MedicineToday PEER REVIEWED ARTICLE CPD 1 POINT A guide to salivary disorders The salivary may be affected by a wide range of neoplastic and inflammatory

disorders. This article reviews the common disorders encountered in

general practice.

RON BOVA The salivary glands include the parotid glands, examination are often adequate to recognise and MB BS, MS, FRACS submandibular glands and sublingual glands differentiate many of these conditions. A wide (Figure 1). There are also hundreds of minor sali- array of benign and malignant may also Dr Bova is an ENT, Head and vary glands located in the mucosa of the hard and affect the salivary glands and a neoplasia should Surgeon, St Vincent’s soft , oral cavity, , and oro - always be considered when assessing a salivary Hospital, Sydney, NSW. . The lies in the preauricular gland mass. region and extends inferiorly over the angle of the . The parotid courses anteriorly Inflammatory disorders from the parotid gland and enters the Acute through the buccal mucosa adjacent to the second Acute of the salivary glands is usu- upper tooth. The lies ally of viral or bacterial origin. is the most in the and its duct passes common causative viral illness, typically affecting anteriorly along the floor of the mouth to enter the parotid glands bilaterally. Children are most adjacent to the frenulum of the tongue. The sub- often affected, with peak incidence occurring at lingual glands are small glands that lie just beneath approximately 4 to 6 years of age. The parotid the mucosa in the lateral floor of mouth region. swelling is accompanied by constitutional symp- The salivary glands may be affected by a range toms such as and malaise, but many cases are of neoplastic and inflammatory disorders. Inflam- mild and subclinical in nature. Treat ment is symp- matory disorders may be due to viral or bacterial tomatic. In addition to the mumps , other , granulomatous conditions or autoim- that may manifest as acute viral sialadenitis mune diseases. A thorough history and physical include , , echovirus,

• Salivary gland disorders represent a heterogeneous group of conditions ranging from inflammatory disorders to a diverse group of benign and malignant neoplasms. • Acute inflammation of the salivary glands is usually of viral or bacterial origin; mumps is the most common causative viral illness. • Chronic inflammation and most often affect the parotid gland. • Most salivary stones (80%) occur in the submandibular gland; 20% occur in the parotid gland. IN SUMMARY • Salivary gland neoplasms are relatively uncommon, comprising only about 2% of all head and neck neoplasms. The histopathology of these tumours is incredibly diverse, with most (80%) occurring in the parotid gland.

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Permission granted for use by Entthyroid.com.au for educational purposes. © Medicine Today 2006. Copyright for illustrations as stated. parainfluenza virus and HIV. Acute suppurative bacterial sialadenitis most often affects the parotid gland and, to a lesser extent, the submandibular glands. Acute reduction © copyright in salivary flow from dehydration or chronic reduction as a result of psychotropic , combined with poor , may predispose to . Fever, painful unilateral gland swel l ing, and purulent sialorrhoea are the typical signs of this potentially serious . Staphy- lococcus aureus is the most common . Treat ment includes rehydration, warm com- presses, repeated gland massage and therapy. If an abscess develops, incision and Parotid drainage may be required once the exact location gland of the collection is localised radiologically.

Chronic sialadenitis Sublingual Chronic inflammation and fibrosis most com- gland Submandibular monly affect the parotid gland, often resulting from gland repeated acute infections with progressive damage to the ductal leading to stricture forma- © CHRIS WIKOFF, 2006 tion and acinar . Patients experience recurrent low grade infec- begins between 7 and 9 years of age, and the fre- Figure 1. Salivary glands, tions in one or both glands, characterised by inter- quency of attacks often subsides after puberty. The showing position of the mittent swelling, or discomfort precipitated cause is thought to be bacterial infection ascend- parotid, sublingual and by eating. Streptococcus viridans is the usual - ing from the oral cavity, and hence treatment with submandibular glands. ism responsible and is the antibiotic of a penicillin based antibiotic is indicated for severe choice. Maintaining adequate hydration and gland acute attacks. massage are adjunctive measures that facilitate resolution of this often frustrating condition. If Sjögren’s syndrome conservative measures fail, excision of the gland Sjögren’s syndrome is an autoimmune disorder may be required; however, the chronic inflamma- that results in immunologically mediated destruc- tory changes and fibrosis can make surgical resec- tion and inflammatory enlargement of the lacrimal tion challenging. and salivary glands. Sjögren’s syndrome occurs Sometimes an enlarged gland raises the possibil- predominantly in postmenopausal women and ity of and both CT scanning and fine presents with dryness of the eyes and mouth, lead- needle aspiration (FNA) are required to ing to chronic mouth and ocular discomfort. exclude a neoplastic process. can also Patients may develop slowly progressive symmetri- support the diagnosis of sialadenitis by demonstrat- cal enlargement of the salivary glands. Sudden ing strictures and dilatation of the relevant salivary increased swelling of the parotid gland should alert ductal system. the GP to the possibility of , which is 40 times more likely to occur in patients with Juvenile recurrent parotitis Sjögren’s syndrome than in the general population. Juvenile recurrent parotitis represents the second Treatment for in Sjögren’s most common inflammatory salivary gland disease syndrome is symptomatic and supportive. Some- of childhood after mumps. Patients usually pre- times superficial is required for sent with unilateral recurrent swelling of the markedly enlarged glands that are causing cos- parotid gland, often with associated pain, fever metic concern, or if recurrent infections become and malaise. This interesting condition generally problematic.

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Figure 3. CT scan demonstrating a large stone impacted in the hilum of the submandibular gland. Stones are typically smaller than this and in the majority of cases can be readily identified with Figure 2. Enlarged submandibular gland. standard plain x-rays.

Chronic granulomatous sialadenitis Noninflammatory disorders suspected but is impalpable, x-rays of Granulomatous disorders may present Salivary calculi the submandibular region with intraoral with acute or chronic salivary gland Most salivary stones (80%) occur in the views may identify the offending calcu- swelling. This group of disorders is often submandibular gland; 20% occur in the lus; however, 20% of stones are radiolu- painless and includes , cat parotid gland. Stone formation is thought cent and thus will be missed with plain scratch disease, , to be more common in the submandibular x-rays. Sialography, where contrast is and Wegener’s granulomatosis. CT scan- gland as a result of the higher and injected into the salivary duct, is techni- ning and FNA biopsy can often assist with calcium content of its . Interest- cally challenging and usually unnecessary the diagnosis. ingly, there is no association between but is the most accurate imaging method serum calcium and phosphorous levels to detect salivary calculi. Both CT scan- and the formation of calculi. Calculi may ning and ultrasound can also be used to be found within the ductal system itself identify calculi with a high degree of or within salivary gland parenchyma. accuracy. They are particularly useful for Submandibular duct stones most often identifying stones in the hilum or present with intermittent salivary gland parenchyma of the affected salivary gland swelling and discomfort associated with (Figure 3). eating (Figure 2). Sometimes mucopuru- Treatment of small stones is initially lent saliva can be expressed from the duct conservative. It includes adequate hydra- in the floor of the mouth and the offend- tion, sialagogues such as lemon juice, ing may be palpable. Most sub- heat, massage, and appropriate anti - mandibular duct stones can be palpated biotics for established infection. Although bimanually. The index finger of one small stones often extrude spontaneously, hand is placed in the floor of the mouth surgical removal is sometimes required. with the other hand palpating the sub- Stone removal may be performed trans - mandibular region. The normal sub- orally for calculi located distally within mandibular gland will feel soft to firm in the duct; however, adequate removal of Figure 4. Submandibular gland removed consistency, while stones will feel hard. larger stones located more proximally and sectioned, demonstrating numerous If a stone is palpable, radiological studies often requires submandibular gland stones filling the hilum of the gland. are usually not necessary. If a stone is resection (Figure 4).

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Permission granted for use by Entthyroid.com.au for educational purposes. © Medicine Today 2006. Copyright for illustrations as stated. Benign lymphoepithelial lesion Benign lymphoepithelial lesion is also known as Mikulicz’s syndrome. It has a predilection for women in the fifth and sixth decades of life and also occurs com- monly in HIV-infected populations. Patients present with unilateral firm or cystic swelling of the parotid gland, with bilateral involvement in 20% of cases. Ultrasound or CT scanning reveals multi- ple cystic lesions, and FNA demonstrates acinar atrophy and diffuse lymphocytic infiltration. Treatment is supportive unless parotid enlargement is severe enough to Figure 5. appearing as a floor of mouth Figure 6. Plunging ranula appearing as a warrant parotidectomy. swelling. submandibular neck mass.

Sialadenosis and systemic diseases chronic infection and autoimmune dis- malignant parotid tumour in Australia. Sialadenosis is the term used to describe orders. It also often occurs after radia- Similarly, malignant melanoma may also the non-neoplastic, noninflammatory tion therapy used to treat patients with metastasise to the parotid, and hence a enlargement of the salivary glands that head and neck . The salivary high index of suspicion is required when occurs in association with many systemic glands are extremely sensitive to the assessing parotid lumps, especially in disorders. The cause is unknown and the effects of radiation and irreversible aci- patients with sun-damaged skin. disease most often presents with bilateral nar cell damage is an inevitable conse- A list of the common benign and parotid gland swelling. quence of . malig nant salivary gland tumours is Associated disorders include: may also be secon dary to the use of cer- shown in the Table. • obesity tain medications, especially those with Most salivary gland tumours present • malnutrition side effects. Treatment is as slow-growing, painless, firm, non- • alcoholic cirrhosis symptomatic, including increased tender masses. Symptoms and signs that • hypothyroidism hydration, sialagogues and artificial saliva. • Recommended sialagogues include • other endocrine abnormalities. lemon with ice, sugarless candies and Table. Salivary gland tumours Salivary gland enlargement usually gum. resolves with treatment of the underlying Benign condition. Neoplastic salivary gland disease Salivary gland neoplasms are relatively Warthin’s tumour Ranula uncommon and constitute only about 2% A ranula is a benign cystic lesion that of all head and neck neoplasms. The Monomorphic adenoma occurs in the floor of mouth as a result histopathology of these tumours is incred- Malignant of mucous extravasation that originates ibly diverse with most (80%) occurring in Metastatic cutaneous squamous cell from the . It appears as the parotid gland, while the remaining carcinoma a bluish cystic lesion in the anterior floor 20% occur in the submandibular and of mouth (Figure 5). A plunging ranula minor salivary glands. About 80% of occurs when a ranula penetrates through parotid tumours are benign; however, the the floor of mouth muscles and presents incidence of malignancy in submandibu- as a sub man dib ular or submental mass lar tumours is approximately 50%. Lymphoma (Figure 6). Australia has the highest incidence of cutaneous Miscellaneous Xerostomia (SCC) and melanoma in the world. Haemangioma Xerostomia (dry mouth) may be secon - Metastatic SCC to the parotid gland from dary to systemic disorders such as diabetes, a facial or scalp SCC is the most common

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structures. FNA cytology is a safe and rence. The multidisciplinary approach for highly reliable test for differentiating managing salivary gland is between neoplastic and non-neoplastic similar to treatment paradigms for other disorders. FNA allows the surgeon to head and neck . This has been cov- counsel patients preoperatively about the ered in a recent article in Medicine Today.2 extent of resection required to optimally manage their tumour type. As with other Conclusion head and neck masses, open biopsy Inflammatory disorders of the salivary should be avoided because tumour glands are relatively common, and usually spillage may compromise future curative respond to medical management. Patients surgical procedures. with salivary gland masses require further Treatment of benign neoplasms invol - investigation and appropriate referral. ves resecting the affected salivary gland. While most salivary gland tumours are As most benign tumours occur in the benign, malignancy needs to be consid- Figure 7. Malignant parotid mass. superficial lobe of the parotid, superficial ered for all salivary masses. The high inci- paroti dectomy is the most common oper- dence of cutaneous cancers in Australia may indicate a malignancy include: ation performed. Careful dissection of the warrants a high index of suspicion when • pain facial is mandatory for all parotid patients present with a persistent salivary • rapid growth resections. Temporary partial facial weak- gland lump. MT • hard mass ness occurs in about 5 to 10% of patients • fixation to overlying skin or having superficial parotidectomy for References underlying structures (Figure 7) benign tumours, while the incidence of • palsy. permanent nerve damage is less than 1%.1 1. Bova , Saylor A, Coman WB. Parotidectomy: Generally, all salivary gland masses Sometimes the facial nerve is invaded by review of treatment and outcomes. ANZ J Surg warrant further investigation. A CT scan tumour and requires sacrifice as part of the 2004; 74: 563-568. is the preferred radiological modality as tumour resection. 2. Bova R. : a guide to it provides excellent anatomical detail High grade salivary gland malignancies diagnosis and an overview of management. that helps the surgeon determine the may also require neck dissection and post- Medicine Today 2005; 6(4): 54-61. exact location of the tumour as well as operative radiotherapy to minimise the demonstrating infiltration of surrounding chance of locoregional tumour recur- DECLARATION OF INTEREST: None.

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