Sjögren's syndrome and sialoses

Classification and etiology of tumor-like lesions

Salivary gland cysts are clinically classified as tumor-like lesions. Depending on their localization, cysts of the minor glands, sublingual gland (ranula), submandibular, and parotid salivary glands are distinguished.

According to their origin, they are divided into two main groups:

1. Retention cysts. Occur due to impaired duct patency, most commonly against the background of glandular trauma and subsequent inflammation. Pathogenesis involves the proliferation of interlobular connective tissue, leading to the obliteration of excretory pathways. This is followed by atrophy and mucous degeneration of the parenchyma. Important to understand: if only isolated duct obturation occurs without concomitant factors, it leads to atrophy of the glandular tissues rather than the formation of a cystic cavity.
2. Congenital cysts. Are the consequence of dysontogenetic disorders of the parenchymal tissue. They form from duct diverticula (classified as congenital conditions) or from aberrant (ectopic) areas of glandular tissue.

Cysts of the minor salivary glands

This pathology is most frequently localized on the lower lip (in areas most susceptible to biting and trauma), though in rare cases it can occur on the upper lip, cheeks, hard and soft palate.

Clinical presentation: Patients often associate the onset of the lesion with a prior trauma. Physical examination reveals a rounded lesion with a soft-elastic consistency. When reaching a significant size, the thinned mucosal membrane gives the cyst a characteristic bluish tint. The thin capsule contains a viscous yellowish fluid. The lesion grows gradually, causing discomfort during eating and speaking. A characteristic feature of its course is periodic spontaneous rupture: after the wall ruptures, the viscous content escapes, the cyst temporarily collapses and disappears, but then inevitably recurs.

Surgical treatment: Treatment is exclusively surgical. The cyst is completely excised using two semi-oval converging incisions. Dissection requires extreme caution as the thin capsule easily ruptures. To prevent recurrences, it is mandatory to remove all hypertrophied lobules of the minor salivary glands remaining in the surgical wound.

Cyst of the sublingual salivary gland (ranula)

A ranula develops from a lobule of the sublingual gland and, when large, bulges the mucous membrane of the floor of the oral cavity, visually resembling a frog's pouch.

Symptomatology and diagnostics:

• Intraorally: a hemispherical bulge of soft tissues of a bluish-pink color, of soft-elastic consistency.
• Extraorally: usually no changes. However, if the ranula extends through the cleft in the mylohyoid muscle (m. mylohyoideus), a swelling is palpated in the submental and submandibular regions.
• Puncture: yields a viscous mucous fluid ranging from light to dark brown.

The surgical anatomy of a ranula is complex: its thin connective tissue capsule penetrates in bundles into the interstices of the glandular lobules, which greatly complicates dissection.

Treatment methods: Periodic aspiration of contents is ineffective. The following approaches are used:

• Plastic cystotomy (marsupialization): excision of the upper wall followed by suturing of the cyst lining to the mucous membrane of the sublingual region. The cavity is tamponed with iodoform gauze or covered with a non-hygroscopic silicone membrane.
• Radical method: removal of the ranula en bloc with the sublingual gland (yields the best results).
• Two-stage operation: used for an extensive ranula. First, the outer part superficial to m. mylohyoideus is removed, followed by plastic cystotomy.

Cysts of the major glands and differential diagnosis

Cysts of the parotid and submandibular glands are rare. These are formations with a thin fibrous capsule fused with the parenchyma.

Clinic: A slowly growing, painless swelling capable of causing facial asymmetry. The skin color is unchanged and can be pinched into a fold. Palpation reveals a positive fluctuation sign. The punctate is a turbid, viscous fluid (sometimes with mucus); after puncture, the cyst temporarily disappears. Sialography shows a filling defect and displacement of the ducts.

Surgical treatment:

• Parotid gland: removal of the cyst along with the adjacent parenchymal tissue.
• Submandibular gland: total extirpation (removal along with the gland).

Differential diagnosis of salivary gland diseases also takes into account forms of chronic sialadenitis (sialadenitis chronica): parenchymatous (often debuting at a certain age), ductal, and interstitial. Sialadenosis (sialadenosis) is differentiated by etiology, as it develops due to underlying systemic diseases.

Duct reconstruction and fistula treatment

Specialized reconstructive interventions are used for injuries, complete fistulas, or strictures of the excretory ducts.

Plastic reconstruction of the parotid duct (ductus parotideus) according to G.A. Vasiliev:

1. Mobilization: mobilization of the damaged area.
2. Flap formation: a tongue-shaped flap is carved out of the buccal mucosa (base facing anteriorly).
3. Passing the flap: the flap is passed through a vertical incision, oriented by the anterior border of the masseter muscle (m. masseter).
4. Anastomosis: the flap is sutured to the isolated duct to ensure saliva outflow, after which the wound is closed.

Alternative tactics:

• Fistula excision: radical removal of the fistulous tract en bloc with the anatomically related glandular lobule.
• Restoration of continuity: suturing the ends of the duct over a pre-inserted Teflon tube.
• For strictures (narrowing): the method of choice is bougienage with salivary probes. If ineffective, surgical elimination of the narrowing is indicated.

What else to study on this topic

• Methodology of sialometry and evaluation of glandular functional activity
• Differential diagnosis of chronic sialadenitis forms (parenchymatous, ductal, interstitial)
• Technique of salivary duct bougienage for strictures
• Features of sialography in major salivary gland cysts

Other topics in the section "Chapter 10. Diseases and injuries of the salivary glands (V.V. Afanasiev)"

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