Salivary

Gland Diseases

Anatomy and Histology
- Serous
o PAS/D-positive zymogen granules
- Mucous
o Clear cytoplasm and sialomucin vacuoles
- Ducts
o Intercalated (excretory), striated and excretory (IN THE GLAND)
- Myoepithelial cells (push and squeeze saliva through)
o SMA, myosin, keratin
- Major
o Parotid: Serous
o Submandibular: Serous>mucous
o Sublingual: Mucous<serous
- Minor
o Most numerous junction hard/soft palate, lips, buccal mucosa
o Ventral tongue, palate, glossopharyngeal area, retromolar pad

Developemental disorders
- Adenomatoid hyperplasia of the minor salivary glands
o Hyperplasia of minor salivary glands (they are numerous, just more of them)
o Palate
o Mimics neoplasm
§ Asymptomatic (other than mass)
§ ?Traumatic in origin
o Histo
§ Normal, just increased number of serous units

Sialadenitis, Sialolithiasis, Sailadenosis
- Infectious
o Viral
§ Mumps
• Acute systemic communicable paramyxovirous infection
• Swelling of one or more glands
• Glands, meninges, pancreas, gonads involved
• Used to be widespread but incidence reduced with vaccine
• Transmitted by droplet nuclei, saliva
• Virus replicates in URTI
• Clinical
o Prodrome fever, malaise, myalgia, anorexis
o Parotitis usually bilaterally (tinnitus, dysphagia, dysphonia)
o Involvement of other glands
o Orchitis in 20% of postpubertal males
o Aseptic meningitis self limited
o Rarely fatal
o May be erythema of ductal opens, FOM swelling
§ CMV, Coxsackie
o Bacterial
• Usually staphylococcus aureus
• Usually parotid gland
• Swelling, pain, fever, trismus
• Purulent discharge from duct orifice
o Histology
 § Chronic shows “sclerosis” (scarring)
§ Acute shows white cells
§ Ductal obstruction
• Sialolithiasis
• Congenital strictures
• Compression by tumor
§ Decreased salivary flow
• Dehydration
o Xerostomia
§ Subjective sensation of dry mouth
§ F>>M
§ More common with increasing age
§ May or may not find objective evidence of decreased
salivary secretions
§ Increased prevalence of oral candidiasis and dental decay
o Etiology
§ Salavary gland aplasia
§ Sjogren syndrome
§ DM/DI
§ Psychogenic disorders
§ Sarcoidosis
§ XRT
§ Aging
§ Smoking
§ Mouth breathing
§ HIV infection
§ Negative fluid balance
§ Medications
• Antihistamines
• Decongestants
• Antidepressants
• Antipsychotics
• Antihypertensives
• Anticholinergics
• Debilitation
• Medications
o Non-infectious
§ Sjögren syndrome
• Chronic systemic auto-immune disorder
• Immunologically mediate destruction of lacrimal and salivary glands
• Xerophthalmia, Xerostomia
• Prevalence 0.5% F>>M
• Unknown etiology
o Environmental factors trigger inflammation in individuals with
genetic predisposition
• Primary
o No other auto-immune disorder present
• Secondary
o Another auto-immune disease present
o RA, SLE, Scleroderma
• Lab
o Increased ESR/serum Ig/RA factor (75%) +ANA/anti-Ro/anti-La
• Diagnostic Criteria
o See 2002 position paper (which is bullshit)
 • Ocular (xerophthalmia, blepharitis, iritis/uveitis) = artificial tears, topical
ciclosporin, topical steroids, lid scrubs
• Oral (xerostomia, periodontal, gingivitis, candidiasis) = mechanical
stimulation, OH, topical FL, artificial saliva and lubricants, secretagogues,
antifungal therapy, diet modification
§ Sarcoidosis
§ Radiation therapy-induced changes
§ Allergic Reactions
o Sialolithiasis
§ Salivary calculi, Salivary stones
§ Most frequently submandibular gland
• Long tortuous duct
• Thicker mucoid secretions
§ Obstruction major and minor glands
• Sialadenitis
o Sialadenosis (sialosis)
§ Uncommon non-inflammatory disorder
§ Asymptomatic salivary parotid gland enlargement
§ Associated with underlying systemic problem
• Hormonal disorders (DM)
• Alcoholism
• Anorexia nervosa
• Bulimia
• Malnutrition
• Drug Reactions
§ Dysregulation of autonomic innervation of salivary gland acini
- Mucocele
o Mucous retention cyst
o Common
o Caused by severance of minor salivary gland duct
o Spillage of mucous into surrounding connective tissue
§ Inflammatory reaction
§ Granulation tissue wall forms around mucus
o Clinical appearance
§ Location - lower lip mucosa
§ Swelling characteristics
• Sessile
• Painless
• Fluctuation In size
• +/- translucent hue
• Soft or fluctuant
o Conservative excision
o Include feeding salivary gland to minimize chance of recurrence
o May recur
o Excellent prognosis
- Ranula
o Mucocele occurring in FOM
o Source of mucin
§ Sublingual, submandibular, minor salivary glands of the FOM
o May dissect into soft tissues
o More difficult to treat because of its location
o Recurrence
o Good prognosis
- Mucous retention cyst
 o Salivary duct cyst, sialocyst
o True cyst or due to obstruction of salivary flow
o Major or minor glands

HIV-associated salivary gland disease
- Enlarged major salivary glands and/or xerostomia
- Can arise anytime during HIV infection
- 5-10%
- Bilateral enlargement in 60% of cases
- Cervical LAD
- Can resemble SS

Diffuse Infiltrative Lymphocytosis Syndrome
- Results of genetically influenced alteration of the immune response to HIV infection
- Associated with a more favorable prognosis of HIV
- Associated with 40-fold increase in development of lymphoma
- CD8 lympocytosis

AIDS related parotid cysts
- Lymphoepithelial cyst - typically occurs in the lateral neck region (or less frequently in the oral
cavity)
- Epithelial remnant retained inside the lymphoid tissue during embryogenesis
- Involvement of the parotid gland more common after HIV infection
- Typically presents as an asymptomatic nodule (frequently bilateral and multicystic)
- Histology
§ Cyst covered by SSE
§ Prominent lymphoid tissue with multiple germinal centres
§ ?Investigation of HIBV antibodies in unknown HVI status
• Treatment options
o Cystic content aspirations
o Sclerosis
o XRT
o Sx

Necrotizing Sialometaplasia
- Local inflammatory destruction of salivary glands à ischemia and infarction
- Swelling and ulceration
- Mimics malignancy
- Resolves spontaneously

Tumors of the salivary Glands
- Relatively Rare
- Histopathological interpretation can be challenging due to diverse appearance between different
tumor types and sometimes within an individual tumor
o Hybrid tumors
o Dedifferentiation
o Malignant transformation of benign tumors
- Immunohistochemical stains rarely useful

WHO Classification (see LARGE list)

Tumors of the salivary glands
- Geographic variation in frequency of tumor types
- Benign 54-79
- Malignant 21-46
 - Generally F>M
- Wide age ranges but average is 46-47
- Most are parotid>minor >submandibular>sublingual

Frequency of type
- Pleomorphic adenoma
- Warthin
- Mucoepidermoid Carcinoma
-
Association between type and anatomic site
- Canalicular adenomas and PLGA - minor glands
- Warthins - parotid

Benign vs. malignant: Minor
- 50% benign

Salivary gland tumors: Etiology
- EBV in lymphoepithelial carcinoma in Asians and Inuits
- RT - MEC and Warthin
- Occupation - rubber manufacturing, metal
- Smoking - Warthin

Diagnostic Imaging
- Plain radiography and sialograhpy for ductal inflammatory disease
- CT, MRI for suspected neoplastic disease

Pleomorphic Adenoma
- Variable encapsulation
- Architectural pleomorphism
- Most common SGT 60%
- Average age 46 but wide distribution
- F>M
- 80% parotid
- 10% submandibular
- 10% minor
- Surgical excision with negative margins
- Tendency to recur
o Variable encapsulation
o Invasion of capsule
o Tumor nodules
- Risk of malignant transformation

Carcinoma ex pleomorphic adenoma
- Most common parotid
- Arise de novo or within longstanding PA
- Prognosis: Capsular invasion
o Non-invasive
o Minimally invasive
o Invasive

Warthin Tumor
- Papillary cystadenoma lymphomatosum
- Almost exclusively parotid gland
- Frequently multicentric or bilateral
- Ling with cigarette smoking M>>F
 - Good prognosis, low chance of recurrence

Canalicular Adenoma
- Predilection for upper lip (75%)
- Often multiple
- F>M
- Peak in 7th decade
- Local excision

Mucoepidermoid Carcinoma
- Most common primary salivary gland malignancy in adults and children
- Character by mucous, intermediate and epidermoid cells
- 53% major glands
- Use WHO grading system for MC
- Grading
o Survival rate 90-100% low grade MEC
o 5y survival 49% for intermediate and high grade

Adenoid Cystic Ca
- Parotid, submandibular and minor glands
- Relentless clinical course
o 5y survival 35%
o 80-90% die in 10-15y
- Fatal outcome
- Propensity for perineural invasion
- Histological pattern prognostic
o Most common is cribiform (swiss-cheese)
- Treated by wide surgical resection and usually adjuvant RT

PLGA
- Terminal duct carcinoma
- Lobular carcinoma
- 2nd most common malignancy intra-oral SGY
- F>M
- Mean age 59y
- 60% palate
- Uncommon major glands
- More favorable outcome

Acinic Cell Carcinoma
- Neoplastic cells show serous acinar cell differentiation
- 80% in parotid
- 17% in minor glands
- Minor gland tumors less aggressive than major gland tumors

Minor SGT
- Slow growing swelling, usually painless
- Diagnosis by incision or excision
- Definite treatment dictate by tumor type