Cysts &tumors of salivary glands /certified fixed orthodontic courses by Indian dental academy

CYSTS AND TUMORS
OF THE
SALIVARY GLANDS
INDIAN
ACADEMY

DENTAL

Leader in continuing dental education
www.indiandentalacademy.com


CYSTS OF THE SALIVARY GLANDS



Mucocele.
Ranula.


B) MUCOCELES


Mucocele is clinical term that
describes swelling caused by
the accumulation of saliva at
the site of a traumatized or
obstructed minor salivary
gland duct or it can be simply
due to obstructed salivary
gland duct.



Mucoceles can be classified as
EXTRAVASATION type and
RETENTION type.



A large mucocele in the floor of
the mouth is called as
RANULA.

ETIOLOGY


Extravasation type of mucocele is believed to be the result of
trauma to a minor salivary gland excretory duct.



Laceration of duct results in pooling of saliva in the adjacent sub
mucosal tissue and consequent swelling.



Retention type is caused by obstruction of minor gland duct by
calculus or contraction of scar around an injured duct



The blockage of salivary flow causes the accumulation of saliva
and dilation of the duct, so eventually an aneurysm like lesion
forms which is lined by epithelium of the dilated duct.


CLINICAL FEATURES


Extravasation type commonly occur in lower lip where trauma is
common followed by buccal mucosa, tongue, floor of the mouth, retro
molar area etc.



Mucous retention cysts are commonly found on the palate or floor of the
mouth.



Mucoceles often present as discrete pain less smooth surfaced
swellings that can range from a few mm to a few cm in diameter.



Superficial lesions have a characteristic blue hue.



Deeper lesions may be more diffuse and covered by normal mucosa
with out blue hue.



The lesions may vary in size over time.

TREATMENT


Surgical excision, to prevent recurrence removal of
associated minor salivary gland is essential.



Aspiration of fluid does not provide long term benefit.



Intra lesional injections with corticosteroids are helpful to
treat mucocele.


C) RANULA




May be extravasation or retention types.
Seen in floor of the mouth as a large mucocele.
Associated with sub lingual salivary gland duct.

Etiology:


Considered due to trauma commonly and less
commonly due to retention of saliva due to obstruction or
aneurysm.



A sarcoid associated ranula is also reported.

CLINICAL FEATURES


As name suggests it resembles the swollen belly of a frog.



Lesion present as painless, slow growing, soft movable mass
located in the floor of the mouth.



It is formed on one side of lingual frenum, some times crosses
the mid line.



Ranulas have typical bluish hue.



Deep lesions terminate through mylohyoid muscle and extend
along the facial planes referred to as plunging ranula. And can
become large, extending into neck.

TREATMENT


Surgical marsupialization procedures unroof the lesion
and are the treatment of choice in smaller lesions.



Excision in case of large lesions and also in recurrence.



Intralesional injections of corticosteroids are successful.


TUMORS OF THE SALIVARY GLAND


Majority about 80% of salivary gland tumors arise in the parotid
gland, the submandibular gland accounts for 10 to 15 % and the
remaining 5 to 10 % arise in minor salivary glands.



About 80% of parotid and 50% of submandibular tumors are
Benign in contrast, more than 60% of tumors in sublingual and
minor salivary glands are Malignant.



The risk of malignancy increases as the size of the tumor
decreases. And over 85% of tumors occur in adults.


CLASSIFICATION
BENIGN TUMORS –

Pleomorphic adenoma.
Monomorphic adenoma.
Oncocytoma.
Basal cell adenoma.
Myoepithelioma.
Ductal papilloma.
Papillary cystadenoma.
Lymphomatosum.
MALIGNANT TUMORS – Mucoepidermoid carcinoma.
Adenocystic carcinoma.
Acinic cell carcinoma.
Adenocarcinoma.
Lymphoma.


SHAFERS CLASSIFICATION
BENIGN TUMORS:
1)
Pleomorphic adenoma (Mixed tumor).
2)

Monomorphic adenoma.

3)

Basal cell adenoma.

4)

Canalicular adenoma.

5)

MALIGNANT TUMORS:
1)
Malignant pleomorphic adenoma (Malignant
“Mixed” tumor, Carcinoma Ex pleomorphic
adenoma).
2)

Adenoid cystic carcinoma (Cylindroma, Adeno
cystic carcinoma, Adeno cystic basal cell
carcinoma, Pseudo adenomatous basal cell
carcinoma, Basaloid mixed tumor).

Papillary cystadenoma lymphomatosum
(Warthin’s tumor, Adenolymphoma).

3)

Acinic cell carcinoma (Acinar cell or serous cell
adenoma and Adenocarcinoma).

6)

Oxyphilic adenoma (Oncocytoma, Acidophilic
adenoma).

4)

Mucoepidermoid carcinoma.

Myoepithelioma.

5)

Central mucoepidermoid carcinoma of the jaw.

7)

Ductal papillomas.

6)

Clear cell carcinoma.

8)

Benign lymphoepithelial lesion (Mickulicz’s
disease).

7)

Adenocarcinoma of miscellaneous forms.

9)

8)

Epidermoid carcinoma (Squamous cell
carcinoma).

9)

Necrotizing sialometaplasia.

10)

Sjogren’s syndrome (Sicca syndrome,
Gougerat – sjogren syndrome).


FOOTE & FRAZELL, 1934
BENIGN:
1)
Mixed tumor.
2)

MALIGNANT:
1)
Malignant mixed tumor.
2)

Oxyphilic adenoma.

4)

Sebaceous cell adenoma.

5)

Benign lymphoepithelial lesion.

6)

Unclassified.

Squamous cell carcinoma.

4)

3)

Mucoepidermoid tumor.

3)

Papillary cystadenoma
lymphomatosum.

Adenocarcinoma
Adenoid cystic
Trabecular or solid
Anaplastic
Mucous cell
Pseudoadamanite
Acinic cell

5) Unclassified.


WHO CLASSIFICATION, 1972
1) Epithelial tumors
A) Adenomas
i) Pleomorphic adenoma
ii) Monomorphic adenoma
a) Adenolymphoma
b) Oxyphilic adenoma
c) Other
B) Mucoepidermoid tumor
C) Acinic cell tumor
D) Carcinomas
i) Adenoid cystic carcinoma
ii) Adenocarcinoma
iii) Epidermoid carcinoma
iv) Undifferentiated carcinoma
v) Carcinoma in pleomorphic adenoma
2) Non epithelial tumors
3) Unclassified tumors
4) Allied conditions
a) Benign lymphoepithelial lesions
b) Sialosis
c) Oncocytosis


BENIGN
TUMORS

A) PLEOMORPHIC ADENOMA
Etiology and prevalence:

Most common tumor of salivary
glands, accounts for 60% of all salivary
gland tumors.


It is a mixed tumor because it consists
of both epithelial and mesenchymal
elements. About 85% of these tumors
found in parotid gland, and 8% found
in submandibular glands and the
remaining in sub lingual and minor
salivary glands.



Pleomorphic adenomas can occur at
any age.



The incidence is in 4th to 6th decades
of life.



Also represents most common salivary
neoplasm in children.

CLINICAL PRESENTATION


Appear as painless, firm and mobile masses that rarely ulcerate the overlying skin
and mucosa.



In the parotid gland, the neoplasm are slow growing and usually occur in posterior
inferior aspect of the superficial lobe mixed tumors in submandibular glands presents
as well defined palpable masses.



Intra orally the tumors occur on the palate, followed by the upper lip and buccal
mucosa.



Adenomas may vary in size depending on gland in which they are located.


PATHOLOGY


Appears as firm smooth mass within a pseudo capsule,
histologically, demonstrates both epithelial and
mesenchymal elements.



The epithelial cells make up a trabecular pattern within a
stroma of chondroid, myxoid, osteoid, or fibroid. Thus the
name pleomorphic tumor or mixed tumor.



One characteristic of this adenoma is the presence of
microscopic projections of the tumor outside the capsule,
and if these are not removed with the tumor, the lesion
will recur.

TREATMENT
•

Consists of surgical removal with adequate margins, this
tumor requires wide resection due to its recurrence.

•

A superficial parotidectomy is sufficient for the majority of
these lesions.

•

Lesions in the sub mandibular gland are treated by
removing the entire gland.


B) MONOMORPHIC ADENOMA


A monomorphic adenoma is a tumor that is composed of
predominantly of one cell type, as opposed to a
pleomorphic type.



Management of monomorphic adenoma is as same as
the pleomorphic.


C) PAPILLARY CYSTADENOMA
LYMPHOMATOSUM


Also known as warthin’s tumor, and is
the second most common benign
tumor of parotid gland.



Almost always located in the parotid in
the inferior pole of the gland, posterior
to the angle of the mandible.



Males usually affected and occur in
5th and 8th decades.



Can occur bilaterally also.



Tumor presents as a well defined slow
growing mass in the tail of the parotid
gland.



Usually painless unless super infected.



This tumor is visible in scintigraph as it contains oncocytes which
takes up the technetium 99 dyes.



The gross appearance of the tumor is smooth with a well defined
capsule.



Cutting a specimen reveals cystic spaces filled with thick mucinious
material.



Treatment of this tumor is excision with a margin of normal tissue
because of its easily accessible location.



Superficial parotidectomy is also performed in case of large lesions.


D) ONCOCYTOMA


Less common benign tumor that make up 1% of all
salivary gland neoplasm.



It contains large granular acidophilic cells called as
oncocytes, so the name oncocytoma.



These are usually solid round tumors that are seen in
any of the major salivary glands and are rare intra orally.



Commonly found in superficial lobe of the gland.



Second most common tumor that occur bilaterally after
warthins tumor.



Grossly these tumors appear non cystic and firm.



Histologically consists of brown granular eosinophillic cells.



Malignant counter part can occur which are aggressive lesions.



Oncocytomas demonstrate very slow growth rate and benign course, so
superficial parotidectomy with preservation of facial nerve is the
treatment of choice.



Smaller lesions can be removed totally leaving normal tissue.



Recurrence is rare.


E) BASAL CELL ADENOMA


Slow growing painless masses accounts for 1 to 2% of
salivary gland adenomas.70% occur in parotid gland and
adenomas of minor salivary glands occur mostly in the
lips.



Histologically three variants are demonstrated they are,
solid, trabecular-tubular, and membranous.



Solid form consists of islands of basiloid cells. A nucleus
is in normal size and is basophilic with minimal
cytoplasmic material.




The trabecular- tubular form consists of trabecular
chords of epithelium and the membranous form is
multilocular and 50% of the lesions are encapsulated
and tends to grow in clusters.



Lesions are removed by conservative surgical excision
extending into normal tissue.


F) MYOEPITHELIOMA


Palate is most common intra oral site, no gender
predilection exists.



Lesions tend to occur in adults, with average age being
53 years.



Lesion present as well circumscribed asymptomatic slow
growing mass.



Consists of spindle shaped cells, plasmacytoid cells, or
combination of two. Diagnosis is based on presence of
myoepitheloid cells.



This tumor is epithelial in origin and best demonstrated
by immunohistochemical staining for actins, cytokeratin,
and S-100 protein.



Surgical excision including a border of normal tissue is
the treatment of choice.


G) DUCTAL PAPILLOMA


Arise from excretory ducts of minor salivary glands.3 forms as
simple (intercalated), inverted ductal, and sialadenoma.



Simple ductal papilloma: presents as exophytic lesion with
pedunculated base. Lesion has a reddish colour.



Microscopically reveals epithelium lined papillary fronds
projecting into cystic cavity with out proliferating into walls of
the cyst. Local surgical excision is the recommended
treatment.



Inverted ductal papilloma: occurs in minor salivary glands,
presents as sub mucosal nodule that is similar to fibroma or
lipoma. Microscopically same as above. And surgical excision
is the treatment.

•

Sialadenoma papilliferum: Analogous to
syringocystadenoma papilliferum of the skin.

•

An adult male predilection exists; occur between 5th and
8th decades of life.

•

Lesion occurs on palate and buccal mucosa and presents
as a painless exophytic mass.

•

Clinically resembles a papilloma.

•

Microscopically lesion shows epithelium lined papillary
projections supported by fibro vascular connective tissue,
forming a series of clefts with in the lesion.

MALIGNANT
TUMORS

A) MUCOEPIDERMOID
CARCINOMA


Most common malignant tumor of the salivary glands.



Men and women are equally affected and the highest incidence
occurs in 3rd and 5th decades of life.



This lesion consists of both epidermal and mucous cells and is
classified as either high grade or low grade, depending on the ratio
of epidermal cells to mucous cells.



A low grade tumor has a higher ratio and is less aggressive lesion
even tough they have the ability to metastasis and local invasion,
they behave like benign tumors.



A high grade form is believed to be more malignant and has poorer
prognosis.


CLINICAL FEATURES


Clinical course depends on its
grade. I.e., a low grade tumor
undergo a longer period of
painless enlargement where as a
high grade tumor often
demonstrate rapid growth and
higher like hood of metastasis.



Pain and ulceration of overlying
tissue are occasionally associated
with this tumor.



If the facial nerve is involved the
patient may exhibit a facial palsy.


PATHOLOGY


Macroscopically, low-grade mucoepidermoid carcinomas
are usually small and partially encapsulated.



After sectioning this low grade tumors demonstrate a
mucinous fluid where as a high grade lesions are usually
solid in appearance.



Microscopically, low grade lesions consist of mucoid
cells with interspersed epithelial strands, high grade
tumors consists of epithelial and few mucinous cells.


TREATMENT


Low grade lesions are treated with superficial
parotidectomy, where as high grade lesions should be
aggressively treated to avoid recurrence.



Neck dissections may be performed for lymph node
removal and staging in high grade lesions.



Post operative radiotherapy has been shown to be useful
adjunct in treating the high grade tumor.


B) ADENOID CYSTIC
CARCINOMA


Most common malignant tumor of minor and sub
mandibular salivary glands.



50% occurs in minor glands, affects men and women
equally and occurs in 5th decade of life.


CLINICALLY


Present as a firm unilocular mass
in the gland, tumor is painful
occasionally and has a propensity
for peri neural invasion thus it can
extend beyond obvious tumor
margin.



Intra oral tumor exhibit mucosal
ulceration which is a distinguishing
feature from a benign mixed
tumor.



Radio graphically the tumor
reveals extension into adjacent
bone.



Metastasis’s into lungs is more
common than regional lymph node
metastasis.

PATHOLOGY


Tumor is unilocular and either partially encapsulated or
non encapsulated.



Microscopically the cells are small and cubiodal, with
dense chromatin.



Pseudo cystic spaces filled with a cellular material is the
characteristic feature of this tumor.


TREATMENT


Radical surgical excision of the lesion is the treatment of
choice because of local invasion.



Neutron beam radiation has shown more effective than
photon beam therapy.



Factors affecting the long term prognosis of the
treatment are the size of primary lesion, its anatomical
location, presence of metastasis at the time of surgery
and facial nerve involvement.


C) ACINIC CELL CARCINOMA


Represents about 1% of all salivary gland tumors, about
90 to 95 % are seen in parotid gland and remaining
located in the submandibular gland.



More seen in women in 5th decade.


CLINICALLY


Present as slow growing masses, pain is present.



The superficial lobe and inferior lobe of parotid are the
frequent sites.



Occur bilaterally in 3 % of cases.


PATHOLOGY


Well defined mass that is often encapsulated.



And two types of cells can be seen microscopically, as
similar to acinar cells in the serous glands are seen
adjacent to cells with a clear cytoplasm.



Which are seen positive in periodic acid Schiff stain.


TREATMENT


Long term survival is not favorable.



Treatment consists of superficial parotidectomy with
facial nerve preservation if possible.



Total gland removal is treatment of choice in tumor of
submandibular gland.


D) ADENOCARCINOMA


Any tumor arising from salivary duct epithelium is
considered as Adeno carcinomas.



These are divided into discrete entities based on
structure and behavior.



Clarification of the type with a histological description
should be obtained in order to determine the appropriate
treatment approach.


E) LYMPHOMA


Primary lymphomas of the salivary glands arise from
lymph tissues with in the glands.



The major forms of lymphoma are non Hodgkin’s and
Hodgkin’s disease.



The parotid gland is most commonly involved followed
by sub mandibular gland.


CLINICALLY


Present as painless gland enlargement or adenopathy


TREATMENT


Superficial parotidectomy, radiation therapy,
chemotherapy or a combination of the two depending on
the staging of the lymphoma.


ABSCENCE OF GLAND DUE TO
SURGERY OR TRAUMA


A) PAROTIDECTOMY


Surgical treatment for most of the low-grade salivary
gland tumors consists of superficial parotidectomy as to
preserve the facial nerve and their location at tail region.



For high grade tumors a total parotidectomy is done.



Complications occurring after parotidectomy include
permanent, partial or total facial nerve paralysis,
temporal nerve palsies, salivary fistulas or sialocele are
all common complications. (Sialocele is a palpable
collection of fluid formed when the edge of the parotid
gland capsule is cut and the gland continues to leak
fluid.)



Frey’s syndrome is common complication of parotidectomy.



This syndrome presents as gustatory sweating (patient flush or
sweat with salivary stimulation due to mix of post gang ionic
sympathetic fibers of sweat glands with that of regenerating post
gang ionic secretary parasympathetic fibers to the sweat glands )



Frey’s syndrome occurs 30 to 60% of patients who have
undergone parotidectomy.



The treatment of this disorder consists of tropical application of
anti cholinergic, and also botulinum toxin injections are also
used.



Xerostomia is most common complication.

B) SUB MANDIBULAR / SUBLINGUAL AND
MINOR SALIVARY GLAND SURGERY


Submandibular, sub lingual salivary gland removal leads
to loss of salivary flow resulting in xerostomia and risks
like hemorrhage, infections, injury to hypoglossal, lingual
or marginal mandibular nerves.



Minor salivary gland removal depends on location and
extent of disease.



Complete excision is desirable for benign tumors and for
malignant tumors complete maxillectomy or composite
resection is recommended.


LAB INVESTIGATIONS
SALIVA AND ITS ROLE AS A SCREENING TOOL
•

Saliva is a convenient fluid used for diagnostic purposes
and has obvious benefits over plasma because of its ease
in collection the samples and its non invasive, non
stressful procedures for the patient.

•

Saliva can be used to determine the profile of the
infection of the oral cavity with pathogens such as
Candida as well as giving lactobacillus and
streptococcus mutant’s scores.


COLLECTION OF SALIVA /
TECHNIQUE
Saliva is collected by 3 different methods they are




PAROTID COLLECTOR
SEGREGATOR AND
COLLECTION OF WHOLE SALIVA BY , Draining technique,
spitting and suction methods


PAROTID COLLECTOR


Developed by Lashley in 1916. This makes possible the
collection of parotid fluid uncontaminated by oral contents.



Composed of two concentric circles made of plastic or
metal. The centre circle is designed such that it fits over the
opening of stensons duct and is connected to a graduated
collecting tube.



The outer concentric circle is attached to a rubber bulb,
which exhausts air from the outer circle, when collector is
held in place and draws the cheek surrounding the opening
of stensons duct into it.



This cannot be used in sub mandibular and sub lingual
glands because of their different anatomical locations.


SEGREGATOR


Developed by Schneyer which allows the collection of saliva from
sub mandibular and sub lingual glands. This also made of plastic
or metal constructed on a stone model for each individual.



On this a pre formed basic plastic collector is utilized then it is
covered by a rubber base impression material and placed on the
floor of the mouth beneath the tongue. In 5 minutes the impression
is removed and a recess is made on the impression over the
opening of Wharton’s duct and a plastic collecting tube is attached.



The collector stays in position when the patient places his tongue
against the lingual surface of the lower incisors



This may be sorted out and reused for individual patient which
collects saliva from sub mandibular and sub lingual glands.


COLLECTION OF WHOLE SALIVA


For this the patient is asked to suck on sour candy or
sour grapes to stimulate the salivary flow. this can also
be done by asking the patient to chew on cimer
paraffin or rubber bands and can also be done by
swabbing 2% citric acid solution on the back of tongue
at 15 minutes interval. Then the saliva is collected by
one of three methods.



SPITTING of saliva into a collecting funnel at regular
intervals can be encouraged by the patient.



SUCTION by using a saliva ejector which is applied
orally in the area of lower incisors and the aspirated
fluid is collected after the patient has remained quits
for fixed time period.

DRAINING METHOD :


Materials used are, a watch, weight machine with 2 digits, a plastic
disposable cups, a saliva stimulator like paraffin and a metronome.



Patient is seated in relaxed position with his/ her head slightly tilted
forward. After an initial swallowing action, the patient is instructed to
allow saliva to passively drawn from the lower lip into the pre weighed
plastic cup.



The collection starts at time zero and at the end of the collection period,
residual saliva is expectorated from mouth into the cup.



Saliva containing cup is reweighed and the flow rate is calculated in gm /
mts which is equivalent to ml / mts.



Collection of stimulated saliva is performed after collection of
unstimulated following the same procedure, with exception of shorter
collection time and application of chewing stimulus.



Every 30 sec, the patient is allowed to drip saliva into the cup and then
collection continues. Measurement is done after 15 mts for unstimulated
saliva and 5 mts for stimulated saliva.




Normal salivary flow rate is 1.0 – 1.5 ml / mts for stimulated
saliva. And for unstimulated saliva, the flow rate is 0.3 ---- 0.5
ml /min.



If the unstimulated flow is less than 0.1 ml/min, then diagnosis
for hypo salivation is marked out , and if stimulated flow rate is
measured less than 0.5 ml/min or less for women and 0.7
ml/min in men , then diagnosis for salivary gland dysfunction
is made and further investigations are carried out.



Thus saliva can serve as an excellent tool for determining
various substances such as drugs, hormones and infections
of the oral and salivary glands.

DIAGNOSIS IS ALSO CONFIRMED BY
CERTAIN DIAGNOSTIC STUDIES

SIALOMETRY: Deals with estimation of
salivary flow rates by draining method.
SIALOGRAPHY : Non specific test, in which
a radio opaque dye is injected into the
duct (such as iodine based dye) and a
radiograph is taken which shows if the
duct is constricted, dilated or there is any
calculus formation.

SALIVARY SCINTISCANNING:
Non invasive procedure, examines all major salivary
glands Technetium-99 is used which emits gamma
radiation, and is associated with small amount of
radiation hazard and is expensive procedure, not always
used.
IMAGING:
Chest radiography to rule out sarcoidosis.
Ultrasonography to exclude sjogrens and neoplasm
MRI scanning to exclude sjogrens.


SALIVARY GLAND BIOPSY:
 To rule out suspicion of organic disease of
salivary glands.


If the dry mouth condition has no evidence of
reduced flow or salivary gland.



Disorder, then there may be a Psychological reason for
the complaint.


SALIVARY GLAND IMAGING


I. PLAIN FILMS


Parotid stones are almost always radiolucent.



Submandibular stones are nearly always
radio-opaque.


II. PANAROMIC RADIOGRAPHY
AND OCCLUSAL RADIOGRAPHY


These are conventional radiographic procedures used to
rule out stones in gland structure and ducts.



Major advantage by this is it is easily affordable, and
chair side decision making can be possible.



Disadvantage is poorly calcified stones and smaller
sialoliths are not visualized.


III. SIALOGRAPHY


Radiographic visualization of salivary gland following retrograde
instillation of soluble contrast media into the ducts of glands is known as
sialography.



This was one of the oldest imaging procedures which was first
mentioned by CARPY in the year 1902.



Later BARSONY & USLENGI in 1925 separately described sialography
as a diagnostic tool.



Salivary ductal obstruction, whether by a sialolith or stricture can easily
be visualized. When patient presents with history of rapid and acute
onset of painful swelling of single gland upon eating, then this is the
indicated imaging technique.



Can be performed on both sub mandibular and parotid glands with oil
and water based contrast media containing iodine as main substrate.



Oil based media has its own self limitations as it is not diluted in saliva
and allows for maximum opacification of ductal and acinar structures.
But residues of oil media can induce granulomas at the site.



Water based media is soluble in saliva and can diffuse into the
glandular tissue resulting in reduced radiographic density and poor
visualization of peripheral ducts.



Recently higher viscosity water based medias are available that allows
better visualization of ductal structures.



Routine radiographic procedures like Panoramic, Lateral oblique,
Anteroposterior views and Puffed cheek AP views reveal ductal
architecture after contrast media induction as a LEAFLADEN TREE
(leaf less tree) appearance.




Non opaque sialoliths appear as Voids, and in sialedinites and sjogrens
sialoliths appear as focal collections of contrast media with in the gland.



Progression of severity is visualized as punctuate, gloubular and
cavitary patterns. This imaging technique is the choice for delineating
ductal anatomy and for identifying and localizing sialoliths.



It is also a valuable tool in pre surgical planning prior to removal of
salivary mass.



It is contraindicated in active infections and allergic condition to contrast
media.



This also provides No quantification.


IV. ULTRA SONOGRAPHY


Due to the superficial location of the parotid and submandibular glands,
these are easily visualized by ultra sonography.



Indicated for biopsy guiding, mass detection and is best used in
differentiating between intra and extra glandular masses as well as
cystic and solid lesions.



Solid benign lesions present as well circumscribed Hypo echoic
intraglandular mass.



USG can demonstrate the presence of abscess in a acutely inflamed
gland and also sialoliths, which appear as Echogenic densities that
exhibit acoustic shadowing.




Parenchymal homogenecity in sjogrens syndrome was
first reported by ultra sonography by MAKULA &
Colleagues.



Main advantage of USG is its Non invasive procedure
and cost effective imaging modality.



Disadvantage is its No ability for quantification of function
and observe variability.



Limited visibility for deeper portions of gland. And
provide no morphologic information.

V. RADIO NUCLIOTIDE SALIVARY IMAGING
OR SCINTIGRAPHY


It is the dynamic and minimally invasive diagnostic test to asses
salivary gland function and to determine any abnormalities in
gland uptake and excretion.



This is the only test which provides information on the functional
capabilities of gland.



Radio active Technetium (TC) 99m Pertechnetate is used for the
purpose which is a pure gamma ray emitting nucleotide that is
taken up by the glands following intravenous injections; it is
transported through glands and then secreted into oral cavity.



Uptake and secretion phases can be recognized on scans.
Uptake indicates that there is functional epithelial tissue.



Tc99m is capable of substituting for chloride in the Na/ K
transport pump and serves as measurement of fluid movement
in the salivary acinar cells.



The injected 10 to 20 mci of Tc99m is viewed in the gland by a
gamma detector that records both the number and the location
of gamma particles released in a given field during the period
of time, this information is stored in a computer for later
analysis or recorded directly on a film from gamma camera to
give static image.



Scintigraphy can provide information regarding salivary gland
function by generating Time – activity curves which has
normally 3 phases.


Phase 1:
FLOW PHASE lasts about 15 to 20 sec,

Represents the phase immediately followed by injection
when the isotope is equilibrating in the blood and
accumulating in the gland at a sub maximal rate.
Phase 2:
CONCENTRATION PHASE:
 Represents accumulation of Tc99m in the gland through active
transport.
 This starts about 1 minute after administration of tracer and
increases over next 10 minutes.
 Approximately after 15 minutes the tracer begins to increase in
oral cavity and decrease in the gland.

Phase 3:
EXCRETORY PHASE:
 Other wise called wash out phase. The patient is given a lemon
drop or citric acid is applied on tongue to stimulate salivary
secretion.
 Normally clearing of Tc99 should be prompt, uniform, and
symmetrical.
 Activity remaining in gland after stimulation is suggestive of
obstruction, tumor or inflammation.


The scintigraphy is used mainly to rule out auto immune
siladenitis and tumors. Basic advantage of this procedure is
quantification of function and major disadvantage is of radiation
hazard and also provides no morphologic information.

VI. COMPUTED TOMOGRAPHY (CT)


C T images are produced by radiographic beams that
penetrate tissues. Computerized analysis of the variance of
absorption produces a reconstructed image of the area.



Coronal and axial images are usually obtained.



C T is useful for evaluating salivary gland pathology, adjacent
structures and proximity of lesions to the facial nerve.



Calcified structures are better visualized by CT, abscess have
a characteristic hyper vascular walls is evident on CT
imaging.




CT images are obtained by continuous fine cuts through
involved gland. Dental restorations or metal implants
may interfere with CT imaging and may require
repositioning of the patient to a semi axial position.



Ultra fast and 3D CT sialography have been reported by
SZOLAR and colleagues as an effective method for
masses that are not well defined by MRI.



Main advantage is it differentiates osseous structures
from soft tissues. And has a dis advantage of having No
quantification, contrast dye injection and radiation
exposure.

VII. MAGENETIC RESONANCE
IMAGING (MRI)


Varying water content of tissues allows for M R I to distinguish tissue
types.



A tissue absorbs and reemits the EM energy when exposed to strong
magnetic field. Analysis of the net magnetization by radiofrequency is
reconstructed to provide an image.



Images are described as T1 or T2 weighted images, according to the
rate of constant with which magnetic polarization or relaxation occurs.



M R I is the choice of imaging in pre operative evaluation of salivary
gland tumors because of its excellent ability to differentiate soft tissues
and its ability to provide multiplanner images.




M R I is preferred imaging technique because needs No
contrast media. Patients are not exposed to radiation
and minimal artifacts from dental restorations.



M R I is contraindicated in patients with Pacemakers or
metallic implant prosthesis such as bone clips



Patients with claustrophobia and pts who have difficulty
maintaining still position have difficulty tolerating the
M R I procedure.


VIII. OPEN BIOPSY


Discrete salivary gland mass:
On no account should this be subjected to incisional
biopsy, unless there is clear or cytological evidence of
malignancy. Incisional biopsy as a primary investigation
will cause tumor implantation.



Diffuse enlargement of the salivary gland:
an incisional biopsy may be necessary, but this should
usually be accompanied by a sublabial biopsy, to
diagnose some of the granulomatous conditions, such as
sjogren’s syndrome

METHODS OF FACIAL NERVE IDENTIFICAION

1.

Tragal pointer.

2.

Posterior belly of diagastric.

3.

Tympanomastoid suture.

4.

Peripheral branches.

5.

Mastoid process.

TECHNIQUE OF SALIVARY GLAND
OPERATIONS


Superficial parotidectomy.



Total conservative parotidectomy.



Total radical parotidectomy.



Extended radical parotidectomy.



Neck dissection.



Removal of a submandibular gland.

Thank you
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