PATHOLOGY OF THE SALIVARY GLANDS
1/ Reminders
1.1 Major salivary glands:
Even and symmetrical, three on each side.
Parotids : Steno’s canal (opening on the inner side of the cheek opposite the 2nd upper molar/ Palpable behind the ascending branch of the mandible above the level of the angle/ swelling which pathognomonically pushes back the lobule of the ear/ deep extension which may be in contact with the pharyngeal wall/ Crossed by the facial nerve which separates it into superficial and deep lobes;
Submandibular : Wharton’s canal (opening on either side of the frenulum of the tongue, palpable under the basilar edge of the mandible, in front of the level of the mandibular angle, fingers hooked / Running along the inside by the lingual nerve (sensory) and the hypoglossal nerve (XII motor).
Sublingual : Rivinus canal (opening adjacent to the Wharton ostium or in the canal itself/ Swelling with endobuccal expression, along the salivary ridge
1.2 Accessory salivary glands:
small size (a few millimeters), distributed throughout the mucosa of the oral cavity, particularly the lips (easy biopsies), the palate and the veil. Uncommon pathology but often malignant tumor.
2/ Problem posed by the diagnosis of salivary swellings:
The causal diagnosis is posed differently:
• in inflammatory swellings, where the cause is generally easily recognized
• in non-inflammatory swellings, where, despite the most advanced additional examinations (ultrasound, MRI, fine needle aspiration cytology, hematological assessment), the cause is only discovered during the extemporaneous examination during the exploratory parotidectomy, or sometimes even during the definitive histological examination of the entire surgical specimen.
So there are:
• Inflammatory swellings (sialitis: sialodochitis and sialadenitis)
• Non-inflammatory swellings
- unilateral: tumors
- bilateral: sialosis
3 / unilateral non-inflammatory swelling: Tumor pathology
Overall course of action:
Benign swelling logically presents in an isolated, asymptomatic manner, with a regular and mobile appearance, whereas the presence of adenopathies, nerve paralysis (VII for the parotid), limited mobility, trismus, or pain should suggest a malignant tumor.
CAT:
In the absence of clinical signs of malignancy:
Ultrasound + Fine-needle aspiration
Questionable CT and MRI: if reluctance to have surgical excision (AEG, refusal) in order to get as close as possible to the natural diagnosis.
Excision + extemporaneous examination +/- cervical dissection if malignant
In the presence of clinical signs of malignancy (PF, ADP, trismus, pain, fixity):
MRI ++ or injected CT scan –> study of resectability
Surgery: excision (superficial or deep exploratory parotidectomy)
depending on the location) + extemporaneous +/- cervical curettage if malignancy confirmed
3.1 Benign tumors:
They are mostly tumors of the parotid gland and develop under
nodule form of the parotid lodge. Their problem is only diagnostic because their treatment by complete excision is effective. Only pleomorphic adenomas pose the problem of local recurrence and possible degeneration.
3.1.1 Pleiomorphic adenomas or mixed tumors of the parotid gland
The most common parotid tumors. They represent more than 50% of
parotid tumors and 80% of benign epithelial tumors
Histology : coexistence of epithelial and mesenchymal elements (hence their name mixed tumor).
Epidemiology : They are observed at all ages, with a maximum frequency between 30 and 60 years, without gender predominance.
Clinic: They are most often located in the superficial lobe of the gland; they
can sometimes affect the anterior or deep extensions, thus posing diagnostic problems with jugal tumors (anterior extension) or
parapharyngeal (deep lobe of the parotid gland).
Clinically, they present as a progressive tumor syndrome and
isolated: a unilateral swelling of the parotid gland, of variable consistency.
Absence of functional sign, absence of adenomegaly. Facial mimicry is always normal; the existence of facial paralysis, even very partial, should lead to a review of the diagnosis of mixed tumor, or to fear its malignant degeneration. The swelling developed at the expense of the deep lobe is responsible for a curvature at the level of the anterior pillar of the tonsil.
Evolution: They are often noticed incidentally, because they are painless and
very slow growth. They can reach considerable proportions if neglected by the patient.
The additional examinations have two objectives:
• Confirm the intraparotid location of the tumor:
– Ultrasound is sufficient: parotid tissue tumor
– CT and MRI are of little use in typical cases, they are
useful in case of parapharyngeal arching (anterior pillar of the tonsil).
• Approach the benign or malignant nature and possibly the type
histological:
– MRI, quite characteristic, but not pathognomonic, shows a
hyposignal in T1, a hypersignal often scalloped in T2. It is not requested
systematically.
– Cytological puncture has only positive value. In all other cases
In this case, they cannot replace histological examination.
The treatment is surgical. It is an exploratory parotidectomy with
identification, dissection and preservation of the facial nerve. Non-invasive tumor excision
capsular, extemporaneous anatomopathological analysis, in case of confirmation of the
diagnosis: total or subtotal parotidectomy. The prognosis is then quite favorable.
The risk of cancer is very low, most often in a tumor that has been developing for several decades or is recurring. Monitoring must be prolonged.
3.1.2 Other benign tumors
a) Cystadenolymphoma or Warthin’s tumor (5 to 10% of tumors)
parotid gland). It is only observed at the level of the parotid gland and can be bilateral.
Prerogative of men aged 40 to 60, it is generally located in the lower pole; its consistency is soft or elastic, its evolution is slow. The diagnosis is confirmed during exploratory parotidectomy and the treatment consists of a partial parotidectomy, with preservation of the facial nerve. The prognosis is benign.
o Monomorphic adenomas, or simple adenoma (10 to 15% of tumors
parotid)
b) oxyphilic adenomas or oncocytoma (1% of parotid tumors)
3.2 Malignant tumors
They represent approximately 8 to 18% of salivary gland tumors.
3.2.1 Tumors with attenuated malignancy
a) Mucoepidermoid carcinomas represent approximately 45% of all tumors
malignant salivary glands. They most often have a benign course (grade I) but can sometimes become infiltrating and give rise to metastases (grade II). They affect men and women between the ages of 20 and 60. Surgical treatment is essential, and the higher the grade, the more aggressive it becomes. Grade III mucoepidermoid carcinomas are tumors with a high potential for malignancy.
b) Acinar cell tumors represent approximately 10% of all tumors
malignant salivary glands. They are more common in women from the 10
fifties. Their evolution is characterized by the occurrence of metastases
lymph node or distant in 5 to 10% of cases, with a 5-year survival of 80%.
3.2.2 Highly malignant tumors
3.2.2.1 Adenocarcinomas
They represent about 20% of malignant tumors of the salivary glands. These
Malignant tumors are observed at any age; The parotid swelling increases rapidly in volume, infiltrating the entire gland. It is often painful. It may be accompanied by cervical adenopathy and facial paralysis. MRI shows a tumor with poorly defined contours, in heterogeneous hypointensity in T1 with strong contrast uptake after gadolinium. Treatment must be aggressive, combining a total parotidectomy with lymph node dissection, followed by radiotherapy. The prognosis is very poor, despite this treatment.
3.2.2.2 Cystic adenoid carcinomas or cylindromas
They represent about 10% of malignant tumors of all glands
salivary, and are observed at any age, readily in women. The clinical picture is that of a hard, uneven parotid tumor, growing fairly rapidly. It is often associated with spontaneous pain and palpation. The examination may reveal a PF.
The severity of this tumor comes from its potential for local recurrence, its
tendency to perineural sheathing and the frequent possibility of metastases
general (pulmonary, bone) sometimes late (many years after the initial treatment). Total parotidectomy with preservation of the facial nerve must be followed by radiotherapy. Curage is questionable (rare lymph node invasion).
3.2.2.3 Other carcinomas
Highly malignant mucoepidermoid carcinomas (grade III)
Squamous cell and undifferentiated carcinomas account for approximately 5% of all
Malignant tumors of the salivary glands. Their prognosis is very poor. Management is aggressive by total parotidectomy + curettage + radiotherapy.
4/ Inflammatory swelling: Sialitis 4.2 Sialadenitis 4.2.1 Bilateral: Mumps parotitis 4.2.2 Unilateral: Microbial parotitis (acute or chronic)
4.3 Salivary lithiasis of the major glands
5/ Sialosis:
5.1 Sarcoidosis or Besnier-Boeck-Schaumann disease (BBS)
The association of bilateral, painless, rapidly established parotid hypertrophy and uveitis (uveoparotitis) results in Heerfordt syndrome, typical of sarcoidosis; it is often accompanied by facial paralysis, and possibly other manifestations: cutaneous, bone, pulmonary, lymph node, visceral of BBS disease. The diagnosis is suspected in the face of a negative IDR, and confirmed by the measurement of plasma activity of the converting enzyme and histological examination. The evolution of this parotid disease is often rapidly favorable.
5.2 Dry syndromes
They associate diffuse bilateral parotid swelling, dry eyes (xerophthalmia) and mouth (xerostomia).
Gougerot-Sjögren syndrome : It is the most characteristic, isolated or associated with other autoimmune manifestations: rheumatoid arthritis, SLE, digestive, renal, muscular, neurological disorders, etc. It occurs mainly in women between 40 and 60 years old. It is an autoimmune disease. The diagnosis is established by biopsy of the accessory salivary glands. This is performed under local anesthesia through the mucosa of the lower lip. At least three glands must be removed, respecting their architecture as much as possible. The treatment, disappointing, involves immunotherapy, corticosteroid therapy , artificial tears and saliva, and sialagogues. It can develop into lymphoma, which should be considered in the event of parotid tumor development.
PATHOLOGY OF THE SALIVARY GLANDS
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