Category Archives: Diagnosis and Management of Salivary Gland Disorders

OBSTRUCTIVE SALIVARY GLAND DISEASE

OBSTRUCTIVE SALIVARY GLAND DISEASE

Sialolithiasis
The formation of stories, or calculi, may occur throughaut the body, including the gallbladder, urinary tract, and salivary glands. The occurrence af salivary gland stories is twice as common in men, with a, peak incidence between ages .30 and SO. Multiple stone formation Occurs in approximately 25’VcIof patients. The pathogenesis of salivary calculi progresses through a seriesof stages beginning with an abnormality In calcium metabolism and salt precipitation, with formation of a nidus that subsequent ly becomes layered with organic and inorganic material,
to. farm a calci fied mass.
‘The incidence of stone formation varies. depending o,n the specific gland involved (Box 20-31. The submandibular gland is involved in 85% of cases, which is more cornman than all other glands cornbinecl.A varietv of factors contribute to the higher incidence ot submandibular calculi.
Salivary gland secretions contain water, electrolytes, urea, ammoma, glucose, fats, proteins, and other substances; in general. parotid secretions are more concentrated than those of the other salivary glands, The main
exception is the concen ration of calcium, which is about twice as abundant, in su bmandibular saliva as in parotid

Sialolithiasis

Sialolithiasis

sallva (see Table 20-2), In addition, the alkaline pH ofsubmandibular saliva may further support stone formation, In addition to salivary composition, several anatomicIactors of the submandibular gland and duct are important, Wharton’s ‘duct is the longest salivary duct; therefore saliva
has a greater distance to travel before being emptied into the oral cavity. In addition, the duct of the submandibular gland has two sharp curves in its course: The first otcurs at the posterior border of the mylohyoid mus-
. de, and the second is near the ductal opening in the anterior floor of the mouth. Finally, the punctum of the submandibular duct is smaller than the opening of Stensen’s duct. These features contribute to a slowed salivarv flow and provide potential areas of stasis 01 salivarv flow, or obstruction. that is not found in the parotid or sublingual ductal systems, Precipitated material, mucus, and cellular debris are more easily trapped in the tortuous and lengthy submandibular duct, especially when its
small orifice is its most elevated location, and its flow the-refore occurs against the force of gravity. The precipitated material forms the nidus of mucous plugs and either radiopaque or radiolucent sialoliths that may eventually  enlarge to-the point of obstructing the flow of saliva
from the gland to the oral cavity.

The clinical, manifestations of the presence of sub:
mandibular stones become apparent when acute ductal

FIG, 20- 13 A, Labial salivary gland biopsy, Thelower lip is everted and controlled v.ith a Chalazion clump. An incision throuqh mucosa permits visualization of the minor salivary glands (attcws). B, The minor salivary glands are -removed and subnl'+-' nr{ fnr histoo.u! tno;c aSSPSCimpnt

FIG, 20- 13 A, Labial salivary gland biopsy, Thelower lip is everted and controlled
v.ith a Chalazion clump. An incision throuqh mucosa permits visualization of the
minor salivary glands (attcws). B, The minor salivary glands are -removed and subnl’+-‘
nr{ fnr histoo.u! tno;c aSSPSCimpnt

FIG. 20-14 Clinical photograph demonstrates a right submandibular swelling (arrow) secondary to' obstruction from a submandibular sialolith.

FIG. 20-14 Clinical photograph demonstrates a right submandibular
swelling (arrow) secondary to’ obstruction from a submandibular
sialolith.

BOX 20-4
Sialolithiasis for the General Dentist
Classic signs and symptoms of sialolithiasis’
• Exacerbation of pain and swelling at mealtimes
• Check for flow from Wharton’s duct
• Check for tenderness of submandibular gland
• Palpate for stone in floor of mouth
• Check mandibular occlusal radiograph
.Treatment ‘
Anterior stone
• Attempt to dilate Wharton’s duct with lacrimal probes
• Careful to not dislodge stone .posteriorly
• “Milk” the gland to express stone
• If successful, prescribe salivary stimulants
Posterior stone or no stone visualized
I: Refer to oral surgeon

obstruction occurs at mealtime, when saliva production is at its maximum and salivary flow is stimulated against a fixed obstruction. The resultant swelling-is sudden and is usually very painful (Box 20-4; Fig. 20-14). Gradual reduc- . tion of the swelling follows, but swelling reoccurs repeatedly when salivary flow is stimulated. This process may
continue until complete obstruction, infection, or both occurs. Obstruction, with or without infection, causes atrophy of the secretory cells of the involved gland. Infection . of the gland manifests itself by swelling in, the floor of the mouth, erythema, and an associated lymphader.opathy, Palpation of the gland and simultaneous examination of
the duct and its opening may reveal the total absence of salivary flow or the presence of purulent material.

The management of submandibular gland calculi depends on the duration of symptoms, the numbe of repeated episodes, the size of the stone, and, perhaps most importantly, _toe location of the stone. Submandibular
stones a  e classified. as either anterior or posterior stones, in relation to a transverse line between the mandibular first molars. Stones that occur anterior to this line are generally well visualized on a mandibular occlusal radiograph and may be amenable to intraoral removal. Small anteriorly located stones may be retrieved through the ductal opening after dilation of the orifice.

Salivary gland calculi occur much less commonly in the parotid gland. In general, parotid gland infection usually leads to stone formation; the opposite, however, is the case for the submandibular gland. The parotid gtand is examined by inspection and palpation of the gland extraorally
over the ascending mandibular ramus. Stenscu’s duct and its orifice can be examined intraorally. Palpation of the gland and simultaneous observation of the duct allow observation of salivary flow or the production of other
.matcrial, such a  purulence, from the punctum reproduct. Parotid sialoliths found in thedistal third of Stensen’s duct that can be palpated intraorally may be removed after

FIG. 19- 1~cont' d 0, Large oroantral communication in left maxilla that developed after removal of second molar tooth. E, Palatal flap outlined. Flap is posteriorly based and receives its blood supply from anterior palatine neurovascular bundle. Width of flap is much larger than clinical oroantral communication. F, Palatal flap is elevated and readied for transposition laterally to cover osseous oroantral defect. Buccal mucosa has also been elevated to facilitate suturing of flap. Larye size ot"osseous defect is demonstrated

FIG. 19- 1~cont’ d 0, Large oroantral communication in left maxilla that developed after removal
of second molar tooth. E, Palatal flap outlined. Flap is posteriorly based and receives its
blood supply from anterior palatine neurovascular bundle. Width of flap is much larger than
clinical oroantral communication. F, Palatal flap is elevated and readied for transposition laterally
to cover osseous oroantral defect. Buccal mucosa has also been elevated to facilitate suturing
of flap. Larye size ot”osseous defect is demonstrated

FIG. 19-14-cont'd G, Palatal flap has been 'rotated laterally and sutured in place. Osseous defect is well covered. Small area of exposed bone near palatal midline will heai by secondary intention. H, Well-closed oroantral communication 4 weeks after rotation of palatal flap. Vestibular depth is maintained with this procedure. Metallic-foil closure of oroantral communications

FIG. 19-14-cont’d G, Palatal flap has been ‘rotated laterally and sutured in place. Osseous
defect is well covered. Small area of exposed bone near palatal midline will heai by secondary
intention. H, Well-closed oroantral communication 4 weeks after rotation of palatal flap. Vestibular
depth is maintained with this procedure. Metallic-foil closure of oroantral communications

. ,~, 19· i:; Metallic-foil closure of oroantral communications. A, Diagrammatic illustration of. oroantral fistula in right maxillary alveolar process in region of missing first molar tooth, which is to be closed with subperiosteal placement of metallic-foil "patch." 8, Botl') facial and palatal mucoperiosteal" flaps are developed. When elevated, these provide ample exposure of underlying atveolar process and fistulous tract. Fistulous tract is excised. Osseous margins must be exposed 360 degrees ,around bony defect to allow placement of metallic-foil patch beneath, mucoperiosteal flaps. Flap is supported on all sides by underlying bone. C, Metallic-foil patch has been adapted to cover osseous defect and positioned between alveolar process and overlying buccal and palatal mucoperiosteal flaps. Foil should be supported on all its margins by sound underlying bone. Mucoperiosteal flaps have been repositioned , and sutured over foil. D, Cross-sectional diagram of metallic-foil closure technique. Both buccal and palatal mucoperiosteal flaps are elevated to expose osseous defect and large area of underlying alveolar borie around oroantral communication.

FIG 20-19· i:; Metallic-foil closure of oroantral communications. A, Diagrammatic illustration of.
oroantral fistula in right maxillary alveolar process in region of missing first molar tooth, which is to be
closed with subperiosteal placement of metallic-foil “patch.” 8, Botl’) facial and palatal mucoperiosteal”
flaps are developed. When elevated, these provide ample exposure of underlying atveolar process and
fistulous tract. Fistulous tract is excised. Osseous margins must be exposed 360 degrees ,around bony
defect to allow placement of metallic-foil patch beneath, mucoperiosteal flaps. Flap is supported on all
sides by underlying bone. C, Metallic-foil patch has been adapted to cover osseous defect and positioned
between alveolar process and overlying buccal and palatal mucoperiosteal flaps. Foil should be
supported on all its margins by sound underlying bone. Mucoperiosteal flaps have been repositioned
, and sutured over foil. D, Cross-sectional diagram of metallic-foil closure technique. Both buccal and
palatal mucoperiosteal flaps are elevated to expose osseous defect and large area of underlying alveolar
borie around oroantral communication.

FIG 19-15

FIG 19-15

F!G. 19-15-cont'd I, Palatal and buccal mucosal flaps are sutured in plac.e over metallic-foil patch. Flaps are minimally advanced, and no real attempt is made to close mucosa primarily over foil. J, Four weeks after closure of right maxillary oroantral defect with the foil patch procedure. Area is well healed. Normal vestibular depth and palatal anatomy are maintained.

F!G. 19-15-cont’d I, Palatal and buccal mucosal flaps are sutured in plac.e over metallic-foil
patch. Flaps are minimally advanced, and no real attempt is made to close mucosa primarily
over foil. J, Four weeks after closure of right maxillary oroantral defect with the foil patch procedure.
Area is well healed. Normal vestibular depth and palatal anatomy are maintained.

 BIBIOLOGY


Bergeron RT, Osborn AG, Sorn P:-‘l, editors: Head oiu! neck
imaging, St Louis, 1984, Mosby.
Ritter FN: Tile paranasal sinuses: IIlIotOJII), and surgica! technique,
St Louis, 1978, Mosby, ‘
Scott JH, Dixon AD: Anatomy for students of (IItistf): Baltimore,
1972,.WilIiams &. ilki·ns.

Sieher H, editor: Orbllll:\ oral Ilistolog), and elllbr)’l1loS.I; St Louis,
1961, :-‘Ic.)sby.
Sicher H, Dullrul EL: Oral ollatoll~St Louis, 1970, :-‘fosby.
Topazran J{G, Goldberg :-’11-[,Hupp JR: Dtul and IIIt/xil/o/j/,illl
infections, cd 4, Philadelphia, 2002, \VB Saunders.

 

 

 

 

 

 

 

 

 

DIAGNOSTIC MODALITIES

DIAGNOSTIC MODALITIES

History and Clinical Examination

The most important component of diagnosis in. salivary gland disorders, as with most other disease processes, is the patient history and the clinical examination. In most cases the patient will guide the doctor to the diagnosis
merely by relating the events that have occurred in association with the presenting complaint. The astute clinician must perform a thorough evaiuation, and, in many – instances, the diagnosis Gin be determined without the necessity of further diagnostic evaluation. At the very least, the clinician may be able to categorize the problem as reactive, obstructive, inflammatory, infectious, metabolic, neoplastic, developmental, or traumatic in origin  and guide further diagnostic testing. Occasionally, the clinician may find it riecessary to use any of several diagnostic  dalities.

Salivary Gland Radiology
Plain film ‘raaiogmphs. The primary purpose of plain films in the assessment of salivary gland disease is to identify salivary stones (calculi), although only 80% to 8S% of all stones are radiopaque and therefore visible
radiographically. The incidence of radiopaque stones varies, depending on the specific gland involved (Box 20-2). A mandibular occlusal film is most useful for detecting sublingual and submandibular gland calculi in
the anterior floor of the mouth (fig. 20-4, A). A “puffed cheek view,” in which the patient forcibly blows the cheek laterally to distend the soft tissues overlying the lateral ramus, can demonstrate parotid stones. Panoramlc radiographs can reveal stones in the parotid gland and
posteriorly located submandibular stones (Fig. 20-S).

FIG. 20-5 Panoramic radiograph demonstrates a right submandibular sialolith (arrows).

FIG. 20-5 Panoramic radiograph demonstrates a right submandibular sialolith (arrows).

Periapical radiographs can show calculiin each salivary gland or duct, including minor salivary glands, depending on film placement. In most instances, the radiographic image corresponds in size and shape to the actual stone’ (see Fig. 20-4, B).

Sialography is a technique in which the salivary duct is. cannulated with a plastic or metal catheter (Fig. 20-6), a radiographic contrast medium is injected into the due- # tal system and the substance of the gland, and a series of radiographs are obtained during this process. Approximately
O.S to 1 nil of contrast material can be injected into the duct and gland before the patient begins to experience pain. The two types of contrast media available for ‘ sialographic studies are water-soluble and oil-based. Both types of contrast material contain relatively high concentrations
(25% to 40%) of iodine. Most clinidans prefer to use water-soluble media, which are more miscible with salivary secretions, more easily injected into the finer portions of the ductal system, and more readily eliminated
from the gland after the study is completed, either by drainage through the duct or systemic absorption from ,the gland and excretion through the’ kidneys. The oilbased media are more viscous and’ require. a higher injection pressure to visualize the finer ductules than do the
water-sol ble media. As a result, they usually produce more 5iiscomfort to the patient during injection. Oilbased media are poorly eliminated from the ductal system  and may cause iatrogenic ductal obstruction.

A complete sialogram consists of three distinct phases depending on the time at which the’ radiograph is obtained after injection of.the contrast materia

l 1. Ductal phase (Fig. 20-7), which occurs almost
immediately after injection of contrast material and allows visualization of the major ducts .

2. Acinar phase (Fig. 20-8), which begins after the
, ductal system has become fully opacified with contrast and the gland parenchyma becomes filled .I , subsequently

3. Evacuation phase, which assesses normal secretary
clearance function of the gland to determine
“whether any evidence, of retention of contrast
remains in the gland or ductal system after the,
sialogram

FIG. 20-6 Cannulation of Sterisen's duct with a plastic catheter

FIG. 20-6 Cannulation of Sterisen’s duct with a plastic catheter

FIG. 20-7 Ductal phase of a submandibular sialogram. Contrast rs contained only within the main salivary ducts (arrows).

FIG. 20-7 Ductal phase of a submandibular sialogram. Contrast rs
contained only within the main salivary ducts (arrows).

FiG, 20-8 Acinar phase of a submandibular sialogram. 'Of. a arborization of the entire ductal system of the gland (arrow) IS , demonstrated.

FiG, 20-8 Acinar phase of a submandibular sialogram. ‘Of. a
arborization of the entire ductal system of the gland (arrow) IS
, demonstrated.

FIG. 20-9 Sialogram of right submandibular gland. Obstruction of duct by- a radiolucent sialolith (arrows) has caused dilation of the duct and loss of normal parenchyma of the gland.

FIG. 20-9 Sialogram of right submandibular gland. Obstruction of duct by- a radiolucent
sialolith (arrows) has caused dilation of the duct and loss of normal parenchyma of the gland.

FIG 20-10 Sialogram of right parotid giand: The characteristic: "sausage link;' appearance of the duct is demonstrated, which indicates ductal damage from obstructive disease with irregular narrowing of duct caused by reparative fibrosis.

FIG 20-10 Sialogram of right parotid giand: The characteristic: “sausage link;’ appearance of
the duct is demonstrated, which indicates ductal damage from obstructive disease with irregular
narrowing of duct caused by reparative fibrosis.

The retention of contrast in the gland or ductal system beyond 5 minutes is considered abnormal normal sialogram shows a Iargeprimary duct branching gradually and smoothly into secondary and terminal ductules.
Evenly distributed contrast will result in opacification of the  cinoparenchyma that will outline the gland and its lobules, When a stone obstructs a salivary duct. continu cretion by the gland .produces  istension of the ductal system proximal to the obstruction and finallyleads to pressure atrophy of the parenchyma of the gland (Fig. 20-9).

Sialodochitis is a dilation of the salivary duct secondary to epithelial atrophy as a result of repeated inflammatory or infectious processes, with irregular narrowing caused by reparative fj.brosis (sausage link paftern)
(Fig. 20-10). Sialaden,i.tis represents inflammation mainly involving the aclnoparenchyma of the gland. Patients with sialadenitis experience sacculardilation

FIG. 20-11 Sialogram of right parotid gland illustrates "ball-in-hand" phenomenon (arrows). The lil,ling defect in this sialogram .locetes a tumor of the gland with displacement of normal surrounding ductal anatorny..,

FIG. 20-11 Sialogram of right parotid gland illustrates “ball-in-hand” phenomenon (arrows).
The lil,ling defect in this sialogram .locetes a tumor of the gland with displacement of normal
surrounding ductal anatorny

of the gland secondary to acinar atrophy and infection, which results in.”pruning” of the normal arborization of the small-ductal system of the gland. Centrally located lesions or tumors that occupy a part of the gland or
impinge on its surface displace the normal ductal anatomy. On sialography, ducts adjacent to the lesion are curvilinearly draped and stretched around the mass, producing a characteristic ball in hand appearance (Fig.·
20-11).

Computed Tomography  magnetic requirement and ultrasound. The use of computed tomography (CT) has been generally reserved for the assessment of mass lesions of  the salivary glands. Although CT scanning results in radiation exposure to patients, it is less . .vasive than sialography and does not require the use of  contrast material. Additionally, CT scanning can demonstrate salivary’ gland calculi, especially submandibular

fiG. 20-12 computerized tomographic scan of the mandible and floor of mouth shows a posterior submandibular sialolith (arrow).

fiG. 20-12 computerized tomographic scan of the mandible and
floor of mouth shows a posterior submandibular sialolith (arrow).

stones that are located posteriorly in the duct, at the . hilum of the gland, or in the substance of the gland itself (Fig. 20-12).

Salivary Gland Endoscopy (Slaloendoscopy)
Minimally invasive modalities of diagnosis and treatment have recently been applied to. the major salivary glands, ‘ Salivary gland endoscopy (sialoendoscopy) is a specialized procedure that uses a small video camera (errdoscope) with a light at the end of ~ flexible cannula, which is introduced into. the ductal orifice. The endoscope can he used diagnostically and therapeutically. Salivary gland endoscopy hasdemonstrated strictures and kinks in the ductal system, as well as mucous plugs and calcifications.  The endoscope 111ay be used to. dilate small strictures and .flush clear small mucous plugs in the salivary gland
ducts. Specialized devices such as small balloon catheters (similar, to those used for coronary angioplasty procedures) may’ be used to. dilate sites of ductal constriction, and small metal baskets may be used to. retrieve stones in the ductal system

Fine-Needle- Aspiration Biopsy
The use of fine-needle aspiration biopsy in the diagnosis of salivary gland tumors has been well documented. This procedure has a high accuracy rate for distinguishinglbenign and malignant lesion Fine-needle aspiration biopsy performed  syringe with a 20-gauge or smaller needle
anesthesia the needle is advanced into the the plunger is activated to. create a vacuum in till’ svringe, and the needle is moved back ‘and forth throughout the mass, with pressure maintained an the plunger ..The pressure is then released, the needle is withdrawn, and the
cellular material and fluid is expelled onto a slide and fixed for histalagic examination. This allows an immediate determination of benign versus malignant disease; it also. offers the passibility of providing a tissue diagnosis, especially if tile oral surgeon and oral pathologist are ,
experienced in performing and interpreting this exarnination and its results.

Salivary Gland Biopsy
A salivary gland biopsy, either incisianal or exclsional can be used to. diagnose a tumor of one of the major salivary glands, but it is usually performed as an aid in the diagnosis of SS. The lower lip labial salivary gland biopsy has been shown to demonstrate certain characteristic
histopathologic changes that pre seen in the major glands in SS. The procedure is performed using local anesthesia, and approximately 10 minor salivary ‘glands are removed far histologic examination (Fig. 20-13).

 

 

 

 

EMBRYOLOGY , ANATOMY AND PHYSIOLOGY

EMBRYOLOGY , ANATOMY AND PHYSIOLOGY

The salivary glands can be divided into two ,groups: the minor and major glands. All salivary glands develop from . the embryonic oral cavity .as buds of epithelium that extend into the underlying mesenchymal tissues. The
epithelial ingrowths branch to form a primitive ductal system that eventually becomes canalized to provide f?r drainage of salivary secretions. The minor salivary J::land~ begin to develop around the fortieth day in utero, WhCTt’-
. as-the larger ma or glands begin to deve-lop sli/-:htly earher, at about the thirty-fifth day in utero, At around the seventh or eighth Elonth in utero, secretory cells called

FIG. 20-1 Parotid gland anatomy. The course of Stensen's duct runs superficial to the masseter muscle and then curves sharply anteriorly to pierce the buccinator muscle fibers and enter the oral cavity.

FIG. 20-1 Parotid gland anatomy. The course of Stensen’s duct runs superficial
to the masseter muscle and then curves sharply anteriorly to pierce the
buccinator muscle fibers and enter the oral cavity.

acini begin to develop around the ductal system. The acinar cells of the salivary glands are classified as either serous’ cetls, which produce .a thin, watery serous secretion, or /IlUCOUS cells, which produce a thicker, viscous mucous secretion. The minor salivary glands are well
‘developed and functional in the newborn infant. The acini of the’ minor salivary glands primarily produce mucous secretions, although some are made ‘up of serous cells, as well. Tile major salivary glands are paired structures and are the parotid, submandibular, and sublingual glands. The parotid glands contain primarily serous acini .’ with few mucous cells. Conversely, the sublingual glands (Ire for the most part composed of mucous cel1s. The submandibular glands are mixed glands, made up of approximately equal numbers of serous and ‘mucous acini.
Between 800 and 1000 minor salivary glands are found throughout the portions of the oral cavity that are covered by mucous membranes, with a few exceptions” such as the anterior third of the hard palate, the attached gingiva, and the dorsal surface of the anterior third of the
tongue. The minor salivary glands are referred to as the labial, buccal, palatine, tonsillar (Weber’s glands), retromolor (Carrnalt’s glands), and lingual glands, which are divided into three groups: (1) inferior apical (glands of Blandin Nuhn), (2) taste buds (Ebner’s glands), and (3) posterior
lubricating glands  Table 20-1).

Occasionally.’ a normal anatomic varlation occursIn which an accessory parotid duct may aid Stenson’s duct. in drainage of salivary secretions. Additionally, an acccssory portion of the parotid gland may be present somewhere along the course of Stenseri’s duct. The duct runs anteriorly from the gland and is superficial to the masseter muscle. At the location of the anterior edge of the masseter muscle, Stensen’s duct turns sharply medial and passes through the fibers of the buccinator muscle. The
duct opens into the oral cavity through the buccal mucosa, usually adjacent to the maxillary first or second molar tooth. The parotid gland receives. innervation from the ninth crania l (glossopharyngeal) nerve via the auriculotemporal nerve from the otic ganglion.

BOX 20-1

BOX 20-1

FlC. 20·2 Submandibular gland anatomy. The anteriorand posterior bellies of the digastric muscles and the inferior border of the mandible form the submandibular triangle.

FlC. 20·2 Submandibular gland anatomy. The anteriorand posterior bellies of the digastric muscles
and the inferior border of the mandible form the submandibular triangle.

in’ rise (I the major duct of the submandibular gland .nov.n J W/lllrt()/I’~ duct. This duct passes forward along h uperior surface of the, mylohyoid muscle in the subngual space, adjacent to the lingual nerve. The anatomic
relationship is such that the lingual nerve loops under ‘harton’s duct, from lateral to medial, in the .posterior floor of the mouth. wharton’s duct is about 5 cm in I ngth, and the diameter of its lumen is 2 to 4 mm.
Wharton’s duct opens into the floor of the mouth via a punctum located close to the incisors at the most anterior aspe~t of the junction of the lingual frenum and the floor of the mouth. The punctum is’ a constricted portion of the duct, and it functions to limit retrograde flow of
bacteria laden DIal fluids. This particularly limits those bacteria that tend to colonize around the ductal orifices.

The functions of saliva are to provide lubrication for speech and mastication, to produce enzymes for digestion, and to produce compounds with antibacterial properties’ (Table 20-2). The salivary glands produce
approxitnately 1000 to 1500 ml of saliva per clay, with the highest flow rates occurring during meals. The relative contributions of each salivary gland to total daily production varies, with the submandibular gland providing 70%, the parotid gland 25%, the sublingual gland 3% to
4%, anu th   minor salivary. glands contributing only trace amou ts of saliva (Box 20-1). The electrolyte composition of saliva also varies between salivary glands.

Composition of Normal Adult Saliva

Composition of Normal Adult Saliva

Daily Saliva Production by Salivary Gland

Daily Saliva Production by Salivary Gland

FIG. 20-3 Sublinqualgland anatomy. The interrelationships between the ductal system~ of the submandibular arid the sublingual glands and the relationship of the lingual nerve to Wharton's duct are demonstrated

FIG. 20-3 Sublinqualgland anatomy. The interrelationships between the ductal system~ of
the submandibular arid the sublingual glands and the relationship of the lingual nerve to
Wharton’s duct are demonstrated

Incidence of Radi .ipaque Stones

Incidence of Radi .ipaque Stones

FIG -. 20-4 A, Mandibular occlusal radiograph shows a radiopaque sialolith (arrow): B, Submandibular sialolith after intraoral removal is demonstrated.

FIG -. 20-4 A, Mandibular occlusal radiograph shows a radiopaque
sialolith (arrow): B, Submandibular sialolith after intraoral removal is
demonstrated.

correspond to the percentage of Illl.iCOUS· and serous cells therefore the highest viscosity is in the sublingual gland, followed by the submandibular gland, and, lastly, the parotid gland,which is composed mainly of- serous cells. Interestingly, the .daily production of saliva begms to . de.crease gradually after the age of 20.

 

 

 

 

CHAPTER OUTLINE

CHAPTER OUTLINE

EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY
DIAGNOSTIC MODALITIES
History and Clinical Examination
Salivary Gland Radiology
Plain Film Radiographs
Sialography
Computed Tomography, Magnetic; Resonance
Imaging, and Ultrasound
Salivary Scintigraphy (Radloactlve Isotope
Scanning)
Salivary Gland Endoscopy (Sialoendoscopy)
Sialochemistry
Fine-Needle Aspiration Biopsy
. Salivary Gland Biopsy

OBSTRUCTIVE SALIVARYGLAND DISEASE
Sialolithiasis
MUCOUS RETENTION AND EXTRAVASATION
PHENOMENA
Mucocele
Ranula
SALIVARY GLAND INFECTIONS
NECROTIZING SIAlOMETAPLASIA
SJOGREN’S SYNDROME,
TRAUMATIC SALIVARYGLAND INJURIES
NEOPLASTIC SALIVARYGLAND DISORDERS
Benign’ Salivary Gland Tumors
Malignant Salivary Gland Tumors

he clinician is frequently confronted with the necessity of assessing and managing salivary gland disorders. A thorough-knowledge of the
embryology, anato y, and pathophysiology is necessary to treat patients appropriately. This chapter examines the cause, diagnostic methodology, radiographic evaluation, and management of a variety of salivary gland disorders, including sialolithiasis and obstructive phenomena (e.g., –
mucocele and ranula), acute ‘and chronic salivary gland infections, traumatic salivary gland disorders, Sjogren’s syndrome (SS), necrotizing slalornetaplasia, and benign and malignant salivary gland tumors.