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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 most Tigure 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 sepsis CHAPTER 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.

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