Salivary Gland Diseases- Reactive Lesions

Reactive Lesions

Mucocele is a clinical term that includes mucus extravasation phenomenon and mucus retention cyst. Because each has a distinctive pathogenesis and microscopy, they are considered separately. Ranula is a clinical term that also includes mucus extravasation phenomenon and mucus retention cyst, but it occurs specifically in the floor of the mouth. Ranula is associated with the sublingual or submandibular glands and presents as a fluctuant, unilateral,soft tissue mass. It often exhibits a bluish color that has been compared to a frog's belly; hence the term ranula. When it is significantly large, it can produce medial and superior deviation of the tongue. It may also cross the midline if the retained mucin dissects through the submucosa. A deep, so-called plunging ranula develops if mucus herniates through the mylohyoid muscle and along the fascial planes of the neck. On rare occasions it may progress into the mediastinum.

The Salivary glands Disease which are included into Reactive Lesions:

1. Mucus Extravasation phenomenon/ Mucocele

2. Mucus Retention cyst/ Ranula

3. Maxillary Sinus Retention Cyst/ Pseudocyst

4. Necrotizing Sialometaplasia

5. Adenomatoid Hyperplasia 

1. Mucus Extravasation Phenomenon

Etiology and Pathogenesis

The cause of mucocele is traumatic severance of a salivary gland excretory duct, resulting in mucus escape, or extravasation, into the surrounding connective tissue. An inflammatory reaction of neutrophils followed by macrophages ensues. Granulation tissue forms a wall around the mucin pool, and the contributing salivary gland undergoes inflammatory change. Ultimately, scarring occurs in and around the
gland.

Clinical Features

The lower lip is the most common site of mucocele, but the buccal mucosa, anterior-ventral surface of the tongue (location of Blandin-Nuhn glands), floor of the mouth, and retromolar region are often affected. Lesions are uncommonly found in other intraoral regions where salivary glands are located, probably because of a lower susceptibility to trauma. Mucus extravasation phenomenon presents as a relatively painless smooth-surfaced mass ranging in size from a few millimeters to 2 cm in diameter. It has a bluish color when mucin is superficially located. Adolescents and children are more commonly affected than adults. Lesions may fluctuate in size because of mucosal rupture over the pooled mucin. Continued production of mucin leads to recurrence. The maximum size is usually reached within several days after injury, and a viscous material is found if aspiration is attempted. Superficial mucocele is a variant of the extravasation type mucocele. Rather than arising from traumatic duct rupture, this form of mucocele is believed to arise as a result of increased pressure in the outer most part of the excretory duct. These lesions are asymptomatic and numerous, occurring most commonly in the retromolar area, soft palate, and posterior buccal mucosa. Their clinical appearance suggest a vesiculobullous disease, but the lesions persist for an extended time. Other than being a diagnostic challenge, they are of little significance.

                                                      retention mucocele on the lower lip

Histopathology

Extravasation of free mucin incites an inflammatory response that is followed by connective tissue repair. Neutrophils and macrophages are seer and granulation tissue forms around the mucin pool. The adjacent salivary gland whose duct was transected shows ductal dilation, chronic inflammation, acinar degeneration, and interstitial fibrosis.

                  histopathologic image of extravasation type mucocele from lower lip

Differential Diagnosis 

Although a history of a traumatic event followed by development of a bluish translucency of the lower lip is characteristic of mucus extravasation phenomenon, other lesions might be considered when a typical history is absent. These include salivary gland neoplasm (especially mucoepidermoid carcinoma), vascular malformation, venous varix, and soft tissue neoplasm such as neurofibroma or lipoma. Rarely, a mucocele may appear in the alveolar gingival mucosa. When this is the case, an eruption cyst or gingival cyst should be included in the differential diagnosis.

Treatment and Prognosis

The treatment of mucus extravasation phenomenon is surgical excision. Aspiration of the fluid content provides no lasting clinical benefit. Removal of the associated minor salivary glands along with the pooled mucus is necessary to prevent recurrence. No treatment is required for superficial mucoceles, since they rupture spontaneously and are short-lived.

                                                      Surgical excision of the mucocele

SM entertainment plans to make SHINee disbanded??

 Rumors and Clarifications due to Jonghyun's scandal

(By 2ndAdm. reblogged by me: Livia)

This is just a collation of what have been going on right now, and the reason why i’m doing this.
(A lot of people have said that they don’t get the way i think most of the time… so i thought i needed to explain. And i don’t do things without considering.)
I am not a pessimist, neither am i really an optimist. I’m more of a realist.
Believe me, I really didn’t want to know what i knew, but i did. I just decided to take the stand of a fan and do something about it. And the reason why i’m saying this, is because i have faith, that fans definitely will be able to think and find out what they want to do, if something like this do happen.
As all of you followers might know, i’ve said before yesterday that i’d want to wait till the rumors are confirmed (to be true) before revealing it.


So why did i decide to release it now?


1. Other facts accounts have been found tweeting them already today. 
I’ll not say what fact account, but… at this rate, other accounts will follow on and retweet it or spread it and if any of the popular news sites get whiff of it.
The chances of it being twisted till it’s beyond salvation is definitely there.
So i decided to get it done and over with and release them while clarifying it.
Take note, THEY’RE ALL STILL RUMORS.


2. Better to know now then when it really happens.
There are only 2 answers to this matter. It happens, or it doesn’t happen.
If it happens, then its great, most of us will be ready for it.
If it doesn’t, precaution is already taken, if it all goes well, SHINee might have a booming comeback. Great album sales and what not.
And if it doesn’t, the possibilities of it happening in the future is still there. And if things continue at this rate, it would inevitably end in a disbandment.


3. It is pretty much confirmed that the pictures of Jjong and Shin Sekyung was staged.
Reminder. I did NOT say for even once that their relationship is fake. (Neither did i say it was real~)
I was just saying, that the pictures taken are fake.
- Jjong is known (in several fan cams anyway) to have a pretty sharp eye, and he spots cameras easily.
- The cameras (resolution and stuff) all adds up to it being pretty huge. (Definitely not a small camera, possibly a canon model.)
- The angles of the camera proves that, the photographer(s) were not in hiding. They can’t possibly take such pictures while hiding behind lamp posts etc.
- The pictures are only of them dating for one day. Same clothes, same day, same time.
However, of course, this still stands as a rumor until something appears to clarify it.

4. I know some people will leave SHINee World when reading these.
There’s no need to tell me that, i am fully aware of the consequences. But then again, if it’s really true, and when that really happens, they’ll leave anyway. Better to leave now unhurt, then leave with a broken heart.
If it doesn’t happen, then no harm’s done, they can come back if they want to. (I hold no responsibilities to what the other fans might do.)
That aside. 
Then appeared several rumors, all different, but all meaning the same thing.

                                            SM debuted artists


Here are what i posted on twitter before. The common points of the rumors. 
1. Jjong’s scandal photos was planned ahead by sm. 
2. Sm plans to get rid of SHINee’s idol image. Esp. Jjong
3. They plan to let jjong debut solo. (leaving SHINee with 4 members)
4. After jjong debuts solo, the other 4 remains and slowly fades off. Then disbanded. With a reason of inactivity or low profits.
5. Sm is in a financial crisis.
==
Ok, now people are saying, it’s definitely a rumor as SHINee have only debuted for 2 years, and they are an asset to SMEnt.


Let’s think over.
1. SHINee is not popular at all in Korea, but they are popular internationally. 
Not a big deal? Since International fans overpowers Korean fans in size?
How about thinking of things in another angle.
You’re not from Korea. Albums will be higher priced in your country (if they do sell it) due to shipping rates.
Even if they are cheap in your country, they’ll reach u slower. (Meaning, you can’t aid SHINee in winning awards in music shows.)
You’re not from Korea, and they aren’t sold in your country. Only one choice. Buy it off online, where the possibilities of it being OVERLY PRICED are pretty high. Usually u’ll buy in bulk to share the shipping rate. (Where most people would decide to not buy, or buy in future when other albums are released or buy with friends)
Then again, you can’t aid SHINee in winning awards.
Regardless of what you say, Awards are gauges to companies in the popularity rate of an idol group in their country, if you’re not popular, you’re not worth investing.
If this continues on, obviously SM Ent wouldn’t value SHINee as much.


2. Even new groups that debuted after SHINee are much more popular and appealing to the mass, and they receive much more endorsements and projects.
SHINee’s image is ever changing, and every image can’t appeal to everyone.
If this continues on, there won’t be more profit going into SM compared to other groups with much better “image”. And if they are indeed in a financial crisis, i don’t see why they won’t drop them, since, cultivating and promoting a group does cost money. (Even f(x) has more projects than SHINee at their time)


3. Better to stop investing right now (and lose more money) then continue investing in a group that >might< not become famous. 
Even more so if they’re in a financial crisis. Risks are not to be meddled with at this stage.
SM isn’t a charity case, they’re a business.
==
Cause of what they’re doing right now and why they’re doing it.
No one knows exactly for sure, and different rumors hold different causes.
Some said that SM Ent was being blackmailed, some said that SM Ent already planned this way before. Another was that they just didn’t have the money to invest.
Regardless of the cause. there’s only one thing we need to be sure of.
SM Ent doesn’t really see SHINee as an important asset.
==
And like what i said before
All these aside, rumors or not, i think, if we just disregard, and it becomes true, it’d be too late to change anything. Too late to help.
so please think over and decide where you stand.
Be angry and “burn” sm with ur words, become an anti, stop buying their albums.
And inevitably, destroy SHINee with your own hands. As if you stop buying their albums = Sales for SHINee will go down = All the more reason for them to stop investing in SHINee.
There is almost no way to go against SM Entertainment, without destroying your own idol.
be a fan, forget revenge, and show sm that SHINee is a group worth investing in. If not, help them accomplish their goal 1 last time, their last album release as a group, help them, win at an overwhelming rate, let them leave with good memories.
If it all goes well, SM Ent might even reconsider their plan and invest in them more.
Even if the plan was just a pure rumor, they have never thought of disbanding SHINee or letting any member debut as a solo artiste, doing such will definitely increase their value in the eyes of the company. Which further ensures their safety.
==
Anyway, if i really wanted to bull shit all of this through, i’d have listed down every single rumor i’ve read and heard, and all of you would be screaming your heads out by now. Who knows, some of them might even be facts.
Believe me, i’ve screamed my head off and cried when i learnt all these, way before most of you found out. I just decided to do this, because i didn’t want to just sit there and let it happen in front of me. 


sources: http://leaderonewfacts.tumblr.com/post/1438242815/rumors-and-clarifications

LEUKOEDEMA

Leukoedema merupakan plak putih yang terletak  pada mukosa bukal yang dianggap sebagai variasi normal. Hal ini dapat diidentifikasi dalam mayoritas penduduk.

Etiologi dan Patogenesis.
Sampai saat ini, penyebab leukoedema belum ditetapkan secara pasti. Faktor-faktor seperti merokok, konsumsi alkohol, infeksi bakteri, saliva kondisi, dan interaksi elektrokimia diduga dapat mempengaruhi, tetapi tidak ada yang terbukti secara klinis.

Gejala klinis
Leukoedema biasanya ditemukan sebagai temuan insidentil. Biasanya asimtomatik dan simetris terdapat pada mukosa bukal. Lesi muncul secara menyebar/difus, abu-abu putih, filmy, memiliki permukaan seperti susu. Dalam banyak kasus, terdapat plak keputihan dengan perubahan tekstur permukaan mukosa, termasuk kerutan. Dengan peregangan bukal mukosa, perubahan opak menghilang. Gambaran ini terlihat lebih jelas pada ras non-kulit putih, terutama Afrika-Amerika.

                                              leukoedema; lesi terletak pada sisi lateral lidah

                                                      leukoedema; lesi terletak pada mukosa bukal

Histopatologi
 Dalam leukoedema epitel mengalami parakeratosis dan akantosis, dengan edema intraseluler. Sel-sel epitel yang membeasar mempunyi inti pyknotic kecil. 

Diagnosa Banding
white sponge nevus, diskeratosis intraepitel  jinak herediter , Lichen Planus.

White Sponge Nevus

White Sponge Nevus (WSN) adalah suatu kondisi klinis dari kelainan autosomal dominan yang tampaknya disebabkan oleh keratin 4 dan / atau 13 titik mutasi. Ini mempengaruhi mukosa oral bilateral, dan pengobatan tidak diperlukan. 

Gambaran  Klinis

Bersifat asimptomatis,  lesi berlekuk-lekuk, putih yang dapat mempengaruhi beberapa bagian mukosa rongga mulut. Lesi cenderung menebal dan memiliki konsistensi kenyal. Presentasi intraoral hampir selalu bilateral dan simetris dan biasanya muncul sebelum masa puber. Karakteristik klinis manifestasi dari bentuk tertentu dari keratosis biasanya lebih jelas diamati pada buccal mukosa, meskipun pada bagian lain seperti lidah dan mukosa vestibular juga mungkin terkena. 

Histopatologi

 epitelium sangat menebal, dengan ditandai  spongiosis, acanthosis, dan parakeratosis. Pada lapisan spinosum , perubahan sel yang ditandai jelas, sering dimulai di lapisan parabasal dan meluas sangat dekat dengan permukaan. Terdapat Perinuclear kondensasi eosinofilik dari sitoplasma. Hal ini sering mungkin untuk melihat lapisan parakeratin membentang dari lapisan spinosum sampai permukaan.

Diagnosa Banding

 Diagnosis diferensial mencakup factor herrediter, dyskeratosis jinak epitel, lichen planus, reaksi obat lichenoid, lupus eritematosus, trauma gigitan pada bukal, dan kemungkinan kandidiasis. Setelah diagnosis jaringan dikonfirmasi, tidak ada tambahan biopsi \diperlukan.

Geographic Tongue

Etiologi

Geographic Tongue, juga dikenal sebagai erythema migrans dan glossitis migrasi jinak, merupakan suatu kondisi yang tidak diketahui penyebabnya. Dalam beberapa pasien stres emosional mungkin meningkatkan proses pembentukan lesi ini. Georaphic tongue telah dikaitkan dengan beberapa kondisi berbeda, termasuk psoriasis, dermatitis seboroik, Sindrom Reiter, dan atopi. 

Gejala Klinis

Geografis lidah diderita sekitar 2% dari populasi penduduk AS. Perempuan sedikit lebih sering menderita daripada pria. Anak-anak terkadang juga dapat terkena. Ciri-ciri klinis awalnya adalah ditandai oleh kehadiran plak atrofik merah yang dikelilingi margin keratotik berwarna putih. Daerah yang epitelnya ter-desquamasi (mengelupas) tampak merah dan mungkin sedikit lunak. Setelah dilakukan pemantauan selama beberapa hari atau minggu, pola lesi mengalami perubahan dan muncul di sekitar dorsum lidah. Ada hubungan kuat antara Geographic tongue dan fissured tongue. hubungan antar keduanya belum diketahui secara signifikan, walaupun gejalanya lebih umum pada saat Fissured tongue muncul, hal ini dimungkinkan karena infeksi sekunder oleh jamur pada dasar fisur sehingga dapat memicu adanya Geographic tongue. Perubahan klinis yang sama dapat terjadi dalam mukosa dasar mulut, mukosa bukal, dan gingiva.
Lesi atrofi merah dan margin keratotic putih mengikuti struktur morfologi lidah. Meskipun kebanyakan pasien dengan lidah geografis tanpa gejala, kadang-kadang pasien mengeluh iritasi, terutama dalam kaitannya dengan konsumsi makanan pedas dan minuman beralkohol. beratnya gejala bervariasi dengan waktu dan sering kali merupakan indikator intensitas proses perkembangan lesi. Lesi menghilang secara berkala dan berulang tanpa sebab yang jelas. 

                                        terdapat lesi atrofik merah dengan margin putih yang keratotik


Histopatologi

Papila filiformis mengalami atrofi, margin lesi menunjukkan hiperkeratosis dan akantosis. Lebih dekat ke bagian tengah dari lesi, berdekatan dengan daerah eritema(kemerahan), terjadi hilangnya keratin, intraepitel neutrofil dan limfosit. Leukosit sering terdapat dalam microabses dekat permukaan. Sel radang berinfiltrasi menuju lapisan lamina propria. sel-sel radang tersebut berupa neutrofil, limfosit, dan sel plasma. 

                                         Geographic tongue, dengan epitel yang mengalami hiperkeratosis



Diferensial Diagnosis/ Diagnosa banding

Berdasarkan penampilan klinis, geografis lidah biasanya diagnostik. Hanya mungkin jarang diperlukan biopsi untuk diagnosis definitif. Dalam kasus samar, diferensial diagnosis klinis mungkin termasuk kandidiasis, leukoplakia, lichen planus, dan lupus eritematosus.

Perawatan dan Prognosis 

Karena membatasi diri dan biasanya secara alami tanpa gejala, pengobatan tidak diperlukan. Namun, ketika gejala-gejala muncul, pengobatan empiris. manfaat yang cukup mungkin diperoleh dengan menjaga kebersihan rongga mulut dengan menggunakan mouthrinse yang terdiri dari natrium bikarbonat dalam air. Topicalsteroid, terutama yang mengandung antijamur, dapat membantu dalam mengurangi gejala. Meyakinkan pasien bahwa kondisi ini benar-benar jinak dan tidak menandakan penyakit dapat membantu meredakan kecemasan.