浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Salivary gland diseases Dr. Yanming Liu Dept. Oral & Maxillofacial Surgery 2nd Affiliated Hospital, ZJU

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Section 1: Clinical anatomy  Submucosal minor salivary glands: labial, buccal, palatal, lingual  Three paired major salivary glands: Parotid gl. Submandibular gl. Sublingual gl.

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Parotid gland  largest  almost entirely serous  between ramus of the mandible, mastoid process, external acoustic meatus, SCM muscle,  Pyramidal in shape  Superficial and deep lobes by facial nerve and branches  Stenson’s duct, its opening opposite 2nd upper molar  Adjacent structures: facial n., external carotid a., retromandibular v.

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Submandibular glands  Submandibular gl.: Intermediate in size A seromucous (predominantly serous) gland Superficial and deep parts Hooked in shape Wharton’s duct, its opening: sublingual papilla Adjacent structures: facial artery/vein, marginal mandibular branch of facial n., lymph nodes, lingual and hypoglossal n.

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Sublingual glands  Sublingual gl.: Smallest seromucous, but predominantly mucous above mylohyoid m., the sublingual fossa Adjacent structures: lingual and hypoglossal n.; deep lingual a./v. Open direct to the oral cavity or through Wharton’s duct

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Physiology of salivary glands  Functions of Saliva lubricates food moistens oral mucosa digestive enzymes antimicrobial agents, e.g. immunoglobulin A (IgA) Xerostomia may result in periodontal inflammation and dental caries  Data about saliva 0.5 L saliva / day 0.3 mL/min when unstimulated, 1.5–2 mL/min when stimulated Unstimulated state: parotid gl. contributes 20%, submandibular gl. 65%, other 15%. When stimulated, parotid contribution rises to 50%.

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Section 2: Investigations

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Investigations  History taking: swelling, pain, mass, nerve functions, etc.  Clinical examination: bimanual palpation; comparing bilateral glands  Auxiliary examination: Radiology (plate radiography, CT, MR, PET/CT) Ultrasound Biopsy Sialometry

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Symptoms and their indication SymptomSuggestion Slowing developing swelling or mass tumor Immediate swelling at meal, then slowly subsiding Obstruction by calculus Pain and swelling, perhaps with bad taste Infection Dry mouthSjogren’s syndrome Facial nerve palsy with a mass in parotid gland Malignant tumor?

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Sialometry  Method: volume of saliva dribble over 5 minutes at the unstimulated condition  Normal saliva flow rate: ml/min  Clinically significant xerostomia: <0.1ml/min

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Clinical situation and auxiliary test option Clinical situationSelection Calculus present?Plain radio.; Ultras. Obstruction in the duct system? Sialography a mass present?Ultrasound, CT, MR Abnormal gland function?Radioisotope imaging Evaluation of salivary function Labial minor gland biopsy

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Biopsy in salivary gland disease Clinical situationSelection Evaluation of overall salivary function Labial minor gland biopsy Tumor of major glandsNo incisional biopsy!!!; Fine needle aspiration biopsy Frozen section

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Section 3: salivary gland diseases

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders  Caused by narrowing or total obstruction of ductal system  Typical symptoms: pain and immediate swelling of the affected gland just before meal, or having meal, or maybe thinking about meal, which then slowly subside after meal.  Occasionally accompanied by a bad taste, indicating associated sialadenitis.

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders Three types:  Extraductal obstruction, e.g. neoplasia  duct wall thickening, caused by trauma or fibrosis  intraductal obstruction (most common type), caused by calculi (sialoliths), 80% in submandibular gland

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders Why do intraductal obstruction and sialolithiasis happen more often in submandibular gl. (80%) than parotid gl.? Submandibular gl.Parotid gl. Mucoserous salivaAlmost serous saliva Containing more calcium saltLess calcium salt Saliva flows upwards, against gravity Nearly horizontally

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders Treatment options of intraductal obstruction by sialoliths:  Antibiotic and anti-inflammatory treatment  Remove sialolith by marsupialization of the duct, when sialolith is close to the wharton’s papilla.  Remove sialolith with the assistance of sialendoscopy  Remove the submandibular gland and the sialolith when it is close to the gland, especially with fibrosis of the gland.

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.1 obstructive salivary disorders

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.2 acute viral sialadenitis  Also named mumps, acute contagious infection, caused by paramyxovirus through direct contact with infected saliva  Incubation period of 2-3 weeks  Fever, malaise  Sudden and painful swelling of one or both parotid gl. (occasionally submandibular gl.)  clear salivary secretion  Occasionally involvement of central nerve system and gonads (orchitis), in rare case resulting in dysgenesis  Lifelong immunity  Rising hemodiastase and urinary amylase in some cases  Treatment: bedrest, massive water drinking, fluid infusion, antiviral treatment, etc.  Avoiding the infected patients to contact with susceptible population

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.3 acute bacterial sialadenitis  Principally involving parotid gl. (parotitis)  Etiological factors: Local: reduced salivary flow leading to bacteria in the ductal system; mainly by staphylococcus aureus Systemic: other chronic diseases or large surgical operation, leading to poor systemic conditions; fluid and electrolyte imbalance  Often unilateral parotid gl., pain and swelling  Red and swelling of duct opening, mucopurulent discharge  fever, erythema of skin  Treatment principles: supporting therapy: bedrest; water drinking or fluid infusion, correction of electrolyte imbalance antibiotic therapy; mouthrinse Incision and abscess discharge when pitting edema and tenderness, or when getting pus by needle aspiration or confirmed by ultrasound

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.3 chronic bacterial sialadenitis  Caused by low-grade bacterial invasion, often follows chronic obstructive disease  Submandibular gland most commonly involved  Symptom: recurrent and painful swelling associated with eating and drinking  Salty and bad taste  Mucopurulent discharge  Can be transformed into acute sialadenitis  Treatment: removal of sialolith, mouthwash, removal of gland when fibrosis

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.4 radiation sialadenitis  History of radiotherapy for head and neck cancers  Acinar damage and fibrous replacement  Low saliva secretion, leading to dental caries and mucositis  Prevention: shielding the salivary glands when radiotherapy  Treatment of xerostomia (dry mouth)

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome  Autoimmune chronic inflammatory disease involving salivary and lacrimal glands  Characterised by polyclonal B-cell proliferation  Continuous destruction of glandular parenchyma and lymphocytic infiltration  Classification: primary Sjögren’s syndrome secondary Sjögren’s syndrome

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome  Primary Sjögren’s syndrome Xerostomia (dry mouth) and xerophthalmia (dry eyes) (and nasal, vaginal, skin... dryness)  Secondary Sjögren’s syndrome Xerostomia (dry mouth) and/or xerophthalmia (dry eyes) an autoimmune connective tissue disease (Rheumatoid disease, renal tubular acidois...)

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome  Clinical features Mostly involving middle-aged females Symptoms of xerostomia including: glazed oral mucosa; lobulated beefy-red tongue; difficulty in eating dry foods, swallowing, speaking, etc. Parotid gland enlargement, occasional acute infection Symptoms of xerophthalmia

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome  Valuable tests in aiding in diagnosis Sialometry (salivary flow rate measurement) Schirmer test (lacrimal flow measurement) Detection of autoantibodies against SS-A, SS-B, RF (rheumatoid factor), etc. Labial gland biopsy: infiltration of lymphocytes around intralobular ducts, resulting in focal lymphocytic sialadenitis

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.5 Sjögren’s syndrome  Management Multidisciplinary team Management of xerostomia Salivary stimulants (sugar-free gum, pilocarpine) if residual salivary function remains Saliva substitutes Prevention of caries and periodontal disease

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6 salivary gland tumors  3% of human tumors  Mostly arising in the parotid gland (80%), in which 90% are benign  Higher relative proportion of malignant tumors in submandibular (40%), sublingual (90%), palatal and other minor glands (60%)

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU 3.6 salivary gland tumors  Common benign salivary gland tumors Pleomorphic adenoma Wharthin’s adenoma  Common malignant salivary gland tumors Adenoid cystic carcinoma Mucoepidermoid carcinoma

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Pleomorphic adenoma  Benign  Accounting for 80-90% of all salivary tumors  Slow-growing, painless nodule, soft or firm in texture, moveable, well-circumscribed  Varied size ( several cm to ~20 cm) and duration ( several months to decades)  Rare involving facial nerve  Low potentiality of canceration

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Pleomorphic adenoma  Also termed “ mixed tumor”  Characteristic cellular and stromal elements  Celluar element: ductal epithelial and myoepithelial cells  Stromal element: myxoid (muscle-like) tissue or chondroid (cartilage-like) tissue  Tumor islands may exist beyond capsule  Management: excision biopsy of tumor together with a margin of normal tissue

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Wharthin ’ s tumour  Also termed “adenolymphoma”  benign  Predominantly in older men and exclusively in parotid  Discrete nodule, smooth, soft in texture, mostly <3cm in diameter  Etiologically related to smoking  Can be multiple nodules and in bilateral parotids  Characteristical pathological feature: a papillary cystic structure composed of double layered ductal cells and a lymphoid stroma

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU Wharthin ’ s tumour  Management: tumor excision, when multiple nodules present, excision the surrounding glandular tissue as well

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU adenoid cystic carcinoma  Middle-aged or elderly patients  Frequently in palatal minor gland and parotid  Slow growing, tendency to invade and spread along nerve, leading to pain, palsy or paraesthesia  Histopathologically “Swiss- cheese”-like structure due to microcysts filled by basement membrane material  Infiltrative, metastasis  Poor long-term prognosis  Treatment: surgery with adjuvant radiotherapy; involved nerve has to be sacrificed Perineural invasion

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU mucoepidermoid carcinoma  Younger and Middle-aged patients  Histopathologically both mucous and squamous differentiation  Painless slow-growing nodule; blue “cyst”  Treatment: high differentiation: surgery, preserving nerve low differentiation: surgery with radiotherapy

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU salivary gland cysts  Blue, fluctuant swellings, with a relapsing history  Mucous extravasation mucocele Tearing of the duct due to trauma, leading to leakage of saliva into the connective tissue; No epithelium lining; Major type, mainly in low labial mucosa, buccal mucosa, sublingual gland (ranula)  Mucous retention mucocele Duct expansion, leading to cyst with epithelium lining Mostly in upper labial mucosa

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU salivary gland cysts Treatment: removal of cyst as well as the minor gland or sublingual gland

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor Slow growth of the tumor for 34 years, painful recently

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor Slow growth of the tumor for 34 years, painful recently

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor

浙 江 大 学 医 学 院 附 属 第 二 医 院 口 腔 颌 面 外 科 Dept. Oral Maxillofac. Surg., Second Affiliated Hospital, ZJU A case of giant cancerized pleomorphic tumor