Salivary gland diseases Lec. Dr. Ban F.

Ibraheem

Objective :
1. To classify the non- neoplastic disorders of salivary gland.
2. To enumerate and describe the etiological factors of specific disorders.
3. To describe the characteristic clinical and histopathological features of specific salivary gland disorders.
4. To explain in detail the etiological factors and characteristic features of functional, obstructive and
immunological disorders associated with the salivary glands.
5. To enumerate and explain the different investigations performed for the diagnosis of salivary gland
disorders.
Diseases
1. Developmental anomalies
2. Reactive/ Obstructive lesions ( mucocele, sialolithiasis, , necrotizing sialometaplasia)
3. Infections sialoadenitis ( acute bacterial , chronic sclerosing, mumps, Post-irradiation)
4. Immune-mediated diseases ( benign lymphoepithelial lesion, sjögren syndrome)
5. Tumors ( benign , malignant)

Salivary glands consist of three paired major glands and the countless
minor salivary glands found in almost every part of the oral cavity, except the
gingiva and anterior regions of the hard palate.
The secretion of saliva is essential for the normal function and health of
the mouth, and disorders of salivary gland function, which affect the
composition and secretion of saliva, predispose to oral disease. Functional
disorders in salivary secretion and composition may be associated with
organic disease of the salivary glands, but in other cases are caused by
systemic factors, such as neurological disease, drug therapy, and endocrine
disturbances.
• Developmental anomalies:
Rare. Aplasia of one or more major glands and atresia of one or more major
salivary gland ducts have been reported. Heterotopic salivary tissue has been reported the most frequent being its
inclusion at the angle or within the body of the mandible, presenting as Stafne's idiopathic bone cavity.
• Salivary mucoceles: K11.69
Cysts arising in connection with minor salivary glands are common. About 90% are of the mucous
extravasation type.
1. Extravasation mucoceles
Over 70 % of all mucous extravasation cysts arise in the lower lip, followed by the cheek and floor of the
mouth. The cyst occurs over a wide age range but most in young patients.
Clinically, the lesion presents as a bluish or translucent submucosal swelling; there may be a history of rupture,
collapse, and refilling which may be repeated. It arises as a result of extravasation of mucus from a ruptured duct,
and a history of trauma can often be elicited from the patient.

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Microscopically, the lesion typically consists of a mucin-filled cystic cavity or cavities lined by inflamed
granulation tissue. There is no epithelial lining. The wall of the cyst is infiltrated by large numbers of macrophages
and neutrophils.
Treatment, surgical excision of mucocele with its underlying feeder gland to minimize the chance of recurrence.
2. Retention mucoceles
Their pathogenesis is unknown but progressive ballooning of a partially obstructed duct, or even spontaneous
cystic change has been suggested.
Clinically, in contrast to extravasation mucoceles, retention mucoceles occur most frequently in patients over 50
years of age and are almost never found in the lower lip. it is painless cystic fluctuant lesion either superficial or
deep-seated cyst ( detected by bimanual palpation)
Microscopically, They are derived from cystic dilatation of a duct and are lined by the epithelium of ductal type
(cuboidal or columnar). Because the mucus is still contained within the duct, there is no surrounding chronic
inflammatory reaction.
Treatment, surgical excision, avoid cyst rupture and trauma to adjacent s.g otherwise result in mucocele

3. Ranula
A ranula is a clinical term used to describe swelling of the floor of the mouth which is said to resemble a frog's
belly. It is not a pathological diagnosis. Histologically, most ranulae are mucous extravasation cysts
• Obstructive and traumatic lesions
are important factors in the etiology of chronic sialadenitis in major glands and mucoceles in minor glands. Duct
obstruction may be due to a blockage within the lumen (chronic trauma, for example from sharp cusps or
overextended dentures, resulting in fibrosis and stenosis) or result from the disease in or around the duct wall (
such as fibrosis or neoplasia).
Salivary calculi (sialolithiasis)
Salivary calculi cause an obstruction within the duct lumen
and can occur at any age, but are most common in middle-
aged adults. The submandibular gland is most frequently
involved, 70-90% (Explain why? give 3 reasons). The
parotid gland is the next most commonly involved, whereas sialolithiasis in sublingual and minor glands is
uncommon. Calculi are usually unilateral. The typical signs and symptoms of calculi associated with major glands

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are pain and sudden enlargement of the gland, especially at meal times when salivary secretion is stimulated. The
reduction in salivary flow predisposes to ascending infection and chronic sialadenitis. The calculi may be detected
by palpation and on radiographs and may be round or ovoid, rough or smooth, and vary considerably in size.
The etiology and pathogenesis of salivary calculi are unknown. It is generally thought that they form by deposition
of calcium salts around an initial organic nidus which might consist of altered salivary mucins together with
desquamated epithelial cells and microorganisms.
Treatment: stone can be removed by normal manipulation through the duct orifice. If this failed surgical cut-down
into the main duct is needed, if there is pyogenic infection exist, incision and drainage with an antibiotic should
proceed or accompany sialoadenectomy.
Necrotizing sialometaplasia k11.85
The etiology of the condition is unknown, but ischemia leading to infarction of
salivary lobules is the most widely accepted theory. In some patients, there may be
a history of trauma from a variety of causes, including local anesthetic injection
and previous surgery.
Clinically: it is uncommon disorder occurs most frequently on the hard plate in middle-aged patients and is about
twice as common in men as women. It presents most commonly as a deep crater-like ulcer which may mimic a
malignant ulcer and which may take up to 10-12 weeks to heal. In some cases, the ulcer may be preceded by an
indurated swelling.
Histopathological examination shows lobular necrosis of salivary glands, squamous metaplasia of ducts and acini,
mucous extravasation, and inflammatory cell infiltration. The overlying palatal mucosa shows pseudo-
epitheliomatous hyperplasia and the histopathological features may be mistaken for either squamous cell
carcinoma or mucoepidermoid carcinoma.

• Sialadenosis/ sialosis
It is unusual bilateral asymptomatic enlargement of salivary gland. Sialosis is a non-inflammatory, non-neoplastic,
non-autoimmune disorder, mostly affect the parotid gland
Etiology:
• Endocrine disorders: Diabetes mellitus and insipidus, acromegaly, hypothyroidism, pregnancy.
• Nutritional conditions: alcoholism, general malnutrition, anorexia nervosa, and bulimia (self starvation, eating and
purging).
• Neurogenic medication: antihypertensive drugs, psychotropic drugs and sympathomimetic drugs used for asthma.
Mechanism: due to dysregulation of the autonomic innervations of the salivary acini causing an aberrant
intercellular secretory cycle. This lead to excessive accumulation of secretory granules, with marked enlargement
of the acinar cells
Clinical Features: commonly affects females with no age predilection. Usually bilateral
recurrent painless enlargement of the parotid gland

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Radiological Features:
Sialography-leafless tree appearance. Due to compression of finer duct by hypertrophic aciner
cells.
Histopathology:
Hypertrophic acinar cells, the cytoplasm packed with granules, inflammatory cells absent. The
long-standing (diabetes and alcoholic) lead to acinar atrophy and replacement with fat

Treatment: Control of underlying cause, Partial parotidectomy and Pilocarpine (stimulate

aciner secretory cells and autonomic nervous system).

• Sialadenitis: Inflammatory disorders of the major salivary glands are usually the result of bacterial or
viral infection, but occasionally sialadenitis is due to other causes, such as trauma, irradiation, and allergic
reactions.
1. Acute bacterial sialadenitis K11.22
This uncommon disorder principally involves the parotid gland. Acute parotitis is an ascending infection, through
the ductal system, the main organisms involved being Streptococcus pyogenes and Staphylococcus aureus. It was
once a common postoperative complication in debilitated and dehydrated patients, particularly following
abdominal surgery. Reduced salivary flow is the major predisposing factor, and acute parotitis may occur in
patients with Sjögren syndrome or following the use of drugs with xerostomic side-effects. Acute infection may
also arise in immunocompromised patients or as a result of acute exacerbation in a previously chronic sialadenitis.
Clinically the onset of acute sialadenitis is rapid. it presents as swelling of the involved gland accompanied by
pain, fever, malaise, and redness of the overlying skin. Pus may be expressed from the affected duct

2. Chronic bacterial sialadenitis (chronic sclerosing sialadenitis): K11.23

a non-specific inflammatory disease associated with duct obstruction, (calculi and low-grade ascending infection).
The parotid gland is much more commonly involved than the submandibular gland, or the predisposing factor may
be a disorder of secretion resulting in decreased salivary flow.
Clinically, usually unilateral, and the symptoms of recurrent tender movable firm swelling of the affected gland are
mainly related to the associated obstruction ( stone or denture flanges in minor S.G.or after radiation). The duct
orifice may appear inflamed, and in acute exacerbations, there may be a purulent or salty-tasting discharge.
Histological examination shows varying degrees of dilatation of
the ductal system, hyperplasia of duct epithelium, periductal
fibrosis, acinar atrophy with replacement fibrosis, and chronic
inflammatory cell infiltration.
Sialography shows the duct obstruction, destruction of glandular
tissue, and duct dilatation (sialectasia) .
Treatment: remove the cause irritation or obstruction, if the

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condition end with non-functioning gland sialoadenectomy is necessary to avoid infection. Supplement therapy is
also necessary to overcome xerostomia complications.

3. Viral sialadenitis : Mumps B26 (epidemic parotitis)

An acute, contagious infection which often occurs in minor epidemics and is caused by a paramyxovirus.
Clinically It is the commonest cause of parotid enlargement and the commonest of all the salivary gland diseases.
Although infection can occur at any age, it is most common in childhood. The virus is transmitted by direct contact
with infected saliva and by droplet spread and has an incubation period of 2-3 weeks. Non-specific symptoms of
fever and malaise are followed by painful swelling of sudden onset involving one or more salivary glands. The
parotid glands are almost always involved (bilaterally 70%) The salivary gland enlargement gradually subsides
over a period of about 7 days. The virus is present in the saliva 2-3 days before the onset of sialadenitis and for
about 6 days afterward.
Occasionally in adults, other internal organs are involved, such as testes, ovaries, central nervous system, and
pancreas. Orchitis is the most common complication,20% adult males.
Treatment; there is no effective antiviral agent, only give the patient supportive therapy. Analgesic and antipyretic
control pain, liquid diet and bed rest. Most children are vaccinated against mumps, once the patient is affected
immunity is permanent no recurrence.
just for knowledge (Cytomegalic inclusion disease (salivary gland inclusion disease)
Infection with cytomegalovirus, a member of the herpesvirus group, is common in humans and endemic
worldwide. Most primary infections are asymptomatic, but the virus can cause severe disseminated
disease in neonates and in immunocompromised hosts such as transplant patients and HIV-infected
patients

4. Post-irradiation sialadenitis
Radiation sialadenitis is a common complication of radiotherapy (irreversible damage leading to a fibrous
replacement of the damaged acini and squamous metaplasia of ducts). Serous acini are more sensitive to
radiation damage than mucous acini.

• Immune-mediated diseases K11.8

1. Benign lymphoepithelial lesion
It is a progressive autoimmune disease, characterized by chronic inflammatory process primarily of the parotid
glands, in which dense infiltrate of T lymphocytes replace the acini. The residual ductal elements are stimulated to
undergo hyperplasia, forming irregularly shaped islands of squamous epithelial-myoepithelial islands. This
condition is seen in Mikilicz disease.

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2. Sjögren syndrome ( SS). M35.0 Sicca syndrome

It is a group of autoimmune conditions with a marked predilection for women that have an intense T
lymphocyte-mediated autoimmune process in the salivary gland and lacrimal glands as one of its most prominent
components. ( the patient had xerostomia, xerophthalmia, and rheumatoid arthritis).
Clinical:
It is not a hereditary disease. It associated with HLA-B8 and HLA-DR3 genotype. 80% were seen in females.
The patient may have a primary SS when it only involves salivary glands and
lacrimal glands. Or be secondary SS when it further associated with rheumatoid
arthritis or other collagen vascular diseases like lupus erythematosus, systemic
sclerosis, …etc.
In 2nd SS special laboratory findings are seen, including increase ESR,
hyper gamma glubulinemia, +ve serological test for rheumatoid factors and
antinuclear antibodies.
Parotid glands enlargement (45%) bilaterally and feel firm yet doughy. The
patient suffers from dry mouth, dry eyes. Biopsy of labial mucosa containing minor salivary glands is diagnostic
(see lymphocytes aggregates around intralobular ducts)
Imaging with contrast sialography (sialogram) reveals a characteristic
picture of “shotgun pellets” throughout the gland.

Histopathology
There is increasing in the number of lymphocytes infiltration (even
forming germinal centers), that result in damaging of acinar units, with ductal
elements myoepithelial cells undergo hyperplasia resulting in epithelial islands
(epi-myoepithelial islands).
Treatment
No effective therapy (supplement therapy)