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Salivary Gland Disorders updated Feb press press

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Salivary Gland Disorders updated Feb press press Powered By Docstoc
					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
           Salivary Gland Anatomy

• Major salivary glands
     • Parotid (2)
     • Submandibular (2)
     • Sublingual (2)


• Minor salivary glands (5000)
              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)
                   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
               Saliva Production

• Max rate 1 ml/min/gm of tissue
• High blood flow (10x equal mass muscle)
• Distribution
     • Parotid       75%   low viscosity
     • Submandib     20%    medium
     • Minor         5%    high
              Take Home Message

• Three categories of problems
  – 1. Altered saliva production
  – 2. Painless swelling of saliva glands
  – 3. Painful swelling of saliva glands
        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
                    Sialadenosis

• Recurrent painless swelling (parotid)
• Etiology
     • Endocrine disorders (diabetes)
     • Malnutrition (protein, ETOH, vitamin)
     • Autonomic dysfunction
• Treatment
     • Correct underlying causes
     • Reassurance
                       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
                          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)
                      Sialolithiasis

• Management
    •   Hydration
    •   Massage (Post --->Ant) + heat
    •   Anti-inflamatories
    •   Antibiotics if infected
    •   Removal of stones
    •   Sialendoscopy
    •   Surgical excision of affected gland
    Disorders of Decreased Saliva
• Irradiation
• Sjogren’s syndrome

• Cystic fibrosis
• Anti-cholinergic side effects of meds
           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
          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
                  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
                 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
                  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
           Swelling of Saliva Glands
• PAINLESS                    • PAINFUL
  –   Sialadenosis              – Bacterial sialadenitis
  –   Sialolithiasis            – Mumps
  –   Sjogren’s                 – Malignant primary
  –   HIV                         tumors
  –   Granulomatous
  –   Benign primary tumors
  –   Lymphoma
            Salivary Infections
• Primary bacterial (sialadenitis)
• Secondary viral
• Granulomatous
                     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
                     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
                  Acute Sialadenitis

• Treatment
    •   B-lactam resistant penicillin or cephalosporin
    •   Augmentin, Clindamycin
    •   Steroids
    •   Fluid replacement
    •   Sialogogues
    •   Analgesics
    •   Manual massage
    •   Topical heat
                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
                  Chronic Sialadenitis

• Usually follows recurrent infections
• Permanent alteration of gland architecture
• Surgical excision required
                    Acute Sialadenitis

• Complications include abscess
     •   Persistent symptoms > 4 days of Rx
     •   Uni or multiloculated
     •   CT scan of neck with contrast
     •   Sialography contraindicated
     •   Surgical drainage
        Secondary Viral Infections

• Hematogenous dissemination
• Mumps
• HIV
                        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
                                  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
                      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
                 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
  Salivary Gland Tumors



Benign vs. Malignant Neoplasms
            Salivary Gland Tumors
• BENIGN                • MALIGNANT
• Painless              • Can be painful
• Slow growing          • Growing rapidly
• Facial nerve intact   • Facial nerve can become
                          paralyzed
                        • Lymphadenopathy
• More common           • Less common
             Salivary Gland Tumors
• Location of Gland     • Incidence of Malignancy
                          – 20%
   – Parotid
                          – 50%
   – Submandibular
                          – 80%
   – Minor
                Benign Salivary Tumors
• Adenomas
        • Pleomorphic
        • Monomorphic
        • Wathin’s tumor
• Oncocytoma
• Oncocytic papillary cystadenoma
• Myoepithelioma
• Sialadenoma
• Inverted ductal papilloma
• Hemangioma
• Lymphangioma
            Malignant Salivary Tumors

• LOW GRADE              • HIGH GRADE
• Mucoepidermoid ca      •   Mucoepidermoid ca
• Acinic cell ca         •   Adenoid cystic ca
• Adenocarcinoma         •   Adenocarcinoma
                         •   Carcinoma ex pleomorphic
                         •   Squamous cell ca
                         •   Undifferentiated ca
             Factors Influencing Survival

•   Histopathologic diagnosis
•   Lymph node metastasis
•   Pain
•   Facial nerve paralysis
•   Skin involvement
•   Stage
•   Location
•   Recurrence
•   Distant metastases
      Evaluation of Suspected Tumors

• FNA
• CT scan of neck with contrast
• Surgery for frozen section analysis

				
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posted:8/17/2011
language:English
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