eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Necrotizing Sialometaplasia

Author: John Svirsky, DDS, Director of Dental Diagnostic Services, Professor, Department of Oral Pathology, Virginia Commonwealth University School of Dentistry
Coauthor(s): John E Fantasia, DDS, Attending, Chief, Division of Oral Pathology, Department of Dermatology, Long Island Jewish Medical Center, North Shore - Long Island Jewish Health System; Josephine Wu, DDS, Assistant Director, Molecular Pathology Laboratory, Department of Pathology, Mount Sinai School of Medicine, Consulting Staff, Division of Oral and Maxillofacial Pathology, Department of Dental Medicine, Long Island Jewish Medical Center
Contributor Information and Disclosures

Updated: Oct 28, 2008

Introduction

Background

Necrotizing sialometaplasia (NS) is a nonneoplastic inflammatory condition of the salivary glands. In 1973, Abrams et al first reported this condition.1 The clinical and histopathologic features of necrotizing sialometaplasia often simulate those of malignancies such as squamous cell carcinoma or salivary gland malignancy.2 All subsequent reports of necrotizing sialometaplasia stress the importance of correct diagnosis. Familiarity with necrotizing sialometaplasia and correct diagnosis are paramount in avoiding misdiagnosis and inappropriate treatment. Ischemia of salivary gland tissue leading to infarction (trauma) is the most likely cause.

A related eMedicine article that may be of interest is Cancers of the Oral Mucosa.

Pathophysiology

Necrotizing sialometaplasia was first reported to involve the minor salivary glands of the oral cavity, particularly those of the palate. Seventy-five percent of all cases occur on the posterior palate.3 Most are unilateral, with one third occurring in a bilateral or midpalatal location. Reports of this entity in the minor glands of the retromolar pad area, buccal mucosa, tongue, incisive canal, and labial mucosa followed. In addition, necrotizing sialometaplasia is recognized in the parotid and submandibular salivary glands,4 minor mucous glands in the lung,5 nasal cavity,6,7 larynx,8,9 trachea,10 nasopharynx, and maxillary sinus.11 Similar lesions are identified in the breast; the condition is referred to as posttraumatic lobular metaplasia of the breast.12

Frequency

United States

Mesa and colleagues reported an incidence of 0.03% based on findings in 10,000 oral biopsy specimens.13 However, they state that this percentage does not account for cases of necrotizing sialometaplasia that heal spontaneously without biopsy.

International

Necrotizing sialometaplasia is reported worldwide. Isolated cases and reviews from Europe, North America, South America, and Asia are reported in the literature.

Mortality/Morbidity

The lesions of necrotizing sialometaplasia often are painless; less frequently, they cause pain and numbness. The clinical appearance that suggests cancer is the significant feature of this lesion. The clinical pictures show a patient with a lesion thought to be cancer who underwent biopsy and was monitored for 9 weeks. Over that time, regression of the lesion can be seen (see Media Files 1-4).

Race

  • Brannon and colleagues14 reported that cases of necrotizing sialometaplasia in whites outnumbered cases in blacks by a ratio of 4.9:1.
  • Given the ratio of whites to blacks in the United States, a significant racial predilection does not appear to exist.

Sex

  • The male-to-female ratio is approximately 2:1.

Age

  • The average age of patients with necrotizing 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 for female patients and 50.3 years for male patients.
  • A case of necrotizing sialometaplasia in an 18-month-old infant is reported.

Clinical

History

  • Most cases of necrotizing sialometaplasia appear to arise spontaneously, whereas others are associated with a history of trauma, vomiting,15,16 radiation therapy, or surgery.15
  • An association with neoplasia, such as parotid tumors, false vocal cord squamous cell carcinoma, and maxillary sinus carcinoma, is also reported.
  • Cases associated with inflammatory conditions such as relapsing polychondritis and acute and chronic sinusitis have been noted to occur in the subglottic and sinus regions, respectively.

Physical

  • Necrotizing sialometaplasia manifests as a swelling with or without ulceration in anatomic sites that have mucous or serous glandular tissue.
  • The typical clinical presentation of necrotizing sialometaplasia is that of a crateriform ulcer of the palate that simulates a malignant process. These ulcerated lesions are 1-3 cm and are usually unilateral, but bilateral synchronous lesions and metachronous lesions can occur.17,18
  • Some lesions of necrotizing sialometaplasia may present as a submucosal swelling, without ulceration of the overlying mucosa. An intact surface mucosa may be noted in an evolving lesion at the time of diagnosis, although most cases are accompanied by mucosal ulceration.
  • 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 a malignant or infectious process or an inflammatory condition such as Wegener granulomatosis.
  • Extranodal lymphoma also may be considered in the clinical differential diagnosis of a palatal swelling or ulceration.

Causes

  • In most cases of necrotizing sialometaplasia, the etiology is believed to be related to vascular ischemia.
  • Cases are reported in which vascular compression is caused by a necrotic myocutaneous reconstruction flap, embolization from carotid endarterectomy, sickle cell anemia,19 Buerger disease,20 or Raynaud phenomenon.20
  • The association of adjacent neoplasia that results in ischemic necrosis of the glandular elements and the histologic features of necrotizing sialometaplasia supports this pathogenic mechanism.
  • In an experimental study in a rat model, local anesthetic injections induced necrotizing sialometaplasia.21
  • Tobacco use is suggested as a possible etiologic risk factor for necrotizing sialometaplasia.

More on Necrotizing Sialometaplasia

Overview: Necrotizing Sialometaplasia
Differential Diagnoses & Workup: Necrotizing Sialometaplasia
Treatment & Medication: Necrotizing Sialometaplasia
Follow-up: Necrotizing Sialometaplasia
Multimedia: Necrotizing Sialometaplasia
References
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References

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Further Reading

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Keywords

necrotizing sialometaplasia, NS, salivary gland inflammation, ischemia of salivary gland

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Contributor Information and Disclosures

Author

John Svirsky, DDS, Director of Dental Diagnostic Services, Professor, Department of Oral Pathology, Virginia Commonwealth University School of Dentistry
John Svirsky, DDS is a member of the following medical societies: American Academy of Oral Medicine and American Dental Association
Disclosure: Nothing to disclose.

Coauthor(s)

John E Fantasia, DDS, Attending, Chief, Division of Oral Pathology, Department of Dermatology, Long Island Jewish Medical Center, North Shore - Long Island Jewish Health System
John E Fantasia, DDS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology
Disclosure: Nothing to disclose.

Josephine Wu, DDS, Assistant Director, Molecular Pathology Laboratory, Department of Pathology, Mount Sinai School of Medicine, Consulting Staff, Division of Oral and Maxillofacial Pathology, Department of Dental Medicine, Long Island Jewish Medical Center
Josephine Wu, DDS is a member of the following medical societies: American Academy of Oral and Maxillofacial Pathology and American Association for Cancer Research
Disclosure: Nothing to disclose.

Medical Editor

Abdul-Ghani Kibbi, MD, Chairman and Professor, Department of Dermatology, American University of Beirut Medical Center, Lebanon
Disclosure: none None None

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
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