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Andrew H. Murr, MD Professor and Chairman Roger Boles, MD Endowed Chair in Otolaryngology Education Department of Otolaryngology- Head and Neck Surgery

Sialadenitis without Stones: RAI, Autoimmune, and Management UCSF Sialendoscopy/Salivary Duct Surgery Course November 6, 2014 University of California, San Francisco

Sialadenitis without Stones Case

• Bacterial sialadenitis • 43 year old female • Radioactive Iodine (RAI) effects • Bilateral Parotid swelling • Autoimmune Disease • In tact VIIth nerve 1/6 • Other • No discrete mass

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Differential Diagnosis of Gland Enlargement: Bacterial Is there pus in the duct? Sialadenitis Yes No • Erythema Bacterial Sialadenitis Other categories • Tenderness • Pus in duct • Dehydrated • Diabetic • Elderly • Often unilateral • “Surgical ”

Salivary Duct Stenosis RAI Koch et al., Arch OHNS, Sept., 2012

Types Causes • RadioActive Iodine Sialadenitis • Inflammatory • Allergic • Web associated • Infectious • Fibrous • Granulomatous • RAI associated • Autoimmune

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Radioiodine (I131) Papillary Thyroid Carcinoma

• Key treatment modality for management of benign and malignant thyroid disease • Utility is due to propensity of thyroid follicular cell uptake •I131 beta emissions cause cellular necrosis

Increasing incidence of differentiated thyroid cancer in the United States, 1988-2005 131 Chen A. et al; Cancer, 2009 I Radiation Sialadenitis

• Salivary glands also concentrate iodine through selective sodium/iodine symporter • Symporter most prevalent in ductal epithelial cells •I131 creates a dose-related injury to salivary glands • Serous glands and acini are more susceptible than mucinous acini: Parotid = serous • more affected than submandibular or sublingual salivary glands

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I131 Radiation Sialadenitis Morbidity and Quality of Life

•I131 injury causes: • Dingle et al: OHNS, May, 2013 - acute and chronic inflammation n = 145 well-differentiated thyroid cancer - duct lumen narrowing and stricture patients formation - altered saliva, mucous plugs • Dose dependent increase in sialadenitis • Salivary stagnation ; obstructive symptoms ( >150mCi I131 2.47 times more likely) • Pain, gland swelling; exacerbated by meals • Xerostomia , taste alteration • Reduced oral and overall QOL if received • Clinical incidence and severity variable >150mCi I131

131 Incidence – I Sialadenitis Prevention –Lack of consensus Van Nostrand; Oral Dis, 2011 Van Nostrand, Oral Diseases, 2011 • Variable • Hydration • Sialagogues • Discontinuation of anticholinergic meds • Gland massage • Anti-inflammatory meds • Cholinergic meds

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Pale mucosa with ductal stenosis, Therapy ductal debris and mucous plugs

• Medical – Hydration – Gland massage – Heat – Anti-inflammatory medication – Cholinergic medication • Interventional – Sialendoscopy – Sialadenectomy

Technique Post-irrigation Gland Swelling

•Introduction of diagnostic sialendoscope •Ductal lumen inspected thoroughly •Duct flushed with copious saline irrigation •Confirmation of gland engorgement

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I131 Radiation Sialadenitis - I131 Radiation Sialadenitis - Sialendoscopy Sialendoscopy • Nahlieli, Nazarian; Oral Diseases, 2006 • De Luca et al; Br J OMFS, 52(7), 2014 n=15 (100 mg hydrocortisone) n=30 (“hydrocortisone solution” irrigation) 100% symptom-free 77% improved symptoms • Kim et al; Laryngoscope, 117, 2007, 133-136 f/u 2wks – 84 months n=6 50% symptom-free • Bomeli et al; Laryngoscope, 2009 n=12 (40 mg triamcinolone in 5cc NSS) 75% improved symptoms

Pre-treatment Patient Characteristics Prendes et al. Arch OHNS, 2012 Prendes, B. L. et al. Arch Otolaryngol Head Neck Surg 2012

11 patients - all patients had previously attempted and failed conservative management - 7/11 (64%) of patients had been treated with a least one course of antibiotics for an episode of presumed bacterial sialadenitis - median time after I 131 16 months

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Treatment Results Proposed Mechanisms of Benefit

• Instrument dilation of papilla and duct • Saline hydraulic dilation of ductal system • Flushing of debris from duct • Additional benefit of steroid irrigation and dosing of steroid irrigant is unclear

Summary Autoimmune

• Sialendoscopy for I 131 induced sialadenitis • Sjogrens provides therapeutic benefit for most patients with symptoms recalcitrant to conservative medical therapy • Effective in providing a sustained period of patient-reported improvement in symptoms • Further experience with this treatment modality, its timing, and long-term outcomes data are needed

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Sjogren’s Syndrome Sjogren’s Syndrome

Primary Secondary: • Inflammation of salivary • Associated with connective tissue disease- glands • RA • Lacrimal gland involved • Keratoconjunctivitis • SLE sicca • Scleroderma • Dermatomyositis

Sjogren’s Work-up Sjogren’s Imaging

Primary Secondary • SSA and SSB • ESR • SS rho and SS la • ANA • “Sjogrens Antibodies” • RF • CBC • EBV • Quantitative immunoglobulins

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Primary Sjogren’s: 20 Years Salivary Gland Biopsy Gomes, JOMFS, Jan-Mar, 2012 • Minor salivary gland – ~50% sensitivity • Parotid tail biopsy – ~100% sensitivity

Sjogrens Treatment Other-viral:

• Symptomatic treatment Systemic treatment • Xerostomia • Corticosteroids/antibiotics – Dental caries • Surveillance for non- • Flouride Hodgkin lymphoma • Dental hygiene – Artificial saliva – Sialogogues – Pilocarpine • Salagen – Role for Sialendoscopy with irrigation

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Other- viral: HIV Other • Pneumoparotitis • Alcoholism • Bulemia • Sarcoid

OHNS Faculty and Residents Conclusion

Sialendoscopy with or without steroid irrigation can be a diagnostic and therapeutic treatment in cases of: • RAI sialadenitis • Sjogren’s • HIV Differential includes: • Viral and other pathologies

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Thank you!

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