H2O, lubricants

    • Salivary promoting drugs


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    Sjogren’s Syndrome

    • Autoimmune disease of major and minor salivary, lacrimal, mucous and sweat glands

    • 1933 Sjogren original description

      • Keratoconjunctivitis sicca

      • Xerostomia

      • Rheumatoid arthritis (scleroderma, mixed connective tissue disease, polyarteritis nodosa, polymyositis, SLE)

  • Classification

    • Primary - Sjogren’s syndrome alone

    • Secondary - Sjogren’s plus other autoimmune


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    Sjogren’s Syndrome

    • Diagnosis

      • Lower lip minor salivary gland biopsy

        • Dense lymphocytic infiltrate/plasma cells

      • Sjogren’s autoantibodies

      • Positive Rheumatoid factor

      • Elevated C-reactive protein

      • High titers IgA, IgG, IgM

  • Demographics

    • Female >> male

    • Middle age


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    Sjogren’s Syndrome

    • Treatment

      • Artificial lubricants for ocular, nasal and oral dryness

      • Salivary stimulants (Evoxac)

      • Immunosuppressants (Plaquenil, MTX, Humara)

  • Predisposition to Non-Hodgkin’s lymphoma

    • Parotid gland mass enlarging (painless)

    • MALToma


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    PAINLESS

    Sialadenosis

    Sialolithiasis

    Sjogren’s

    HIV

    Granulomatous

    Benign primary tumors

    Lymphoma

    PAINFUL

    Bacterial sialadenitis

    Mumps

    Malignant primary tumors

    Swelling of Saliva Glands


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    Salivary Infections

    • Primary bacterial (sialadenitis)

    • Secondary viral

    • Granulomatous


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    Sialadenitis

    • Bacterial infections of salivary glands

    • Mechanical blockage of salivary ducts or reduced production of saliva

    • Retrograde contamination by oral cavity flora

    • Classification

      • Acute

      • Recurrent

      • Chronic


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    Acute Sialadenitis

    • All glands - parotid most frequent

    • Contributing factors

      • Stasis; immunocompromise; poor oral hygiene

      • Post-op

      • Dehydration

      • Anti-cholinergics or diuretics

  • Rapid onset pain, swelling, induration

  • Suppurative discharge from duct

  • S.aureus, S. pyogenes, S. viridans, S. pneumoniae, H. flu


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    Acute Sialadenitis

    • Treatment

      • B-lactam resistant penicillin or cephalosporin

      • Augmentin, Clindamycin

      • Steroids

      • Fluid replacement

      • Sialogogues

      • Analgesics

      • Manual massage

      • Topical heat


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    Recurrent Sialadenitis

    • Mechanical obstruction most common factor

    • CT scan of neck with contrast to rule out stones or intrinsic lesions or abscess pockets

    • Oral anaerobes prominent

    • Clindamycin, Augmentin, Flagyl + ceph, Avelox

    • Surgical excision of gland as last resort


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    Chronic Sialadenitis

    • Usually follows recurrent infections

    • Permanent alteration of gland architecture

    • Surgical excision required


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    Acute Sialadenitis

    • Complications include abscess

      • Persistent symptoms > 4 days of Rx

      • Uni or multiloculated

      • CT scan of neck with contrast

      • Sialography contraindicated

      • Surgical drainage


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    Secondary Viral Infections

    • Hematogenous dissemination

    • Mumps

    • HIV


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    Mumps

    • Single most common cause of acute nonsuppurative sialadenitis in childhood

    • Bilateral parotid swelling (+++)

    • Rarely submandibular

    • Pain exacerbated by eating

    • Paramyxovirus

    • Highly contagious - airborne droplets

    • Incubation 18 days

    • MMR vaccination


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    Mumps

    • Diagnosis is clinical

    • Hemagglutination inhibition or complement fixation

    • Elevated serum salivary type amylase

    • Viremia abates in 7 days

    • Gland swelling abates in weeks

    • Hydration and rest

    • Severe cases

      • Meningoencephalitis, orchitis, pancreatitis, nephritis

  • Other viruses rarely mimic

    • Parainfluenza, coxsackie, echovirus, EBV


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    HIV Infection

    • HIV-SGD: HIV-associated salivary gland disease

    • Parotid glands most commonly affected

    • Gradual painless cystic enlargement

    • Xerostomia, xerophthalmia, arthralgias

    • Cysts up to several cm in size

      • Originate within lymph nodes

  • 10% coexistence of lymphoma

  • CT scan and FNA if suspicious

  • Surgical excision if considering lymphoma diagnosis


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    Granulomatous Infections

    • Not uncommon

    • Painless gradual enlargement of isolated mass in gland

    • DDX includes neoplasm

    • Etiology

      • Typical and atypical TB

      • Actinomycosis

      • Cat scratch

      • Toxoplasmosis

      • Tularemia

  • CT scan, FNA, serology


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    Salivary Gland Tumors

    Benign vs. Malignant Neoplasms


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    BENIGN

    Painless

    Slow growing

    Facial nerve intact

    More common

    MALIGNANT

    Can be painful

    Growing rapidly

    Facial nerve can become paralyzed

    Lymphadenopathy

    Less common

    Salivary Gland Tumors


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    Location of Gland

    Parotid

    Submandibular

    Minor

    Incidence of Malignancy

    20%

    50%

    80%

    Salivary Gland Tumors


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    Benign Salivary Tumors

    • Adenomas

      • Pleomorphic

      • Monomorphic

      • Wathin’s tumor

  • Oncocytoma

  • Oncocytic papillary cystadenoma

  • Myoepithelioma

  • Sialadenoma

  • Inverted ductal papilloma

  • Hemangioma

  • Lymphangioma


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    LOW GRADE

    Mucoepidermoid ca

    Acinic cell ca

    Adenocarcinoma

    HIGH GRADE

    Mucoepidermoid ca

    Adenoid cystic ca

    Adenocarcinoma

    Carcinoma ex pleomorphic

    Squamous cell ca

    Undifferentiated ca

    Malignant Salivary Tumors


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    Factors Influencing Survival

    • Histopathologic diagnosis

    • Lymph node metastasis

    • Pain

    • Facial nerve paralysis

    • Skin involvement

    • Stage

    • Location

    • Recurrence

    • Distant metastases


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    Evaluation of Suspected Tumors

    • FNA

    • CT scan of neck with contrast

    • Surgery for frozen section analysis


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