Classification of the salivary glands. Acute inflammatory diseases of the salivary glands
Classification of inflammatory diseases of the salivary glands
Acute inflammation of the salivary glands.
a) sialadenitis of viral etiology: mumps, influenza sialoadenitis
b) sialadenitis caused by general or local causes (after surgery on the abdominal cavity, infectious, lymphogenous parotitis, the spread of the inflammatory process from the oral cavity, etc.).
Chronic inflammation of the salivary glands.
a) nonspecific: interstitial sialadenitis, parenchymal sialadenitis, sialodochitis
b) specific: actinomycosis, tuberculosis, syphilis of the salivary glands
c) salivary stone disease.
There are several possible ways of infection of the salivary glands: stomatogenic, hematogenous, lymphogenous and along the length.
Acute sialadenitis due to general and local causes
Acute sialadenitis often occurs due to various general and local adverse factors. Among the former, the transferred infections (influenza, measles, scarlet fever, chicken pox), impaired salivation, dehydration, severe general condition, postoperative condition, neurovegetative disorders. Local causes that can contribute to the development of the disease include trauma, the presence of gingivitis, pathological gingival pockets, dental deposits, various changes in the gland region that disrupt salivation (entering the duct foreign bodies, inflammation of the lymph nodes surrounding the gland), lymphogenous infection from nearby chronic infectious foci is also possible. General condition of patients with moderate sialoadenitis. Mumps are more severe. Sleep, food intake is disturbed, pains occur, which intensify while eating. Dry mouth is noted, the temperature rises.
Acute inflammation of the parotid salivary gland occurs more often than others. Edema appears in the parotid-masticatory area, which grows rapidly, spreads to neighboring areas. The ear lobe protrudes. The skin over the gland becomes tense. In the area of \u200b\u200bthe gland, a dense inflammatory infiltrate is formed, sharply painful on palpation. The infiltrate gradually increases in size and can spread around the earlobe and posteriorly to the mastoid process. The lower pole of the infiltrate is defined at the level of the lower edge of the lower jaw. The inflammatory infiltrate retains its density for a long time. With an unfavorable course of mumps, purulent melting of the gland can occur in certain areas. In these cases, softening appears, fluctuation is determined, symptoms of abscess formation appear. Mouth opening may be difficult. The mouth of the parotid (stenon) duct is widened, surrounded by a corolla of hyperemia. Saliva is not secreted or is secreted during intensive massage of the gland in a small amount. Its color is cloudy, the consistency is thick, viscous. Sometimes pus, whitish flakes are released.
In acute inflammation of the submandibular salivary gland, swelling occurs in the submandibular region. Skin changes are less pronounced. The gland increases in size, palpable as a dense, painful formation. The mouth of the submandibular (Warton's) duct is dilated, hyperemic. Salivation is impaired. When the gland is massaged, cloudy saliva is released, sometimes with pus.
Treatmentdepends on the stage of the process. In case of serous inflammation, therapeutic measures should be aimed at stopping inflammation and restoring salivation. To increase salivation, an appropriate diet is prescribed, 3-4 drops of a 1% solution of pilocarpine hydrochloride 2-3 times a day (no more than 10 consecutive days). Bougienage of the excretory duct of the salivary gland is carried out, solutions of antiseptics, enzymes are injected through the duct, compresses with Dimexide are prescribed on the area of \u200b\u200bthe inflamed gland, physiotherapy (UHF, fluctuating). Anti-inflammatory, antibacterial, desensitizing therapy is given. With abscess formation - surgical treatment.
Mumps of newborns. The disease is rare. Weakened children are prone to it. Mastitis of a nursing mother contributes to the development of the disease. The clinical symptoms are typical of mumps. On one or both sides, swelling of the parotid-chewing area appears, the child is capricious, does not sleep well and does not suckle well, the temperature rises. The zone of the gland is compacted, painful on palpation. The mouth of the excretory duct is widened. Fluctuation and purulent discharge from dilated ducts may appear quite quickly.
Acute sialadenitis of viral etiology
Mumps (mumps) - an infectious disease, sometimes complicated by suppuration. As a rule, only the parotid salivary glands are affected. The causative agent of mumps is a filterable virus.
Mumps mainly affects children, but sometimes adults. Epidemic outbreaks are limited, and they become more frequent in cold weather (January - March). Sources of the virus are patients who remain infectious for up to 14 days after the disappearance of clinical phenomena. The incubation period lasts an average of 16 days, followed by a short prodromal stage, during which there is always catarrhal stomatitis.
Clinic. At the onset of the disease, swelling occurs in one parotid gland; quite often the second gland also swells soon. The body temperature rises to 37-39º С, rarely higher. Children have vomiting, convulsive twitching, and sometimes meningeal phenomena. There are pulling pains in the parotid region, tinnitus, pain when chewing. On examination, the swelling in the parotid gland is located in a horseshoe-like manner around the lower lobule of the auricle, the earlobe protrudes. Skin at first they are not changed, then they become tense, shiny. Swelling of the glands is accompanied by the cessation of salivation, occasionally there is abundant salivation. Three painful points can be noted on palpation: in front of the ear tragus, at the apex of the mastoid process, above the notch of the lower jaw. The duration of the febrile period is 4-7 days. The swelling gradually disappears within 2-4 weeks. In the blood, leukopenia is noted, sometimes leukocytosis, ESR is increased.
Complications. Most frequent complication boys have orchitis (inflammation of the testicle) that develops a few days after the onset of mumps. Orchitis proceeds with severe pain and high temperatures reaching 40 ° C. The outcome is usually favorable, in rare cases there is testicular atrophy.
Sometimes suppuration of the salivary gland is noted, several purulent foci are formed. After emptying the abscesses, mumps develops back. Sometimes salivary fistulas remain. In isolated cases, mumps ends in necrosis of the salivary gland. There are also cases of damage to peripheral nerves (facial, ear).
Prevention consists in the isolation of patients during the illness and for 14 days after the disappearance of all clinical manifestations.
Treatment. Bed rest, liquid food, care of the oral cavity, in the absence of suppuration, compresses on the gland area. In protracted cases, antibiotics are indicated to prevent complications. With suppuration - opening of abscesses.
Influenza sialadenitis. In some patients with influenza, against the background of general malaise and fever, swelling suddenly appears in the salivary glands. The edema rapidly increases, an infiltrate of woody density in the area of \u200b\u200bthe affected glands is palpable. The mouths of the ducts of the salivary glands are hyperemic. There is no salivation from the affected glands. In some patients, the affected gland quickly abscesses and melts, while pus is released from the duct. Infiltrates in the area of \u200b\u200bglands in such patients dissolve very slowly.
In the early days of the disease, the use of interferon gives a promising effect. In addition, the same treatment is carried out as for acute sialoadenitis caused by general or local causes.
Chronic sialadenitis
The disease is more often a consequence of acute sialadenitis. Apparently, the transition to the chronic form of inflammation is facilitated by an unfavorable premorbid background, irrational and insufficiently intensive therapy in the acute period of the disease, and a persistent decrease in the body's immune resistance. Primary chronic forms of the disease are also observed.
According to the type of tissue damage, sialadenitis is divided into parenchymal and interstitial.
Parenchymal are more difficult, are characterized by sudden exacerbations, violation general condition, sharp soreness and compaction of the gland, purulent discharge from the duct.
Interstitial sialadenitis are less common and are characterized by a calmer sluggish course with slowly increasing periods of exacerbation. They do not give a picture of acute inflammation. The gland is enlarged, but slightly compacted, the nature of the secretion changes little. At first, the secretion of saliva from the duct is reduced and only in the later stages it increases, the saliva becomes cloudy or purulent.
Sialadenitis can occur with a predominant lesion of the ducts - sialodochitis . The clinical manifestations of this form of the disease do not have clearly delineated distinguishing features from sialadenitis, and the diagnosis is clarified after sialography.
Exacerbation of chronic sialadenitis is characterized by all the signs of acute mumps. Relapses of the disease can occur from several times a year to once every 1-2 years. During the period of remission, moderate edema and swelling of the gland may persist. The consistency of the gland is densely elastic, the boundaries are clear, the surface is bumpy.
The nature of the defeat of the glands in chronic inflammation stands out well in sialographic examination. The sialogram is performed in the straight and lateral surfaces. On the sialogram with parenchymal sialadenitis, small rounded cavities filled with a contrast agent are revealed, the excretory ducts expand over time. The shadows of the terminal ducts become intermittent. Interstitial sialadenitis is characterized by a narrowing of the mesh of the ducts of the gland, without the presence of discontinuity. The shadow of the parenchyma is poorly detected, and in the later stages it is not detected. The sialogram of chronic sialodochitis shows an uneven expansion of the ducts of the gland with clear contours, the parenchyma of the gland remains unchanged. In the late stage, the contours of the ducts become uneven, the expanded sections of the duct alternate with sections of narrowing.
Treatment symptomatic, restorative therapy is performed. During the period of exacerbation, the same methods of treatment are used as in acute sialoadenitis.
Salivary stone disease
Salivary stone disease (sialolithiasis, calculous sialadenitis) is characterized by the formation of stones in the ducts or parenchyma of the salivary glands. The disease occurs equally often in men and women at all ages. IN childhood the disease is rare. It is observed more often at puberty.
Among the complex of various reasons that contribute to the development of the disease, the main ones are metabolic disorders, vitamin deficiencies, and changes in the physicochemical properties of saliva. A necessary condition for the formation of a stone is the presence of a foreign core. This nucleus can become the so-called salivary thrombus (an accumulation of cells of sloughing epithelium and leukocytes glued by fibrin). In some cases, stones form around foreign bodies that enter the duct from the outside. Predisposing moments for the formation of a stone are injuries and inflammation of the ducts and salivary glands. In the ducts of the gland, calculi are formed that interfere with the flow of saliva. Retention of saliva causes the flow to expand. Conditions are created for the occurrence of secondary inflammation in the gland and in the duct.
Clinic. The disease first manifests itself as swelling in the area of \u200b\u200bthe affected salivary gland and pain, which is clearly aggravated when eating or immediately before it. Swelling can disappear and re-form due to a temporary delay in saliva. With an increase in the size of the stone, it can completely block the duct, which is manifested by severe bursting pains.
For the final diagnosis, X-ray and ultrasound are used. X-ray contrast salivary stones are well projected on radiographs.
Treatment. Small stones may spontaneously flake off. Surgical methods of stone removal are more often used. If the stone is located in the duct of the gland, the duct is dissected, the stone is removed, and the duct is drained. In chronic calculous submandibular sialadenitis, the submandibular salivary gland is removed.
In addition to the small salivary glands (labial, buccal, palatine, lingual), the excretory ducts of 3 paired large salivary glands open into the oral cavity: 1) parotid; 2) submandibular and 3) sublingual.
General plan of the building. Each large salivary gland is covered with a connective tissue capsule, from which partitions (trabeculae) extend, dividing the gland into lobules. The lobules include end sections and intralobular excretory ducts. Intralobular excretory ducts are interlobular and striated.
The end sections of the lobules are not the same in each gland. In the parotid gland there are only protein (serous) end sections; in the submandibular - protein and protein-mucous; in the sublingual gland - proteinaceous, mixed and mucous.
In the interlobular trabeculae, blood and lymphatic vessels, nerves and interlobular excretory ducts pass, into which the striated intralobular ducts flow. The interlobular ducts flow into the gland duct, which opens either on the eve of the oral cavity (parotid duct) or into the oral cavity (ducts of the submandibular and sublingual glands).
Parotid salivary glands.These are the largest glands of all salivary glands, covered with a connective tissue capsule, from which trabeculae extend, dividing it into lobules. The lobules include protein end sections, intercalated and striated ducts. These glands are complex branched alveolar glands, they produce a protein (serous) secret.
Protein end sections have a round or oval shape, and also 2 types of cells: I) glandular cells called serocytes, and 2) myoepithelial. Thin interlayers are located between the end sections connective tissue, forming the stroma of the gland.
Interlobular excretory ducts - the smallest, start from the end sections, consist of an inner layer of epithelial cells of a cubic or flattened form and myoepithelial cells. In the parotid gland, these ducts are well developed, branching. These ducts flow into intralobular striated ducts.
Striated intralobular excretory ducts well developed consist of one layer of prismatic epithelial cells and a layer of myoepithelial cells. The striated ducts flow into the interlobular excretory ducts.
located in the interlobular connective tissue. At the source, these ducts are lined with two-layer, at the mouth - with multilayer cubic epithelium. The interlobular excretory ducts flow into the common duct of the gland.
Common duct of the gland at the source is lined with multilayer cubic, at the mouth - with multilayer flat non-keratinizing epithelium. The duct pierces the chewing muscle and opens on the eve of the oral cavity at the level of the upper 2nd large molar.
Submandibular salivary glands.These are complex, branched, alveolar-tubular glands located under the lower jaw and are also covered with a connective tissue capsule, from which connective tissue trabeculae extend, dividing it into lobules. The lobule of these glands consists of proteinaceous and protein-mucous end sections, intercalated and striated ducts. The structure of the protein ends of the submandibular salivary gland is similar to their structure in the parotid gland.
Protein-mucous (mixed) end sections consist of mucous cells - mucocytes (mucocvtus), serocytes and myoepithelial cells. Serocytes are located on the periphery in the form of serous (protein) Gianuzzi crescents.
Protein half moon consist of cubic serocytes, between them there are intercellular microtubules. Mixed-end mucocytes located in their central part, have a conical shape, light color, there are microtubules between them. Mixed terminal myoepithelial cells are located between the basal ends of the serocytes of protein crescents and the basement membrane. Their function is to participate in the secretion of secretions from the glandular cells and terminal sections.
Inserted intralobular ducts in the submandibular gland are poorly developed, they are short and do not branch.
Striated intralobular grooves well developed, branched, have extensions. The walls of these ducts include tall light cells, wide dark cells, goblet-shaped cells and poorly differentiated conical cells. These cells produce some hormonal products: growth factors, insulin-like factor, etc. The striated ducts flow into the interlobular.
Interlobular ducts at the sources are lined with two-layer, at the mouth - with multilayer cubic epithelium. They flow into the duct of the gland.
Duct of the gland, lined at the origins with a multilayer cubic, at the mouth - with a multilayered squamous epithelium, opens under the tongue, next to its bridle.
Sublingual salivary glands.These are the smallest glands among the large salivary glands. They are also covered with a connective tissue capsule and are also divided into lobules by trabeculae extending from the capsule. In the lobules of these glands, there are 3 types of terminal sections: 1) protein: 2) protein-mucous and 3) mucous. Protein and protein-mucous end sections are similar in structure to the previously described protein in the parotid gland and protein-mucous - in the submandibular gland.
Mucous end sections consist of conical mucocytes and myoepithelial cells. Mucocytes are light in color, with intercellular microtubules located between them. The functional significance of these cells is the synthesis and secretion of mucous secretions. Myoepithelial cells are located between the base of mucocytes and the basement membrane.
Intercalated excretory ducts poorly developed.
Striated excretory ducts in the sublingual salivary glands poorly developed. They flow into the interlobular excretory ducts.
Interlobular excretory ducts at the sources are lined with two-layer, at the mouth - with multilayer cubic epithelium; flow into the duct of the gland.
Duct of the gland, lined at first with a multilayer cubic, at the mouth - with a multilayer squamous epithelium, opens next to the duct of the submandibular salivary gland.
Sialoadenitis is an inflammation of any salivary gland; mumps - inflammation of the parotid gland. Sialoadenitis can be primary (independent disease) or more often secondary (complication or manifestation of another disease). The process may involve one gland or two symmetrically located simultaneously; sometimes there may be multiple lesions of the glands. Sialoadenitis is acute or chronic, often with exacerbations.
Etiology and pathogenesis. The development of sialoadenitis is usually associated with an infection. Primary sialoadenitis, represented by mumps and cytomegaly, is associated with a viral infection (see Children's infections). Secondary sialoadenitis is caused by a variety of bacteria and fungi. The ways of penetration of infection into the gland are different: stomatogenic (through the ducts of the glands), hematogenous, lymphogenous, contact. Sialoadenitis of a non-infectious nature develops when poisoning with salts of heavy metals (when excreted with saliva).
Pathological anatomy. Acute sialoadenitis can be serous, purulent (focal or diffuse), rarely gangrenous. Chronic sialoadenitis is usually an interstitial productive one. A special type of chronic sialoadenitis with pronounced lymphocytic infiltration of the stroma is observed with dry Sjogren's syndrome (see Diseases of the gastrointestinal tract) and Mikulich's disease, in which, unlike dry syndrome, arthritis is absent.
Complications and outcomes. Acute sialoadenitis ends with recovery or transition to chronic. The outcome of chronic sialoadenitis is sclerosis (cirrhosis) of the gland with atrophy of the acinar sections, lipomatosis of the stroma, with a decrease or loss of function, which is especially dangerous in case of systemic damage to the glands (Sjogren's syndrome), as this leads to xerostomia.
Glandular cysts: very common in the small salivary glands. They are caused by trauma, inflammation of the ducts, followed by their sclerosis and obliteration. In this regard, by their genesis, cysts of the salivary glands should be attributed to retention. The size of the cysts is different. A cyst with mucoid contents is called a mucocele.
QUESTION No. 17
Salivary stone disease. Etiology, pathogenesis, pathological anatomy, complications, outcomes.
Salivary stone disease (sialolithiasis) is a disease associated with the formation of calculi (stones) in the gland, and more often in its ducts. More often than others, the submandibular gland is affected, in the parotid stones are rarely formed, the sublingual gland is almost never affected. Mostly middle-aged men get sick.
Etiology and pathogenesis. The formation of salivary stones is associated with dyskinesia of the ducts, their inflammation, stagnation and alkalization (pH 7.1-7.4) of saliva, an increase in its viscosity, ingress of foreign
tel. These factors contribute to the loss of various salts from saliva (calcium phosphate, calcium carbonate) with their crystallization on an organic basis - a matrix (deflated epithelial cells, mucin).
Pathological anatomy. Stones are of different sizes (from grains of sand to 2 cm in diameter), shape (oval or oblong), color (gray, yellowish), consistency (soft, dense). When the duct is obstructed, inflammation occurs or aggravates in it - sialodochitis. Purulent sialoadenitis develops. Over time, sialoadenitis becomes chronic with periodic exacerbations.
Complications and outcomes. In a chronic course, sclerosis (cirrhosis) of the gland develops.
QUESTION No. 18
Tumors of the salivary glands. Classification, pathological anatomy (macro- and microscopic characteristics), complications
Tumors of the salivary glands account for about 6% of all tumors found in humans, but in dental oncology they make up a large proportion. Tumors can develop both in large (parotid, submandibular, sublingual) and in small salivary glands of the oral mucosa: the cheeks, soft and hard palate, oropharynx, floor of the mouth, tongue, lips. The most common tumors of the salivary glands of epithelial genesis. In the International Classification of Tumors of the Salivary Glands (WHO), epithelial tumors are represented by the following forms: I. Adenomas: pleomorphic; monomorphic (oxyphilic; adenolymphoma, other types). II. Mucoepidermoid tumor. III. Acinocellular tumor. IV. Carcinoma: adenocystic, adenocarcinoma, epidermoid, undifferentiated, carcinoma in polymorphic adenoma (malignant mixed tumor).
Pleomorphic adenoma is the most common epithelial tumor of the salivary glands, accounting for more than 50% of tumors in this localization. In almost 90% of cases, it is localized in the parotid gland. The tumor is more common in people over 40, but it can occur at any age. In women, it happens 2 times more often than in men. The tumor grows slowly (10-15 years). The tumor is a round or oval node, sometimes lumpy, dense or elastic, up to 5-6 cm in size. The tumor is surrounded by a thin capsule. On the cut, the tumor tissue is whitish, often mucous, with small cysts. Histologically, the tumor is extremely diverse, for which it was called pleomorphic adenoma. Epithelial formations have the structure of ducts, solid fields, individual nests, anastomo-
strands interconnecting each other, built of cells of a round, polygonal, cubic, sometimes cylindrical, shape. Clusters of elongated spindle-shaped myoepithelium cells with light cytoplasm are frequent. In addition to epithelial structures, the presence of foci and fields of mucoid, myxoid and chondroid substances is characteristic (Fig. 362), which is the product of the secretion of myoepithelial cells that have undergone tumor transformation. In the tumor, foci of stromal hyalinosis can occur, in the epithelial areas - keratinization.
Monomorphic adenoma is a rare benign tumor of the salivary glands (1-3%). It is localized more often in the parotid gland. It grows slowly, it looks like an encapsulated round node, 1-2 cm in diameter, soft or dense in consistency, whitish-pinkish or in some cases brownish. Histologically, adenomytubular, trabecular structure, basal cell and clear cell types, papillary cystadenoma are distinguished. Within the limits of one tumor, their structure is the same, the stroma is poorly developed.
Oxyphilic adenoma (oncocytoma) is built of large eosinophilic cells with fine granular cytoplasm.
Adenolymphoma has a special place among monomorphic adenomas. It is a relatively rare tumor, found almost exclusively in the parotid glands and predominantly in older men. It is a clearly delimited node, up to 5 cm in diameter, grayish-white, lobular structure, with many small or large cysts. Histological structure characteristic: prismatic epithelium with sharply eosinophilic cytoplasm is located in two rows, forms papillary outgrowths and lines the formed cavities. The stroma is profusely infiltrated by lymphocytes that form follicles.
Mucoepidermoid tumor is a neoplasm characterized by double differentiation of cells - into epidermoid and mucus-forming ones. It occurs at any age, somewhat more often in women, mainly in the parotid gland, less often in other glands. The tumor is not always clearly demarcated, sometimes round or irregular in shape, may consist of several nodes. Its color is grayish-white or grayish-pink, the consistency is dense, cysts with mucous contents are often found. Histologically, a different combination of cells of the epidermoid type is found, forming solid structures and strands of mucus-forming cells, which can line the cavities containing mucus. Keratinization is not observed, the stroma is well expressed. Sometimes there are small and dark cells of an intermediate type, capable of differentiating in different directions, and fields of light cells. The predominance of intermediate-type cells, the loss of the ability to produce mucus is an indicator of low tumor differentiation. Such a tumor can have pronounced invasive growth and metastases. Signs of malignancy in the form of nuclear hyperchromicity, polymorphism and atypism of cells are rare. Some researchers call this tumor mucoepidermoid cancer.
An acinic cell tumor (acinous cell) is a rather rare tumor that can develop at any age and have any localization. Tumor cells resemble serous (acinar) cells of the salivary glands, which is why this tumor got its name. Their cytoplasm is basophilic, fine-grained, sometimes light. Acinocellular tumors are often well demarcated, but they can also show pronounced invasive growth. Formation of solid fields is characteristic. A feature of the tumor is the ability to metastasize in the absence of morphological signs of malignancy.
Carcinoma (cancer) of the salivary glands is diverse. The first place among malignant epithelial tumors of the salivary glands belongs to adenocystic carcinoma, which accounts for 10-20% of all epithelial neoplasms of the salivary glands. The tumor is found in all glands, but especially often in the small glands of the hard and soft palate. It is observed more often at the age of 40-60 years in both men and women. The tumor consists of a dense, small node, grayish, without a clear border. The histological picture is characteristic: small, cubic cells with a hyperchromic nucleus form alveoli, anastomosing trabeculae, solid and characteristic lattice (cribrous) structures. Between the cells, a basophilic or oxyphilic substance accumulates, forming columns and cylinders, in connection with which this tumor was previously called a cylindroma. The growth of the tumor is invasive, with a characteristic overgrowth of nerve trunks; metastases mainly by hematogenous route to the lungs and bones.
Other types of carcinomas are found in the salivary glands much less frequently. Their histological variants are diverse and are similar to adenocarcinomas of other organs. Undifferentiated carcinomas have rapid growth, give lymphogenous and hematogenous metastases.
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Introduction
Sialoadenitis
Salivary stone disease
Tumors of the salivary glands
Conclusion
List of references
Introduction
Sialoadenitis and sialosis occupy a significant place among diseases of the maxillofacial region. Sialoadenitis is one of the most common diseases of the salivary glands. The clinical manifestations of sialoadenitis are varied. It depends on the etiology, localization of the inflammatory process in one or another gland, the reactivity of the body, concomitant diseases, the age of patients and other factors. Under the term sialosis, dystrophic diseases of the salivary glands are combined, caused by general disorders in the body and lead to pathological changes in secretion.
The clinical manifestations of inflammatory diseases of the salivary glands are diverse. This is due to etiological factors, the localization of the process in a particular gland, the immunological state of the body, and concomitant diseases.
inflammatory salivary gland sialoadenitis
Classification of diseases of the salivary glands
Classification diseases of the salivary glands was developed by many foreign and domestic scientists (Sazama L., 1971; Klementov A.V., 1974; Romacheva I.F. et al., 1987; Afanasyev V.V., 1993; Denisov A.B., 1993; Ivasenko I P., 1995; and others). The proposed classification basically retains the generally accepted classification groups, and is built taking into account clinical, radiological and histological criteria. 1 . Sialoadenitis:
By localization: parotitis, sialosubmandibulitis, sialosublingvitis, sialoadenitis of the small salivary glands (sialoadenitis minoris)
Downstream: acute:
o viral (mumps virus, influenza, etc.);
o bacterial (serous, purulent, purulent-necrotic); chronic:
o nonspecific (parenchymal, interstitial, ductal form);
o specific (tuberculosis, actinomycosis, syphilis);
o exacerbation of chronic sialoadenitis.
2 . Salivary stone disease (sialolithiasis):
· With the localization of salivary stone in the main excretory duct;
· With the localization of salivary stone in the inside of the glandular part;
Exacerbation of sialolithiasis;
· Condition after removal of salivary calculus.
3. Sialose:
Mikulich's disease;
· Sjogren's syndrome.
4 . Sialoadenopathy:
Endocrine;
· Neuroreflex;
· Medicinal;
· Beam.
5 . Congenital malformations of the salivary glands:
· Hypoplasia - deformation of the acinar-ductal system;
· Aplasia - absence of the salivary gland.
6 . Cysts of the salivary glands.
7 . Damage to the salivary glands.
8 . Tumors of the salivary glands.
Sialoadenitis
Depending on the clinical course, two groups of patients are distinguished. In one of them, the disease begins and proceeds sharply and generally ends with recovery. In another, the inflammatory process in the gland begins unnoticed by the patient and proceeds chronically, with a periodic exacerbation of the process. In most patients with acute sialoadenitis, it is possible to establish the etiology of the disease. The causative agent of acute sialoadenitis can be a virus: mumps, grappa and other species, as well as bacterial flora that affects the salivary glands under certain external conditions or with a decrease in the body's resistance. The most common and well-studied viral disease is mumps.
Parotitis. Mumps, mumps. Mumps is an acute infectious disease caused by a filterable virus. The virus was first isolated from patients in 1934 by Johnson and Goodpasture. It is more common in countries of temperate and cold climates, mainly affects the child population, adults get sick less often. It is characterized by inflammation of the large salivary glands (typical clinical form). Involvement in the process of the submandibular and sublingual glands in mumps is rare. Characteristic feature mumps is the spread of the disease during epidemic outbreaks in extremely limited areas. It is not always possible to establish contact between patients. Asymptomatic forms of mumps have been described. Infection occurs by direct transmission from a patient to a healthy person through the upper respiratory tract by droplet-air route, but transmission is also possible when using objects that patients have come into contact with. The incubation period ranges from 2-3 weeks. When the body is infected, the virus is most often detected during the first three days of the disease. After a short (2-3 days) prodromal period, mumps is manifested by malaise, poor appetite, chills, headache, soreness in the neck, joints and muscles of the limbs, sometimes - a slight increase in temperature and dry mouth. The disease is characterized by an acute onset, enlargement of one or more salivary glands. The most persistent symptom is fever, and an increase in body temperature is usually observed from the first day of illness and reaches its maximum within 24-48 hours after the detection of swelling of the salivary glands. By the end of the second day, the body temperature can reach 38-39-40 ° C. The average duration of a fever is 5-7 days.
Pretty frequent symptoms mumps is swelling of the papilla and hyperemia of the mucous membrane around the opening of the excretory duct. Pain in the area of \u200b\u200bthe enlarged salivary gland is a constant symptom. The pain intensifies when opening the mouth, chewing, sometimes patients notice pain even with one kind of acidic food. Patients often report dry mouth. In the development of swelling of the salivary glands during the course of the disease, three periods are determined:
1.the period of swelling growth, lasting 3-5 days
2.period of maximum enlargement of the salivary gland (4-7 days)
3. period of reduction of swelling (4-7 days).
Depending on the severity of the disease, 3 forms are observed.
In patients with an uncomplicated form of mumps, a blood test usually shows a normal white blood cell count. Less commonly, leukopenia, moderate monocytosis and lymphocytosis are observed; ESR remains within normal limits.
With a complicated form of mumps, when the process covers various glandular organs and systems, bradycardia, tachycardia, damage is often observed nervous system (meningitis, encephalitis, sometimes with paralysis of the cranial spinal nerves.) The optic, oculomotor, abducens, facial and vestibular nerves are affected. Sometimes damage to the nervous system is accompanied by mental disorders. Orchitis is a common complication. Swelling of the testicle may occur simultaneously with swelling of the parotid glands, sometimes sooner or later. In most patients, the outcome of this complication is favorable, but sometimes testicular atrophy occurs (more often unilateral). Oovforitis is observed much less frequently. Mastitis is also known, which develops on the 3-5th day of the disease.
Often, with mumps, the pancreas is affected. In most cases, this complication proceeds favorably and ends with recovery, however, pancreatitis may go into a chronic stage. The phenomena of acute nephritis, which is accompanied by the appearance of protein, hyaline and granular casts in the urine, can be observed. Kidney damage is benign and does not become chronic. In most patients, the disease ends with recovery. However, in case of damage to the nervous system, with the development of a purulent-necrotic process in the region of the parotid gland, spreading to the adjacent areas, a lethal outcome can be observed. After recovery, persistent immunity remains. To establish a diagnosis, in addition to using the clinical picture data, it is advisable to carry out special studies (sugar content and the amount of diastase in the blood and urine), the isolation of the clinical mumps virus, the complement binding reaction, the hemagglutinin inhibition reaction, the skin-allergic test.
Treatment of mumps is mostly symptomatic. It consists in caring for the sick and preventing complications. Bed rest is required for a period of temperature rise, within 7-8 days. Dairy and vegetable food, sour drink, crackers. Regular oral care, rinsing and irrigation. Irrigation of the oral cavity with interferon 5-6 times a day.
Prevention: wet cleaning, disinfection, separation of children for 21 days from the beginning of contact with patients. Active immunization with live mumps vaccine.
Influenza sialoadenitis is observed against the background of influenza: an increase in several large and small salivary glands, as well as after influenza vaccination.
Distinguish between mild, moderate and severe clinical form of the disease. Against the background of general malaise and an increase in temperature, the salivary glands increase and their excretory function decreases. In the area of \u200b\u200bthe inflamed gland, a seal remains for a long time.
Acute bacterial non-epidemic parotitis
Acute inflammation of the parotid gland can depend on many causes, both local and general.
Local: the introduction of foreign bodies into the excretory duct, inflammatory processes in the surrounding areas and the spread of infection from the oral cavity.
General: any serious illness (typhoid, diphtheria, scarlet fever, pneumonia, after surgery on the abdominal cavity and in malnourished patients.
The disease is characterized by the appearance of pain and swelling in the orcologic gland, often on one side, but bilateral damage is also possible. The body temperature rises to 39 degrees and above. The skin over the gland is tense. Palpation is sharply painful, fluctuation in the initial period is not determined, there is also no hyperemia. Opening the mouth is somewhat difficult and limited. The mucous membrane of the oral cavity is dry; several drops of pus appear from the excretory duct when massaging the gland. The blood picture corresponds to an acute purulent process.
Pathoanatomically, there are three forms of acute parotitis: catarrhal, purulent and gangrenous.
Complications: breakthrough of pus into the external auditory canal, into the periopharyngeal space and further up or down into the mediastinum.
Treatment: a diet that breaks salivation, a solution of pilocarpine hydrochloride 1% 5-6 drops 3-4 times a day. In the duct - broad-spectrum antibiotics. Compresses: dimethyl sulfacid, dimexide for 20-30 minutes. Within 5-10 days, blockade of the gland with a solution of antibiotics 3-4 times with an interval of 1-2 days. Inside - urotropin with salol (urosol 0.5 three times). Intramuscularly - trypsin solution. Opening.
Chronic inflammation of the salivary glands.
Chronic sialoadenitis is an inflammatory disease of undetected etiology and poorly understood pathogenesis.
Most often, chronic sialoadenitis occurs in the parotid glands, less often in the posterior jaw, sublingual and small mucous glands. Chronic sialoadenitis is often bilateral.
Interstitial sialoadenitis - a disorder in the salivary glands occurs against the background of a general pathology of the body - a violation of metabolic processes or a reactive-dystrophic process, and only when the gland is infected does inflammation occur ..
Pathological examination determines loose connective tissue in the interlobular layers with edema and angiomatosis; the blood vessels are dilated and filled with blood. In other parts, the glands and lobules are separated by layers of dense fibrous tissue, in which there are dense lymphohistocytic infiltrates. The parenchyma of the gland is replaced by diffuse accumulations of lymphoid elements; only single acini and intralobular excretory ducts remain. The ducts are sharply narrowed.
Clinic: women in old age are more likely to suffer from interstitial parotitis. A characteristic sign is a uniform swelling of the salivary glands (parotid), accompanied by a sluggish exacerbation.
In the initial stage, patients note discomfort in the area of \u200b\u200bone or two ear glands, a feeling of unpleasantness in the ears, painless swelling of the gland appears. The skin of the gland is changed. The mouth opens freely. The mucous membrane is pale pink, well moisturized. The mouth of the excretory ducts does not change, saliva is released freely. There are no changes on the sialogram.
Clinically pronounced stage: swelling in the gland area is constant, but painless gland is evenly enlarged, mobile, doughy consistency. Opening the mouth is not difficult, the saliva is clean, in moderation. On the sialogram, the area of \u200b\u200bthe gland is increased, a slight decrease in the concentration capacity of the parenchyma.
Late stage: mild pain, decreased performance, sometimes hearing. At times, there is dryness in the mouth. The swelling is painless or slightly painful. The glands are significantly enlarged, Focal compacted, little saliva is released.
Scanning. The area is increased, the ability to concentrate is reduced.
Thermovisiography. Decrease in temperature.
The aggravation is observed after 2-3 years.
Parenchymal sialoadenitis.
The etiology of parenchymal sialoadenitis is unknown. Many authors suggest that the disease is a consequence of congenital changes in the duct system and dysplasia of its tissues with the formation of cystic cavities.
Some have linked it to mumps.
Clinic: it can manifest itself in a different age period from 1.5 to 70 years, evenly distributed among age groups. Women and the parotid glands (99%), the submandibular gland (1% 0.
In the initial stage, local changes are not observed. Cytological examination of secretion: mucus, a few partially degenerated neutrophils, lymphocytes, reticular cells, single histocytes. On the sialogram, rounded cavities are determined against the background of changes in the parenchyma and ducts of the gland.
On the thermovisiogram, a significant increase in temperature during an exacerbation of the process.
In the clinically expressed stage - a feeling of heaviness in the gland and salty discharge from the duct when massaging. Sometimes the glands are enlarged, elastic-elastic consistency. The mouth opens freely, saliva is released from the duct with an admixture of mucous lumps, sometimes purulent lumps or transparent moderately viscous. Sialogram - the presence of many cavities up to 2-3 mm in diameter. The parenchyma and ducts P.Sh.1U and U of the order are not determined. The ducts of the 1st order are intermittent. The excretory duct is narrowed and widened in places.
With an exacerbation, the zone of hyperemia is well defined on thermovisiograms. In the later stages - swelling in the region of the gland, a feeling of heaviness or slight soreness in the parotid region, discharge of purulent saliva, sometimes dry mouth. The parotid gland is tuberous, painless. The skin under the gland is sometimes thinned. The function of the gland is reduced. Sialogram of the cavity - up to 5-10 mm. The duct is deformed.
Chronic parenchymal parotitis in children.
This inflammation occurs relatively often in children. Its etiology is unknown. It is assumed that the reason is the re-infection of the gland through the duct with inflammation of the oral mucosa, with tonsillitis, neglected untreated tooth and in diseases with a decrease in salivation. As a further cause, congenital or acquired dystrophy of elastic periacinous tissue and alteration of the flow system are cited, which results in the accumulation of saliva, which is then exposed to a secondary infection.
In most cases, the inflammation is mild, slightly painful, with pressure and often uneven, swelling of the parotid gland, the inflammation has a chronic course for months and years. It subsides and reappears in the form of mumps symptoms. With an outbreak, all the phenomena of inflammation increase together with a slightly reduced body temperature sometimes. Salivation is reduced. The sialogram picture is characterized by the expansion of the ducts of varying degrees, in particular, by small roundish ectasias of the terminal branches of the ducts in the acini of the gland.
Treatment consists of maintaining salivation with salivation-enhancing agents, antibiotics, and X-ray therapy.
The salivary glands are subtle to respond to many changes in the body, both of a physiological nature (pregnancy, childbirth, feeding a child, menopause), and pathological conditions of the body (diseases of the nervous, digestive, endocrine system, blood, connective tissue - collagenosis, vitamin deficiency, etc.). Rective dystrophic changes in the salivary glands are manifested by various pathological conditions: disorders of the excretory and secretaronic functions, hyperplasia of the gland - its swelling. Currently, these changes in the salivary glands are defined by the term "sialosis". There is a group of reactive diseases of the salivary glands, the symptoms of which are always naturally combined with damage to a number of other organs. These diseases are described as syndromes: Mikulich's disease and syndrome, Sjogren's disease and syndrome.
At present, the following groups of sialoses have been characterized to some extent: impairment of the excretory and secretory functions of the salivary glands; disturbances in the salivary glands in neuroendocrine diseases, disturbances in the salivary glands in autoimmune rheumatic diseases (collagenoses).
Changes in the salivary glands in rheumatic diseases (collagenoses)
Multiple clinical observations have shown the presence of a number of diseases of the salivary glands in the pathogenesis of which the signs of impaired immune status are determined. Such diseases include Mikulich's disease and syndrome, Sjogren's disease and syndrome, Heerford's disease and syndrome. They have common features (systemic damage to the mucous and salivary glands, long-term chronic course of the process with periodic exacerbation, but their etiology and pathogenesis are different.
Disease (syndrome) Mikulich. The combined increase in the lacrimal and all salivary glands is called Mikulich's disease, and if it is observed with leukemia, lymphogranulomatosis, tuberculosis, syphilis, endocrine disorders, with lesions of the lymphoid apparatus, spleen, liver, then Mikaulich's syndrome. This disease was first described by Mikulich in 1888-1892. He found that the increase in the size of the glands is due to massive small-cell infiltration, interstitial connective tissue, the corresponding lymphoid tissue. Moreover, this process is common for the lacrimal and salivary glands. Mikulich believes that the disease of the lacrimal glands is the most constant, but it also occurs earlier than other pathological processes. Currently, this disease has begun to be defined as the result of damage to the entire lymphatic system, including the salivary and lacrimal glands, as aleukemic (less often leukemic) lymphomatosis. The etiology and pathogenesis of the disease remain unknown, the clinic has been studied alo. Currently, neurotrophic and endocrine autoimmune disorders are considered the most likely cause of the disease.
Clinic. The disease is characterized by a symmetrical enlargement of the salivary and lacrimal glands. The glands are dense, enlarged, lumpy, painless, the skin covering them in color is not changed due to an increase in the lacrimal glands, the upper eyelids are lowered, the eye slits are narrowed, a decrease in the amount of saliva in the oral cavity is sometimes noted in a late stage. The disease can be complicated by an inflammatory process, sialosis turns into sialoadenitis. With sialography, there is a significant increase in the boundaries of the glands, a significant narrowing of the excretory ducts. With generalized damage to the lymphoid apparatus, including the lacrimal and salivary glands, the clinical manifestation of the disease is interpreted as lymphogranulomatosis. In this case, the disease is diagnosed as Mikulich syndrome.
Treatment of Mikulich's disease presents great difficulties. Good results, according to the observations of A.F. Romacheva, are given by X-ray therapy: the swelling of the gland sharply decreases or completely disappears. However, the effect of treatment is unstable, relapses occur frequently. AF Romacheva recommends novocaine blockade, the use of gelantamine (inject daily subcutaneously 1 ml of 0.5% solution No. 30), which improves tissue trophism and stimulates the secretory function of the salivary glands. The complex of therapeutic measures should also include drugs that increase the body's nonspecific resistance: vitamins, methyluracil, sodium nucleinate, etc. In addition, steroid drugs are used in the treatment of Mikulich's disease. These patients should be under the supervision of a rheumatologist, dentist, ophthalmologist, oncologist, hematologist and therapist.
Disease (syndrome) Guzhero-Sjogren. Synonyms: xerodermatosis, Predtechensky syndrome, Guzhero-Sjogren, dry syndrome.
Sjogren's disease (syndrome) is a disease of unclear etiology (some researchers associate it with endocrine disorders, collagenosis, vitamin A deficiency, characterized by a combination of signs of insufficiency of the external secretion glands: lacrimal, salivary, sweat, sebaceous, etc.
In 1933 Sjögren (Swedish ophthalmologist) described the symptom complex in 19 patients with keratoconjunctivitis dry. He noted complaints of gritty eyes, photophobia, and decreased secretion of tears (even when the patient cries, the eyes remain dry). In addition, patients are worried about dryness of the mucous membrane of the nose, pharynx, larynx. There is tooth decay, achilia, increased ESR, lymphocytosis. 80% of patients had polyarthritis. Fully developed syndrome is characterized by dry keratocon
Junctivitis, xerostomia, dry rhinitis, pharyngitis, laryngitis, chronic polyarthritis and an increase in the size of the salivary glands (especially the parotid), decreased function of sweat and sebaceous glands skin (dry skin), glands of the gastrointestinal tract (achilia). Hair loss, deformation and soft nails are also observed.
Pathological changes in the glands: interstitial chronic inflammation with lymphoid infiltration, leading to acini atrophy.
Differentiation of chronic sialoadenitis in Shchekhren's disease and syndromes follows from a tumor, chronic parenchymal interstitial parotitis.
Treatment of Sjogren's disease and syndrome should be carried out in a rheumatological clinic, but the systemic nature of damage to various organs necessitates symptomatic and sometimes pathogenetic therapy by specialists of various profiles: ophthalmologists, dentists, neuropathologists, gynecologists, endocrinologists, etc. The best effect is provided by complex treatment. Local: novocaine blockade, galvanization, electrophoresis, Dimexidum applications. Vitamins, ACTH, prednisolone, cytostatin, galantamine injections, salicylates.
Salivary stone disease
Etiology
The etiology of SKB has not yet been finally established. There are a number of assumptions about the causes and mechanism of the formation of salivary stones.
Based on the results of clinical and experimental studies, it was found that BSC develops against the background of congenital disorders of the duct system. In this case, the formation of salivary calculus occurred in the dilated parts of the duct, in front of its stricted (stenotic) part. The expansion of individual sections of the duct is a consequence of congenital disorders, and not the result of the formation and growth of salivary stone, as some scientists previously believed. Areas of stenosis (strictures) of the duct were, in fact, physiologically normal, however, in relation to the ectatic parts of the duct, they became stenotic, slowing down the rate of secretion. In addition to the presence of congenital changes in the duct system, for the formation of calculus, a special anatomical shape of the parotid or submandibular ducts was also required, which looked like a broken line with sharp bends.
All the known theories of the origin of SKB did not contradict, but complemented each other, therefore, the opinion that the disease is polyetiological is considered correct.
Salivary stones contain organic and mineral substances. The structure of stones is dominated by such mineral components as phosphate, calcium carbonate and magnesium phosphate, and the organic basis of the stone in the form of proteins is 25-30%. In the same time. It was found that organic substances prevail in the composition of the stone (75-90%) in the form of various amino acids with a predominance of alanine, glutamic acid, glycine, and serine. The mineral component is represented by carbonate-containing hydroxylapatite, vitlockite and traces of gypsum. It was found that their organic component (proteins) can fluctuate in the range of 33-66% and higher.
The pathogenesis of stone formation has not been completely clarified. There are a number of theories that put forward the importance of a particular factor or a set of factors. For example, back in 1899, there are four conditions that contribute to stone formation: delayed saliva secretion (leading to its stagnation and thickening); increased concentration of fresh saliva; the appearance in saliva of foreign substances - bacteria, fibrin clots, mucus, rejected cells; changes in the composition of saliva (chemical decomposition processes in it, contributing to the loss of insoluble compounds). Some authors attach great importance to the entry of microbes into the gland duct, especially actinomycetes. The process of stone formation is interpreted as follows: the resulting inflammation in the excretory ducts and parenchyma of the salivary glands leads to swelling of the walls of the ducts and narrowing of their lumen; this entails a difficulty in the outflow of saliva and its stagnation. In addition, inflammation and exposure to microorganisms disrupt the physicochemical structure of the wall of the excretory duct, cause the rejection of cellular elements of the walls of the ducts, and the loss of the gel. The rejected cells and gel form lumps that form the core of the future stone. This core is gradually encrusted with lime salts that fall out of saliva as a result of stagnation or changes in its composition. An essential role in stone formation is played by such a factor as an increase in the content of calcium and phosphorus in the blood plasma, noted by them in patients with salivary stone disease. Age changes the biochemical composition of saliva and the penetration of a number of substances through the salivary glands contribute, as the body grows and ages, to the loss of salivary stone. Her data indicate that with age, the amount of soluble substances in saliva decreases and the concentration of precipitated compounds increases. It is possible that A-avitaminosis also plays a role in the formation of salivary stones. According to X-ray studies, the most frequent localization of salivary stones in the submandibular glands is due to the fact that in the places of the bends of the Varton duct, its peristalsis is much weaker than in other areas. This contributes to the stagnation of saliva and the loss of salts from it. According to other authors, this process is favored by factors such as the large size of the duct and parenchyma of the submandibular salivary gland, frequent irritation of the mouth of the duct and the surrounding mucous membrane of the floor of the mouth with food and other irritants, the presence of a large amount of protein substances in the saliva of the submandibular gland, and the presence of a gland in the duct. diverticula. Thus, the process of formation of salivary stones is very complex, depending, obviously, on a number of local and general factors, among which one should take into account such as the strength of the inflammatory response of the body and, in particular, of the gland tissues to the introduction of microorganisms, to traumatic effects, etc. ...
Pathological anatomy
Changes in the duct are as follows: its expansion and chronic inflammation of the walls, periodic abscess formation and phlegmon around the stone. Changes in the gland: chronic inflammation with round cell infiltration, proliferation of connective tissue, and atrophy of the glandular parenchyma. Pathohistological changes are characterized by chronic inflammation of the salivary gland, sclerosis and atrophy of the glandular tissue. The most significant changes with almost complete atrophy of the parenchyma of the gland are observed with a long course of the disease, as well as in the presence of many stones in the gland. In some cases, along with strongly altered lobules of the gland, at a relatively small distance from the location of the stone, it is possible to find completely preserved glandular tissue and excretory ducts, which have a normal lumen. Although rare, druses of the radiant fungus can be found both in the parenchyma of the affected gland and in the thickness of salivary stones. This indicates a certain role of actinomycotic lesions in the development of stone formation. Exacerbation of chronic inflammation occurs periodically. The size of salivary stones detected ranges from a grain of sand to the volume of a hen's egg; weight - up to 35 g; shape: in the ducts they are oblong, in the parenchyma - oval; the color of the stones is grayish yellow, grayish white; their surface is rough. Chemical composition: 70-75% of the stone is calcium phosphate
Classification of salivary stone disease according to A.V. Klementov:
I. Salivary stone disease with localization of a stone in the gland duct:
1.submandibular;
2.neck;
II. Salivary stone disease with stone localization in the gland:
1.submandibular;
2.neck;
Sublingual: a) without clinical manifestations of inflammation in the gland, b) with chronic inflammation of the gland, c) with exacerbation of chronic inflammation of the gland.
III. Chronic inflammation of the gland due to salivary stone disease:
1.submandibular;
2.neck;
Sublingual a) after spontaneous stone discharge, b) after surgical removal of the stone.
The duration of latent (without clinical manifestations) or outwardly noticeable chronic inflammation depends on many factors, among which the degree of elasticity and the possibility of stretching the tissues that make up the wall of the excretory duct of the salivary gland are of great importance. If a stone has formed in the duct, but its size is still small and salivation is possible, the disease at first passes almost imperceptibly to the patient. In addition to minor pains and some "awkwardness" in the area of \u200b\u200bthe duct, the patient experiences nothing. Later, as a result of the onset of obstruction of the duct, aching and shooting pains of significant intensity appear during a meal or at the sight of it, especially acidic (salivary colic); the gland swells at the same time. Pain radiates in the presence of a stone in the Wharton duct towards the root of the tongue.
Treatment
Treating people with SCB is quite challenging. It includes surgery (removal of calculus) and subsequent anti-inflammatory and stimulatory therapy. Surgical intervention is of decisive importance.
The conservative method of treating SCB is ineffective; it is used in the presence of small stones (up to 1 mm) located near the mouth. For this purpose, the patients were prescribed substances that stimulate salivation, after which the stones were excreted with a stream of saliva. Salivary preparations were combined with a bougienage of the duct.
A method such as squeezing a stone out of a duct is not currently used.
The operation to remove calculus is performed in a quiet period, that is, without exacerbation. The operative tactics followed by most doctors are as follows: if the stone is located in the parotid or submandibular duct, the calculus is removed. When a stone is located in the submandibular gland, it is extirpated together with the stone. If the stone is located in the parotid gland, some authors recommend removing the stone, others - the stone along with the gland.
Despite the fact that long-term results surgical treatment SKB has been studied in detail and at the same time favorable clinical results have been obtained; the opinions of the authors about the choice of the method of surgical intervention are ambiguous. So, some of them considered it necessary to expand the indications for extirpation of the submandibular gland, while others, on the contrary, suggested removing only the stone as much as possible, preserving even a weakly functioning salivary gland.
There are four stages of changes in the pathological process in the salivary gland: focal lymphocytic sialadenitis, initial interstitial fibrosis of the gland, chronic sclerosing sialadenitis with signs of vacate obesity and atrophic sclerosis of the gland with vacate obesity. At the 1st stage, the removal of the stone leads to the normalization of the function of the SG; in the presence of the 2nd or 3rd stage, it is necessary to raise the question of its extirpation.
At the same time, it is recommended to narrow the indications for extirpation of the salivary glands, referring to the fact that their function is restored in most cases after removal of the stone. In this case, the gland is preserved and the presence of a scar in the submandibular region is excluded.
After removal of the stone, the secretory function of the SF is restored both by the amount of unconditioned secretion and by a number of qualitative indicators of the secreted saliva. After the root cause (stone) is eliminated, inflammation in the SF stops and it continues to function without any complications. At the same time, an important organ is preserved, the duration of treatment is reduced by almost 2 times, and complications are observed much less frequently than when the SF is removed together with the stone.
Surgical treatment of salivary stone disease with localization of the stone in the parotid differs from the treatment of the disease with localization of the calculus in the submandibular gland in that parotidectomy is performed in extreme cases.
To remove a stone from the parotid gland, an incision is made in the skin directly above the stone or, if the stone was located in the ducts of the 1-3rd order, by the method of G. Kovtunovich. To prevent complications such as injury to the branches of the facial nerve and the formation of external salivary fistulas, the authors advise, after dissecting the skin, to push the tissues in a blunt way and after removing the stone, carefully suturing the parotid fascia.
When the stone is localized in the duct of the gland, it is removed by intraoral access, after which anti-inflammatory and restorative therapy is prescribed, then dynamic monitoring of the state of the SG is carried out for several months. If the discharge of purulent exudate continues from the duct, or the SF remains enlarged, dense and slightly painful, it is recommended to remove such a submandibular gland in the second stage.
Most authors, when removing a calculus from a duct, recommend making a longitudinal incision of soft tissues along a metal probe inserted into the duct or fistula. During surgery, the stone can slip into the distal duct, making it difficult to find and remove. In this case, it is shown to stop searching for a stone and wait for its spontaneous departure. To prevent this complication, some authors fixed the duct behind the stone.
We believe that one of the reasons for the recurrence of stone formation is a significant decrease in the functional activity of the gland and the difficulty in the outflow of secretions. This is due to the fact that the clearance (the ratio of the diameter of the duct to the diameter of its mouth) in patients with salivary stone disease is quite high and averages 3-4 units. Therefore, after removing the stone, we carry out plastic surgery of the mouth - we create a new mouth of the duct to increase its diameter by 2-3 times. Plastic surgery is carried out in various ways: from a linear or U-shaped incision of the mucous membrane in the sublingual region and cheek, which created conditions for a free outflow of saliva, reducing its retention and preventing the risk of recurrent stone formation.
In the long-term period after the removal of calculus, 30% of patients often experienced partial or complete stricture of the duct in the area of \u200b\u200bsurgical intervention or recurrence of stone formation, detected in 29-39.6% of patients, and therefore the indications for extirpation of the SF along with the stone expanded.
Surgery to remove the salivary gland is associated with the risk of complications such as injury to the branches of the facial, lingual and hypoglossal nerves, leaving calculus in the duct stump or neck tissues. In addition, a poorly tied duct stump can further serve as a source of infection. Removing a calculus from the parotid gland may injure the branches of the facial nerve and form external salivary fistulas. These complications are especially often observed in the late stage of the disease, when there are many scar tissue around the gland.
The first experience of treating patients with salivary stones with extracorporeal lithotripsy using shock waves dates back to 1989-1990. At first, devices used to crush kidney stones were used to crush salivary stones. They had a limited focal volume. Currently, lithotripters with a small focal volume (mini-lithotripters) have been created, which are used to crush salivary stones.
The essence of lithotripsy is that shock waves generated by the electromagnetic coil of the generator in a liquid medium, propagating in all directions, are reflected from an elliptical metal reflector and are collected in the form of a focal spot on its opposite side. The greatest pressure is created in the center of the focal spot, with distance from which the pressure in the area of \u200b\u200bshock wave action decreases. Shock waves propagate better in liquid and solid media, therefore, the presence of an air gap in the path of their passage reduces the effectiveness of the impact on the stone. Shockwave focusing on the stone is performed using an X-ray machine or an ultrasonic sensor 3.5 MHz or 5 MHz.
Clinicians who used sialolithotripsy reported successful crushing of calculi in 40-64% of patients with a stone located in the submandibular gland and in 62.5-81% with localization in the parotid. The higher percentage of success in crushing the parotid calculus was explained by the fact that the parotid duct is shorter and wider than the submandibular, and the secretion in it is less viscous.
Salivary Stone Disease (Extraoral Stone Removal Method)
The extraoral method of stone removal together with the submandibular salivary gland is indicated for frequent exacerbations, anatomical and functional inferiority of the glandular tissue parenchyma. It is possible to preserve the gland, giving preference to the intraoral approach for removing stones, since they are localized mainly in the upper part of the submandibular gland at the site of its bend through the posterior edge of m. mylohioideus. To facilitate the process of surgery using intraoral access. In the process of removing a stone from the gland, its bed should be rinsed from a syringe with a solution of furacilin and at the same time sucked out of the wound with saliva ejectors, and the capsule surrounding the stone, sometimes containing foci of calcification, is recommended to be excised. These measures are aimed at preventing sand in the wound and recurrence of stone formation. If the salivary calculus is localized in the parotid parenchyma, it must be removed through an extraoral skin incision. When performing extirpation of the submandibular salivary gland, one should remember about the possibility of injury to the marginal branch of the facial nerve if the incision is made, as recommended in some guidelines, parallel to the edge of the mandible (at a distance of 2 cm below it).
Salivary stone disease (Conservative treatment)
Conservative treatment of salivary stone disease is permissible only after spontaneous discharge of the stone and the presence, in fact, of only residual chronic sialoadenitis or sialodochitis. Long-term results of surgical treatment of salivary stone disease are favorable in the vast majority of patients. According to VM Soboleva, after removing the stone from the gland, its function is restored; quantitative and qualitative indicators of salivation (including the viscosity of saliva, its pH, the concentration of calcium, magnesium, phosphorus, potassium ions, etc.) after a while are set within normal limits. However, various complications are also possible, in particular, relapse of the disease; this can occur after spontaneous discharge or intraoral surgical removal of a stone from a duct (gland). The reason for the relapse may lie in the tendency of the body to stone formation or in the insufficient radicality of the operation, when when a stone is removed from the excretory duct, a piece of stone or sand remains, which served as the basis for repeated stone formation. There are cases when in a patient who had several stones, the surgeon was able to remove only part of them; the reason for such incomplete removal can be both the difficulty of detecting small stones in the wound, and their "elusiveness" on the radiograph (due to X-ray permeability).
Treatment
Like any other disease, at the first stage, salivary stone disease is recommended to be treated with non-invasive methods, which include massage of the glands, sucking on sour candies to stimulate saliva production, and applying warm compresses. Dentists have had some success using two-handed gland palpation to reduce the size of small stones (European Journal of Dentistry, April 2009, Vol. 3:02, pp. 135-139). In some cases, the use of antibiotics is recommended.
If the primary methods do not give the desired result, the doctors come to the aid of modern endoscopy capabilities, which make it possible to correctly diagnose and remove stones using minimally invasive methods.
According to clinical statistics, about 20% of submandibular and 50% of parotid calculi remain invisible for radiography, therefore, ultrasound and CT are more preferable as diagnostic devices in this case. Same nice results enables the use of endoscopes, which allows the surgeon to see, visualize the problem and remove it in one treatment session.
Depending on the clinical indications and the extent of the problem, with the help of an endoscope, the doctor can remove already existing salivary calculi directly in the canal, irrigate the glands or administer medications, and expand the duct lumen during stenosis. The endoscopy procedure is performed under local or general anesthesia, and the risk of complications in the treatment of salivary stones with an endoscope is minimal.
In 1990, the first successful use of endoscopes in the treatment of salivary stones was presented for the first time, the results of the work of the German surgeon who performed the treatment were published in the Journal of the American Dental Association (October, 2006, pp. 1394-1400). Since then, technology in endoscopy has made significant strides forward: instruments have become even smaller, and therefore less traumatic for the patient and more convenient for the doctor to use.
To solve problems with stones in the salivary glands, several options for endoscope diameters are used: 0.8 mm - for diagnostics and irrigation, 1.1 and 1.6 mm with a "working channel" for the introduction of the necessary instruments (tweezers, micro drills for breaking stones, laser, inflatable balloons to expand the channel with stenosis). The flexibility of such endoscopes should not be less than 45 degrees. The cost of this instrument starts at $ 25,000.
It is interesting that the methods of working with an endoscope in the case of salivary calculus have some very significant differences. So in Europe, surgeons prefer to carry out diagnostics and surgery to remove stones from the salivary glands, combining extracorporeal shock wave lithotripsy (ESWL) for crushing very large or dense stones and endoscopy. The ESWL procedure lasts about 45 minutes, sometimes it takes about 45 procedures to achieve an absolute result. However, this technique, despite the relative duration of treatment, will allow you to get rid of calculi, resorting only to local anesthesia and allowing you to completely eliminate the patient's recovery period.
In the United States, there is no official approval for ESWL procedures, so American surgeons are forced to use the endoscope exclusively for diagnostic and auxiliary purposes (duct irrigation), combining it with minimally invasive percutaneous surgical interventions (small transoral, transcervical incisions), which requires general anesthesia. Naturally, this approach to treatment significantly increases the patient's recovery time after surgery; in some cases, hospitalization of the patient for a period of 3 to 4 days may be indicated.
Previously, the treatment of salivary stone disease was mainly dealt with by surgeons and otolaryngologists, but recently there are more and more dentists who can successfully diagnose and carry out these operations.
Tumors of the salivary glands
Morbidity
Salivary gland neoplasms occur in about 1-2% of human tumors. Benign tumors of the salivary glands are more common - in 60% of cases. Tumors of the parotid and submandibular salivary glands occur in the ratio (6-15): 1.
Most often, neoplasms of the salivary glands occur in people aged 50-60 years, although they can be observed in the elderly and in newborns. Men and women suffer from these diseases in approximately equal proportions.
Most often, the parotid glands are affected on one side of the face, neoplasms of the sublingual salivary glands occur very rarely. Of the small salivary glands, tumors most often affect the glands of the mucous membrane of the hard, less often the soft palate.
Malignant neoplasms of the parotid salivary glands during invasive growth can invade the facial nerve, causing paresis or paralysis of its branches. Tumors invade the lower jaw, primarily the branch and angle, the mastoid process temporal bone, spreading under the base of the skull, into the oral cavity. In advanced cases, the skin of the lateral parts of the face is involved in the tumor process.
Local metastasis malignant tumors salivary glands occurs in the regional superficial and deep lymph nodes of the neck, but can also proceed in a hematogenous way.
Morphological classification of tumors of the salivary glands
Tumors of the salivary glands are divided into the following types:
1. Benign tumors:
Epithelial: polymorphic adenoma, monomorphic adenomas (adenolymphoma, oxyphilic adenoma, etc.)
Non-epithelial: hemangioma, fibroma, neuroma, etc.
2. Localized tumors
Acinous cell tumor
3. Malignant tumors
Epithelial: adenocarcinoma, epidermoid carcinoma, undifferentiated carcinoma, adenocystic carcinoma, mucoepidermoid tumor
Malignant tumors developed in polymorphic adenoma
Non-epithelial tumors (sarcoma)
Secondary (metastatic) tumors
Classification of the development of malignant tumors
The development of malignant tumors of the salivary glands is divided into the following stages:
· Stage I (T 1 ) - the tumor does not exceed 2.0 cm in the largest dimension, is located in the parenchyma of the gland and does not extend to the capsule of the gland. Skin and facial nerve are not affected
· Stage II (T 2 ) - a tumor 2-3 cm in size, there is paresis of facial muscles
· Stage III (T Z) - the tumor spreads to most glands, one of the nearest anatomical structures (skin, lower jaw, ear canal, masseter muscles, etc.) grows.
· Stage IV (T 4 ) - the tumor invades several anatomical structures. Paralysis of facial muscles on the affected side
Benign tumors
Adenoma of the salivary glands
It is rare. It is usually localized in the parotid glands and consists of epithelial structures that resemble the gland itself. A painless, smooth and soft tumor node grows slowly, delimiting from adjacent tissues by a capsule. ICD D 11.0
Adenolymphoma of the salivary glands
A rare tumor, it consists of glandular epithelial structures with accumulations of lymphoid tissue and is most often located in the thickness of the parotid gland. The tumor node is soft and painless, it grows slowly, it is delimited from the surrounding tissues by a capsule. The tumor is accompanied by inflammatory processes and on the cut looks like brittle pale yellow tissues with small cysts.
Polymorphic adenoma
It occurs often - in 60% of cases and is most often located in the parotid salivary glands. They usually grow painlessly, slowly, and can reach considerable sizes. The tumor is dense and bumpy.
Polymorphic adenomas have a number of features:
Often occur as multiple nodes
The tumor capsule does not completely cover the tumor
Tumor tissue has a complex structure, consisting of epithelial, myxochondro-like and bone cells
In 5% of cases, they become malignant, acquiring all the properties of malignant growth, which is manifested by paresis of the facial nerve
Localized tumors
Acinous cell tumor
Tumor tissue consists of basophilic cells that resemble the serous cells of the acini of the normal salivary gland. The tumor node has a capsule, but sometimes it shows invasive growth, penetrating into adjacent tissues.
Malignant tumors
Mucoepidermoid tumor
It occurs in 10% of cases, most often in women 40-60 years old, mainly affects the parotid salivary glands. In half of the cases, the course is benign, clinically similar to polymorphic adenoma.
A malignant type of tumor is a painful dense knot without a clear border, which in 25% of cases gives metastases. The neoplasm is accompanied by ulceration, suppuration by the formation of fistulas with the release of pus-like contents. Sensitive to radiation therapy.
Cylinder
Neoplasm occurs in 9-13% of cases. On the cut, the tumor tissue resembles a sarcoma. It is a dense lumpy knot with a pseudocapsule, accompanied by pain, paresis or paralysis of the facial nerve. The cylinder grows with infiltrative growth, often recurs, in 8-9% of cases it gives metastases. Distant metastases affect the lungs and bones.
Carcinomas
Salivary gland carcinomas occur in 12-17% of cases. Morphologically, they are squamous cell carcinoma, adenocarcinoma, undifferentiated cancer. In 21% of cases, they are formed as a result of malignancy of a benign tumor. More often women over 40 are affected. About 2/3 of the carcinomas develop in the large salivary glands.
The tumor appears as a dense, painless nodule with indistinct boundaries. Subsequently, pains, phenomena of paresis of the facial nerve join. The neoplasm invades muscles and bones up to contracture of the masticatory muscles. Metastases affect regional lymph nodes, distant metastases develop in the lungs and bones.
Sarcomas
Sarcomas are very rare and arise from smooth and striated muscles, elements of the stroma of the salivary glands, blood vessels. These types of tumors include rhabdomyosarcomas, reticulosarcomas, lymphosarcomas, chondrosarcomas, hemangiopericytomas, spindle cell sarcomas.
Chondro-, rhabdo- and spindle cell sarcomas are dense nodes, clearly delimited from neighboring tissues. They grow rapidly in size, ulcerate and destroy neighboring organs, especially bones, give extensive hematogenous metastases.
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The salivary glands are organs located in the oral cavity that produce saliva. They are localized on the mucous membrane of the cheeks, lips, palate, under the jaw, near the ears, behind the tongue.
But unfortunately, it often happens that they become inflamed and cause a lot of discomfort. Diseases of the salivary glands are a group of diseases that should not be ignored, because it is with them that the production of saliva and the beginning of the digestion process begin.
Inflammation causes
Diseases of the salivary glands can appear as a result of many reasons. The most common ones are:
- viral or bacterial infection (causative agents of influenza, herpes, HIV, mumps, pneumonia, meningitis, and others);
- obstruction of the salivary ducts due to the ingress of a foreign object or formed stones into them;
- improper or inadequate oral hygiene. Teeth damaged by caries, gum disease and irregular brushing promote the growth of bacteria and make the glands more vulnerable to foreign agents;
- complications after undergoing surgery;
- severe intoxication from heavy metal salts;
- dehydration of the body;
- exhausting diets, poor in essential vitamins and minerals.
The most common diseases of the salivary glands
The branch of medicine, like dentistry, includes not only the treatment of diseases of the teeth and gums. It involves the treatment of all pathologies that have developed in the oral cavity and inflammation of the salivary glands, including. Further, the main diseases of the salivary glands, which dentists have to deal with most often.
Sialolithiasis
Salivary stone disease is a chronic disease characterized by the formation of calculi in the ducts of the salivary glands. Most often, the submandibular gland is affected, less often the parotid, and it is extremely rare to find a defeat of the sublingual gland.
Pathology is widespread among the male population and practically does not occur in children. Improper functioning of the salivary glands leads to stagnation of saliva in the duct. At this point, salts precipitate and stones begin to form.
Concrements consist of phosphate and calcium carbonate, in them you can find the content of sodium, iron and magnesium
Stones can grow at a rapid pace, and the size of dense formations sometimes reaches the size of a hen's egg. Symptoms of the pathology are edema and hyperemia of the skin in the affected area, difficulty in chewing, swallowing and talking, dryness of the oral mucosa, pain on palpation in the mouth and cheeks, an unpleasant taste in the mouth, pyrexia, deterioration of the general condition, headache and weakness.
Treatment involves conservative (drugs that enhance the secretion of the salivary glands, relieve swelling and inflammation, antipyretic, pain relievers, antibacterial) and surgical treatment.
Sialoadenitis
Acute or chronic inflammatory disease of the salivary glands, which occurs for various reasons ( infectious diseases, trauma, developmental anomalies). The disease most often occurs in children and people over 60 years of age. There are 3 types of sialoadenitis: submandibular, sublingual and parotid.
In addition to pain in the ears, throat and nose, the following symptoms can be attributed: increased body temperature, hyperemia and swelling of the skin in the ear area, an unpleasant taste in the mouth (putrid breath), soreness when pressing on the earlobe, impaired taste, dryness oral mucosa as a result of insufficient saliva secretion.
In case of complications, stenosis of the ducts, salivary fistulas, abscess, phlegmon of the parotid and submandibular zone may appear. Treatment of sialoadenitis is carried out conservatively with antibiotics, antiviral drugs, physiotherapy procedures. With a frequent recurrent course of the disease, complete removal of the salivary gland is recommended.
Salivary cyst
Education, which is formed as a result of a difficult or complete cessation of the outflow of saliva, a violation of the patency of the salivary ducts due to their blockage. The classification of the cyst is as follows: retention cyst of the small gland (56%), wound, cyst of the submandibular gland, cyst of the parotid gland.
Most often it forms on the mucous membrane of the cheeks and lips. Most often it is asymptomatic. Measures to combat cystic formation in any place of localization does not provide for conservative treatment. The best option is to remove the cyst together with the adjacent tissues with self-absorbable sutures.
Sjogren's syndrome
Dry syndrome is an autoimmune disease that affects the glands of external secretion, as a result of which you can observe dryness of the mucous membranes not only in the mouth, but also in the nose, eyes, vagina and other organs. Pathology most often occurs among women after 40 years of age, often accompanied by diseases such as scleroderma, lupus, periarteritis.
The first nonspecific signs of Sjogren's syndrome are dry mouth and soreness of the eyes, which is cutting and sharp when watching, for example, TV.
When examining the tongue, there is its complete dryness, the inability to swallow saliva, a dry lump in the throat, causing discomfort.
With the development of the disease, photophobia, pain in the eyes, blurred vision, dystrophic changes appear. If you want to "squeeze out" a tear, nothing happens, because there is no tear fluid. Two weeks after the onset of the disease, loosening of the teeth and loss of fillings can be noticed.
Treatment includes taking glucocorticosteroids, immunosuppressive cytostatics, symptomatic therapy.
Tumors
Oncological diseasesrarely affecting the salivary glands. Among all cancers, they account for only 0.5–1% of all oncological pathologies. Despite its rarity, cancer of the salivary gland poses a great danger, since the course of the disease is secretive and asymptomatic at the first stage.
Neoplasms are 2 times more common in women after 50 years of age, they tend to malignancy and metastasis. As the tumor grows, swelling may appear in the localization area, a feeling of fullness from the inside. In later stages, discomfort, soreness, ulceration appear.
Treatment of neoplasms is exclusively surgical, followed by chemotherapy and radiation therapy. Measures aimed at eliminating diseases are coordinated by several doctors: dentist, surgeon, otorhinolaryngologist.
Diagnostics
All patients who have asked for help from a specialist, without fail, for the purpose of diagnosis, are examined, palpated, surveyed, blood and urine tests. Depending on the results obtained, the specialist can send him for a comprehensive examination in a hospital setting.
Most often this happens if there is a history of diseases such as diabetes mellitus, pathologies of the thyroid and gonads, diseases of the digestive tract, liver, kidneys, of cardio-vascular system, nervous and mental disorders and others. All of them can cause inflammation of the salivary glands or aggravate the course of the disease.
The probing procedure is carried out carefully, without the use of force, since the duct wall is very thin and does not have a muscle layer, so it can be easily damaged
To more accurately diagnose, doctors prescribe the following procedures:
- Probing the ducts of the salivary glands - carried out with a special salivary probe. With this method, you can determine the direction of the duct, its narrowing, stone in the duct.
- X-ray of salivary ducts (sialography) - a diagnostic method aimed at introducing a contrast agent into the ducts and performing radiography. It can be used to determine the expansion or narrowing of the ducts of the salivary glands, the clarity of the contours, the presence of calculi, cysts and tumors, etc. The procedure is carried out using a syringe and can cause discomfort to the patient.
- Sialometry is a method that determines the functional ability of small and large salivary glands. The procedure is performed on an empty stomach, you cannot brush your teeth, rinse your mouth, smoke, or chew chewing gum. The patient takes orally 8 drops of 1% polycarpine diluted in half a glass of water. After that, a special cannula is inserted into the gland duct and the secretion of the salivary glands is collected in a test tube for 20 minutes. After a certain time, the amount of saliva produced is estimated;
- Cytological examination of saliva - a method that helps to identify inflammation and tumor diseases of the small and large salivary glands.
Preventive actions
To try to completely protect yourself from damage to the salivary glands, you must follow simple rules: observe the rules of oral hygiene, monitor the condition of the teeth, gums and tonsils. If any viral or bacterial disease occurs, the necessary therapeutic measures should be taken on time.
When the first signs of inflammation of the salivary glands are found, it is necessary to rinse the mouth with a weak solution of citric acid. It promotes abundant production of saliva and frees the ducts from the accumulation of infections or foreign bodies in them.