**2. Surgical technique and possible complications of LSGB**

Labial salivary gland biopsy is considered a minor surgical procedure and can be performed on the ambulatory basis. There is no standardized technique that yields adequate tissue for analysis and minimizes adverse effects. The lack of uniformity in methodology and potential adverse effects of LSGB hinders its application. LSGB is treated as a safe and simple surgical procedure without severe postoperative complications. One of the most severe complications of LSGB is sensitive nerve injury. This localized sensory alternation can be described as an anesthesia, a reduced or partial loss of sensation, a transitory numbness, or a hypoesthesia. These sensations can last for a few months or can be permanent. Persistent lip numbness occurs in up to 6% of biopsies performed in the lower lip [8]. The branches of the mental nerve in the lower lip are closely associated with the salivary glands, and this anatomical relationship increases the risk of postoperative sensory sensations. Additionally, the branch of the mental nerve usually divides into two sub-branches: a horizontal and a vertical, which have an ascending course toward the vermillion border and are in close relation to the

**57**

of neural damage [12–16].

*Laryngological and Dental Manifestations of Sjögren's Syndrome*

labial salivary glands. Incisional biopsies shorter than 2 cm performed with a scalpel have reported complications ranging from 0 to 9.3%, whereas those using larger incisions (2–3 cm) have described complications in the range of 3.7–31%. Transient disorders of lip sensitivity are found to occur in up to 11.7% of procedures. Persistent lower lip hypoesthesia is reported in about 3.4–4% of cases. Larger incisional biopsies and punch biopsies are associated with a higher risk of both transient and persistent lower lip numbness. Other possible complications of LSGB are less severe, usually transient or temporary, and are associated with localized postoperative inflammation or improper healing. The symptoms of postoperative inflammations are local pain and swelling. Blood vessel injuries result in hematoma. The possible delayed complications are the formation of granulomas, internal scarring, and cheloid formation. Labial salivary gland injuries can result in mucous extravasation cysts. Some patients can report burning or tingling sensations, and functional deficits during the immedi-

ate postbiopsy period such as eating, sleeping, or speech difficulties [9–12].

Labial glands biopsy may be an excisional or incisional technique. The most recommended site is normal-appearing mucosa of the lower lip. Usually, it is a scalpel biopsy. A wide range of surgical approaches have been described for harvesting a few accessory glands from the lower lip using different instruments such as a scalpel, a punch, or cup forceps. The use of a forceps with a fenestrated active end to stabilize the lip has also been suggested. The excisional biopsy is carried out by excising an ellipse of oral mucous membrane down to the muscle layer. Ideally, 6–8 minor glands must be harvested and sent for histopathologic examination. The wound should be closed with 4-0 silk sutures, which are removed after 4–5 days. The modification of this method is the technique with a mucosal excision of 3.0 × 0.75 cm. Another recommended technique is a 1.0–1.5-cm-wedge-shaped excision of the mucosa between the midline and commissure. The incisional biopsy is described as a 1.5–2.0-cm linear incision of mucosa, parallel to the vermillion border and lateral to the midline. Gorson and Ropper reported a 1-cm vertical incision just behind the wet line through the mucosa and submucosa [31]. It is usually that case that the lateral lip compartments are advocated for biopsy, because of the glandular-free zone in the center of the lower lip. Berquin et al. described an oblique incision, starting 1.5 cm from the midline and proceeding latero-inferiorly to avoid the central glandular-free zone. The vertical incision technique is associated with less pain, less swelling, less scar formation, and less difficulty in eating when compared with the horizontal incision technique. There is insufficient evidence to support the superiority of one technique over the others, and the shape and the size of the incision can be considered a matter of preference. The incision shape includes elliptical, circular, linear, horizontal, vertical, and wedge shapes, and the incision length varies from a few millimeters to 2 cm. Another recommended modification is using loupe operation glasses to precisely excise the salivary glands without disturbing the direct underlying sensible nerves. The alternative technique to scalpel biopsy is the minor salivary gland punch biopsy. This biopsy can be performed by a single operator, and it is less expensive than classical scalpel biopsy. This technique consists of obtaining the biopsy from the buccal side of the lower lip, which is stabilized by the patient him/herself using a 4–5 mm punch, which permits the retrieval of a cylinder of tissue up to 8 mm in length. The punch biopsy is suggested because of the absence of risk to the patient and because of its simplicity. However, the punch biopsies do not provide enough material for the diagnosis of Sjögren's syndrome. Moreover, the findings of this study strongly discouraged the punch technique for minor salivary gland lip biopsy and provided information on the superiority of the linear incisional biopsy in terms

Based on our own clinical experience, a 1.0–1.5-cm linear, horizontal incision of mucosa parallel to the vermillion border and lateral to the midline with the

*DOI: http://dx.doi.org/10.5772/intechopen.85687*

#### *Laryngological and Dental Manifestations of Sjögren's Syndrome DOI: http://dx.doi.org/10.5772/intechopen.85687*

*Chronic Autoimmune Epithelitis - Sjogren's Syndrome and Other Autoimmune Diseases...*

paresthesias, facial hypaesthesia, and trigeminal nerve neuropathy.

pose of labial salivary glands to the biopsy [1–7].

**2. Surgical technique and possible complications of LSGB**

Labial salivary gland biopsy is considered a minor surgical procedure and can be performed on the ambulatory basis. There is no standardized technique that yields adequate tissue for analysis and minimizes adverse effects. The lack of uniformity in methodology and potential adverse effects of LSGB hinders its application. LSGB is treated as a safe and simple surgical procedure without severe postoperative complications. One of the most severe complications of LSGB is sensitive nerve injury. This localized sensory alternation can be described as an anesthesia, a reduced or partial loss of sensation, a transitory numbness, or a hypoesthesia. These sensations can last for a few months or can be permanent. Persistent lip numbness occurs in up to 6% of biopsies performed in the lower lip [8]. The branches of the mental nerve in the lower lip are closely associated with the salivary glands, and this anatomical relationship increases the risk of postoperative sensory sensations. Additionally, the branch of the mental nerve usually divides into two sub-branches: a horizontal and a vertical, which have an ascending course toward the vermillion border and are in close relation to the

**1. Introduction**

or atrophy of the nasal mucosa, dryness of the throat, dysphagia, hoarseness, otalgia and tinnitus, gastro-esophageal reflux, and chronic cough. Patients with SS tend to have a higher prevalence of sensorineural hearing impairment compared with the general population. Idiopathic hearing loss may represent the initial manifestation of SS. Furthermore, authors present and discuss the main neurological symptoms of SS. Neurological manifestations are reported in about 20% of patients with SS. In patients with SS, neurological manifestations may occur, such as peripheral neuropathy and other forms of neuropathies, including sensory ataxia, painful sensory neuropathy without sensory ataxia, multiple mononeuropathy, multiple cranial neuropathy, autonomic neuropathy, radiculoneuropathy and intra- and extraoral

**Keywords:** Sjögren's syndrome, hearing loss, cranial nerve neuropathy, xerostomia

Microscopic findings involving lymphocytic infiltration surrounding the excretory ducts in combination with the destruction of acinar tissue are representative for both minor and major salivary glands and are pathognomonic changes for SS. Parotid, lip, or sublingual salivary gland biopsy is performed in the diagnosis and monitoring of SS, but currently only labial salivary gland biopsy (LSGB) is included into classification criteria of SS. LSGB is used for the diagnosis of Sjögren's syndrome (SS). The current classification criteria of SS, approved by the American College of Rheumatology (ACR) and the European League against Rheumatism (EULAR) in 2016, include LSGB as a part of weighted sum of five items [1]. The presence of focal lymphocytic sialadenitis (FLS) with a focus score of 1 foci/4 mm2 glandular tissue is a positive score of LSGB. Lip salivary glands are widely distributed in the labial mucosa of the oral cavity. They are largely used for assisting the diagnosis of SS, because they are easily accessible and lie above the muscle layer. They are separated from the oral mucous membrane by a thin layer of fibrous connective tissue. Orientation and identification of glandular tissue is the easiest. The risk of excessive postoperative bleeding is decreased because the arterial supply to the lip lies deep. These anatomical implications and pathognomic changes predis-

**56**

labial salivary glands. Incisional biopsies shorter than 2 cm performed with a scalpel have reported complications ranging from 0 to 9.3%, whereas those using larger incisions (2–3 cm) have described complications in the range of 3.7–31%. Transient disorders of lip sensitivity are found to occur in up to 11.7% of procedures. Persistent lower lip hypoesthesia is reported in about 3.4–4% of cases. Larger incisional biopsies and punch biopsies are associated with a higher risk of both transient and persistent lower lip numbness. Other possible complications of LSGB are less severe, usually transient or temporary, and are associated with localized postoperative inflammation or improper healing. The symptoms of postoperative inflammations are local pain and swelling. Blood vessel injuries result in hematoma. The possible delayed complications are the formation of granulomas, internal scarring, and cheloid formation. Labial salivary gland injuries can result in mucous extravasation cysts. Some patients can report burning or tingling sensations, and functional deficits during the immediate postbiopsy period such as eating, sleeping, or speech difficulties [9–12].

Labial glands biopsy may be an excisional or incisional technique. The most recommended site is normal-appearing mucosa of the lower lip. Usually, it is a scalpel biopsy. A wide range of surgical approaches have been described for harvesting a few accessory glands from the lower lip using different instruments such as a scalpel, a punch, or cup forceps. The use of a forceps with a fenestrated active end to stabilize the lip has also been suggested. The excisional biopsy is carried out by excising an ellipse of oral mucous membrane down to the muscle layer. Ideally, 6–8 minor glands must be harvested and sent for histopathologic examination. The wound should be closed with 4-0 silk sutures, which are removed after 4–5 days. The modification of this method is the technique with a mucosal excision of 3.0 × 0.75 cm. Another recommended technique is a 1.0–1.5-cm-wedge-shaped excision of the mucosa between the midline and commissure. The incisional biopsy is described as a 1.5–2.0-cm linear incision of mucosa, parallel to the vermillion border and lateral to the midline. Gorson and Ropper reported a 1-cm vertical incision just behind the wet line through the mucosa and submucosa [31]. It is usually that case that the lateral lip compartments are advocated for biopsy, because of the glandular-free zone in the center of the lower lip. Berquin et al. described an oblique incision, starting 1.5 cm from the midline and proceeding latero-inferiorly to avoid the central glandular-free zone. The vertical incision technique is associated with less pain, less swelling, less scar formation, and less difficulty in eating when compared with the horizontal incision technique. There is insufficient evidence to support the superiority of one technique over the others, and the shape and the size of the incision can be considered a matter of preference. The incision shape includes elliptical, circular, linear, horizontal, vertical, and wedge shapes, and the incision length varies from a few millimeters to 2 cm.

Another recommended modification is using loupe operation glasses to precisely excise the salivary glands without disturbing the direct underlying sensible nerves. The alternative technique to scalpel biopsy is the minor salivary gland punch biopsy. This biopsy can be performed by a single operator, and it is less expensive than classical scalpel biopsy. This technique consists of obtaining the biopsy from the buccal side of the lower lip, which is stabilized by the patient him/herself using a 4–5 mm punch, which permits the retrieval of a cylinder of tissue up to 8 mm in length. The punch biopsy is suggested because of the absence of risk to the patient and because of its simplicity. However, the punch biopsies do not provide enough material for the diagnosis of Sjögren's syndrome. Moreover, the findings of this study strongly discouraged the punch technique for minor salivary gland lip biopsy and provided information on the superiority of the linear incisional biopsy in terms of neural damage [12–16].

Based on our own clinical experience, a 1.0–1.5-cm linear, horizontal incision of mucosa parallel to the vermillion border and lateral to the midline with the

tip of a 15 scalpel is worth to recommend. The lower lip should be retracted and everted under tension to expose the inner surface and allow visualization of the minor salivary glands just to the depth of the mucosa. Local anesthesia injected submucosally with 0.5–1.0 ml of 1% lidocaine with 1:200,000 epinephrine is sufficient. The anesthesia hydrodissects and lifts the mucosa away from the salivary glands, provides delivery of local anesthetic directly to sensory nerve fibers, and temporarily displaces small vessels deep in the glands to promote hemostasis and visualization during the dissection. In this technique, both margins of incision should be gently crafted to access the submucosal layer. This stage of procedure can be performed using blunt-tipped iris scissors or a scalpel by spreading in a plane perpendicular to the mucosal incision and parallel to the direction of the sensory nerve fibers. This technique is fast, simple, and leaves a small scar. The linear incision secures a good adherence of wound margins and proper and fast healing. Unfortunately, this method is not effective in small amounts of salivary glands. Sometimes, it is difficult to find the sufficient amount of labial glands. Moreover, it may be difficult to harvest a sufficient number of labial salivary glands in atrophic mucosa of patients with long-standing SS. In these cases, the recommended method is a 1-cm lenticular incision of mucosa, lateral to the midline, and removal of the mucosa to uncover the submucosal layer and obtain a few adjacent salivary glands. This technique ensures good visibility into the operating field to avoid blood vessels and nerve injures. This incision provides adequate glandular tissue for diagnosis. The wound should be closed by a few nonresorbable, single, interrupted stitches. One very important issue is to harvest only labial salivary glands without muscular or other tissues. It is the most valuable specimen for histopathological examination, because it only includes glandular tissue. Additionally, this technique decreases the risk of nerve damage and postoperative pain and assures successful healing. Sensory nerve fibers are almost always visible just below the plane of dissection, and care should be taken to identify and preserve them. The next very important issue is not to puncture the labial glands to reduce the risk of mucous extravasation cyst formation. It is even better to remove all visible labial salivary glands from the operating field before suturing in order not to damage the glands or their ducts. Patients should also avoid taking steroids before the biopsy. The factors potentially contributing to a false-negative rate include the use of oral steroids that may result in immunosuppression and confound histopathologic results. The tissue specimens should be immediately placed in a wide-mouthed container, coded, and fixed in a generous amount of 10% formalin buffered saline for 24 h (**Figures 1** and **2**).

#### **Figure 1.**

*Linear incision and scalpel biopsy of labial salivary gland biopsy. A few labial salivary glands exposed and visible in the operating field.*

**59**

focus/4 mm<sup>2</sup>

**Figure 2.**

*Labial salivary gland specimen.*

foci (**Table 2**) [16, 17].

*Laryngological and Dental Manifestations of Sjögren's Syndrome*

**3. Histologic criteria for diagnosis of SS on labial salivary gland biopsies**

Labial salivary gland biopsy is an objective test of SS and plays a significant role in the diagnostic process. In fact, the presence of either anti-SSA/SSB seropositivity or a positive lip biopsy is a requirement for an individual to be classified as having SS. The microscopic confirmation of SS is based on the presence of focal

tissue. According to the revised American-European Consensus Group's (AECG) classification criteria and the ACR classification criteria for SS, an LSGB is considered positive if minor salivary glands demonstrate FLS, with a focus score of 1 or more, as evaluated by an expert histopathologist. A lymphocytic focus is defined as a dense aggregate of 50 or more lymphocytes adjacent to normal-appearing mucous acini in salivary gland lobules that lacked ductal dilatation. Focal lymphocytic sialadenitis is applied to specimens that show the presence of 1 or more foci of lymphocytes located in periductal and perivascular locations. The foci can contain plasma cells, but these must be a minority constituent of the inflammatory infiltrate. The focus score can be calculated for those specimens showing the histopathologic appearance of FLS. The number of lymphocytic foci is then determined for all the gland lobules in a single tissue section. The focus score is then calculated as the number of foci per square millimeter of glandular tissue

. To determine the focus, a calibrated eyepiece grid or image analysis

software with a closed polygon tool is used. FLS has to be distinguished from nonspecific chronic sialadenitis. The symptoms of nonspecific sialadenitis are mild to moderate acinar atrophy, interstitial fibrosis, and ductal dilatation, with lymphocytes and macrophages often scattered in the parenchyma, but not forming dense aggregates of 50 or more lymphocytes immediately adjacent to normal-appearing acini. In addition to the focus score (FS), two scoring systems for salivary glands are in use for the diagnosis and classification of SS. These systems are based on the presence of foci [7]. Grading according to Tarpley's system involves destruction of acinar tissue and fibrosis (**Table 1**). Grading according to the Chisholm and Mason system is based on the presence of infiltrates from slight to one or more

Aggregate: approximately 50 cells (lymphocytes, plasma cells, or histiocytes).

Focus: a cluster of 50 or more lymphocytes and histiocytes.

of glandular

. A focus score of 1 equates to 1

lymphocytic sialadenitis (FLS) with a focus score ≥ 1 per 4 mm<sup>2</sup>

multiplied by four, which then yields foci/4mm<sup>2</sup>

*DOI: http://dx.doi.org/10.5772/intechopen.85687*

*Laryngological and Dental Manifestations of Sjögren's Syndrome DOI: http://dx.doi.org/10.5772/intechopen.85687*

**Figure 2.** *Labial salivary gland specimen.*

*Chronic Autoimmune Epithelitis - Sjogren's Syndrome and Other Autoimmune Diseases...*

tip of a 15 scalpel is worth to recommend. The lower lip should be retracted and everted under tension to expose the inner surface and allow visualization of the minor salivary glands just to the depth of the mucosa. Local anesthesia injected submucosally with 0.5–1.0 ml of 1% lidocaine with 1:200,000 epinephrine is sufficient. The anesthesia hydrodissects and lifts the mucosa away from the salivary glands, provides delivery of local anesthetic directly to sensory nerve fibers, and temporarily displaces small vessels deep in the glands to promote hemostasis and visualization during the dissection. In this technique, both margins of incision should be gently crafted to access the submucosal layer. This stage of procedure can be performed using blunt-tipped iris scissors or a scalpel by spreading in a plane perpendicular to the mucosal incision and parallel to the direction of the sensory nerve fibers. This technique is fast, simple, and leaves a small scar. The linear incision secures a good adherence of wound margins and proper and fast healing. Unfortunately, this method is not effective in small amounts of salivary glands. Sometimes, it is difficult to find the sufficient amount of labial glands. Moreover, it may be difficult to harvest a sufficient number of labial salivary glands in atrophic mucosa of patients with long-standing SS. In these cases, the recommended method is a 1-cm lenticular incision of mucosa, lateral to the midline, and removal of the mucosa to uncover the submucosal layer and obtain a few adjacent salivary glands. This technique ensures good visibility into the operating field to avoid blood vessels and nerve injures. This incision provides adequate glandular tissue for diagnosis. The wound should be closed by a few nonresorbable, single, interrupted stitches. One very important issue is to harvest only labial salivary glands without muscular or other tissues. It is the most valuable specimen for histopathological examination, because it only includes glandular tissue. Additionally, this technique decreases the risk of nerve damage and postoperative pain and assures successful healing. Sensory nerve fibers are almost always visible just below the plane of dissection, and care should be taken to identify and preserve them. The next very important issue is not to puncture the labial glands to reduce the risk of mucous extravasation cyst formation. It is even better to remove all visible labial salivary glands from the operating field before suturing in order not to damage the glands or their ducts. Patients should also avoid taking steroids before the biopsy. The factors potentially contributing to a false-negative rate include the use of oral steroids that may result in immunosuppression and confound histopathologic results. The tissue specimens should be immediately placed in a wide-mouthed container, coded, and fixed in a generous amount of 10% formalin buffered saline for 24 h (**Figures 1** and **2**).

*Linear incision and scalpel biopsy of labial salivary gland biopsy. A few labial salivary glands exposed and* 

**58**

**Figure 1.**

*visible in the operating field.*
