AHNS series: Do you know your guidelines? Diagnosis and management of salivary gland tumors

This article is the next installment of the series "Do you know your guidelines" presented by the Education Committee of the American Head and Neck Society. Guidelines for the workup and management of tumors of the major and minor salivary glands are reviewed.

Effect of laterality, gender, age and body mass index on the fat fraction of salivary glands in healthy volunteers: assessed using iterative decomposition of water and fat with echo asymmetry and least-squares estimation method

OBJECTIVES:

To evaluate the effect of laterality, gender, age and body mass index (BMI) on fat fraction (FF) measurements of both parotid glands (PGs) and submandibular glands (SMGs) by using: Iterative decomposition of water and fat with echo asymmetry and least-squares estimation method (IDEAL-IQ).

METHODS:

A total of 87 healthy participants were enrolled in our study. IDEAL-IQ image was scanned using a 3.0 T scanner. Paired t test was performed to compare the difference on FF of both PGs and SMGs between left and right side. The FF of two glands between male and female healthy participants were compared using an unpaired t-test. The correlation between the FF of two glands and participant age or BMI were analyzed by Pearson's correlation.

RESULTS:

Excellent inter- and intrareader agreements were obtained during the measurements of FF by IDEAL-IQ method (ICC, 0.952-0.981). FF values correlated positively with the age and BMI in both left and right PGs and SMGs (p < 0.05). No significant difference was found on FF between left and right PGs and SMGs (p > 0.05). There was also no difference on FF between male and female healthy participants (p > 0.05).

CONCLUSIONS:

FFs of PGs and SMGs were age- and BMI- dependent, but not laterality- and gender-dependent. The effect of age and BMI need to be considered in further studies using Ideal-IQ technology to evaluate FFs of salivary gland diseases.

Localized Delivery of Amifostine Enhances Salivary Gland Radioprotection

Radiotherapy for head and neck cancers commonly causes damage to salivary gland tissue, resulting in xerostomia (dry mouth) and numerous adverse medical and quality-of-life issues. Amifostine is the only Food and Drug Administration-approved radioprotective drug used clinically to prevent xerostomia. However, systemic administration of amifostine is limited by severe side effects, including rapid decrease in blood pressure (hypotension), nausea, and a narrow therapeutic window. In this study, we demonstrate that retroductal delivery of amifostine and its active metabolite, WR-1065, to murine submandibular glands prior to a single radiation dose of 15 Gy maintained gland function and significantly increased acinar cell survival. Furthermore, in vivo stimulated saliva secretion was maintained in retrograde-treated groups at levels significantly higher than irradiated-only and systemically treated groups. In contrast to intravenous injections, retroductal delivery of WR-1065 or amifostine significantly attenuated hypotension. We conclude that localized delivery to salivary glands markedly improves radioprotection at the cellular level, as well as mitigates the adverse side effects associated with systemic administration. These results support the further development of a localized delivery system that would be compatible with the fractionated dose regimen used clinically.

An experimental chronic obstructive sialadenitis model by partial ligation of the submandibular duct characterised by sialography, histology, and transmission electron microscopy

Extensive investigation into the mechanism of chronic obstructive sialadenitis (COS) calls for a reliable model that mimics the onset and progression of the disease. Duct obstruction is closely correlated with COS, and partial duct obstruction is usually observed in COS. Partial ligation of ducts or vessels is a valid treatment to mimic pathological processes in certain animal studies. In this study, we developed a novel animal model of COS by incomplete ligation of Wharton's duct and clarified the corresponding morphological alterations in the submandibular gland. Partial ligation of Wharton's duct in Japanese white rabbits resulted in a gradually progressive COS model as demonstrated by sialographic, gross, microscopic, and ultrastructural changes in acinar and ductal degenerations over 8 weeks. The model is a feasible option for investigating the pathogenesis of COS and evaluating the efficacy and safety of novel treatments of COS.

Botulinum toxin A treatment of epiphora secondary to autologous submandibular gland transplantation

The aim of this study was to explore whether botulinum toxin A (BTXA) injection treats epiphora secondary to submandibular gland (SMG) transplantation for severe keratoconjunctivitis sicca. Fifteen patients with epiphora after SMG transplantation were separated to three groups, and received 15U, 20U and 25U BTXA injection in the transplanted SMG, respectively. Secretion of transplanted SMG was assessed subjectively by visual analogue scale (VAS) regarding epiphora, and objectively by Schirmer test. There were no significant differences in the 15-U BTXA group regarding the values of the VAS on epihora before and 1 month after BTXA injection. While in 20-U group and 25-U group, the values of VAS on epihora decreased significantly after BTXA injection, and lasted for 6months. Under resting conditions, the secretion of transplanted SMG decreased 64.4%, 73.0% and 78.0% in 15-U, 20-U and 25-U groups, respectively (P<0.01), in 1month after BTXA injection; significant secretion decreasing lasted 3months only in the 25-U BTXA group. BTXA injection can decrease the secretion of transplanted SMG significantly, relieving the symptoms of epiphora; 25U BTXA is a suitable dose to treat 'opportunistic epiphora' after SMG transplantation.

Determinants of level Ib involvement in oral squamous cell carcinoma and implications for submandibular gland-sparing neck dissection

Traditional neck dissection for oral squamous cell carcinoma (OSCC) involves removal of the submandibular salivary gland. Several studies have cited the low incidence of direct gland invasion by tumours and have recommended gland-sparing neck dissection. In this study, a detailed audit of level Ib involvement in OSCC was performed in order to assess the feasibility of submandibular gland-sparing in neck dissection; the rate of direct involvement by the primary tumours, the involvement of periglandular level Ib nodes, and their determinants were investigated. A total of 586 neck dissection specimens obtained between 2005 and 2014 from patients operated on at the study institution for floor of mouth, tongue, and buccal primaries, were evaluated for direct invasion of the gland and periglandular lymphadenopathy. Of 226 node-positive patients, 21 (9.3%) had direct gland invasion by tumour. Risk factors were tumour diameter >4cm (P=0.002) and depth of invasion >10mm (P=0.003). Determinants of periglandular lymphadenopathy were depth of invasion >10mm (P<0.001), perineural invasion (P=0.02), lymphovascular invasion (P=0.014), and moderate/poor differentiation (P<0.0001). Gland-sparing neck dissection is safe in early tumours (pT1pN0-1), with a good chance of minimizing xerostomia without radiotherapy. Larger tumours without clear evidence of submandibular gland invasion or suspicious level Ib lymphadenopathy may be considered for gland preservation, however the oncological safety is unclear.

Aquaporin 5 is degraded by autophagy in diabetic submandibular gland

Autophagy is a catabolic process which is involved in the development of many diseases including diabetes mellitus and its complications. Hyposalivation is a common complication of diabetes mellitus, whereas its mechanism remains unclear. Here, we observed that the stimulated salivary flow rate of SMG was significantly decreased in db/db mice, a diabetic mice model. The expressions of aquaporin 5 (AQP5), a water channel protein, were decreased, whereas the mRNA level of AQP5 was increased in SMGs of both diabetic patients and mice. Under transmission electron microcope, more autophagosomes were detected in diabetic SMGs. Expressions of autophagy related proteins LC3II, Beclin-1 and ATG5 were increased, meanwhile autophagy substrate p62 was decreased in SMGs of diabetic patients and mice, indicating that autophagy was activated in diabetic SMG. Double immunofluorescence staining showed that the colocalization of AQP5 and LC3 was increased in SMGs of diabetic mice. In cultured SMG-C6 cells, high glucose (HG), but not high osmotic pressure, reduced AQP5 protein expression and induced autophagy. Moreover, inhibition of autophagy by 3-methyladenin, an autophagy inhibitor, or by autophagy-related gene 5 siRNA, decreased HG-induced AQP5 reduction in SMG-C6 cells. Additionally, the expression of p-p85, p-Akt and p-mTOR were decreased in HG-treated SMG-C6 cells. Pretreatment with 740Y-P, a PI3K agonist, significantly suppressed HG-induced autophagy and AQP5 degradation. Taken together, these results indicate that autophagy plays a crucial role in AQP5 degradation in diabetic SMG via PI3K/Akt/mTOR signaling pathway, which contributes to the dysfunction of diabetic SMG. Our study provides a novel mechanism of diabetic hyposalivation.

The Effectiveness of Botulinum Toxin Type A Injections in the Management of Sialorrhea

OBJECTIVE

The aim of this study was to evaluate the effect of Botulinum toxin type A by injecting in the submandibular and parotid glands on the frequency and severity of sialorrhea.

METHODS

Pediatric patients who were referred to our department with sialorrhea were evaluated using their parents' frequency and severity scores of sialorrhea with visual analog scales before and after 3 months of botulinum toxin type A injections. Bilateral submandibular and parotid glands were injected with Botulinum toxin type A.

RESULTS

Twenty-seven pediatric patients who were referred to our department with a complaint of sialorrhea were included in this study. Seventeen patients were female and 10 were male. Severe sialorrhea with cerebral palsy was present in all the patients. There were no complications after the procedure.

CONCLUSION

Botulinum toxin A injected in the major salivary glands in pediatric patients with neurological disorders is a safe and effective method.

Pediatric Salivary Cancer: Epidemiology, Treatment Trends, and Association of Treatment Modality with Survival

Objective To characterize the epidemiology of pediatric salivary cancer and associate patient, tumor, and treatment factors with treatment modality and survival. Study Design Cross-sectional analysis. Setting US national database. Subjects and Methods We identified 588 patients 19 years or younger diagnosed with salivary cancer in the National Cancer Database 2004-2013. We characterized patient, tumor, and treatment factors as proportions and associated these factors with treatment modality and overall survival via multivariable logistic regression and multivariable Cox proportional hazards regression, respectively. Results In total, 588 patients were included. Mucoepidermoid carcinoma was identified in 234 of 588 patients (40%) and acinar cell carcinoma in 215 of 588 (37%). Parotid tumors were seen in 504 (86%) of patients. Surgery alone was used to treat 351 (60%) of patients; surgery plus adjuvant radiation was used to treat 145 (25%). Overall 5-year survival was 93%. Controlling for patient and tumor characteristics, treatment with surgery and radiation vs surgery alone was associated with improved overall survival (hazard ratio [HR] = 0.15; 95% confidence interval [CI], 0.02-0.92; P = .041). High tumor grade was associated with decreased overall survival (HR = 33.17; 95% CI, 5.89-186.8; P < .001). Treatment with surgery plus radiation remained associated with improved overall survival in the subset of patients with high tumor grade (HR = 0.12; 95% CI, 0.02-0.64; P = .014). Conclusion Tumor grade is an important predictor of survival in pediatric patients with salivary gland cancer. Surgery plus adjuvant radiation vs surgery alone is associated with improved overall survival and may be considered for high-risk patients, particularly those with high-grade tumors.

The biphasic effect of extracellular glucose concentration on carbachol-induced fluid secretion from mouse submandibular glands

Cholinergic agonists evoke elevations of the cytoplasmic free-calcium concentration ([Ca²⁺ ]_i ) to stimulate fluid secretion in salivary glands. Salivary flow rates are significantly reduced in diabetic patients. However, it remains elusive how salivary secretion is impaired in diabetes. Here, we used an ex vivo submandibular gland perfusion technique to characterize the dependency of salivary flow rates on extracellular glucose concentration and activities of glucose transporters expressed in the glands. The cholinergic agonist carbachol (CCh) induced sustained fluid secretion, the rates of which were modulated by the extracellular glucose concentration in a biphasic manner. Both lowering the extracellular glucose concentration to less than 2.5 mM and elevating it to higher than 5 mM resulted in decreased CCh-induced fluid secretion. The CCh-induced salivary flow was suppressed by phlorizin, an inhibitor of the sodium-glucose cotransporter 1 (SGLT1) located basolaterally in submandibular acinar cells, which is altered at the protein expression level in diabetic animal models. Our data suggest that SGLT1-mediated glucose uptake in acinar cells is required to maintain the fluid secretion by sustaining Cl^- secretion in real-time. High extracellular glucose levels may suppress the CCh-induced secretion of salivary fluid by altering the activities of ion channels and transporters downstream of [Ca²⁺ ]_i signals.

Percutaneous Salivary Gland Ablation using Ethanol in a Rat Model

Objectives

Sialorrhea is a common health and psychosocial problem for children with neuromuscular dysfunction secondary to a variety of disorders such as cerebral palsy. Current accepted treatments include the injection of botulinum toxin into the submandibular glands for temporary symptom relief. The purpose of this study is to demonstrate the feasibility of percutaneous ethanol injection for longer lasting salivary gland ablation in an animal model.

Material and Methods

Twenty rats were used in this study. In each rat, 98% ethanol was injected into the right submandibular gland under ultrasound guidance. No intervention was performed on the left gland, which served as the control. Ten rats were sacrificed and glands evaluated at three weeks, with the remaining 10 rats sacrificed and evaluated at three months. Unpaired, 1-tailed T-tests were used to analyse the data.

Results

Ethanol injections induced a significant and sustained reduction in salivary gland size. Treated glands were 41% smaller by mass than untreated controls in the 10 rats sacrificed at three weeks (P < 0.001). Treated glands were 43% smaller by mass than untreated controls in the 10 rats sacrificed at three months (P < 0.001). Qualitative histologic analysis demonstrated extensive parenchymal damage, inflammation, and fibrosis at both three week and three month time points.

Conclusions

Using a rat model, we demonstrated dramatic and sustained submandibular gland damage after percutaneous injection of ethanol.

Marked Differences in the Submandibular Salivary Proteome between Sardinian Alcohol-Preferring and Sardinian Alcohol-Non Preferring Rats Revealed by an Integrated Top-Down-Bottom-Up Proteomic Platform

Sardinian alcohol-preferring (sP) and Sardinian alcohol-non preferring (sNP) rats have been selectively bred for opposite alcohol preference and consumption. Aiming to verify possible differences at the proteomics level between sP and sNP rats, we investigated the salivary proteome by a a liquid chromatography-mass spectrometry top-down-bottom-up integrated approach. For this purpose, submandibular saliva was collected from alcohol-naive sP and sNP rats under isoprenaline stimulation. A total of 200 peptides and proteins were detected and quantified in the two rat lines, 149 of which were characterized in their naturally occurring structure. The data are available via ProteomeXchange with identifier PXD006997. Surprisingly, sP rats exhibited marked quantitative and qualitative differences with respect to sNP rats, namely higher levels of proteoforms originating from submandibular gland protein C, and from submandibular rat protein 2, as well as those of several unidentified peptides and proteins. sP rats expressed some proteins not detectable in sNP rats such as the glutamine and glutamic acid-rich protein (GRP)-CB. The isoform GRP-B, detectable in both rat lines, was more abundant in sNP rats. The submandibular saliva of sNP rats was also characterized by very high levels of GRP-B proteolytic peptides and rat salivary protein 1. Whether these differences could contribute to the opposite alcohol preference and consumption of sP and sNP rats is currently unknown and requires further investigation.

[Pitfalls in diagnostic and treatment of salivary glands disorders]

The paper presents a clinical case demonstrating difficulties in differential diagnosis of salivary glands disorders. The patient underwent several surgical procedures none of which was indicated. The article summarizes the reasons for diagnostic pitfalls of the case.

Daily voluntary exercise enhances pilocarpine-induced saliva secretion and aquaporin 1 expression in rat submandibular glands

Saliva—a water‐based fluid containing electrolytes, immunoglobulins, and enzymes—has many functions, including the protection and hydration of mucosal structures within the oral cavity and the initiation of digestion. Aquaporins (AQPs) are proteins that act as water channels through membranes. We have previously reported upregulation of the expression levels of AQP 1 and 5 in the submandibular glands (SMGs) in heat‐acclimated rats. In this study, we investigated pilocarpine‐induced saliva secretion and AQP expression in rats after voluntary exercise. Male, 10‐week‐old Wistar rats were initially maintained at an ambient temperature of 24 °C for 10 days and were then kept for 40 days in cages either with a running wheel (exercise rats, n = 6) or with a locked wheel [control rats (CN), n = 6]. After the training period, the rats were anesthetized and pilocarpine, an M3 muscarinic receptor agonist, was intraperitoneally injected (0.5 mg·kg⁻¹) to stimulate saliva secretion. Saliva was collected, and the SMGs were sampled and subjected to western blot, RT‐PCR, and immunohistochemical analyses. Pilocarpine induced a greater amount of saliva in the exercised rats than in the CN. Expression levels of AQP1 mRNA and protein were significantly higher in SMGs of exercised rats than in those of the CN, but the expression of AQP5 was not affected by voluntary exercise. Voluntary exercise increased the expression of vascular endothelial growth factor (VEGF) and cluster of differentiation 31 (CD31), a marker for endothelial cells, in the SMGs. Voluntary exercise promoted pilocarpine‐induced saliva secretion, probably via an increase in the expression level of AQP1 due to VEGF‐induced CD31‐positive angiogenesis in the SMG.

"Ancient" schwannoma of the submandibular gland: A case report and literature review

RATIONALE

Schwannomas are solitary neurogenic tumors that arise from cells of the neural sheath. Ancient schwannoma is a relatively rare variant of schwannoma, characterized by increased cellularity and atypia. These cellular changes could be confusing and make the accurate pathologic diagnosis difficult.

PATIENT CONCERNS AND DIAGNOSES

A 36-year-old man presented with painless swelling in left submandibular region for more than 2 years. The computed tomography confirmed a well-defined cystic lesion in the left submandibular space, which caused superior and posterior displacement of the left submandibular gland. Surgical excision was performed and the pathology confirmed the diagnosis of ancient schwannoma. To our knowledge, this patient is the second case of primary submandibular ancient schwannoma reported in the literatures.

INTERVENTIONS AND OUTCOMES

The patient underwent tumor resection and postoperative recovery was uneventful. There were no nerve deficits after the operation. There was no recurrence within 1 year of follow-up.

LESSONS

Schwannoma originated from the submandibular gland is extremely rare and only a few cases have been reported. Ancient schwannoma is an even more rare tumor. The increased cellularity and atypia of ancient schwannoma can resemble features of malignancy. Great care must be taken to make differential diagnosis with fibrosarcomas and malignant schwannoma.

Expression of Ror2 Associated with Fibrosis of the Submandibular Gland

The submandibular gland (SMG) is one of the major salivary glands that play important roles for variety of physiological functions, such as digestion of foods, prevention of infection, and lubrication of the mouth. Dysfunction of the SMG, often associated with a salivary inflammation, adversely influences a person's quality of life. However, the mechanism underlying inflammation-driven dysfunction of the SMG is largely unknown. Here, we used a mouse model in which the main excretory duct of the SMG is ligated unilaterally to induce inflammation of the gland and examined the expression of Wnt5a, Ror1 and Ror2 genes, encoding Wnt5a ligand and its cognate receptors, which have been implicated in tissue damage or inflammatory responses in variety of tissues. We show that expression levels of Ror1, Ror2, and Wnt5a are increased in the ligated SMG undergoing interstitial fibrosis, which is accompanied by robust expression of fibrosis-associated genes, such as TGF-β1, TNF-α, IL-1β, and MMP-2. Increased immunostaining signal of Ror2 was detected in the fibrotic tissues with abundant accumulation of fibroblasts and collagen fibers in the ligated SMG, suggesting that Ror2-mediated signaling might be activated in response to tissue damage and associated with progression of fibrosis in the SMG.Key words: submandibular gland, Ror2, Wnt5a, fibrosis, inflammation.

Long-term oncologic and functional outcome in pleomorphic adenomas of the submandibular gland

Objectives

The aim of the study was to evaluate the oncologic and functional long‐term outcome after surgical therapy of pleomorphic adenomas of the submandibular gland.

Methods

The medical charts of all patients treated for pleomorphic adenomas of the submandibular gland by means of submandibulectomy between 2000 and 2016 were studied retrospectively. Patients who had had revision after external primary surgery, as well as patients with insufficient data were excluded from our study sample.

Results

A total of 75 patients formed our study sample (28 men, 47 women, male:female ratio 0.59:1). Their mean age was 48 years (14–78 years). Mean follow‐up was 82 months (12–170 months). No recurrences of a pleomorphic adenoma could be detected in our study cases. Normal facial nerve function (House‐Brackmann grade I) in the direct postoperative phase was shown in 54/75 cases (72%). In the remaining 21/75 cases (28%), mild paresis of the marginal mandibular branch of the facial nerve (House‐Brackmann II) could be detected in the direct postoperative phase. All cases with facial palsy had recovered with normal facial nerve function (House‐Brackmann I) in 3–6 months.

Conclusion

Our study was able to show oncologic and consistently acceptable oncologic and functional outcomes after submandibulectomy for pleomorphic adenomas of the submandibular gland.

Level of Evidence

4.

Fine-needle aspiration cytology of cysticercosis in submandibular gland

Fine-needle aspiration cytology (FNAC) has emerged as simple, minimally invasive, low-cost, outpatient diagnostic modality for the evaluation of nodules caused by parasites. Cysticercosis is caused by larval stage of Taenia solium, pork tapeworm. It is endemic in Southeast Asia, Latin America and South Africa. We report a case of cysticercosis in a 25-year-old male who presented with painless swelling of submandibular gland which was diagnosed on FNAC. The patient was recommended antihelminthic therapy which resulted in complete resolution of the swelling.

Changes in the Submandibular Gland in Patients with Head and Neck Cancer After Radiation Therapy: A Preliminary Study

AIM

The purpose of this study was to assess the impairment of the submandibular gland, in terms of changes in volume by computed tomography (CT) and CT value, which was the mean pixel value at a region of interest, in a group of patients with head and neck cancer treated with radiation therapy (RT).

PATIENTS AND METHODS

Eleven patients treated with RT, where the effective radiation dose to the submandibular gland was known, were included in the study. CT scanning was performed both before and after RT. The average follow-up period after RT was 555 days (range=107-1231 days).

RESULTS

The mean volume of the submandibular gland decreased by around 38% (p<0.001) compared to the pre-treatment average until 600 days after RT. The mean CT value of the submandibular gland decreased until 200 days after RT (p<0.05).

CONCLUSION

Both volume and CT value of the submandibular gland showed signs of impairment of the gland during the first several months after RT for head and neck cancer.

Two Phase Modulation of [Formula: see text] Entry and Cl-/[Formula: see text] Exchanger in Submandibular Glands Cells by Dexmedetomidine

Dexmedetomidine (Dex), a highly selective α2-adrenoceptor agonist, attenuates inflammatory responses induced by lipopolysaccharide (LPS) and induces sedative and analgesic effects. Administration of Dex also reduces salivary secretion in human subjects and inhibits osmotic water permeability in rat cortical collecting ducts. However, little is known about the mechanisms underlying the effects of Dex on salivary glands fluid secretion. We demonstrated the α2-adrenoceptor expression in the basolateral membrane of mouse submandibular glands (SMG). To investigate fluid secretion upon treatment with Dex, we studied the effects of Dex on the activity of Na+-K+-2Cl- cotransporter1 (NKCC1) and Cl-/[Formula: see text] exchange (CBE), and on downstream pro-inflammatory cytokine expression in isolated primary mouse SMG cells. Dex acutely increased CBE activity and NKCC1-mediated and independent [Formula: see text] entry in SMG duct cells, and enhanced ductal fluid secretion in a sealed duct system. Dex showed differential effects on cholinergic/adrenergic stimulations and inflammatory mediators, histamine, and LPS, stimulations-induced Ca2+ in mouse SMG cells. Both, histamine- and LPS-induced intracellular Ca2+ increases were inhibited by Dex, whereas carbachol-stimulated Ca2+ signals were not. Long-lasting (2 h) treatment with Dex reduced CBE activity in SMG and in human submandibular glands (HSG) cells. Moreover, when isolated SMG cells were stimulated with Dex for 2 h, phosphodiesterase 4D (PDE4D) expression was enhanced. These results confirm the anti-inflammatory properties of Dex on LPS-mediated signaling. Further, Dex also inhibited mRNA expression of interleukin-6 and NADPH oxidase 4. The present study also showed that α2-adrenoceptor activation by Dex reduces salivary glands fluid secretion by increasing PDE4D expression, and subsequently reducing the concentration of cAMP. These findings reveal an interaction between the α2-adrenoceptor and PDE4D, which should be considered when using α2-adrenoceptor agonists as sedative or analgesics.

Sialendoscopy under local anaesthesia

CONCLUSIONS

In most cases, both diagnostic and interventional sialendoscopy are well tolerated under local anaesthesia (LA) or under local anaesthesia with sedation (LAS), with reasonably low patient-reported discomfort. Sialendoscopy can be considered a patient-friendly and relatively painless, gland-preserving, minimally invasive procedure suitable for day surgery.

OBJECTIVE

To investigate patient experience and compliance in sialendoscopy under LA/LAS.

METHODS

This prospective study was conducted at an academic tertiary-care university hospital. During a period of 22 months, 89 patients between ages 16-81 years underwent diagnostic or interventional sialendoscopy under LA (20%) or LAS (80%). After the operation the patients filled in a questionnaire formulated by the authors concerning their procedure-related experiences. Patients' demographic data, ASA status score, pre- and intra-operative blood pressure and heart rate measurements, affected gland, operation time, intervention type, as well as pre-, peri-, and postoperative medication were gathered later from the medical records.

RESULTS

The level of discomfort and pain experienced during the operation was assessed as 'mild' or 'none' by 85% and 89% of the patients, respectively. The level of pain experienced after the operation was 'major' in 4% of patients and 'mild' or 'none' in the majority (87%) of patients. The patients' estimations showed no significant difference between the diagnostic and interventional procedures, although it seems that patients who underwent stone removal by transoral incision experienced the operation as a bit more uncomfortable and painful than other patients. Afterwards 97% of patients stated that they would agree to a new LA/LAS sialendoscopy in the future if needed.

Endothelial Tight Junctions Are Opened in Cholinergic-Evoked Salivation In Vivo

Blood vessels provide the original supplies for the formation of primary saliva, which is regulated by the tight junctions (TJs) between endothelial cells. Previous studies have shown that blood flow increases with vasodilatation during cholinergic-evoked salivation. However, changes in vascular paracellular permeability and the role of endothelial TJs in salivation are unknown. Here, we established an in vivo paracellular permeability detection system and observed that the endothelial TJs were permeable to 4-kDa fluorescein isothiocyanate (FITC)-dextran while impermeable to 40- and 70-kDa FITC-dextran under an unstimulated condition in mouse submandibular glands (SMGs). Pilocarpine increased the flux of 4- and 40-kDa FITC-dextran out of blood vessels but did not affect 70-kDa FITC-dextran. Claudin 5, a TJ protein specifically localized in salivary endothelial cells, was redistributed from the apicolateral membranes to the lateral and basolateral membranes and cytoplasm in cholinergic-stimulated mouse SMGs and freshly cultured human SMG tissues. In the transplanted SMGs from epiphora patients, we found that claudin 5 was present in the basolateral membranes and cytoplasm, instead of the apical region in control SMGs. Moreover, the level of phospho-myosin light chain 2 increased within the blood vessels of the pilocarpine-stimulated mouse SMGs and transplanted human SMGs, while the downstream molecule F-actin was reorganized in the endothelial cells of the transplanted human SMGs. Taken together, our findings provide direct visual evidence that the opening of endothelial TJs and the redistribution of claudin 5 are essential events contributing to cholinergic-evoked salivation, thus enriching our understanding of the secretory mechanisms that link blood flow to primary saliva formation by regulating the endothelial paracellular permeability.

Parasympathectomy increases resting salivary secretion in normal and irradiated submandibular glands of rats

Fluid and ion secretion from the submandibular gland (SMG) is mainly regulated by parasympathetic nerves. This study evaluated the effect of parasympathectomy on salivary secretion from normal and irradiated rat SMGs from 1 to 24 wk after denervation. Although stimulated salivary secretion was significantly lower in denervated SMGs compared with contralateral self-controls, the resting salivary flow rates were markedly higher in the denervated SMGs at 1, 12, and 24 wk after denervation. The levels of muscarinic acetylcholine M1 and M3 receptors, as well as of aquaporin 5, were up-regulated. Notably, although irradiated SMGs showed significantly lower resting and stimulated salivary secretion rates than non-irradiated SMGs, the resting salivary secretion rates of the irradiated and denervated SMGs were markedly higher than seen in the irradiated self-control SMGs at 1, 12, and 24 wk after parasympathectomy, and were even higher than seen in the non-irradiated sham-operated rats. The expression of M1 and M3 receptors was similarly elevated. Taken together, our results suggest that parasympathetic denervation increases resting salivary secretion of both normal and irradiated SMGs. This approach might provide a potential modality for relieving radiation-induced xerostomia, which is a common complication following treatment of head and neck cancer.

Transoral submandibulotomy for deep hilar submandibular gland sialolithiasis

OBJECTIVES/HYPOTHESIS

To assess the long-term results after transoral submandibulotomy for stones located in the deep hilar and intraparenchymal submandibular region.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

Retrospective evaluation including all patients treated with transoral submandibulotomy for sialolithiasis at a tertiary referral center.

RESULTS

Complete stone removal at the first transoral surgical treatment was achieved in 185 of 234 patients (79.1%). One hundred seventy-five of the 234 patients were followed up for a mean of 31.2 ( ± 20.5) months. During the follow-up period, 140 of the 175 patients (80.0%) became symptom free after one operation. In patients with residual symptoms, no further treatment was needed in 12 patients (6.9%) due to the mildness of the symptoms; 23 patients (13.1%) received further therapy, which was successful in 15 cases. Submandibulectomy only had to be performed in 3.4% of the patients with follow-up (6/175). In a questionnaire survey, 91.4% of the patients stated that they would be prepared to have the same operation again.

CONCLUSIONS

These findings show that transoral removal of submandibular sialoliths located in the deep hilum or adjacent intraglandular parenchyma is an effective treatment that can be assisted by additional measures. The techniques described show high success rates, good long-term results, low complication rates, and they avoided the need for submandibulectomy in >95% of cases.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2038-2044, 2017.

Morphological Changes of Myoepithelial Cells in the Rat Submandibular Gland Following the Application of Surgical Stimuli

Myoepithelial cells (MECs) exist on the basal surface of acini in major exocrine glands, include myofilaments and various constructive proteins, and share characteristics with smooth muscle and epithelial cells. MECs project several ramified processes to invest acini, and possibly contract to compress acini to support the secretion by the glandular cells. However, the functional roles of MECs in salivary secretion are still unclear. We investigated morphological changes in immunostained MECs using the anti-α-smooth muscle actin (αSMA) antibody in operated or non-operated contralateral (NC) submandibular glands after partial or total resection. Furthermore, we investigated and discuss other salivary glands of rats. MECs in the parotid, sublingual and submandibular gland of adult rats exhibited different shapes and localizations. After surgery, in both operated and NC glands, the number of MECs and αSMA-immunopositive areas increased significantly. Three-dimensional analysis using a confocal laser-scanning microscope revealed that substantial and significant enhancement became evident in the number, length, and thickness of MEC-processes covering acini of the operated and NC submandibular glands. The preset findings indicate that MECs alter the morphology of their processes in operated and NC glands after surgery of the partial or total resection. It is suggested that MECs promote salivary secretion using elongated, thickened, and more ramified processes.

The Presence of Select Tau Species in Human Peripheral Tissues and Their Relation to Alzheimer's Disease

Tau becomes excessively phosphorylated in Alzheimer's disease (AD) and is widely studied within the brain. Further examination of the extent and types of tau present in peripheral tissues and their relation to AD is warranted given recent publications on pathologic spreading. Cases were selected based on the presence of pathological tau spinal cord deposits (n = 18). Tissue samples from sigmoid colon, scalp, abdominal skin, liver, and submandibular gland were analyzed by western blot and enzyme-linked immunosorbent assays (ELISAs) for certain tau species; frontal cortex gray matter was used for comparison. ELISAs revealed brain to have the highest total tau levels, followed by submandibular gland, sigmoid colon, liver, scalp, and abdominal skin. Western blots with antibodies recognizing tau phosphorylated at threonine 231(pT231), serine 396 and 404 (PHF-1), and an unmodified total human tau between residues 159 and 163 (HT7) revealed multiple banding patterns, some of which predominated in peripheral tissues. As submandibular gland had the highest levels of peripheral tau, a second set of submandibular gland samples were analyzed (n = 36; 19 AD, 17 non-demented controls). ELISAs revealed significantly lower levels of pS396 (p = 0.009) and pT231 (p = 0.005) in AD cases but not total tau (p = 0.18). Furthermore, pT231 levels in submandibular gland inversely correlated with Braak neurofibrillary tangle stage (p = 0.04), after adjusting for age at death, gender, and postmortem interval. These results provide evidence that certain tau species are present in peripheral tissues. Of potential importance, submandibular gland pT231 is progressively less abundant with increasing Braak neurofibrillary tangle stage.

[Giant sialolithiasis: Diagnosis and management. Case reports]

Sialolithiasis is one of the most frequent form of calcifications in the maxillofacial area. 0.45% of the population is affected by symptoms caused by salivary calculi, though the estimated frequency including asymptomatic form may exceed 1% in adult population. Radiographs presenting a large portion of the maxillofacial region (panoramic radiography, computed tomography) could detect salivary calculi with high accuracy. The size of the sialoliths is usually less than 10 mm in diameter. Salivary calculi larger than 15 mm (considering the largest diameter) are classified as giant sialoliths and most of them are located in the submandibular gland or in its duct. Two unusually large submandibular salivary calculi cases are represented (diameters of 27 and 34 mm), whereas in one of the cases development and dimensional changes of the calculus are described via a seven years period. This case report represents diagnostic and therapeutic consequences in giant sialolithiasis and demonstrates possible differential diagnostic difficulties. Orv. Hetil., 2016, 157(49), 1967-1972.

Massive sialadenitis resulting in critical airway after elective craniotomy: case report

The authors report an unusual case of acute, rapidly progressive, unilateral neck swelling following extubation after elective left anterior temporal lobectomy with amygdalohippocampectomy. Due to severe neck swelling, the patient developed critical airway compromise, brachial plexopathy, and Horner's syndrome. After critical airway management and appropriate rehabilitation, the patient recovered completely and remains seizure free at 1.5 years of follow-up. This case highlights the importance of early recognition of acute postoperative sialadenitis and the steps needed to prevent serious morbidity and possible mortality from this rare complication.

Par-1b is required for morphogenesis and differentiation of myoepithelial cells during salivary gland development

The salivary epithelium initiates as a solid mass of epithelial cells that are organized into a primary bud that undergoes morphogenesis and differentiation to yield bilayered acini consisting of interior secretory acinar cells that are surrounded by contractile myoepithelial cells in mature salivary glands. How the primary bud transitions into acini has not been previously documented. We document here that the outer epithelial cells subsequently undergo a vertical compression as they express smooth muscle α-actin and differentiate into myoepithelial cells. The outermost layer of polarized epithelial cells assemble and organize the basal deposition of basement membrane, which requires basal positioning of the polarity protein, Par-1b. Whether Par-1b is required for the vertical compression and differentiation of the myoepithelial cells is unknown. Following manipulation of Par-1b in salivary gland organ explants, Par-1b-inhibited explants showed both a reduced vertical compression of differentiating myoepithelial cells and reduced levels of smooth muscle α-actin. Rac1 knockdown and inhibition of Rac GTPase function also inhibited branching morphogenesis. Since Rac regulates cellular morphology, we investigated a contribution for Rac in myoepithelial cell differentiation. Inhibition of Rac GTPase activity showed a similar reduction in vertical compression and smooth muscle α-actin levels while decreasing the levels of Par-1b protein and altering its basal localization in the outer cells. Inhibition of ROCK, which is required for basal positioning of Par-1b, resulted in mislocalization of Par-1b and loss of vertical cellular compression, but did not significantly alter levels of smooth muscle α-actin in these cells. Overexpression of Par-1b in the presence of Rac inhibition restored basement membrane protein levels and localization. Our results indicate that the basal localization of Par-1b in the outer epithelial cells is required for myoepithelial cell compression, and Par-1b is required for myoepithelial differentiation, regardless of its localization.

Submandibular oncocytic carcinoma: A case report and literature review

BACKGROUND

Oncocytic carcinoma (OC) arising in the submandibular gland is an unusual malignant neoplasm, with <20 cases previously reported. The cancer is characterized by numerous morphologically abnormal mitochondria present in the cytoplasm and marked cellular pleomorphism. At its most severe, the tumor may invade into the surrounding tissues, including intravascular, lymphatic, or perineural invasion, and lead to regional nodal or distant metastasis.

METHODS

The current study describes a novel OC case in a 46-year-old male, the youngest case of the review. The patient presented with a 5-month history of an intermittently painful mass.

RESULTS

Following magnetic resonance imaging, excisional biopsy, hematoxylin-eosin staining, phosphotungstic acid-hematoxylin staining, and immunohistochemical examination, an OC of the submandibular gland was diagnosed.

CONCLUSION

The current study summarizes the pathogenesis, diagnosis, therapeutics, and the prognosis of OC. The literature review regarding this rare disease is also presented to emphasize the lack of specific markers of OC and the risk of cervical lymph metastasis.

Simvastatin attenuates radiation-induced salivary gland dysfunction in mice

Objective

Statins are widely used lipid-lowering drugs, which have pleiotropic effects, such as anti-inflammation, and vascular protection. In our study, we investigated the radioprotective potential of simvastatin (SIM) in a murine model of radiation-induced salivary gland dysfunction.

Design

Ninety-six Institute of Cancer Research mice were randomly divided into four groups: solvent + sham irradiation (IR) (Group I), SIM + sham IR (Group II), IR + solvent (Group III), and IR + SIM (Group IV). SIM (10 mg/kg body weight, three times per week) was administered intraperitoneally 1 week prior to IR through to the end of the experiment. Saliva and submandibular gland tissues were obtained for biochemical, morphological (hematoxylin and eosin staining and Masson’s trichrome), and Western blot analysis at 8 hours, 24 hours, and 4 weeks after head and neck IR.

Results

IR caused a significant reduction of salivary secretion and amylase activity but elevation of malondialdehyde. SIM remitted the reduction of saliva secretion and restored salivary amylase activity. The protective benefits of SIM may be attributed to scavenging malondialdehyde, remitting collagen deposition, and reducing and delaying the elevation of transforming growth factor β1 expression induced by radiation.

Conclusion

SIM may be clinically useful to alleviate side effects of radiotherapy on salivary gland.

Standards for the assessment of salivary glands - an update

The paper is an update of 2011 Standards for Ultrasound Assessment of Salivary Glands, which were developed by the Polish Ultrasound Society. We have described current ultrasound technical requirements, assessment and measurement techniques as well as guidelines for ultrasound description. We have also discussed an ultrasound image of normal salivary glands as well as the most important pathologies, such as inflammation, sialosis, collagenosis, injuries and proliferative processes, with particular emphasis on lesions indicating high risk of malignancy. In acute bacterial inflammation, the salivary glands appear as hypoechoic, enlarged or normal-sized, with increased parenchymal flow. The echogenicity is significantly increased in viral infections. Degenerative lesions may be seen in chronic inflammations. Hyperechoic deposits with acoustic shadowing can be visualized in lithiasis. Parenchymal fibrosis is a dominant feature of sialosis. Sjögren syndrome produces different pictures of salivary gland parenchymal lesions at different stages of the disease. Pleomorphic adenomas are usually hypoechoic, well-defined and polycyclic in most cases. Warthin tumor usually presents as a hypoechoic, oval-shaped lesion with anechoic cystic spaces. Malignancies are characterized by blurred outlines, irregular shape, usually heterogeneous echogenicity and pathological neovascularization. The accompanying metastatic lesions are another indicator of malignancy, however, final diagnosis should be based on biopsy findings.

Mistakes in ultrasound examination of salivary glands

Ultrasonography is the first imaging method applied in the case of diseases of the salivary glands. The article discusses basic mistakes that can be made during an ultrasound examination of these structures. The reasons for these mistakes may be examiner-dependent or may be beyond their control. The latter may include, inter alia, difficult conditions during examination (technical or patient-related), similarity of ultrasound images in different diseases, the lack of clinical and laboratory data as well as the lack of results of other examinations, their insufficient number or incorrectness. Doctor-related mistakes include: the lack of knowledge of normal anatomy, characteristics of ultrasound images in various salivary gland diseases and statistical incidence of diseases, but also attaching excessive importance to such statistical data. The complex anatomical structures of the floor of the oral cavity may be mistaken for benign or malignant tumors. Fragments of correct anatomical structures (bones, arterial wall fibrosis, air bubbles in the mouth) can be wrongly interpreted as deposits in the salivary gland or in its excretory duct. Correct lymph nodes in the parotid glands may be treated as pathologic structures. Lesions not being a simple cyst, e.g. lymphoma, benign or malignant tumors of the salivary glands or metastatic lymph nodes, can be mistaken for one. The image of disseminated focal changes, both anechoic and solid, is not pathognomonic for specific diseases in the salivary glands. However, in part, it occurs typically and requires an extended differential diagnosis. Small focal changes and infiltrative lesions pose a diagnostic problem because their etiology cannot be safely suggested on the basis of an ultrasound examination itself. The safest approach is to refer patients with abnormal focal changes for an ultrasoundguided fine-needle aspiration biopsy.

Pharmacokinetic Behaviors of Intravenously Administered siRNA in Glandular Tissues

The pharmacokinetics of small interfering RNAs (siRNAs) is a pivotal issue for siRNA-based drug development. In this study, we comprehensively investigated the behavior of siRNAs in vivo in various tissues and demonstrated that intravenously-injected naked siRNA accumulated remarkably in the submandibular gland, bulbourethral gland, and pancreas, with a respective half-life of ~22.7, ~45.6, and ~30.3 h. This was further confirmed by gel separation of tissue homogenates and/or supernatants. In vivo imaging and cryosectioning suggested that delivery carriers significantly influence the distribution and elimination profiles of siRNA. Gene-silencing assays revealed that neither naked nor liposome-formulated siRNA resulted in gene knockdown in the submandibular and bulbourethral glands after systemic administration, suggesting that these glands function as drug reservoirs that enable slow siRNA release into the circulation. But robust gene-silencing was achieved by local injection of liposome-encapsulated siRNA into the submandibular gland. Our results enhance understanding of the pharmacokinetic properties of siRNAs and we believe that they will facilitate the development of siRNA therapy, especially for the submandibular gland.

Invasive cervical cancer accompanied by IgG4-related disease

IgG4-related disease (IgG4-RD) is a systemic disease that affects multiple organs and generates nodules or thickening. Discriminating these diseases from malignancy is important because glucocorticoid treatment is effective for patients with IgG4-RD. Coexistence of IgG4-RD with various malignant diseases has been reported, but there are few reports with regard to gynecologic malignant diseases. We encountered a case of invasive cervical cancer stage IIB accompanied by IgG4-RD. The patient was a 46-year-old woman. On pelvic magnetic resonance imaging, fluorodeoxyglucose-positron emission tomography and computed tomography, systemic multiple lymph node swelling was seen, including in the neck and the mediastinum in addition to uterine cervix. Diagnosis (and hence, appropriate treatment choice) was achieved on pathology of the submandibular gland and uterus, and analysis of serum IgG4. IgG4-RD should be suspected in patients presenting with malignancy and unusual multiple lymph node swelling.

β-Actin protein expression differs in the submandibular glands of male and female mice

β-actin, a cytoskeletal protein, is the most widely used housekeeping gene. Although housekeeping genes are expressed in all tissues, the β-actin gene is expressed in certain cell types because of differential binding of transcriptional factors to the regulatory elements of the gene. The expression and localization of β-actin protein in the submandibular glands (SMG) of mice were investigated in this study, using Western blot analysis and immunohistochemistry. In ICR and C57BL/6J mice, the levels of β-actin protein in the SMG of females are significantly higher than those in the SMG of males. β-actin protein is majorly distributed in acinar cells of SMG. There is no significant difference in the expression level of β-actin protein between females and castrated males. After castrated male ICR mice are treated with 10 mg/kg/day testosterone propionate (TP) for 3 weeks, the levels of β-actin protein in SMG decrease. The numbers of duct per unit area increase, whereas the numbers of acinus per unit area decrease after TP administration. These data suggest that β-actin protein is mainly distributed in acinar cells of SMG and results in a marked sexual dimorphism in mice.

Atrophy of submandibular gland by the duct ligation and a blockade of SP receptor in rats

To clarify the mechanisms underlying the submandibular gland atrophies associated with ptyalolithiasis, morphological changes were examined in the rat submandibular gland following either surgical intervention of the duct or functional blockade at substance P receptors (SPRs). Progressive acinar atrophy was observed after duct ligation or avulsion of periductal tissues. This suggested that damage to periductal tissue involving nerve fibers might contribute to ligation-associated acinar atrophy. Immunohistochemically labeled-substance P positive nerve fibers (SPFs) coursed in parallel with the main duct and were distributed around the interlobular, striated, granular and intercalated duct, and glandular acini. Strong SPR immunoreactivity was observed in the duct. Injection into the submandibular gland of a SPR antagonist induced marked acinar atrophy. The results revealed that disturbance of SPFs and SPRs might be involved in the atrophy of the submandibular gland associated with ptyalolithiasis.

Identification of Stem Cells in the Secretory Complex of Salivary Glands

Salivary glands have an essential secretory function for maintaining oral and overall health. The epithelial compartment of the gland is composed of several highly specialized cell types that cooperate to secrete and deliver saliva to the oral cavity. The mouse submandibular gland has been used as a model for major salivary glands in human. The secretory complex in this model is composed of 2 secretory compartments, including acini and granular ducts connected by intercalated ducts. Contractile myoepithelial cells surround the secretory complex to facilitate salivary flow. Whether differentiated cells in the secretory complex are maintained by self-duplication or contribution from stem cells has remained an open question. Here, in analyzing the expression of basal cytokeratin (K) 14 in the secretory complex, we discovered a subset of K14(+) ductal cells in the intercalated ducts of the adult gland. These cells are distinct from the K14-expressing basal/myoepithelial cells, proliferate at a significantly higher rate than any other epithelial cell type in the gland, and reside in a spatially defined domain within the intercalated duct. Using inducible genetic lineage tracing, we show that K14(+) ductal cells represent a long-lived yet cycling population of stem cells that are established during development and contribute to the formation and maintenance of the granular ducts throughout life. Our data provide direct evidence for the existence of stem cells contributing to homeostasis of salivary glands, as well as new insights into glandular pathobiology.

Adenoid cystic carcinoma of the submandibular gland with rare metastasis to the sternum in a 52-year-old male

Adenoid cystic carcinoma (ACC) is a rare tumor, described as being one of the most biologically destructive tumors of the head and neck. It is the most common malignancy that affects the minor salivary glands. Lung and bones are the most common regions of ACC distant metastasis. To the best of our knowledge, herein, we report the first ever case of latent isolated sternal metastasis from ACC in a 52-year-old gentleman, who was diagnosed to have ACC of the submandibular gland, excised 10 years ago.

Interleukin-17 Impairs Salivary Tight Junction Integrity in Sjögren's Syndrome

Sjögren's syndrome (SS) is an inflammatory autoimmune disease that causes secretory dysfunction of the salivary glands. It has been reported that proinflammatory cytokine interleukin-17 (IL-17) was elevated and tight junction (TJ) integrity disrupted in minor salivary glands from SS patients. However, whether the elevated IL-17 in SS affects TJ integrity and thereby alters the function of salivary gland is unknown. Here, by using nonobese diabetic (NOD) mice as SS model, we found that the stimulated salivary flow rate was significantly decreased in NOD mice. Lymphocyte infiltration was mainly observed in submandibular glands (SMGs), but not parotid glands (PGs), of NOD mice. IL-17 was significantly increased and mainly located in lymphocytic-infiltrating regions in SMGs but not detectable in PGs of NOD mice. Meanwhile, the epithelial barrier function was disrupted, as evidenced by an increased paracellular tracer clearance and an enlarged acinar TJ width in SMGs of NOD mice. Furthermore, claudin-1 and -3 were elevated especially at the basolateral membranes, whereas claudin-4, occludin, and zonula occludens-1 (ZO-1) were reduced in SMGs of NOD mice. Moreover, occludin and ZO-1 were dispersed into cytoplasm in SMGs of NOD mice. However, no change in the expression and distribution of TJ proteins was found in PGs. In vitro, IL-17 significantly decreased the levels and apical staining of claudin-4 and ZO-1 proteins in the cultured SMG tissues, as well as claudin-1, occludin, and ZO-1 in PG tissues. Moreover, IL-17 activated the phosphorylation of IκBα and p65 in SMG cells, whereas pretreatment with NF-κB inhibitor pyrrolidine dithiocarbamate suppressed the IL-17-induced downregulation of claudin-4 and ZO-1 in SMG tissues. Taken together, these findings indicate that IL-17 derived from infiltrating lymphocyte impairs the integrity of TJ barrier through NF-κB signaling pathway, and thus might contribute to salivary gland dysfunction in SS.

Submandibular Gland Surgery: Our Clinical Experience

Objective

The aim of this study was to assess the demographic findings and surgical results of patients who underwent submandibular gland excision at a tertiary care center.

Methods

The clinical characteristics and histopathological results of 45 patients who had undergone submandibular gland excision between 1997 and 2014 were evaluated in detail.

Results

Twenty-eight (62.2%) and 17 (37.8%) patients presented with a complaint of a painful mass and painless mass, respectively. Histopathologic investigation of the surgical specimens revealed sialolithiasis in 14 patients (31.1%), chronic sialadenitis in 16 (35.6%), benign tumor in 12 (26.7%), malignant tumor in two (4.4%), and mucocele extravasation in one. As complications, permanent paralysis of the marginal mandibular branch of the facial nerve was seen in one patient (2.2%), temporary paralysis of the marginal mandibular branch of the facial nerve was seen in seven (15.6%), orocutaneous fistula was seen in one (2.2%), and temporary paralysis of the hypoglossal nerve was seen in one (2.2%).

Conclusion

This study revealed that in patients presenting with complaints of a submandibular gland mass, sialolithiasis, sialadenitis, and benign masses were the mostly diagnosed disorders. Transcervical submandibular gland excision is a satisfactory procedure with low complication and recurrence rates when it is performed on selected patients and obeyed to surgical techniques.

Myeloid sarcoma of submandibular salivary gland

Objective:

To report a rare case of a myeloid sarcoma of submandibular salivary gland.

Methods:

A 65-year-old woman with a history of successfully treated myelodysplastic syndrome, presenting with periodic painful swelling of her right submandibular area.

Results:

Physical evaluation, ultrasound and CT scan revealed the presence of a 3-cm mass contiguous to the submandibular salivary gland. A core needle biopsy confirmed the diagnosis of myeloid sarcoma. Bone marrow biopsy was still showing complete remission and the submandibular gland was the only extramedullary site involved. The patient was submitted to chemotherapy.

Conclusion:

Myeloid sarcoma is a rare extramedullary neoplasm. It can virtually involve any anatomic site, but it usually involves lymph nodes, paranasal sinuses, skin, soft tissue and periostium. Myeloid sarcomas of salivary glands are very rare and ENTs should be aware of this disease in order to include it in the differential diagnosis of a solitary neck mass.

Dysgenetic polycystic disease of the minor and submandibular salivary glands

BACKGROUND

Dysgenetic polycystic salivary gland disease is a rare pathology. No case of minor salivary gland involvement has been reported in the literature.

METHODS

A female patient presented with bilateral tumors of the parotid glands, bilateral submandibular gland enlargement, and multiple cystic lesions of the oral mucosa. MRI of the neck was performed along with fine-needle aspiration (FNA) of the parotid tumors and excisional biopsy of an oral lesion.

RESULTS

Imaging and FNA findings of the parotid glands were suggestive of bilateral Warthin tumors. Excisional biopsy of the oral lesion revealed a minor salivary gland with histopathological features of dysgenetic polycystic salivary gland disease. Submandibular gland enlargement was also attributed to this rare entity based on the imaging characteristics.

CONCLUSION

This is the first report of dysgenetic polycystic salivary gland disease of the minor salivary glands, combined with involvement of the submandibular glands and bilateral Warthin tumors of the parotid gland. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2437-E2439, 2016.

Intensity-modulated radiotherapy or volumetric-modulated arc therapy in patients with head and neck cancer: Focus on salivary glands dosimetry

BACKGROUND

Despite radiotherapy (RT) technical improvements, high salivary dysfunction rates are still reported in patients with head and neck squamous cell carcinoma (HNSCC). The purpose of the present study was to report salivary glands dosimetry with volumetric-modulated arc therapy (VMAT) and intensity-modulated RT (IMRT).

METHODS

Dosimetry of consecutive patients receiving IMRT or VMAT for proven HNSCC between 2007 and 2013 were retrospectively reviewed.

RESULTS

Data of 609 patients were studied. Mean dose, mean maximum dose, and mean percentage of salivary gland volume receiving at least 26 Gy (V26) of the contralateral parotid were 24.50 Gy (range, 0-70.4 Gy), 39.08 Gy (range, 0.38-76.45 Gy), and 40.92% (range, 0% to 100%), respectively. Mean and maximum dose on contralateral submandibular gland were 48.18 Gy (range, 0.19-70.73 Gy), and 61.25 Gy (range, 0-75.8 Gy), respectively.

CONCLUSION

Target volume coverage still has to be prioritized over organs at risk (OAR) sparing with new RT techniques. Submandibular glands are not sufficiently taken into account in guidelines. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1028-1034, 2016.

Peripheral Synucleinopathy in Early Parkinson's Disease: Submandibular Gland Needle Biopsy Findings

INTRODUCTION

Finding a peripheral tissue biopsy site to diagnose early PD would be of value for clinical care, biomarker validation, and as research enrollment criteria. Whereas autopsy and advanced PD studies suggest that the submandibular gland is an important biopsy site, there are no studies in early PD. The aim of this study was to determine whether needle biopsy of the submandibular gland reveals Lewy type alpha-synucleinopathy in early PD.

METHODS

Twenty-five early PD (duration < 5 years) and 10 controls underwent transcutaneous needle core biopsies of the submandibular gland. Tissue was stained for phosphorylated alpha-synuclein, reviewed blind to clinical diagnosis, and only nerve element staining was considered positive.

RESULTS

Mean (standard deviation) age was 69.5 (8.3) for the PD group, 64.8 (8.0) years for controls, and disease duration 2.6 (1.1) years. Six PD and 1 control subject had inadequate glandular tissue. Positive staining was found in 14 of 19 (74%) PD and 2 of 9 (22%) control subjects. PD-positive and -negative cases did not differ clinically. Adverse events (mainly swelling and bruising) were common (77% of cases), but were minor and transient.

CONCLUSIONS

Submandibular gland needle biopsies identified phosphorylated alpha-synuclein staining in 74% of early PD subjects. False positives may be true false positives or may represent prodromal PD. If confirmed in larger studies with eventual autopsy confirmation, the potential value of submandibular gland biopsies for early PD may be to aid in clinical trial inclusion/exclusion and eventually serve as a gold standard for biomarker studies short of autopsy confirmation.

Oncocytic Carcinoma of the Submandibular Gland: A Case Report

Oncocytic carcinoma (OC) of the submandibular gland is extremely rare. A 76-year-old man complained of a painless tumor of the right neck. Ultrasonography demonstrated swelling in the lymph nodes of the neck, and fine-needle aspiration cytology of a node showed metastatic carcinoma with oncocytic features. Radical surgery revealed infiltrating carcinoma of the right submandibular gland with lymph node metastases (19/23). Tumor cells showed less atypia and had abundant eosinophilic cytoplasm, which stained deep blue with phosphotungstic acid-hematoxylin stain. The cells were immunohistochemically positive for cytokeratin 7 but negative for p63 and SOX10. We diagnosed the tumor as OC. Chemoradiotherapy was performed after surgery. The patient showed no sign of recurrence until 42 months after the operation, when lymph node swelling was detected in the mediastinum by computed tomography scanning. With no further treatment, the patient is alive with lymph node swellings in the mediastinum and pulmonary hilum 80 months after surgery.

CT features and pathologic characteristics of IgG4-related systemic disease of submandibular gland

The submandibular gland is one of the most frequently affected salivary gland in IgG4-related systemic disease, usually demonstrate homogeneous attenuation on CT imaging as reported, but without much pathological comparison of many cases. This article is to investigate and analyze the typical CT findings and pathologic characteristics of IgG4-related systemic disease (IgG4-RSD) of submandibular gland. A retrospective analysis of the preoperative CT findings in patients with IgG4-RSD of submandibular glands who underwent surgical resection between January 2010 and February 2014 was performed. Twenty patients (16 women) were identified, with a mean age of 58.1±10.2 years. All patients presented with painless submandibular gland swelling. Diffuse gland enlargement, with clear margins and homogeneous density, was found on non-enhanced CT scans in all cases. There were no calcifications or stones within the involved glands. Based on contrast-enhanced CT appearance the patients could be divided into two groups: 11 cases showed homogeneous gland enhancement; and multiple hyperenhancing foci, with a crazy-paving pattern, were detected in 9 cases, which were in consistent with the pathologic findings. The maximum submandibular gland diameter on transverse images was significantly larger (P=0.008) in patients with crazy-paving appearance (32±4 mm) compared to patients with homogeneous enhancement (28±3 mm). It is concluded that the submandibular glands with IgG4-RSD can be characterized by either homogenous appearance or crazy-paving pattern on contrast-enhanced CT imaging.

Establishment of immortalized mesenchymal stem cells derived from the submandibular glands of tdTomato transgenic mice

Transgenic mice that overexpress the red fluorescent protein tdTomato (tdTomato mice) are well suited for use in regenerative medicine studies. Cultured cells from this murine model exhibit strong red fluorescence, enabling real-time in vivo imaging through the body surface of grafted animals. Mesenchymal stem cells (MSCs) have marked potential for use in cell therapy and regenerative medicine; however, the mechanisms that regulate their dynamics in vivo are poorly understood. In the present study, an MSC line was derived from the submandibular gland fibroblasts of tdTomato mice. The fluorescent signal from this cell line was observed in organs throughout the body, as well as in salivary glands. Primary culture cells derived from the submandibular gland were immortalized with SV40 large T antigen (GManSV cells); these cells exhibited increased migratory ability, as compared with those isolated from the sublingual gland. GManSV cells were tdTomato-positive and exhibited spindle-shaped fibroblastic morphology; they also robustly expressed mouse MSC markers: Stem cell antigen-1 (Sca-1), CD44, and CD90. This cell line retained multipotent stem cell characteristics, as evidenced by its ability to differentiate into both osteogenic and adipogenic lineages. These results indicate that Sca-1⁺/CD44⁺/CD90⁺-GManSV cells may be useful for kinetic studies of submandibular gland-derived MSCs in the context of in vitro co-culture with other types of salivary gland-derived cells. These cells may also be used for in vivo imaging studies, in order to identify novel cell therapy and regenerative medicine for the treatment of salivary gland diseases.

Dysregulation of the Bmi-1/p16(Ink⁴a) pathway provokes an aging-associated decline of submandibular gland function

Bmi-1 prevents stem cell aging, at least partly, by blocking expression of the cyclin-dependent kinase inhibitor p16(Ink4a) . Therefore, dysregulation of the Bmi-1/p16(Ink4a) pathway is considered key to the loss of tissue homeostasis and development of associated degenerative diseases during aging. However, because Bmi-1 knockout (KO) mice die within 20 weeks after birth, it is difficult to determine exactly where and when dysregulation of the Bmi-1/p16(Ink4a) pathway occurs during aging in vivo. Using real-time in vivo imaging of p16(Ink4a) expression in Bmi-1-KO mice, we uncovered a novel function of the Bmi-1/p16(Ink4a) pathway in controlling homeostasis of the submandibular glands (SMGs), which secrete saliva into the oral cavity. This pathway is dysregulated during aging in vivo, leading to induction of p16(Ink4a) expression and subsequent declined SMG function. These findings will advance our understanding of the molecular mechanisms underlying the aging-related decline of SMG function and associated salivary gland hypofunction, which is particularly problematic among the elderly.

Actinomycosis of submandibular gland: An unusual presentation of a rare entity

Actinomycosis is a chronic suppurative infection that can occur in the head and neck region. Though cervico-facial actinomycosis is well described, primary actinomycosis of the salivary gland is rare and can present as any other suppurative infection or can simulate malignancy. We hereby report a case of a young male with primary actinomycosis of submandibular gland, presenting as acute suppurative infection and diagnosed on histopathology.