Referat Kelainan Kelenjar Saliva

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  • Kelainan Kelenjar SalivaPembimbing: dr. Hj. Yanti Daryanti, Sp. B-KBD

    Penyaji: Christi Ervina H.; Rulita Situmorang

  • Kelenjar Saliva2 Submandibular gl.2 Parotid gl.2 Sublingual gl.750 Kelenjar saliva minor tersebar di submukosa rongga mulut, orofaring, hipofaring, laring, ruang parafaringeal dan nasofaring.

  • FungsiUtama: proses digesti, lubrikasi, dan proteksi.Saliva berperan dalam digesti Karbohidrat dan Lipid melalui 2 enzim: ptyalin (-amylase) dan lingual lipase.Fungsi lain:menstimulasi taste buds.sebagai buffer protektif.Antibakteri dalam saliva: IgA; Lysozyme (menyebabkan aglutinasi dan autolisis bakteri teraktivasi sehingga mendegradasi dinding bakteri); Lactoferrin (menghambat pertumbuhan bakteri).Sekresi, aliran darah, dan pertumbuhan kel. saliva dikontrol oleh autonomic nervous system. (parasimpatis > simpatis)

  • Saat tidak terstimulasi: 69% saliva berasal dari kel. submandibular, 26% oleh parotis, dan 5% oleh sublingual.Saat terstimulasi, 2/3 sekret berasal dari kel. parotid.Stimulus: ada makanan dalam mulut dan saat proses mengunyah.Penghambat: tidur, fatigue, dehidrasi, and ketakutan.

  • Kelenjar ParotisPaling besar; berat 1530 gram.Lokasi: regio preauricular hingga permukaan posterior mandible.Lobus superfisial: pada permukaan lateral masseter, merupakan bagian lateral dari nervus fasialis.Lobus profunda: medial dari nervus fasialis dan berada diantara prosesus mastoideus os temporal dan ramus mandibula.Keganasan paling sering berasal dari lobus superfisial dan dapat diangkat secara superficial parotidectomy.

  • Fascia parotis membentuk kapsul yang padat (dense) tak elastik yang sekaligus melapisi otot masseter, sehingga kadang dapat menyebabkan nyeri menjalar disebut parotid masseteric fascia.

  • Ductus Stensen: sekresikan saliva serosa ke dalam vestibulum rongga mulut.Terletak sejajar dengan zygoma, sekitar 1 cm di bawahnya, menembus otot masseter. Kemudian melewati otot buccinator dan masuk ke dalam rongga mulut berlawanan dengan gigi M2 atas.

  • Glossopharyngeal nerve (CN IX) mempersarafi sekresi kelenjar parotis.Suplai darah kel. parotis dari cabang A. Carotis eksternal.V. Retromandibular terbentuk dari persatuan antara V. Maxillary dan V. Temporal superfisial.Drainase limfatikus: drain ke sistem limfatikus servikal superfisial dan profunda.

  • Kelenjar SubmandibulaBerada superior dari M. DigastrikusDibagi menjadi lobus superfisial dan profunda oleh M. MylohoidSekresinya oleh duktus Wharton dengan muaranya di Caruncula SublingualisSuplai darah Kel. Submandibula berasal dari A. Facialis dan Lingualis.Persarafan oleh simpatis dan parasimpatis.

  • Kelenjar SublingualSepasang dan tidak memiliki kapsulBerada anterior dari Kel. Submandibula, di dasar lidahDrainase oleh 8-20 duktus Rivinus, namun yang terbesar adalah duktus BartholinsSuplai darah oleh A. Sublingual dan SubmentalDrainase limfatikus menuju KBG Submandibula

  • Patologis Kelenjar SalivaTraumaInfeksi/ SialadenitisSialolithiasisKeganasan/ Neoplasma

  • SialadenitisSialadenitis: inflamasi kel. saliva akut/ subakut/ kronik.Sialadenitis akut: sering pada kel. Parotis. Dapat disebabkan oleh: bakteri (sering Staphylococcus aureus) atau viral (mumps).Sialadenitis kronik: akibat inflamasi granulomatosa kelenjar dan sering berhubungan dengan sarcoidosis, actinomycosis, tuberculosis.FR sering: oral hygiene buruk, oral intake kurang, sehingga produksi saliva menurun.

  • Manifestasi Klinis:- Onset mendadak- Nyeri- Indurasi- Eritema- Lobulus telinga naik/ tertarik ke atas- Suhu > 37.8oC.- Progresi edema dasar mulut, disfagia dan sumbatan airway

    Apabila terjadi post operasi, sering oleh karena:-dehidrasi-prolonged ETT/ NGT-puasa -medikasi: atropin/ scopolamin.

  • Pembengkakan sisi wajah Kulit kemerahan Purulent dischargeFluktuasi (+)

  • Penunjang:Parotitis merupakan diagnosis klinisLab test: leukositosisMRI, CT atau ultrasoundAspirasi absesTatalaksana: Antibiotik IV ; hidrasi >>; sialogogue; jaga oral hygiene. Jika fluktuasi (+): incision & drainage.

  • MUMPSParamyxovirusMasa inkubasi 12-24 hari SYSTEMIC from the onsetNyeri kepala, myalgia, anorexia, malaise, demamKelenjar membengkak (tegang, keras) Nyeri telinga, nyeri pada kelenjar parotis, disfagia dan trismusPinna ispilateral terangkat75% kasus mengenai parotis bilateral

  • Tatalaksana: Suportif HidrasiAnti-inflamasi & AnalgesikKomplikasi:Orchitis 20% Meningitis 10%Oophoritis 5% Pancreatitis 5%Hearing loss
  • Sialolothiasis

    = salivary calculiKalsifikasi stau atau lebih duktus kelenjar saliva mayor atau minor.Mostly: submandibular gl (90%)Nyeri rekuren terutama saat makan - kelenjar membengkakBimanual palpationDD: submandibula gland lymphadenitis.

  • Tatalaksana:Konservatif: Antibiotik dan Anti-inflamasi: spontaneous stone passage.Eksisi:LithotripsySialendoscopyBila gagal: surgical cut.Eksisi kelenjar: bila batu berada dalam kelenjar dan atau kelenjar sudah rusak.

  • Sjogren SyndromeAutoimmune condition causing progressive degeneration of salivary and lacrimal glands

    Connective tissue disorder, such as rheumatoid arthritis

  • Sjogren SyndromeSering pada kelenjar parotisPembesaran kelenjar persisten atau intermitenPembengkakan kelenjar bilateral, tidak nyeri, keras, difus saliva: xerostomiaRisiko tinggi terjadi B-cell lymphomaKeratoconjunctivitis siccaDiagnosis: biopsi

  • Sjogren's SyndromeTatalaksana: - Atasi infeksi rekuren- Pengganti saliva/sprays - Cholinergic drugs (Pilocarpine)- Hindari alkohol, rokok- Immunosuppressive; corticosteroids or cytotoxic

  • Diagnosis & Management Diseases of The Salivary Gland

  • Komplikasi

    DIAGNOSISCOMPLICATIONViralSevere systemic injuryAcute suppurative sialadenitisSepticemia, deathChronic sialadenitisXerostomiaBenign lymphoepithelial lesionLymphoma, pseudolymphoma, carcinomaSarcoidosisFacial paralysis; severe systemic illnessSjogren syndromeXerostomiaSialolithiasisSepticemiaFirst branchial cleft cystSalivary-cutaneoous fistula; facial paralysisPenetrating injury

  • Jarang; 2%-5% dari semua neoplasma kepala dan leher.Kel parotis (70%), kel. submandibular (22%); kel. sublingual dan minor (8%).Manifestasi sering: slow-growing, well-circumscribed masses.NEOPLASMA KELENJAR SALIVA

  • BENIGNMALIGNANTPleomorphic AdenomaAcinic cell carcinomaWhartin's tumorMucopeidermoid carcinomaCapillary hemangiomaAdenoid cystic carcinomaPncocytomaPolymorhous low-grade adenocarcinomaBasal cell adenomaEpitheliat-myoepithelial carcinomaCanalicular adenomaBasal cell adenocarcinomaMyoepitheliomaSebaceous carcinomaSialadenoma papilliferumPapillary cystadenocarcinomaIntraductal papillomaMucinous adenocarcinomaInverted ductal papillomaOncocytic carcinomaSalivary duct carcinomaAdenocarcinomaMyoepithelial carcinomaMalignant mixed tumorSquamous cell carcinomaLymphoma, Metastatic carcinomaCarcinoma ex pleomorphic adenoma

  • Rasio neoplasma maligna Vs benigna:Kel. Parotis, 80% benigna; 20% maligna;Kel. Submandibular dan Sublingual, 50% benigna; 50% maligna;Kel. Saliva minor 25% benigna dan 75% maligna

    - Gejala nyeri, tumbuh cepat, kelumpuhan saraf, dan paresthesia serta ada cervical lymphadenopathy dan fiksasi ke kulit atau otot sekitarnya menandakan keganasan.-Trismus berhubungan dengan keterkaitan M. Pterygoideus oleh keganasan lobus parotis.

  • Penunjang:FNAB.Eksisi biopsi.CT and MRI untuk membuktikan batas tumor dan penyebarannya.

    DD sering Bell's Palsy

  • Tumor benigna:Pleomorphic adenomas (40%-70% dari total tumor kel. saliva)Monomorphic adenomas (cth: Warthins tumor or papillary cystadenoma lymphomatosum (2nd most common), oncocytomas, basal cell adenomas, canalicular adenomas, and myoepitheliomas)Tatalaksana: eksisi dengan batas hingga jaringan normal.Enukleasi tidak direkomendasikan risiko eksisi inkomplit dan penyebaran tumor

  • Tumor maligna epitelial:Aggressiveness from low to high gradeTergantung dari histologi tumor, derajat invasif, metastasis regionalTersering: Mucoepidermoid carcinomaLow grade mucoepidermoid terdiri dari mucin secreting cellsHigh grade tumors dominan epidermoid cells

  • Staging berdasarkan ukuran tumor:T1 < 2 cmT2 : 2 s/d 4 cmT3 > 4 cm (atau tumor dengan ekstensi secara makroskopis tampak ekstraparenkim)T4 invasi ke jaringan sekitarnyaTatalaksana primer keganasan saliva surgical excision:En bloc removalTumor parotis yang meluas hingga ke lateral superficial parotidectomy dengan mempertahankan CN VII Jika tumor meluas hingga lobus profunda total parotidecomy Postoperative radiation Indikasi:Penyakit ekstraglandular; Invasi perineural; Invasi langsung ke struktur regional; Metastase regional; histologi derajat tinggi.

  • Ptyalin is an -amylase in saliva that cleaves the internal -1,4-glycosidic bonds of starches to yield maltose, maltotriose, and-limit dextrins. This enzyme functions at an optimal pH of 7, but rapidly denatures when exposed to a pH less than 4, such as when in contact with the acidic secretions of the stomach.

    Lingual lipase which functions to break down triglycerides. Unlike ptyalin, this enzyme is functional within the acidic stomach and proximal duodenum because it is optimally active at a low pH.

    Saliva is mostly hypotonic to plasma, but its osmolarity increases with increasing rate of secretion, and at its highest rate saliva approaches isotonicity. The concentration of electrolytes in saliva also changes with varying secretion rates.

    Parasympathetic stimulation activates both acinar activity and ductal transport mechanisms, leading to glandular vasodilation as well as myoepithelial cell contraction. Acetylcholine (ACh) serves as the parasympathetic neurotransmitter that acts on the muscarinic receptors of the salivary glands. Glandular secretion is sustained by acetylcholinesterases, which inhibit the breakdown of ACh. The muscarinic antagonist ATROPIN, however, decreases salivation by competing with ACh for the salivary receptor site.

    Binding of the neurotransmitter norepinephrine to -adrenergic receptor results in formation of 3',5'-cyclic adenosine monophosphate(cAMP), which then leads to phosphorylation of various proteins and activation of different enzymes. Increases in cAMP result in increased salivary enzyme and mucus content.

    Within saliva, K+ concentrations increase while Na+ concentrations decrease in the presence of antidiuretic hormone (ADH) or aldosterone.

    Parasimpatis mengikuti cabang Nervus Fasialis dan Glossopharyngeal.Simpatis berasal dari cabang nervus thoracic spinal di superior cervical ganglion.The deep cervical fascia continues superiorly to form the parotid fascia.

    The thicker superficial fascia is extended superiorly from the masseter and sternocleidomastoid muscles to the zygomatic arch. The deep layer extends to the stylomandibular ligament (or membrane), which separates the superficial and deep lobes of the parotid gland. The transverse facial artery branches off the superficial temporal artery and runs anteriorly between the zygoma and parotid ductto supply the parotid gland, parotid duct, and the masseter muscle [10].The great auricular nerve is a sensory branch of the cervical plexus, particularly C2 and C3, and innervates the posterior portion of the pinna and the lobule. The nerve parallels the external jugular vein along the lateral surface of the sternocleidomastoid muscle to the tail of the parotid gland, where it splits into anterior and posterior branches.The great auricular nerve is often injured during parotidectomy, which can result in long-term sensory loss in the lobule. The auriculotemporal nerve is a branch of the mandibular nerve, the third inferior subdivision of the trigeminal nerve (V3).

    The facial nerve (CN VII) exits the skull base via the stylomastoid foramen, which is slightly posterolateral to the styloid process and anteromedial to the mastoid process. Before entering the posterior portion of the parotid gland, three motor branches are given off to innervate the posterior belly of the digastric muscle, the stylohyoid muscle, and the postauricular muscles.The upper temporofacial division forms the frontal, temporal, zygomatic, and buccal branches. The lower cervicofacial division forms the marginal mandibular and cervical branches.

    The temporal branch traverses parallel to the superficial temporal vessels across the zygoma to supply the frontal belly of the occipitofrontalis muscle, the orbicularis oculi, the corrugator supercilii, and the anterior and superior auricular muscles. The zygomatic branch travels directly over the periosteum of the zygomatic arch to innervate the zygomatic, orbital, and infraorbital muscles.The buccal branch travels with Stensens duct anteriorly over the masseter muscle to supply the buccinator, upper lip, and nostril muscles. Buccal branches can either arise from the upper temporofacial or the lower cervicofacial division. The marginal mandibular branch courses along the inferior border of the parotid gland to innervate the lower lip and chin muscles. It lies superficial to the posterior facial vein and retromandibular veins in the plane of the deep cervical fascia directly beneath the platysma muscle. The cervical branch supplies the platysma muscle. Like the marginal mandibular branch, it is located within the plane of the deep cervical fascia direct underneath the platysma.

    Distal to the inferior ganglion, a small branch of CN IX (Jacobsens nerve) reenters the skull through the inferior tympanic canaliculusand into the middle ear to form the tympanic plexus ganglion. Postganglionic parasympathetic fibers exit the otic ganglion beneaththe mandibular nerve to join the auriculotemporal nerve in the infratemporal fossa. These fibers innervate the parotid gland for the secretion of saliva. Postganglionic sympathetic fibers innervate salivary glands, sweat glands, and cutaneous blood vessels through the external carotid plexus from the superior cervical ganglion.ganglion. Postganglionic parasympathetic fibers exit the otic ganglion beneath the mandibular nerve to join the auriculotemporal nerve in the infratemporal fossa. These fibers innervatethe parotid gland for the secretion of saliva. Postganglionic sympathetic fibers innervate salivary glands, sweat glands, and cutaneous blood vessels through the external carotid plexus from the superior cervical ganglion.Parasympathetic innervation to the submandibular glands is provided by the superior salivatory nucleus via the chorda tympani, a branch of the facial nerve, that becomes part of the trigeminal nerve's lingual nerve prior to synapsing on the submandibular ganglion. Increased parasympathetic activity promotes the secretion of saliva.[5]The sympathetic nervous system regulates submandibular secretions through vasoconstriction of the arteries that supply it. Increased sympathetic activity reduces glandular bloodflow, thereby decreasing the volume of fluid in salivary secretions, producing an enzyme rich mucous saliva. Nevertheless, direct stimulation of sympathetic nerves will cause an increase in salivary enzymatic secretions. In sum, the volume decreases, but the secretions are increased by parasympathetic and sympathetic innervation.

    Mandibular gland is less affected because of tongue movement and high level of mucin in saliva which as potent antimicrobial activity, while parotid is adjacent to first molar which has calculus and debris.Bacterial: Acute Chronic Recurrent parotitisViral: Mumps CytomegalovirusAllergic sialadenitisPost-irradiation/ Post Surgery

    Post-surgery parotitis found in patient with ETT or NGT more than 1 day and fasting.Parotitis pascabedah yg seperti itu akibat tidak ngunyah, tidak pake otot pengunyah dan kelenjar liurnya sehingga mudah infeksi melalui duktus parotis. makanya perlu pertahankan OH.WIKIPEDIA:scopolamine: muskarinik antagonis. Scopolamine exerts its effects by acting as a competitive antagonist at muscarinic acetylcholine receptors; it is thus classified as an anticholinergic, antimuscarinic drug. Uses being in the treatment of motion sickness and postoperative nausea and vomiting.

    Atropin: In general, atropine counters the "rest and digest" activity of glands regulated by the parasympathetic nervous system. This occurs because atropine is a competitive antagonist of the muscarinic acetylcholine receptors (acetylcholine being the main neurotransmitter used by the parasympathetic nervous system). Atropine dilates the pupils, increases heart rate, and reduces salivation and other secretions. Topical atropine is used as a cycloplegic, to temporarily paralyze the accommodation reflex, and as a mydriatic, to dilate the pupils. Atropine degrades slowly, typically wearing off in 7 to 14 days, so it is generally used as a therapeutic mydriatic, whereas tropicamide (a shorter-acting cholinergic antagonist) or phenylephrine (an -adrenergic agonist) is preferred as an aid to ophthalmic examination.MEDSCAPE: Patients are most often treated on an outpatient basis, with the administration of a single dose of parenteral antibiotics in an emergency department, followed by oral antibiotics for a period of 7-10 days. Clindamycin (900 mg IV q8h or 300 mg PO q8h) is an excellent choice and provides good coverage against typical organisms.

    Lincosamide (KLINDAMISIN) for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

    The most serious complication of acute sialadenitis is the formation of an abscess. Management is described above.Complications of chronic sialadenitis and autoimmune sialadenitis are most often dental in nature because of the decreased function of the gland and the protective effect provided against caries.Chronic inflammation of the gland with or without calculi often renders the gland difficult to excise because of the loss of normal tissue planes.

    MERCK MANUAL: Hydration, sialagogues (eg, lemon juice, hard candy, or some other substance that triggers saliva flow), warm compresses, gland massage, and good oral hygiene are also important. Abscesses require drainage.

    WIKIPEDIA: SIALOGOGUE: Parasympathomimetic drugs act on parasympathetic muscarinic receptors to induce an increased saliva flow. The M3 receptor has been identified as the principle target to increase salivary flow rates.[3] Pilocarpine is an example; the maximum dose of this drug is 30 mg/day. Contraindications include many lung conditions, such as asthma, cardiac problems, epilepsy and Parkinson's disease; side effects include flushing, increased urination, increase perspiration, and GI disturbances.Chewing gum induces stimulated saliva secretion of the minor salivary glands in the oral cavity. During mastication (chewing), the resultant compression forces acting on the periodontal ligament cause the simulated release of gingival crevicular fluid. Further salivation can be also achieved by the stimulation of taste receptors (parasympathetic fibers from the chorda tympani and the lingual nerve are involved).Maltic and ascorbic acid are effective sialogogues, but are not ideal as they cause demineralisation of tooth enamel.The Centers for Disease Control and Prevention now recommend isolation of infected patients with standard and respiratory droplet precautions for 5 days after the onset of parotitis. Susceptible contacts should be vaccinated, but this intervention is unlikely to abort an outbreak in progress. Nonimmune asymptomatic healthcare providers should be excused from work from 11 days after the initial exposure until 25 days after the last exposure.parotitis pascabedah yg seperti itu tidak ngunyah, tidak pake otot pengunyah dan kelenjar liurnya sehingga mudah infeksi melalui duktus parotis. makanya perlu pertahankan OH.Submandibular and sublingual gland tumors present as a neck mass or floor of mouth swelling, respectively. Malignant tumors of the sublingual or submandibular gland may invade the lingual or hypoglossal nerves, causing paresthesias or paralysis. Bimanual examination is important for determining the size of the tumor and possible fixation to the mandible or involvement of the tongue. Minor salivary gland tumors present as painless submucosal masses and are most frequently seen at the junction of the hard and soft palate. Minor salivary gland tumors arising in the prestyloid parapharyngeal space may produce medial displacement of the lateral oropharyngeal wall and tonsil.

    When the initial symptom is complete unilateral facial paralysis, Bells palsy may be misdiagnosed as the cause, and it is important to remember that all patients with Bells palsy will show some improvement in facial movement within 6 months of the onset of weakness.

    Shelling out of pleomorphic adenomas is to be avoided: increase rate reccurenceIndikasi dilakukan perotidectomy adalah : Superfisial parotidektomi:Mengangkat tumor pada kelenjar parotis lobus superfisialisEksplorasi nervus fasialis pada trauma tajam daerah wajah daerah segitiga sudut bibir tragus angulus mandibula.Sebagai langkah awal dari total parotidektomiUntuk mengontrol parotitis supuratif kronis jika terapi medikamentosa gagal. Total parotidektomi:Tumor lobus profundus Recurrent pleomorphic adenoma Keganasan kelenjar parotisParotitis supuratif berulang, akibat stenosis atau batu pada duktus Stenoni