Salivary Gland
Diseases
Cells in Salivary Glands and Ducts
Acinus Intercalated
duct
Striated
duct
Excretory
duct
Myoepithelial cell
•1- Functional Disorders:1(Xerostomia
•2- Developmental1(Aplasia2(Atrasia
3(Aberrancy•3- Infectious (sialadenitis):
.ABacterial:1(Acute bacterial sialadenitis.
2(Chronic sialadenitis..BViral:
•Mumps•
Classification Of SG Diseases
Classification Of SG Diseases
4- Cysts:1. Mucous retention cyst
2. Mucous extravasation cyst
3. Ranula5- Obstructive
• Sialolithiasis
6- Autoimmune
• Sjogren`s Syndrome
7- Tumor like lesions
• Sialoadenosis
Classification of SG Diseases
7-Neoplastic1)Benign
a) Pleomorphic Adenoma
b) Monomorphic andenoma
I. Whartin’s tumor
II. Oncyocytoma
2)Malignant
a) Malignant Pleomorphic Adenoma AndCarcinoma Ex Pleomorphic Adenoma
b) Adenocystic Carcinoma
c) Mucoepidermoid Carcinoma
•Xerostomia
Functional Disorders
•Definition:
➢Means dry mouth
➢It may be temporary or chronic (persistent)
➢Temporary xerostomia is of no clinical significance
➢Persistent xerostomia is of grave consequences
•Classification:
➢Primary, due to defective glands.
➢Secondary, due to defects outside the glands
•Normal Salivary Flow:
–1 – 2 ml/minute , 1 – 2 Liters/Day
Xerostomia
•Causes:
1.Developmental (Salivary gland aplasia)
2.Loss of body fluids as:
➢Impaired fluid intake
➢Hemorrhage
➢Vomiting and diarrhea
3.Medications as antihistamines, diruetics and antidepressants
4.Radiation therapy to the head and neck
5.Systemic diseases as Sjogren’s syndrome and diabetes
6.Local Factors as smoking and mouth breathing
Xerostomia
•Oral Manifestations:
1.Sever dental caries (especially cervical caries).
2.Sever periodontal diseases
3.Atrophied and ulcerated oral mucosa and tongue
4.Superimposed infection, particularly candida albicnans
fungus due to changes in oral flora because of the reduction
in the cleansing and antimicrobial activity of the saliva
5.Difficulty in speech, mastication and swallowing
6.Loss of taste
7.Inability to wear dentures
Xerostomia
1.Remove the cause if possible
2.Check for any associated drug contributing to xerostomia
3.Frequent small sips of water
4.Prescribe saliva substitutes (artificial saliva)
5.Suggest sugar-free gum
6.Maintain good oral hygiene
7.Chlorohexidine (0.2%) rinses
8.Control caries with fluoride application
9.Monitor for candidosis (antifungal drugs)
10.Treat difficulties with dentures
11.Observe regularly for possible ascending parotitis or chronic sialoadenitis
Xerostomia - Management
Infections
•Definition:
•Acute suppurative inflammation of the parotid
•Cause and pathogenesis:
–Predisposing factors are :
1.xerostomia resulting from postoperative dehydration (One
of the common causes of acute bacterial sialadenitisis is
Recent surgery because the patient has been kept without
food or fluids and has received medications that produce
xerostomia)
2.Irradiation
3.Sjogren’s syndrome
Acute suppurative parotitis(Acute Bacterial Sialadenitis), (Acute ascending
parotitis)
–The causative organisms :
–Staphylococci, streptococci and pneumococci
▪The mode of infection is ascending i.e. via the duct and
rarely blood born.
▪The disease is now very rare due to the invention of
antibiotics and proper post-operative care
Acute suppurative parotitis(Acute Bacterial Sialadenitis), (Acute ascending
parotitis)
•Clinically:
✓Mainly affect the parotid gland and may be bilateral .
✓Painful swelling of the gland with uplifting of the ear lobe
✓The overlying skin is red, shiny and tense
✓In severe cases edema and difficulty in opening the mouth
(trismus)
✓Purulent discharge or pus from the affected duct
✓Fever and malaise
Acute suppurative parotitis(Acute Bacterial Sialadenitis), (Acute ascending
parotitis)
Acute suppurative parotitis(Acute Bacterial Sialadenitis), (Acute ascending
parotitis)
Histopathologic features
✓ Accumulation of neutrophils is observed within the ductal
system and acini.
Treatment
The treatment of acute sialadenitis includes:
✓ Appropriate antibiotic therapy
✓ Rehydration of the patient to stimulate salivary flow.
✓ Surgical drainage may be needed if there is abscess
formation.
Acute suppurative parotitis(Acute Bacterial Sialadenitis), (Acute ascending
parotitis)
•Definition:•This is a chronic inflammation of the salivary glands
•Cause and pathogenesis:
–Usually results form recurrent or persistent ductal obstruction caused by :
1.Sialolithiasis
2.Congenital strictures
3.compression by an adjacent tumor
Chronic Sialadenitis
•Clinically:
✓Painless or painful swelling of the affected gland which become worse at mealtime when salivary flow is stimulated.
✓Chronic sialadenitis can affect the parotid gland, submandibular gland, or the minor salivary glands.
•Histologically:
✓Atrophy of the acini
✓Ductal hyperplasia and dilatation.
✓Lymphocytic infiltration.
✓Fibrosis of the stroma
Chronic Sialadenitis
•Treatment:
–If possible remove the obstruction
–More often the gland has to be excised and
biopsied to exclude the possibility of neoplasms
Chronic Sialadenitis
Sialadenitis
Nonspecific chronic
sialadenitis reveals
dilatation of ducts,
interstitial infiltration of
lymphocytes and
fibrosis
Sialadenitis
Marked interstitial
fibrosis, infiltration
of chronic
inflammatory cells
and acinar atrophy
Mumps (Epidemic Parotitis)
▪ Definition:
Acute viral infection of the parotid
▪ Cause and pathogenesis:
• The causative virus is paramyxovirus which is RNA.
• The mode of infection is droplet infection.
• The virus reaches the gland through the duct or more commonly via blood.
• One attack produces permanent immunity.
• The incubation period is 2 - 3 weeks.
• The virus could be detected in saliva and blood (viraemia) prior to the appearance of the disease by 2 - 3 days using complement fixing antibodies
Mumps (Epidemic Parotitis)
▪ Clinically:
• Fever and malaise.
• Enlargement of one parotid followed by enlargement of the other one within 2 - 3 days - rarely enlargement of both parotids occurs
• The enlargement is firm - painful - elevate the lobule of the ear and causing trismus
• No pus formation unless secondary infection occurs
• The disease is self limiting and spontaneous regression occurs after 2 - 3 weeks
▪ Histologically:
• Degeneration of the acini.
• Acute inflammatory cell infiltration
Mumps (Epidemic Parotitis)
▪ Complications (rare, usually in adults):
• Extension to other salivary glands.
• Hepatitis.
• Pancreatitis
• C.N.S. affection
• Orchitis and ovaritis which may lead to sterility
▪ Prevention:
• Vaccination with MMR
▪ Treatment:
• Supportive treatment (analgesics & antipyretics)
• Plenty of fluids and soft diet
• Maintain good oral hygiene
Mumps
Obstructive disorders
•Definition:•calcified structures that develop within the
•salivary ductal system
•Clinically:➢Occurs usually in adults.
➢Usually in submandibular more than parotid because the duct of the submandibular is more tortuous and the secretion is more viscous. The direction of the saliva flow is antigravity.
➢The stone occurs in the duct or in the salivary gland.
➢The condition is rare in edentulous mouths.
SialolithiasisSialolith (Salivary Calculus)
•Pathogenesis:➢They arise from deposition of calcium salts
•around a nidus of:
.athickened mucus
.bMicroorganisms
.cdesquamated ductal epithelial cells
.dforeign body (that enter the ducts of a salivary gland from the mouth)
➢Calculus consists mainly of calcium carbonate and phosphate in addition to some trace minerals.
SialolithiasisSialolith (Salivary Calculus)
•Radiographic picture:•They could be detected in X-ray as a radiopaque mass.
•Complication:•The stone causes obstruction and secondary infection of the
involved gland. It may cause mucous retention cyst.
•Features:➢Tender enlargement of the gland and the duct become visible in
the floor of the mouth.
➢Periodic swelling and pain occur within the affected gland. Swelling usually develop at meal time.
➢If the stone is located toward the terminal portion of the duct, a hardmass may be palpated beneath the mucosa that have a yellowish color.
SialolithiasisSialolith (Salivary Calculus)
Sialolithiasis – Salivary Stones
•Wharton's duct is much more commonly
involved by a sialolith than is
Stensen's duct. In many cases, the
stone is difficult to see and often no
intraoral manifestations are
evident
Sialolithiasis – Salivary Stones
•Radiographs are helpful in detecting the stone, or stones, as in this good example.
Sialolithiasis – Salivary
Stones
Treatment•Small sialoliths of the major glands
sometimes can be treated
conservatively by gentle massage of the
gland in an effort to bring the stone
toward the duct orifice.
•Larger sialoliths usually need to be
removed surgically.
•If significant inflammatory damage
has occurred within the gland, and in
case of minor gland sialoliths, the gland
may need to be removed.
Sialolithiasis – Salivary Stones
•The usual result of duct
obstruction is
inflammation of the
gland. The changes
consist of ductal
dilatation, acinar
degeneration, chronic
inflammation and fibrosis
Sialolithiasis – Salivary Stones
•This higher power
displays the remnants
of degenerating
mucous acini (green
arrow) surrounded by
lymphocytes and
plasma cells with
areas of early fibrosis
(yellow arrow).
Cysts of Salivary Glands
1. Mucous Retention Cyst
2. Mucous Extravasation Cyst
3. Ranula
Mucocele
Cysts of the salivary
glandsI- Mucous retention cyst
• Definition:
A cyst affecting minor salivary glands due retention of
mucous.
• Pathogenesis:
Partial obstruction of the duct by stone or stenosis
due to inflammation.
Cysts of the salivary
glandsI- Mucous retention cyst
Cysts of the salivary
glandsI- Mucous retention cyst
• Clinical picture:
➢Usually affects lip, tongue or buccal mucosa.
➢ small swelling which is fluctuant.
➢Pain may become worse at meal time.
• Histopathology:
➢Epithelial lining: compressed ductal epithelium
ranging from pseudo stratified to stratified squamous.
➢ connective tissue wall is minimally inflamed.
➢ lumen of the cyst contains mucin.
Cysts of the salivary
glandsI- Mucous retention cyst
Cysts of the salivary
glandsI- Mucous retention cyst
Cysts of the salivary
glandsII- Mucous extravasation cyst
• Definition:
A pseudocyst affecting minor salivary glands due
extravasation of mucous into connective tissue as a
result of torn duct.
• Pathogenesis:
Trauma.
Cysts of the salivary
glandsII- Mucous extravasation cyst
• Clinical features:
➢Usually affects lip, tongue or buccal mucosa.
➢ small swelling which is fluctuant.
➢Pain may become worse at meal time.
• Histopathology:
An area of spilled mucin surrounded by a
granulation tissue that is infiltrated by inflammatory
cells usually includes neutrophils and macrophages.
Cysts of the salivary
glandsII- Mucous extravasation cyst
Cysts of the salivary
glandsII- Mucous extravasation cyst
Cysts of the salivary
glandsII- Mucous extravasation cyst
Cysts of the salivary
glandsII- Mucous extravasation cyst
Cysts of the salivary
glandsIII- Ranula
• Definition:
A mucous retention or mucous extravasation cyst
occurring in the floor of the mouth related to
submandibular salivary gland.
• Pathogenesis:
Partial obstruction or Trauma.
Cysts of the salivary
glandsIII- Ranula
Cysts of the salivary
glandsIII- Ranula
• Clinically:
A large fluctuant bluish swelling in the floor of the
mouth.
• Histopathology:
Mucous retention or mucous extravasation cyst.
Cysts of the salivary
glandsIII- Ranula
Mucous Retention Versus
Mucous Extravasation
Ranula
Ranula
•Ranula (salivary extravasation phenomenon;
mucous retention phenomenon;
mucocele): A large compressible bluish
soft tissue enlargement of the floor of the mouth
Ranula
•Large mucocele of
the left sublingual gland with extension across the
midline.
Autoimmune diseases
•Definition:
–An autoimmune disease that principally involves salivary and
lacrimal glands resulting in xerostomia (dry mouth) and
xerophthalmia (dry eyes).
Sjogren’s Syndrome
Sjogren’s
Syndrome
•Types:
1.Primary Sjogren`s syndrome,
–(Sicca Syndrome, Benign Lymphoepithelial Lesion),
characterized by:
•Dryness of the mouth “Xerostomia”
•Dryness of the eyes “Xerophthalmia”
1.Secondary Sjogren`s Syndrome
–characterized by:
•Dryness of the mouth
•Dryness of the eyes
•Other systemic diseases such as Rheumatoid arithritis
and lupus erythematosis.
Sjogren’s Syndrome
•Etiology:
1.Autoimmune
2.Retroviral infection, suspected but not
proven yet
Sjogren’s Syndrome
•Clinically:
–Age: over 40 years.
–Sex: usually females (9– 1).
–Features:
1.Enlargement of lacrimal glands with keratoconguctivitis
sicca: Dryness, redness, burning sensation of eyes and
sensation of presence of a foreign body in the eye.
Sjogren’s Syndrome
•Clinically:
2.Oral manifestations:
.aXerostomia.
•(Difficulty in swallowing, Altered taste, The tongue often becomes
fissured and exhibits atrophy of the papillae, The oral mucosa is dry
and may be red and tender (usually as a result of candidiasis),
Difficulty in wearing dentures Increased risk for dental caries
(especially cervical caries).
.bEnlargement of salivary glands (particularly parotid): diffuse,
firm, bilateral. It may be non painful or slightly tender
.cAny other autoimmune disease e. g. rheumatoid arthritis or lupus
erythematosus.
Sjogren’s Syndrome
Sjogren’s Syndrome
•Sjogren's syndrome: The
patient has diffuse firm nontender
enlargement of the left parotid gland,
accompanied by xerostomia and xerophthalmia
Sjogren’s Syndrome
Sjogren’s Syndorme – Consequences of
Xerostomia
Atrophy of tongue papillae
(bald tongue) and angular
chelitis with inflammation of
the oral mucous membrane
resulting from Xerostomia
•Histopathology:
1.Atrophy of the acini.
2.Ductal hyperplasia forming masses of epithelial and myoepithelial
cells called epimyoepithelial islands
3.Dense lymphocytic infiltration with or without germinal centers,
thus the disease is described as a lymphoepithelial lesion.
4.85 % of minor salivary gland show the same picture particularly
those of the lip.
5.There is a great risk of Malignant transformationto lymphoma
(more common in primary Sjogren)
Sjogren’s Syndrome
•Differential Diagnosis:
1(Malignant lymphoma:
–there is:
1.Absence of epimyoepithelial islands
2.Atypical lymphocytes
3.Invasion of the connective tissue septa and the capsule
2(Papillary cystadenoma lymphomatosum
Sjogren’s Syndrome
•Serologic Abnormalities:
1.Increased sedimentation rate
2.Numerous auto-antibodies may be found,
including
(arheumatoid factor.
(banti-Sjogren's syndrome-A (SS-A).
(canti-Sjogren's syndrome-B (SS-B).
✓Antibodies SS-A and SS-B may be seen in
association with both primary and
secondary Sjogren's syndrome.
Sjogren’s Syndrome
•Sialography:
–The injected material will escape
from the ducts and produce
radiopaque mass scattered within
the gland due to significant ductal
and acinar damage
–This picture is called sialoectasis
or snow storm appearance or
branchless fruit laden tree
Sjogren’s Syndrome
Sjogren’s Syndorme – Sialography
This picture is
called sialoectasis
or snow storm
appearance or
branchless fruit
laden tree
•Diagnosis:
1.Labial gland biopsy.
2.Sialography.
3.Serological tests.
•Treatment:
▪No available treatment
▪However management of xerostomia and xerophthalmia is essential (Best managed symptomatically, Artificial saliva and artificial tears and good oral hygiene.
▪Treatment with immunosuppressive drugs e.g. corticosteroids is contraindicated
Sjogren’s Syndrome
•Complications:
▪Malignant lymphoma in 6% of patients.
▪Squamous cell carcinoma is rare.
–For these reasons treatment with
immunosuppressive drugs e.g. corticosteroids
is contraindicated
Sjogren’s Syndrome
Sialoadenosis
Definition
Sialoadenosis is a non-neoplastic, non-inflammatory
enlargement of salivary glands, most usually affecting the
parotids bilaterally.
Sialoadenosis
▪ Etiology
• Alcoholism
• Diabetes mellitus
• Drugs (sympathomimetics)
• Bulimia and obesity
• Endocrine disturbances
• Idiopathic
▪ Histologically
• Hypertrophy of serous acini
• Edema of the interstitial connective tissue
Sialoadenosis
Enlarged parotid (P) and
submandibular (SM)
glands. The patient has
alcoholic cirrhosis and
diabetes, which results in
sialosis, a benign
inflammatory enlargement.
This condition usually does
not require surgical
management. Note the
prominent masseter muscle
which can be confused
with glandular
enlargement.
Sjogren’s Syndrome
Lymphocytic infiltrate destroying salivary gland in Sjogren’s
syndrome.
Sjogren’s Syndrome
Lymphocytic infiltrate destroying salivary gland in Sjogren’s
syndrome.
Sjogren’s
Syndrome
•Introduction••Both major or minor glands are affected by salivary gland
tumors.
••Most cases are found within the parotid. Approximately 80% of parotid tumors are benign. Approximately 60% of submandibular tumors are benign. The sublingual gland, are uncommon site for neoplasms, the majority are malignant.
••The palate is the most common site for minor salivary gland neoplasms.
•In minor salivary glands, however, the benign‐malignant ratio is closer to 1:1.
SG Tumors
Histogenesis of SG tumors
.IEpithelial tumors
.ABenign (Adenomas)
1.Pleomorphic adenoma.
2.Monomorphic adenoma:
•-Papillary Cystadenoma Lymphomatosum (Warthin'stumor).
•-Oncocytoma.
.AMalignant (Carcinomas)
1.Malignant pleomorphic adenoma.
2.Mucoepidermoid carcinoma.
3.Adenoid cystic carcinoma.
Classification of SG Tumors
.IINon-epithelial tumors
••Lymphomas arising in patients with Sjogren’s
syndrome or within parotid lymph nodes.
••Sarcomas and benign mesenchymal tumors
arising from stroma of salivary gland (fibroblasts,
blood vessels, fat cells and nerves).
••Metastases to the salivary gland.
Classification of SG Tumors
.1Slow growth.
.2Long duration.
.3No pain.
.4No facial nerve palsy.
.5Movable (except palate because of the tight palatal mucosa).
.6Unattached to skin or mucosa (except palate).
.7No ulceration of skin or mucosa unless by trauma
Features Suggestive of Benignancy
1.Rapid growth; rapid spurt.
2.Short duration.
3.Pain, often severe.
4.Facial nerve palsy
5.Induration.
6.Fixed to overlying skin or mucosa.
7.Ulceration of skin or mucosa
Features Suggestive of Malignancy
Facial Paralysis
Ulcerated mass
Benign Salivary Gland Tumors
•Definition:
✓Benign tumor of salivary gland characterized by variable histologic appearances.
✓The term pleomorphic or mixed denotes a diverse histological appearance.
✓The term mixed is not accurate as it is an epithelial neoplasm and not a mixed one. The myoepithelial cells is responsible for the mesenchyme-like components of the tumor.
Pleomorphic Adenoma
(Mixed Tumor of The Parotid)
Pleomorphic
Adenoma
•Clinically:
➢Frequency: the most common SG neoplasm.
➢Age: middle age (40-50).
➢Site: major salivary gland more than minor.
•Among major salivary gland parotid is mostly affected.
•Among minor glands, palatal glands are mostly affected.
➢Features: swelling - painless - slowly growing – not fixed to the surrounding structures - does not ulcerate unless by trauma - does not affect facial nerve if it occurs in the parotid.
➢If neglected, the tumor can reach a huge size.
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
•Histologically:
1.Connective tissue capsule of varying thickness and completeness some tumor cells lie inside and outside this capsule this fact is responsible for the high recurrence rate of this tumor.
2.The tumor is composed of a mixture of ductal epithelium and myoepithelial cells within a mesenchyme-like background.
3.The epithelium form duct structures or may be found in nests or sheets. Ducts are lined by inner row of cuboidal cells, and outer layer of Clear myoepithelialcells and contain eosinophilic material produced by myoepithelial cells.
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
•Histologically:
4.Myoepithelial cells may appear angular or spindle with deeply stained
nucei. It may appear as plasmacytoid cells (resemble plasma cells,
rounded with eccentric nucleus and eosinophilic cytoplasm).
5.Rarely, squamous metaplasia
•with keratin production may be seen
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
•Histologically:
5.Mesenchyme-like stroma The highly
characteristic stromal changes are
believed to be produced by
myoepithelial cells.
•a. Chondroid appearance: The clear
myoepithelial cells may become rounded,
swollen and progressively separated by
accumulated mucoid basophilic material
so they become similar to cartilage cells.
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
–b. Myxoid appearance: Due to mucoid
accumulation between stellate
myoepithelial cells with long
anastomosing processes.
–c. Fibroid appearance: Due to presence
of spindle shaped myoepithelial cells.
–d. Osseous tissue:On rare occasions, bone
may be found due to stromal metaplasia.
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
1
23
4
5
6
7
8
1
23
4
5
6
7
8
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
•Histogenesis:
➢It was thought that the tumor is mixed this theory was an
attempt to explain the unusual matrix of this tumor.
➢Now it is believed that the tumor is not mixed. It arises
from the epithelial and myoepithelial cells of intercalated
ducts.
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
•Behavior and complications:
➢Benign but there is high recurrence rate
–with multifocal appearance of the recurrent tumor.
➢Rare cases may progress into malignant pleomorphic
adenoma.
➢Proximity to facial nerve in parotid tumor may cause nerve
damaged at operation and leads to facial paralysis (The
facial nerve passes through the parotid gland)
–Treatment
–Wide surgical excision.
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
•This is an example of what can happen if a mixed tumor should recur. Although this is
a bizarre example, it demonstrates well the
multinodularity so typical of recurrent tumor. The reason for this is that during the first
surgical procedure many small pieces of tumor were distributed throughout the
operative site and each formed the nidus for a
recurrent mass.
Pleomorphic Adenoma – With Malignant
Transformation
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
•Pleomorphic adenoma: A firm well
circumscribed soft tissue enlargement fills
up the palatal vault. The lesion has a blue
color but it does not blanch upon pressure.
This means it is not vascular
Pleomorphic Adenoma
(Mixed Tumor Of The Parotid)
Pleomor
phic
Adenom
a
•Definition:
–A benign tumor of salivary gland consists of two
elements, epithelial and lymphoid and occurs almost
exclusively in the parotid gland.
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
•Clinically:
–Age: Usually old ages (above forty years).
–Sex: males more than femals(associated with
–cigarette smoking).
–Site: Parotid gland. it is bilateral in most cases.
–Features:
–Small slowly growing nodule occupying
–a superficial position just beneath the capsule
–of the gland.
–The lesion feels soft and fluctuant to palpation.
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
•Histopathologic Features:
•(2 elements): Epithelial element and
Lymphoid element
•1.This tumor is capsulated and consists of
multiple cystic spaces contains mucoid
material and surrounded by lymphoid
stroma rich in lymphocytes and show
germinal centers.
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
•Histologically: (2 elements):
–2.cystic spaces are lined by double layers of ductal epithelial cells
with rounded nucleus and finely granular eosinophilic cytoplasm
(similar to oncocytic cells , the granules represent mitochondria).
–3. The inner luminal layer consists of Tall columnar cells with
centrally placed, palisaded, hyperchromatic nuclei.
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
•Histologically: (2 elements):
–4. The cells of the outer layer are Small
cuboidal or polygonal with vesicular
nuclei and separated from the stroma by
basement membrane.
–5. The lining epithelium demonstrates
multiple papillary folding or projections
into the cystic spaces.
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
1
3
2
1
3
2
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
Two layers of pink staining epithelium
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
Two layers of pink staining epithelium
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
Cystic spaces lined
by double layer of
epithelial cells
resting on a dense
lymphoid stroma
sometimes bearing
germinal centers
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
Double layer of
epithelial cells:
Surface epithelial
cells are columnar
cells having abundant,
finely granular,
eosinophilic
cytoplasms, imparting
an oncocytic
appearance which rest
on layers of cuboidal
to polygonal cells
–Histogenesis:
–It arises from entrapment of salivary gland tissue within
parotid lymph nodes during development.(due to late
encapsulation of parotid gland, some small lymph nodes are
enclosed within the parotid gland).
–Treatment:
–Surgical excision.
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
•Special features of Warthin’s tumor:
▪Occurs only in the parotid gland
▪The second most common benign tumor of parotid gland
▪May be unilateral or bilateral
▪May occur as multiple lesions
▪More common in males (26:1)
▪May be associated with acute onset of pain and a sudden increase in size (papillary cystadenoma lymphomatosumsyndrome)
▪Ear symptoms (tinnitus, deafness, earache).
Warthin’s Tumor
(Papillary Cystadenoma Lymphomatosum)
Malignant Tumors of Salivary Glands
•2 types exist:
1.Primary malignant pleomorphic adenoma:
–Which is malignant from the start, the malignant cells are the
epithelial and myoepithelial cells, hence metastasis in the remote
area consists of both types of cells.
2.Malignant pleomorphic adenoma EX benign
pleomorphic adenoma:
–It is a salivary gland neoplasm characterized by malignant
transformation of the epithelial component of a previously
benign pleomorphic adenoma. It is aggressive and considered to
be a high grade malignancy.
Malignant Pleomorphic Adenoma
•Clinical Features:
•It occurs in old age (60 years).
•painful, rapidly growing mass.
•Facial nerve paralysis (if the neoplasm affects the
parotid).
•Ulceration and fixation.
Carcinoma Ex Pleomorphic Adenoma
•Histopathologic Features:
➢Areas of typical benign pleomorphic adenoma usually can be
found within the tumor.
➢Areas of malignant epithelial component ,characterized by
cellular pleomorphism and abnormal mitotic activity.
•Treatment:
•Radical surgical removal.
Carcinoma Ex Pleomorphic Adenoma
•Definition:
•A malignant tumor of salivary gland consists of mucous,
epidermoid and intermediate cells
•It is the most common malignancy in children.
Mucoepidermoid Carcinoma
–Clinical features:
▪Occurs most commonly in the parotid gland
▪The palate is the most common intraoral site.
▪It affects a wide age range (10-70 years)
▪Two grades have been described.
–The low grade malignancy type which resembles benign
tumors. The high grade type which appears as a swelling -
painful - rapidly growing - fixed to the surrounding tissues -
cause facial nerve paralysis if the tumor occurs in the parotid.
Tumors of intermediate behavior have been also describe
Mucoepidermoid Carcinoma
–Clinical Features
–Neoplasms of minor salivary glands appears as:
–•Swelling or ulcerated mass.
–•Swelling may be fluctuant and have a blue color (resemble
mucocele).
–•It is painless in early stages.
–•May affects the palate, buccal mucosa,
–Tongue or lip.
Mucoepidermoid Carcinoma
–Histogenesis:–Arises from epithelial cells of excretory ducts
Mucoepidermoid Carcinoma
–Histopathologic Features:
•Mucoepidermoid carcinoma is composed of a mixture of:
••Mucous–producing cells.
••Squamous (epidermoid) cells.
••Intermediate cell , which is believed
•to be a progenitor of both the mucous
•and the epidermoid cells.
Mucoepidermoid Carcinoma
••The mucous –secreting cells are
•cubical or columnar with foamy
•cytoplasm. They tend to line the cystic
•spaces, or arranged in solid sheets .
••The epidermoid cells form solid sheets
•or line the cystic spaces. These cells
•are of squamous epithelial type
•having a polygonal shape .
••Intermediate cells are smaller than
•Either mucous or epidermoid cells .
•They appearas small basaloid cells.
Mucoepidermoid Carcinoma
•1. Low-grade tumors show
••high proportion of mucous cells,
••prominent cyst formation,
••minimal cellular atypia.
•2. High-grade tumors show
••high proportion of solid sheets of
•Squamous and intermediate cells
••cells demonstrate considerable
•pleomorphism, and mitotic activity.
••few cystic spaces.
•3. Intermediate-grade tumors :
•show features between those of the low-grade and high-grade
neoplasms.
Mucoepidermoid Carcinoma
1
2
3
45
5
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
Mucoepidermoid carcinoma. Cystic spaces lined by mucous secreting cells (M) and intermediate cells (I).
Mucoepidermoid Carcinoma
Mucoepidermoid carcinoma, mandible. Cystic spaces (C) and nests of neoplastic squamous (N) cells along with bone spicules at the periphery (B).
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
•High
Grade
Behavior of Mucoepidermoid Carcinoma
Low
Grade
Intermediate
Grade
Mucous Cells Epidermoid CellsMucous &
Intermediate
Cells
•Central Mucoepidermoid Carcinoma:
•A rare situation in which mucoepidermoid carcinoma might occur centrally inside the bone. The lesion may arise from:
1.Entrapment of retromolar mucous glands within the mandible.
2.Inclusion of the submandibular gland within the mandible (latent bone cyst).
3.Neoplastic transformation of mucous secreting cells (goblet cells) present in the wall of dentigerous cyst.
4.Neoplastic transformation of mucous secreting cells (goblet cells) present in the lining of the maxillary sinus.
–Treatment:–Surgical excision.
Mucoepidermoid Carcinoma
Mucoepidermoid Carcinoma
•Like all malignancy of
salivary glands,
mucoepidermoid
carcinoma tends to
ulcerate with metastasis
to regional lymph nodes
•Definition:▪A malignant tumor of salivary
–gland characterized by formation of
–multiple cysts.
▪It is a high grade salivary gland malignancy.
▪It is the most common minor salivary gland malignancy.
▪Because of its distinctive histopathologic features, it was
originally called a "cylindroma”.
▪The use of the term cylindroma should be avoided because it
does not denote the malignant nature of the tumor and because
the same term is used for a benign skin tumor.
Adenoid Cystic Carcinoma
Cylinderoma
•Clinically:
•Frequency: rare
•Age: middle age
•Site: minor more than major among the minor salivarygland palatal glands are mostly affected. Among the major salivary gland parotid is mostly affected.
•Features: ......................................+
•Tendency of the tumor to spread through perineurallymphatics thus early pain and tenderness is a constant feature of this tumor + late metastasis via blood.
Adenoid Cystic Carcinoma
Cylinderoma
•Histopathologic Features
.aThe adenoid cystic carcinoma is composed of a mixture of myoepithelial cells and ductal cells.
.bThe ductal cells are small and cuboidal, with deeply stained basophilic nuclei and little cytoplasm.
.cMyoepithelial cells have clear cytoplasm and darkly staining angular nuclei.
•Three histopathologic patterns are recognized:(1) cribriform, (2) tubular, and (3) solid.
Adenoid Cystic Carcinoma
Cylinderoma
•(1) Cribriform pattern
••is the most common pattern.
••It is characterized by islands of basaloid
•epithelial cells that contain multiple cystic spaces
resembling swiss cheese.
••These spaces often contain basophilic mucoid material.
Adenoid Cystic Carcinoma – Cylinderoma
•(2) tubular pattern
••The tumor cells occur as multiple small ducts or tubules.
within a hyalinized stroma.
••The duct like spaces are lined by an inner row of cuboidal
epithelial cells and an outer zone of myoepithelial cells.
Adenoid Cystic Carcinoma – Cylinderoma
•(3) solid pattern
••It consists of large islands or sheets of cuboidal epithelial
cells.
••This type may also show more pleomorphism and mitotic
activity than the other forms.
••This type is the most aggressive type.
Adenoid Cystic Carcinoma – Cylinderoma
Cribriform pattern
Tubular pattern
Solid pattern
Adenoid Cystic Carcinoma – Cylinderoma
•Behavior:
–The cribriform and the tubular patterns are of low grade
malignancy, while the solid pattern is considered to be grade
malignancy.
•Histogenesis:
–Adenoid Cystic Carcinoma originate from intercalated duct
cells and myoepithelial cells
–Treatment
–Radical surgical removal.
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
cribriform
pattern
–Most
common
–“swiss
cheese”
appearance
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
cribriform pattern
–Most common
–“swiss cheese”
appearance
Adenoid Cystic Carcinoma – Cylinderoma
tubular pattern–
Layered cells
forming duct-like
structures–
Basophilic
mucinous
substance
Adenoid Cystic Carcinoma – Cylinderoma
solid pattern–Solid
nests of cells
without cystic or
tubular spaces
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
This is the typical
cribriform pattern of tumor
cells in adenoid cystic
carcinoma. There are small
spaces lined by ductal cells
and larger spaces
containing basement
membrane-like material.
The pattern overall
resembles a slice of Swiss
cheese
Adenoid Cystic Carcinoma – Cylinderoma
At Hi Mag, the duct
lining cells are visible
in small clusters with
pink cytoplasm. The
stellate cells
surrounding the ducts
and the larger round
spaces are
myoepithelial variants
Adenoid Cystic Carcinoma – Cylinderoma
Adenoid Cystic Carcinoma – Cylinderoma
Low power of
adenoid cystic
carcinoma
showing
cribriform
pattern at the left
and tubular
pattern at the
right
Adenoid Cystic Carcinoma
Perineural & Endoneural Invasion
•What is the significance of this section? How does it
influence your differential diagnosis?
•This section demonstrates perineural and endoneural
invasion. Given this finding, you can safely eliminate
pleomorphic adenoma from the differential diagnosis.
Remember
•What is the significance of this section? How does it influence your differential diagnosis?
•Bilateral parotid swelling may occur in:
••Mumps
••Acute bacterial sialadenitis
••Sjogren’s syndrome
••Warthin’s tumor
1.Necrotizing Sialometaplasia
2.Sialoadenosis
Tumor-Like Lesions
•Definition
–This is a tumor-like lesion usually affects minor
salivary glands of the palate.
•Etiology
–Exact etiology is unknown; however the
presumed cause is ischemia of the minor
salivary glands resulting from infection, trauma,
irradiation, or irritation caused by ill-fitting
dentures.
Necrotizing Sialometaplasia
•Clinically
–Resembles carcinoma clinically and histologically and is readily mistaken for it.
–Most commonly develops in males in the form of a painless deep, sudden ulcer of the hard palate usually
opposite to the first molar.
–Lesions resolve without treatment within 6 to 10 weeks.
•Histologically
–Biopsy is usually necessary to rule out squamous cell carcinoma or a minor salivary gland malignancy. Review
of the tissue by a pathologist well versed in head and neck pathology is essential.
–Characteristic histologic findings include necrosis of the acini, ductal squamous metaplasia, and chronic
inflammatory cell infiltration.
Necrotizing Sialometaplasia
•Necrotizing sialometaplasia
at the typical site. The
ulceration is full-thickness, deep
and there has been
involvement and exposure of the underlying bone
Necrotizing Sialometaplasia
•Painful ulceration of the palate of 2 weeks duration
Necrotizing Sialometaplasia
•This lesion is more superficial.
The clinical similarity to
squamous cell carcinoma is
obvious. Note, however, the surrounding
inflammatory erythema
Necrotizing Sialometaplasia
•The sub-acute variant,
unusually occurring
bilaterally (note erythema also).
Biopsy confirmed necrotizing
sialometaplasia, but the lesions
did not ulcerate.
Necrotizing Sialometaplasia
•Ulcerated lesion with squamous proliferation at edge
of ulcer
Necrotizing Sialometaplasia
•Note extent and
worrying complex
architecture of
squamous proliferatio
n.
Necrotizing Sialometaplasia
•Definition
–Sialoadenosis is a non-neoplastic, non-
inflammatory enlargement of salivary glands,
most usually affecting the parotids bilaterally.
Sialoadenosis
•Etiology
–•Alcoholism
–•Diabetes mellitus
–•Drugs (sympathomimetics)
–•Bulimia and obesity
–•Endocrine disturbances
–•Idiopathic
•Histologically
–•Hypertrophy of serous acini
–•Edema of the interstitial connective tissue
Sialoadenosis
•Enlarged parotid (P) and submandibular
(SM) glands. The patient has alcoholic
cirrhosis and diabetes, which results in
sialosis, a benign inflammatory
enlargement. This condition usually does
not require surgical management. Note the
prominent masseter muscle which can be
confused with glandular enlargement.
Sialoadenosis