SPECIFIC DISEASES AND DISORDERS OF THE SALIVARY GLANDS
Salivary Gland Diseases
Developmental
Obstructive
Inflammatory
Cystic
Neoplastic
Developmental Disturbances of The Salivary Glands
Aplasia (agenesis), atresia.
Aberrancy. (Latent bone cyst)
Salivary Gland Aplasia
Congenital absence of major salivary glands Cl. Presentation (Xerostomia, Mucositis, Glossitis,Caries)
Sialometry (flow rate) < 0.1 ml/min (unstimulated)< 0.5 ml/min (stimulated)
Scintigraphy
Diagnostic Approaches :
A part of the submand. SG lies within a well-defined depression on the lingual posterior surface of the mandible.It is an aberrant SGSite
Recognition of the defect should preclude any treatment or surgical exploration.
Latent bone(Staphne’s) cyst
Obstructive Salivary Gland Disorders
Causes of obstruction include
Salivary calculi (Sialolithiasis)
Strictures or kinks of the duct wall
Oedema or fibrosis of the papilla
Pressure on the duct due to an adjacent mass
Invasion of the duct by a malignant neoplasm.
Mucous retention/extravasation
♦ The main cause of obstructive salivary diseases
Obstructive Salivary Gland Disorders
Sialolithiasis
Sialolith are calcified and organic matter that form within the duct system of the major salivary glands.
Sialolithiasis
• The exact etiology and pathogenesis of salivary calculi is unknown.
• The calculi are believed to arise from the deposition of ca ++ salt around a nidus of debris within the duct lumen, these debris include bacteria, ductal epith cells, or foreign bodies.
30% of salivary diseases
Most of SMG calculi are radio-opaque & solitary
Most of parotid calculi are radiolucent & multiple
Minor salivary glands (buccal mucosa or upper lip) → firm nodule.
Sialolithiasis: Incidence
submandibular83%
parotid10%
sublingual7%
• The submandibular gland is the most common site of involvement, and 80 - 90% of sialoliths occur in this gland. ….. Why?
• Higher concentration of calcium and phosphate• Torturous course of the Wharton’s duct• The dependent position of the submandibular
glands, which leave them prone to stasis. (Anti-gravity flow)
Sialolithiasis: Incidence
Sialolithiasis: Clinical presentation
May be asymptomatic for a long time.History of pain and/or swelling of the concerned gland during eating followed by gradual reduction between meals.The degree of symptoms is dependent on the extent of salivary duct obstruction and the presence of secondary infection.Complete obstruction causes constant pain and swellingAn examination of the soft tissue surrounding the duct may show a severe inflammatory reaction.
Sialolithiasis: Clinical presentation
Palpation along the pathway of the duct may confirm the presence of a stone.
The involved gland is usually enlarged and tender. Stasis of the saliva may lead to infection, ductal stricture, and ductal dilatation fibrosis, and gland atrophy.
A uniformly firm gland suggests a hypo- or non-functional gland
No salivary flow or purulent discharge.
Signs of systemic infection may be present.
Diagnostic AidsRadiographic examination is often necessary since the stone may not be accessible to bimanual palpation.
The recommended view for radiography of sialoliths
50% of parotid gland sialoliths and 20% of submandibular gland sialoliths are poorly calcified. This is clinically significant because such sialoliths are not radiographically detectable.Calcified phleboliths and lymph nodes can be easily mistaken radiographically for sialoliths. Sialography can aid in differentiating these lesions.
Diagnostic Aids
Type, site & size of stones Associated inflammatory disorders Assess the gland function →
longstanding recurrent swelling
Objectives Diagnostic modalities
Plain films, CT, MRI, ultrasound ,sialography, sialoscopy
Sialolithiasis: Treatment Effective treatment of the sialolith depends
on the location of the stone and on its effect on gland function.
Stones in the Anterior Duct Stones in the Posterior Duct Stones in the Hilum or Gland
Removal of the stone:♦ Conservative management by:
Milking the gland Shock-wave Lithotripsy (external and
intraductal)Interventional sialendoscopy
♦ Surgical removal (Sialolithotomy)
Gland excision (Sialadenectomy)
Sialolithiasis Treatment Modalities
♦ Stone may be removed by spontaneous exfoliation on stimulation of salivation to flush the stone out of the duct.
♦ Indication: Small, mobile stone at or just behinde
the duct orifice Stone causing partial obstruction
♦ Procedures
♦Hydration♦Application of moist warm heat ♦Gland massage♦The use of sialogogues♦Infection → antibiotic
Conservative Management
Sialolithiasis: Treatment
♦ Stone may be removed by manipulation
♦ Indication: Small, mobile stone at or just
behinde the duct orifice♦ Procedures
Open the duct with the aid of lacrimal probes and dilators.
By gentle probing, the stone can be identified, milked forward, grasped and removed.
The gland is then milked to remove any other debris in the more posterior portion of the duct
Conservative Management
Sialolithiasis: Treatment
Extraglandular removal of the stone
(sialolithotomy), intraoral approach.
Intraglandular removal of the gland
Intraoral approach (sublingual gL.)
Extraoral approach (Parotid,
submand. gL.)
Surgical Treatment
Extraglandular stone• Stones in the Anterior
Duct
located in the distal third of the submandibular duct √
• Stones in the Posterior Duct
TRANSORAL REMOVAL
Indication
Surgical Removal of Sialolith from Duct of Submandibular Gland
Surgical Removal of Sialolith from Ant.Duct of Submandibular Gland
rubber tube
o The wound held open
o The incised duct is closed over silastic catheter
Surgical Removal of Sialolith from Ant.Duct of Submandibular Gland
Surgical Removal of Sialolith from Post.Duct of Submandibular Gland
guidewire
Lingual n
Wharton’s duct
Lingual n Wharton’s duct
Surgical removal of a submandibular duct stone at the hilum
Gland Excision (Sialadenectomy)
Indication Very posterior stones Intra-glandular stones Irreversible parenchymal damage
• Stones in the Terminal Duct
• Stones in the Posterior Duct
• Stones in the hilum or gland
Surgical Removal of Parotid Gland Stones
Surgical Removal of Sialolith from Duct of Parotid Gland
Parotid duct meatotomy
Sialolithotomy when the stone is at or just behind the duct orifice
Meatotomy: An incision made to enlarge a meatus
Surgical removal of a stone in the Terminal parotid duct
Surgical removal of a posterior parotid duct stone
Gland Excision
Parotidectomy
Modern treatment of obstructive salivary diseases
Shock-wave Lithotripsy
Interventional sialendoscopy
Sialoendoscopy
Minigrasping forceps
← Sialendoscope
Sialostent basket retrieving
It allows removal the stone while preserving the gland.
Laser fragmentation and extraction of debris using a wire basket through a minimal incision of Wharton’s papilla is followed by a complete clearance of the duct.
Shock-wave lithotripsy
Shock-waves → fragmenting salivary stones → flushing out from the salivary duct system
Types External lithotripsy; results
were poor specifically in patients with large calculi
External lithotripter
Interventional sialendoscopy with intraductal laser fragmentation and basket extraction of calculi (success rate 80%)
Endoscopically Intracorporeal Electrohydraulic Lithotripsy
Sialendoscope
Electrohydraulic lithotripter, Autolith, and a probe which can be inserted into the working channel of the sialendoscope.
Endoscopically Intracorporeal Electrohydraulic Lithotripsy
Sialolith at the hilus