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DIAGNOSIS AND MANAGEMENT

DIAGNOSIS AND MANAGEMENT. SALIVARY GLAND PATHOLOGY. DISTRIBUTION OF MINOR SALIVARY GLANDS. Palate 60% Tongue 10% Lips 10% Cheeks 10% Retromolar 10%. TONGUE GLANDS (LINGUAL). Inferior apical—glands of Blandin Nuhn (mucous secretion) Taste buds—vonEbner’s glands (serous secretion)

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DIAGNOSIS AND MANAGEMENT

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  1. DIAGNOSIS AND MANAGEMENT SALIVARY GLAND PATHOLOGY

  2. DISTRIBUTION OF MINOR SALIVARY GLANDS • Palate 60% • Tongue 10% • Lips 10% • Cheeks 10% • Retromolar 10%

  3. TONGUE GLANDS(LINGUAL) • Inferior apical—glands of Blandin Nuhn (mucous secretion) • Taste buds—vonEbner’s glands (serous secretion) • Posterior lubricating

  4. PAROTID GLAND • Mainly serous; largest of all major glands • The duct is referred to as STENSEN’S DUCT, length of 6cm, diam. of 1-3mm • 3 major structures pass through substance of gland—facial nerve, retromandibular vein, and external carotid artery • Thickening in gland capsule is the stylomandibular ligament • 25 % of daily salivary production

  5. PAROTID GLAND • Located on the face and is palpable between the mandibular ramus and mastoid process • Lateral surface covered by skin and dermis, thus vulnerable to injury with lacerations • Described as having superficial and deep lobes, the plane between is defined by the facial nerve

  6. INNERVATION OF PAROTID GLAND

  7. SUBMANDIBULAR GLAND • 2nd largest of major saliv. glands • Mixed mucous/serous • Located in submandibular triangle, with the lingual & hypoglossal nn. in intimate contact; fed by lingual and facial arteries • Duct: Wharton’s duct, length of 5cm and diam. Of 2-4mm • 70% of daily salivary production

  8. SUBMANDIBULAR GLAND • Fills major portion of the digastric or submandibular triangle • 2 portions: superficial lobe lying superficial to the mylohyoid and a deep lobe which wraps around the posterior border of the mylohyoid

  9. SUBMANDIBULAR AND SUBLINGUAL GLAND INNERVATION

  10. SUBLINGUAL GLAND • Smallest of major saliv. glands • Lies in the submucosal plane in the anterior FOM • Mainly mucous • The acinar ducts called Bartholin’s ducts and coalesce to form the ducts of Rivinus • 3-4% of daily salivary production

  11. EMBRYOLOGY • Parotid gland is first to make appearance at the 6th gestational week • Sumandibular gland first appears at end of the 6th gestational week • Sublingual gland develops at the 8th gestational week

  12. SALIVA • 500-1500 cc/day or about 1ml/min however salivary flow decreases after age 20; max. rate is 1 ml/min/g of glandular tissue • FUNCTIONS: a) Lubrication for food bolus, removal of food debris (concept of xerostomia and caries) b) Antimicrobial: sIgA, lactoferrin, lactoperoxidase, mucins, histatins

  13. SALIVARY FUNCTIONS CON’T • DIGESTIVE: amylase, lipase, proteases, gustin, mucins • REMINERALIZATION: Ca++, phosphate,statherin,secreted saliv. Fl • TASTE: for a substance to be tasted, it must be in aqueous solution; fluid seal for suckling and sucking • MUCOSAL INTEGRITY

  14. HYPERSECRETION ASSOCIATIONS • INFLAMMATORY: Stomatitis, Rabies • ENDOCRINE: Pregnancy, Graves disease • NEUROPSYCHIATRIC: Epilepsy, Cerebral palsy, Hysteria • DRUGS: Mercury, Iodine, Pilocarpine

  15. XEROSTOMIA • LOCAL: Irradiation, chronic sialoadenitis, interruption of chorda tympani, surgery • SYSTEMIC: Sjogren’s, diabetes, dehydration,debilitation, mental stress, infection, anemia • DRUGS:diuretics, antihypertensives, antiemetics, antispasmodics, anticonvulsants, psychotropics

  16. IRRADIATION • 50% of function lost after only 1000cGy (1 week of radiation) and conventional radiotherapy is 6-7K cGY. This radiation dose causes 80% salivary dysfunction. • Damage is to the acinar parenchyma

  17. DIAGNOSTIC METHODS • Sialography: refers to the contrast study of a particular gland • Radiosialography: the study of salivary gl. employing radioisotopes. Useful for studying the dynamic activity of a given gl. Has a flow phase, a concentration phase and a washout phase-also called salivary scintigraphy

  18. DIAGNOSTIC METHODS CON’T • SIALOCHEMISTRY: The spit test associated with Cystic Fibrosis to evaluate levels of NaCl • CAT SCAN/ MRI • ULTRASOUND • FINE NEEDLE ASPIRATION BIOPSY (to check for malignancy) • OPEN BIOPSY

  19. SIALOENDOSCOPY

  20. SIALOENDOSCOPY • In 1991, Katz introduced a flexible mini-endoscope into the ductal system of the major salivary glands

  21. SALIVARY GLAND DISEASES: CLASSIFICATION • 1. Nonneoplastic a) Infectious b) Noninfectious • 2. Neoplastic a) Benign b) Malignant

  22. Acute sialodenitis: acute inflamma. of gl. that causes erythema, pain, tenderness, swelling, & purulent discharge Chronic recurrent sialodenitis Granulomatous sialodenitis (TB/HIV) Parotid abscess/acute parotitis Viral parotitis-MUMPS caused by the paramyxovirus. Target organs are: parotid, testes, pancreas, brain, cochlea Actinomycosis NONNEOPLASTIC-INFECTIOUS

  23. SIALOLITHIASIS: Preferentially affects the SBM gl (80%). Calculi composed of hydroxyapatite. 65% of parotid calculi are lucent & 65% of SBM are opaque BRANCHIAL APPARATUS ANOM. May form cysts or sinus tracts BENIGN LYMPHO- EPITHELIAL LESION-Assd. HIV and lymphoma in 10% NONNEOPLASTICNONINFECTIOUS

  24. SIALOLITHS

  25. PLAIN FILMS TO VISUALIZE SIALOLITHS • Periapical • Occlusal • Panelipse • “Puffed cheek” lateral oblique

  26. SIALOLITHS • WHY SO MANY SBM GL STONES Parotid secretions are more [ ] exc. for the Ca ion, which is 2x more abundant in SBM gl. Also, SBM gl. saliva is of an alkaline pH, which further supports stone formation. Wharton’s duct is longest duct and has 2 sharp curves (stasis and slow flow)

  27. SIALOLITH • A hair follicle found in Stenson’s duct and after removal note the material on the follicle

  28. SIALOENDOSCOPY • Sialolith located in orifice of Wharton’s duct

  29. Lithotripsy fragment

  30. MUCOCOELES- mucous extravasation reaction • Most common site= lower lip, then buccal mucosa • Results from rupture of a saliv. gl. duct with spillage of mucin • Dome –shaped mucosal swelling • TX: EXCISIONAL BX

  31. RANULA • Is a mucocoele of the FOM. “Rana” in Latin is a frog’s belly • Usually arises from the sublingual gl • May be simple or plunging • Do not regress, surgery is indicated

  32. NECROTIZING SIALOMETAPLASIA • Represents a nonspecific reaction of the salivary and mucous glands to ischemic injury • Is a benign necrotizing self-healing crater, usu. of palate. Mistaken for SCCA.

  33. SJOGREN’S SYNDROME • Autoimmune; 90% female • Affects lacrimation and salivation • DX: Schirmer’s test, salivary flow testing, biopsy of salivary gland tissue, high sedimentation rate, antinuclear antibodies • Is an association with lymphoma • Primary vs.seconday Sjogrens

  34. CHEILITIS GLANDULARIS • A suppurative inflammatory swelling of the lower lip, with prominent salivary duct orifices

  35. SUBMANDIBULAR GLAND REMOVAL • Sbm gl. lithiasis is the most common disorder of the gl., and the most common location is extraglandular • For removal, must be concerned with scar formation, damage to lingual or hypoglossal nn. • Will tie off the facial a./v. and the duct. Close in layers & drain.

  36. PAROTID GLAND REMOVAL • Facial nerve and brs. located between the superficial and deep lobe. If facial nerve is sacrificed, facial nerve grafting to reanimate the face is advocated. • Frey,s Syndrome: gustatory sweating seen in 50-100% of patients. Due to parasympathetic cross-innervation of Ach sweat gl.

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