MedicineToday PEER REVIEWED ARTICLE CPD 1 POINT A guide to salivary gland disorders The salivary glands may be affected by a wide range of neoplastic and inflammatory disorders. This article reviews the common salivary gland 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 neoplasms 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 Neck Surgeon, St Vincent’s soft palate, oral cavity, lips, tongue and oro - always be considered when assessing a salivary Hospital, Sydney, NSW. pharynx. The parotid gland lies in the preauricular gland mass. region and extends inferiorly over the angle of the mandible. The parotid duct courses anteriorly Inflammatory disorders from the parotid gland and enters the mouth Acute sialadenitis through the buccal mucosa adjacent to the second Acute inflammation of the salivary glands is usu- upper molar tooth. The submandibular gland lies ally of viral or bacterial origin. Mumps is the most in the submandibular triangle 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 fever 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 virus, other infections, granulomatous conditions or autoim- viruses that may manifest as acute viral sialadenitis mune diseases. A thorough history and physical include cytomegalovirus, coxsackievirus, 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 fibrosis 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. 44 MedicineToday ❙ February 2006, Volume 7, Number 2 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 medications, combined with poor oral hygiene, may predispose to parotitis. Fever, painful unilateral gland swel l ing, trismus and purulent sialorrhoea are the typical signs of this potentially serious infection. Staphy- lococcus aureus is the most common pathogen. Treat ment includes rehydration, warm com- presses, repeated gland massage and antibiotic therapy. If an abscess develops, incision and Parotid drainage may be required once the exact location gland of the collection is localised radiologically. Parotid duct 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 Submandibular duct to the ductal epithelium leading to stricture forma- © CHRIS WIKOFF, 2006 tion and acinar atrophy. 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, pain or discomfort precipitated cause is thought to be bacterial infection ascend- parotid, sublingual and by eating. Streptococcus viridans is the usual organ- ing from the oral cavity, and hence treatment with submandibular glands. ism responsible and penicillin 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 malignancy and both CT scanning and fine presents with dryness of the eyes and mouth, lead- needle aspiration (FNA) biopsy are required to ing to chronic mouth and ocular discomfort. exclude a neoplastic process. Sialography 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 lymphoma, 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 salivary gland disease in Sjögren’s most common inflammatory salivary gland disease syndrome is symptomatic and supportive. Some- of childhood after mumps. Patients usually pre- times superficial parotidectomy 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. MedicineToday ❙ February 2006, Volume 7, Number 2 45 Permission granted for use by Entthyroid.com.au for educational purposes. © Medicine Today 2006. Copyright for illustrations as stated. Salivary gland disorders continued 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 tuberculosis, cat parotid gland. Stone formation is thought cent and thus will be missed with plain scratch disease, sarcoidosis, actinomycosis 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 mucin and injected into the salivary duct, is techni- ning and FNA biopsy can often assist with calcium content of its saliva. 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 calculus 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