Salivary gland disorders

SALIVARY

GLAND

DISORDERS

Thilanka Umesh Sugathadasa(D/10/064)

Thilanka Umesh Sugathadasa Page 1

Non-neoplastic diseases of salivary glands including dry mouth

Classification

Non- neoplastic SG disorders

Congenital/

Developmental

Inflammatory

/Traumatic/

Ischemic

Infective Endocrine/

Metabolic

(Sialosis)

Autoimmune/

Benign

lymphoepithelial

Obstructive

Drug induced

Aplasia/

Hypoplasia

Agenesis

Atresia of the

duct &

congenital

strictures

Aberrancy

Accessory

ducts & lobes

Haemangioma

s

Polycystic

disease of

parotid

Stomatitis

nicotina

Necrotizing

sialometapla

sia

Cheilitis

glandularis

Mucocele &

other cystic

lesions

Bacterial

- Acute (Ascending)

sialadenitis

- Chronic non-specific

Sialadenitis(with or

without sialolithiasis)

- Chronic specific

sialadenitis(TB/

syphilis/ Sarcoidosis) &

granulomatous

inflammation.

- Recurrent subacute/

chronic sialadenitis(eg-

juvenile parotitis)

Viral

- Mumps

- Mumps like diseases

(Cytomegalic inclusion

disease/ Coxaskie A

infection/ ECHO or

Lymphocytic

Choriomeningitis viral

infection)

- HIV induced SG

disease.

Painless

salivary

swellings

Alcoholic

cirrhosis

DM

Acromegaly

Malnutrition

Chronic renal

failure

Cystic fibrosis

Sjogren’s

syndrome

Chlorhexidin

e

Isoprenaline

Iodine

Phenyl

butazone

Sialolithiasis

Strictures


Dry Mouth/ Xerostomia

Introduction

This is significantly a patient perception.

Dry mouth & Oral dryness are general terms that encompasses 2 medical entities

- Xerostomia (This is a symptom) – subjective complaints

- Hyposalivation – Objective reduction in salivary secretion

Mainly occur due to decreased salivary flow or decrease composition of the saliva.

& there are many of other causes.

So this is a subjective clinical condition due to absolute or relative reduction in amount of saliva

Advancing of the age also increasingly associated with the dry mouth. But this is usually due to

medications & diseases.

Causes

Causes

Iatrogenic

1.Drugs

-Atropine

-Antidepressants : Tricyclic(eg:

Amitriptyline, Nortriptyline),

Selective serotonin reuptake

inhibitors

-Antihypertensive : Can also cause

the compositional changes of the

saliva as well as the changes of the

flow rate.

- Antihistamines

- Opioids

- Cytotoxic drugs

-Antiemetics

2.Irradiation(External irradiation

doses above 40 Gy & Iodine 131)

3.Graft versus host reaction

Physiological Diseases of Salivary

glands

Dehydration

Psychogenic(Anxiety,

Depression)

Post exercise/ mouth breathing

Salivary aplasia

Sjogren’s syndrome

Sarcoidosis

Parotidectomy

Cystic fibrosis

Ectodermal

dysplasia

Infections

Controlled

diabetes

CRF

Mouth breathing due to nasal

polyp, etc

When doing presentation or

social speech.


Clinical features of dry mouth

Symptoms

1. Sensation of burning.

2. Swallowing difficulty(Eating difficulty of dry foods “cracker sign”)

3. Stability & retention of dentures become low

4. Speaking difficulty(Clicking quality speech due to tongue sticking to

the palate)

5. Sensation of taste reduction

6. Increase incidence of dental caries & periodontal disease.

7. Infection

8. Recurrent ulceration

9. Tongue or check getting accidental bitten frequently.

Signs

1. Dryness of the lips & oral mucosa.

2. Pale & corrugated buccal mucosa.

3. Lack of salivary pooling in floor of the mouth.

4. Atrophy/ inflammation/ fissuring/ cracking/ of tongue

5. Erythema/ Ulceration

6. Infections

7. Lipstick sign

8. Crackers sign

9. Tongue blade sign

10. Increase levels of dental caries & periodontal disease.

11. Mucosa tends to stick to the dental mouth mirror & dry

Complications of dry mouth

Soft tissue changes Hard tissue changes Other

The mucosal tissues may become painful, “Burning”, dry & atrophic.

Cracked lips.

Soreness & redness due to candidosis.

Ascending suppurative sialadenitis.

Tingling sensation of the mouth.

Angular cheilitis

Severe & uncontrolled dental caries

Marked increase in erosions especially in the non-carious risk areas & the root surfaces, & even in the cusp tips.

Caries may be progressive even with the excellent oral hygiene.

Difficulty in speaking.

Difficulty in swallowing especially dry foods.

Reduced denture retention.

Reduced taste sensation.

Painful salivary gland enlargement.

Increased thirst.

Increase uptake of the fluids when eating.

Periodontal disease?

Halitosis

Dry mouth

patient can be

classified in to

3 types

Those having

asymptomatic

hyposalivation,ie reduction

in the salivary secretion

not significant enough to

cause xerostomia.

Those with symptomatically significant hyposalivation, thus suffering from xerostomia. Those suffering from xerostomia but with no evident decrease in salivary secretion


Diagnosis & Ix

Diagnosis is mainly by the combination of the

- Hx

- Ix

- Clinical features.

Investigations

Salivary function studies

1. Salivary flow rate

2. Sialography

3. Salivary scintiscanning

Other

1. Lacrimation flow – exclude sjogren's syndrome

2. Urinanalysis – exclude DM

3. Blood tests

ESR – exclude Sjorgren’s syndrome or sarcoidosis

antinuclear antibodies – exclude Sjorgren’s syndrome or sarcoidosis.

Rheumatoid factor – Exclude Sjorgren’s syndrome

Serology – Viral disease

Serum calcium & phosphate – exclude hyperparathyroidism.

4. Imaging

CXR –exclude Sarcoidosis

Ultrasonography – exclude Sjorgren’s syndrome or Neoplasia

MRI –exclude Sjorgren’s syndrome

5. Bx

Biopsy is taken if there is a suspicion about the organic disease of the salivary glands. Here

always possible to take biopsy from the major salivary glands but usually perform the minor SG

Bx due to risks of nerve damage, scars. So usually preferable site is the lower labial mucosa.

Management

Can divide in to 3 categories

1. Symptomatic Rx

2. Preventive Rx

3. Curative Rx

Salivary flow over a 24-hour period

Sleep

40 ml saliva will be produced over 7 hours

Awake

300 ml of unstimulated saliva over 16 hours

200 ml of stimulated saliva during meals over 54 minutes


Symptomatic Rx Preventive Rx Curative Rx

(- Directed at alleviating or minimizing complaints associated

with decreased salivation. Range from simple methods of

hydration & lubrication to systemic secretagogues to stimulate

the salivary function)

Non sugar containing fluids & frequent small sips of them. Helps to hydrate the mucosa & removal of retained debris

Avoids fluids containing sugars.

Humidifiers specially closer to bed at night (Can use jug of water)

Lip moisturizers & emollients.

Penetrating creams are preferred over the petroleum based products.

Avoid dry foods.

Avoiding spicy foods, alcohol & strong flavoring may reduce oral mucosal sensitivity.

Avoid mouth rinses with high alcohol content. (Listerine), which can induce mucosal irritation & sensitivity.

Mechanical, local saliva induce with sugarless candy, gums or rinses. disadvantages of local stimulants - short lived - Frequent application can be inconvenient. - Citric acid may irritate the oral mucosa. - continue use may contribute to demineralization.

Systemic sialologues - Only use for the patients who have salivary tissues that can be stimulated. - Pilorcarpine hydrochloride- parasympathomimetic agonist that increase exocrine output. - Most widely tested sialagogue. - Recommended dose = 5mg tds - Cevimeline hydrochloride – similar to Pilorcarpine. (This product can’t use in high in high conc as it containing metals.)

Salivary replacement products (Substitute) commonly containing Carboxymethylcellulose or hydroxycellulose as lubricants, artificial sweeteners, preservatives, chloride & Fluorides

(- To limit the consequences of

salivary gland hypofunction on oral

& dental tissues)

Increase oral hygiene measures.

Professional care.

Oral application of topical fluorides to minimize the dental caries risk.

If bacterial infection is identified, appropriate antibiotics should be identified. It may require prolonged therapy.

If swelling which is not due to infection a short course of steroids are beneficial.

NSAIDs are not helpful

If candidal infection presents use topical or systemic antifungals prolongly those antifungals should not contain sugars. Composition of the artificial saliva - Carboxymethylcellulose 10g/L(Keep the watery content of saliva) - Sorbitol 30mg/L - Sodium chloride - Magnesium chloride - Calcium chloride - Dipotasium hydrogen phosphate

Disadvantages - Regular use is

inconvenient. - More viscous than the

natural saliva so feel odd. - Expensive - No antimicrobial & other

protective functions.

(Managing underlying cause

or symptoms)

If dry mouth is due to drugs, stopping/changing drugs if possible, in consultation with patient’s physician.

If possible alternative drug.

Identify the cause by history, examination & further investigations & Rx

- Secretagogues can provide transient relief but will not address the underlying cause.

- Patients may leave with gradual decline in function over time & worsening the symptoms & signs.


Mx of the Xerostomia can be presents as

1. Replacement of saliva

2. Avoidance of harmful effects.

3. Prevention of oral disease

4. Stimulation of the residual secretory capacity.

5. Curative Rx.

Replacement of saliva

Frequent sips of water

Glycerol & Thymol or Glycerol & lemon

Luborant- Methyl cellulose based products

Glandosane - ;;

Above having enough hydration but not enough lubrication

Saliva orthana is having (Mucin- based products) better

lubrication properties

Avoidance of harmful effects

Dry and cariogenic foods.

Tobacco smoking and alcohol intake

Alter treatment with medicaments if there are any medicines

which cause dry mouth.

Avoid wearing dentures at night

Prevention of oral disease

Meticulous (careful) oral hygiene.

Dietary advice

Topical F-

Chlorhexidine mouth wash 0.2%

Antifungal agents

Stimulation of the residual secretory capacity

Sugar free chewing gums

Saliva orthana lozenges(release Mucin)

Pilorcarpine tablets 5mg tds

Pilorcarpine eye drops 0.5- 1% also can be swallowed (2-4 drops)

every 4 hours.

Other drugs (Anethole trithione, yohimbine, neostigmine)


Condition Features & etiology Clinical features/ Ix & Diagnosis

Mx

Sjogren’s syndrome

An autoimmune inflammatory disorder

Immunologically mediated chronic inflammatory disorder of exocrine glands mainly affecting salivary, lacrimal glands.

Common in the middle aged Females.

Two types present - Primary SS (sicca syndrome)-: Dry eyes (Keratoconjunctivitis/ xerophthalmia) & dry mouth. - Secondary SS-: Dry eyes, Dry mouth & connective tissue disorder (RA, SLE, Systemic sclerosis, mixed CT disease, primary biliary cirrhosis)

Causes - Genetic predisposition - Hormones - Inflammatory events - Auto antibodies - Liver disease - Processes mediating salivary gland dysfunction. -Viruses

A benign autoimmune inflammatory exocrinopathy (epithelitis) directed against alpha fodrin, a cytoskeletal protein involved in actin binding, with lymphocyte-mediated destruction of salivary, lacrimal and other exocrine glands. Tumor necrosis factor (TNF), interferon (IFN) and B cell activating factor (BAFF) are implicated. A viral etiology, possibly human retrovirus 5 (HRV-5), and a genetic predisposition May be implicated. A SS type of disease may follow HIV, EBV, HCV, or Helicobacter pylori infection, or graft-versus-host disease.

Symptoms Mouth

Xerostomia is the main problem. But only some have unpleasant taste.

Angular cheilitis

Pus discharge from the ductal orifices.

Unilateral/ Bilateral intermittent enlargement of salivary glands mainly parotids.

Thick frothy saliva, later stage with loss of saliva pooling.

Glazed, dry mucosa that tend to form wrinkles.

Redness/soreness of the mucosa due to candida infection.

Lobulated, reddish, partial/complete depapillated tongue with reduced no of taste buds

Gross accumulation of plaque

Several dental caries including root caries.

Periodontal diseases

Recurrent attacks of the acute bacterial sialadenitis: SS is the most common cause for the acute bacterial sialadenitis.

Enlarged tender regional lymph nodes. Signs

Unpleasant taste

Difficulty in eating

Soreness of the mouth.

Difficulty in speech.

Most patients are treated with symptomatically

Oral hygiene improvement

Mx of dry mouth

Mx of dry eyes

Agents against CD20(B lymphocyte surface antigen) SS is characterized by glandular lymphocytic infiltration

As curative Rx most of the time Systemic steroids, cyclosporines, Methotrexate, etc…using


Rheumatic Diseases associated with Sjogren’s’ syndrome - RA

- SLE - Progressive systemic sclerosis - Mixed CT disease. - Dermatomyositis. - Polyarteritis nodosa. - Reynaud’s phenomenon.

Immunologically related diseases associated with SS

- 1ry biliary cirrhosis - Chronic active hepatitis - Autoimmune thyroid disease - Pemphigus vulgaris - Coeliac disease - Myasthenia gravis - Graft versus host disease

Eye

Sensation of dryness

Burning sensation

Redness

Frequent conjunctival infections

Ulceration

Also dryness of pharynx, larynx, and genital areas also may present.

CT disorders clinical features also can present in the 2ry SS. Radiological features

1. Multiple sialectasias (snow storm app) in sialogram with atrophy of ductal system delayed emptying of dye.

2. Impaired salivary activity seen in salivary scintiscanning

Reduced sialometry & abnormal sialochemistry.

Positive ose Bengal staining test & schirmer test


Diagnosis

Dry mouth

Reduced salivary flow (measured by sialometry) with dry eyes (measured by Schirmer test)

Biopsy of labial salivary glands

(> 1 focus of lymphocytes in 4 mm2 Laboratory test ANA, ENA ,SS-A and SS-B

No

Yes

Sicca syndrome

and

Positive Negative

Sjögren’s syndrome

Others, autoimmune diseases associates

No Yes

2ry SS

If biopsy of labial salivary glands – positive(> 1 focus of lymphocytes in 4 mm2)

review some months later syndrome and ask for laboratory test in a Consider an incomplete form of Sjogren’s

Primary SS


Diagnostic criteria (American-European) for Sjögren’s syndrome.

I Ocular symptoms

A positive response to at least one of the following questions:

(1) Have you had daily ocular symptoms or persistent, troublesome dry eyes

For more than three months? (2) Do you have a recurrent sensation of

sand or gravel in the eyes? (3) Do you use tear substitutes more than 3

times a day?

II Oral symptoms

A positive response to at least one of the following questions

(1) Have you had a daily feeling of dry mouth for more than 3 months?

(2) Have you had recurrently or persistently swollen salivary glands as an adult?

(3) Do you frequently drink liquids to aid in swallowing dry food?

III Ocular signs

That is, objective evidence of ocular involvement defined as a positive result for at least one of: In minor salivary glands (obtained through normal-appearing mucosa).

(1) Schirmer test, performed without anesthesia (< 5 mm in 5 minutes).

(2) Rose-Bengal score or other ocular dye score (> 4 according to van

Bijsterveld’s scoring system). Focal lymphocytic sialadenitis evaluated

by an expert histopathologist, with a focus score > 1, defined as a number

of lymphocytic foci (which are adjacent to

normal-appearing mucous acini and contain more than 50 lymphocytes)

per 4 mm2 of glandular tissue.

IV Histopathology

V Salivary gland Involvement

Objective evidence of salivary gland involvement, defined by a positive result for one of the following:

(1) Unstimulated whole salivary flow ≤ 1.5 ml in 15 minutes.

(2) Parotid sialography showing the presence of ductal sialectasis (punctate,

cavitary or destructive pattern) without evidence of obstruction in the major ducts.

(3) Salivary scintigraphy showing delayed uptake, reduced concentration and/or

delayed excretion of tracer.

VI Autoantibodies

Presence in the serum of the following autoantibodies:

Antibodies to Ro (SS-A) or La (SS-B) antigens, or both


For the diagnosis of primary SS: In patients without any potentially associated disease, primary SS may be defined as follows:

The presence of any 4 of the 6 items is indicative of primary SS, as long as either item IV (histopathology) or VI (serology) is positive

The presence of any 3 of the 4 objective criteria items (that, is items III, IV, V, VI) The classification tree procedure represents a valid alternative method of classification,

although it should be more properly used in clinical “epidemiological survey

For the diagnosis of secondary SS:

In patients with a potentially associated disease (for instance, another well-defined connective tissue disease), the presence of item I or item II plus any 2 from among items III, IV, and V may be considered as indicative of secondary SS

Exclusion criteria:

1. Past head and neck radiation treatment

2. Hepatitis C infection

3. Acquired immunodeficiency disease (AIDS)

4. Pre-existing lymphoma

5. Sarcoidosis

6. Graft versus host disease

7. Use of anticholinergic drugs (since a time shorter than 3-fold the half-life of the drug).


Obstructive disorders

Condition Features & etiology Clinical features/ Ix & Diagnosis

Sialolithiasis(Salivary gland calculi or stones)

Calculi composed of laminated layers of organic materials covered with concentric shells of calcified materials.

Mainly hydroxyapatite crystals containing octacalcium phosphate.

Etiology & pathogenesis Nuerohumoral mechanisms Metabolic mechanisms(eg: presence of existing inflammation)

Common in the submandibular glands(80%) 10% in the parotid gland.

Reasons for higher prevalence of sialoliths in the SMG Physiological factors - Saliva more alkaline - Presence higher conc of Calcium & Phosphate - Higher mucus content - Richness in phosphatase enzyme. - Low content of Co2

Anatomical factors - Longer duct - anti gravity flow(position of the gland) - Smaller orifice than the ductal luman. - Irregular course of duct.

Middle aged people with slight male predilection

Size can vary from few mm to several cm.

Intraglandular sialoliths cause less problems to the patients than extraglandular/ ductal sialoliths.

Symptoms - Sometimes there are no any symptoms - Meal time swelling (due to increase demands) - Moderate pain(due to increase pressure) - fever & malaise due to infections (If untreated)

Signs - Pus discharge through the orifice - Severe inflammation in the soft tissues. - Overlying mucosa may be ulcerated. - Sialoliths may be palpated if it presents in the extraglandular portion. - Reduce salivary flow - Enlargement of the glands.

Radiological features - Radiolucent calculi(Here 80-90% of SMG calculi are radio-opaque & 50-80% of parotid calculi are radiolucent.) - Solitary or Multiple(30% of the SMG stones are multiple & 60% of the parotid stones are multiple) - Usually oval shape & is cylindrical with multiple layers of calcifications.

Sialography is indicated when sialoliths are radiolucent, Here we can see easily the ductal dilatation & the sialodochitis.

Radiological DD - Hyoid bone - Myositis ossificans - Phleboliths - Calcific submandibular lymph nodes - Gas bubble in sialography

Plain radiographic views Parotid - DPT - Oblique lateral/ Rotated PA or AP Intraoral view of the cheek to show the duct using an occlusal radiographs SMG -DPT/ Oblique lateral - Lower 900 occlusal - Lower oblique occlusal(to show the gland)


Diagram of submandibular sialogram.

The subsidiary duct descending from the angle of the jaw to join the angle of the main duct is very constant.

Sialolithiasis.

Diagram of parotid sialogram. There are usually

three ascending ducts as well as the duct of the socia, if present, and one or two descending ducts depending on the size of the gland. Several small retromandibular ducts drain the deep, part of the gland.

Sialolithiasis.

Sialadenitis showing pus from Stensen duct .

Dormaia basket

Tiny apparatus consisting of four

wires that can be advanced

through an endoscope to the body

cavity or tube, manipulated to trap

a calculus or other object,&

withdrawn

Used in the bile duct & the ureter


Management of the sialolithiasis

Traditional Mx of the sialolithiasis

Non-surgical Mx of the sialolithiasis

Ductal dilatation

Incision & dissection

Sialadenectomy(Do when the gland has fibrosed)

Side effects of the sialoendoscopy

1. Transient glandular swelling

2. Ductal strictures 3. Lacerations 4. Basket block 5. Infections 6. Temporary parasthesia 7. Bleeding 8. Ranula formation

Interventional radiology Various techniques are using - coronary angioplasty balloon - Wire loop - Embolectomy catheter Under fluoroscopy guidance

Best method is the fluoroscopically guided stone retrieval (success rate 40-100%) Main complications are Gland swelling Infections Main limitation is the administration of ionizing radiation.

Antibiotics if acute infection is present

Increase salivation & allow stone to come out through orifice.

Manual manipulation(milking) E/O & I/O palpation behind the calculi in to the orifice.

Lithotripsy(shock wave)- sialolithotripsy - Introduced in 1989 - Noninvasive method of fragmenting the stones in to smaller portions to allow possible flushing out spontaneously. - stone fracture by producing a compressive wave that spread through calculus & expansive wave that pit stone & induce cavitations - shock wave can be generated Extra-corporeally using piezoelectric or electromagnetic techniques Intra-corporeally using electro-hydrolic, pneumatic or laser endoscopic techniques

Sialoendoscopy - First used to diagnosis but now also used for the calculi removal. - First describe in 1991 - Rigid, semi rigid, or moderately flexible endoscopes presents with different diametres. - Equipped with working channels & irrigation ports - Main problem is the entering through orifice - this problems are overcome by Dilatation with lacrimal probes/ guiding wires Papillotomy with CO2 laser Microsurgical dissection of anterior duct(ductal cut down) Graspers, miniforceps, dormaia baskets & balloons to remove stone - Not indicated if the calculi is located deeply inside the gland or embedded in wall. - Success rate is around 89% for submandibular & 83-86% for parotid calculi - Also effective in removing mucus plugs, foreign bodies, polyps & granulation tissue. - Contraindicated if there is complete distal obliteration of duct. - insertion of the sialostent averts recurrences


Infective conditions

Condition Features & etiology Mx & Diagnosis

Acute bacterial sialadenitis(Ascending)

Definition Sialadenitis due to bacterial infection ascending from the oral cavity.

Prevalence (approximate): Rare.

Age mainly affected: Older adults.

Gender mainly affected: M = F.

Etiopathogenesis: The organisms most. commonly isolated in ascending sialadenitis are Streptococcus viridans and Staphylococcus aureus (often penicillin-resistant). The parotid glands are most commonly affected

Causes Host factors - Decreased host resistance - salivary secretion & bacterial effects - Composition of the saliva - Calculi, Mucus plugs, duct strictures Other predisposing factors - After radiotherapy to the head & neck. - In Sjogren’s syndrome - Occasionally in the GI surgery due to dehydration & dry mouth.

Clinical features Symptoms - Painful & tender enlargement in the gland -Trismus - Pain in TMJ region. -Fever - Taste disturbances Signs - The overlying skin can be redded. - Pus exuding from, or in milked form through the parotid duct orifice - Become hot, indurated & tender on percussion. - Can spread to the surrounding tissues also. - Leucocytosis - Malaise

Diagnosis Pus should be sent for a culture & ABST

DD Parotitis/ Submasseteric abcess Deep parotid abcess vs Otitis media

Mx - Must treat aggressively as it can cause death in debilitated patient, even with antibiotics - Improvement of oral hygiene - Pus for culture & ABST - High dose of parental antibiotics against staphylococcus. (flucloxacillin or

amoxicillin/ clavulanate if staphylococcus and not allergic to penicillin;

erythromycin or azithromycin in penicillin allergy).) - Improve hydration - Maintain electrolyte balance. - Analgesics. - soft diet as chewing is painful to the patient. - Stimulate salivation to facilitate drainage of pus - If there is no improvement drainage of the affected gland. - Lemon juice suction for promote salivary flow.


Chronic bacterial sialadenitis

Definition: Chronic salivary gland infection.

Prevalence (approximate): Rare.

Age mainly affected: Older adults.

Gender mainly affected: M = F.

Etiopathogenesis: May develop after salivary calculus formation or acute sialadenitis, particularly if inappropriate antibiotics are used, or predisposing factors not eliminated. Serous acini atrophy when salivary outflow is chronically obstructed, further reducing saliva secretion.

Usually caused by streptococcus viridans

Recurrent forms are due to duct obstruction, congenital stenosis, Sjogren’s syndrome,Allergy or previous viral infection

Salivary flow is accompanied by the flecks of purulent material

Fibrosis of gland after several recurrences causing reduced salivary flow

Clinical features -Single, swollen, firm , non-tender salivary gland

Differential diagnosis: Calculus, neoplasm.

Diagnosis is from clinical features, and imaging (radiography, MRI, ultrasonography).

Mx - Intraductal injection of antibiotics - Ligation of duct to induce fibrosis. - Radiotherapy to induce fibrosis but this increase the risk of head & neck cancers. - Total removal of the gland Radiological features - Multiple ectasias & dilatations of main excretory duct in sialogram - Multiple cavitations in the USS

Juvenile recurrent parotitis

Definition Repeated parotitis &sialectasis in a child, associated with a sialographic pattern of sialectasis

Prevalence (approximate): Uncommon.

Age mainly affected: Usually begins in pre-school children.

Gender mainly affected: M > F.

Etiopathogenesis: Congenital or autoimmune duct defects.

Symptoms - Intermittent pain, - Unilateral parotid swelling which lasts < 3weeks with spontaneous regression. - It may occur simultaneously or alternately contra- laterally. - fever

Signs - parotid swelling

DD Sjorgren’s syndrome

Diagnosis is mainly on clinical grounds but serum anti-SS-A and SS-B

antibodies are indicated to exclude Sjögren's syndrome, and imaging with ultrasonography and CT scan or sialography showing sialectasis is confirmatory

Mx In- patients hospital

admission if condition warrants

Culture & ABST(from salivary exudate)

Appropriate antibiotics. High fluid intake. Lemon juice suction to

promote salivary flow


Chronic sclerosing sialadenitis(Kuttner’s tumor)

Commonly seen in SMG

Is a chronic inflammatory disease of major salivary glands causing fibrosis & firm tumor like enlargement of the gland.

Due to ductal calculi causing subsequent bacterial infection resulting chronic inflammation, acinar destruction & replacement fibrosis.

Radiological features - Multiple globular sialectasias in sialogram. - Sialodochitis (sausage like appearance of ducts) in sialogram. - Absence of terminal branches & presence of constricted ductal lumens. - Multiple cavitations with reduced echogenicity in USS.

Granulomatous diseases of salivary glands(Chronic specific sialadenitis)

Main one is Sarcoidosis which produce Heerfordt’s syndrome

Features of the Heerfordt’s syndrome are - Uveitis of the eye - Salivary gland swelling - Facial palsy

Mumps

This is the most commonest & important condition.

Acute contagious viral infection

Characterized by bilateral/ unilateral gland enlargement.

Mainly affects the major salivary glands but also can affects testis, meninges, pancreas, heart & mammary glands.

Also called endemic parotitis

Caused by paramyxovirus

Endemic in most urban population

Airborne infection

Clinical features - more common in boys & often between 5-15 years of age. - Incubation period is 2-3 weeks - Prodromal symptoms(Onset of headache, chills, moderate fever, vomiting, pain below ear & last about 1 week) - Parotids are usually affected & mostly bilateral. - SMG is less commonly involved & when affected have less swelling & pain.

Symptoms – Prodromal symptoms followed by sudden onset of painful salivary gland swelling without purulent discharge from duct.

Signs- Elevation of ear lobe, Firm/ rubbery/ elastic gland enlargement., Puffy & reddened papilla.

No antiviral therapy or antibiotics advocated.

Bed rest & isolation

Hydration with plenty of fluid intake.

NSAIDs(ibuprofen) for children’s: Ibuprofen syrup 100mg/5ml


Asymptomatic enlargement (Sialosis/ Sialadenosis)

Non- neoplastic, non- inflammatory enlargement of the salivary glands

Usually bilateral & may presents as recurrent painless enlargements.

Commonly in parotids in males.

Associated with systemic conditions such as cirrhosis, diabetes, thyroid insufficiency, alcoholism & malnutrition

Alteration occurs in the chemical composition of saliva.

Significant elevation of salivary potassium & decrease in sodium.

Sialorrhea (Ptyalism)

Increase salivary secretions occurs.

2 types - True Sialorrhea: Rare, may be due to rabies, metal poisoning, inflammatory lesion in the mouth - Pseudo Sialorrhea: Common in infants(drooling), Neuromuscular problems, Down’s syndrome, paralysis, Mental handicaps

Etiology - Drugs - Local factors such as stomatitis, erythema multeforme & ANUG - Systemic disease such as rabies, paralysis, alcoholic neuritis, epilepsy, Down’s syndrome, Neuromuscular disorder - Miscellaneous causes such as psychic factors, metal poisoning & facial paralysis

Clinical features - Excessive production or inadequate swallowing due to neuromuscular in-coordination. - Affected individuals may need several cloths - Emotional & physical impairment. - Infections due to chronic exposure to saliva - Ulceration & cheek scarring due to recurrent infections & necrosis of tissues.

Botulinum toxin injection is an effective method

Cause selective chemical denervation by blocking neurotransmitter release at the cholinergic parasympathetic nerve terminals of the salivary glands. So secretory capacity of the gland is reduced.

Botulinum toxin therapy is also used to treat sialocele & chronic & recurrent parotitis.

Diseases of minor salivary glands

Mucocele

Nicotinic Stomatitis

Necrotizing sialometaplasia

Neoplasms


Tree in winter appearance(normal appearance of the parotid gland)


Brush in winter appearance (SMG)

Sjorgren’s syndrome

Sialadenitis

Sialadochitis(Sausage link appearance)


Education

Salivary gland disorders