口腔頜面外科學(xué)：Chapter 9 Salivary gland disease

1、Chapter 9 Salivary gland disease Salivary can be divided into two groups:Major glands: Paired structures as Parotid glands, Submandibular glandsSublingual glandsMinor glands: Located in mucosa of oral cavity, larynx, nasal cavity, maxilla sinus. Minor salivary glands in oral cavityAccording to its l

2、ocation, minor salivary glands in oral cavity can be divided as: Labial, buccal, palatine, tonsillar, retromolar and lingual glandsFunction of salivary gland:All of the salivary glands can secrete saliva.The salivary glands produce approximately 1000 to 1500ml of saliva per day.The function of saliv

3、a is as follows:Provide lubrication for speech and mastication, digestion;protect oral mucosa; prevent caries of teeth. Content of this chaptersalivary glands:Inflammation; Trauma; Salivary tumors of Epithelial origin; Tumor-like lesion.Part 1. SialadenitisAccording to character of infection, sialad

4、enitis can be divided as follows:PyogenicViralSpecific infection 1.Acute pyogenic(Suppurative) parotitisIt was usually called Postoperative Parotitis.Etiology :Salivary gland infections may be caused by a variety of organisms, including aerobic and anaerobic bacteria, viruses et al.The single most c

5、ommon organism implicated in salivary gland infection is Staphylococcus aureus EtiologyThe cause of acute pyogenic parotitis usually involves a change in fluid balance that is likely to occur in patients who are elderly, dibilitated, malnourished, dehydrated, or plagued with chronic illness, bad ora

6、l hygiene, severe system disease, metabolic disease, major abdominal surgery, et al. EtiologyThe incidence rate of acute pyogenic sialadenitis of submandibular gland post operation is less than that in parotid gland. It is possible that the adherin protein in saliva of submandibular is higher than t

7、hat in parotid gland and adherin has strong antibacterial property. EtiologySecondary Acute Parotitis :Injury of parotid glandExpansion of adjacent inflammationAcute inflammation of lymph node in parotid gland area. Pathological ExaminationEarly stage:Acute inflammation of duct: swelling of duct epi

8、thelia cell; narrow of duct; obstructive substance caused by bacteria, cell and separated epithelial cells. Late stage:White cell infiltration around duct, damage of duct epithelial cell; abscess foci formation and lose of acinus. SymptomUsually be unilateral. At early stage: symptom is not obvious.

9、Developing stage: enlargement of parotid gland with associated induration and tenderness; Swelling and pain at duct orifice. SymptomAbscess stage (Necrosis of gland tissue):Severe pain in parotid gland area upon application of pressure. The gland become sore and tense.Purulent saliva and pus can be

10、seen at the duct orifice, especially with massage of the gland; Swelling and redness of overlying skin; Slight obstacle in mouth open; SymptomObvious systemic symptom: Patients temperature may rise;increase in pulse and breath rate; The blood picture reflect the relative toxicity of the infection;WB

11、C SymptomAt late stage:multiple abscess formation;Infiltration mass at parotid gland area;Severe pain with high pressure; Infection can break parotid membrane and expand to adjacent tissue or space;After drainage or break through skin, saliva fistula formation can be seen Diagnosis and Differential

12、Diagnosis According to history and clinical examination, diagnosis can be made.MumpsMasseteric space infection PreventionNursing;Hydrate balance;Nutrition;Anti-infection;Oral hygiene TreatmentSupportive care: Correct disorders. IV fluid hydration and Amino acid;Sensitive antibiotics usage: Culture a

13、nd sensitivity studies of purulent material should be obtained to aid in selecting the most appropriate antibiotics for each patient. Penicillin and Cephoradin should be used for S.aureus infection. Antibiotics should be administrated IV in high doses for the majority of these patients. Treatment3.

14、Other conservative treatment: physical treatment, vitamin C, pilocarpine, NaHCO3, et al.4. Surgery consisting of incision and drainage become necessary on most occasions. Treatment2.Chronic recurrent parotitisAlso called chronic pyogenic parotitis (include chronic obstructive parotitis) before. Etio

15、logyCongenital development disorder: Family history, structural disorder of parotid gland, immune deficiency.Abnormality of self-immune: Allergy historyRetrograde infection of bacteria: upper respiratory duct infection or oral infection.PathologyAt early stage: lesions occur at duct system;The duct

16、system dilate; exerts pressure to adjacent gland; Obstruction and stasis increase the pressure. PathologyAt middle stage:Inflammation infiltration around duct;Atrophy and fibrosis of the gland occur;Expansion of duct near gland;At late stage:Damage of acinus;Replaced by fat and connective tissure. S

17、ymptomCommonly seen in children around 5 years.Male more than female.Sudden onset or chronic progression;With no obvious underlying cause.Recurrent swelling and uncomfortable of parotid gland;Pus can be seen at duct orifice with massage of the gland;Abscess formation in few patient;Recurrent history

18、. Diagnosis and Differential DiagnosisAccording to symptom and sialography.Recurrent pain and enlargement of gland history, point silate of duct.MumpsSjogren syndrome TreatmentThe disease may disappear or continue into adulthood.No active treatment is usually needed;Enhance resistance ability;Preven

19、t infection;Reduce the recurrence;Drink more water;Massage of the gland TreatmentRinse with Sodium Chloride solution;Improve oral hygiene;Gum usage;Antibiotics during acute recurrence;Sialogram. 3. Chronic obstructive parotitis EtiologyLocal lesion is the most common etiological factor.Injury of ora

20、l mucosa near duct orifice induce scar formation and narrow of duct;Improper denture;Salivary gland stone. PathologyDuct silate;Atrophy of acinus;Sialometaplasia of duct epithelia;Infiltration of lymphocyte around duct;Mini stone formation. SymptomMale more than female;Frequently occur in adult;Most

21、 cases are unilateral, bilateral is rare;The accurate original time is not sure;Gland swell, especially at mealtimes;Gland become tense and sore;Swelling and tenderness may subside;Pus may be seen at the orifice;Slight pain.SymptomPus or cloudy saliva may be obtained by milking the gland;The stone m

22、ay be palpable by bimanual manipulation and may be movable up and down the duct;The stone may be visualized in radiographs;Dilation at the site of the stone and of the duct in a sialogram. Diagnosis and Differential DiagnosisAccording to symptom and sialogram.Adult chronic recurrent parotitis;Sjogre

23、n syndrome combine with secondary infection Treatment1. Remove etiological factor2. Duct dilation3. Drug injection into duct4. Physical treatment Treatment Surgery:Duct orifice ligation;Parotidectomy. DISCUSSION 4. Sialolithiasis and infection of submandibular gland Sun Yat-sen Memorial HospitalSun

24、Yat-sen University2017 - 02 DefinationThe formation of stones, or calculi, in salivary gland or duct system.85% occur in submandibular gland, then parotid gland, rare in minor gland at labial and buccal mucosa.Salivary stone, or sialolith, induce obstruction of saliva excrete, cause secondary infect

25、ion of related salivary gland.EtiologyThe reason of sialoth formation is not sure. It may be related to local factors, such as foreign body, inflammation, saliva detaining, calcium metabolism disorder, salt precipitation ,et al.The most popular theory of sialolith formation is that an accertion of m

26、ineral salts forms in and around a soft plug of mucus, bacteria, or desquamated epithelial cells. EtiologyThe incidence of stone formation varied, depending on the specific gland involved.The submandibular gland involved in 85% of cases, which is more common than all other glands combined. The relat

27、ed factors are as follows: 1.The concentration of calcium is about twice as abundant in submandibular saliva as in parotid saliva, adherin protein is also abundant and alkaline pH of submandibular saliva may further support stone formation.2. Several anatomic factors of the submandibular gland and d

28、uct are important. Whartons duct is the longest salivary duct. The duct of submandibular gland has two sharp curves in its course. Etiology3. Its small orifice is the most elevated location, and its flow therefore occurs against the force of gravity, contribute to a slowed salivary flow. Precipitate

29、d material, and cellular debris are more easily trapped in. it is benefit to sialolith formation.SymptomNo difference in gender. Frequently seen in 20-40 younger. History from several days to several decades.Mini stone can not cause obstruction and without symptom. The systems are as follows when ob

30、struction induced:SymptomSwell and pain in related gland , particularly at mealtimes, sometimes with severe pain;Redness and erythema of duct orifice. Pus can be seen while massage of gland; The clinical manifestations of the presence of submandibular stones become apparent when acute ductal obstruc

31、tion occurs.Symptom4.The stone may be palpable by bimanual manipulation; Inflammation infiltration in underlying mucosa.5. Secondary gland infection can be induced and occur repeated. Infection can expand to adjacent submandibular space.6. In chronic infection of submandibular gland, the symptom is

32、slight, repeated swell, hard mass in submandibular area, Pus saliva at orifice.Diagnosis and Differential DiagnosisAccording to symptom and clinical examination.Repeated swell and pain. Radiograph is necessary.Sublingual gland tumor;Submandibular gland tumor;Chronic infection of submandibular gland;

33、Infection of submandibular lymph node;Infection of submandibular space.TreatmentPrinciple: remove stone, remove obstruction factor, preserve submandibular gland.Conservative treatment;Surgery;Excision of submandibular gland;Excision of Submandibular gland1.Incision;2.Ligation of facial artery and in

34、ferior facial vein;Excision of Submandibular gland3.Separate gland, ligation of paracentral facial artery, preserve sublingual nerve;4.Ligation and cut wathons duct, preserve lingual nerve;Excision of Submandibular gland5.Suture the incision;6.Postoperative management; 5. Specific infection of Saliv

35、ary glandSun Yat-sen Memorial HospitalSun Yat-sen University2017 - 02 The most common specific infection of salivary gland is as follows:1. Tuberculosis;2. Actinomycosis;3. Sarcoidosis.1. Tuberculosis of salivary glandsEtiology: Tuberculosis of lymph node in parotid region and break through membrane

36、, the salivary gland was involved.The incidence rate is higher recently.Infection pathway:Blood;Lymph drainage;Retrograde.Classification:1. Primary tuberculosis of the salivary glands2. Secondary tuberculosis of the salivary glands Location:The most common site is parotid gland, then submandibular g

37、land. It is rare in sublingual gland and minor salivary gland. SymptomIn tuberculosis of lymph node, the symptom is not significant. Localized mass with clear border and movement, thought to be benign tumor.In some patients with slight pain.In tuberculosis of salivary gland, with short history, swel

38、l of the related gland. Pus can be seen at the orifice when milking the gland. SymptomMass can be hard or soft;Adhesion to skin;Fistula formation;Facial paralyze. DiagnosisAcid-fast salivary stain;Purified protein derivative (PPD) skin test;Fine needle aspiration cytology; TreatmentMass excision;In

39、abcess of tuberculosis, aspirate the pus, anti-tuberculosis drugs be used.System treatment. 2. ActinomycosisActinomycosis of salivary gland is a kind of chronic pyogenic granulomatous disease. It is rare in clinic. EtiologyIsraelii infection.Retrograde infection.Classified as primary actinomycosis a

40、nd secondary actinomycosis. SymptomWith long history;Hard mass and without clear border;Dark brown-red skin;System symptom is not significant;Multiple fistula formation;Sulfur granule can be seen in pus. TreatmentAntibiotics and Sulfonamide are effective.Penicillin G.Kalii Iodidum.Surgery: Drainage

41、of pus and remove granulation tissue.Hyperbaric oxygenation.3. SarcoidosisSarcoidosis is a granulomatous disease of unknown etiology. It is systemic and with abnormality of immune function. PathologyGranular tissue consisted of epithelial cell, without necrosis.Bilateral in parotid gland. SymptomSwe

42、ll of parotid gland;Hard mass without pain;In the early stage of 40% patient, only swell of pulmonary hilar lymph node and mediastinal lymph node.Kveim skin test is positive;Pathologic diagnosis. Treatment1. In localized lesion, Surgery is effective.In systemic cases, hormone treatment can be used.H

43、eerfordt syndrome can be treated with hormone. Section 2. Injury of salivary gland and salivary fistulaThe Second Affiliated HospitalSun Yat-sen University2017-02Location of lesions: Parotid gland and duct;Rare in submandibular gland and sublingual gland.Salivary fistula:Saliva was excreted into ora

44、l cavity or facial skin outside the duct system.The most common site of saliva fistula is parotid gland. Etiology of salivary fistulaInjury is the main etiological factor;Operation;Pyogenic infection;Other disease.SymptomSalivary fistula of gland body:fistula of skin in parotid area;Scar;Clear saliv

45、a from fistula;The quantity of saliva increase during meal time;Saliva from orifice is normal. SymptomSalivary fistula of duct:Occur in duct part.Complete fistula and incomplete fistula.Clear saliva or pus during infection;Up to 2000ml per day;Redness and ulcer of skin around fistula. DiagnosisAccor

46、ding to history and symptom.Clinical examination.Parotid gland sialogram. Treatment1.Tight package in fresh fistula;2.Remove fistula and damage epithelia, then tight package; Atropine be used orally;3.Fistula closure. Section 3. Sjogren syndromeSjogren syndrome is an autoimmune disease, which charac

47、terized by lymphocytic infiltration and acinar destruction of salivary and lacrimal glands, induce xerostomia (dry mouth) and xerophthalmia (dry eyes). Sjogren syndrome is classified into two groups: Primary sjogren syndrome:exocrine glands destruction only and leading to dry mouth and dry eyes.Seco

48、ndary sjogren syndrome:The triad of xerostomia, xerophthalmia, and a connective tissue disease (usually rheumatoid arthritis). Etiology and PathologyThe exact etiological factor and mechanism of sjogren syndrome is not sure. It maybe related to following factors:Congenital abnormality of immune syst

49、em, such as the abnormality of B cell, T cell.The change of antigen at the surface of related cell induced by viral disease.The result induced by abnormality of immune system and acquired etiological factor. PathologyAtrophy of related acini; Lymphocytic infiltration;Epimyoepithelial islands. Pathol

50、ogy Early stage: Lymphocytic infiltration around intralobular duct, localized acini atrophy;Middle stage:Obvious lymphocytic infiltration and acini atrophy, duct epithelial metaplasia and proliferation of epimyoepithelial cell;Late stage:Epimyoepithelial islands formation, expansion and disappear of

51、 duct, destruction of lobules. SymptomOccur predominantly in middle aged women over 40 years (the female: male ratio is 9:1). The period from symptom occurring to diagnosis varies in patients.The common complain is xerostomia (dry mouth) and xerophthalmia (dry eyes), swelling and enlargement of paro

52、tid gland and lacrimal gland, reumatoid arthritis et al. SymptomKeratoconjuctivitis sicca manifests as dryness of the eyes with conjunctivitis, and cause a gritty, burning sensation Symptom2. Oral cavity: Atrophy of lobules, decrease of saliva secretion, induce xerostomia: Dryness and soreness of th

53、e mouth, burning oral discomfort; difficulty in swallowing and speaking, increased fluid intake, diturbances of taste. The oral mucosa appears dry, smooth, redness, and glazed. Rapidly progressive dental caries. Lingual change maybe prominent. The dorsum of the tongue often appearing red and atrophi

54、c and showing varying degree of fissuring and lobulation. Symptom3. Enlargement of salivary gland: Salivary enlargement is very variable. The most common site is parotid gland, with/without enlargement of submandibular gland, sublingual gland and minor gland. The enlargement is usually bilateral, oc

55、casionally unilateral, is seldom pain. Less or no saliva secretion at the orifice during milking the gland. Secondary retrograde infection can occur, with repeated swell, slight pain. Pus can be seen at the orifice of parotid gland. Granular mass can be found in some cases, single or multiple, with

56、unclear border, called granular sjogren syndrom. Symptom4. Expression of other related excrete gland: otherwise salivary gland and lacrimal gland, glands in upper and lower respiratory duct, skin, nasal mucosa can be invaded. Dry throat, nasal cavity, cough, dryness and atrophy of skin.Symptom5. Dis

57、ease of connective tissue: Half patients suffered from rheumatoid arthritis ; 10% patients suffered from systemic lupus erythematosus(SLE); In some patients with dermatasclerosis and polymyositis. Symptom6. Other complications: Renal tubular insufficiency; Renal tubular acidosis; Otitis media; Perip

58、heral neuritis; polymyositis; Myasthenia gravis; Arteriolitis; Raynauds phenomenon; Hashimotos thyroiditis.DiagnosisAccording history and physical examination. Some special test as follows:1. Schirmers test: detect the function of lacrimal gland;2. Tetra-iodofluorescein(Rose bengal) stain;3. Salivar

59、y flow rate study;4. Sialogram; Diagnosis5. Nuclein function detection;6. Laboratory test: Blood sedimentation become fast; gamma globulins increase; Ig G increase; Ig M and Ig A maybe increase; rheumatoid factor, antinuclear antibody (ANA), anti-SS-A, anti-SS-B maybe positive. Diagnosis6. Labial gl

60、and biopsy: lymphocytic infiltration of lobules, atrophy of acini, expansion of duct, metaplasia of duct epithelial cell. Epimyoepithelial island is rare to see. Change can be seen at rheunoid arthritis and SLE. Treatment1. Conservative treatment.0.5% methyl cellulose be used for treatment of dry ey