Normal structure of salivary glands

In body there are three major salivary glands: parotid, sub-mandibular (submaxillary) and sub-lingual. In addition, numerous minor salivary glands are present in submucosa, in large part of oral cavity Main duct of parotid gland (Stensens duct) opens into oral cavity opposite the crown of 2nd maxillary molar. Duct of both submandibular (Whartons duct) and sublingual glands (Bartholins duct) opens into the floor of the mouth on each side of the frenulam. Microscopically, salivary glands are compound exocrine glands, i.e. they consist of multiple acini at the end of a highly branched duct system. The acinar portion can be either serous or mucinous. The parotid gland is totally serous, submandibular and sublingual glands are mixed in character. The intercalated ducts (terminal branches of duct system) and acini, together form what is known as ductoacinar unit. Some amount of lymphoid tissue may be normally present in stroma of the salivary glands.

Major Salivary Glands

Ducto-acinar unit

Sialadenitis

Sialadenitis may be
 Acute
infectious or non-infectious

 Chronic
infectious or non-infectious

Sialadenitis can be
 Local, or  Manifestation of a systemic disorder.

Acute Infectious Sialadenitis

Acute infectious sialadenitis can be:
Viral: as in mumps, coxsackie, influenza A and B, CMV and EB virus. Bacterial: As in staphylococcal, streptococcal and gram negative bacterial infections.

Predisposing factors for bacterial sialadenitis are

Sialolithiasis Stricture Decreased salivary secretions as in
Dehydration Drugs, xerostomaia, post abdominal surgery

Chronic Sialadenitis
Chronic sialadenitis may be due to
Recurrent duct obstruction In association with conditions like
Rheumatoid arthritis Sjogrens syndrome (sialadenitis + xerostomia + dry eyes) Radiation therapy

Kuttners tumor: an immune form of chronic sclerosing sialadenitis of submandibular gland.

Chronic granulomatous sialadenitis is seen in

Tuberculosis Fungal infections Sarcoidosis and Sometimes with chronic duct obstruction.

Chronic Sialadenitis

Chronic Sialadenitis
It is characterized by Lymphocytic and plasma cell infiltration. Acinar atrophy Fibrosis that may be extensive enough to encase ducts in thick fibrous tissue called chronic sclerosing sialadenitis

Common Salivary Gland tumors

Benign tumors usually occur in adults, malignant tumors at more advanced age. About 3/4th of salivary gland tumors arise in parotid gland, 10% in submandibular gland. , rest in other glands. About 25% of parotid tumors, 40% of submandibular and 80% of sublingual gland tumors are malignant. Presence of facial nerve palsy in parotid tumor is almost diagnostic of malignancy.

Benign
Warthin tumor (5% - 10%) Oncocytoma (1%) Other adenomas (5% - 10%)

Malignant

Pleomorphic adenoma (50%) Mucoepidermoid carcinoma (15%) Adenocarcinoma (10%) Acinic cell carcinoma (5%) Malignant Mixed tumor (3% - 5%)

Pleomorphic Adenoma

 Pleomorphic adenoma is the commonest tumor of salivary glands. It originates from a mixture of ductal and myoepithelial cells. Although also known as mixed tumor of salivary gland, it is not a true mixed tumor, since it is not composed of tissues derived from more than one germ cell layer. The tumor occurs most commonly in the parotid gland. It is also seen in palate, upper lip and buccal mucosa. It is rare in sublingual gland. In parotid gland, about 75% cases are seen in superficial lobe. Rest occur in deep lobe and these tumors may present as pharyngeal masses. Grossly, the tumor is rubbery and bosselated. It may reach massive proportions. Cut surface shows a variable appearance. Although well circumscribed, it sends extensions into surrounding normal tissue.

 OHE, many different types of tissue may be seen. This may lead to a mistaken diagnosis of malignancy, although this tumor is entirely benign. In a typical case, a biphasic pattern consisting of epithelial and stromal cells are seen. Most commonly epithelial cells forms glands, often they may be squamous in nature. Stromal cells can be fibrous, myxoid, fatty , cartilaginous or of many other types. Myoepithelial cells are present in variable amount. Treatment consists of total excision along with a margin of surrounding tissue if feasible. Facial nerve is to be preserved. If simple enucleation of the tumor is done, multi focal recurrence can occur. The tumor if left untreated for a long time may undergo malignant transformation in up to 5% of cases.

Malignant salivary gland tumors

Amongst malignant tumors of salivary gland, muco-epidermoid cancer, acinic cell carcinoma and adenoid cystic carcinomas are the more common variants. Muco-epidermoid carcinoma can be seen in all age groups, even in children. Its prognosis is highly variable and its behavior is dependent on histological grade oft the tumor. 5 year survival is up to 98% for low grade tumors and about 50% for high grade cancers. Acinic cell carcinomas occur predominantly in males, mostly in parotid glands. The tumor has good prognosis, having a death rate of only ~ 5%. Adenoid cystic carcinoma is the commonest malignant tumor of manor salivary glands. It is a highly malignant tumor, recurrences are frequent and 15 year survival is less than 5%. It frequently metastasizes to the lungs.