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Salivary gland disease

Salivary gland disease

Author:

Mr. Altaf H Malik

Department of Oral and Maxillofacial Surgery

Govt. Dental College, Srinagar.

Co-authors:

Dr. Shah Ajaz A

Associate Professor and Director of

Department of Oral and Maxillofacial Surgery

Govt. Dental College, Srinagar.

 

Dr. Lato Suhail

Speaker

Department Oral Pathology and Microbiology,

Govt. Dental College, Srinagar.

Dr. Manzoor Ahmad Malik

J & K Health Services, SDH Banipora

 

Dr. Tabasum Rubeena

Resident

CD Hospital, Srinagar.

Dr. Shazia Qadir

Department of Oral and Maxillofacial Surgery

Govt. College Dental, Srinagar.

 

Introduction

Major and minor salivary glands, form a complex system anatomical and physiological body to produce the enzyme, lubrication, mixing agent and immune factors. Salivary glands respond to the characteristics physical (food and beverages) and emotional (theft, drunkenness and fatigue) stimuli. Fall prey to a number of pathological conditions, including infection, kidney, immune disorders, hypertrophy and atrophy, tumors, systemic diseases, both benign and malignant.

Diseases salivary glands can be divided into

1. Development abnormalities
2. Acute

Chronicle

systemic

1. Benign

malignant

1. Autoimmune
2. Several sialometaplasia necrotizing

Cystic Fibrosis

mucocele and ranula

Development abnormalities

Aberrant salivary gland

An aberrant (ectopic) salivary glands which is growing at a site which is not normally found. This condition is reported as an anomaly, or in combination with other abnormalities facial. They are the most commonly reported in the cervical region near the parotid gland or the body of the mandible. The latter is located behind the first molar and communication often with a Major salivary glands. Most aberrant salivary glands in the neck occurs in the upper part of branchial cleft cysts and bronchial slot.

Aplasia and hypoplasia

total aplasia of major salivary glands, although rare, may occur in association with other congenital anomalies such as cleft palate. The main symptom is severe xerostomia. Hypoplasia of the parotid glands has been reported in patients with Melkersson-Rosenthal syndrome presenting as a classic triad of orofacial granulomas, facial paralysis and the crack language.

glands accessory

This is a common condition in more than half of the people. Is generally superior and anterior to the orifice leads to normal Stensson.

Diverticula

These are small pockets or outpocketings canal system of the major salivary glands, and this leads to episodes repeated acute mumps.

The salivary gland infections

Sialadenitis, salivary gland infection is relatively common tissue. Can be classified as

(I) bacterial and viral

mumps) (mumps virus)

b) bacterial parotitis (Sialadenitis) i. acute

ii. Chronicle

c) recurrent parotitis of childhood

(II) obstructive sialadenitis

Sialolithiasis a)

b) mucus plugs

c) stenosis – stenosis

d) a foreign body

(III) systems granulomatous disease

TB)

b) Actinomycosis

c) fungal infection

d) African uveoparotídea

Acute bacterial parotitis

Mumps is an acute bacterial disease of the elderly, malnutrition, dehydration, postoperative patients with chronic diseases. illness- Acute or cause a weakening of the decrease in salivary flow and retrograde infection leads to dehydration Stensson. Antisialogogue, diuretics, antihistamines and tranquilizers may also be causes. Clinically, the disease is characterized by sudden onset Company, erythematous swelling of the parotid region and the exquisite pain and tenderness. increase in body temperature and the flow of pus may emanate from Stensson duct. If left untreated, leads to a clearly toxic and deadly.

The treatment of mumps Bacterial includes hydration, antibiotic therapy (semisynthetic penicillins are considered adequate), and drainage if necessary. Drainage is achieved by surgical exposure of the gland and the penetration of the capsule by blunt probing with a small clip of Kelly.

Chronic bacterial parotitis

This may be secondary to an episode of acute mumps, and is characterized by unilateral or bilateral swelling of parotid and evolution intermittent exacerbations and remissions. Parotidectomy is considered the definitive treatment.

Viral parotitis (mumps)

Mumps an acute contagious disease, which occurs in epidemics and is transmitted by saliva and secretions from infected urine. Usually, there is a child or an adult who has escaped to early infection. Mumps is characterized by a rapid pain, swelling of parotid or two 15 to 18 days after initial exposure. Prodromal Phase 1 to 2 days of fever, headache, etc. before swelling. Complications include pancreatitis, orchitis, and meningitis (due to viremia). Mumps spontaneously resolves in 5 to 10 days. Symptomatic treatment of fever and pain are needed.

Submandibular sialadenitis

This is less common infection of the parotid gland, and is mainly stones and strictures. The clinical significance is that it can be confused with space infections submandibular odontogenic origin.

Sialolithiasis

Salivary stones are calcified and organic matter that develop in the parenchyma salivary glands or ducts of higher or lower. Biochemically, there are stratified with layers of organic material covered with concentric layers of calcified material. The crystal structure is mainly hydroxyapatite and octacalcium phosphate contains.

The etiology of sialolith is varied. Inflammation, local irritation, antisialogogue etc. are expected to play an important role.

The stones are a common etiologic factor for sialadenitis. Mucus plugs, stenosis, etc. produces a table similar clinic.

About 80 to 90% occur in the submandibular gland or duct for the following reasons.

• Wharton duct contains closed curves that can trap mucin plugs or cellular debris
• Calcium levels are elevated in the submandibular saliva
• depending position of the gland

5 to 15% of stones occur in the parotid gland and from 2 to 5% in the sublingual salivary glands.

Clinically, the most common symptom is painful inflammation of this condition intermittently in the area of the major salivary glands which increases in food and decide after meals. The pain migrates to the protection of saliva behind the stone or sheet.

Sialoliths Stenson's duct, if Wharton will be palpable or present on the periphery of the sheath. The cliché of the oral mucosa are calculated and presented as an asymptomatic, well circumscribed, move drain freely inflammation.

Diagnosis:

1. radiograph
2. Sialography
3. TC

Treatment:

Acute infections secondary to immobilization should be treated with antibiotics. The distal duct stones can often be deleted manually. deepest rocks require surgery. Lithotripsy has been described as a noninvasive method to break sialoliths.

various salivary gland infections

TB

Salivary glands may be primarily related to tuberculosis and the disease can infect the lymph nodes periglandular. Gland parotid gland is the most frequently affected. The clinical picture of a business, not painful swelling, resembling a tumor. evacuees may be present. research the diagnosis of salivary gland enlargement review should include a chest x-ray, skin test and acid drainage staining and culture.

Sarcoidosis (a disease Heerfodt)

It is a systemic chronic granulomatous inflammation of the salivary glands involvement in 60% uveoparotídea fever cases occur in 10% of cases with a triad of results -. facial paralysis, hypertrophy of the parotid gland and uveitis.

Corticosteroid treatment is supportive care and long-term treatment.

Actinomycosis

Actinomycosis israelii is a common member of the oral flora and may invade the salivary glands. Sialadenitis occurs in up to 10 percent of cases of orofacial actinomycosis. The long-term treatment with high dose Penicillin is the treatment of choice.

The diagnosis of salivary gland infections

A detailed history and physical examination are useful in the diagnosis of salivary gland infection. The patient had acute inflammation of the salivary glands can be diagnosed meals acute ductal obstruction. Children should be carefully questioned for exposure to the epidemic of mumps in the recent past.

Close inspection of the oral cavity is mandatory to differentiate between a salivary gland inflammation and infection of dental origin space. The physical examination should include palpation fresh all major salivary glands and bimanual palpation of channels in and out.

diagnostic radiology may be helpful. The indications of radiographs simple or sialography

detection) stenosis, calculus, foreign

b) the detection of large abscess parenchyma

c) estimating the severity of parenchymal damage or residual function

The salivary gland tumors

Gland tumors Salivary are a heterogeneous group of lesions greater morphological variation, and this presents difficulties in obtaining a general classification.

Tumors benign

Pleomorphic adenoma (mixed tumor)

The most common of all salivary gland tumors, constituting over 50% of all tumors and 90% of all benign tumors of the salivary glands. It is characterized by a complex morphology and histological marked by the presence of a variety cell types.

Many theories have been proposed to explain the histogenesis of this tumor, and the current arguments center around the cell myoepithelial cell and intercalated duct reserve. It is said that the myoepithelial cell is responsible for the morphological diversity of the tumor, whereas the intercalated cells Reserve pipe can differentiate into duct cells and myoepithelial cells, which may undergo mesenchymal metaplasia giving birth several different types of cells.

Clinical features:

The parotid gland is the most common site of pleomorphic adenoma (90%). Sometimes, however, throughout the gland It is more common in women and in patients in the fourth to sixth year. The story is a small, painless nodule at rest that increases slowly in size. Usually an irregular nodular lesion is firm. The pain is a common symptom. Among the minor salivary glands, palatine glands are frequently affected. May cause difficulty breathing, speaking and chewing.

Histology:

The tumor is still encapsulated. The characteristic histological appearance is variety. Some areas cuboidal cells are arranged in the duct-like eosinophilic clot. In other areas the tumor cells can make a star-shaped, polyhedral or spindle. Some even see the character or chondroid bone.

Treatment:

The treatment is surgical excision accepted. The tumor and the lobe are involved removed. Intra-oral lesions may be treated more conservatively capsular excision. Malignant transformation can occur in a long-standing tumor untreated or recurrent one.

monomorphic adenomas

WHO classification of monomorphic adenomas are subdivided into

1) adenolymphoma (Warthin tumor)

2) oxyphilic adenoma

3) others, including tubular, alveolar (trabecular) adenoma of basal cells and clear cell.

Adenolymphoma (Warthin tumor)

This rare type of tumor is found almost exclusively in the parotid gland. This shows a marked preference for men and age groups for decades 4, 5 and 6.

The tumor is usually the surface, just below the parotid capsule or protruding through it. It is not usually grow more than 3 to 4 cm in diameter. painless, firm to palpation and it is impossible to distinguish clinically from other benign lesions.

Histologically, the tumor is composed of two elements – Epithelial and lymphoid tissues. It is essential for cyst formation adenoma with papillary projections cystic spaces showing the matrix and lymphoid germinal centers.

The currently accepted theory of histogenesis is that the tumor originates in the tissue salivary gland trapped in the lymph nodes or embyogenesis paraparotid intraparotid course.

The treatment is surgical removal of the tumor.

oxyphilic adenoma (oncocytoma / acidophilic adenoma)

This is a rare tumor, usually in the parotid gland. is more common among women and the elderly. Not grow to great size and is clinically no different from other benign tumors

Under the microscope, the tumor is characterized by large cells eosinophilic cytoplasm and distinct cell membranes, and tends to be arranged in tight rows cables. These tumor cells resemble normal cells called oncocytic appearance, which is often seen in many places in the body.

The treatment of choice is surgical excision. The tumor not tend to recur and malignant transformation is rare.

Basal cell adenoma

This tumor usually occurs in the major salivary glands, and most patients are over 60 years. It appears as a painless slow-growing lesion. Histologically, has a clear strategy connective tissue capsule and cells and basaloid are isomorphic basaloid appearance with any oval stone. The cells are similar to the secretory cells of the intercalated ducts. cell adenoma Baseline is treated by excision.

Canalicular adenoma

This occurs in intra-oral minor salivary glands, mainly on the upper lip. Patients often more than 60 years. Looks like a slow-growing, painless nodule, no lip fixed. histological features of the epithelial cells of the laces, arranged in two rows. The canalicular adenoma is treated by simple excision.

Myoepithelioma

Occurs and adult parotid gland is the most frequent event. The site palates often intra-oral. The tumor is composed of spindled or plasmacytoid cells or a combination thereof in a myxoid background. The definitive diagnosis is based on the identification of myoepithelial ultrastructural calls. The lesion was treated by excision.

Ductal papillomas

Papillomas of the excretory ducts of the salivary glands present three ways.

papilloma single channel 1) – an exophytic with a papillary surface and a base pedicle.

2) invest ductal papilloma – presents as a nodule in the oral mucosa.

3) papilliferum Sialadenoma – exophytic growth of the hard palate.

All types are treated by excision.

Benign lymphoepithelial lesion

This injury is a common feature of both inflammatory and neoplastic diseases. The lesion occurs mainly as a unilateral or bilateral involvement of the parotid or submandibular glands mild discomfort, occasional pain and xerostomia.

He is considered an autoimmune disease in which salivary gland tissue is antigenic. It is often vague, poorly described enlargement of the gland rather than forming a discrete nodule. Histologically, there is an ordered lymphocytic infiltration of the gland tissue, destroy or replace the acini.

The condition was treated by surgical resection and radiotherapy. However, it is not used today because of the possibility of radiation-induced cancer.

Value Mikulicz's disease

The disease was first described by Mikulicz in 1988 was characterized by chronic symmetrical or bilateral, painless enlargement lacrimal glands and saliva. Mikulicz patient shows a benign course, without lymph node. Some workers later noted that in some cases, the disease Mikulicz taught a course is often rapidly fatal. Turned out to be malignant lymphoma.

It is now believed that Mikulicz disease, benign lymphocytes are identical in nature.

Malignant tumors

Malignant pleomorphic adenoma

This term includes histologically benign tumors presented with metastases is similar to the primary lesion, and that clinically resemble benign pleomorphic adenoma, but this cytologically malignant changes. There is debate about whether they come from a benign or earlier, representing a malignant tumor from the beginning.

There is no obvious difference between the pleomorphic adenomas clinically benign and malignant, except occasionally a fixity to deeper structures and a higher incidence of ulcer area, pain and enlarged lymph regional nodes in cases of malignancy. frequently metastasizes to the lungs, bones, viscera and brain were collected.

Histologically The malignant component may invade Benin or may remain localized in discrete locations. nuclear changes, invasion of connective tissue, focal necrosis, etc are the features used to determine malignancy.

Treatment is essentially surgical and recurrences are managed with surgery and radiotherapy combined.

Adenoid cystic carcinoma

This is a form of carcinoma of polyps, which often affect intra-oral minor salivary glands, parotid glands and submaxillary. Clinical manifestations include local pain, facial paralysis (in the case of the involvement of the parotid), fixation of the deeper structures, local invasion and ulceration of the surface. Histologically, the tumor is composed of small cells resembling uniforms deeply staining cells base, arranged in the center-product-like substance containing a mucoid. spread of tumor cells and perineurial spaces or ducts is a feature common.

Treatment is primarily surgical, but often in conjunction with radiation therapy. This tumor metastasis usually at the end of their course and Therefore the long-term monitoring is required.

Acinar cell carcinoma

This injury is common in the cells showing differentiation acinar cells rather than model driven, as seen in other tumors. It closely resembles the pleomorphic adenoma in the natural appearance. It is reported that mainly occur parotid gland. acinar cell carcinoma consists of cells of different degrees of differentiation. well differentiated cells resemble cells acinar normal. lymphoid elements are also often seen.

Treatment is primarily surgical. The recurrence rate is 8 to 59%, which occurs many years after surgery. In the long-term monitoring is necessary.

Mucoepidermoid Carcinoma

This is an unusual type of salivary gland tumors, described as a separate entity in 1945 by Stewart, Foote and Becker. Most cases occurred in the parotid gland. Other glands may also be affected. This tumor has a variety of low-grade malignancy and a type of high-grade malignant tumor. The first appears as a slow growing painless. Because of the tendency to develop cystic areas, Intraoral lesions resemble mucocoele. The high quality malignant tumor is growing rapidly and cause pain and facial nerve palsy.

MEC encapsulated and seeps into the surrounding tissues and metastases show. Histologically, a tumor composed of pleomorphic cells mucus-secreting cells, squamous cells of intermediate type.

The treatment is surgical. Recent data have shown a favorable response to radiotherapy. low-grade malignant type can be treated by surgery alone.

Clear cell carcinoma

This is a relatively recently recognized lesion, characterized by the presence of certain "clear cell" believed to originate from intercalated duct cells and myoepithelial cells. This lesion is found mainly in the major glands, especially parotid. Clear cell carcinoma tends to occur in older adults and women. The presentation clinic is not different from other tumors. Histology shows clear cell groups surrounded by thin walls of connective tissue fibers. The injury is treated by surgery. Usually shows a relatively favorable prognosis.

Epidermoid (squamous) carcinoma

This tumor has a grave prognosis as metastatic infiltration properties easily and reproduces easily. It can occur in the salivary gland. Appears to be of ductal squamous metaplasia of ducts easily. A combination of surgery and radiation therapy is indicated.

the involvement of salivary glands in rheumatic diseases

Swelling of the salivary glands, particularly the parotid gland may be a manifestation of autoimmune disease. Different subsets of the disease autoimmune salivary glands

1) allergic sialadenitis,

2) Sjögren's Syndrome / myoepithelial sialadenitis and

3) sialadenitis epithelial cells / granulomatous sialadenitis.

Allergic sialadenitis

This is an acute, but rare. The deposit antigen-antibody complexes results in inflammation of the parenchyma. The elimination of the allergen is curative. These allergens certain foods and medicines as Butazone phenyl and nitrofurantoin.

Myoepithelial sialadenitis (Sjogren syndrome)

It is a condition initially described as a triad of keratoconjunctivitis sicca, xerostomia and rheumatoid arthritis. Some patients present only with dry eyes and dry mouth (primary Sjögren syndrome Sjögren /), While others develop collagen vascular diseases such as lupus erythematosus, periarteritis nodosa, scleroderma and rheumatoid arthritis (syndrome secondary Sjogren's).

Disease occurs primarily in women over 40 years of age. The clinical diagnosis requires a combination of two the classic triad. Granularity cause dry eyes and pain in the mouth and eyes, pain and burning sensation in the oral mucosa. Oral candidiasis, rampant caries and cracks are common language. The patients often have bilateral parotid involvement. Other glands may also be affected.

Mikulicz disease is believed to be synonymous with the component of the saliva of Sjogren's syndrome. The injury may have extra-glandular manifestations such as lymphoma.

Histologically intense lymphocytic infiltration of the salivary glands and proliferation of ductal epithelium are seen. Antiductal antibodies may be present in patients serum. Other factors such as rheumatoid factor and antinuclear antibodies are also frequent. ESR can amount to 80%.

Sialography can be of diagnostic value in Sjögren syndrome. Shows typical cherry blossom "(without the branches of fruit trees laden) appearance.

There is no satisfactory treatment for Sjogren's syndrome. Patients are treated symptomatically with artificial tears and saliva substitutes.

various diseases

Cystic Fibrosis

This condition is inherited as an autosomal recessive and is the most common lethal genetic syndrome among white children. Children suffering from a disease pulmonary disease, pancreatic insufficiency and the high concentration of electrolytes in sweat.

Despite the mucus-secreting glands are pathological cases, parotid saliva was also slightly affected. Elevation levels of calcium and protein of the results of the gland secretes in turbidity due to formation of calcium-protein complexes.

Necrotizing sialometaplasia

Sialometaplasia necrotizing inflammation is a benign salivary gland, which both clinically and histologically mimic malignancy. The most likely cause is a local ischemia, the cause is not known whether alcohol and snuff have been implicated by some workers.

The condition is more common in men. Most patients are in 4 th and 5 th. Most cases occur in the palace, but other intraoral sites were also observed. The lesion usually presents as an ulcer. The pain is not common. The inflammation may in some cases.

sialometaplasia characterized histologically by necrotizing ulceration of the mucosa, epithelial hyperplasia pseudoepitheliomatous acinar necrosis and metaplasia mucosa squamous salivary glands.

This lesion is essentially self-limiting and heal by secondary intention.

retention phenomenon mucosa (mucocoele)

It is generally acknowledged to be traumatic, and is a common injury. It can be caused by the traumatic separation of a salivary duct, or a partial blockage of a salivary duct. So mucocoeles can be classified as leakage rate and the rate of retention. The first is the most common.

The condition is most common in the lower lip. The injury may be sufficiently deep in the tissue or unusually low. The lesion is a raised surface, the limited vesicle with a transparent blue cast less than 10 mm in diameter. The deepest injury is inflammation, but the appearance of color and surface are normal mucosa. The content is usually thick, mucinous.

The histology shows an increase in thinning mucous lining of a wall formed by compressed fibrous connective tissue and filled with light eosinophilic cells containing clot variables.

The treatment is excision of the lesion and removal partner salivary gland acini.

Ranula

This is a form of mucocoele happens mostly on the floor of the mouth, in association with the duct Wharton or sublingual ducts. The etiology and pathology are essentially the same as for other mucocoele glands.

The lesion develops as a slowly growing mass without pain in one side of the floor of the mouth. Since the lesion is deep, covering the mucosa is normal in appearance. If superficial, the mucosa has a blue color translucent. The treatment is damage to empty unroof.

The image of Diseases of the salivary glands

Several imaging techniques can be used in the diagnostic evaluation of salivary gland. They range from plain radiographs MRI of the most complex (RM).

Standard radiography

Plain radiography still plays an important role in the examination of the salivary glands. It is recommended to identify radiopaque sialoliths phleboliths or dystrophic calcification present in the gland or duct.

For the evaluation of parotid gland, see PA, right lateral oblique and side, chin and mouth open, you must perform. For evaluation of submandibular gland, lateral radiograph should be taken with the index finger pressing the tongue to the floor. In addition, an intra-oral occlusal view can be useful.

About 80% of salivary stones can be visualized by x-ray simple. Appear as focal calcified densities, most often associated with the submandibular gland.

Nuclear medicine (scintigraphy)

The results of nuclear medicine techniques is less specific than sialography, CT, or MRI. But it may be useful as an adjunct these techniques.

Intravenous injection of 10 mCi of Tc-99m pertechnate is done with gamma camera images obtained every 2 minutes. Anomalies can be defined as increased absorption of radionuclides decreased or absent. increased uptake is seen in sialadenitis and granulomatous diseases and oncocytoma and Warthin's tumor. Decreased absorption seen in aging, viral infections and most of the tumors.

Ultrasound

This offers a noninvasive test of the salivary glands, with the exception of the deep lobe of parotid. The differentiation between cystic and solid compartments can be done easily. Fluid-filled structures without tissue interfaces, such as an abscess or cyst, look no echo in the ultrasound studies. solid structures including heterogeneous tumors, seems full of echoes and various shades of gray.

High frequency transducers order of 7.5 MHz are used. sequential images transverse and longitudinal planes are made. Ultrasound can be used in evaluating all types of salivary gland pathology. In the case of injuries inflammatory process chronic determines the structure of ultrasound.

Sialography

Sialography is the direct manifestation radiographic salivary gland and injection of radiopaque contrast through the hole in the duct. The three main indications of the results sialography

(I) sudden acute inflammation of a gland, probably secondary to duct obstruction by a stone or stricture,

(Ii) the progressive glandular or symptoms suggestive of recurrent inflammation,

(Iii) palpable masses in the salivary glands.

Technique:

Before driving the pipeline, Classic radiographic examination is indicated to determine the radiological point of view. No premedication or local anesthesia is necessary for sialography. After placement of the cannula into the canal, a dye, such as fat ethiodol introduced by hydrostatic pressure or mild intermittent manual injection. contrast injection is performed under fluoroscopic guidance. Gland ducts must be seen in acinar filling, filling, evacuation and after the evacuation.

Results:

In chronic inflammatory sialadenitis, dilated ducts and peripheral coordination or globular collections of contrast was observed saccular in an irregular pattern throughout the gland. delay in the evacuation of contrast is observed.

In autoimmune diseases, or punctate collections material globular homogeneous contrast seen throughout the gland, and do not disappear during the evacuation. The sicca syndrome is characterized by a "cherry blossom" (No tree branches laden with fruit) appearance.

In the assessment calculations, the film is greater than sialography because most stones are radio-opaque, and the contrast can be hidden. granulomatous disease and lymphoma has a similar appearance sialographic. The results have been progressive in terms the evolution of the disease. Sialography can also be used to assess laceration or hematoma formation.

Cons sialography is indicated if

(I) and acute infection

(Ii) the history of allergies to contrast material.

Computed tomography (CT)

The main indications for CT include evaluation of the mass or generalized enlargement of the glands in one or more acute inflammation or abscess. This technique is useful in diagnosis, treatment planning and to assess response to treatment.

Routine CT can be performed with or without intravenous contrast. TC has a 10 times conventional radiography in the detection of calcifications in the gland. Acute and chronic inflammation, benign and malignant tumors and cysts can be seen. In the case of malignant tumors, infiltration of surrounding tissue can be seen. In addition, the facial nerve and other structures can be associated see, and this helps in planning treatment.

Magnetic resonance imaging (MRI)

CT and MRI signs overlap. MRI is the modality of choice for the evaluation of neoplastic lesions. The advantages of MRI include increased soft tissue contrast in the tumor margin. The main drawbacks are the high cost, limited availability of facilities and increasing technical complexity.

MRI of the salivary glands using a superconducting magnet with an intensity field of 1.5 T. Routine examination includes deepening $ 5 mm or less. The occurrence of pleomorphic adenoma and Warthin tumor Mr homogeneous with a low signal intensity compared with normal gland. In case of Warthin tumor, cystic components found. Fibrosis or calcifications appear as areas of weak signal or no signal. Malignant tumors show low signal intensity than benign tumors. haemorrhagic spots appear as images of high intensity.

Use of MRI in the salivary gland disease is limited, because many diseases show similar trends. The contra-indications for MRI are the pacemaker, Videos ferromagnetic valve implanted neurostimulation devices.

Surgical treatment of diseases of the glands salivary

Except for possible surgical treatment of cysts and retention mucoceles Ranuli, transoral Sialolithotomy is the most frequently performed procedure system saliva. It is a simple operation, but often neglected by the physician without training in oral surgery for the enucleation of the gland. If the stone is great location, its elimination through the mouth and thus preserves the function of the gland.

The submandibular gland can be enucleated without effects effects if the operation was performed. In most patients with normal salivary glands remains the withdrawal of no consequence.

However, parotid gland is the most worrying. Danger in the facial nerve is present even if meticulous surgery allows the removal of the gland with only passing a weak point in most cases.

The removal of a gland will lead to significant deformation face. However, these factors are more important if the operation is necessary, but the methods of contra-indications for such procedures when conservative enough.

Tumors affecting the parotid glands, submandibular, sublingual, or located in the cheek, lips, mouth, may also justify their removal in some cases. These procedures are spelled out below.

submandibular sialoliths

stones of the submandibular gland is the most disorders submandibular gland common and the most common are glandular. Although these estimates are large, and are rarely painful birth canal Wharton is larger and more scalable than the duct Stenson. The usual symptoms are pain and sudden increase in the gland during feeding. Usually there is a return of function in most patients after the removal of this condition.

Those in the anterior sheath

As general, the rocks opposite the second molar is best removed with local anesthesia. These first set in a line connecting the mesial surfaces of second molars are designated as previous calculations.

Preoperative evaluation of previous estimates depends on the history, clinical examination and radiographs. As Generally, a preoperative sialography is indicated because of the possibility of the stone moves in a posterior part of the pipe by force of injection.

Procedure

A suture is passed around the back leads to the stone to prevent detachment during subsequent handling, after spending a suture on the floor of the mouth to test the tissue to facilitate passage of suture circumductal. Ducts can be easily located by bisecting the angle formed by the fold sublingual and the line connecting the tongue.

Circumductal suture is then attached to a hemostat and placed on adjacent teeth that leads to deformation ducts. A second suture is placed between the submandibular duct papilla and brake. gentle traction applied to these sutures to tissue at the surgical site was tight and the lining for easy cutting.

The incision is made along the line of the channel in the stone. Knife should not be sunk deeply, but you have to divide the mucosa and enters the underlying tissues. The tube is then both dissection and strong with scissors Fine Point in the loose connective tissue always be aware of language sublingual veins. So moved. Often at this stage, the calculation is visible through the duct wall and a longitudinal incision, and released. If adheres to the duct wall and is released slowly with a small curette without damaging the duct.

A few interrupted sutures to the floor of the mouth and then close the wound. ductal incision is not sutured to prevent the formation of a stricture.

Those in the rear channel

These are best removed under In general anesthesia, few patients tolerate retraction required under local anesthesia.

Enough to cause obstruction symptoms may occur in one of two ways: – stone can grow to a size that only a small amount of saliva may be secreted or infection can set in

If the stone is not visible in the center of the occlusal film, then can not be eliminated by the method used for the stones placed on the front and should be treated as a stone placed behind a stone or intraglandular. Most stones can be seen after a posterior oblique occlusal film. Is complemented by a film side of the jaw so that its angular position on the jaw may be evaluated. But the best way to locate your position and status of the gland by sialography. If it is an aspect of "sausage string" in sialography a good chance of recovery exists. intraglandular When ducts are illegal, grossly dilated cavity and then removing the gland is the best option.

Procedure

Best performed under general anesthesia. The language is returned aside. A lacrimal probe is inserted through the opening of channels and high to help locate the channel and the mucosa becomes dry in the premolar region. Identified and pulled through forward with a suture passed around. Is followed through again and lingual nerve were identified where it crosses under the canal. Once the lingual nerve is identified, a then the initial incision is enlarged lingual nerve moves laterally and passed retraction sutures to expose the surgical site.

An assistant then pushes the lower pole of the gland up to the upper pole is visible. Suture then turned on the trailing edge of the mylohyoid before to retract. If the stone is visible, is issued by a longitudinal incision. If it is not open vent is the most likely location and explored until recovery. Wound irrigation is removed and transferred retraction sutures incised left open membranes, mucosa are closed with sutures.

The pipes on the position submaxillary-intraglandular

Here is the entire gland is removed. If the stone is an incidental finding small, asymptomatic and normal sialographically, can be left in place and there is no change in condition or operation of the gland. Any change for the worse indicates the need for removal of the glands.

Procedure

An incision is made convex two inches long, is parallel to the fold of skin, about 1.5 to 2 cm below the lower edge of the jaw.

Long incision through the superficial cervical fascia, vein reflects low anterior facial identified and divided between ligatures. A top cover fabric connective is collected near the surface of the gland in order to protect all branches of the facial nerve with the flap lifted.

Face artery dissection is in and retraction of the lower pole of the gland upward and forward. The posterior belly of digastric is identified with the style-hyoid retracts downward and backward. The facial artery is seen passing behind the muscles around the gland. Divide is clamped and then ligated.

Then, the anterior bottom of the gland is reflected upward and backward. With dissection of the fingers and keeping close to the gland, a sheath of connective tissue remains in the hypoglossal nerve is within the gland.

The gland is then pulled down, exposing the V-shaped fold of tissue that contains lingual nerve and submandibular duct. These two structures were carefully dissected. At this stage one should be able to clearly delineate the three basic structures within the gland above the lingual nerve, ie, toward the middle and lower hypoglossal nerve.

Now that the canal and a deep part of the gland still remain united. The edge posterior mylohyoid retracts and a branch of the sublingual artery league. After holding the submandibular duct, split and double bond so that only a strain on short rest.

The tissues were closed in the layer, a drain inserted if necessary and apply a bandage.

Sialoliths parotid

• Stensen leads is where 10.6% of salivary stones. Of these 40% are opaque. Observed in four basic areas: –
• Impacted in the papilla
• In the bottom of the channel walls
• Intraglandularly
• Outside the extra glandular duct buccinator.

Those in the papilla and the driving submucosa

The calculations at this point can be released by the incision of the papilla. A leaf of a pair of scissors sharp heavy fine is inserted part way into the duct and a small incision behind the hole. In general, the active worksheet when the scissor blade is removed, if the pressure is not as smooth on the gland require the calculation with the amount of saliva. The wound heals quickly.

The buccinator exterior extraglandularly –

The calculations in this region can be approached through an incision in the intra-oral aspect of the cheek. The injection of local anesthetic with a vasoconstrictor to reduce bleeding and increase the mucosal surface of the buccinator to assist in tissue dissection soft. A traction suture is placed in front of the papilla, a change of incision is made through the mucosa, and the triangle that contains the disc and then through rises from the buccinator. top and bottom flaps are mobilized and stay sutures to keep them off the road. Dissection reached where the tube passes through the buccinator is reached. The top and bottom of the buccinator dehiscence are identified and each child is placed in power lines and retracted to expand the dehiscence. Is drawn through lateral and medial retracted in the mouth with a suture. With this approach to calculations in the duct Stenson, much can be removed easily, even more Beyond the masseter muscles. Once the calculations are, adhesions to the surrounding tissues were cut longitudinal incision made in the conduct and pitted. The line is sutured, but the tissues around it are closed with absorbable sutures.

The located in the duct-intraglandular

Stones located intraglandularly can be achieved by intra-oral route. One type of parotidectomy incision is recommended. The skin and subcutaneous tissue rose from the deep fascia covering the gland until its leading edge is found. Then aponeurosis is incised horizontally on the pod involved. Led to this point lies on a line connecting the angle of the mouth and nasal ala. The nerve buccal branch of the face is usually on the surface and transverse facial vessels are usually about 1 cm higher than the canal.

Once the duct is identified, then is back in the gland. facial nerve branches tend to cross immediately superficial to drive and must be preserved. When the section containing the calculations is achieved, a longitudinal incision is made in the usual way and are provided after the approval needed points stitched into the front and back of stone around the sheath to prevent slipping. Gland capsule is closed and continuous plain catgut beautiful skin incision is closed by planes with vacuum drainage.

The salivary gland tumors

The salivary gland tumors are rare and represent less 3% of all tumors of the head and neck. Between approximately 75-85% of these tumors occur in the parotid gland, 10-20% in the salivary glands more often in the language of the mouth (58%) (10%) and upper lip (9%).

sublingual gland has the highest proportion of malignant tumors benign. In fact, 80% of the parotid gland, 65% of submandibular, 50% of minor salivary and 20% of sublingual gland tumors are benign.

The only curative treatment of salivary gland tumors is surgical removal. Resection of parotid gland tumors is complicated by the presence of the facial nerve in the gland. Except for Warthin tumors, enucleation of tumors of the parotid gland is recommended. mixed tumors are often poorly encapsulated and malignant tumors often invade surrounding glandular tissue, therefore, adequate margins of normal salivary tissue should be resected to reduce the risk of local recurrence.

Total resection of the submandibular gland is the treatment of choice for all tumors under the jaw. gland tumors palatal minor salivary or mucosal often periosteum or bone and therefore parts should be included in the surgical removal.

Parotidectomy with facial nerve preservation

This operation is also known as superficial parotidectomy or conservative. superficial parotidectomy is used to describe the removal of the surface of the gland facial nerve. However, both shallow and deep parts can be removed if necessary for the preservation of the facial nerve.

After proper preparation instead of surgery, a solution of 1 to 200,000 pieces of epinephrine in saline is injected under the skin of the portion parotid previous outer ear and ear canal tightly against. Not more than 10 ml is injected.

The incision starts at the hairline above and ahead of the atrium and came down and return to the free edges of the drink, is still in its coverage and is carried in a gentle curve at the junction of the mastoid practice skinfold passing down and forward on the neck behind the jaw.

Crease incision in the neck is further dividing the first platysma to the fascia is reached. The greater auricular nerve is identified as it passes through the posterior edge of sternum reside in the wound of 1 cm and 1 cm below the earlobe opposite just below the deep fascia on the surface of branching glands. The nerve branches were hidden under the bottom edge of the wound to keep it moist.

Once the deep fascia is identified in the rest of the depth of the wound at this level and reflects skin before him. Often, one or more parts of the face will be identifiable through the transparent fascia, as the leading edge of the gland. Are discovered by opening the fascia, each branch is identified, added running under a black silk and ends, fixing mosquito hemostat.

The main trunk of the facial nerve is deep in the angle between the ear canal outer bone and the anterior surface of the mastoid process. It lies between the lower pole of the gland anterior edge of sternum and mastoid process and part of the duct ear cartilage. Parotid gland is retracted forward as a dissection of the product and the nerve is identified as shown in the angle between the eardrum and bones of the anterior border of the mastoid process and just above the upper edge of the posterior belly of digastric. The posterior branch of stylomastoid artery auricular nerve passes surface to enter the stylomastoid foramen and raw instrumentation can break this little vessel that causes bleeding.

Since the facial nerve and its branches are invested by connective tissue and are found in the tunnels of the parotid gland that are released by the introduction of the tip of the blade of a curved artery forceps mosquito and then open a short length of the substance of the gland carpet to cut through a pair of scissors to expose the gland.

The trunk nervous and moves laterally in the parotid gland goes around the back edge of the jaw, just below the condylar neck before dividing into a higher division and cervicofascial temporofacial. In general, it is better to follow the bottom of the first division and the traceability of the cervix or at least marginal branch of the mandible forward to a point opposite the parotid gland, which mobilizes the lower pole after which progresses upward branch of industry, the mobilization of others is achieved. These branches pass into the tumor must be divided and when they emerge identified and divided and the two ends together to repair later.

interconnection branches linking two vertically peripheral branches must be preserved if possible. In general retromandibular nerve passes superficial vein, mobilization of care both nerve and vein with division and ligation of this is necessary. Small veins are sealed by diathermy.

Pleomorphic adenomas a margin of about half cm of tissue normal appearance, must be removed within the tumor mass is palpable lobulated and some of these lobes can be left in the dissection passes too close. Low-grade tumors mucoepidermoid or acinic cell tumors must be removed with a margin slightly larger and more uniform.

Once the tumor is removed, the wound is flushed with saline and checked for hemostasis. The facial nerve branches can be repaired with auricular nerve grafts if necessary large. A vacuum leak is then passed through the skin in the ear wound is closed in layers and a light dressing applied.

total parotidectomy

This is indicated when: –

• A slowly growing mass is not clinically evil is present in the deeper parts
• When a small tumor is clinically recognized as evil and give the necessary room, the kidnapping of the entire gland is expected.
• large tumor in the deep part of parotid gland presenting as swelling of the soft palate (often dumbbell-shaped form with the isthmus extends into the space between the styloid process and the back of the jaw).

Procedure

A skin flap is raised in the usual way, but the incision in the fold of neck skin is continued until the first molar. facial nerve dissected; periosteum is divided into the lower edge of the angle of the jaw bone and high masseter. A vertical section similar to that used for sub-osteotomy sigmoid vertical hole just behind the jaw, medial pterygoid is released from the posterior fragment, which is then moved forward anterior lateral fragment. This opens the space between the styloid process and the mandible.

lower pole and then moved and continued sytlohyoid digastric their origins, divided front and on. External carotid artery arising from the muscles is identified and ligated and divided.

At this stage the mouth is found and confiscated. A solution of 1:200,000 epinephrine in saline is injected into the soft palate and inflammation in a vertical incision, limiting any scar previous biopsy is done. The borders are compromised by leaving a thin layer of muscle and connective tissue in the tumor. The mass is released from work sometimes with injuries. Great care exercises above and behind all the injury for fear of damaging the internal jugular vein or carotid artery, both of which lie deep in the styloid process.

After removal, the wound is irrigated, the oral tissues are closed with chromic catgut. The fragments of the jaw are connected together. preauricular wound is closed in layers and drainage established.

Parotidomandibulectomy

This is indicated when there is invasion of the mandible with malignancy.

Procedure: –

After preparing the surgery site, a flap of skin that arises is the removal of benign tumor deep in the gland parotid. Glans then moved back and bottom and the main trunk of the facial nerve identified. Like many industries that can be dissected, sometimes sacrifice around the nerve may be necessary.

ATM next capsule opens, the condyle and mobilized. Masseter is separated from the zygomatic arch and the mandible divided into third molar region. parotid and mandibular branch is inclined upward and forward and separated from the styloid process and its muscle attachment. Then the elevation of the other branch is possible, after the origin of the medial pterygoid tubercle is palpated and separated. Before this is done in the carotid artery identified in external emerging from behind the pen-and between the hyoid in the deep part of the gland. First, linked and divided to prevent bleeding problems of maxillary artery pterygoid is divided.

pull down strong now allow for the separation of temporal integration in the pterygoid condyle and lateral coronoid. Because hemostasis is complete maxillary artery and ligated requested. facial nerve is repaired using a graft that great auricular nerve. A graft Bone can be placed within a course of postoperative radiotherapy should be used. If a bone graft substitute is not a branch, the patient will end up with a deep depression in front of the ear, but may be covered by a suitable hairstyle. There will be a tendency to switch to training affected the mandible and therefore early part is necessary to overcome this problem.

If the condyle is invaded, then the fossa and articular eminence may also be withdrawn. styloid and muscles can also be removed to increase margins, but must be done after the resection of the main mass.

Temporoparotidectomy

Small-scale removal of the external ear canal can be included in the removal of the skin overlying the parotid flag, when these structures are involved. Mastoid process may also be removed without too much difficulty, exploring and trunk to deal with sutures and nerve grafts easily.

Extension of a parotid tumor in the vertebral column is ready for removal of the parotid gland, the mandibular branch and ATM, along with the temporal bone. However, the operation carries a high risk of the need for dense bone section and separate it from the internal carotid artery, internal jugular vein and superior sigmoid and inferior petrosal sinus. must be provided adequate coverage for the duration of the wound is closed. The hypoglossal nerve was mobilized anatomised and peripheral nerve branches facial at the end of the operation.

Continuing parotidectomy with neck dissection

A radial neck dissection should be performed when cervical nodes are involved or when there is a mass in the inferior pole of the parotid gland size due to a more aggressive tumor invasion of lymph upper cervical can not be excluded. Consideration should be given to preoperative radiation neck at a dose of 400 to 500 rads.

Extracapsular removal of the submandibular salivary gland

There is a high incidence of recurrence of parotid submandibular gland resection of a slow-growing tumor such as adenomas pleomorphic.

The gland is removed with its fascia, which is separated from the anterior and posterior belly of digastric and stylo hyoid. The hypoglossal nerve is identified and preserved. The facial artery is identified in leaving under the cover of the stylohyoid and again on the lateral surface of the mandible. marginal mandibular nerve is isolated and preserved, then divided the fascia in the jaw. Acorn is thrown out of mylohyoid front fascia angled rear channels.

If the lingual nerve is involved in tumor mass and then cut in front and behind the gland and suturing the cut ends. If a wider margin of tissue from the capsule is immediately necessary laterally and the periosteum of the mandible was divided at the lower edge and stripped of the submandibular fossa. The channel is divided behind the disc and the wound closed drainage layers in the usual way.

Surgical removal of tumors of the submandibular gland / sublingual

Tumor excision frankly invasive malignant salivary gland submaxillary or sublingual understand the language of the other party, the floor of the mouth and jaw with radical neck dissection palpable lymph node if present.

The excision of pleomorphic adenomas palate

The palatal pleomorphic adenomas Small pressure resorption of the Palace and rarely invade the bone. The incision is deepened to the bone and the sample reflects the hard palate with the periosteum. The tumor was located often in the hole and the periosteum of the palate is released here until the lesion can be pulled down and neurovascular bundle fixing, cutting and coagulation diathermy before being cut. silk sutures are placed and bonded to keep a package soaked in lacquer Whitehead.

When the entire thickness of the soft palate must be removed for proper cleaning the tumor, the defect is repaired with a "flap" described by Worthington (1974).

Excision Mucoepidermoid carcinoma of Palatine

low-grade mucoepidermoid carcinoma can be treated by excision of full thickness hard palate, including alveolar bone and palate. Nasal and oral mucosa are sewn around the defect and stabilized with gutta-percha shot. Surgical repair of these defects should be carried out at least 5 years due to the possibility of a recurrence.

The split of the palate adenoid cystic carcinoma

Danger of these tumors is the surgical margin may be insufficient and the spread may occur along the perineural tissue palatine nerves at the base of the skull. Therefore, a combination of surgery and radiotherapy is the best.

Surgical excision should include hemimaxillectomy including the orbital floor, which is the minimum. When the soft palate and pterygoid region referred to as "the extended maxillectomy Crockelt approach is essential to eliminate adequate excision under direct vision.

Tumors of the cheek and lips

slow-growing parts can be removed with a margin of adjacent normal tissue, using dissection scissors effect. A biopsy is mandatory if there is no doubt in the mind of the creator. Clinically aggressive tumors can be biopsied appropriate treatment can lead to radiation and full thickness excision and repair.

Strictures

The stenosis may result from resolutions of the mucosa ulcers that occurred secondary leads to the presence of sialoliths. Sometimes ulcers result in the rejection of the stone in his mouth forming a fistula. But if the fistula is closed causes of stenosis. If transverse incisions are made in the channel, stenosis may develop. Relatives of the disc can be treated by papillotomy. These later in the channel can be treated by implanting the end of dividing the channel in the floor of the mouth namely sialodochoplasty, but those near the submandibular gland, the removal of the glands.

Expansion

Parotid duct strictures can be managed by dilatation catheters. This is done slowly and the procedure can be repeated two or three times at intervals 2 weeks, but the expansion can be effective over a long period of time.

Papillotomy

A thin tube is passed through the channel in light. With a probe or guide wire to a pair of fine pointed scissors is passed through the canal and the disc is accessible to the public. Reduce continues until the portion dilated proximal canal stenosis is attained. Using a 5.0 chromic suture, cut edge of the canal wall is sewn to the lining of the mouth. resulting opening is a bit great for a month or two, then reduced to an acceptable level.

Sialodochoplasty

Here, the canal is completely divided and implanted into floor of the mouth. Two stitches are made from a disc and then the other behind the surgical area for the voltage on the mucous membrane. An incision is made in the channel and the region of narrowing is identified. A suture is placed around the sheath, then a longitudinal incision is made in line behind the stenosis. rear end the slit is sewn to the rear edge of the wound with 5.0 chromic suture. In addition sutures are placed so that each side of the slot can be sewn on each side of the incision on the floor of the mouth. Then a suture is passed through the lower surface of the canal just below the top slot on the front, the tube is treated to the anterior longitudinal

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