Salivary glands + case

Salivary intro

Anat and physiology At the end of the lecture, you should be able to….. ϒ Clinically identify the common benign and malignant conditions affecting the salivary glands ϒ To be able to outline the modalities of management available for each condition ϒ To able to devise a plan of investigation and management for a suspected neoplastic lump of the salivary glands

-------------------------------------- T/F? a) Includes more than 600 minor salivary glands b) Produces 1.5 L of saliva/day c) Secretion is controlled the sympathetic system d) The parotid gland produces a mucoid secretion rich in Amylase e) The sub-mandibular gland is closely associated with the hypoglossal nerve

--------------------------------------

Consist of 3 major paired exocrine glands – Parotid, Submandibular, Sublingual

Additionally, 600-1000 Minor Salivary Glands are present scattered across the upper aerodigestive tract

Consist of mucous and serous secretory cells

• Salivary glands supply 1 to 1.5 L of saliva per day

• Parasympathetic innervation

----------------------------The parotid gland

overlies the recess between the mandible, mastoid process and base of skull

Is divided in to a deep and superficial part by the facial nerve

Surrounded by a fibrous capsule which is continuous with the deep cervical fascia

-Produces mainly serous secretions

The submandibular gland

lies within the submandibular triangle -Drains via the submandibular duct of Wharton to open near the frenula in the floor of the mouth

Is associated superficially with the marginal mandibular nerve and deeply with the lingual nerve and the hypoglossal nerve

Produces a mixture of serous & mucinous secretions

Sublingual glands

lie deep to the floor of the mouth between mylohyoid and genioglossus

Open directly in to the mucosa or the submandibular ducts

Produce mucinous secretion

----------------------------------Triangles of the neckhttps://www.youtube.com/watch?v=mpsNKUcmZys

CLASSIFICATION OF SALIVARY GLAND CONDITIONS

BENIGN SALIVARY GLAND CONDITIONS

Infections of the Salivary Glands

Viral Sialadenitis

• Commonly due to Mumps virus infection of the parotid gland in children

• Other agents: Coxsackie, Parainfluenza viruses

Acute painful swelling of the gland, usually bilateral

Pain worsened on eating and drinking

Settles over 5-10 days

Treatment –symptomatic

Complications: Orchitis, oophoritis, carditis, pancreatitis, meningitis

Acute Bacterial Sialadenitis

Usually due to the obstruction of duct or salivary stasis •

Can affect both the parotid & submandibular glands

Seen in ▪ Dehydration esp. elderly post-surgical patients ▪ Ductal obstruction due to calculi

Causative organisms are Staphylococcus aureus, Streptococcus spp., Haemophilus spp.

Presents with painful swelling which arises over a few hours

• Affected gland is tender and indurated with erythema of overlying skin

• Pus may be noticed discharging from duct orifice

Fever usually present, Elevated WBC count

Management of Bacterial Sialadenitis

Antibiotics IV/Oral usually a broad spectrum anti- staphylococcal agent – Flucloxacillin

• Oral hygiene

• Adequate hydration

• Sialogogues

Management of calculi if cause

Complications of Bacterial Sialadenitis

▪ Abscess formation - Requires radiologically guided/ open surgical drainage

Chronic sialadenitis- Requires removal of the gland

--------------------------------------

Extravasation Cyst

Extravasation cysts usually following trauma to minor salivary glands

Painless, usually translucent

May resolve spontaneously

• Surgical removal is indicated in persistent cases

Ranula

This is an extravasation cyst usually of the sublingual glands

May present as a translucent, cystic mass in the floor of the mouth

Occasionally a cyst may extend inferiorly behind the floor of the mouth and present as a neck mass ‘plunging ranula’

Excision of the entire cyst as well as the entire associated major salivary gland is necessary to ensure a low risk of recurrence

The differential diagnosis is a midline dermoid cyst and a sub-hyoid bursa

---------------------------------------------------------

Salivary Calculi (Sialolithiasis)

Formation of calculi within the salivary glands

Can obstruct the duct •

Usually idiopathic, but can be associated with dehydration, chronic infection, hypercalcaemia & Sjogren’s disease

80% occur in the submandibular gland

What are the reasons for calculi to be more common in the submandibular gland?ϒ Submandibular secretions are more mucoid with higher calcium content ϒ The submandibular duct drains against gravity which may contribute to stasis

Presentation of salivary calculi

Classically presents with an acute sometimes painful swelling after meals

Resolves spontaneously over a couple of hours, but recurs with the next meal

• Partial obstruction may give rise to minimal symptoms

Bimanual palpation reveals a firm enlarged tender submandibular gland

Pus may be visible at the ductal opening in the presence of infection

Investigations

80-90% of submandibular duct stones are radio-opaque

Intra-oral occlusal views should be obtained

Management

Small stones may be expelled spontaneously with conservative measures

• Ductal stones requires lay opening of the duct and stone removal

Stones within the gland- require removal of the gland - Submandibular sialadenectomy - Parotidectomy

Newer therapies ▪ ESWL ▪ Sialoendoscopic removal

Key points:

80% of salivary calculi occur in the submandibular gland

80-90% of submandibular duct stones are radio-opaque

Treatment of a submandibular duct stone is removal of the stone via incision of the duct

Treatment of a stone in the submandibular gland is removal of the gland

Salivary Gland Neoplasms

Relatively uncommon ▪ 6% of head and neck neoplasms in US

• Distribution ▪ Parotid: 80% overall; 80% benign ▪ Submandibular: 15% overall; 50% benign ▪ Sublingual/Minor: 5% overall; 40% benign

• Incidence of major salivary gland cancer in Sri Lanka 0.8 per 100,000

-----------------------------------

Pleomorphic Adenoma

Most common of all salivary gland neoplasms o 70% of parotid tumors o 50% of submandibular tumors o 45% of minor salivary gland tumors o 6% of sublingual tumors

• Peak 5th decade

• Although non- malignant can give rise to troublesome local recurrence o 5-7% following surgery

• Presentation o Slow-growing, painless mass with an imperfect psuedocapsule o Parotid: 90% in superficial lobe, most in tail of gland o Rarely undergoes malignant transformation o On examination the tumour is firm, non-tender, mobile over deep structures, facial nerve examination should be normal

Pleomorphic Adenoma is the commonest parotid and salivary gland tumour

------------------------------------------------------

Warthin’s Tumour

Also known as papillary cystadenoma lymphomatosum/ Adenolymphoma • 6-10% of parotid neoplasms • Older, Caucasian, males • 10% bilateral or multicentric • Smoking is a risk factor • Presentation: slow-growing, painless mass encased by a thin but complete capsule

-------------------------------Salivary Gland Cancers

Muco-epidermoid carcinoma-Most common salivary gland malignancy, Poor prognosis with high grade histology • Adenoid Cystic carcinoma- spreads along nerve sheath- Facial nerve palsy • Acinic Cell Carcinoma- Commonest in paediatric patients, Good prognosis

What features are suggestive of malignancy in a salivary gland tumour?ϒ Rapid growth ϒ Pain ϒ Hard consistency ϒ Nerve involvement- Facial nerve palsy etc ϒ Overlying skin involvement ϒ Enlarged lymph nodes

Investigations of a Salivary Mass

Imaging • Ultrasound • CT • MRI • FDG/PET • Tc 99 scintigraphy Histology • Partial excision/ incision biopsy in undiagnosed tumours are contra-indicated • Risk of tumour spillage giving rise to local recurrence • Fine-Needle Aspiration Cytology o Efficacy is well established ▪ Accuracy = 84-97% ▪ Sensitivity = 54-95% ▪ Specificity = 86=100% o Safe, well tolerated o Use is controversial o Negative FNA does not supersede clinical judgment in management of salivary tumours

Histological diagnosis

o The histological diagnosis and definitive surgical treatment are often the same for parotid masses o Superficial lobe tumours -en bloc superficial parotidectomy o Deep lobe tumours- Total parotidectomy o Submandibular gland ▪ FNA may be helpful ▪ For FNA (-)ve clinically/radiologically suspicious lesions o Submandibular triangle dissection

Management of salivary gland tumours

Surgery o Surgery is the mainstay of treatment of both benign & malignant salivary tumours o The extent of surgery is based on the size of the tumor, local extension, and neck metastases. ▪ Superficial Parotidectomy ▪ Total Parotidectomy/Radical parotidectomy ▪ Neck dissection ▪ Submandibular gland excision ▪ Submandibular triangle dissection ▪ Neck dissections • Malignant salivary tumors o Radical surgery o Radiotherapy- As an adjuvant to surgery o Chemotherapy- Minimal efficacy

Complications of Parotidectomy

Facial nerve palsy - Some degree of facial nerve palsy is common after most surgery due to neuropraxia but permanent palsy can occur if the facial nerve is transected - Facial nerve palsy is inevitable after radical parotidectomy 9 • Flap dehiscence • Salivary fistula • Freys Syndrome

Frey’s Syndrome (Gustatory Sweating)

This condition presents with sweating, erythema or warmth over the parotid bed area whilst eating • It is thought to be due to parasympathetic nerve fibres from the auriculotemporal nerve inappropriately re-anastomosing with sweat glands following parotidectomy (Sweat glands normally have a sympathetic innervation)

Most parotid tumours are benign (70% are Pleomorphic adenomas) More than 50% of minor salivary gland tumours are malignant

-----------------------------------------

Clinical case learning salivary glands??????? Learn short case?

Bimanual exam, intepretation. presentation and discussion all of this..

Go through case book and make clinical cae vcard as well

MCQS some: With regard to salivary gland calculi A. 80% of parotid ductal stones are seen on x-ray B. In the submandibular gland may be a cause of recurrent infection C. A stone in the submandibular gland is treated with excision of the gland D. Sialoendoscopy is the gold standard in the management of parotid duct stones E. Submandibulectomy may be associated with marginal mandibular nerve injury T/F regarding salivary neoplasms A. Pleomorphic adenoma is the commonest malignant salivary tumour B. Trucut needle biopsy could be helpful in establishing the diagnosis C. Surgery is the mainstay in the management of all salivary neoplasms D. Total parotidectomy includes removal of the facial nerve E. Facial nerve palsy after parotidectomy may be temporary

The importance and provision of oral hygiene in surgical patients must know how nurses maintain oral hygiene Peri operative oral care????

Author links open overlay panelSamuel J.Ford

Show more

https://doi.org/10.1016/j.ijsu.2007.01.002Get rights and content

Under an Elsevier user license

open archive

Abstract

The provision of mouth care on the general surgical ward and intensive care setting has recently gained momentum as an important aspect of patient care. Oropharyngeal morbidity can cause pain and disordered swallowing leading to reluctance in commencing or maintaining an adequate dietary intake. On the intensive care unit, aside from patient discomfort and general well-being, oral hygiene is integral to the prevention of ventilator-associated pneumonia. Chlorhexidine (0.2%) is widely used to decrease oral bacterial loading, dental bacterial plaque and gingivitis. Pineapple juice has gained favour as a salivary stimulant in those with a dry mouth or coated tongue. Tooth brushing is the ideal method of promoting oral hygiene. Brushing is feasible in the vast majority, although access is problematic in ventilated patients. Surgical patients undergoing palliative treatment are particularly prone to oral morbidity that may require specific but simple remedies. Neglect of basic aspects of patient care, typified by poor oral hygiene, can be detrimental to surgical outcome.

Previous article in issue

Next article in issue

Keywords

Oral hygiene

Mouth care

Surgical patients

The provision of mouth care on the general surgical ward and intensive care setting has recently gained momentum as an important facet of nursing care. Increasingly over the past few years the nil by mouth sign above the patient's bed is accompanied by an intriguing pot of pink solution or fruit juice with a pink dressing sponge on a stick for application. Aside from the potential spillage when hastily moving the patient's bedside trolley before examination, clinicians should pay more attention to this simple measure as it can alter clinical outcome.

Surgeons encounter issues regarding oral hygiene and mouth care in three broad settings: ward patients unable to tolerate oral fluids or diet; ventilated or sedated patients on the intensive care unit or those requiring palliative care. However, many surgical patients have poor oral hygiene exacerbated by debility, xerostomia, chemotherapy and dehydration.

Oropharyngeal morbidity can cause pain, altered taste or disordered swallowing that can lead to reluctance in commencing or maintaining an adequate dietary intake.1

Tooth brushing is the ideal method of promoting oral hygiene. Most patients will be able to perform the task adequately with the minority requiring encouragement or relying on clinical staff to brush for them. On the surgical ward, simple antiseptic mouthwashes such as 0.2% chlorhexidine are widely used as an adjunct to promote a decrease in oral bacterial loading, dental bacterial plaque and gingivitis.2, 3 Physical inability to rinse the mouth should not preclude tooth brushing. Pink dressing sponges can be soaked with water or chlorhexidine and apposed against the teeth to effect delivery and aid mechanical removal of oral debris.

Fruit juices, namely pineapple has gained favour as a salivary stimulant in those with a dry mouth or coated tongue. Pineapple probably exerts its effects via a non-specific increase in salivary flow rather than the specific action of the contained proteolytic enzyme ananase.4 However, caution is required as such acidic substance can rapidly precipitate dental caries in those with xerostomia, especially if used for any length of time.5 Indeed, many would strongly discourage fruit juices in favour of regular sips of water in those deemed nil by mouth. Other effective salivary stimulants include sugar free chewing gum and mints.4

Oral candidiasis is usually pseudomembranous with creamy white curd-like patches which can be removed with a swab. Occasionally candidiasis is evidenced by erythematous plaques or angular cheilitis.1 Nystatin suspension is widely prescribed, however, more refractory cases of multifactorial origin, are notoriously difficult to remedy and may require fluconazole 50 mg or guidance from an expert on oral medicine. Aphthous ulcers are commonly encountered and can be soothed with topical corticosteroids (betamethasone 0.5 mg in 5 ml water as mouthwash or triamcinolone/carmellose paste) or tetracycline mouthwash (250 mg – contents of one capsule dissolved in 5 ml water every 8 h) although these must be used with caution as they can promote oral candidiasis.5, 1 Pain from persistent ulceration or mucositis may be eased by coating agents (sucralfate suspension or carmellose paste) or a topical anaesthetics (benzydamine mouthwash or lidocaine lozenges).1 Herpes Simplex or Zoster, if severe, may require oral antiviral therapy with aciclovir or famciclovir, respectively.

In the intensive care setting, aside from patient discomfort and general well-being, oral hygiene is integral to the prevention of ventilator-associated pneumonia.6 Colonisation of dental plaque and oropharyngeal epithelial cells with respiratory pathogens such as Pseudomonas aeruginosa is thought to be mediated via alterations in oral physiology with depletion of the glycoprotein fibronectin facilitating pathogen adhesion.7 Oropharyngeal flora of critically ill patients undergoes a change from the usual predominance of gram positive streptococci to that of gram negative organisms with the potential to translocate and colonise the lung.8

Although provision of oral hygiene is considered to be a basic nursing practice, it risks being relegated to a lower priority when caring for the complex intensive care patient.9

The use of mechanised toothbrushes for a ventilated patient has been shown to be superior to sponges for mechanical removal of dental plaque,10 although the oral cavity is often difficult to access in the critically ill due to the presence of endotracheal and nasogastric tubes.11 It is possible to use toothbrushes designed for minors, however, tooth brushing runs the theoretical risk of dislodging the endotracheal tube.11 If brushing is impossible, valuable alternatives include chlorhexidine soaked sponges or more controversially sodium bicarbonate mouthwash to reduce the viscosity of oral mucus to enhance removal of debris.11 Mouthwashes can also be delivered with the use of a syringe and extracted with a flexible suction device with special attention to secretions pooled above the endotracheal tube cuff.11 Emollients such as petroleum jelly can promote maintenance of perioral skin integrity.1

Collectively surgical patients are prone to poor oral hygiene. Prevention of oropharyngeal morbidity should be given a high clinical and nursing priority as it not only promotes patient comfort and general well-being but can also reduce the incidence of ventilator-associated pneumonia and therefore surgical outcome.

SALIVARY CONDITION ADD AND LEARN SHORT CASE =>eXAMINATION INTEPRETATION

PRESENTATION

DISCUSSION

OTHER POINTS? aDD FROM CASE BOOKS! MANAGING FACIAL NERVE PARALYSIS AFTER PARTOIDECTOMY??????????

DDS ACCORDING TO THE DIFFERENT TRIANGLES OF THE NECK?

aNTERIOIR, MIDLINE AND LATERAL CAUSE OF LUMPS?

Sjogren's syndrome

Overview Sjogren's (SHOW-grins) syndrome is a disorder of your immune system identified by its two most common symptoms — dry eyes and a dry mouth. The condition often accompanies other immune system disorders, such as rheumatoid arthritis and lupus. In Sjogren's syndrome, the mucous membranes and moisture-secreting glands of your eyes and mouth are usually affected first — resulting in decreased tears and saliva. Although you can develop Sjogren's syndrome at any age, most people are older than 40 at the time of diagnosis. The condition is much more common in women. Treatment focuses on relieving symptoms. The two main symptoms of Sjogren's syndrome are: Dry eyes. Your eyes might burn, itch or feel gritty — as if there's sand in them. Dry mouth. Your mouth might feel like it's full of cotton, making it difficult to swallow or speak. Some people with Sjogren's syndrome also have one or more of the following: Joint pain, swelling and stiffness Swollen salivary glands — particularly the set located behind your jaw and in front of your ears Skin rashes or dry skin Vaginal dryness Persistent dry cough Prolonged fatigue Causes Sjogren's syndrome is an autoimmune disorder. Your immune system mistakenly attacks your body's own cells and tissues. Scientists aren't certain why some people develop Sjogren's syndrome. Certain genes put people at higher risk of the disorder, but it appears that a triggering mechanism — such as infection with a particular virus or strain of bacteria — is also necessary. In Sjogren's syndrome, your immune system first targets the glands that make tears and saliva. But it can also damage other parts of your body, such as: Joints Thyroid Kidneys Liver Lungs Skin Nerves Risk factors Sjogren's syndrome typically occurs in people with one or more known risk factors, including: Age. Sjogren's syndrome is usually diagnosed in people older than 40. Sex. Women are much more likely to have Sjogren's syndrome. Rheumatic disease. It's common for people who have Sjogren's syndrome to also have a rheumatic disease — such as rheumatoid arthritis or lupus. Complications The most common complications of Sjogren's syndrome involve your eyes and mouth. Dental cavities. Because saliva helps protect the teeth from the bacteria that cause cavities, you're more prone to developing cavities if your mouth is dry. Yeast infections. People with Sjogren's syndrome are much more likely to develop oral thrush, a yeast infection in the mouth. Vision problems. Dry eyes can lead to light sensitivity, blurred vision and corneal damage. Less common complications might affect: Lungs, kidneys or liver. Inflammation can cause pneumonia, bronchitis or other problems in your lungs; lead to problems with kidney function; and cause hepatitis or cirrhosis in your liver. Lymph nodes. A small percentage of people with Sjogren's syndrome develop cancer of the lymph nodes (lymphoma). Nerves. You might develop numbness, tingling and burning in your hands and feet (peripheral neuropathy).

Sialogogues

Salivary glands + case

Case

Parotid lump - surgery made easy case

Submandibular lump

Ariyathne 2

Cases

Prep Ladder

marrow