4 Salivary Glad Pathology
Tiga 11-16~ Sialolithass, Soft tissue ndiogmph of the same
leon depietedin Rue Tl 15, A laminated called mass
res
gue 11-17. Sialoithinss Inrductalcaletied muss showing
‘comentic hi matons The dst exhibits squammus metaphsin.
‘Treatment and Prognosis
‘Small sialoiths of the major glands sometimes can be
treated conservatively by gentle massage of the gland in
‘aneffort to milk the stone toward the duct orifice. Siala-
g2gues (drugs that stimulate salivary flow). moist heat,
and increased fluid intake also may promote passage of
the done. Larger slaloliths usually naed to be removed
surgeally. If significant inflammatory damage has
‘ocurred within the feeding gland. the gland may need
tobe removed. Minor gland sialoliths are best treated by
surgial removal. including the associated gland
Salvary gland endoscopy is @ newer method that has
proven useful in the removal of some major gland sialo-
lths. This technique may be combi ned with mtracorpo-
‘sal lthotrpsy to help fragment the stones. Extracorpo-
real shock wave lithotripsy also has Beth used success-
fully in Europe and Japan for the management of some
pationts
SIALADENITIS
Inflammation of the salivary glands (sialadcnitts) can
arise from various infectious and noninfectious causes.
‘The most common viral infection is mumps (see page
233) although a numberof other viruses also can invoNe
the salivary glands. including Coxsackie A. ECHO.chorio~
meningitis. parainfluenza, and cytomegalovirus (in
neonates). Most bacterial infections arise as a result of
ductal obstruction or decreased calvary low. allowin gFet=
rograde spread of bacteria throughout the ductal system
Blockage of the duct can be caused by sialoithiasis (seo
age 393). congenital strictures. or compression by an
‘adjacent tumor. Decreased flow can result from dehydra-
tion, debiltaion, or medications that inhibit secretions
‘One ofthe more common causes of siladenits is recent
surgery (especially abdominal surgery), afterwhichan acute
parotts(sugjca/ mumps) may arise because the patient has.
been kept without food or fluids (NPO)and has received
atropine during the surgical procedure. Other medications
that produce xerstomiaasa sideeffect also can predispose
patients to such an infection. Most cases of acute bacterial
Saladentis are due to Staphylococcus aureus, but they also
may arise from streptococci or other organisms. Noninfec~
tious causes of salivary inflammation include Sjogren
‘syndrome (see page 401). sarcoidosis (see page 202)
radiation therapy (see page 261). and various allergens.
Clinical and Radiographic Features
‘Acute bacterial sialadenitis is most common in the
parotid gland and is bilateral in 10% to 25% of cases.
The affected gland is swollen and painful. and the over-
lying skin may be erythematous (Figure I-18). An asso-
ciated low-grade fever may be present, as well as
trismus. A purulent discharge often is observed from the
uct orifice when the gland is massaged (Figure 11-19.
Recutent or persistent ductal obstruction (most com-
‘monly caused by sialoliths) can lead to a chronic
sialadenitis. Periodic swelling and pain occur within the
affected gland, usually developing at mealtime when sal-
vary flow is stimulated. Salography often demonstrates
Sialectasia (ductal dilatation) proximal to the area of
obstruction (Figure 11-20). In the submandibular land,
persistent enlargement may occur (Karina tumor, which
's difficult to distinguish from a true neoplasm. Chronic
sialadenits also can occur in the minor glands, possibly
as a result of blockage of ductal flow o¢ local trauma.
‘Subacute necrotizing slaladenitis Is a recently rec-
gnized form of salivary inflammation that occurs mostTigure 11-18 Sialadeni
Uargland.
Tender sweling ofthe submandiy-
Figure 11-20 » Chronic saladents Parotid dalogram demon:
‘Statingduct dilatation proxtral to an area of obstruction
(Courtesy of De George Blais]
commonly in teenagers and young adults. The lesion
Usually invohes the minor salivary glands of the hard or
soft palate, presenting as a painful nodule that is cov-
‘red by intact, erythematous mucosa. Unlike necrotizing
sialometaplasia (see page 405), the lesion does not
LUlcerate or slough necrotic tissue. An infectious or allergic
cause has been hypothesized.
Histopathologic Features
In patients with acute sialadenitis, accumulation of neu-
trophils is observed within the ductal system and acini
Chronic sialadenitisischaracterized by scattered or patchy
Inflation ofthe salivary parenciyma by lymphocytes and
plasma cells. Atrophy of the acini is common, asis ductal
dilatation. Ifassociated fibrosis is present, the term chronic
sdlerosing sialadenitis is used (Figure 1121).
‘ORAL & MAXILLOFACIAL PATHOLOGY
Se
Figure 11-19 = Sialadenitis 4 purulent exedae can be seen
atsing from Stensen's duct when the pare land i massaged.
Figure 11-21 = Chronic sclerosing sialadontis, Chron inflam
‘matoryinfitate with sssocited achar atrophy ductal dilaton.
‘and ross.
Subacute necrotizing sialadenitis is characterized by
2 heavy mixed inflammatory infiltrate consisting of
neutrophils, lymphocytes, histiocytes, and eosinophils.
‘There is loss of most of the acinar calls, and many ofthe
remaining ones exhibit necrosis. The ducts tend to be
atrophic and do not show hyperplasia or squamous
metaplasia.
‘Treatment and Prognosis
The treatment of acute sialadenitis includes appropriate
‘antibiotic therapy and rehydration ofthe patient to stim:
ulate salivary flow, Sugical drainage may be neoded if
there is abscess formation Although this regimen is usu-
ally sufficient, a 20% to 80% mortality rate has bee
reported in debilitated patients because of the spreadot
the infection and sepsisCHAPTER L1+ Salivary Glafta Pathology
‘The management of chronic sialadenitis depends on
the severty and duration of the condition. Early cases
that develop secondary to ductal blockage may respond
toremoval ofthe sialolith or other obstruction. If sialec-
‘asia is present. the dilated ducts can lead to stasis of
secetions and predispose the gland to further sialolith
formation. If sufficient inflammatory destruction of the
salivary tissue has occurred. surgical removal of the
affected gland may be necessary.
Subacute necrotizing sialadenitis is a self-limiting
condition that usually resolves within 2 weeks of diag-
resis without treatment.
CHEILITIS GLANDULARIS
Challitis glandulatis isa rare inflammatory condition of
the minor salivary glands. The cause is uncertain,
although several etiologic factors have been suggested,
Including actinic damage, tobacco, syphilis, poor
hygiene, and heredity.
Clinical Features
Chelitis glandularis characteristically occurs on the
lower lip, although there are also purported cases
invdving the upper lip and palate. Affected individuals,
experience swelling and eversion of the lower lip as a
result of hypertrophy and inflammation of the glands
(Figure 11-22). The openings of the minor salivary ducts
areinflamed and dilated, and pressure on the glands may
produce mucopurulent secretions from the ductal open-
ings. The condition most often has been reported in
middle-aged and older men. although cases also have
teen described in women and children. However, some
ofthe childhood cases may represent other entities, such
as exfoliative cheilits (see page 266),
Historically. chellitis glandula ris has been classified
into three types. based on the severity of the disease:
1. Simple
2. Superficial suppurative (Baelz’s disease)
3. Deep suppurative (cheilitis gland ularis. apostern
alosa)
The latter two types represent progressive stages of
‘he disease with bacterial involvement and are charac-
terized by increasing inflammation, suppuration. ulcer-
‘aon. and swelling of the tip
Histopathologic Features
‘The microscopic findings of cheilitis glandularis are not,
‘specific and usually consist of chronic sialadenitis and
duct dilatation. Concomitant dysplastic changes may
2 observed in the overlying surface epithelium in some
397
Figure 11-22 + Chelitisglandulais.Prominontlonor Ip with
Inflared openings ofthe miner sdivarygland ducts An early
‘squamous cellcarchom has devebped on the patient’ lft side
jus lateralto the midline (aro), (Courtesy of Dr. George Bbzis)
‘Treatment and Prognosis
The treatment of choice for most cases of persistent
hells glandula is associated with actinic damage is
vermilionectomy (lip shave), which usualy produces a
salisfactory cosmetic result A significant percentage of
cases 18% to 35%) have been associated withthe deve
‘opment of squamous cell carcinoma of the overlying
epithelium of the lip. Because actinic damage has been
implicated in many cases of cheilts glandularis, itis
likely that this same solar radiation is responsible for the
malignant degeneration,
SIALORRHEA
Sialorthea, or excessive salivation, is an uncommon
Condition that has various causes. Minor sialorrhea may
result from local irritations, such as aphthou s ulcers or
iILfitting dentures. Patients with new dentures often
ince excess saliva production until they become
accustomed to the prosthesis. Episodic hypersecretion
of saliva, or "water brash,” may occur as a protective
buffering system to neutralize stomach acid in individ-
uals with gastroesophageal reflux disease. Sialorrhea is
‘a well-known clinical feature of rabies and heavy metal
poisoning (see page 272). It also may occur as a conse-
‘quence of certain medications, such as lithium and
cholinergic agonists,
Drooling can be a problem for patients who are men=
tally retarded, who have a neurologic disorder such as
cerebral palsy, or who have undergone surgical resec-
tion of the mandible. In these instances. the drool ng is
probably not caused by overproduction of saliva but to
oor neuromuscular control.