Necrotizing Sialometaplasia -

8/10/2019 Necrotizing Sialometaplasia -

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Oleh:

Drg. Jaka kusnanta W., Sp BM



Necrotizing sialometaplasia is a benign ulcerative lesion found mostly on the

posterior hard palate. It is due to a necrosis of

minor salivary glands due to trauma (often palatal

infiltrations of local anaesthetic or trauma during

intubation).

http://en.wikipedia.org/wiki/Hard_palate

http://en.wikipedia.org/wiki/Necrosis

http://en.wikipedia.org/wiki/Salivary_gland

http://en.wikipedia.org/wiki/Physical_trauma

http://en.wikipedia.org/wiki/Local_anaesthetic

http://en.wikipedia.org/wiki/Intubation

http://en.wikipedia.org/wiki/Intubation



http://en.wikipedia.org/wiki/Physical_trauma

http://en.wikipedia.org/wiki/Salivary_gland

http://en.wikipedia.org/wiki/Necrosis

http://en.wikipedia.org/wiki/Hard_palate



is a nonneoplastic inflammatory

condition of the salivary glands.The clinical and histopathologic

features of necrotizingsialometaplasia often simulate

those of malignancies such assquamous cell carcinoma or

salivary gland malignancy .



Tanda dan gejalaGejala :

Ulcerasi yg sakit di palatum

Tanda:Lokasi : bagian tengah palatum durum

di antara raphe palatal dan tepi gingiva

Biasanya di daerah molarPada bbrp kasus ditemukan juga di

bibir dan retromolar pad



Jumlah : satu

Ukuran : diameter bisa mencapai 2 cmBentuk: bulat dg tepi tdk beraturan

Jaringan dasar : tulang palatalDasar lesi : kekuningan disertai debris

necrotik

Tepi lesi : masuk kedalam ataumenonjol disertai indurasi









Pathophysiology

Necrotizing sialometaplasia was first

reported to involve the minor salivary glandsof the oral cavity, particularly those of thepalate. Seventy-five percent of all cases

occur on the posterior palate.

Most areunilateral, with one third occurring in abilateral or midpalatal location. Reports ofthis entity in the minor glands of the

retromolar pad area, buccal mucosa,tongue, incisive canal, and labial mucosafollowed



In addition, necrotizing

sialometaplasia is recognized in theparotid and submandibular salivaryglands, minor mucous glands in the

lung,nasal cavity,

larynx,trachea,

nasopharynx, and maxillary sinus.Similar lesions are identified in the

breast; the condition is referred to asposttraumatic lobular metaplasia of thebreast.



Pathogenesis The initial cause is unknown, but

necrotizing sialometaplasia is due torestriction of blood supply or damage to

the salivary tissue. The lesion usually

occurs at the juncture of the hard andsoft palate. Because of the damaged

appearance of the tissue, the patient may

be extremely anxious after noticing thislesion , tooth brushing of the lesion may

produce exudate or bleeding , adding to

the frightening appearance.



Etiology:

The cause of necrotizingsialometaplasia is not known, but it isusually preceded by trauma. It is locally

destructive, with inflammation to anarea of tissue resulting in damage andischemic necrosis. This may occur not

only in the salivary glands but also insinus/nasal tracts and the respiratorytract.



In most cases of necrotizing

sialometaplasia, the etiology is believedto be related to vascular ischemia.Cases are reported in which vascular

compression is caused by a necroticmyocutaneous reconstruction flap,embolization from carotid

endarterectomy, sickle cellanemia,Buerger disease,or Raynaudphenomenon.



The association of adjacent neoplasia

that results in ischemic necrosis of theglandular elements and the histologicfeatures of necrotizing sialometaplasiasupports this pathogenic mechanism.In an experimental study in a ratmodel, local anesthetic injectionsinduced necrotizing sialometaplasia.

Tobacco use is suggested as a possibleetiologic risk factor for necrotizingsialometaplasia.



Epidemiology: Men are reported to develop necrotizing

sialometaplasia more often than women by a2:1 ratio. The palatal salivary glands are

involved in 75% of cases, and thesubmandibular and sublingual glands arerarely involved (but there are reported casesthat do involve these areas). The initial

lesion may present as a tissue swelling and within several weeks develop into the crater-like lesion presented in the case study.



whites outnumbered cases in blacks by a

ratio of 4.9:1..The average age of patients withnecrotizing sialometaplasia in the Armed

Forces Institute of Pathology (AFIP)registry is 47.9 years, with a range of 17-80 years. The average age is 43.1 years forfemale patients and 50.3 years for male

patients. A case of necrotizingsialometaplasia in an 18-month-old infantis reported



Mortality/Morbidity

The lesions of necrotizing sialometaplasiaoften are painless; less frequently, they causepain and numbness. The clinical appearance

that suggests cancer is the significantfeature of this lesion. The clinical picturesshow a patient with a lesion thought to be

cancer who underwent biopsy and wasmonitored for 9 weeks. Over that time,regression of the lesion can be seen



History Most cases of necrotizing sialometaplasia appear

to arise spontaneously, whereas others areassociated with a history of trauma, vomiting,

radiation therapy, or surgery. An association with

neoplasia, such as parotid tumors, false vocal cordsquamous cell carcinoma, and maxillary sinuscarcinoma, is also reported. Cases associated withinflammatory conditions such as relapsing

polychondritis and acute and chronic sinusitishave been noted to occur in the subglottic andsinus regions, respectively.



PhysicalNecrotizing sialometaplasia manifests as a

swelling with or without ulceration inanatomic sites that have mucous or serousglandular tissue.

The typical clinical presentation ofnecrotizing sialometaplasia is that of acrateriform ulcer of the palate that simulatesa malignant process. These ulcerated lesionsare 1-3 cm and are usually unilateral, butbilateral synchronous lesions andmetachronous lesions can occur.



Some lesions of necrotizing sialometaplasia maypresent as a submucosal swelling, without ulceration

of the overlying mucosa. An intact surface mucosa maybe noted in an evolving lesion at the time of diagnosis,although most cases are accompanied by mucosalulceration. Erosion of the palatal bone may occur in

either ulcerated or nonulcerated lesions. Examination of a biopsy specimen is usually required

to establish the correct diagnosis and to exclude amalignant or infectious process or an inflammatory

condition such as Wegener granulomatosis.Extranodal lymphoma also may be considered in theclinical differential diagnosis of a palatal swelling orulceration.



Differential Diagnoses Aphthous Stomatitis

Behcet Disease

Squamous Cell Carcinoma

Syphilis

Wegener Granulomatosis

http://emedicine.medscape.com/article/1075570-overview















Aphthous Stomatitis











Behcet Disease







Squamous Cell Carcinoma



Syphilis





Procedur to work up

Imaging Studies

A definitive tissue diagnosis of

necrotizing sialometaplasia shouldexclude the need for radiographicimaging. If erosion of the palatal bone

occurs with or without perforation,radiologic examination may beperformed.



Procedures Incisional biopsy is necessary to establish

the diagnosis of necrotizing sialometaplasia.

An inadequate biopsy specimen may lead tothe misdiagnosis of squamous cellcarcinoma or mucoepidermoid carcinoma.Findings in a superficial or limited biopsy

specimen may be misinterpreted as anonspecific ulcer or pseudoepitheliomatoushyperplasia of the surface mucosa.





Pseudoepitheliomatous hyperplasia of

the overlying mucosa can also bepresent, but the cytologic features ofthe squamous component are usually

bland. Occasionally, isolated mucouscells may be entrapped within thesquamous islands; these cells should

not be confused with those ofmucoepidermoid carcinoma.



The microscopic differential diagnosis

for necrotizing sialometaplasiaincludes mucoepidermoid carcinomaand squamous cell carcinoma. Some

believe that subacute necrotizingsialadenitis is yet another entity thatoccurs within the spectrum ofnecrotizing sialometaplasia; it should

be distinguished from necrotizingsialometaplasia.



Treatment

Analgesics may be needed, as well as

elimination of alcohol and tobacco

when usage is noted. There is no

surgical intervention, but a biopsy withmicroscopic evaluation is needed to

rule out other more serious disease

states so that early intervention may betaken.



The lesion usually heals after

several weeks without anytreatment. In some cases, though,the tissue may take months to fully

respond. A bland baking soda and water mixture is often suggested

along with analgesics. Dietcounseling and nutritionalevaluation is crucial as well.



PrognosisThe prognosis for necrotizing sialometaplasia isexcellent. Spontaneous resolution usually occurs

within weeks, although in the case presented, thelesion took more than 9 weeks to reach completehealing.

The average healing time for necrotizingsialometaplasia of the minor salivary glands of the

hard and soft palates is approximately 5 weeks.The size of the lesion and whether or not bonyperforation has occurred are clinical parametersthat may influence the healing time.

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Necrotizing Sialometaplasia -