Salivary Gland Tumors

1. Salivary Gland Tumors Done By: Souad Haj Yahia Nour Refaai

2. Salivary Glands Introduction The Major Salivary Glands 2 Parotid 2 Submandibular 2 Sublingual The Minor Salivary Glands

3. Salivary Glands Minor salivary glands: Widely distributed in the oral mucosa : The lips, cheeks, hard & soft palate, uvula, floor of the mouth, tongue & peritonsillar area A few are found in the nasoph., paranasal sinuses, larynx, trachea, bronchi & lacrimal glands.

5. Parotid glands Are located inferior and anterior to the ears, between the skin and the masseter muscle, each secretes saliva through parotid duct that pierces the buccinator muscle to open into the vestibule opposite to the second maxillary (upper) molar tooth. The Facial nerve divides the parotid gland into superficial and deep .

6. Submandibular gland Are found beneath the base of the tongue in the posterior part of the floor of the mouth. Their ducts (Wharton’s ducts) run under the mucosa on either side of the midline of the floor of the mouth and enter the oral cavity proper lateral to the lingual frenulum.

7. Sublingual gland Are superior the submandibular glands. Their ducts the lesser sublingual ducts, open into the floor of the mouth into the oral cavity .

8. Type of cells There are 3 main types of cells that are found in the major salivary glands: 1. Secretory cells : A. Serous B. Mucous 2 . Myoepithelial cells .

10. B. Myoepithelial : cells surround each secretory portion and are able to contract to accelerate secretion of the saliva.

12. Physiology Physiological control of the Salivary glands is almost entirely by the autonomic nervous system; parasympathetic effects predominate. If parasympathetic innervation is interrupted, glandular atrophy occurs. Normal saliva is 99.5% water

13. Function Of Salivary Glands About 1.5 L of saliva is produced each day It facilitates swallowing. It keeps the mouth moist & aids speech. It serves as a solvent for molecules which stimulate the taste buds. It cleans the mouth, gum, & teeth. It contains ptylin, an enzyme which breaks-down starch.

14. Diseases of the salivary glands Inflammatory: Acute parotitis, TB., Mumps, Actinomycosis, cat scratch disease Obstruction : Sialolithiasis, Sjogren’s, stricture. Neoplasms.

15. : I. Epithelial tumours A. Adenomas: pleomorphic (mixed) & monomorphic e.g. basal cell adenoma, oncocytoma & adeno-lymphoma B. Mucoepidermoid C. Acinic cell tumour D.Carcinoma: Carcinoma in a mixed t., adenocarcinoma, undifferentiated ca,adenoid cystic ca., & epidermoid ca. high grade mucoepidermoid ca. II. Nonepithelial tumours : (Lipomas, Fibromas or Neuromas )

16. Acute suppurative sialadenitis It is an ascending infection (Staph. Aureus & strept. viridans) from the oral cavity predisposed by a reduction in salivary flow or partial obstruction Following major surgical operations due to dehydration & poor oral hygiene

17. Sialadenitis During deblitating illnesses e.g Cholera or Typhoid fever. Following radiotherapy Sjogren’s syndrome.

18. Acute Suppurative Sialadenitis. Clinically: Brawny swelling on the side of the face, in advanced cases the skin becomes dusky red. Taking the shape of the parotid gland. It raises the lobule of the ear. Temp. is usually above 37.8 C. (low grade

19. Acute Suppurative Sialadenitis Fluctuations occur only after pus has penetrated the dense fascia of the parotid sheath. Pus can be expressed from the parotid duct and taken for Culture&Sensitivity. Sialogram following resolution of symptoms to asses salivary function Meticulous oral hygiene.

20. Continue… Dentures are worn only at meal time Improve the general state of the patient. Antibiotics “broad spectrum antibiotics”. Soft diet & plenty of fluids are taken as chewing is painful. Message the gland, if not improved incision & drainage is essential.

21. Sjogren's Syndrome Autoimmune Disease – mainly charactrized by dry mouth, dry eyes and connective tissue disease. Etiology - collagen vascular disease Signs and Symptoms -keratoconjunctivitis sicca, xerostomia, and a connective tissue disorder, such as rheumatoid arthritis. Enlargement of salivary and lacrimal glands, often with recurrent sialoadenitis

23. Diagnosis : Biopsy of salivary glands usually the lower lip , shows lymphoreticular hyperplasia . Treatment : First we should treat the primary disease that is causing recurrent infections Patients may develop a superimposed malignancy, therefore, if a mass appears surgical excision is needed also. Any mass should be examined .

24. Ranula A sialocele of the floor of the mouth (cyst in the duct of salivary gland) Types Circumscribed - obstruction and cystic dilatation of sublingual gland or submandibular duct. Plunging - extravasations of saliva into tissues of the floor of the mouth. May extend deep into floor of the mouth

26. Ranula Signs and Symptoms - cystic sub mucosal mass in the floor of the mouth; may periodically shrink with discharge of contents into mouth Treatment Circumscribed cyst may be excised, along with involved gland or glands Plunging ranulas cannot be excised and should be marsupialized (change it into plate-shaped mass)

27. Branchial Cleft Cysts branchial cysts is a remnant of branchial cleft , usually the second cleft, less commonly it is First branchial cleft cysts present as cysts or draining sinuses in pre auricular area Type I cysts track deep into parotid along Ext. Aud. Canal. Type II cysts track deep into parotid and are intimately involved with facial nerve Treatment-surgical excision but in the1st branchial clefs by superficial parotidectomy

28. HIV associated sialadenitis Children recurrent chronic parotitis. Adults sicca syndrome dry mouth, dry eyes. Lymphocytic infiltration of the salivary glands ‘enlarged salivary & lymph glands. Similar to Sjögren’s syndrome. Multiple painless parotid cystic lesions. Surgery may be indicated for appearance.

30. Salivary calculi The submandibular (SM) calculi are the most common and easy to demonstrate by XR. Swelling and pain; dull ache radiate to the ear, before or during eating last through the meal. Pain goes away before swelling. Recurrent painful swelling at mealtime especially lemon

31. Salivary calculi Hx of symptoms on the other side due to bilateral calculi Pressure on the gland may give foul tasting saliva (purulent saliva) Acute & subacute infection may be the first indication of a stone. Persistent obstruction damages the gland making it harder and tender

32. Salivary calculi The SM gland lies beneath the horizontal ramus of the mandible on the mylohyoid muscle anterior to the anterior border of the sternomastoid Skin is red, edematous ,hot and tender if infected Bimanual palpation one finger inside the mouth and others on the skin over the lump.

33. Calculi Calculi within the duct may be removed through the floor of the mouth Sialography is necessary to demonstrate the lumen of the ducts for stone, tumor, or stricture. Excision of the gland where the stone is within the gland or the gland is severely damaged by chronic infection.

34. Salivary neoplasms Parotid gl. 75% of all salivary t., 80% are benign and 80% of the benign are pleo-morphic ad. Sub mand. gl. 15% of all salivary t., 60% are benign and 95% of the benign are pleomorphic ad. Minor salivary gl. 10% of all salivary t., only 40% are benign pleomorhic ad.

35. Pleomorphic adenoma The most common salivary tumor. In middle aged & more in women than in men, Slowly growing benign tumor but strands or lobules of the tumor tends to penetrate the thin capsule and extend beyond the main limits of the mass (enucleation is inadequate).

36. Pleomorphic adenoma Histopathology: Epit.cells proliferate in strands or duct like Myoepith. cells proliferate in sheets with the production of a mucoid material which separate the cells producing a myxomatous appearance cartilage like.

37. Pleom. ad. Cystic areas may appear due to excessive mucoid accumulation. After many years ( 10-30) few tumors may exhibit malignancy(ca in pleom. ad.) Treatment of benign t. is by superficial parotidectomy.

38. Adenolymphoma (Warthin’s tumor) A benign tumor. It is formed of a double layered epithelium. Spaces or cysts, with papillary like app. The stroma contains lymphoid tissues and follicles Slowly enlarging soft or fluctuant swelling.

39. Adenolymphoma usually toward the lower pole (10% of parotid t.), can be multiple and bilateral. Mostly in middle aged or elderly males. It form a hot spot in a 99mTc-pertechnetate Treated by superficial parotidectomy

40. Mucoepidermoid tumor It is composed of sheets and masses of epidermoid cells and cystic spaces lined by mucus secreting cells (no cartilage like app) They are of varying speed of growth and degree of differentiation. Mostly they are slow growing and invade local tissues to a limited degree. Only occasionally grow rapidly and metastasize to lymph nodes, lungs or skin.

41. Mucoep. t. Clinically they are usually harder than mixed t., yet become fixed when large. Mostly they do not cause facial paralysis FNA Superficial parotidectomy and radiotherapy may be advisable

42. Carcinomas It tends to produce obvious clinical signs of malignancy at an early stage Hard, rapidly growing infiltrating mass Fixation, resorption of adjacent bone & ulceration

43. Carcinoma Pain, anesthesia, muscle spasm and later paralysis in the case of parotid ca. FNA cytology CT scan. Radical excision, block dissection & radiotherapy