5- Salivary Gland Pathology (Dr. Lerman)

- Parotid

- Submandibular

- Sublingual

P S S

what are the 3 major salivary glands

- Palate

- Buccal mucosa

- Floor of mouth

- Labial mucosa

what are the 4 minor salivary glands

100% serous glands

What type of glands are in the parotid gland?

Mostly serous glands

What type of glands are in the submandibular gland?

Mostly mucous glands

What type of glands are in the sublingual gland?

100% mucous glands

What type of glands are on the palate?

Mucocele

What is the most common reactive salivary gland lesion?

Mucocele

ID the pathology:

- Common reactive salivary gland lesion

- - Traumatized duct spills mucus into adjacent tissues

- Characteristic hx of increasing/decreasing in size

Mucocele

These are clinical features of what pathology?

- Dome-shaped fluctuant vesicle

- Blue or mucosa-colored

- Most common on lower lip

- - May be seen anywhere w/ salivary glands

Mucocele

Patient presents with a dome-shaped fluctuant vesicle that looks bluish in color on the lower lip. Patient admits to biting lip sometimes. Patient also said that "sometimes the bump gets big and then shrinks again"

Mucocele

ID the pathology:

- Traumatized duct spills mucus into adjacent tissues

- Characteristic history of increasing and decreasing in size

lower lip

What is the most common location for mucocele to present?

Mucocele

ID the pathology:

Mucocele

ID the pathology:

Mucocele

ID the pathology based on the histology findings:

– Spilled mucin surrounded by granulation tissue

– Numerous neutrophils + foamy histiocytes/muciphages

- No epithelial lining

Mucocele

ID the pathology based on the histology findings:

– Spilled mucin surrounded by granulation tissue

– Numerous neutrophils and foamy histiocytes/muciphages

- No epithelial lining

- May be self-limiting or require local excision

- Adjacent gland should be excised to prevent recurrence

What is the treatment for a mucocele?

Ranula

A mucocele on floor of mouth is called a ______

sublingual gland

A Ranula is usually associated with what gland?

mylohyoid

A plunging ranula variant dissects through the _______ muscle into neck

Ranula

patient presents with a dome-shaped fluctuant vesicle that looks bluish in color on the floor of the mouth. What is the diagnosis?

floor of mouth

what is the most common location for a Ranula to present?

Ranula

ID the pathology:

- Ranula

- Salivary duct cyst

- Dermoid/Epidermoid cyst

Patient presents with a large nodule on the floor of the mouth lateral to the midline. What is in your differential diagnosis (3)?

Excisional biopsy with gland

What is the treatment for a ranula?

Sialolitiasis

Calcified structures within the salivary duct system lead to ________

Sialolithiasis

Patient present to your office complaining of pain upon salivation. A small firm, non-fluctuant mass is visible on the floor of the mouth lateral to the midline. Radiograph shows a radiopaque mass in the location of interest. What is the diagnosis?

Sialolithiasis

ID the pathology:

Swelling in wharton's duct

Sialolithiasis

ID the pathology during surgery:

Sialolithiasis

ID the pathology:

Associated with pain upon salivation

Sialolithiasis

What pathology is associated with pain upon salivation?

submandibular gland

80% of Sialolithiasis are associated with what gland?

Radiopaque mass

What is the radiographic features of a

Sialolithiasis?

Sialolithiasis

ID the pathology:

Sialolithiasis

ID the pathology:

Sialolithiasis

ID the pathology:

Sialolithiasis

ID the pathology:

Sialolithiasis

ID the pathology:

Sialolithiasis

ID the pathology based on the histology findings:

- Laminated calcified structure with central nidus

- Milking stone toward duct orifice

- Sialologues

- Surgical removal

- Lithotripsy

What is the treatment for Sialolithiasis (4)?

Necrotizing Sialometaplasia

Patient presents with single ulceration on the hard palatal mucosa. Patient claims it "used to be red and swollen, now it's like a crater". Histo path report reveals Acinar necrosis with preservation of lobular architecture, squamous metaplasia and Pseudoepitheliomatous hyperplasia. What is the diagnosis?

Necrotizing Sialometaplasia

ID the pathology:

- Rare inflammatory, destructive condition of salivary glands

- Mimics malignancy clinically AND microscopically

- - Early swelling and erythema

- - Later ulceration

- Related to ischemia?

necrotizing sialometaplasia

ID the pathology:

- Male predilection

- Initial swelling, then crater-like ulcer develops

- Rare destruction of palatal bone

hard palatal mucosa (75%)

The most common location for Necrotizing Sialometaplasia to present is the ______

Necrotizing Sialometaplasia

ID the pathology:

Necrotizing Sialometaplasia

ID the pathology:

Necrotizing Sialometaplasia

ID the pathology:

Necrotizing Sialometaplasia

ID the pathology based on the histology findings:

- Acinar necrosis with preservation of lobular architecture

- Squamous metaplasia

- Pseudoepitheliomatous hyperplasia

- Biopsy necessary to confirm diagnosis

- Resolves without treatment in 5-6 weeks

What is the treatment for Necrotizing Sialometaplasia?

Sjögren Syndrome

ID the pathology:

- Chronic, systemic, autoimmune disorder

~ 0.5% of population

- Affects salivary glands and lacrimal glands

Primary Sjögren (Sicca) syndrome

What form of an autoimmune disorder only causes dry eyes and dry mouth?

Secondary Sjögren syndrome

What form of an autoimmune disorder causes...

- Dry eyes

- Dry mouth

- Rheumatoid arthritis (15%)

- Systemic lupus erythematosus (30%)

- Rheumatoid arthritis

- Systemic lupus erythematosus

Along with dry eyes and dry mouth, Secondary Sjögren syndrome is associated with what other conditions?

9:1

Sjögren Syndrome has a __:1 female predilection

lymphoma

patients with Sjögren Syndrome have a 20-fold increased risk of developing ______

parotid gland (33-50%)

Sjögren Syndrome is associated with bilateral swelling of which gland?

- Xerostomia

- Dysphagia

- Cervical caries

- Fissured tongue with atrophy of papillae

- Secondary candidiasis

5 oral symptoms of Sjögren Syndrome

Sjögren Syndrome

Patient presents to your office complaining of xerostomia and dysphagia. Patient admits that they also experience dry eyes. Patient also has numerous cervical caries, fissured tongue with atrophy of papillae, and a minor case of secondary candidiasis. Upon physical examination, you notice bilateral swelling of the parotid glands. Lab work up shows elevated IgG, positive rheumatoid factor (RF) and Antinuclear antibodies (ANA). What is the diagnosis?

Sjögren Syndrome

What pathology is associated with...

- Elevated IgG, ESR

- Positive rheumatoid factor (RF)

- Antinuclear antibodies (ANA):

- - Anti SS-A (anti-Ro)

- - Anti SS-B (anti-La)

Schirmer test

What test is this used to diagnose Sjögren Syndrome:

- < 5mm wetting of filter paper in 5 minutes suggestive of diagnosis

Sjögren Syndrome

These are ocular signs of what condition?

- Dry eyes >3 months

- Foreign body sensation

- Tear substitutes used >3 times/day

- Schirmer test w/o anesthesia 5mm in 5 minutes

- Rose Bengal or other score

Sjögren Syndrome

These are oral signs of what condition?

- Feeling of dry mouth

- Recurrent swollen salivary glands

- Liquids needed to aid swallowing

- Abnormal scintigraphy

- Abnormal parotid sialography

- Abnormal sialometry (UWS <.50.1 mL/15 min)

Anti-SS-A or anti-SS-B antibodies

What antibodies are present with Sjögren Syndrome?

Labial salivary gland biopsy

What test is this used to diagnose Sjögren Syndrome:

- Focus score >1 supports diagnosis

- - Greater than 50 lymphocytes in 4 mm square of normal salivary gland tissue

- Symptomatic therapy

- Sialogogues

- Anti-rheumatic agents

- Biological agents

What is the treatment for Sjögren Syndrome?

true

t/f: for salivary gland tumors, malignancies mimic benign tumors both clinically and/or histologically

- Palate

- Upper lip

- Buccal mucosa

P U B

what oral cavity locations are most common sites for minor gland tumors?

Smaller major glands

Where are salivary gland neoplasms more likely: Smaller or larger major glands?

parotid gland

About 64-80% of salivary tumors are in the _____________, but only about 15-32% are malignant

submandibular gland

About 10% of salivary tumors are in the _____________, and about 45% are malignant

sublingual gland

About 1% of salivary tumors are in the _____________, and about 90% of them are malignant

minor glands

About 9-23% of salivary tumors are in the _____________, and about 50% of them are malignant

Asymptomatic swelling

What is the most common presentation of salivary gland tumors?

false, does not indicate malignancy

T/F: For Salivary Gland Tumors, pain is indicative of malignancy

true

t/f: for Salivary Gland Tumors, paresthesia is indicative of malignancy

lower lip

In minor gland tumors, _______ tumors are rare but 50-90% malignant

Paresthesia

what clinical presentation of salivary gland tumors suggests poor prognosis/malignancy?

true

t/f: for salivary gland tumors, paresthesia suggests poor prognosis

Salivary gland neoplasms

ID the pathology:

- Growth rate usually slow

- Size variable

- Increased incidence post irradiation and with breast cancers

Benign Salivary Gland Neoplasms

What are all of the following?

- Pleomorphic Adenoma

- Canalicular Adenoma

- Basal Cell Adenoma

- Papillary Cystadenoma Lymphomatosum

- Oncocytoma

Pleomorphic Adenoma

What is the most common salivary gland tumor?

pleomorphic adenoma

ID the pathology:

- Asymptomatic

- Slow growing but great size potential

- Firm slowing

- May undergo maligant transformation

- Average duration until dx = 6 yrs

Pleomorphic Adenoma

ID the pathology:

Pleomorphic Adenoma

ID the pathology:

Pleomorphic Adenoma

Patient presents with firm swelling on the palatal mucosa. Patient is asymptomatic. Patient says they noticed the growth, but didn't realize it had gotten so big because it took a while to grow. Histopath report shows well-circumscribed/encapsulated, Double-layered ducts and Plasmacytoid cells. What is the diagnosis?

Pleomorphic Adenoma

What common salivary gland tumor is at risk of undergoing malignant transformation?

Pleomorphic Adenoma

ID the pathology based on the histology findings:

- Usually well-circumscribed if not encapsulated

- Double-layered ducts

- Plasmacytoid cells

Surgical excision

What is the treatment for Pleomorphic Adenoma?

false, small

T/F: Pleomorphic adenoma has a large risk of malignant transformation

Monomorphic Adenoma

ID the pathology:

- Term previously used to describe benign salivary gland tumors with similar histopathology

- - Canalicular Adenoma

- - Basal Cell Adenoma

Canalicular Adenoma

ID the pathology:

- 75% located on upper lip

- Female predilection 2:1

- Average age = 65; wide range (4th-9th decade)

upper lip

What is the most common location for a Canalicular Adenoma to present (75%)?

Canalicular Adenoma

ID the pathology based on the histology findings:

- Encapsulated or well-circumscribed

- Parallel cords of single cuboidal cells

- Forming double row "canals" with central lumina

parotid gland

What is the most common location for a Basal Cell Adenoma to present?

female

Basal Cell Adenomas have a ______ gender predilection

Basal cell adenoma

ID the pathology:

- Average age ~ 60 with range 3rd-9th decades

- More common in females

- Asymptomatic swelling

- Usually < 3 cm

- - Most common site is parotid gland

- Surgical excision

- Recurrences rare

(Basal cell adenocarcinoma may arise de novo, but some represent transformation of benign tumors)

What is the treatment for basal cell adenoma?

Warthin Tumor

ID the pathology

- Papillary cystadenoma lymphomatosum

male

Warthin Tumors have a ______ gender predilection

Warthin Tumor

What salivary tumor is associated with cigarette smoking?