1. Cystic DISORDERS
   1. Mucocele
      1. Also known as MUCOUS RETENTION PHENOMENON or MUCOUS RETENTION CYST
      2. - It is a benign , mucous containing cystic lesion of minor Salivary glands. - Generally of Traumatic origin. - Common lesion.
         1. Extravasation
            1. - More common - Results from a broken salivary gland duct and consequent spillage into the soft tissue around this gland
            2. No epithelial lining and is formed by mucous pool surrounded by granulation tissue ,so not a true cyst
         2. Retention
            1. - Appears due to decrease or absence of glandular secretion produced by blockage of salivary gland ducts.
            2. Has epithelial lining ( intact, flattened ) , so a true retention cyst. The flattened epithelial lining has been referred to as epithelium of 'feeder duct'
      3. Clinical features
         1. - Most commonly occurs on lower lip - Also may occur on palate, cheek, tongue( involving glands of Blandin-Nuhn) and floor of the mouth
         2. - No age group predilection - Equally divided among all decades of life - Equal distribution of occurrence between males and females
         3. Deep or Superficial 1.Superficial : Appears as raised, circumscribed vesicle, with a bluish translucent cast 2. Deep : Appears as swelling but because of overlying tissue, colour and surface appearance are those of normal mucosa
         4. Arise within few days, reaches certain size and may present as such for months unless treated
      4. Treatment
         1. 1.Surgical Excision with removal of any projecting peripheral salivary gland
         2. 2.If the lesion is simply incised, its contents will be evacuated, but rapidly filled again as soon as the incision heals.
   2. Ranula
      1. - Form of mucocele but larger. - Specifically occurs in the floor of the mouth in association with ducts of submaxillary and sublingual gland. - Filled with saliva that has leaked out of damaged salivary gland
      2. Occurs due to duct blockage or through development of a ductal aneurysm
         1. HISTOLOGIC FEATURES : Sometimes a definite epithelial lining is present, so considered as a true retention cyst.
         2. TREATMENT : 1. Marsupialisation 2. More often excision of entire sublingual gland, that decreases chances of recurrence
         3. superficial The mucosa may have a translucent bluish color which resembles translucent under the belly of the frog, hence the name.
      3. - If the ranula stays in the mouth underneath the tongue it is called Simple Ranula - If it grows down into the neck under the mouth it is called Plunging Ranula
   3. Benign cysts of parotid gland
      1. Less common
         1. Lymphoepithelial cyst
         2. Salivary duct cyst
         3. Dysgenetic cyst
2. TUMOR LIKE LESION
   1. Sialadenosis ( SIALOSIS)
      1. Non inflammatory, non neoplastic enlargement of salivary gland
         1. ETIOLOGY
            1. 1. Hormonal
            2. 2.Malnuitrition
            3. 3. Alcohol cirrhosis
      2. Periauricular or retromandibular portion of parotid gland commonly affected
         1. Sialograph shows LEAFLESS TREE pattern
   2. Necrotizing Sialometaplasia (Salivary gland infarction)
      1. Non neoplastic inflammatory condition of the salivary glands.
         1. Tobacco use risk factor
      2. ETIOLOGY
         1. 1.Vascular ischemia in most cases
         2. 2.History of trauma, radiation therapy or surgery
      3. 1.Involve minor Salivary gland 2. Palate most common site followed by buccal mucosa
         1. Type of necrosis coagulative necrosis
      4. D/D
         1. 1. Mucoepidermoid carcinoma
         2. 2. Squamous cell carcinoma
      5. TREATMENT
         1. No treatment necessary, resolves spontaneously
         2. Prognosis is excellent
      6. Similar type of lesions in skin is called SYRINGOMETAPLASIA
   3. Autoimmune
      1. Benign lymphoepithelial lesion ( Mikulicz syndrome)
         1. Chronic condition characterized by abnormal enlargement of salivary and lacrimal glands
         2. - Also called Mikulicz Syndrome if enlargement associated with known disease - Called Mikulicz Disease if the cause is unknown
            1. An autoimmune disorder
            2. Mikulicz Disease affects more females than males
            3. - Xerostomia leading to difficulty in swallowing and tooth decay - Enlarged lacrimal glands leading to absence of decrease in tears - Painless swelling of salivary glands
            4. - Biopsy of one of the swollen glands is key to the diagyof Mikulicz disease - Treatment is Symptomatic
      2. Sjogren's Syndrome
         1. Sicca syndrome or Gougerot-Sjogren syndrome
            1. Female to male ratio 10:1
         2. Triad of 1. Keratoconjunctivitis sicca 2. Xerostomia 3. Rheumatoid Arthritis
            1. Autoimmune disorder
            2. 1. Primary Sjogren's syndrome ( Sicca complex )
            3. Dry eyes, Dry mouth
            4. Parotid gland enlargement, lymphadenopathy is common, Raynaud's phenomenon
            5. 2. Secondary Sjogren's syndrome
            6. Primary symptoms associated with autoimmune disease are Rheumatoid Arthritis,Systemic lupus erythematous, Scleroderma
            7. Rheumatoid Arthritis is the integral part
         3. HISTOLOGIC FEATURES
            1. -Intense lymphocytic infiltration of the gland replaces the acinar structures preserving the lobular architecture. -The proliferation of the ductal epithelium and myoepithelium to form epi myoepithelial islands -Atrophy of the glands sequential to the lymphocytic infiltration
         4. Radiographic findings
            1. Sialographs demonstrate punctuate, cavitary defects which produce "CHERRY BLOSSOM" or "BRANCHLESS FRUIT LADEN TREE" pattern
            2. MRI shows SALT and PEPPER appearance of the glands
         5. Diagnostic features
            1. Lacrimal gland function -Break-up Time (BUT) -Schirmer's Test -Quantitative rose bengal dye test The salivary gland function -Salivary flow rate (Normal- 5ml/min,In SS patients-0.5ml/min) -Minor salivary gland biopsy -Salivary scintigraphy- The total uptake of radioisotope 99mTC - Pertechnetate is less in SS patients -The sialography-Cherry blossom or branchless fruit-laden effect.
            2. American European Consensus Group classification criteria
            3. -At least 4 of the 6 following criteria be satisfied for the diagnosis of Sjogren's syndrome: -2 related to oral and ocular dryness symptoms -one measuring ocular function, one quantifying oral function. -Labial minor salivary gland biopsy ( the best sole diagnostic criteria for salivary component) -The presence of auto antibodies anti SS-A and anti SS-B antibodies.
         6. Treatment is symptomatic
            1. -Parasympathomimetic secretagogues- pilocarpine (5 mg tid), cevimeline (30 mg tid). -Steroids -Biological therapies -Anti-TNF-alpha drugs-etanercept, Rituximab, infliximab, thalidomide -Monoclonal antibodies-interferon alpha
         7. Complication
            1. 1.Pseudolymphoma
            2. 2. Malignant lymphoma
3. SIALOLITHIASIS
   1. Salivary duct stone or Salivary duct Calculi
      1. Produces pain on eating
   2. Formed by deposition of calcium salts around central nidus which may consist of altered salivary mucins, desquamated cells, bacteria, foreign bodies or products of bacterial decomposition
      1. Sialoliths are crystalline in nature primarily composed of hydroxyapatite
      2. - 50% of parotid and 20% of submandibular sialoliths are poorly calcified - This is clinically significant because such sialoliths are radiographically detectable
   3. - Higher rate of Sialolith formation in the Submandibular gland (80 to 90%) - Most common in wharton's duct
   4. Treatment
      1. 1.Small calculi removed by manipulation or increasing salivation by sucking lemon leading to expulsion of stone 2. Antibiotics i.v given for bacterial infection due to persistent obstruction of duct 3. Surgical removal of larger stones
4. Infections
   1. MUMPS (Epidemic parotitis)
      1. - Acute contagious viral infection characterized by unilateral or bilateral non- suppurative swelling of the salivary glands - Caused by Mumps virus (MuV), Paramyxoviridae family of RNA virus
      2. Usually involves Parotid, other glands involved occassionally
      3. Characterized by painful inflammatory symptoms such as parotitis or orchitis and also pancreatitis
         1. Complications
            1. - Meningoencephalitis, deafness, mastoiditis, epididymitis
         2. - When mumps involve adult male, Orchitis is a great danger - Involvement of pancreas causes an increase in Serum lipase enzyme
         3. D/D
            1. Parotid swelling caused by Influenza, Parainfluenza 1 and 30, Coxsackie, HIV, Cytomegalovirus, Sjogren's syndrome, Pleomorphic adenoma
         4. Treatment
            1. 1. Conservative treatment, maintaining hydration and alimentation
            2. 2. Prevention by vaccination
      4. - Incubation period : 14 to18 days - Transmitted through respiratory route
   2. SIAladenitis
      1. Inflammatory disease of salivary glands
      2. Bacterial or Viral
         1. Bacterial parotitis caused by staphylococcus aureus
      3. Sialodochitis (Ductal Sialadenitis) dilation of ductal system by repeated inflammatory or infective processes
         1. SAUSAGE STRING appearnce on Sialographs
      4. Firm and tender on bimanual palpation Increases on intake of food
5. Tumors
   1. Benign
      1. Pleomorphic Adenoma
         1. Also known as Mixed Tumor, Enclavoma, Branchioma, Endothelioma, Endochondroma
         2. Benign neoplasm characterized by neoplastic proliferation of epithelial (ductal) cells along with myoepithelial components
            1. CLINICAL FEATURES : - Seen on th pre- auricular region - In parotid most often present in the lower pole of the superficial lobe of the gland - Palate is the most common site of minor Salivary gland involvement - More frequently in females than males - Relatively common in young adults - Pain not a common symptom but local discomfort present - High chances of recurrence because of incomplete capsule.
            2. HISTOLOGIC FEATURES : 1. Epithelial component forming inner layer of cyst and tubules 2. Myoepithelial cells as the outer layer of cyst and tubules scattered within the mucous stroma and are major component 3. Stromal component is myoid , chondroid or myxochondroid
            3. Involves chromosome region 12q13-15 PLAG-1 - Chromosome 8q12
            4. TREATMENT : Surgical Excision
         3. - Most common type of Salivary gland tumor - Most common tumor of parotid gland
      2. Warthin's Tumour
         1. Also known as Papillary Cystadenoma, Lymphomatosum, Adenolymphoma
         2. - Second most common tumor in the Salivary glands. - Occurs mostly in the parotid gland
            1. - Disease of men - Not painful, is firm to palpation - Superficial, lying just beneath parotid capsule or protruding through it
            2. HISTOLOGIC FEATURES : - Tumor contains cysts containing clear fluid - Composed of Epithelial and Lymphoid tissue -Shows double layer of epithelial cells - Adenoma of cystic formation with papillary projections into cystic spaces and Lymphoid matrix showing germinal centres - Eosionophilic coagulum present within cystic spaces , that appears an a CHOCOLATE COLOURED FLUID in the gross specimen
            3. TREATMENT : Surgical excision
         3. RISK FACTORS : Smoking, Epstein Barr virus
   2. Malignant
      1. Mucoepidermoid carcinoma
         1. Malignant epithelial tumor, composed of both mucus secreting cells and epidermoid type cells
            1. VARIANTS
            2. 1. Sclerosing mucoepidermoid carcinoma
            3. 2. Intraosseous mucoepidermoid carcinoma
            4. Mandible commonly affected
         2. Most common malignant neoplasm of both major and minor Salivary glands -Most common salivary gland tumor in childre
            1. CLINICAL FEATURES : - Most common malignant salivary gland tumor of children - More in females than males - Low grade malignancy appears as slowly enlarging , painless mass - High grade malignancy grows rapidly and does produce pain as an early symptom - Distant metastases to lung, bone, brain common
            2. HISTOLOGIC FEATURES : - Composed of mucus secreting cells, squamous cells and intermediate cells 1. LOW GRADE : Mucin filled cystic spaces, minimal cellular atypia, high proportion of mucous cells 2. INTERMEDIATE GRADE : Squamous cells with intermediate basaloid cells. Cyst formation less than low grade. Intermediate cells predominate 3. HIGH GRADE : Intermediate basaloid and squamous cells. Cystic component less than 20%. Necrosis and perineurial invasion present
         3. - Parotid gland is the most common site of occurrence - Intraorally most commonly seen on palate - Other sites Intraorally are buccal mucosa, tongue and retromolar area
            1. Facial nerve paralysis is frequent in parotid tumor
            2. In tumors of minor salivary glands patient complains of trismus, drainage from the ear, dysphagia, numbness of adjacent areas and ulceration
         4. TREATMENT
            1. 1. Conservative Excision for low and intermediate grade carcinoma of parotid gland and preservation of facial nerve 2. Affected submandibular gland removed entirely. 3. Radical neck dissection for cervical node metastasis
      2. Adenoid cystic carcinoma
         1. Also known Cylindroma, Adenocystic carcinoma, Adenocystic basal cell carcinoma, Pseudoadenomatous basal cell carcinoma, Basaloid mixed tumor
         2. Fifth most common malignant epithelial tumor of salivary glands
         3. Slow growing but aggressive neoplasm with a remarkable capacity of recurrence
            1. - Most commonly involve parotid, submaxillary and accessory glands in the palate and tongue - More common in Females
            2. HISTOLOGIC FEATURES : - Composed of myoepithelial cells and ductal cells - Basal cells are arranged in "HONEY- COMB" or "SWISS CHEESE" pattern - Connective tissue surrounds tumor cells in form of cylinders, so called as CYLINDROMA
            3. TREATMENT : Surgical
            4. Shows peri neural spread
   3. % occurance
      1. According to age
         1. Adult-85% Children-15%
            1. Pleomorphic adenoma- 90%
      2. According to location
         1. Parotid- 80%
            1. Benign- 50%
            2. Malignant- 50%
         2. Submandibular- 10-15%
            1. Benign-50%
            2. pleomorphic tumor- 75-80%
            3. Malignant-50%
            4. Mucoepidermoid carcinoma- 20-25%
         3. Sublingual and minor salivary gland- 5-10%
6. Scintigraphy with technitium-99m pertechnetate- Minimally invasive diagnostic test to assess salivary gland function. Salivary gland tumors do not concentrate Tc 99m except Warthin's tumor and oncocytomas
7. Xerostomia associated with- Diabetes mellitus Parkinson's disease Cystic fibrosis Sarcoidosis Drugs like anticholinergic, sympathomimetic agents, tricyclic antidepressants, bronchodilators, antihistamines
8. Sialographic appearance -Normal salivary gland ductal system- Leafless tree -Sialodochitis- Sausage string appearance -Sjorgran’s syndrome- Branchless fruit laden appearance -Benign salivary gland tumor- Ball in hand appearance