The clinical, histologic, and treatment spectrum in necrotizing sialometaplasia

Non-Ulcerated and Ulcerated Necrotizing Sialometaplasia: Report of an Additional Case and Literature Review

Necrotizing sialometaplasia (NS) is a rare, self-limiting, necrotizing inflammatory lesion, often involving the minor salivary glands of the palate. NS occurs often in men (60%) older than 45 years. Commonly, it presents as an ulcerative lesion, measuring 1 to 3 cm in diameter, with an evolution time of a few weeks or days, simulating malignancy. However, in some instances, the mucosal surface is intact, thus emphasizing the importance of considering NS in the differential diagnosis of oral ulcerative and non-ulcerative lesions. To date, 12 cases of non-ulcerated NS in the palate have been reported. Here, we report a 50-year-old male patient who presented a non-ulcerated, asymptomatic, nodular swelling 3 months ago, located on the hard palate, clinically suggesting salivary gland tumor or lymphoproliferative disorder. After biopsy, a diagnosis of non-ulcerated NS was established. After 4 weeks, the lesion evolved with complete resolution. After literature review, notably, unlike ulcerated NS, the non-ulcerated NS affected patients a decade younger (33 years vs. 45 years), with marked female predilection (83% vs. 40%) and not uncommon bilateral presentation (33% vs. 10%). NS should be considered in the differential diagnosis of ulcerative and non-ulcerative lesions affecting the palate.

Diagnostic dilemma: our experience with necrotising sialometaplasia

A man in his 40s presented to our outpatient department with a painful ulcer in the oral cavity for 1 week. After intraoral examination, a single hard palate ulcer, which was non-tender on palpation, was noted. Baseline blood investigations such as haemogram and serological evaluation were within normal limits. Under local anaesthesia, an excisional biopsy was performed. The histopathological examination revealed a reactive necrotising inflammatory process involving minor salivary glands with no cytological atypia. Weekly follow-up was performed and at the end of 4 weeks, complete healing of the lesion had occurred without any further intervention.

Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Tumours of the Oral Cavity and Mobile Tongue

The fifth chapter of the upcoming fifth edition of the 2022 World Health Organization Classification of Tumours of the Head and Neck titled Tumours of the oral cavity and mobile tongue, has had some modifications from the 2017 fourth edition. A new section "Non-neoplastic Lesions", introduces two new entries: necrotizing sialometaplasia and melanoacanthoma. The combined Oral potentially malignant disorders and Oral epithelial dysplasia section in the 2015 WHO has now been separated and submucous fibrosis and HPV-associated dysplasia are also discussed in separate sections. Carcinoma cuniculatum and verrucous carcinoma are described in dedicated sections, reflecting that the oral cavity is the most common location in the head and neck for both these entities which have distinct clinical and histologic features from conventional squamous cell carcinoma. This review summarizes the changes in Chapter 5 with special reference to new additions, deletions, and sections that reflect current clinical, histological, and molecular advances.

Non-ulcerated necrotizing sialometaplasia may mimic a salivary gland tumor

Necrotizing sialometaplasia (NS) is a benign, self-limiting inflammatory entity that mainly affects the minor salivary glands located in the hard palate. Classically, NS is characterized as a nodule that evolves to a central ulcer. The most widely recognized triggering factor is an ischemic event. The diagnosis becomes a challenge in non-ulcerated NS cases which is essential to rule out the possibility of salivary gland tumors, especially the malignant ones. Here, we presented a case of a 32-year-old male patient with a 1-month complaint of a painful, slightly elevated erythematous area on the hard palate. Incisional biopsy was performed, and NS was diagnosed based on histopathological and immunohistochemical analyses. Clinicians should be aware of and consider NS as a differential diagnosis of minor salivary gland tumors, particularly when it presents as a non-ulcerated clinical aspect.

Necrotizing sialometaplasia of the tonsillar pillar. An unusual case

Necrotizing Sialometaplasia (NS) is a rare, benign, self-limited, inflammatory and necrotizing reaction of the salivary glandular tissue. Due to the clinical picture (a painful ulcer with well-defined edges), and histopathological characteristics (nuclear and cellular pleomorphism of ductal cells) NS can mimic a malignant lesion. The correct diagnosis is important because NS shows a spontaneous resolution and therefore no further treatment is needed. We report a very unusual case of spontaneous and recurrent NS located on the anterior tonsillar pillar in a 43-year old man, which clinically mimics a malignant lesion. The clinician should be aware to include NS in the differential diagnosis of ulcers in soft palate and tonsillar pillars. Key words:Minor salivary gland, necrotizing sialometaplasia, oral ulcer, squamous cell carcinoma, tonsillar pillar.

Oral cavity and eating disorders: An insight to holistic health

Oral health is vital to the general well being and is a time-tested indicator of the systemic health of an individual. Oral cavity may be the primary site affected in endocrine disorders, renal disorders, gastrointestinal, cardiovascular, hematological, autoimmune cutaneous disorders, and psychosomatic disorders. Eating disorders (primarily Anorexia nervosa and bulimia) are psychosomatic disorders having multifaceted etiology, and characterized by abnormal eating patterns. In many cases, the oral cavity may be the only site of the manifestations of eating disorders. An oral physician may often unveil the mystery of this underlying systemic pathology by a vigilant and meticulous examination of the oral cavity. This not only helps in nabbing the disease in its early course but also prevents the patients from the appalling consequences due to the disease. This article aims to highlight the etiopathogenesis and various oral features in eating disorders. The oral physician should be familiar with the bizarre oral features of eating disorders and should work in close connection with other healthcare physicians to prevent the psychosomatic and systemic consequences.

Necrotizing sialometaplasia of the parotid gland associated with facial nerve paralysis

INTRODUCTION

Necrotizing sialometaplasia is a benign inflammatory lesion involving most frequently the minor salivary gland of the hard palate. Involvement of the parotid gland is rare, involvement of the parotid gland associated with facial palsy is exceptional.

CASE REPORT

A 56-year-old male patient with Marfan syndrome presented with swelling and inflammation of the left parotid gland associated with progressively complete facial nerve paralysis. CT scan and MRI showed a parotid collection with hyper signal of the nearest tissues associated with erosion of the styloid process. A malignant tumor was suspected. The histological examination of a biopsy showed a lobulocentric process with necrosis, squamous metaplasia, and inflammation. The immunohistochemical examination supported a final diagnosis of necrotizing sialometaplasia.

DISCUSSION

Necrotizing sialometaplasia of the parotid gland associated with facial nerve paralysis presents like a malignant neoplasm, both clinically and histologically. Only advanced immunohistochemical examination can really confirm the diagnosis.

Gastrointestinal Manifestations of Eating Disorders

Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.

Bilateral necrotising sialometaplasia

Necrotising sialometaplasia is a benign, necrotising, self-healing inflammatory condition categorised as idiopathic disease of salivary glands. This condition holds diagnostic importance because of its clinical and histopathological presentation, which is ambiguous, and can be misdiagnosed as carcinoma particularly squamous cell carcinoma or mucoepidermoid carcinoma. This report describes a case of bilateral necrotising sialometaplasia occurring in a 38-year-old male patient.

Bilateral necrotising sialometaplasia

Necrotising sialometaplasia is a benign, necrotising, self-healing inflammatory condition categorised as idiopathic disease of salivary glands. This condition holds diagnostic importance because of its clinical and histopathological presentation, which is ambiguous, and can be misdiagnosed as carcinoma particularly squamous cell carcinoma or mucoepidermoid carcinoma. This report describes a case of bilateral necrotising sialometaplasia occurring in a 38-year-old male patient.

Necrotizing Sialometaplasia of the Hard Palate in a Patient Treated with Topical Nonsteroidal Anti-Inflammatory Drug

Necrotizing sialometaplasia is a rare, benign, self-limiting, necrotizing process involving the minor salivary glands, mainly the mucoserous glands of the hard palate. It is thought to be the result of an ischemic event of the vasculature supplying the salivary gland lobules. Some predisposing factors such as smoking, use of alcohol, denture wearing, recent surgery, traumatic injuries, respiratory infections, systemic diseases bulimia, and anorexia have been described. Herein we present a case of necrotizing sialometaplasia of the hard palate in a patient without known predisposing factors, in our opinion, resulting from the use of topical anti-inflammatory drug. After diagnosis, the patient underwent treatment with chlorhexidine gluconate and a full palatal acrylic guard to protect the exposed bone from food residues during meals. After the sixth week the lesion regressed.

Necrotizing sialometaplasia of the lacrimal sac mimicking squamous cell carcinoma: Necrotizing dacyocystometaplasia

INTRODUCTION

Necrotizing sialometaplasia is thought to represent an inflammatory reaction directed against an ischemic insult or local trauma within a glandular tissue and is most commonly observed in the minor salivary glands of the oral mucosa. The importance of this condition arises from the fact that its clinical and histological aspects may raise issues of differential diagnosis with malignant neoplasms. The authors present a case of necrotizing sialometaplasia involving the lacrimal sac simulating a well-differentiated squamous cell carcinoma.

CASE

A 52-year-old man presented with epiphora in the left eye after having sustained an orbital blowout fracture during a motor vehicle accident. During subsequent external dacryocystorhinostomy, an abnormal lacrimal sac mucosa was observed and analyzed histologically revealing a well-differentiated squamous cell carcinoma. However, the subsequent biopsies of the lacrimal sac were negative for malignancy; in view of these findings, two pathologists reviewed the first specimen and immunohistochemical staining was performed allowing us to arrive at a diagnosis of necrotizing sialometaplasia. We suggest the term necrotizing dacryocystometaplasia for the involvement at this site.

CONCLUSION

Although exceedingly unusual, necrotizing dacryocystomeplasia should be considered in patients presenting with epiphora in the appropriate clinical context. Notably, this condition can be mistaken for a malignant disease, presenting a diagnostic challenge both clinically and histopathologically.

Necrotizing sialometaplasia-like change of the esophageal submucosal glands is associated with Barrett's esophagus

The esophageal submucosal glands (SMG) protect the squamous epithelium from insults such as gastroesophageal reflux disease by secreting mucins and bicarbonate. We have observed metaplastic changes within the SMG acini that we have termed oncocytic glandular metaplasia (OGM), and necrotizing sialometaplasia-like change (NSMLC). The aim of this study is to evaluate the associated clinicopathological parameters of, and to phenotypically characterize the SMG metaplasias. Esophagectomy specimens were retrospectively assessed on hematoxylin and eosin sections and assigned to either a Barrett's esophagus (BE) or non-BE control group. Clinicopathologic data was collected, and univariate analysis and multivariate logistic regression models were performed to assess the adjusted associations with NSMLC and OGM. Selected cases of SMG metaplasia were characterized. SMG were present in 82 esophagi that met inclusion criteria. On univariate analysis, NSMLC was associated with BE (p = 0.002). There was no relationship between NSMLC and patient age, sex, tumor size, or treatment history. OGM was associated with BE (p = 0.031). No relationship was found between OGM and patient age, sex, or tumor size. On multivariate analysis, BE was independently associated with NSMLC (odds ratio [OR] 4.95, p = 0.003). Treatment history was also independently associated with OGM (p = 0.029), but not NSMLC. Both NSMLC and OGM were non-mucinous ductal type epithelia retaining a p63-smooth muscle actin co-positive myoepithelial cell layer. NSMLC and OGM were present in endoscopic mucosal resection specimens. Our study suggests that SMG metaplasia is primarily a reflux-induced pathology. NSMLC may pose diagnostic dilemmas in resection specimens or when only partially represented in mucosal biopsies or endoscopic resection specimens.

Necrotizing sialometaplasia of the palatal mucosa in patient with history of anorexia: review and case report

Necrotizing sialometaplasia is a self-limiting disorder affecting minor salivary glands resembling a malignant process both clinically and histopathologically. The etiology of this rare inflammatory` disorder is related to an ischemic event. Identified risk factors include alcohol abuse, smoking, drugs, denture wearing, injury and systemic diseases. Also reported are cases of necrotizing sialometaplasia associated with bulimia. This paper identifies the whole body incitement among additional risk factors by presenting a case of necrotizing sialometaplasia in an 18 year old patient with the history of anorexia nervosa. Furthermore it describes the effects of extreme cooling of palatal mucosa with ice chips resulting in constriction of blood vessels as the direct cause, reinforcing ischemic etiology of necrotizing sialometaplasia.

HIF-1α, VEGF, and EGFR: contributing factors in the pathogenesis of necrotizing sialometaplasia

OBJECTIVES

Necrotizing sialometaplasia (NS) is an uncommon reactive lesion involving the minor salivary glands. This study aimed to investigate the expression of hypoxia-inducible factor alpha (HIF-1α), vascular endothelial growth factor (VEGF), and epithelial growth factor receptor (EGFR) in the pathogenesis of NS.

METHODS

Paraffin-embedded tissue sections from 10 cases of NS were immunohistochemically stained for HIF-1α, VEGF, and EGFR. A semiquantitative morphometric analysis was performed and compared with normal palatal salivary glands and traumatic ulcerations.

RESULTS

Hypoxia-inducible factor alpha staining was observed in most elements of the affected area, the acini and ducts of the involved salivary glands as well as in the inflammatory infiltrate, the endothelial cells, and stromal cells. HIF-1α was almost absent in the control glands (P < 0.0001). VEGF staining was positive in the stromal capillaries and in the inflammatory infiltrate. The expression was higher in cases of NS compared with the normal salivary glands (P < 0.001). EGFR was expressed in the surface epithelium, the pseudo-epitheliomatous hyperplasia, and the islands of squamous metaplasia. VEGF expression in traumatic ulcerations was lower than that in cases of NS.

CONCLUSION

This study provides molecular evidence to the role of hypoxia in NS; HIF-1α, the main regulator of hypoxia, was expressed in the infarcted salivary glands, EGFR in the metaplastic epithelium and VEGF in the stromal capillaries, all three components are the key factors induced by hypoxia.

Necrotising sialometaplasia in the floor of mouth

INTRODUCTION

Necrotising sialometaplasia is a benign self-limiting inflammatory process which occurs in the salivary gland tissue. The condition is a diagnostic challenge mimicking malignancy both clinically and histopathologically. Commonly, it presents in the hard palate.

CASE REPORT

Here, we report an unusual case in a 56-year-old man which presented in the floor of the mouth.

Necrotizing sialometaplasia in a patient with an eating disorder: palatal ulcer accompanied by dental erosion due to binge-purging

This report describes a case of necrotizing sialometaplasia (NS) accompanied by significant dental erosion of the maxillary teeth of the palatal surfaces owing to chronic self-induced vomiting. This observation contributed to the determination of an immediate and appropriate provisional diagnosis of NS in a patient with an eating disorder, which subsequently was confirmed histopathologically as NS. The diagnostic challenges presented by NS associated with eating disorders and its management are discussed.