Benign Salivary Gland Diseases - MU

Sialadenitis

• Inflammation of the salivary glands.

Classification of Sialadenitis

• Acute or Chronic

Acute Sialadenitis

• Epidemic or Acute Suppurative

Epidemic Acute Sialadenitis

• Includes mumps and influenza.

Acute Suppurative

• Includes acute parotitis and acute submandibular sialadenitis.

Chronic Sialadenitis

• Endemic or Chronic Pyogenic

Endemic Chronic Sialadenitis

• Includes parasitic infestation (anklyostoma), liver cirrhosis, and malnutrition.

Chronic Pyogenic

• Includes chronic parotitis and chronic submandibular sialoadenitis.

Epidemic Disease Defined

• A disease that is widespread, affecting a large number of individuals within a population, community, or region at the same time.

Endemic Disease Defined

• A disease that is found in a certain geographic region or in a specific race of people.
• Malaria is endemic to parts of Africa.

Acute Suppurative Sialadenitis Etiology

• Predisposing factors include poor oral hygiene, obstruction of the salivary duct by food particles, foreign bodies, or stones, dehydration (postoperatively), and debility.
• Organisms include Staph. aureus (most common), Streptococci, and Pneumococci.
• Route of entry is either direct (along the duct from the mouth – most common, or from a nearby focus) or blood borne.

Acute Suppurative Sialadenitis Pathology

• The parotid gland is the most commonly involved gland.
• The gland and duct are congested, edematous and may suppurate.

Acute Suppurative Sialadenitis Clinical Picture

• General symptoms: Toxemic symptoms, such as fever and headache.
• Local symptoms:
  • Pain: Early dull aching, later severe throbbing.
  • Swelling: Elevating the lobule of the ear, red, warm, edematous, tender, and fluctuant (late due to thicker parotid fascia).
  • Opening of the duct: Red, raised, edematous, with possible discharge.
  • Trismus: Restricted movement of the temporomandibular joint (TMJ).

Acute Suppurative Sialadenitis Complications

• Abscess: If it ruptures, it may lead to a fistula.
• Chronicity & stone formation.
• Spread:
  • General: Toxemia, septicemia, pyemia.
  • Local to surrounding: If submandibular, Ludwig's angina.

Acute Suppurative Sialadenitis Investigations

• CBC: Leukocytosis (to identify infection)
• X-ray: May show calcifications or stones
• Ultrasound (US)

Acute Suppurative Sialadenitis Conservative Treatment

• General:
  • Rest
  • Antibiotics (Clindamycin)
  • Analgesics
  • Tonics
• Local:
  • Hot fomentation
  • KI as sialagogue
• Observation:
  • General: Pulse and temperature
  • Local: Swelling

Acute Suppurative Sialadenitis Progression

• After 3 days of conservative treatment:
  • Improvement: Continue conservative treatment until complete cure.
  • Worsening: Signs of suppuration (throbbing pain, hectic fever, pitting edema) Incision & drainage (do not wait for fluctuation).

Surgical Treatment Indications

• Failure of conservative treatment.
• Signs of suppuration (abscess formation).

Surgical Treatment Procedure in Parotid Abscess

• Vertical skin incision in front of the ear.
• The deep fascia is incised transversely.
• To avoid injury to the branches of the facial nerve
• A sinus forceps is then introduced closed and then opened to drain the pus (Hilton's method).

Surgical Treatment Procedure in Submandibular Abscess

• Skin incision parallel to the lower border of the mandible 1.5 inches below and in front of the angle of the mandible.
• To avoid injury to the mandibular branch of the facial nerve
• Incise the deep fascia
• A sinus forceps is then introduced closed and then opened to drain the pus (Hilton's method).

Chronic Sialadenitis Etiology

• Two Types: Chronic calcular and non-calculus.

Chronic Calcular Sialadenitis

• Involves the presence of stones.

Chronic Non-Calculus Sialadenitis

• Poor oral hygiene
• Obstruction of the salivary duct by food particles, foreign bodies, or stones
• Imperfect drainage of acute sialadenitis

Chronic Calcular Sialadenitis Pathology

• Stones lie in the gland or duct
• Submandibular glands to parotid ratio is 50:1
• Submandibular secretions are more viscous
• The duct opens in the floor of the mouth causing obstruction by food.
• Drainage of the submandibular gland is independent.
• Composition: Calcium - Magnesium phosphate – Carbonate

Chronic Non-Calculus Sialadenitis Pathology

• Gland and duct are chronically inflamed.
• The submandibular gland is the most commonly involved.

Chronic Calcular Sialadenitis Complications

• Obstruction and infection that may lead to abscess and fistula formation.
• Migration of stones "if small."
• Malignancy.

Chronic Non-Calculus Sialadenitis Complications

• Recurrent acute attacks.
• Stone formation.
• Sialectasis (Dilatation of the salivary ducts).

Chronic Sialadenitis Clinical Picture- Symptoms

• Pain: Dull aching pain if the stone is in the gland, or colicky pain if it is in the duct
  • May be referred to tip of the tongue or teeth.
  • Pain increases with meals and mastication
• Swelling: Can increases after meals
• Discharge: Bloody or purulent, may be seen coming from the duct

Chronic Sialadenitis Clinical Picture- Signs

• Lemon Test: Pain and gland increase in size when the patient is given a lemon to suck.
• Gland: Enlarged and tender.
  • Cannot be rolled over the lower border of the mandible with preservation of the sulcus.
• Bidigital palpation: The gland is better felt from inside the mouth.
• Palpated duct: The duct itself may be palpated with a stone in it.
• Opening of the duct: Red, raised, discharging blood or pus/ stone may be seen peeping from the duct opening.

Chronic Sialadenitis Investigations

• Plain X-ray: Stones are 100% radio-opaque (may be hidden by the mandible).
• Neck Ultrasound (US).
• Sialography: Radio-opaque material is injected into the cannulated duct to delineate it and shows sialectasis behind the stone.
  • Lipidol or Hypaque (Na diatrizoate)
  • 0.5-2 ml injected in the cannulated duct to delineate it and shows sialectasis behind stone

Enlarged Submandibular Salivary Gland vs. Enlarged Submandibular Lymph Node

• Number:
  • Salivary gland: Single swelling
  • Lymph node: Usually multiple
• Lemon test:
  • Salivary gland: +ve
  • Lymph node: -ve
• Rolling:
  • Salivary gland: Cannot be rolled around mandible and preserved sulcus
  • Lymph node: Can be rolled around mandible
• Bidigital examination:
  • Salivary gland: Best palpated from inside
  • Lymph node: Best palpated from outside
• Signs:
  • Salivary gland: Duct - Discharge - Sign
  • Lymph node: -ve

Chronic Sialadenitis Treatment - Submandibular Gland

• Peeping stone from orifice: Meatotomy.
• Stone in the duct:
  • Under local anesthesia, the duct is underrun by an anchoring stitch to avoid slippage of the stone to the gland.
  • Slit the duct open from the orifice to the stone.
  • Remove the stone
  • Leave the duct opened after removal of the anchoring stitch to allow better drainage.
• Recurrent ductal stones OR associated with gland stones: Submandibular Sialadenectomy
• Submandibular sialadenectomy involves a curved incision starting 1.5 inches below and in front of the angle of the mandible to avoid injury to the mandibular branch of the facial nerve.

Chronic Sialadenitis Treatment - Parotid Gland

• Stone in duct:
  • Can be removed intraorally
• Stone in gland:
  • Total conservative parotidectomy: Superficial parotidectomy leads to postoperative salivary fistula due to the diseased cystic deep lobe.

Von Mikulicz Disease

• It is an autoimmune disease causing enlargement of both parotid, both submandibular, and both lacrimal glands
• It is a precursor of lymphoma of the salivary gland.
• The salivary glands are the seat of heavy lymphocytic infiltration.
• The disease responds to prednisolone
• The syndrome also includes:
  • Narrowing of the palpebral fissure due to enlargement of the lacrimal gland.
  • Dry mouth.

Sjogren Syndrome & Osicca Syndrome

• Sjogren syndrome: Dry mouth, dry eyes, and generalized arthritis.
• Osicca syndrome: Dry mouth and dry eyes.

Cysts of Salivary Glands

• Mucocele: A retention cyst which affects either minor salivary glands (in the oral cavity, especially in the buccal mucosa) or major salivary glands. The treatment is excision of the cyst and minor salivary gland if it is arising from it.
• Sialocele: It is due to trauma to the salivary ducts leading to extravasation of secretion.
• Ranula: A mucocele of the sublingual salivary gland that presents as a large, tense, bluish swelling in the floor of the mouth, which displaces the tongue. It may push its way through the mylohyoid raphe and protrude to the neck plunging ranula and managed by Deroofing & excision of sublingual salivary gland