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Salivary Swelling (Parotid and Submandibular Glands)

 

  1. Differential Diagnosis
    1. Obstructive Sialadenitis
      1. Sialolithiasis (salivary stones)
      2. Ductal stenosis (stricture or narrowing of drainage tubes)
      3. Sialectasis (chronic changes in the salivary glands)
    2. Autoimmune
      1. Sjogrens (primary, secondary = associated with other autoimmune disorder)  (see Sjogren's Syndrome)
      2. Graft v Host Disease aka "Sjogren's - like syndrome"
        1. Complication after transplantation: interaction of immunocompetent donor cells with recipient. Xerostomia similar to Sjogrens - may use lip biopsy to monitor
    3. Granulomatous Sialadenitis (Non-caseating)
      1. Sarcoidosis ; parotid commonly affected. Heerfordt's: uveoparotid fever
      2. Crohn's disease
      3. Melkersson-Rosenthal syndrome
        1. "cheilitis granulomatosa Miescher"
      4. Granulomatous giant cell sialadenitis
      5. Xanthogranulomatous sialadenitis
      6. Wegeners Granulomatosis
      7. Churg-Strauss granulomatosis
      8. Inflamatory pseudotumor
    4. Sialadenosis (sialosis) see also:Sialosis or sialadenosis Case example of surgical treatment; and    Sialosis - Rads 
      1. Endocrine/Metabolic
        1. Acromegaly, Alcoholism, Diabetes insipidus, Diabetes mellitus, Hypothyroidism, Cirrhosis of the liver, Uraemia. 
      2. Drug induced
        1. Antihypertensives, Guanacline, Iodine, Isoprenaline, Lead, Mercury, Naproxen, Oxphenbutazone, Pheylbutazone, Sulfisoxazole, Thiocyanate, Thiouracil, Valproic acid
      3. Nutritional
        1. Beriberi, bulimia, gastrointesitnal disease, malnutrition, pallagra, amylophagia, vitamin A deficiency
    5. Viral Sialadenitis
      1. Mumps
      2. Paramyxovirus: swelling 2-7 days/ systemic effects (orchitis in 25% of adult males)
      3. Mimics mumps
      4. Influenza, parainfluenza, coxsackie, CMV, adenovirus
      5. Human immunodeficiency virus
      6. Hepatits C virus
      7. Gland enlargement due to multiple lymphoepithelial cysts
    6. Bacterial Sialadenitis
      1. Parotid more commonly affected that SMG (?more bacteriostatic saliva in SMG)
      2. Related to decreased salivary flow / dehydration
    7. Paraglandular node infection
      1. Myobacterial tuberculosis
      2. Atypical mycobacterial - M. avium-intracellulare and M. scrofulaceum.
    8. Tumor
      1. See Further Reading (below) for detailed discussion of benign/malignant process arising in parotid
        1. note occasional clinical presentation of Warthins tumor or cystic mucoepidermoid carcinoma with a presentation that is more consistent with infection or ductal obstruction than tumor
        2. see Head and Neck Pathology for specific tumor histology
        3. see Parotidectomy with Facial Nerve Dissection 
        4. see Submandibular Gland Resection
      2. Metastatic to periglandular nodes
      3. Lymphoma - MALT associated
    9. Masseter hypertrophy
      1. Impression of parotid swelling from underlying masseter enlargement
    10. Radiation (I131) I131 sialadenitis (Radioiodine Sialadenitis)
           i.   I-131 hones in on the salivary glands where it is concentrated and secreted into the saliva. May be associated with xerostomia and taste alteration.
    11. Miscellaneous (see Chen 2013)
      1. Iodide mumps
      2. Kimura disease
      3. General anesthesia
      4. Polycystic parotid disease
      5. Amyloidosis
      6. Pneumoparotitis
  2. History
    1. Non painful swelling versus painful (acute infectious, sialoadenitis)
    2. Chronic versus Acute swelling (inflammatory)
    3. Aggravating factors: Eating (Sialoadenitis)
    4. Constitutional "B type symptoms" (HIV
    5. Unilateral versus Bilateral (Viral parotitis, Sialadenosis)
    6. History of radioactive iodine treatment
      1. Radioactive iodine (I 131) targets the thyroid gland is utilized in the treatment of differentiated papillary and follicular cancers. Dose related damage to the salivary glands occurs secondary to 131I irradiation. Salivary gland swelling and pain may develop acutely or months later. Xerostomia with concomitant increase in dental caries, changing taste, infection, facial nerve involvement, stomatitis, and candidiasis. Treatment of the varied complications that may develop encompass numerous approaches and include gland massage, sialogogic agents, duct probing, antibiotics, mouthwashes, good oral hygiene, and adequate hydration
    7. History of Radiation treatment: Acute suppurative sialoadenitis
    8. History of Measles, mumps, rubella vaccine:
      1. Mumps associated with sensorineural hearing loss, infertility, encephalitis, pancreatitis, nephritis.
    9. History of Sarcoidosis:
      1. Heerfordt syndrome:uveitis, parotid enlargement, facial palsy
    10. History of Sjogren's:
      1. Associated with dry mouth (xerostomia), dry eyes (keratoconjunctiva sicca), abnormal taste, intermitted unilateral or bilateral salivary gland enlargement, d
      2. Can be in association with another connective tissue disorder such as Rheumatoid Arthritis, Systemic Lupus Erythramatosis, or Polyarteritis Nodosum.
    11. History of Tuberculosis:
    12. History of Gout: associated with sialolithiasis
  3. Physical
    1. Inspection
      1. Unilateral or bilateral gland enlargement
      2. Skin/Mucosal lesions: cancer metastasis to glands
      3. Facial nerve involvement would increase malignant potential
    2. Palpation
      1. Warm skin: sialoadenitis
      2. Tender: inflammatory condition is tender
      3. Salivary gland massage:
        1. purulent saliva: inflammatory, sialoadenitis
        2. Decreased saliva
      4. Lymphadenopathy of neck
  4. Diagnostic Imaging and Tests
    1. Ultrasound
      1. Distinct margins vs. Indistinct margins (suspicious for malignancy)
      2. Echogenicity - increased with malignancy, decreased with inflammatory lesions
    2. Fine Needle Aspirate:
      1. Indicated for discrete nodules: differentiates benign, malignant
      2. Controversial use: multiple passes dangerous to tumor seeding.
    3. Core needle biopsy
      1. Alternative if FNA cytology has failed to give a definitive diagnosis. Higher sensitivity, positive predictive value, and diagnostic accuracy compared to FNA in both benign and malignant lesions. Also decreased non diagnostic rates with low risk. ??Facial nerve?
    4. CT/MRI for dimensions
      1. Pre-operative evaluation
      2. CT: deep lobe parotid tumors
      3. MRI: parapharyngeal space, may differentiate neoplastic from inflammatory
    5. Sialograms and Sialography: Water soluble contrast injection into cannulated ducts to evaluate size, functional characteristics and ductal anatomy.
      1. Most accurate imaging method to detect calculi
      2. Contraindicated in acute infections
      3. Radiosialography evaluated dynamic activity via radioisotopic concentration in gland
        1. Increased uptake with Warthin's tumor, oncocytoma
    6. Sialoendoscopy
      1. Minimal morbidity: Intraoral extraction without transverse cervical incision.  Also can be therapeutic.
    7. Blood Studies
      1. Serologic tests for viral parotiditis: viral culture from urine, saliva, cerebrospinal fluid
      2. Sjogren's Syndrome: Rhematoid factor, anti-nuclear antibody, autoantibodies SS-A, SS-B, ANA, ESR
      3. Wegener's Syndrome: Cytoplasmic antineutrophil cytoplasmic antibody (C-ANCA)
  5. Surgical treatment
    1. Sialendoscopy
    2. Parotidectomy with Facial Nerve Dissection
    3. Case example Submandibular Gland Resection
  6. Non Surgical Treatment
      1. Recurrent Parotitis
        1. Calculi or strictures produce sialectasis (dilation of salivary duct) à pain and swelling with eating
        2. May require parotidectomy if symptomatic
      2. Sialolithiasis:
        1. Caused by salivary stones, usually the submandibular gland because of longer length duct and salivary content
        2. Pain and swelling worse at mealtime
        3. Stones composed of hydroxyapatite, +/- radiolucency
        4. History of xerostomia or gout
        5. Colic relived by conservative management to increase salivary flow: rehydration, salivary gland massage, warm compress, sialoagogues, and oral irrigations
        6. Stones within duct: sialodochoplasty
        7. Symptomatic with stone situated toward hilum: Sialoendoscopy or submandibular gland resection.
      3. Chronic Recurring Sialoadenitis:
        1. Risk Factors: repeat acute infections, trauma, radiation, immunocompromised state, smoking
        2. Exclude malignancy with CT scan
        3. Conservative management to increase salivary flow: rehydration, salivary gland massage, warm compress, sialoagogues, and oral irrigations
        4. Salivary duct dilation, sialoendoscopy
      4. Sjogren's Syndrome: Benign lymphoepithelial lesion, myoepithelial sialadenitis:
          1. Salivary gland swelling with xerostomia and keratoconjunctiva sicca sometimes in association with another connective tissue disease.
          2. Diagnosis with minor salivary gland biopsy with laboratory tests for autoantibodies.
          3. Symptomatic relief of xerostomia and xerophthalmia.
          4. Primary Sjogren's at high risk for development of malignant lymphoma
      5. Chronic Granulomatous Sialadenitis
        1. Sarcoidosis
          1. non-caseating granulomas
          2. Heerfordt syndrome: Uveoparotid syndrome
            1. Parotid enlargement, facial palsy, uveits
        2. Wegener Granulomatosis
          1. Acute unilateral mass +/- pain
      6. Sialadenosis
        1. Chronic, bilateral, diffuse, non-inflammatory, non-neoplastic, painless enlargement
        2. Associated with many other metabolic/medical conditions, see above.
        3. Treat underlying medical condition.
    1. Infectious Disease
      1. Acute Suppurative Sialoadenitis:
        1. Salivary stasis caused by stones, dehydration, leads to stricture or obstruction of the ducts.
        2. Pain, erythema, swelling, with fever
        3. Post operative or elderly patients with chronic comorbidities. History of radiation or chemotherapy.
        4. Conservative management to increase salivary flow: rehydration, salivary gland massage, warm compress, sialoagogues, and oral irrigations
        5. Antimicrobials (anti-staphalococcal) and culture if purulent discharge
        6. Submandibular abscess can mimic Luwig angina
      2. Viral Parotitis or Mumps:
        1. Bilateral painful swelling, malaise and trismus
        2. Supportive care with hydration and analgesics, usually self-limited
        3. Other manifestations: orchitis, pancratitis, nephritis, encephalitis, meningitis, cochleitis
        4. Follow up: audiology, vaccine,
      3. Chronic Granulomatous Sialadenitis
        1. Tuberculosis:
          1. diagnosis: acid-fast staining for organisms, culture saliva, PPD skin test
          2. multi-drug anti-tuberculous medications
        2. Syphilis
        3. Benign Lymphoepithelial lesion (HIV association)
          1. also known as Godwin tumor, Mikulicz syndrome
          2. Inflammatory condition of parotid gland
          3. May present as painless bilateral salivary cysts possibly with associated cervical lymphadenopathy
          4. Known risk factors
          5. Treatment with fine needle aspiration: amylase in cyst fluid confirms diagnosis
        4. Actinomycosis
          1. May be acute or chronic, usually with history of dental trauma
          2. Anaerobic culture for diagnosis
          3. Treat with long-term penicillin therapy
        5. Cat-scratch disease: Bartonella henslae##### periparotid lymph nodes
          1. self-limited disease with supportive treatment
  7. Further Reading
    1. Fox PC, Hong CH, Brun AG and Brennan MT: Ch12 Diagnosis and Mangement of Autoimmune Salivary Gland Disorders" pp 201-219 in Salivary Gland Disorders eds Myers EN and Ferris RL Springer, Berlin 2007
    2. Hoffman HT, Funk G, Endres D. Evaluation and Surgical Treatment of Tumors of the Salivary Glands, Chapter 54 (pp 1147-1182). In Comprehensive Management of Head and Neck Tumors, 2nd ed. 1999.
    3. Ogren FP, Huerter JV, Pearson PH et al (1987) Transient salivary gland hypertrophy in bulimics. Laryngoscope 97:951-953
    4. Susan J. Mandel, Louis Mandel. Radioactive Iodine and the Salivary Glands Thyroid. March 1, 2003, 13(3): 265-271.
    5. Pratap R, Qayyum A, Ahmed N, Jani P, Berman LH. Ultrasound-guided core needle biopsy of parotid gland swellings. J Laryngol Otol.2008 Sep 30:1-4.
    6. Pape SA, MacLeod RI, McLean NR, Soames JV.  Sialadenosis of the salivary glands.  British Journal of Plastic Surgery. (1995) 48:419-422.
    7. Scully C, Bagan JV, Eveson JW, Barnard N, Turner F.  Sialosis: 35 cases of persistent parotid swelling from two countries.  British Journal of Oral and Maxillofaical Surger (2008) 46: 468-472
    8. Fritsch MH: Algorithms for Treatment of Salivary Gland obstructions Witout access to Extracorporeal Lithotripsy. Otolaryngologic Clinics of North America Volume 42, Issue 6, December 2009, pages 1193-1197 mfritsch@iupui.edu 
    9. Vitali C: Immunopathologic differences of Sjogren's syndrome versus sicca syndrome in HCV and HIV infection Arthritis Res Ther. 2011 Aug 19;13(4):23
      KB, HH 11-29-08
    10. Chen S, Benjamin C and Myssiorek D: An Algorithm Approach to Diagnosing Bilateral Parotid Enlargement  Otolaryngology – Head and Neck Surgery 148(5) 732-739