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Chronic sclerosing sialadenitis

August 23, 2023

Chronic sclerosing sialadenitis is a chronic (long-lasting) inflammatory condition affecting the salivary gland. Relatively rare in occurrence, this condition is benign, but presents as hard, indurated and enlarged masses that are clinically indistinguishable from salivary gland neoplasms or tumors. It is now regarded as a manifestation of IgG4-related disease.[1]

Chronic sclerosing sialadenitis
SpecialtyDentistry

Involvement of the submandibular glands is also known as Küttner's tumor, named after Hermann Küttner (1870–1932), a German Oral and Maxillofacial Surgeon, who reported four cases of submandibular gland lesions for the first time in 1896.[2]

Presentation

The inflammatory lesions in Küttner's tumor may occur on one side (unilateral) or both sides (bilateral), predominantly involving the submandibular gland,[3] but is also known to occur in other major and minor salivary glands,[4] including the parotid gland.[5][6] Overall, salivary gland tumors are relatively rare, with approximately 2.5–3 cases per 100,000 people per year seen in the Western world; however, salivary gland malignancies account for 3–5% of all head and neck cancers.[7] However, salivary tumors show a great deal of morphological diversity, as well as variations in the nature of the lesion (malignant vs. benign): approximately 20% to 25% of parotid tumors, 35% to 40% of submandibular tumors, and more than 90% of sublingual gland tumors are malignant.[8] This situation underscores the diagnostic challenges in respect of Küttner's tumor; despite being benign, this condition mimics the clinical appearance of malignancy in the salivary gland.

The swollen masses of Küttner's tumor are generally painful, and patients are advised surgical resection (known as 'sialadenectomy') of a part or whole of the glandular tissue upon suspicion of possible malignancy. It is only upon post-surgical histopathology of the excised mass that the diagnosis of Küttner's tumor is definitively made.

Histological features

The histopathological features that characterize Küttner's tumor[9] include:

  • Heavy infiltration of the glandular tissue by lymphocytes (predominantly activated B-cells and helper T-cells) as well as plasma cells (collectively known as 'Lymphoplasmacytic Infiltrate').
  • Presence of reactive lymphoid follicles in the infiltrate, marked by a lack of atypical lymphoid cells (this is in sharp contrast to the presentations in lymphoma).
  • Atrophy and loss of acini (groups of secretory cells found in the salivary glands).
  • Encasement of the glandular ducts in thick fibrous tissues, as a result of chronic presence of inflammatory infiltrate in that area - a condition known as periductal fibrosis.
  • Eventual periductal and interlobular (inside the gland) sclerosis (replacement of regular tissue with hard connective tissue).

Pathogenesis

The cause and pathogenesis of this chronic condition are not very well understood. Several factors have been postulated:

  • Formation of a hard salivary calculus or sialolith by accumulation of calcium salts in the duct of the salivary gland (a process known as Sialolithiasis). This has been proposed as the most common cause for Küttner's tumor of the submandibular gland, with sialoliths observed in an appreciable proportion of cases.[10][11] However, sialolith involvement may not be found in many cases.
  • Abnormalities of the salivary gland ducts leading to excessive accumulation or retention of ductal secretions, which can excite chronic inflammations.[6]
  • Immune, especially autoimmune, cause[12] - which has gained steam, given the observation that the tissue of the glands is overrun with lymphoid immune cells[13] and fibrous connective tissue, as well as corroboration from markedly similar lesions (with histologic and immunohistochemical findings) seen elsewhere in the body.[14][15] The presence of abundant Immunoglobulin G4 (IgG4) associated with Plasma cells infiltrating into the salivary glands, as well as increased serum IgG4 concentration, has been noted with patients with Küttner's tumor.[16][17][18]

This chronic condition is primarily observed in adult (40–70 years) patients. However, Küttner's tumor, with prominent immunopathological features, has been described in an 11-year-old boy in Brazil in 2012.[19]

Diagnosis

Given the difficulties of a definitive pre-operative diagnosis, the clinical entity of Küttner's tumor has so far remained significantly under-reported and under-recognized. In recent times, armed with a better understanding of the occurrences and observable features of this condition, surgeons are increasingly depending upon pre-operative ultrasonography along with Fine-needle aspiration cytological (FNAC) examinations to make an accurate presumptive diagnosis,[20] and according to one estimate, about 44% of patients undergoing submandibular resection are found to have this condition.[20] In the ultrasonogram, Küttner's tumor is characterized by a diffuse, heterogeneous zone of echo-shadows.[21] The FNAC finds cells greatly reduced in number (called 'paucicellularity') along with scattered tubular ducts against a backdrop of lymphoplasmacytic infiltration and fibrous depositions.[21] There may be a reduced but moderate number of cells and ducts enveloped in fibrous sheaths, as well as fibrous proliferation of the gland's septa.[22] The cytologic findings by themselves may not be specific, and the diagnosis requires adjunct consideration of both the ultrasonogram and clinical presentation. Application of magnetic resonance imaging (MRI) has been tried to non-invasively examine the morphological variations in Küttner's tumor and differentiate them from those seen in malignant tumors;[23] while MRI findings of the affected tissue and the pattern of cellular infiltration may offer some diagnostic clues for this condition, so far the results have been inconclusive.[23]

Existing treatment

Standard, and most effective, therapy to date is glandular sialadenectomy, which is associated with fairly low operative morbidity; however, in recent times, the administration of steroid (which can shrink the inflammatory lesion and is known to reduce serum IgG4 values) has been considered favorably,[16][17] and may be useful in younger patients or those who refuse surgery.

See also

References

  1. ^ John H. Stone; Arezou Khosroshahi; Vikram Deshpande; et al. (October 2012). "Recommendations for the nomenclature of IgG4-related disease and its individual organ system manifestations". Arthritis & Rheumatism. 64 (10): 3061–3067. doi:10.1002/art.34593. PMC 5963880. PMID 22736240.
  2. ^ Küttner, H (1896). "Ueber entzündliche Tumoren der submaxillar-speicheldrüse". Beiträge zur Klinischen Chirurgie. 15: 815–828. hdl:2027/uc1.b3731679.
  3. ^ Kiverniti, E; Singh A; Clarke P (2008). "Küttner's tumour: an unusual cause of salivary gland enlargement". Hippokratia. 12 (1): 56–58. PMC 2532958. PMID 18923750.
  4. ^ Blanco, Mario; Mesko T; Cura M; Cabello-Inchausti B (2003). "Chronic sclerosing sialadenitis (Kuttner's tumor): unusual presentation with bilateral involvement of major and minor salivary glands". Annals of Diagnostic Pathology. 7 (1): 25–30. doi:10.1053/adpa.2003.50004. PMID 12616471.
  5. ^ Beriat, GK; Akmansu SH; Kocatürk S; Ataoğlu O (2010). "Chronic Sclerosing Sialadenitis (Küttner's tumour) of the Parotid Gland". Malaysian Journal of Medical Sciences. 17 (4): 57–61. PMC 3216182. PMID 22135562.
  6. ^ a b de Vicente, JC; López-Arranz E; García J; López-Arranz JS (2003). "Chronic sclerosing sialadenitis of the parotid gland". Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 96 (1): 77–80. doi:10.1016/s1079-2104(03)00096-9. PMID 12847448.
  7. ^ Speight, PM; Barrett AW (2002). "Salivary gland tumours". Oral Diseases. 8 (5): 229–240. doi:10.1034/j.1601-0825.2002.02870.x. PMID 12363107.
  8. ^ National Cancer Institute (NCI/NIH) (20 July 2012). "General Information About Salivary Gland Cancer". cancer.gov. Retrieved 15 November 2013.
  9. ^ Chan ACL; Chan JKC; Abbondanzo SL (2005). (PDF). In Leon Barnes; John W. Eveson; Peter Reichart; David Sidransky (eds.). World Health Organization Classification of Tumours: Pathology and Genetics of Head and Neck Tumours. Lyon, France: WHO/IARC Press. p. 278. ISBN 92-83-22417-5. Archived from the original (PDF) on 1 April 2017. Retrieved 15 November 2013.
  10. ^ Epivatianos, A; Harrison JD; Dimitriou T (2006). "Ultrastructural and histochemical observations on microcalculi in chronic submandibular sialadenitis". Journal of Oral Pathology and Medicine. 16 (10): 514–517. doi:10.1111/j.1600-0714.1987.tb00683.x. PMID 3127566.
  11. ^ Chan, JKC (1998). "Kuttner tumor (chronic sclerosing sialadenitis) of the submandibular gland: an underrecognized entity". Advances in Anatomic Pathology. 5 (4): 239–51. doi:10.1097/00125480-199807000-00004. PMID 9859756. S2CID 33288884.
  12. ^ Ikeda, M; Ikui A; Tanaka M; Omori H; Tomita H (1994). "Immunohistopathological investigation on unspecific chronic sclerosing sialadenitis of the submandibular gland (Kuttner tumor)". Auris Nasus Larynx. 21 (2): 103–110. doi:10.1016/s0385-8146(12)80028-9. PMID 7993223.
  13. ^ Tiemann, M; Teymoortash A; Schrader C; Werner JA; Parwaresch R; Seifert G; Klöppel G (2002). "Chronic sclerosing sialadenitis of the submandibular gland is mainly due to a T lymphocyte immune reaction". Modern Pathology. 15 (8): 845–852. doi:10.1097/01.MP.0000022280.72359.04. PMID 12181270.
  14. ^ Tsuneyama, K; Saito K; Ruebner BH; Konishi I; Nakanuma Y; Gershwin ME (2000). "Immunological similarities between primary sclerosing cholangitis and chronic sclerosing sialadenitisreport of the overlapping of these two autoimmune diseases". Digestive Diseases and Sciences. 45 (2): 366–372. doi:10.1023/A:1005429130150. PMID 10711453. S2CID 24581402.
  15. ^ Sekine, S; Nagata M; Watanabe T (1999). "Chronic sclerosing sialadenitis of the submandibular gland associated with idiopathic retroperitoneal fibrosis". Pathology International. 49 (7): 663–667. doi:10.1046/j.1440-1827.1999.00926.x. PMID 10504530. S2CID 21548017.
  16. ^ a b Kamisawa, T; Nakajima H; Hishima T (2006). "Close correlation between chronic sclerosing sialadenitis and immunoglobulin G4". Internal Medicine Journal. 36 (8): 527–529. doi:10.1111/j.1445-5994.2006.01119.x. PMID 16866659. S2CID 33328260.
  17. ^ a b Nagai, K; Andoh K; Ogata A; Aoki N; Nakamura N; Hosaka H; Kurihara R (2010). "A new category for chronic sclerosing sialadenitis as an IgG4 related syndrome". BMJ Case Reports. 2010: bcr1020092412. doi:10.1136/bcr.10.2009.2412. PMC 3028012. PMID 22448185.
  18. ^ Cheuk, W; Yuen HK; Chu SY; Chiu EK; Lam LK; Chan JK (2008). "Lymphadenopathy of IgG4-related sclerosing disease". Am J Surg Pathol. 32 (5): 671–681. doi:10.1097/PAS.0b013e318157c068. PMID 18344866. S2CID 27175700.
  19. ^ Melo, JC; Kitsko D; Reyes-Múgica M (2012). "Pediatric chronic sclerosing sialadenitis: Küttner tumor". Pediatric and Developmental Pathology. 15 (2): 165–169. doi:10.2350/11-04-1023-OA.1. PMID 21985393. S2CID 26785007.
  20. ^ a b Chow, TL; Chan TT; Choi CY; Lam SH (2008). "Kuttner's tumour (chronic sclerosing sialadenitis) of the submandibular gland: a clinical perspective" (PDF). Hong Kong Medical Journal. 14 (1): 46–9. PMID 18239243. Retrieved 15 November 2013.
  21. ^ a b Chou, YH; Tiu CM; Li WY; Liu CY; Cheng YC; Chiou HJ; Chiou SY; Wang HK; Hung GS (2005). "Chronic sclerosing sialadenitis of the parotid gland: diagnosis using color Doppler sonography and sonographically guided needle biopsy". Journal of Ultrasound in Medicine. 24 (4): 551–555. doi:10.7863/jum.2005.24.4.551. PMID 15784774. S2CID 24563080. Retrieved 17 November 2013.
  22. ^ Cheuk, W; Chan, JKC (2002). "Kuttner Tumor of the Submandibular Gland: Fine-Needle Aspiration Cytologic Findings of Seven Case" (PDF). American Journal of Clinical Pathology. 117 (1): 103–108. doi:10.1309/g9t3-22mh-q7kl-g2dl. PMID 11791589. Retrieved 5 December 2013.
  23. ^ a b Abu, A; Motoori K; Yamamoto S; Hanazawa T; Nagai Y; Kaneoya K; Ito H (2008). "MRI of chronic sclerosing sialoadenitis". British Journal of Radiology. 81 (967): 531–536. doi:10.1259/bjr/38960620. PMID 18316344.

External links


August 23, 2023
chronic, sclerosing, sialadenitis, chronic, long, lasting, inflammatory, condition, affecting, salivary, gland, relatively, rare, occurrence, this, condition, benign, presents, hard, indurated, enlarged, masses, that, clinically, indistinguishable, from, saliv. Chronic sclerosing sialadenitis is a chronic long lasting inflammatory condition affecting the salivary gland Relatively rare in occurrence this condition is benign but presents as hard indurated and enlarged masses that are clinically indistinguishable from salivary gland neoplasms or tumors It is now regarded as a manifestation of IgG4 related disease 1 Chronic sclerosing sialadenitisSpecialtyDentistryInvolvement of the submandibular glands is also known as Kuttner s tumor named after Hermann Kuttner 1870 1932 a German Oral and Maxillofacial Surgeon who reported four cases of submandibular gland lesions for the first time in 1896 2 Contents 1 Presentation 2 Histological features 3 Pathogenesis 4 Diagnosis 5 Existing treatment 6 See also 7 References 8 External linksPresentation EditThe inflammatory lesions in Kuttner s tumor may occur on one side unilateral or both sides bilateral predominantly involving the submandibular gland 3 but is also known to occur in other major and minor salivary glands 4 including the parotid gland 5 6 Overall salivary gland tumors are relatively rare with approximately 2 5 3 cases per 100 000 people per year seen in the Western world however salivary gland malignancies account for 3 5 of all head and neck cancers 7 However salivary tumors show a great deal of morphological diversity as well as variations in the nature of the lesion malignant vs benign approximately 20 to 25 of parotid tumors 35 to 40 of submandibular tumors and more than 90 of sublingual gland tumors are malignant 8 This situation underscores the diagnostic challenges in respect of Kuttner s tumor despite being benign this condition mimics the clinical appearance of malignancy in the salivary gland The swollen masses of Kuttner s tumor are generally painful and patients are advised surgical resection known as sialadenectomy of a part or whole of the glandular tissue upon suspicion of possible malignancy It is only upon post surgical histopathology of the excised mass that the diagnosis of Kuttner s tumor is definitively made Histological features EditThe histopathological features that characterize Kuttner s tumor 9 include Heavy infiltration of the glandular tissue by lymphocytes predominantly activated B cells and helper T cells as well as plasma cells collectively known as Lymphoplasmacytic Infiltrate Presence of reactive lymphoid follicles in the infiltrate marked by a lack of atypical lymphoid cells this is in sharp contrast to the presentations in lymphoma Atrophy and loss of acini groups of secretory cells found in the salivary glands Encasement of the glandular ducts in thick fibrous tissues as a result of chronic presence of inflammatory infiltrate in that area a condition known as periductal fibrosis Eventual periductal and interlobular inside the gland sclerosis replacement of regular tissue with hard connective tissue Pathogenesis EditThe cause and pathogenesis of this chronic condition are not very well understood Several factors have been postulated Formation of a hard salivary calculus or sialolith by accumulation of calcium salts in the duct of the salivary gland a process known as Sialolithiasis This has been proposed as the most common cause for Kuttner s tumor of the submandibular gland with sialoliths observed in an appreciable proportion of cases 10 11 However sialolith involvement may not be found in many cases Abnormalities of the salivary gland ducts leading to excessive accumulation or retention of ductal secretions which can excite chronic inflammations 6 Immune especially autoimmune cause 12 which has gained steam given the observation that the tissue of the glands is overrun with lymphoid immune cells 13 and fibrous connective tissue as well as corroboration from markedly similar lesions with histologic and immunohistochemical findings seen elsewhere in the body 14 15 The presence of abundant Immunoglobulin G4 IgG4 associated with Plasma cells infiltrating into the salivary glands as well as increased serum IgG4 concentration has been noted with patients with Kuttner s tumor 16 17 18 This chronic condition is primarily observed in adult 40 70 years patients However Kuttner s tumor with prominent immunopathological features has been described in an 11 year old boy in Brazil in 2012 19 Diagnosis EditGiven the difficulties of a definitive pre operative diagnosis the clinical entity of Kuttner s tumor has so far remained significantly under reported and under recognized In recent times armed with a better understanding of the occurrences and observable features of this condition surgeons are increasingly depending upon pre operative ultrasonography along with Fine needle aspiration cytological FNAC examinations to make an accurate presumptive diagnosis 20 and according to one estimate about 44 of patients undergoing submandibular resection are found to have this condition 20 In the ultrasonogram Kuttner s tumor is characterized by a diffuse heterogeneous zone of echo shadows 21 The FNAC finds cells greatly reduced in number called paucicellularity along with scattered tubular ducts against a backdrop of lymphoplasmacytic infiltration and fibrous depositions 21 There may be a reduced but moderate number of cells and ducts enveloped in fibrous sheaths as well as fibrous proliferation of the gland s septa 22 The cytologic findings by themselves may not be specific and the diagnosis requires adjunct consideration of both the ultrasonogram and clinical presentation Application of magnetic resonance imaging MRI has been tried to non invasively examine the morphological variations in Kuttner s tumor and differentiate them from those seen in malignant tumors 23 while MRI findings of the affected tissue and the pattern of cellular infiltration may offer some diagnostic clues for this condition so far the results have been inconclusive 23 Existing treatment EditStandard and most effective therapy to date is glandular sialadenectomy which is associated with fairly low operative morbidity however in recent times the administration of steroid which can shrink the inflammatory lesion and is known to reduce serum IgG4 values has been considered favorably 16 17 and may be useful in younger patients or those who refuse surgery See also EditSialadenitisReferences Edit John H Stone Arezou Khosroshahi Vikram Deshpande et al October 2012 Recommendations for the nomenclature of IgG4 related disease and its individual organ system manifestations Arthritis amp Rheumatism 64 10 3061 3067 doi 10 1002 art 34593 PMC 5963880 PMID 22736240 Kuttner H 1896 Ueber entzundliche Tumoren der submaxillar speicheldruse Beitrage zur Klinischen Chirurgie 15 815 828 hdl 2027 uc1 b3731679 Kiverniti E Singh A Clarke P 2008 Kuttner s tumour an unusual cause of salivary gland enlargement Hippokratia 12 1 56 58 PMC 2532958 PMID 18923750 Blanco Mario Mesko T Cura M Cabello Inchausti B 2003 Chronic sclerosing sialadenitis Kuttner s tumor unusual presentation with bilateral involvement of major and minor salivary glands Annals of Diagnostic Pathology 7 1 25 30 doi 10 1053 adpa 2003 50004 PMID 12616471 Beriat GK Akmansu SH Kocaturk S Ataoglu O 2010 Chronic Sclerosing Sialadenitis Kuttner s tumour of the Parotid Gland Malaysian Journal of Medical Sciences 17 4 57 61 PMC 3216182 PMID 22135562 a b de Vicente JC Lopez Arranz E Garcia J Lopez Arranz JS 2003 Chronic sclerosing sialadenitis of the parotid gland Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontology 96 1 77 80 doi 10 1016 s1079 2104 03 00096 9 PMID 12847448 Speight PM Barrett AW 2002 Salivary gland tumours Oral Diseases 8 5 229 240 doi 10 1034 j 1601 0825 2002 02870 x PMID 12363107 National Cancer Institute NCI NIH 20 July 2012 General Information About Salivary Gland Cancer cancer gov Retrieved 15 November 2013 Chan ACL Chan JKC Abbondanzo SL 2005 Chapter 5 Tumours of the Salivary Glands PDF In Leon Barnes John W Eveson Peter Reichart David Sidransky eds World Health Organization Classification of Tumours Pathology and Genetics of Head and Neck Tumours Lyon France WHO IARC Press p 278 ISBN 92 83 22417 5 Archived from the original PDF on 1 April 2017 Retrieved 15 November 2013 Epivatianos A Harrison JD Dimitriou T 2006 Ultrastructural and histochemical observations on microcalculi in chronic submandibular sialadenitis Journal of Oral Pathology and Medicine 16 10 514 517 doi 10 1111 j 1600 0714 1987 tb00683 x PMID 3127566 Chan JKC 1998 Kuttner tumor chronic sclerosing sialadenitis of the submandibular gland an underrecognized entity Advances in Anatomic Pathology 5 4 239 51 doi 10 1097 00125480 199807000 00004 PMID 9859756 S2CID 33288884 Ikeda M Ikui A Tanaka M Omori H Tomita H 1994 Immunohistopathological investigation on unspecific chronic sclerosing sialadenitis of the submandibular gland Kuttner tumor Auris Nasus Larynx 21 2 103 110 doi 10 1016 s0385 8146 12 80028 9 PMID 7993223 Tiemann M Teymoortash A Schrader C Werner JA Parwaresch R Seifert G Kloppel G 2002 Chronic sclerosing sialadenitis of the submandibular gland is mainly due to a T lymphocyte immune reaction Modern Pathology 15 8 845 852 doi 10 1097 01 MP 0000022280 72359 04 PMID 12181270 Tsuneyama K Saito K Ruebner BH Konishi I Nakanuma Y Gershwin ME 2000 Immunological similarities between primary sclerosing cholangitis and chronic sclerosing sialadenitisreport of the overlapping of these two autoimmune diseases Digestive Diseases and Sciences 45 2 366 372 doi 10 1023 A 1005429130150 PMID 10711453 S2CID 24581402 Sekine S Nagata M Watanabe T 1999 Chronic sclerosing sialadenitis of the submandibular gland associated with idiopathic retroperitoneal fibrosis Pathology International 49 7 663 667 doi 10 1046 j 1440 1827 1999 00926 x PMID 10504530 S2CID 21548017 a b Kamisawa T Nakajima H Hishima T 2006 Close correlation between chronic sclerosing sialadenitis and immunoglobulin G4 Internal Medicine Journal 36 8 527 529 doi 10 1111 j 1445 5994 2006 01119 x PMID 16866659 S2CID 33328260 a b Nagai K Andoh K Ogata A Aoki N Nakamura N Hosaka H Kurihara R 2010 A new category for chronic sclerosing sialadenitis as an IgG4 related syndrome BMJ Case Reports 2010 bcr1020092412 doi 10 1136 bcr 10 2009 2412 PMC 3028012 PMID 22448185 Cheuk W Yuen HK Chu SY Chiu EK Lam LK Chan JK 2008 Lymphadenopathy of IgG4 related sclerosing disease Am J Surg Pathol 32 5 671 681 doi 10 1097 PAS 0b013e318157c068 PMID 18344866 S2CID 27175700 Melo JC Kitsko D Reyes Mugica M 2012 Pediatric chronic sclerosing sialadenitis Kuttner tumor Pediatric and Developmental Pathology 15 2 165 169 doi 10 2350 11 04 1023 OA 1 PMID 21985393 S2CID 26785007 a b Chow TL Chan TT Choi CY Lam SH 2008 Kuttner s tumour chronic sclerosing sialadenitis of the submandibular gland a clinical perspective PDF Hong Kong Medical Journal 14 1 46 9 PMID 18239243 Retrieved 15 November 2013 a b Chou YH Tiu CM Li WY Liu CY Cheng YC Chiou HJ Chiou SY Wang HK Hung GS 2005 Chronic sclerosing sialadenitis of the parotid gland diagnosis using color Doppler sonography and sonographically guided needle biopsy Journal of Ultrasound in Medicine 24 4 551 555 doi 10 7863 jum 2005 24 4 551 PMID 15784774 S2CID 24563080 Retrieved 17 November 2013 Cheuk W Chan JKC 2002 Kuttner Tumor of the Submandibular Gland Fine Needle Aspiration Cytologic Findings of Seven Case PDF American Journal of Clinical Pathology 117 1 103 108 doi 10 1309 g9t3 22mh q7kl g2dl PMID 11791589 Retrieved 5 December 2013 a b Abu A Motoori K Yamamoto S Hanazawa T Nagai Y Kaneoya K Ito H 2008 MRI of chronic sclerosing sialoadenitis British Journal of Radiology 81 967 531 536 doi 10 1259 bjr 38960620 PMID 18316344 External links Edit Retrieved from https en wikipedia org w index php title Chronic sclerosing sialadenitis amp oldid 1134898145, wikipedia, wiki, book, books, library,

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