Inflammatory n infectious diseases of salivary gland- Dr Sanjana Ravindra

Inflammatoryand

Infectious diseases of salivary gland

SEMINAR NO. 10

Dr Sanjana RavindraOral Medicine and RadiologyRajarajeswari dental college, Bangalore

SALIVARY GLAND

Introduction Classification Composition of saliva Properties of Saliva Functions of Saliva Salivary gland

examination Classification of

Salivary gland diseases

INFLAMMATORY and INFECTIOUS DISEASES OF SALIVARY GLAND

Introduction Classification Various diseases

Summary References

Dr sanjana ravindra

INTRODUCTION

Salivary glands are compound, tubuloacinar, merocrine, exocrine glands whose ducts open into the oral cavity

It has more

than one tubule

entering the main

duct

Morphology

of the secreting

cells

Only the secretion

of the cell is

released

Secretes fluid

onto a free

surface

Sembulingam k., Sembulingam P. Digestive System. In: Essentials of Medical Physiology. 6th ed. Jaypee Brothers Medical Publishers (P) Ltd.

2012; 220-302 Dr sanjana ravindra

CLASSIFICATION A

cco

rdin

g to

th

e si

ze

Major salivary glands.

Minor salivary glands.

Acc

ord

ing

to t

he

typ

e o

f se

cret

ion

:

Serous secreting

- Parotid - von ebners

Mucous secreting

- Glossopalatine - palatine.

Mixed

Submandibular – sublingual - labial and buccal - glands of blandin and

nuhn



TYPES

Parotid: largest, anterior to ear, serous,25% of total saliva.

Submandibular: Intermediate, angle of mandible,60% of total saliva.

Sublingual: Smallest, anterior floor of mouth, 5% of total saliva.

Major salivary Glands



Labial (lips) – mixed

Buccal (cheeks) - mixed

Palatine - mucous

Lingual:

• Anterior – mixed

• Middle – serous

• Posterior – mucous.

Minor salivary Glands


2012; 220-302

TYPES

anterior glands of blandin and nuhn

posterior von ebner glands

Dr sanjana ravindra

Parotid glands are the largest of all salivary

glands, situated at the side of the face just

below and in front of the ear. Each gland

weighs about 20 to 30 g in adults.

Secretions from these glands are emptied into

the oral cavity by Stensen duct.

This duct is about 35 mm to 40 mm long and opens inside the cheek

against the upper second molar tooth

Parotid Glands


2012; 220-302

TYPES

Dr sanjana ravindra

Submaxillary glands or submandibular glands are

located in submaxillary triangle, medial to

mandible.

Each gland weighs about 8 to 10 g.

Saliva from these glands is emptied into the oral cavity by Wharton duct, which is

about 40 mm long.

The duct opens at the side of frenulum of tongue, by means of a small opening on the summit of papilla

called caruncula sublingualis.

Submandibular Glands


2012; 220-302

TYPES

Dr sanjana ravindra

Sublingual glands are the smallest salivary glands situated in the mucosa at the floor of the

mouth.

Each gland weighs about 2 to 3 g. Saliva from these glands is

poured into 5 to 15 small ducts called ducts of Rivinus.

These ducts open on small papillae beneath the tongue.

One of the ducts is larger and it is called Bartholin duct.

It drains the anterior part of the gland and opens on caruncula

sublingualis near the opening of submaxillary duct.

Sublingual Glands


2012; 220-302

TYPES

Dr sanjana ravindra

1. Lingual Mucus Glands Lingual mucus glands are situated in posterior one third of the tongue, behind circumvallate papillae and at the tip and margins of tongue.

2. Lingual Serous Glands Lingual serous glands are located near circumvallate papillae and filiform papillae.

3. Buccal Glands Buccal glands or molar glands are present between the mucus membrane and buccinator muscle. Four to five of these are larger and situated outside buccinator, around the terminal part of parotid duct.

4. Labial Glands Labial glands are situated beneath the mucus membrane around the orifice of mouth.

5. Palatal Glands Palatal glands are found beneath the mucus membrane of the soft palate.

Minor salivary glands


2012; 220-302

TYPES

anterior glands of blandin and nuhn

posterior von ebner glands

Dr sanjana ravindra


2012; 220-302

COMPOSITION OF SALIVA

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PROPERTIES OF SALIVA

1.Volume: 1000 mL to 1500 mL of saliva is secreted per day and it is approximately about 1 mL/minute.

2.Reaction: Mixed saliva from all the glands is slightly acidic with pH of 6.35 to 6.85

3. Specific gravity: It ranges between 1.002 and 1.012

4. Tonicity: Saliva is hypotonic to plasma.



FUNCTIONS OF SALIVA

1. PREPARATION OF FOOD FOR SWALLOWING

• Food - moistened and dissolved by saliva. • Mucous membrane - moistened by saliva. It

facilitates chewing.

• Mucin of saliva lubricates the bolus and

facilitates swallowing.

2. APPRECIATION OF TASTE

• Taste is a chemical sensation. By its solvent action, saliva dissolves the solid food substances, so that the dissolved substances can stimulate the taste buds.

• The stimulated taste buds recognize the taste.



3. DIGESTIVE FUNCTION

Saliva has three digestive enzymes, namely salivary amylase, maltase and lingual lipase


2012; 220-302

FUNCTIONS OF SALIVA

Dr sanjana ravindra

4. CLEANSING AND PROTECTIVE FUNCTIONS

Due to the constant secretion of saliva, the mouth and teeth - rinsed - free off food debris, shed epithelial cells and foreign particles., saliva prevents bacterial growth by removing materials

Enzyme lysozyme of saliva kills bacteria such as staphylococcus, streptococcus and brucella.

Proline-rich proteins present in saliva posses antimicrobial property and neutralize the toxic substances such as tannins. Tannins are present in many food substances including fruits.

Lactoferrin of saliva also has antimicrobial property.

Proline-rich proteins and lactoferrin protect the teeth by stimulating enamel formation.

Immunoglobulin IgA in saliva also has antibacterial and antiviral actions.

Mucin present in the saliva protects the mouth by lubricating the mucus membrane of mouth.


2012; 220-302

FUNCTIONS OF SALIVA

Dr sanjana ravindra

ROLE IN SPEECHBy moistening and lubricating soft parts of mouth and lips, saliva helps in speech. If the mouth becomes dry, articulation and pronunciation becomes difficult.

„REGULATION OF WATER BALANCEWhen the body water content decreases, salivary excretion also decreases. This causes dryness of the mouth and induces thirst. When water is taken, it quenches the thirst and restores the body water content.

EXCRETORY FUNCTIONMany substances, both organic and inorganic, are excreted in saliva. It excretes substances like mercury, potassium iodide, lead, and thiocyanate.


2012; 220-302

FUNCTIONS OF SALIVA

Dr sanjana ravindra

Salivary

Families

Anti-

BacterialBuffering

Digestion

Mineral-

ization

Lubricat-

ion &Visco-

elasticity

Tissue

Coating

Anti-

Fungal

Anti-

Viral

Carbonic anhydrases,

Histatins

Amylases,

Mucins, Lipase

Cystatins,

Histatins, Proline-

rich proteins,

Statherins

Mucins, Statherins

Amylases,

Cystatins, Mucins,

Proline-rich proteins, Statherins

Histatins

Cystatins,

Mucins

Amylases, Cystatins,

Histatins, Mucins,

Peroxidases

FUNCTIONS OF SALIVA

Dr sanjana ravindra

SALIVARY GLAND EXAMINATION

INSPECTION OF PAROTID GLAND

The parotid gland region between the

ramus of the mandible and the mastoid

process is examined for any swelling

Parotid swelling lifts the ear lobe

The skin over the region is observed for

any changes

In case of infection, the skin is distended, and in

the absence of inflammation there will

be no hyperaemia.

I/O, the orifrice of the duct is checked for

inflammation, swelling or fluid escape

Dr sanjana ravindra


PALPATION OF PAROTID GLAND

Palpated with thumb and

index/middle finger.

Margins of the gland are felt

externally for any warmth or

tenderness over the skin

Consistency of the gland is checked

whether soft, firm, nodular or indurated

Dr sanjana ravindra


INSPECTION OF SUBMANDIBULAR OR SUBLINGUAL GLAND

Inspected for any

abnormalities both I/o

and E/o

I/o one side of the floor

of the mouth is isolated

and dried –sterile

cotton rolls.

Swelling and colour

change in the

surrounding mucosa is

noted

Orifrice of the ducts of the glands

are observed for any

inflammatory changes and fluid

escape

Dr sanjana ravindra


PALPATION OF SUBMANDIBULAR AND SUBLINGUAL GLAND

Bimanually

Index finger of one hand is

placed along the lingual

surface of the mandible, and

one or two fingers of the

other hand used to palpate the gland from

outside.

Margins of the gland are felt externally for

any warmth or tenderness

over the skin

Consistency of the gland is

checked whether soft or

hard

Dr sanjana ravindra

INFLAMMATORY AND INFECTIOUS DISEASES OF

SALIVARY GLAND

Dr sanjana ravindra

CLASSIFICATION

CLASSIFICATION

SALIVARY GLAND DISEASES

Neoplastic

Benign

Malignant

Non- neoplastic

Developmental

Aplasia / Agenesis

Hyperplasia of minor salivary

glands

Infectious

Bacterial

Viral

Systemic

Sarcoidosis

Sjogrens’

Sialosis

Obstructive

Sialolith

Mucocele

Ranula

Autoimmune

Sjogrenssyndrome

Mikulicz’sdisease

CLASSIFICATION

Dr sanjana ravindra

Infl

am

ma

tory

Bacterial

Acute

Chronic

Viral

Mumps

HIV infection

Cytomegalovirus infection

Autoimmune

Sjogren’s Syndrome

Mikulicz’s Disease

Uveoparotid fever

CLASSIFICATION

Infl

am

ma

tory

Bacterial

Acute

Chronic

Viral

Mumps

HIV infection

Cytomegalovirus infection Allergic sialadenitis

Benign inflammatory condition

Necrotising sialometaplasia

CLASSIFICATION

Inflammatory diseases of salivary

gland

Acute

Acute Sialadenitis

Epidemic parotitis/ Mumps

Chronic

Chronic Sialadenitis

Sjogrens’ syndrome

Chronic Sclerosing Sialadenitis

Mickulicz disease

Stomatitis palatinii

Cheilitis glandularis

CLASSIFICATION

BACTERIAL SIALADENITIS

Dr sanjana ravindra

BACTERIAL SIALADENITIS

Staphylococcus aureus

Streptococcus viridans

Streptococcus pneumoniae

Escherichia coli

HaemophilusinfluenzaeAcute

Chronic

Sialadenitis, a generic term to describe infection of the salivary glands, has

a diverse range of signs and symptoms and predisposing factors.

Dr sanjana ravindra

ACUTE BACTERIAL SIALADENITIS

• Acute Suppurative Parotitis

• Surgical Parotitis

• Acute Bacterial Parotitis

PAROTID GLAND

• Acute SuppurativeSubmandibular Sialadenitis

• Acute Bacterial Submandibular Sialadenitis

SUBMANDIBULAR GLAND

Dr sanjana ravindra

ACUTE BACTERIAL SIALADENITISM

ICR

OO

RG

AN

ISM

S Most commonly caused by penicillin resistant Staph. Aureus or Strept. viridians

HO

ST F

AC

TO

RS May be caused

due to decreased host resistance, decreased salivary secretion and decreased bactericidal effects of saliva

SUR

GIC

AL

PR

OC

ED

UR

E

When major surgical procedure is carried out in patients with poor oral hygiene

DR

UG

S

Few reports suggests that drugs

ETIOLOGY

TRUMPET BLOWER’S SYNDROME: a pneumoparotitis associated with tissue

emphysema and crepitus, does not have the symptoms of acute infection. Swelling is

present because of collection of air within the tissue

Dr sanjana ravindra

SIALOLITHIASIS is the most common disorder of major salivary glands characterized by the development

of calculi within the parenchyma or ductal system.

It is the cause of 42–77% cases of salivary duct obstruction.

AGE GROUP

30 to 60 years.

SITE

Submandibular salivary gland – 80%.

Parotid gland - 10–20%

Sublingual gland - 1–5%

Greek word: sialon (saliva) and lithos (stone), and the Latin -iasis meaning "process" or "morbid condition

Dr sanjana ravindra

Composition

The salivary stones are comprised primarily of calcium carbonates and phosphate with traces of magnesium and ammonia. The organic matrix consists of carbohydrates and amino acids.

Sizes

0.1 to 30 mm

Number

In 25% of cases, the stones are multiple.

Dr sanjana ravindra

It produces a viscous, mucous and more alkaline saliva, with a relatively high concentration

of hydroxyapatites and phosphates This predisposes

to the precipitation of salts

Opening of Wharton’s duct is narrower than the diameter of

the whole duct

Gland and ductal system lies in a dependant position i.e. the

duct ascends towards its opening, which is also

conducive to saliva retention

Submandibular gland is the most common site for calculi formation

Dr sanjana ravindra

The nidus subsequently becomes bathed in a solution supersaturated with respect to calcium and phosphate and slowly

calcifies

Stagnation of saliva enhances the development of the sialolith and occurs secondary to either the nidus itself or due to the tortuosity

of the ductal system

Progression occurs once the nidus becomes lodged within the salivary ductal system

Salivary gland calculi develop around a central nidus made of desquamated epithelial cells, foreign bodies, bacteria or mucus

plugs

(Bodner 1993)

ETIOPATHOGENESIS

Dr sanjana ravindra

Static flow of saliva leading to migration of oral flora up to the Stensen duct

The reduced flow of saliva may be caused by duct stricture, obstruction (most commonly from sialoliths), or decreased saliva production secondary to illness or medication

The decline in saliva flow creates stasis- which potentiates bacterial growth

loss of saliva’s bacteriostatic effects-

PRONE prone to bacterial infection


PATHOPHYSIOLOGY

Dr sanjana ravindra

HO

SPIT

AL

-AC

QU

IRE

D • Staphylococcus aureus • Common in debilitated and

immunocompromised patients

CO

MM

UN

ITY

-AC

QU

IRE

D • Staphylococcus and streptococcus• Salivary flow stasis Because of

• Medications that decrease salivary flow,

• Cheek biting• Medical conditions such as

diabetes, malnutrition, and dehydration from gastrointestinal disorders associated with loss of intravascular volume such as diarrhea and vomiting.

TYPES


Dr sanjana ravindra

• Mostly in adults (male) but neonates and childhood form of disease may occur

AGE

• Unilateral parotid gland/ Submandibular gland

SITE

• Begins with elevation of body temperature and sudden onset of pain at the angle of the jaw which is intense when the extensive infection is contained within the confines of the parotid capsule

PRODROMAL SYMPTOMS

• Localized symptoms are accompanied by fever, leucocytosis

SYMPTOMS

• Gland is tender, enlarged and overlying skin is warm and red. Swelling causes elevation of earlobule and the overlying skin is characteristically warm and erythematous

SIGNS

SIGNS

SYMPTOMS

CLINICAL FEATURES


Dr sanjana ravindra

SIGNS

SYMPTOMS

CLINICAL FEATURES


salivary duct: initially flecks of purulent material –salivary duct orifrice,

surrounding erythematous

lymph nodes: cervical lymphadenopathy

Downwards into the deep facial plane of

neck

Backwards into the external

auditory canal

Outwards into the skin of

face

SPREAD OF INFECTION

Dr sanjana ravindra

Complete blood count with differential, and Gram stain

and culture sensitivity of the suppurative discharge

Direct aspiration of any abscess that is identified or aspiration of the parotid is

more likely to identify a causative pathogen

USG,CT and MRI -effective imaging modality to

• Assess for parotid inflammation

• Sialoliths• Cystic lesions • Abscesses

DIAGNOSIS


• Leukocytosiswith immature polymorphoneuclear leukocytes

• increased haemacrit due to dehydration

• Elevated urine specific gravity

• Decreased urine flow rate

Dr sanjana ravindra

SONOGRAPHY: the affected gland shows swelling, increased vascularity

CT features: when the glands are involved in cellulitis, swelling of the glands and obscuration of the glands’ contour can be observed.

On enhanced CT, the affected glands are seen with a higher CT values compared with the normal side because of the increased vascularity


DIAGNOSIS

Ultrasonogram of the right and left

submandibular glands. The right

submandibular gland with the

features of inflammatory process –

hypoechogenic parenchyma with

increased blood flow in Power

Doppler. The left submandibular

gland normal

Dr sanjana ravindra


TREATMENT

Treatment of ASP is focused on rehydration (intravenous or oral) and emperic antibiotic therapy

Stabilization of underlying acute and chronic conditions, and minimizing medications that cause xerostomia

Treatments that may increase salivary flow are also helpful, including warm compresses, sialagogues, and/or parotid massage

Removal of sialolith

Dr sanjana ravindra

COMPLICATIONS


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FOLLOW-UP

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CHRONIC SIALADENITIS

Defined as “repeat episodes of Acute bacterial sialadenitis that are separated by intervening periods of remission.”

Long history of intermittent exacerbations of unilateral parotid swelling, with asymptomatic periods in between exacerbations

The periods of illness may last weeks or even months at a time with a spectrum of severity

There is generally less pain with eating and less purulent drainage

ADULT FORM

( Staphylococcus aureus )

JUVENILE FORM

( Streptococcus viridans )

Dr sanjana ravindra

TREATMENT


Reduction or elimination of inflammation in the gland

• short term corticosteroids-tapering dosage of Dexamethasone

• 0.75 mg four times daily for 3 days

• Followed by 0.75 mg three times daily for 3 days

• Followed by 0.75 mg two times daily for 3 days

• One-half tablet twice daily for 3 days

Clear the preciptated serum protiens within the intraductal system

• Lozenges • Appropriate medication

management• Warm compresses

Dr sanjana ravindra


Dr sanjana ravindra

Dr sanjana ravindra

CHRONIC SCLEROSING SIALADENITIS

Etiology. The etiopathogenesis is unknown, but it has been suggested to be the result of an immune process triggered by intraductal agents.

Clinical Presentation. Patients present with clinical features simulating a salivary tumor with enlarged, firm, and painful unilateral or bilateral submandibular salivary glands.

Diagnosis. This condition requires biopsy for histologic diagnosis since, clinically, it cannot be differentiated from a neoplasm. It is characterized by progressive periductal fibrosis, dilated ducts with a dense lymphocyte infiltration, and lymphoid follicle formation, with acinaratrophy. Sonographic findings include duct dilatation and calculi and prominent intraglandular vessels.

(Kuttner ’s Tumor)

Chronic sclerosing sialadenitis is a rare chronic inflammatory disease of the submandibular salivary gland, although it has been reported to occur in

parotid and minor salivary glands.

Dr sanjana ravindra

ALLERGIC SIALADENITIS

Description and Etiology Enlargement of the salivary glands - exposure to various pharmaceutical agents and allergens. Unclear - true allergic reactions or whether some represent secondary infections - medications that reduced salivary output.

Clinical Description The characteristic feature - acute salivary gland enlargement -itching over the gland. Cases have been reported of salivary gland enlargement without rash or other signs of allergy.

Diagnosis The diagnosis of allergic reaction should be made judiciously, especially when salivary gland enlargement is not accompanied by other signs of an allergic reaction. The possibility of infection or autoimmune disease should also be considered.

Dr sanjana ravindra

SIALOGRAPHY

• Sialography is defined as the radiographic demonstration of the major salivary glands by introducing a radiopaque contrast medium into their ductal system.

Sialography visualises the ducts and the parenchyma of the salivary gland, after contrast administration into the main salivary duct.

The preoperative

phase

The filling phase

The emptying

phase.

The procedure is divided into three phases.

Dr sanjana ravindra

PREOPERATIVE PHASE

This involves taking preoperative

(scout) radiographs, if not already taken,

before the introduction of the contrast

medium, for the following reasons:

• To note the position and/or presence of

any radiopaque obstruction

• To assess the position of shadows cast

by normal anatomical structures that

may overlie the gland, such as the hyoid

bone

• To assess the exposure factors.

Dr sanjana ravindra

FILLING PHASE

• Having obtained the scout films,

the relevant duct orifice needs to

be found, probed and dilated and

then cannulated. The contrast

medium can then be introduced.

• When this is complete, the filling

phase radiographs are taken,

ideally at least two different views

at right angles to one another.

EMPTYING PHASE

• The cannula is removed and the

patient allowed to rinse out.

• The use of lemon juice at this stage to

aid excretion of the contrast medium

is often advocated but is seldom

necessary.

• After 1 and 5 minutes, the emptying

phase radiographs are taken, usually

oblique laterals. These films can be

used as a crude assessment of

function.

Dr sanjana ravindra

Contrast media

• IONIC AQUEOUS SOLUTIONS— Diatrizoate (Urografin®)— Metrizoate (Triosil®)

• NON-IONIC AQUEOUS SOLUTIONS— lohexol (Omnipaque®)

• OIL-BASED SOLUTIONS— Iodized oil, [ Lipiodol®]

• WATER-INSOLUBLE ORGANIC IODINE COMPOUNDS,

-Pantopaque®.

Dr sanjana ravindra

Simple injection technique

Oil-based or aqueous contrast

medium is introduced using

gentle hand pressure until the

patient experiences tightness or

discomfort in the gland, (about

0.7 ml for the parotid gland,

0.5 ml for the submandibular

gland).

Hydrostatic technique

Aqueous contrast media is

allowed to flow freely into

the gland under the force of

gravity until the patient

experiences discomfort.

Continuous infusion

pressure-monitored

technique

Using aqueous contrast

medium, a constant flow

rate is adopted and the

ductal pressure monitored

throughout the procedure.

Advantages • The controlled introduction of contrast

medium is less likely to cause damage or give an artefactual

picture • Simple • Inexpensive.

Disadvantages • Reliant on the patient's responses • Patients

have to lie down during the procedure, so they need to be positioned in advance for the

filling-phase radiographs.

Advantages

• Simple

• Inexpensive

Disadvantages

• The arbitrary pressure which is applied may cause damage to the

gland

• Reliance on patient's responses may lead to underfilling or

overfilling of the gland.

Advantages • The controlled introduction of contrast media

at known pressures is not likely to cause damage • Does

not cause overfilling of the gland • Does not rely on the

patient's responses.

Disadvantages • Complex equipment is required • Time

consuming.

Dr sanjana ravindra

SIALOGRAPHIC APPEARANCES

Normal – Parotid gland: Tree in winter appearance

Submandibular gland: Bush in winter

Salivary gland calculi

Dr sanjana ravindra

Sjogrens’ syndrome : snowstorm appearance

SIALOGRAPHIC APPEARANCES

Sialadenitis – blobs/ dots

Dr sanjana ravindra

VIRAL SIALADENITIS

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EPIDEMIC PAROTITIS MumpsAcute viral parotitis

Paramyxovirus

Coxsackie A virus

Cytomegalovirus

Epstein-Barr virusInfluenza A

Parainfluenza virus type 3

Human herpes virus 6

“ Acute, contagious, self limiting viral infection usually affecting the parotid glands and sometimes submandibular and sublingual salivary glands”

Dr sanjana ravindra

EPIDEMIC PAROTITIS

Incidence has decreased due to immunisation

programs- MMR (measles, Mumps, Rubella) vaccines

Spread of infection-direct contact,: saliva,

fomites and respiratory tract droplets

Incubation period: 2-3 weeks

Age: 5-6 years

Rare- adults

CLINICAL FEATURES

90% parotid gland

10% submand

ibular and

sublingual

Dr sanjana ravindra

EPIDEMIC PAROTITIS

Bilateral (75%) or unilateral (25%) swelling of the parotid glands with pain, tenderness to palpation, erythema, malaise, and fever

Patients often complain of pain with speech, swallowing, and eating

Trismus may be present if there is inflammation involving the pterygoid muscles

CLINICAL FEATURES

Enlargement is sudden and

often bilateral

Skin over the gland is

oedematous, gland is tender

No discharge, although

ductal orifrice is inflamed.

Dr sanjana ravindra

EPIDEMIC PAROTITIS

DIAGNOSIS

Serum amylase level

Specific IgM level

Proteins levels

Leukopenia with lymphocytosis

Glucose level( less than normal) SEROLOGICAL STUDIES

Complement fixing antibodies to paramyxovirus S antigen or soluble

antibodies directed against viral neucleoprotein appear

Titres peak within 2wks and persist for

8 or 9 months

Antibodies directed against the surface haemagglutination

appear -------

1st week of infection

Weeks but persist up to 5 years

Dr sanjana ravindra

EPIDEMIC PAROTITIS

TREATMENT

• MMR vaccine at the age of 12-15 months

• Booster dose at 4-12 years of age

• Symptomatic treatment : controlling the pain and swelling

MMR VACCINE

• The MMR vaccine is

an immunization vaccine

against measles, mumps,

and rubella (German measles).

• It is a mixture of live attenuated

viruses of the three diseases,

administered via injection.

• It was first developed by Maurice

Hilleman while at Merck.

"Measles, Mumps, and Rubella -- Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and

Control of Mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP)Dr sanjana ravindra

https://en.wikipedia.org/wiki/Measles

https://en.wikipedia.org/wiki/Mumps

https://en.wikipedia.org/wiki/Rubella

https://en.wikipedia.org/wiki/Attenuated_virus

https://en.wikipedia.org/wiki/Maurice_Hilleman

https://en.wikipedia.org/wiki/Merck_&_Co.

EPIDEMIC PAROTITIS

COMPLICATIONS

Mild meningitis

Encephalitis : marked decrease in level of consciousness, convulsions,

paresis, involuntary movements and high fever

Pancreatitis

Myocarditis

Oophoritis : associated with fever, nausea, vomiting, low abdominal pain,

impaired fertility and early menopause

Orchitis and epididymitis : may result in testicular atrophy

Fetal deaths in the 1st trimester of pregnancy

Dr sanjana ravindra

CYTOMEGALOVIRUS INFECTION

MAJOR MANIFESTATION

• Fever and malaise

LESS COMMON

• Pharyngitis, tonsillitis, sphenomegaly and lymphadenopathy

Xerostomia and reduced saliva production were found with the presence of CMV and salivary gland

dysfunction

COMPLICATIONS: Interstitial pneumonia,

hepatitis, meningoencephalopathyand haemolytic anaemia

Dr sanjana ravindra

HIV INFECTION

Characterized by – xerostomia with unilateral or bilateral salivary gland enlargement

Reactivation of a latent

virus

ETIOLOGY

Frequency of salivary gland enlargement is

more among homosexuals

and Intravenous

drug users than those infected

by other routes of transmission

If enlargement increases, biopsy of gland is indicated as

chances of development of lymphoma and Kaposi

sarcoma are high

Dr sanjana ravindra

HEPATITIS C VIRUS ( HCV) INFECTION

Salivary gland enlargement is one of the extrahepatic manifestations of HCV infection

Sialadenitisappears to be more frequent in women with

chronic HCV infection than

men

Patients may complain of

salivary gland enlargement

with xerostomiabut not

commonly dryness of eyes

57-77% of HCV infected

persons were found to have

sialadenitisresembling SS

Detection of HCV-DNA and anti- HCV antibodies helps to confirm the diagnosis

Dr sanjana ravindra

NECROTIZING SIALOMETAPLASIA

Dr sanjana ravindra


“Benign self-limiting reactive inflammatory disorder of the salivary tissue”

ETIOLOGY

Clinically, this lesion mimics a malignancy, and failure to recognize this lesion has resulted in unnecessary radical surgery. Etiology - unknown, - local ischemic event, infectious process, or perhaps an immune response to an unknown allergen

describedby Abrams - 1973

Traumatic injury

Dental injections

Ill-fitting denture

Upper respiratory

tract infections

Previous surgeries

PREDISPOSING FACTORS

Dr sanjana ravindra

Vasoconstriction Sluggish blood

flow

Compromised vascular blood

supply from trauma

Likely etiopathogenesis

It also reported in patients with other conditions, such

as sickle cell disease, Buerger disease, Raynaud

phenomenon, lymphoma and bulimia


Carlson DL. Necrotizing sialometaplasia: a practical approach to the diagnosis. Arch Pathol Lab Med 2009;133:692-8.Dr sanjana ravindra

Trauma was noted in 2%-9% of cases

Pain reported in 22%-45% of cases, and up

to 12% reported

numbness.

Approximately 12% of cases involve the

palate bilaterally

Other oral sites include buccal

mucosa, lip, retromolar

pad, and major salivary glands.

The lesion also occur at extra salivary sites including lungs, breast, and skin.

Lesion occurring outside the salivary glands - designated as adenometaplasia

Skin was affected, lesion termed as syringometaplasia or metaplasia of sweat ducts

The average age is 40 years, with a 2:1 male predilection


Commonly affects the mucoserous glands of hard palate but can occur anywhere, with 10% of cases affecting the major salivary glands

Affects hard palatal mucosa in 40%-60% of cases; Junction of hard and soft palate in 13% of cases ; Soft palate in 3%-10% of cases; Tongue affected in only 3% of cases

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Necrotizing sialometaplasiapresents initially as a swelling.

Subsequent ulceration innecrotizing sialometaplasia


Classically, NS presents initially as slight unilateral swelling

that over a few days develops into a 1-3-cm ulcer on the

posterior hard palate or at the junction of hard and soft palate.

The initial swelling suggest the diagnosis of an abscess, the

subsequent ulceration suggests a malignancy, such as a

squamous cell carcinoma or salivary gland malignancy.

The ulcerated and necrotic tissue separates from the

adjacent vital tissue, and it is common for the former to

sequestrate


Anneroth and Hansen described histopathogenesis of NSby proposing five histological stages: infarction, sequestration,

ulceration, repair, and healing.

A reactive inflammatory infiltrate composed of neutrophils, chronic inflammatory cells, & histiocytes develops, with

squamous metaplasia of ducts & acini

Small acini-sized pools of mucus bordered by basement membrane and delicate fibrous septa

Infarcted salivary lobules in the earliest stages exhibit escape of mucus into the parenchyma



• Metaplasia of salivary ducts in NS – extensive, to be mistaken for

islands of invasive squamous cell carcinoma

However, maintenance of lobular architecture, lack of significant

cytologic atypia and lack of overlying dysplasia rule out a squamous

cell carcinoma


Treatment is directed toward

symptom relief, and spontaneous

resolution occurs within 2-3 months

after biopsy

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GRANULOMATOUS CONDITIONS

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TUBERCULOSIS

Tuberculosis (TB) is a chronic bacterial infection, caused by Mycobacterium tuberculosis, leading to the formation of granulomas in the infected tissues.

“First case of parotid gland tuberculosis – DePaoli – 1893

Sinve then only 100 cases have been reported in the literature”

1st mode

• It may begin as infection of tonsillar tissue or by autoinoculation with infected sputum, which reaches the parenchyma or lymphatic system of the parotid gland by the afferent lymphatics or by ducts

2nd mode

• Gland may be infected by metastasis from the lungs by a haematogenous or lymphatic route

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TUBERCULOSIS

Diffuse, parenchymatiusdisease resembling common parotid inflammation

Nodal involvement-acute inflammatory reaction with diffuse generalised glandular swelling

Involvement of intraglandular lymph nodes.

Presents with chronic, slow-growing, painless and firm parotid lump simulating a neoplasm

Glandular parenchymal involvement- presents as an encapsulated, chronic mass.

The mass is typically unilateral and associated with matted lymph nodes.

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SARCOIDOSIS

Sarcoidosis is a chronic condition in which T lymphocytes, mononuclear phagocytes, and granulomas cause destruction of involved tissue.

represents an infection or a hypersensitivity response to atypical mycobacteria

The parotid is affected in less than 10% of cases of sarcoidosis

Clinically- bilateral painless enlargement of the parotids that has a diffuse or multinodular character may be seen

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SARCOIDOSIS

Heerfordt syndrome - also known as uveoparotid fever-Pathognomonic for sarcoidosis-it consists of

Parotid enlargement,Bilateral uveitis, andFacial nerve palsy.

TREATMENT• Primarily palliative

• Chloroquine alone or in combination with corticosteroids

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CHEILITIS GLANDULARIS

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Rare inflammatory disorder of the minor salivary glands affecting mostly those of the lower lip

Self- inflicted trauma such as

biting and excessive wetting

habitual licking

Actinic exposure

ETIOLOGY

SIMPLE: Lesions are multiple superficial papules with central

depression and dilated ducts

SUPERFICIAL SUPPURATIVE: (Baelz disease) : indurated

swelling of the lip with painless shallow ulcers and crusting

DEEP SUPPURATIVE: (Cheilitisglandularis apostematosa):

abscesses, sinus tracts, fistulas and in few cases scarring

TYPES

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Progressive chronic condition, most often diagnosed 3-12 months after onset

Early stages: Asymptomatic lower lip swelling with clear viscous secretion on the mucosal surface

Patient may complain of discomfort or a raw sensation at the vermilion border

Pain which may be transient or recurrent – mucopurulentdischarge through the opening of inflamed salivary gland ducts

With increasing in swelling- lip gets everted, demarcation by the vermilion border vanishes,

Exposed labial mucosa –susceptible to drying,

erosion, ulceration and fissuring

When exposed to actinic rays, the chances of

development of SCC also increases.

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NICOTINIC STOMATITIS

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NICOTINIC STOMATITIS

M>F, 5th-7th decade of life

Seen commonly in reverse smokers.

Minor SG of hard palate is affected

Palatal mucosa becomes diffusely grey or numerous elevated papules with punctate centres maybe seen

‘Dried mud appearance’ - keratinized palatal epithelium

Seen in cigar smokers and pipe smokers

ETIOLOGY- inflammation of minor salivary

glands and their orifices due to chronic

irritation from tobacco smoke

TREATMENT

Completely

reversible with

smoking cessation

within 2-5 weeks

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MIKULICZ’S DISEASE

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Symmetric or bilateral, chronic, painless lacrimal, parotid, and submandibular gland enlargement with associated lymphocytic infiltrations

1st coined by Mikulicz -

1888

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MIKULICZ’S DISEASEAGE AND SEX

Commonly in women in middle and later life

SITE

Unilateral or bilateral enlargement of parotid and/or submandibular gland

PRODOMAL SYMPTOMS

Associated with fever, upper respiratory tract infection, oral infection, tooth extraction or some local inflammatory disorders

Mild local discomfort, occasional pain and xerostomia

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MIKULICZ’S DISEASESI

GN

S Often diffuse, poorly outlined enlargement of salivary gland rather than formation of a discrete tumor nodule.The enlargement varies in sizes but generally few centimeters in diameter

H/O alternating increase and decrease in size of mass, from time to time

DU

RA

TIO

N Few months or many

years

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DIAGNOSIS

Clinical diagnosis

• Unilateral or bilateral enlargement of parotid and lacrimal gland

Laboratory diagnosis

• Biopsy shows solid nest or clumps of poorly defined epithelial which termed as “ epimyoepithelialisland”

TREATMENT:Surgical excision of involved gland

Good prognosis

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SJOGRENS’ SYNDROME

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Sjogren syndrome (SS) is an autoimmune disorder in which immunocytes damage the salivary, lacrimal and other exocrine glands and is thus termed an autoimmune exocrinopathy


SS has two major forms

Primary Sjögrensyndrome (SS-1)

• dry eyes and dry mouth are seen in the absence of a connective tissue disease.

• Uncommon and sometimes termed ‘sicca syndrome’, but the latter term is also used non-specifically for dry mouth and eyes.

Secondary Sjögrensyndrome (SS-2)

• is more common: dry eyes and dry mouth are seen together with other autoimmune diseases,

• usually primary biliary cirrhosis (PBC) or a connective tissue –most usually (in descending order of frequency)

■ Rheumatoid arthritis (RA)■ Systemic lupus erythematosus■ Polymyositis■ Scleroderma■ Mixed connective tissue disease.

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Dr sanjana ravindra


AGE can affect any age, but the onset is

most common in middle-age or older.

GENDER The majority of patients

affected by SS are women.

GEOGRAPHIC There is no known

geographic incidence to SS.

Estimated to affect 1–3% of the general

population.

Menopausal women in the fourth and fifth

decades of life.

More prevalent in women than men, with a ratio

of 9:1.

EPIDEMIOLOGY

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AETIOLOGY

Initiation by an exogenous factor

disruption of salivary gland epithelial cells

T lymphocyte migration and lymphocytic infiltration of exogenous glands

B lymphocyte hyper-reactivity and production of rheumatoid factor and antibodies to Ro(SS-A) and La(SS-B)

Konttinen Y, Kasna-Ronkainen L. Sjogren’s syndrome viewpoint on pathogenesis. Scand J Rheumatol 2002;116:15–22.Dr sanjana ravindra


RISK FACTORS

A genetic predisposition to SS has been suggested because of multiple reports of two or more members of the same family developing the syndrome.

A family history of the disease puts people at an increased risk of developing SS compared to the general population.

This is also supported by the development of SS in twins.

It has been suggested that a genetic susceptibility is required for the development of autoantibodies which are found in SS and this may be associated with a link between polymorphic major histocompatibility complex (MHC) genes and the

development of autoimmune diseases.

This area needs further exploration before a definitive link can be found.

GENETIC PREDISPOSITION

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VIRAL INITIATING FACTORRISK FACTORS

Cytomegalovirus infection led to the development of SS-like symptoms

Other viruses potentially involved in the aetiology of SS are Epstein-Barr virus, hepatitis C virus (HCV) and human T-cell Leukaemia virus-1

It is hypothesized that viruses can promote autoantibody production through molecular mimicry, resulting in cross-reactivity of immune reagents with host antigens.

The amino-acid sequence and structural similarities between foreign and self-peptides (molecules from dissimilar genes) allows an immune response directed against the virus to concurrently elicit a tissue-specific immune response via the creation of cytotoxic cross-reactive lymphocytes and antibodies which result in cell and tissue destruction

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The early manifestations may be non-specific, such as fatigue, arthralgia, and Raynaud phenomenon, and it can be 8–10 years from the initial symptoms to

full-blown disease.

CLINICAL FEATURES

It presents with a clinical spectrum that ranges from an organ-specific autoimmune process to a systemic disorder

Systemic lupus erythematosus

Scleroderma

mixed connective tissue

disease

primary biliary cirrhosis

hyperthyroidism (Graves disease)

hypothyroidism (Hashimoto thyroiditis).

Mothers with SS can pass autoantibodiesacross the placenta into the foetal circulation –leading to foetal heart block

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CLINICAL FEATURES

Sensations of grittiness, soreness, itching, dryness, blurred vision or light intolerance.

The eyes may be red with infection of the conjunctivae and soft crusts at the angles (keratoconjunctivitis sicca).

The lacrimal glands may swell.

EYE

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CLINICAL FEATURES

Xerostomia: often the most frequent although not all patients complain of dry mouth

Soreness or burning sensation

Difficulty eating dry foods, such as biscuits (the cracker sign)

Difficulties in controlling dentures

Difficulties in speech: there may be a clicking quality of the speech as the tongue tends to stick to the palateDifficulties in swallowing

Complications such as unpleasant taste or loss of sense of taste; oral malodour; caries; candidiasis; sialadenitis.

ORAL

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Hyposalivation

Tendency of the mucosa to stick to a dental mirror

Food residues

Lack of salivary pooling

Frothiness of saliva and absence of frank salivation from

Major gland duct orifices

A characteristic tongue appearance; lobulated, usually

red, surface with partial or complete depapillation

In advanced cases – obviously dry and glazed oral

mucosae.

OBJECTIVE SIGNS

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■ Raynaud phenomenon

■ arthralgia

■ myalgia ■ fatigue

■ skin ulceration or

rash

■ dyspnoea ■ dry vagina

■ bruising, bleeding and

purpura

numbness

EXTRAORAL (EXTRA-GLANDULAR) COMPLICATIONS OF SS

Connective tissue disease in SS usually precedes the onset of dry eyes and dry mouth, and, therefore, patients presenting

With dry eyes and dry mouth alone probably have Primary SS

■ Other neurological features, including orofacial sensory loss, orofacial pain or facial palsy, and other cranial neuropathies.

Dr sanjana ravindra

A non-productive cough secondary to dryness of tracheobronchial mucosa (xerotrachea) or dyspnea due to small airway obstruction is

relatively common

High-resolution CT of the lungs often demonstrate wall thickening at the segmental bronchi, and bronchial biopsy shows peribronchial

and/or peribronchiolar mononuclear inflammation.

Interstitial lung disease in Sjogren’s syndrome is less common.

Pleural effusions are infrequently found in primary Sjogren’s syndrome. Lymphoma should always be suspected when lung

nodules or hilar or mediastinal lymphadenopathy are present in chest radiographs.


RESPIRATORY TRACT DISEASE

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MUSCULOSKELETON SYMPTOMS

Polyarthralgias

polymyalgias

morning stiffness

intermittent inflammatory

synovitis

chronic polyarthritis.

Despite myalgia and easy fatigue, frank myositis is unusual.

Inflammatory arthritis is observed in 50% of patients but, in contrast to RA, there are usually no erosive changes.

Rare cases of inflammatory myositis have been reported.

Dr sanjana ravindra


Pseudolymphoma,

Monoclonal gammopathies (such as waldenstrom's macroglobulinaemia)

Mixed monoclonal cryoglobulins

Non-hodgkin lymphoma of the diffuse large b-cell type

Extranodal marginal zone b-cell lymphomas of the mucosa-associated lymphoid tissue type.

LYMPHOPROLIFERATIVE DISEASES

Mostly seen in primary SS, as b-cell lymphoproliferation in mucosal- associated lymphoid tissue (MALT)

Patients with SS have a 15–40-fold increased risk of the development of B-cell non-Hodgkin lymphoma.

This is < 1 case per 100 patients per year; 2% of cases at 5 years and up to 5% of cases with time.

Dr sanjana ravindra


o Most lymphomas complicating SS arise in mucosal extranodal sites, especially the

salivary glands.

o Most lymphomas are low-grade marginal zone B-cell lymphoma with long-term

survival.

Pseudolymphoma or frank lymphoma should be suspected when:■ persistent salivary gland enlargement■ lymphadenopathy■ hepatosplenomegaly

Lymphomas may be predicted if there are features such as:■ fever■ palpable purpura■ leg ulcers■ peripheral neuropathy■ lymphopenia with low CD4 counts■ hypocomplementaemia■ cryoglobulinaemia.

Dr sanjana ravindra


• Benign lymphoepithelial lesions of the salivary glands do not necessarily require surgical treatment.

• For lymphomas,; chemotherapy or rituximab.(or) radioimmunotherapy using (90)Y-ibritumomab tiuxetan.

Dr sanjana ravindra


DIAGNOSIS OF SJOGREN SYNDROME

History

Clinical examination

Investigation findings

A subjective feeling of dry mouth (xerostomia) is common in the general population, although reduced salivary flow (hyposalivation) is not always confirmed by objective studies

ocular symptoms oral symptoms ocular signs autoantibodies and other

blood tests salivary gland studies

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SJOGRENS’ SYNDROME DIAGNOSTIC CRITERIA

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INVESTIGATIONS

Dr sanjana ravindra


SIALOMETRY

To measure salivary flow rate (resting /

stimulated)

Provide essential information for diagnostic and

research purposes

Calculated from the individual major salivary gland or

from a mixed sample of the oral

fluids, termed “whole saliva”.

Passive drool

sialometricsoral swab

Infant swabSpitting method

Suction method

INVESTIGATIONS

Dr sanjana ravindra


SIALOMETRY

• Avoid having alcohol,caffenine,prescribed medication 12 hours before collection of saliva.

• Avoid eating major meal within 60 min of sample collection

• Avoid dairy products for 20 min before sample collection

• Participants should not brush their teeth within 45 minutes prior to sample collection.

• Rinse mouth with water to remove food residue before sample collection. Wait at least 10

minutes after rinsing before collecting saliva to avoid sample dilution.

• Also while pipetting saliva, greater accuracy is obtained by aspirating slowly in order to

avoid formation of bubbles.

PRECAUTIONS

INVESTIGATIONS

Dr sanjana ravindra


SIALOMETRY

PASSIVE DROOL• Passive drool - highly recommended

because it is both cost effective and approved for use with almost all analytes.

• To avoid problems with introduction of contaminants, use only high quality polypropylene vials for collection .

• The vials used must seal tight and be able to withstand temperatures down to -80ºC.

• Should allow saliva to pool in the mouth.

• Unwrap the saliva collection aid (SCA) and insert it into the top of the cryovial .

• With head tilted forward, drool down the SCA to collect saliva in the cryovial.

INVESTIGATIONS

Dr sanjana ravindra


SIALOMETRY

SALIMETRICS ORAL SWAB (SOS)

• An excellent alternative to passive drool

• SOS also helps filter large macro molecules and other particulate matter from the sample.

• Not recommended for children below 6 yrs of age

INVESTIGATIONS

Dr sanjana ravindra


AUTOANTIBODIES AND OTHER BLOOD TESTS

Serology is used to establish the presence of anti-SS-A/Ro and

anti-SS-B/La auto-antibodies,based on (enzyme-linked immunosorbent assay).

Anti-SS-A/Ro antibodies can also be detected in other autoimmune

processes such as rheumatoid arthritis and systemic lupus

erythematosus; for this reason, anti-SS-B/La antibodies are

considered to be more specific of SS.

Anti- SS-A/Ro can be isolated in 25-65% of cases, and anti- SS-

B/La in 13-48%

INVESTIGATIONS

SEROLOGIC TESTS

Dr sanjana ravindra


AUTOANTIBODIES AND OTHER BLOOD TESTSINVESTIGATIONS

SEROLOGIC TESTS

Erythrocyte Sedimentation Rate (ESR),

C-reactive Protein (CRP)

Plasma Viscosity (PV

Dr sanjana ravindra


The sialography typically shows sialectasias in contrast to the fine arborization seen in normal parotid ductules.

Diagnosis is generally based on the classification

Sjogrens’ syndrome : snowstorm appearance

SIALOGRAPHY

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SS is a mixture of increased inflammatory proteins and decreased acinar proteins when compared with healthy controls.

SIALOCHEMISTRY

Analysis of saliva composition (sialochemistry) for the diagnosis and monitoring of salivary disease

■ lactoferrin

■ beta 2 -microglobulin

■ interleukin-6

■ lysozyme

■ sodium, chloride, albumin, IgA and IgG

Dr sanjana ravindra


• In the scintigraphic test, 99mTc-pertechnate is given intravenously, and

in SS patients the typical finding is decreased uptake in response to

stimulation of the parotid and submandibular salivary glands.

• This test is a sensitive and valid method to measure abnormalities in

salivary gland function

SCINTIGRAPHY

Dr sanjana ravindra


However, the lymphocytic foci are

not present in all minor salivary

glands, and multiple glands should be

examined to secure an accurate diagnosis

Focal aggregates of at least 50

lymphocytes and plasma cells and adjacent to ducts

and replacing aciniare seen in patients

with Sjogren’ssyndrome.

Lip biopsy confirms lymphocytic

infiltration of the minor salivary

glands.

LIP BIOPSY

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1. Schirmer test

2. Rose Bengal

Staining

3. Tear break up

time (BUT)

OCULAR DIAGNOSTIC TESTS

Dr sanjana ravindra


SCHIRMER’S TEST

• The tip of a strip of filter paper 30 mm

long is slipped beneath the inferior lid,

with the remainder of the paper

hanging out.

• After 5 minutes, the length of paper

wetted is measured.

• Wetting of less than 5 mm is a strong

indication of diminished tearing.

Dr sanjana ravindra


• Rose bengal is stains the devitalized or damaged

epithelium of both the cornea and conjunctiva.

• In Sjogren’s syndrome, slit lamp examination after

rose bengal staining shows a punctate pattern of

filamentary keratitis.

ROSE BENGAL STAINING

Dr sanjana ravindra


• A drop of fluoroscein is instilled into the eye,

and the time between the last blink and

appearance of dark, nonfluorescent areas in the

tear film is measured.

• An overly rapid break-up of the tear film

indicates an abnormality of either the mucin or

the lipid layer.

TEAR BREAK-UP TIME

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Dr sanjana ravindra


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Dr sanjana ravindra


NOTABLE CASES

CARRIE ANN INABA(SINGER-ACTRESS)

VENUS WILLIAMS(WORLD CHAMPION TENNIS PLAYER)

Dr sanjana ravindra

Dr sanjana ravindra


Dr sanjana ravindra

REFERENCES

Dr sanjana ravindra

REFERENCES

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2. Tucker A.S., Miletich I. Salivary Gland diseases. In: Salivary Glands - Development, adaptations and diseases 2nd

Ed. Krager, Switzerland, 2010.p.129-146.

3. Scully C. Common and important oral conditions .p. 183-406.

4. Lynch MA. Salivary Gland Diseases. In: Lynch MA, Brightman VJ, Greenberg MS eds. Burket's Oral Medicine:

Diagnosis and Treatment. 8th ed. USA: JB Lippincott Company; 1984. 842-848.

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7. Silvermann S., Eversole R.L., Truelove E.L. Salivary gland diseases. In: Essentials of Oral Medicine. 3rd ed. London:

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Dr sanjana ravindra

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literature on necrotizing sialometaplasia . Quintessence Int. 2015;46(1):67-72.

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Dr sanjana ravindra

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REFERENCES

Dr sanjana ravindra

Health & Medicine

Inflammatory n infectious diseases of salivary gland- Dr Sanjana Ravindra