Septum Piercing Dangers

PATHOLOGIES SALIVAIRES OF GLAND

PATHOLOGIES SALIVAIRES OF GLAND

Author:

Dr. Altaf O'CLOCK Malik

The department. of Oral and Surgery of Maxillofacial,

Govt. The dental university, Srinagar.

Co composes:

Dr. Ajaz A shah

Master of lectures and the Head,

The department. of Oral and Surgery of Maxillofacial,

Govt. The dental university, Srinagar.

Dr. Suhail Latoo

Lecturer

The department of Pathology and Oral Microbiology,

Govt. The dental university, Srinagar.

Dr. Manzoor Ahmad Malik

J &the amplifier; the Services of Health of K, SDH Banipora

Dr. Rubeena Tabasum

Living

The hospital of c.d, Srinagar.

Dr. Shazia Qadir

The department. of Oral and Surgery of Maxillofacial,

Govt. The dental university, Srinagar.

Introduction

The glands salivaires, major and minors, understand a system of complex, anatomical organ and physiologique produces the enzyme, the lubrication, mixing the agent and the immunized factors. The glands salivaires reply to physics (the food and the drink) and emotional (the flight, the excessive joy and the exhaustion) the stimuli. They can fall the prey to a big number of pathological conditions, including the infection, the calculation, the immunized disorders, the hypertrophy and atrophy, the diseases and the system nedoplasmes, benign and cunning.

The diseases of glands salivaires could be divided in

1. Abnormalities dedveloppementales
2. The sharp infections

chronic

system

1. The benign nedoplasmes

cunning

1. Autoimmune
2. Various necrotising sialometaplasia

mucoviscidose

mucocele and ranula

Abnormalities dedveloppementales

The gland salivaire aberrant

An aberrant one (uterine first rate) fabric salivaire of gland that develops to a site where it normally is not found. This condition is retrieved as an only abnormality or in the combination with the other abnormalities of the face. They the most frequently are retrieved in the cervical region close to the gland of parotid or the body of the mandibule. The last one is found posterior to the first molar and has often a communication with a gland salivaire major. Most of glands salivaires aberrant in the neck arrive in the superior portion in the sector of the slit of branchial one and of cracked cysts of the falter.

Aplasia and hypoplasia

Total Aplasia of the glands salivaires major, although rare, can arrive in the combination with the other congenital abnormalities as the cracked palace. The major symptom is harsh xerostomia. Hypoplasia of glands of parotid was retrieved in the patients with the melkerson-rosenthal syndrome, that presents as a classical triad of orofacial granulomas, the paralysis and the fissure of the face languetent.

Incidental glands

This is a common condition, found in more than the half the people. It is of ordinary one found the superior one and previous to the orifice of driving of normal Stensson.

Diverticuli

These are small pockets or outpocketings of the system of ductal of one of the glands salivaires major, and these take to the repeated episodes of sharp parotitis.

The infections of the glands salivaires

Sialadenitis, the infection of fabric of gland salivaire is a comparatively common fabric. It could be classified as

(I) Bacterial and viral

one) the Oreillons (viral parotitis)

b) Bacterial parotitis (sialadenitis) i. Sharp

II. chronic

c) Recurrent parotitis of childhood

(II) sialadenitis not very cooperative

one) Sialolithiasis

b) the corks Muqueux

c) the Condemnation ae" stenosis

d) the Foreign body

(III) the diseases of the system of granulomatous

one) the Tuberculosis

b) Actinomycosis

c) the Fungal infection

d) the fever of Uveoparotid

Sharp bacterial Parotitis

Sharp bacterial Parotitis is a disease of the elderly, malnourished persons, has dehydrated, the patient posts opedratif and sick chroniquement. Secondary dehydration to the disease or the sharp deficiency has for diminished result salivaire the flow and the infection demotes driving of Stensson. Antisialogogues, the diuretics, the antihistamines and the tranquillisants can be also the causes. From the standpoint clinic, the condition is characterized by the sudden beginning of business, erythematous increasing by region of parotid and of pain and of exquisite sensitiveness. The body temperature rises and the purulent disposal can emanate driving of Stensson. So non-treaty, it takes to one to the clearly toxic and critical position.

The treatment of bacterial parotitis includes the hydration, antimicrobial therapy (the penicillins of semisynthetic are found to be sufficient), and the drainage if necessary. The drainage is accomplished by the surgical exposition of the gland and of penetration of capsule by to probe blunted using a small greenhouse joins Kelly.

Chronic bacterial Parotitis

This can be secondary to an episode of sharp parotitis, and is characterized by the unilateral or bilateral growth of the parotid and by a course of exacerbations and of intermittent discounts. Parotidectomy is considered to be final therapy.

Viral Parotitis (the oreillons)

The oreillons are a sharp transmittable disease, arriving in the epidemics and transmitted by the secretions and the urine salivaires infected. It arrives from ordinary in a child or in an adult that escaped beforehand the preceding infection. The oreillons are characterized by a quick one, a painful growth of the one/the two parotids 15 ae" 18 days after the initial exposition. The phase of Prodromal of 1 ae" 2 days of fever, the headache etc. precedes the growth. The complications include pancreatitis, orchitis and the meningitis (because of viremia). The oreillons resolve spontanedment in 5 ae"10 days. The treatment symptomatique for the fever and the pain is necessary.

Submandibular sialadenitis

This is less common than the infection of parotid, and is especially because of the rocks and the condemnations. Importance clinic is that it could be confused with submandibular the spatial infections of origin of odontogenic.

Sialolithiasis

Sialoliths is calcified and the organic question that develops in the parenchyma or the drivings of the major glands or minors salivaires. Biochemically, they appear laminated with the put to bed organic equipment cover with the concentric shells of calcified question. The crystalline structure principally is hydroxyapatite and contains applies phosphates to it octacalcium.

The aetiology of a sialolith is varied. The inflammation, the irritating local, antisialogogues etc. are thought to play a significant role.

The rocks are a factor of common etiologic for sialadenitis. The corks muqueux, the condemnations etc. produces a picture clinic similar.

About 80 ae" 90% arrivals in the gland of submandibular or the driving for the following reasons.

• The driving of Wharton contains bends probably splitting to take to the trap the corks of mucin or the cell debris
• The calcium levels are high in the saliva of submandibular
• The position depending on the gland

5 ae" 15% of sialoliths arrives in the gland of parotid and 2 ae" 5% in the glands sublinguales and minors salivaires.

From the standpoint clinic, the symptom more common of sialolithiasis is the painful intermittent growth in the sector of a gland salivaire major, that worsens during to eat and the resolutions after meal. The pain migrates of the safeguard of saliva behind the rock or cork.

Sialoliths of driving of the Stenson or Wharton will be tangible so present in the peripheral portion of driving. The common site of calculation is oral mucosa and it presents as one to drain freely movable growth, well circumscribes and asymptomatic.

Diagnosis:

1. Xray ordinary
2. Sialography
3. CT sweeping

Treatment:

The secondary sharp infections to stasis should be treated with antibiotics. The rocks in the portion distale of driving can be removed often manuellement. The deeper rocks demand surgery. Lithotripsy was described as a method non-invasif to disintegrate sialoliths.

The various infections of glands salivaires

Tuberculosis

The glands salivaires principally could be implied in the tuberculosis, or the disease can infect lymphatic ganglions of periglandular. The parotid the most ordinarily is affected. The picture clinic is of a business, a not growth to stretch, resembling a tumor. To drain fistulas can be present. The diagnostic investigation of enlargement of gland salivaire chronic should include xrays it chest, the test of skin and the acid staining quickly drainage and of culture.

Sarcoidosis (the disease of Heerfodt)

This is a chronicle, system, the inflammation of granulomatous implying glands salivaires in 60% of the cases. The fever of Uveoparotid arrives in 10% of case that present a conclusion triad ae" the face trembling, the enlargement of parotid and uveitis.

The treatment is the care symptomatique and the therapy of corticoa¯de in the long term.

Actinomycosis

Actinomycosis israelii Is a common member of oral flora and can invade the glands salivaires. Sialadenitis arrives in also top as 10 percent of case of orofacial actinomycosis. The high therapy of penicillin of dose in the long term is the choice treatment.

The diagnosis of infections of gland salivaire

A detailed history and physical examination are useful in the diagnosis of infections of gland salivaire. The patient that retrieves the sharp growth of a gland salivaire to the meal time could be diagnosed as having an obstruction of sharp ductal. The children carefully should be questioned for the exposition to the oreillons epidemics in the passed recent.

The prudent inspection of oral cavity is obligatory to differentiate between a gland salivaire increasing and a spatial infection of dental origin. The physical examination must include light palpation of all glands and bimanual intraoral and extraoral palpation salivaires major of drivings.

Diagnostic Roentgenology can be useful. The indications for the films or simple sialography are

one) the condemnation detection, the calculations, the foreign bodies

b) the detection of big abscesses of parenchymal

c) the judgement of severity of damages of parenchymal or of residual function

The tumors of glands salivaires

The tumors of glands salivaires constitute a heterogenous group of lesions of big variations morphologiques, and this presents difficulties in to have a general classification.

Benign tumors

Pleomorphic adenoma (mixed the tumor)

This is the most common one of all tumors salivaires of gland, more than 50% constituent one of all the cases of tumors and about 90% of all tumors of gland salivaires benign. It is characterized by a morphologique and complexity of histologic marked by the presence of a selection of types of cell.

The numerous theories were advanced to explain the histogenesis of this tumor, and the current arguments concentrate on the cell of myoepithelial and a reserve cell in driving inserted. It is said that the cell of myoepithelial is responsible of the variety morphologique of the tumor, while the cells of reserve of driving inserted can differentiate in the cells of ductal and the cells of myoepithelial, that can undergo mesenchymal metaplasia to generate typical more of the different ones of cells.

Characteristic clinics:

The parotid is the site more common of pleomorphic adenoma (90%). It can arrive nevertheless in any gland and is more common in the women and in the patients in fourth to the sixth decades. The history is that of a small, benign nodule and in rest that increases slowly in the size. The this is of ordinary a lesion nodulaire irregular that is firm in the consistency. The pain is not a common symptom. Among the glands minors, the palatal glands frequently are affected. It can cause difficulties in the breathing, speaking and mastication.

Histology:

The tumor always is encapsulated. The various model of histologic is characteristic. Some sectors some cells of present cuboidal arranged in the model drives affectiant with a clot of eosinophilic. In the other sectors, the tumor cells can suppose a stellate, the form of polyhedral or spindle. Someone can show same chondroid or the bony character.

Treatment:

The admitted treatment is the surgical excision. The tumor and lobs it implied are removed. The lesions in oral could be treated more conservatively by the excision of extracapsular. The cunning transformation can arrive in a non treated tumor of long date or in a recurrent the one.

Adenoma monomorphe

WHAT the classification of adenomas monomorphe them under divides in

1) adenolymphoma (the tumor of Warthin)

2) oxyphilic adenoma

3) of others, that includes tubulaire, alveolar (trabecular), the basal cell and clarifyes cell adenomas.

Adenolymphoma (the tumor of Warthin)

This curious type of tumor is found almost exclusively in the gland of parotid. This exposes a defined predilection for the men and for the slicees of is a question of fifth fourth and sixth decades.

The tumor is generally superficial, remaining just underneath the capsule of parotid or surpassing by him. It does not grow any ordinary more than 3 ae"4 cm in the diameter. the it is benign, the business to palpation and is from the standpoint clinic indistingued of the other benign lesions.

Histological, the tumor consists in two components ae" fabric edpithedlial and lymphoid. The it is essential that an adenoma exposes the cyst formation, with the projections of papillary in the cystic spaces and a lymphoid matrix showing germinal centers.

The currently admitted theory of histogenesis is that the tumor presents itself in the fabric of gland salivaire take to the trap in the lymphatic ganglions of paraparotid or intraparotid during embyogenesis.

The treatment is the surgical excision of the tumor.

Oxyphilic adenoma (oncocytoma acidophilic adenoma)

This is a rare tumor arriving from ordinary in the gland of parotid. the this is more common in the women and in the elderly persons. It does not grow to the big size and is from the standpoint not different clinic of the other benign tumors

Microscopiquement, the tumor is characterized by the big cells with a cytoplasm of eosinophilic and a membrane cytoplasmique distinct, and that has tendency to be arranged in the rows or the narrow ropes. These tumor cells resemble the apparently normal cells "oncocytes" called, that are ordinary view in a big number of locations in the body.

The choice treatment is the surgical excision. The tumor has not tendency to reproduce itself and the cunning transformation is rare.

Basal Adenoma of cell

This tumor arrives from ordinary in the glands salivaires major and a majority of patients are more than 60 major years. It presents as a lesions to benign slow developments. Histological, it has a fabric conjunctive well defined capsule, and the cells are isomorphes and basaloid in the appearance with basaloid in round to the oval kernels. The cells carry the similarity to the cells of secretory of driving inserted. The basal adenoma of cell is treated by the excision.

Canalicular adenoma

This arrives in the glands salivaires, incidental and in oral, principally in the superior lip. The patients are of more than 60 ordinary major years. It presents as one to slow, benign development, the nodule of repaired no of the lip. The presentation of Histologic is ropes of cells edpithedliales, arranged in a double row. The canalicular adenoma is treated by the simple excision.

Myoepithelioma

It arrives in the adults and the gland of parotid is the site more common of event. The site in oral the most common one is the palace. The tumor is composed from in form of spindle or cells of plasmacytoid or a combination of the two, regulate in a bottom of myxomatous. The final diagnosis remains in the identification ultrastructurale of calls of myoepithelial. The lesion is treated by the excision.

Ductal papillomas

Resultant Papillomas of excretory drivings of glands salivaires present in three forms.

1) Simple ductal papilloma ae" a lesion of exophytic with a surface of papillary and a pedunculated bases.

2) Inverted ductal papilloma ae" the presents as a nodule of the oral mucosa.

3) Sialadenoma papilliferum ae" the growth of exophytic of hard palace.

All types are treated by the excision.

The benign lesion of lymphoepithelial

This common lesion exposes the inflammatory character and nedoplastique. The lesion essentially is shown as a unilateral or bilateral engagement of the parotid and/or the glands of submandibular with the soft malaise, the pain and occasional xerostomia.

It is considered to be an autoimmune disease in which the fabric of gland salivaire becomes antigenic. There is often a diffuse, poorly sketched enlargement of the gland instead of the formation of a discreet nodule. Histological, there is a methodical infiltration of lymphocytic of fabric of gland, destroying or replace the acini.

The condition was treated by the surgical excision and radiance. But the last one now is not used being given the radiance possibility induced the malignancy.

The relation to the disease of Mikulicz

The disease at first describes by Mikulicz in 1988 was characterized by a symmetrical or bilateral, chronic and benign enlargement of the of lachrymal glands and salivaires. The patient of Mikulicz showed a benign course without the lymphatic engagement. Some later workers noticed that the certain cases diagnosed as the disease of Mikulicz ran often a quickly fatal course. These were revealed later cunning lymphomes.

It now is believed that the disease of Mikulicz and the lesion of benign lymphoepithelial are identical in the nature.

Cunning tumors

Cunning Pleomorphic adenoma

This term includes these histological benign tumors that are showed to have metastasises resemble the primary lesion, just like those that resemble from the standpoint clinic to pleomorphic adenoma benign but exposes changes cytological of the cunning ones. There is the considerable debate themselves they result from a preceding benign lesion or they represent a cunning lesion of the beginning.

There is not difference clinic evident between pleomorphic adenomas benign and cunning, except an occasional fixity to the deeper structures and to the increased incidences of ulceration of surface, to the pain and to the enlargement of regional lymphatic ganglion in the cunning cases. Frequent metastasises to the lungs, the bones, the visca¨res and the brain are seen.

Histological, the cunning component can cover the benign one one or can remain localized in the discreet locations. The nuclear changes, the invasion of conjunctive fabric, necroses it focal etc. are the characteristics that is used to determine the malignancy.

The treatment is lesions essentially of the surgical and recurrent ones are managed by surgery and the combined radiotherapies.

The adenoidal cystic carcinome

This is a form of adenoidal carcinome, that affects frequently of the the glands salivaires, incidental and in oral, the glands of parotid and submaxillary. The demonstrations clinics include the local pain, the face paralysis (in case of the engagement of parotid), the fixity to the deeper structures, the local invasion and the surface ulceration. Histological, the tumor is composed from small, staining deeply uniform cells resemble the basal cells, arranged in the model drives affectiant, the central portion of which contains an equipment of mucoid. the broadcasting of cells of tumor alongside the spaces of perineural or the sheaths is a common characteristic.

The treatment principally is surgical, but it often is coupled with radiance. This tumor these of ordinary only last metastasises in his course and the continuation therefore in the long term are obligatory.

The carcinome of cell of Acinic

This lesion is special in that the cells show the cell to acinar differentiation instead of the model drives affectiant seen in the other tumors. It resembles closely to pleomorphic adenoma in the appearance brute. It is retrieved to principally arrive in the parotid. The carcinome of cell of Acinic is composed from cells of variable degrees of differentiation. The well differentiated cells resemble the cells of normal acinar. The lymphoid elements ordinarily also are seen.

The treatment is essentially surgical. The return rate is 8 ae" 59%, that arrives a lot of years after surgery. The continuation in the long term is necessary.

Mucoepidermoid carcinome

This is a curious type of tumor of gland salivaire, described as a separated entity in 1945 by Stewart, Foote and Becker. The case majority arrived in parotid. The other gland also could be affected. This tumor has a cunning variety of inferior quality and a cunning type of superior quality. The old one appears as one enlarging slowly the benign mass. Because of the tendency to develop cystic sectors, the lesions in oral resemble mucocoele. The tumor of malignancy of superior quality grows quickly and produces the pain and the paralysis of nerve of the face.

The carcinome of mucoepidermoid is not encapsulated; it seeps in in in surrounding fabric and the spectacle metastasises. Histological, this is a tumor of pleomorphic calms cells muqueux-sedcredtants, the cells of epidermoid-type and the intermediary cells.

The treatment is surgical. The recent data showed the response in favor of radiance therapy. The cunning type of inferior quality can be managed by only surgery.

Eclaircir the carcinome of cell

This is a comparatively lesion recently recognized, characterized by the presence of special one 'clarifyes cells' that are thought to result from the driving cells inserted or the cells of myoepithelial. This lesion is found also principally in the major glands, especially parotid. The clear carcinome of cell tends to arrive in the elderly adults and in the female ones. The presentation clinic is not different of the other tumors. The histology shows groups of clear cells surrounded by a thin septum of fibrous conjunctive fabric. The lesion is treated by surgery. It shows of ordinary a comparatively favorable prognostic.

Epidermoid (the cell of squamous) the carcinome

This tumor implies a prognostic engraves, since it exposes the property of infiltrative, the metastasises and reproduces itself easily easily. It can present himself in the gland salivaire. It seems to be origin of ductal, since drivings undergo squamous metaplasia with the comfort. A therapy of combination of surgery and of radiotherapy is indicated.

The engagement salivaire of gland in the rheumatic disease

A growth salivaire of gland, especially parotid, can be a demonstration of autoimmune disease. The under distinct bodies of disease of gland salivaire autoimmune are

1) allergic sialadenitis,

2) The syndrome of Sja¶gren/myoepithelial sialadenitis and

3) sialadenitis Epithedlial of cell/granulomatous sialadenitis.

Allergic Sialadenitis

This is a sharp one, but rare, the condition. The deposition of complexes of antiga¨ne-anticorps in the parenchyma has for result the growth glandulaire. The allergen abduction is curative. The allergens include certain foods and the certain drugs as phenyl butazone and as nitrofurantoin.

Myoepithelial sialadenitis (the syndrome of Sja¶gren)

This is a condition described at first as a triad consists in keratoconjunctivitis sicca, xerostomia and the polyarthrite rhumatoa¯de. Some patients present only with the dry and dry eyes the mouth (the syndrome of Sja¶gren primary/the complex of sicca) while of others develop other collagen diseases vascular as SLE, polyarteritis nodosa, scleroderma and the polyarthrite rhumatoa¯de (the syndrome of secondary Sja¶gren).

The disease arrives in a predominant way in the more than 40 women major years. The diagnosis clinic demands a combination of two of the classical triad. The drought of eyes and of grittiness of cause of mouth and the pain in the eyes, and bother and the sensation of burn of oral mucosa. Oral Candidiasis, the decay galloping and the language of fissured are common. The patients have often the engagement of bilateral parotid. The other glands also could be affected.

The disease of Mikulicz is thought to be synonymous with the component salivaire of syndrome of Sja¶gren. The lesion can have additional demonstrations glandulaires as the lymphomes.

Histological, the excessive infiltration of lymphocytic of glands and the proliferation salivaires of edpithedlium of ductal is seen. The antibodies of Antiductal can be present in the sedrum of the patients. The other factors as the factor rhumatoa¯de and as the antinuclear antibodies are so common. ESR can rise to 80%.

Sialography can be diagnostic value in the syndrome of Sja¶gren. It shows a cherry flower typical (branchless the tree fruit loaded) the appearance.

There is not satisfactory treatment to the syndrome of Sja¶gren. The patients are symptomatiquement treated with the artificial tears and the substitutes salivaires.

Various diseases

Mucoviscidose

This condition is transmitted as an autosomal the trait redcessif and is the genetic, mortal syndrome and the most common one among the white children. The children suffer from the chronic lung disease, insufficiency pancredatique and high concentration of edlectrolytes in the sweat.

Although the glands muqueux-sedcredtant pathologically more are implied, the saliva of parotid lightly also is affected. The elevation of levels of calcium and protein in the glands has for result the muddiness of secreted liquid due to the formation of complexes of calcium protein.

Necrotising sialometaplasia

Necrotising sialometaplasia is a benign inflammatory reaction of fabric of gland salivaire, that the two and from the standpoint clinic histological imitates the malignancy. The cause more probable is local ischaemia, the cause not of which is well known that the abuse of alcohol and tobacco was implied by some workers.

The condition arrives more ordinarily in the men. Most of the patients are in the fourth and fifth decades. Most of the cases arrive in the palace, but the other sites in oral also were noticed. The lesion generally presents as an ulcer. The pain is not common. The growth can present in some cases.

Necrotising sialometaplasia histological is characterized by ulcerated mucosa, pseudoepitheliomatous hyperplasia of the edpithedlium of mucosal, necroses it acinar and squamous metaplasia of glands salivaires.

The lesion is essentially oneself limiting and heals by the secondary intention.

The phenomenon muqueux of retention (mucocoele)

This generally is granted to be of traumatic origin, and is a common lesion. It could be caused by the traumatic rupture of a driving salivaire, or a chronic partial obstruction of a driving salivaire. Thus mucocoeles could be classified in the type of extravasation and the retention type. The old one is more common.

The condition arrives more ordinarily in the lower lip. The lesion can remain enough deeply in fabric or is exceptionally superficial. The superficial lesion is a raised and circumscribed vesicle with a bluish and transparent distribution and is less than 10 mm in the diameter. The deeper lesion is also a growth, but the appearance of color and surface is normal mucosa. The contents consists in of thick ordinary, the equipment of mucinous.

The histology shows to the elevation of mucosa, diluting edpithedlium, the wall did a surface of conjunctive, fibrous fabric and squeezed and a lumen filled with a clot of eosinophilic, containing variable cells.

The treatment is the lesion excision with the abduction o f the acini of gland salivaire associated.

Ranula

This is a form of mucocoele that arrives in particular in the mouth floor in the association with the driving of Wharton or of drivings sublinguaux. The aetiology and pathology is essentially it same as for mucocoele of other glands.

The lesion develops as one enlarging slowly the benign mass on a side of the floor of the mouth. Since the lesion is mucosa anchored and recovering is normal in the appearance. If the it is superficial, the mucosa will have a bluish color translucide. The treatment is at unroof that the lesion to drain the contents.

The imagery in the diseases of gland salivaire

The multiple techniques of imagery could be used in the diagnostic evaluation of gland salivaire. These spread examination radiographique simple to the imagery of magnetic resonance the more complex (the MRI).

Xray simple

Xrays it simple always serves an important function in the examination of the glands salivaires. It is indicated to identify sialoliths, phleboliths or the present of calcification of dystrophic radios opaque in the gland or driving.

For the evaluation of gland of parotid, the view of PA, the lateral true views and lateral indirect with the extended chin and mouth opens, should be executed. For the evaluation of gland of submandibular, xrays it lateral view should be taken with the index leaning on the language. Besides, a view in oral of occlusal can be serviable.

About 80% of calculations salivaires can be envisioned with xrays it simple. They appear as focal calcified densites, the most ordinarily associated with the gland of submandibular.

Nuclear medicine (the imagery of radionuclide)

The conclusions of techniques of nuclear medicine are less specific than sialography, CT or the MRI. But this can be useful as an assistant one to these techniques.

The intravenous injection of 10 mCi of Tc 99M pertechnate is executed with the pictures of camera of gamma obtained every 2 minutes. The abnormalities could be defined as the increased admission, diminished or leaves radionuclide. The increased admission is seen in the diseases of sialadenitis and granulomatous and in the tumor of oncocytoma and Warthin. The diminished admission is seen in the ageing, the infections and most of the viral tumors.

Ultrasonography

This furnishes a means non-invasifs for the examination of the glands salivaires, with the exception of the lobs deep parotid. The differentiation between the cystic and solid compartments easily can be done. The full structures of liquid with no fabric interfaces, as an abscess or a cyst, appear free echo on the studies of ultransonic sounds. The solid structures, as the heterogenous tumor, appear filled with the multiple echos and the various shadows of gray one.

The high transducers of frequency in the order of 7.5 MHz are used. The sequential pictures in the transverse and longitudinal airplanes are executed. Ultrasonography could be used in the evaluation of all types of pathology in the glands salivaires. In the case of inflammatory lesions, the process chronicity determines the model of sonographic.

Sialography

Sialography is the demonstration radiographique direct of the gland salivaire and the driving system by the injection of equipment of constraste radio opaque in the orifice of ductal. The three principal indications for the execution of sialography are

(I) the sudden sharp growth of a probably secondary gland to the obstruction of ductal by a rock or a condemnation,

(II) enlargement or the symptoms glandulaires progressive suggesting the recurrent inflammation,

(Iii) the masses of gland salivaires tangible.

Technical:

Before driving canulation, the examination radiographique conventional is indicated to determine the view radiographique. No premedication or the local anesthedsie is demanded for sialography. After the placement of cannula in driving, an equipment of oily constraste as ethiodol is introduced by the pressure injection hydrostatic or intermittent light manuelle. The injection of constraste is executed under the direction fluoroscopique. The gland should be envisioned during the accessories of ductal, the accessories of acinar, the steps of discharge and posts discharge.

Conclusions:

In chronic inflammatory sialadenitis, focal expansion of peripheral and spherical drivings or the collections of sacular of constraste are noted in an irregular model through the gland. The delayed discharge of constraste is noted.

In the autoimmune diseases, punctate or the spherical collections of equipment of constraste homogenously is seen through the gland, and these not to disappear during the discharge. The syndrome of Sja¶gren is characterized by a cherry flower (branchless the tree fruit loaded) the appearance.

In the calculation evaluation, xrays it simple is superior to sialography since most of the calculations are opaque radios, and the constraste can obscure it. The diseases of Granulomatous and the lymphome have an appearance of similar sialographic. The conclusions have a progressive nature depends on the course of the disease. Sialography also could be used to evaluate formations of ripping up or haematoma.

Sialography is contraindicates in the cases of

(I) the sharp infection and

(II) the allergy history by means of constraste.

The calculated tomographie (CT)

The primary indications of evaluation of CT include masses or generalized enlargements of one or more of glands, the processes or the sharp inflammatory abscesses. This technique is serviable in the diagnosis, the treatment planning and in to evaluate response to the treatment.

Routine CT could be executed with or without the administration of intravenous constraste. The CT has an advantage of 10 pleats on xray them conventional in the calcification detection in the glands. Sharp and chronic inflammation, tumors and the benign and cunning cysts can be envisioned. In the case of cunning tumors, the infiltration to surrounding fabrics could be seen. Also, the nerve of the face and other associated structures could be envisioned, and this assistance in the treatment planning.

The magnetic imagery of resonance (the MRI)

The indications for CT and MRI overlap. The MRI is the choice examination for the evaluation of lesions nedoplastiques. The advantages of MRI include the soft fabric constraste increased to the tumor margins. Major disabilities include the high cost, limited availability of opportunities and of technical increased complexity.

The examination of MRI of glands salivaires uses a superconductive magnet with a field forces of 1.5 examinations of Routine of T. includes the slice edpaissit of 5 mm or less. The M appearance of pleomorphic adenoma and of tumor of Warthin is inhomogeneous with the intensity of low signal compared to the normal gland. In the tumor of Warthin, the cystic components are met. The fibrosis or calcifications appear as the sectors of signal or the empty low signal. The cunning tumors show a signal of lower intensity than that of benign tumors. The places of Haemorrhagic appear as the high pictures of intensity.

The usage of MRI in the disease of gland salivaire is limited because a lot of diseases show similar models. The counterindication to MRI includes pacemakers, the valvular clips ferromagnedtiques and the devices of established neurostimulation.

Surgical direction of Diseases of Gland Salivaire

With the possible exception of surgical direction of cysts of retention as mucoceles and of ranulas, transoral sialolithotomy is the operation more frequented executed on the system salivaire. This is a simple operation often but neglected by the medical practicien without formation in oral surgery in the service of enucleation of the gland. If the rock is favorable localized, his abduction by the mouth preserves the gland and therefore his function.

The gland of submandibular can be enucleated without harmful sequelae if the operation properly is accomplished. In most of the patients with the secretion salivaire normal in the glands remaining his abduction is of no consequence.

Nevertheless the gland of parotid is bigger worry. The danger to the face nerve always is present although prudent surgery that the permit the abduction of this gland with only fleeting weakness in most of the examples.

The abduction of or the gland will have for result a deformity of the significant face. Nevertheless these factors are the most significant if the operation is necessary but contraindicates such procedures when the conservative methods would suffice.

The tumors implying the parotid, submandibular, the glands sublinguales or minors salivaires localized in the cheek, the lip palace can deserve also their abduction in the certain examples. Such procedures were discussed in detail to the under.

Submandibular sialoliths

Lithiasis of gland of Submandibular is the disorder more common of gland of submandibular and frequents the more the location is additional glandulaire. Despite the Fact that these calculations are big they are rarely painful since the lumen of driving of Wharton is bigger and more expansible than the driving of Stenson. The normal symptoms are the pain and the enlargement of sudden gland during to eat. Of ordinary one there is the function return in most of the patients after the abduction of sialolithiasis.

These localized one in the previous party of driving

Of ordinary the rocks localized previous to the second molar of mandibular more better are removed under the local anesthedsie. These previous remainders to a line joining the surfaces of mesial of second molars are designated as the previous calculations.

The evaluation predopedratoire of previous calculations depends on the history, examination clinic and of the xray simple. Of ordinary a sialogram predopedratoire is not indicated because of the rock possibility is propelled in a more posterior party of the driving by the injection force.

Procedure

One sutures around is passed posterior driving to the rock to prevent his posterior dislodgement during the manipulation after passing one sutures in the mouth floor to try the fabrics in top for the easy passage of sutures it circumductal. Driving easily can be localized while dividing in two equal parties the angle formed by the plica sublingual and the devotion of line of the language.

Sutures it circumductal then is obtained to a haemostat and placed on the adjacent teeth has for result to twist driving. A second one sutures then is placed between the papilla of driving of submandibular and frenum. The light traction applied to these suture will do the fabrics to the surgical stretched site allowing this manner to mucosa easily to be cut.

The incision is done alongside the driving line on the rock. The scalpel should not be deeply dived but should divide only the muqueuse and between just in basic fabrics. Driving then is discovered by blunt dissection and splitting with a goods scissors pointed by conjunctive detached fabric always is conscious veins sublinguales lingually. It then is mobilized. Frequently to this step the calculation is visible by the wall of driving and by a longitudinal incision, it is relaxed. If the it is adhesive to the driving wall, then it slowly is relaxed with a small curette without ampler damaging driving.

Someone suture interrupted to the mouth floor the then injury of end. The incision of Ductal is not sewn up to prevent the formation of a condemnation.

These localized one in the posterior party of driving-

These more better are removed under the general anesthedsie, as few patients will tolerate demanded retraction under the local anesthedsie.

A sufficient obstruction to cause symptoms can arrive in any one of the two manners: - The rock can increase to a such cuts that only a minimal quantity of saliva can be secreted or an infection can regulate in.

If the rock is not visible on a film of central occlusal, this not to be feasible to remove it then by the used method for the rocks antedrieuresment placed and it must be treated as the placed rock has posteriori or a rock of intraglandular. The majority of the posterior rocks can be looked in the film of indirect occlusal has posteriori. This is completed with a jaw lateral indirect film for that his position relating to the mandibule also can be evaluated. Nevertheless the better means to localize his position and his gland statute are by sialography. If it paints a "the appearance of string of sausage" in the sialogram a good chance of restoration exists. When the drivings of intraglandular are more irregular, more crudely more expanded and more formed of the cavities then the abduction of the gland is the better choice.

Procedure

The more better does under the general anesthedsie. The language laterally is retracted. A lachrymal probe is inserted through the orifice of ductal and student to help to localize driving and then mucosa is excised in the region of predmolaire. Driving is identified and is drawn of the before using one sutures passed around him. Driving is followed then posterior and the nerve of lingual identified where it crosses underneath driving. Once the nerve of lingual is identified the then initial incision is enlarged, the nerve of lingual is mobilized latedralment and suture them retraction passed to expose the surgical site.

An assistance pushes then the lower center of the gland towards the top for than the superior center is brought in the view. One sutures then is not mentioned the posterior margin of mylohyoid to retract the dispatches. If the rock is visible, it is delivered through a longitudinal incision. So not driving is opened to the location more probable and explored until resume. Injure then is irrigated; retraction sews up removed and incised driving left open, the fabrics of mucosal then are closed with suture them interrupted.

These localized one in the position of intraglandular of the driving of submandibular-

Here the entire gland is removed. If the rock is a chance finding and is small, asymptomatic and normal sialographically, it can have left for his place and observed for any changes in his location or his gland function. Any change for the worse one indicates the need for the gland excision.

Procedure

A two thumbs incision long convex is done the analogy to skin the pleat, roughly 1.5-2cm to the under inferior border of mandibule.

The incision deepened down below by the superficial cervical fascia, reflected inferiorly, the vein of the previous face identified and divided between tie them. A superior flap of conjunctive fabric is raised then near to the gland surface protecting thus any branches of nerve of the raised face with the flap.

The face artery is found while dissecting and retracting then the lower center of the gland towards the top and before. The posterior stomach of digastric is identified and it with the stylohyoid is retracted down below and of return. The face artery is seen the passage behind the muscle towards the gland. It is squeezed and is divided, then ligated.

Then the previous aspect of the lower center of the gland is reflected towards the top and behind. By the dissection of finger and keep close to the gland, a fabric conjunctive detached cover is maintained on the nerve of hypoglossal that remains average to the gland.

The gland then is pulled descending, exposing the pleat in form of V of conjunctive fabric containing the nerve of lingual and the driving of submandibular. These two structures are dissected then out with care. To this step that the one clearly should be able to delineate three average basic structures to the gland it to know nerve of lingual superiorly, in a manner centralized driving and nerve of hypoglossal inferiorly.

Now only drives it and the deep party of the gland always remain attached. The posterior border of the mylohyoid is retracted and a branch of the ligated of artery sublinguale. Then drives it submandibular is squeezed, is divided and doubles ligated for that only a short stump remains.

Fabrics then are compared the layer, a sewer inserted if necessary and a pressure dressing itself applied.

Parotid sialoliths

• The driving of Stensen is the location of 6-10% of calculations salivaires. Of these 40% is opaque. They are seen to 4 basic locations: -
• Enclosed in the papilla
• In the party under driving muqueuse
• Intraglandularly
• In the party glandulaire additional of external driving to the buccinator.

Those in the party of papilla and driving submucous

The calculations in this location can be relaxed in hilarious the papilla. A blade of a pair of fine scissors pointed splitting are inserted a manner portion in driving and a small denomination is done behind of the orifice. Of ordinary the calculation does to jump immediately that the scissors blade is removed, if the not pressure then light on the gland will do go out of force the calculation with a quantity of saliva. The injury heals quickly.

These external localized extraglandularly to the buccinator ae"

The localized calculations in this region can be approached through an incision in the The aspect in oral of the cheek. The injection of an anesthetic local one with a vaso-constrictive one will reduce bleeding and student also the muqueuse of the surface of buccinator to help in the dissection of soft fabric. One sutures traction is placed previous to the papilla, an u-incision is done by the mucosa, and the triangle containing the papilla and driving then student of the buccinator. Superior flap and lower are mobilized and remain of the suture placed to be anxious them a place where it will not bother you. Dissection is proceeded until the point where driving pierces the buccinator is attained. The superior one and the bottom margins of buccinator dehiscence are identified and suture them traction placed to every margins and retracted to enlarge the dehiscence. Then drives it is traced latedralment and average is retracted in the mouth with one sutures. With these approach calculations in a big portion of driving of Stenson can be removed easily even well outside the musculature of masseter. Once the calculations are localized, the adherence to the fabrics around are divided; the longitudinal incision converted driving and the rock removed. Driving is not sewn up of the but the fabrics around are closed with suture them of absorbable one.

These localized one in the portion of intraglandular of driving-

The rocks localized intraglandularly cannot be attained by one approach intraoral. An incision of type of parotidectomy is recommended. The skin and subcutaneous fabrics are raised deep fascia covering the gland until his previous border is discovered. The then deep fascia horizontally is incised on the presumed portion of driving. The driving to these lies of not at all on a line joining the angle of mouth and nose ala. The branch of oral one of nerve of the face of ordinary lies on his surface and its vessels of the transverse faces remain of ordinary almost 1 HIGHER cm than driving.

Once drives it is identified, it then is climbed back up until the origin of in the gland. The branches of nerve of the face tend to cross immediately superficial to driving and must be preserved. When the section containing the calculations are attained the this is incises longitudinalment and delivered as usual after to pass suture them necessary in front of and behind the rock around the driving to prevent the delay. The gland capsule is closed with the goods catgut and the simple continuous skin incision is come close to the put to bed with an emptiness drainage.

The tumors of glands salivaires

The nedoplasmes salivaires of gland are rare and represents less than 3% of all tumors of region of head and neck. Of these tumors about 75-85% arrival on parotid, 10-20% in the glands salivaires minors, the most ordinarily in the palace (58%), language (10%) and the superior lip (9%).

The gland sublinguale has the highest proportion of cunning one to the benign nedoplasmes. In does 80% of parotid, 65% of submandibular, 50% of minor salivaire and 20% of tumors sublinguales of gland is benign.

The only curative treatment of tumors of gland salivaire is the surgical extirpation. The resection of tumors of gland of parotid is complicated by the presence of nerve of the face in the gland. With the exception of tumors of Warthin, enucleation of tumors of parotid is not counseled. The mixed tumors poorly often are encapsulated of the and the cunning tumors invade often to surround fabric glandulaire, the margins therefore sufficient of fabric salivaire normal must be resected to reduce the chances of local return.

The total resection of gland of submandibular is the favorite treatment for all nedoplasmes of submandibular. The nedoplasmes of gland salivaires minors of palace or of mucosa imply frequently periosteum or the bone and therefore the portions of these must be incluses with the surgical excision.

Parotidectomy with the preservation of nerve of the face

This operation also is called superficial or conservative parotidectomy. Superficial Parotidectomy is used to describe the abduction of the superficial gland to the face nerve. But the superficial and deep parties can be removed as necessary with the preservation of nerve of the face.

After the sufficient preparation of surgical site, a solution of 1 in 200,000 adrenalines of parties in salt marsh is injected under the skin on the previous parotid to the external and close ear against the external auditory medat. Not more than 10ML is injected.

The incision begins in the forehead above and previous to the house and brought down and of return to liberate margins of tragus, follows it and under his cover is carried a light bend on the mastoa¯de to join a pleat of convenient skin pass down below and dispatches in the neck behind the mandibule.

The incision in the neck pleat first is deepened, dividing the platysma until the deep fascia is attained. The big nerve little finger then is identified as it crosses the posterior border of sternomastoid to remain in the injury almost 1 cm to the under and 1 cm in front of lobs it ear, immediately to the under deep fascia, diverging on the gland surface. The nerve with the branches is wrinkled under the lower edge of the injury to keep it humid.

The once deep fascia is identified the injury remainder are deepened to this level and to the skin reflected of the before of him. Often one or the branches more of the face will be identifiables by the deep fascia translucide as they emerging of the previous border of the gland. They are discovered while opening the fascia, every branch is identified, edtiqueted by under to run it with silk and the black ends of him are squeezed in the forceps of artery of mosquito.

The principal trunk of the lie of nerve of the ampler face at the far end of the heart in the angle between the canal more auditory, more external and bonier and the previous surface of process of mastoa¯de. It is found while separating lowers the center of gland of the previous border of sternomastoid and mastoa¯de treats and the cartilaginous party of external auditory medat. Parotid is retracted of the before as dissection proceeds and the nerve is identified as it emerges in the angle between the bone of tympanic and the previous border of the process of mastoa¯de and superior just to the superior border of the posterior stomach of the digastric. The branch of stylomastoid of passes of artery little fingers superficial posterior to the nerve to enter the foramen of stylomastoid and the gnarled instrumentation can tear this small vessel causes the hemorrhage.

Since the nerve of the face and its branches are invested by fabric and the conjunctive lies detached in the tunnels in the parotid, they are liberated while introducing the point of the blades of a forceps of artery of bent mosquito and opening it after that a short length of the rug of substance of gland is cut by with the scissors to expose the gland.

The nerve trunk travels latedralment in the parotid, passing around the posterior border of mandibule and just to the under neck of the condyle before it splits in a superior temporofacial and the division of cervicofascial. Generally it this is more better to follow the first lower division and track connects it cervical or at least marginal mandibular earlier to a point in front of the parotid, therefore the lower center is after mobilizing that progresses towards the top the branch by the branch, the amplest mobilization is attained. These branches that pass in the tumor must be divided and it not at all to which they emerging identified and divided and the two ends are edtiquetedes for the subsequent repair.

Connect the branches joining two peripheral branches vertically should be preserved if possible. In the pass general superficial nerves to the vein of retromandibular; the prudent mobilization of nerve and the vein with the division and the ligation of the last one is necessary. The small veins are sealed by diathermy.

For pleomorphic adenomas a margin of a half cm of apparently normal fabric around should be removed tangible mass as the tumor is lobulated and certain of these lobules could have left behind if dissection passes also closely. The tumors of inferior quality of mucoepidermoid or the tumors of cell of acinic should be removed with one a little bigger more uniform margin.

Once the tumor is removed, the injury liberal is rinsed with salt marsh and haemostasis verified. The branches of nerve of the face could be repaired with transplants if necessary of the big nerve little finger. An emptiness sewer is passed then out by the skin to the under ear; the injury is come close to the put to bed and lights pressure dressing itself applied.

Total Parotidectomy

This is indicated when: -

• One to grow slow not mass from the standpoint cunning clinic is present in the deeper parties
• When a small nedoplasme is recognized from the standpoint clinic as cunning and obtain the necessary margin, the abduction of entire gland is planned.
• The big tumor in the deep party to present gland of parotid as a growth of the soft palace (often the halta¨re in the form with to remain isthmus in the gap between the process of styloid and the back of mandibule).

Procedure

A flap of skin student in the normal manner, but the incision in the pleat of skin of neck is continued the before also moved away as the first region of molar. The face nerve out is dissected; periosteum then is divided to the lower border of angle of mandibule and to masseter student of the bone. A similar vertical cut to this used one for vertical under sigmoid osteotomy is just does behind the foramen of mandibular, average pterygoid then is liberated posterior fragment, that then is moved of the before, lateral to the previous fragment. This opens the interval between the process of styloid and the mandibule.

Lower the center then is mobilized and digastric and sytlohyoid followed by return to their origins, the before divided and turned. External carotid Emerger above the muscles is identified and is divided and ligated.

To this step mouth is discovered and entered. An adrenaline solution 1:200,000 in salt marsh is injected in the soft palace on the growth and a vertical incision, circonscrisant the scar of preceding biopsy is done. The edges are mined leaving a thin layer of muscle and conjunctive fabric on the tumor. The mass is liberated the functioning by the two injuries. The big care is above exercised and notably behind the lesion for the fear to damage the internal jugular vein or the carotid internal artery, the two remainders deeply to the process of styloid.

The following abduction, the injury is irrigated; oral fabrics are closed with the catgut chromique. The fragments of mandibular are telegraphed then together. The injury of Preauricular is come close to the put to bed and the drainage established.

Parotidomandibulectomy

This is indicated when there is the invasion of mandibule by a cunning nedoplasme.

Procedure: -

After the preparation of surgical site, a skin flap is according student to the excision of a benign nedoplasme on the part deep of parotid. The gland is mobilized then posterior and inferiorly and the principal trunk of nerve of the identified face. As much of branches out are dissected as possible, sometimes the sacrifice of the entire nerve can be necessary.

Next the capsule of TMJ is opened, and the condyle mobilized. Masseter is separated arch and zygomatic mandibule is divided in the third region of molar. Ramus of Parotid and mandibular is looked into and forward and separated process of styloid and its devotion muscles. The then ampler elevation of the ramus is possible after than the origin of the muscle of average pterygoid of the tuberosity is touched and is separated. Before this is did the external carotid one is identified where it emerges from behind the stylohyoid and between the deep party of the gland. The it is first ligated and transected to prevent the painful hemorrhage of the artery jawbone as the average pterygoid is divided.

The strong descending traction will allow now the separation of the insert of temporalis in the coronoid and lateral pterygoid to the condyle. As hemostasis is completed the artery jawbone is looked for and ligated. The face nerve is repaired using the big nerve little finger as transplant. A bone transplant then can be placed unless a course postopedratoire of radiotherapy is to be employed. Where a transplant of bone does not replace ramus, the patient will have left with a deep depression in front of the ear, but this can be covered by a suitable hairstyle. There will be a tendency for the mandibule to balance itself towards the affected side and therefore early training is necessary to overcome this problem.

If the condyle is invaded, the pit and then articular eminentia also can be removed. The process of Styloid and the muscles also can be excised to increase the margins, but should be done after the resection of the principal mass.

Temporoparotidectomy

The resection to small ladder of external auditory canal could be incluse with the excision of pinna and cover the skin of parotid when these structures are implied. The process of mastoa¯de also can be detached without the a lot of difficulties, exploring thus the trunk of the face to do sews up and the nerve transplant easy.

The extension of a nedoplasme of parotid of return in the bone is therefore willing to the excision of gland of parotid, to mandibular ramus and to TMJ together with the temporal bone. Nevertheless the operation carries the top risks for the need to divide the dense bone and the separates internal carotid artery, the jugular internal vein and sigmoid, the superior and the sinus of inferior petrosal. The sufficient cover needs to be provided at the pachymedninge as the injury is closed. The nerve of hypoglossal is mobilized and is dissected to the peripheral branches of nerve of the face at the end of the operation.

Parotidectomy in to continue with neck dissection

A radial dissection of neck should be executed where the cervical lymphatic ganglions are implied or where there is a mass to the lower center of parotid because of an aggressive tumor of a lot of size than the invasion of cervical superior knots cannot be excluded. The consideration should be given to radiance predopedratoire of the neck to a dose of 400-500 rads.

The excision of Extracapsular of submandibular the gland salivaire

There is a big incidence of return for the gland of submandibular that for the parotid after the excision to grow the slow nedoplasme as pleomorphic adenomas.

The gland together is removed with his fascia investing, that is separated previous and posterior stomachs of muscle of digastric and stylohyoid. The nerve of hypoglossal is identified and is preserved. The face artery is identified where it emerges from under the cover of the stylohyoid and again on the lateral surface of the mandibule. The marginal nerve of mandibular is isolated and is preserved and then the fascia divided to the lower border of the mandibule. The gland is liberated muscle of mylohyoid earlier and the angular range of fascia posterior.

If the nerve of lingual is implied in the tumor mass then it is divided in front of and behind the ends of gland and cut sewed up. If a bigger margin of fabric than the immediate capsule is necessary latedralment then the periosteum of the mandibule is divided to the lower border and stripped at the top of the pit of submandibular. Driving near is divided behind the papilla and the injury came close to the put to bed with the drainage in the normal manner.

The radical excision of nedoplasmes of gland submandibular/sublingual

The excision of nedoplasmes invasifs frankly cunning of submandibular or the gland salivaire sublinguale will include the language on this side, this floor of the mouth and the mandibule together with a dissection of radical neck of tangible so present knots.

The excision of pleomorphic adenomas palatal

The small cause of adenomas of palatal pleomorphic only resorption of pressure of palace and invades rarely the bone. The incision is deepened to bone and the specimen reflected hard palace with the periosteum. The nedoplasme sits frequently on the biggest foramen of Palatine and the periosteum here is liberated until the lesion can be drawn down below and the package of neurovascular is squeezed, is divided and is coagulated with diathermy before it is