METHODICAL RECOMMENDATIONS FOR INDIVIDUAL WORK OF STUDENTS DURING PREPARATION TO PRACTICAL (SEMINAR) LESSON
Academic discipline Surgical stomatology Module № 6 Topic of the lesson№7 General characteristic of inflammatory processes of the maxillofacial area.Acute and chronic nonspecific sialoadenit (non-calculous and calculous). Diagnosis and comprehensive treatment of sialoadenits. Sialosis. Course V Faculty International (Stomatological)
Poltava 1. Relevance of the topic:
Your skin is a natural barrier against infection. Even with many precautions and protocols to prevent infection in place, any surgery that causes a break in the skin can lead to an infection. Doctors call these infections surgical site infections (SSIs) because they occur on the part of the body where the surgery took place. If you have surgery, the chances of developing an SSI are about 1% to 3%. Acute sialadenitis is defined as inflammation of the salivary glands arising from infectious or noninfectious causes. Common viral etiologies include Coxsackie A, paramyxovirus (mumps), and cytomegalovirus. Most bacterial suppurative infections of the salivary glands are associated with a decreased salivary flow or obstruction of the Stensen or Wharton ducts, allowing retrograde spread of bacteria. Staphylococcus aureus is most frequently the cause, which is often resistant to penicillin. Viridans streptococci, Streptococcus pyogenes, and anaerobic bacteria can also be involved. Acute bacterial sialadenitis is more prevalent in the parotid glands, with rates of bilateral involvement ranging from 15% to 25% of cases.
2. THE SPECIFIC AIMS:
2.1. To analyze the statistics of inflammatory and degenerative lesions of the salivary glands. 2.2. To explain to the causes of inflammatory and degenerative lesions of the salivary glands. 2.3. To offer new approaches in the diagnosis of inflammatory and degenerative lesions of the salivary glands. 2.4. To classify inflammatory and degenerative lesions of the salivary glands. 2.5. To interpret results of radiological investigation at inflammatory and degenerative lesions of the salivary glands. 2.6. To diagrammatize plan of examination of patients with various forms of inflammatory and degenerative lesions of the salivary glands. 2.7. To analyze complications, consequences and prognosis of different forms of inflammatory and degenerative lesions of the salivary glands. 2.8. To diagrammatize plan of treatment of patients with pathology of the salivary glands of different genesis.
3. BASIC KNOWLEDGE, ABILITIES, SKILLS, WHICH ARE NECESSARY FOR STUDY THEMES (intradisciplinary integration) Names of previous The received skills disciplines 1. Internal medicine. To know the relationship of pathological processes in the salivary glands diseases with different organs and systems of human. 2. Human Anatomy. To know the anatomy of the maxillofacial area, blood supply and innervations of the head and neck. To determine the localization of the major salivary glands. 4. Pathophysiology. To know the etiology and pathogenesis of diseases, metabolism of abnormal tissues. 4. Pathomorphology. To know the histological structure and morphological structure of pathologically altered tissue.
4. TASKS FOR INDIVIDUAL WORK DURING PREPARATION TO LESSON. 4.1. List of basic terms, parameters, characteristic, which a student must master at preparation to lesson: Term Definition 1. Sialoadenitis. Inflammatory process in salivary gland. 2. Sialolitiasis. Inflammation of salivary gland which develops because of stone. 3. Sialosis. Dystrophic process in salivary gland.
4.2. Theoretical questions for the lesson: 1. Etiology and pathogenesis of acute and chronic sialoadenitis. 2. Etiology and pathogenesis of sialosis. 3. Classification of acute and chronic sialoadenitis and sialosis. 4. The clinical picture of acute and chronic sialoadenitis. 5. The clinical picture of sialosis. 6. Diagnostics and differential diagnostics of inflammatory and dystrophic diseases of the salivary glands. 7. Complex treatment of inflammatory and dystrophic diseases of the salivary glands.
4.2. Practical works (task) which are executed on lesson: 1. To spend curation of patients with pathology of the salivary glands (role-playing and situational training, atypical clinical tasks). 2. To develop a plan for a comprehensive survey of patients with inflammatory diseases of the salivary glands and dystrophic (individual and team assignments). 3. To plan complex treatment of patients with inflammatory and degenerative diseases of the salivary glands (individual and team assignments).
THE CONTENT OF THE TOPIC: The knowledge of the anatomy of fascial spaces is essential for the correct diagnosis and treatment of head and neck infections, because both facial and cervical fasciae work as an effective barrier against the spread of infections in this region. Once these infections occur, they are often difficult to assess accurately by clinical examinations and conventional radiographic techniques, and the outcome may be serious and potentially life-threatening. The fasciae of the neck are glossy and divided into two separated layers: the superficial fascia and the deep fascia. The superficial fascia is actually a component of the fatty subcutaneous tissue while the deep cervical fascia is divided into three layers: the superficial layer, the visceral or middle layer, and the pre vertebral or deep layer. The deep cervical fascia plays an important role in determining the location and course of spread of infections within the soft tissues of the neck. The infections that commonly affect head and cervical areas are frequently from odontogenic origin and to a lesser frequency, proceeding from foreign bodies or trauma to this region. An impacted mandibular third molar is one of the most frequent causes of odontogenic infection. Moreover, an semi-impacted third molar results in odontogenic infection more commonly than fully erupted or completely impacted molars. Odontogenic infections occasionally spread beyond the barriers of the fascial spaces, which are formed, as seen, by the deep cervical fascia of the suprahyoid regions of the neck. Among various spaces, the submandibular space is one of the first to be involved in odontogenic infections, similar to the masticatory space. As infection may spread along deep cervical facial planes and neck cavities, widespread cellulitis, necrosis, abscess formation, and sepsis may occur in these cases. Therefore, it is important to understand the anatomy, rate of progression and potential for airway compromise of an infection.spontaneous dissemination of an odontogenic infection is however, very rare in immunocompetent patients. In patients with anatomical abnormalities, systemic diseases or immunosuppression, bacteremia caused by dental procedures may lead to generalized or metastatic systemic infection complications leading to hospital care. In particular, patients with poorly controlled diabetes mellitus are more susceptible to bacterial infections. However, death from odontogenic infection is quite rare.
Despite being rare, facial and neck fasciae spaces involved by infections from odontogenic origin may lead to a very morbid condition. The diagnosis delay and late or wrong therapeutic approachs to deep infections in these areas are the main causes of high mortality rate in this life-threatening situation. Dentistry has made great progress in prevention and early intervention of odontogenic infection. The introduction of antibiotics reduced significantly the mortality and morbidity of these infections, however, even in this contemporary postantibiotic era, serious infections such as a descending necrotizing mediastinitis still have a high mortality rate with a fulminating course, leading frequently to death.
Anatomy of the fascial spaces in axial (A) and coronal (B) images. SMS: submandibular space; SLS: sublingual space; PPS: parapharyngeal space; CS: carotid space; MS: masticatory space. SMG: submandibular gland; GGM: genioglossus muscle; MHM: mylohyoid muscle; MM: masseter muscle; MPM: medial pterygoid muscle; LPM: lateral pterygoid muscle; TM: temporal muscle.
What is surgical infection? A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only.
How does a surgical wound get infected? Causes and risk factors of surgical site infections
Germs can infect a surgical wound through various forms of contact, such as from the touch of a contaminated caregiver or surgical instrument, through germs in the air, or through germs that are already on or in your body and then spread into the wound.
How long after surgery can you get an infection? A surgical wound infection can develop at any time from 2-3 days after surgery until the wound has visibly healed (usually 2-3 weeks after the operation). Very occasionally, an infection can occur several months after an operation.
What antibiotic is used for surgical site infection? Antibiotic Prophylaxis Operation Expected Pathogens Recommended Antibiotic
Vascular S aureus, Staphylococcusepidermidis, Cefazolin 1-2 g surgery gram-negative bacilli
S aureus, streptococci, anaerobes and Head and streptococci present in an oropharyngeal Cefazolin 1-2 g neck surgery approach
Types of surgical site infections An surgical site infections (SSIs) typically occurs within 30 days after surgery. The CDC describes 3 types of surgical site infections: Superficial incisional SSI. This infection occurs just in the area of the skin where the incision was made.
Deep incisional SSI. This infection occurs beneath the incision area in muscle and the tissues surrounding the muscles.
Organ or space SSI. This type of infection can be in any area of the body other than skin, muscle, and surrounding tissue that was involved in the surgery. This includes a body organ or a space between organs.
Signs and symptoms of surgical site infections
Any SSI may cause redness, delayed healing, fever, pain, tenderness, warmth, or swelling. These are the other signs and symptoms for specific types of SSI:
A superficial incisional SSI may produce pus from the wound site. Samples of the pus may be grown in a culture to find out the types of germs that are causing the infection. A deep incisional SSI may also produce pus. The wound site may reopen on its own, or a surgeon may reopen the wound and find pus inside the wound. An organ or space SSI may show a discharge of pus coming from a drain placed through the skin into a body space or organ. A collection of pus, called an abscess, is an enclosed area of pus and disintegrating tissue surrounded by inflammation. An abscess may be seen when the surgeon reopens the wound or by special X-ray studies.
Causes and risk factors of surgical site infections Infections after surgery are caused by germs. The most common of these include the bacteria Staphylococcus, Streptococcus, and Pseudomonas. Germs can infect a surgical wound through various forms of contact, such as from the touch of a contaminated caregiver or surgical instrument, through germs in the air, or through germs that are already on or in your body and then spread into the wound.
The degree of risk for an SSI is linked to the type of surgical wound you have. Surgical wounds can be classified in this way:
Clean wounds. These are not inflamed or contaminated and do not involve operating on an internal organ. Clean-contaminated wounds. These have no evidence of infection at the time of surgery, but do involve operating on an internal organ. Contaminated wounds. These involve operating on an internal organ with a spilling of contents from the organ into the wound. Dirty wounds. These are wounds in which a known infection is present at the time of the surgery.
These are other risk factors for SSIs:
Having surgery that lasts more than 2 hours Having other medical problems or diseases Being an elderly adult Being overweight Smoking Having cancer Having a weak immune system Having diabetes Having emergency surgery Having abdominal surgery
Treating surgical site infections Most ssis can be treated with antibiotics. Sometimes additional surgery or procedures may be required to treat the SSI.
Sialoadenitis Definition. Inflammation or infection of Salivary Gland or duct Signs and symptoms of sialadenitis may include fever, chills, and unilateral pain and swelling in the affected area. The affected gland may be firm and tender, with redness of the overlying skin. Pus may drain through the gland into the mouth.
The treatment of sialadenitis depends on what type of microbe is causing the infection. If the infection is bacterial, an antibiotic effective against whichever bacteria is present will be the treatment of choice. If the infection is due to a virus, such as herpes, treatment is usually symptomatic but may include antiviral medications.
In addition, since sialadenitis usually occurs after decreased flow of saliva (hyposecretion), patients are usually advised to drink plenty of fluids and eat or drink things that trigger saliva flow (such as lemon juice or hard candy). Warm compresses, and gland massage may also be helpful if the flow is obstructed in some way. Good oral hygiene are also important. Occasionally an abscess may form which needs to be drained especially if it proves resistant to antibiotics (or antiviral medication)
In rare cases of chronic or relapsing sialadenitis, surgery may be needed to remove part or all of the gland. This is more common when there is an underlying condition which is causing the hyposecretion.
The prognosis of acute sialadenitis is very good. Most salivary gland infections go away on their own or are easily cured with treatment with conservative medical management (medication, increasing fluid intake and warm compresses or gland massage). Acute symptoms usually resolve within 1 week; however, edema in the area may last several weeks. Complications are not common, but may occur and can include abscess of the salivary gland or localized spreading of bacterial infection (such as cellulitis or Ludwig's angina). Causes
A. Acute Nonsuppurative Sialoadenitis (Viral) B. Acute Suppurative Sialoadenitis (Bacterial) C. Chronic Suppurative Sialadenitis D. Neonatal Sialadenitis
Acute Nonsuppurative Sialoadenitis Epidemiology
A. Common in children 1. Mumps cases are in children under age 15 years in 85% of cases B. Less common in adults 1. Sialolithiasis, Bacterial Sialadenitis affect adults most commonly
Causes
A. Mumps Parotitis 1. Historically, the most common cause prior to Vaccination a. Incidence reduced by 99% following routine Vaccination 2. Transmitted easily by airborne droplet spread 3. Local pain and swelling of Parotid Glands (may start unilaterally, but is bilateral ultimately) 4. Associated with Otalgia and Trismus B. Human Herpesvirus 6 (Roseola or Exanthem Subitum) C. Epstein-Barr Virus Infection (Mononucleosis) D. Coxsackievirus Infection and other enteroviruses E. Parainfluenza Virus F. Influenza A G. HIV Infection 1. Diffuse cystic involvement of the major glands 2. Presents with gradual, non-tender enlargement (typically affects Parotid Gland)
Symptoms and signs
A. Swollen, tender Salivary Gland Differential Diagnosis
A. See Neck Masses in Children B. Acute Suppurative Sialoadenitis C. Recurrent Parotitis of Childhood D. Sialolithiasis E. Sjogren Syndrome
Labs
A. Mumps serology B. Consider Monospot (or EBV and CMV serology) C. Consider HIV Test if risk factors
Management
A. Hydration B. NSAIDs for analgesia
Course
A. Mumps Parotitis resolves within 2 weeks
Prevention
A. MMR Vaccine is 88% effective in preventing Mumps
Acute Suppurative Sialoadenitis Pathophysiology
A. Mechanism 1. Bacterial Infection with seeding via retrograde infection from the oral cavity 2. Stasis due to volume depletion or Xerostomia allows for Salivary GlandBacterial parenchymal infection B. Most common in age >50 years 1. Contrast with Viral Sialoadenitis C. Parotid Gland is most commonly affected Salivary Gland 1. Less bacteriostatic secretions than submandibular Causes: Bacterial
A. Viral Sialoadenitis B. Staphylococcus aureus (most common, cultured in >50% of cases) C. Streptococcus species (esp. Streptococcus Pyogenes) D. Haemophilus Influenzae E. Gram Negative Bacteria F. Anaerobic Bacteria
Risk Factors
A. Advanced age B. Volume depletion C. Diabetes Mellitus D. Hypothyroidism E. Renal Failure F. Sjogren Syndrome G. Debilitated or recently post-operative or post-hospitalization H. Anticholinergic Medications causing Xerostomia I. Secondary to Salivary Gland Calculus 1. Known as Obstructive Sialadenitis
Symptoms
A. Acute pain and swelling localized over affected Salivary Gland B. High fever with chills often present
Signs
A. Ill appearing patient B. Exquisitely tender, warm, swollen Salivary Gland (usually Parotid Gland) C. Regional Lymphadenopathy D. Pus at affected Salivary duct orifice 1. Affected gland may be massaged to express pus for culture 2. Parotid duct (Stensen's Duct) at upper second molar 3. Submandibular duct (Wharton's Duct) at frenulum
Labs
A. Gram Stain and culture of Salivary duct discharge Imaging
A. CT Scan if not improving within 3-4 days B. Avoid sialography in acute Bacterial Sialoadenitis
Differential Diagnosis
A. Lymphadenopathy of the Head and Neck B. Sialolithiasis C. Viral Sialoadenitis D. Chronic Sialoadenitis
Management
A. Precautions 1. Acute Parotitis and other severe Sialadenitis may require initial inpatient parenteral antibiotics (e.g. Nafcillin and metronizadole) 2. MRSA coverage should be considered in cases failing to improve or immunocompromised patients (e.g. Vancomycin) B. Start antibiotic coverage for Staphylococcus aureus and other Gram Positive organisms (as well as Anaerobes) 1. Total treatment course: 10-14 days 2. Oral agents (non-toxic patient) a. Augmentin b. Dicloxacillin c. Clindamycin 3. Parenteral agents a. Use broad spectrum coverage instead for immunosuppressed patients (e.g. Zosyn and Vancomycin) b. Clindamycin 600 mg IV every 6-8 hours OR c. Nafcillin 2 g IV every 4 hours AND Metronidazole 500 mg IV every 6 to 8 hours C. Increase Saliva production 1. Increase fluid intake 2. Lemon drops to increase Saliva secretion 3. Stop Anticholinergics and other Xerostomia causes D. Symptomatic therapy 1. Analgesics 2. Warm compresses over affected Salivary Gland 3. Attempt to milk gland of discharge E. Otolaryngology Consultation 1. Surgical drainage may be required 2. Consider early intervention or if no improvement in 3-4 days
Complications
A. Salivary Gland abscess (rare)
Chronic Sialoadenitis Pathophysiology
A. Repeated episodes of Salivary Gland (typically Parotid Gland) pain and inflammation 1. Secondary to Sialolithiasis (due to stone, stricture, scarring or external compression) 2. Salivary Gland stasis and acini replaced with cysts B. Chronic, low-grade Salivary gland Bacterial Infection 1. Staphylococcus aureus 2. Mixed Bacterial Infection C. Ultimately results in Salivary Gland destruction 1. Progressive Salivary acini destruction and fibrosis 2. Sialectasis
Symptoms
A. Recurrent Parotitis B. Mild Salivary Gland swelling and tenderness provoked with eating
Signs
A. Salivary Gland prominent and firm initially and later small and atrophic B. Unlike acute Sialoadenitis, the region is not warm, and tenderness is minimal to mild C. No Saliva typically expressed on Salivary Gland massage
Differential Diagnosis
A. General 1. Lymphadenopathy of the Head and Neck 2. Sialolithiasis B. Parotid Gland 1. Recurrent Parotitis of Childhood 2. Sjogren Syndrome 3. Sarcoidosis 4. Fungal infections 5. Mycobacterium species 6. Diabetes Mellitus 7. Cirrhosis 8. Salivary Gland Neoplasm 9. Medications (rare)
Imaging
A. Evaluate for Sialolithiasis (intraductal stone or stenosis, or external compression) B. Modalities 1. Sialogram 2. Computed Tomography (CT) 3. Sialendoscopy
Management
A. Exclude obstruction (see imaging above) 1. Treat Sialolithiasis if present B. Conservative therapy for non-obstructive cases 1. Hydration 2. Lemon drops and other sialagogues 3. Salivary Gland massage 4. NSAIDs C. Antibiotics D. Salivary Gland resection (e.g. Parotidectomy
Sialolithiasis Calculus within Salivary Gland duct
Most common in ages 30 to 50 years (rare in children)
Pathophysiology: Salivary Gland duct calculus
A. Submandibular Gland duct or Wharton's Duct obstruction (80-90% of cases) 1. Located adjacent to frenulum B. Parotid Gland duct or Stensen's Duct obstruction (10-20% of cases) 1. Adjacent to second upper molar
Etiologies
A. Trauma or local inflammation B. Chronic disease 1. Stasis of Saliva and change in composition C. Infection 1. Viral Infection (e.g. Mumps) 2. Bacterial Infection
Symptoms
A. Localized pain and swelling at affected gland 1. Usually occurs at Submandibular Gland (angle of jaw) B. Pain increases immediately before meals 1. Persists after the meal Differential Diagnosis
A. Sialadenitis B. Lymphadenitis C. Dental abscess
Diagnosis
A. Calculi occur in Submandibular Glands in 90% of cases B. Ultrasound 1. Sensitive in identifying Salivary calculi C. CT Reconstruction 1. Most sensitive for calculi D. Sialogram 1. Demonstrates 80% of radiopaque calculi
Labs: Indicators of infectious Sialadenitis
A. White Blood Cell Count increased B. C-Reactive Protein (C-RP) increased C. Serum Amylase increased Management
A. Removal of stone by massage or milking gland B. Oral antibiotics 1. Augmentin 2. Cefzil or Ceftin 3. Clindamycin C. Sialologues 1. Lemon drops induce Salivation, help clear stone D. Maintain hydration with 64 ounces water per day 1. Avoid Diuretics (Caffeine or Alcohol) E. Otolaryngology for surgical management 1. Indicated if Salivary calculus does not pass within 5-7 days 2. Sialendoscopy (calculus removal with small endoscope) a. Effective alternative to surgical excision of calculus b. Best efficacy when implemented early in course 3. Surgical excision of stone indications a. Submandibular stones are accessible to local excision if palpable in the anterior floor of the mouth 4. Salivary Gland excision indications (if failed sialendoscopy) a. Submandibular hilar stones b. Parotid duct stones
Complications
Obstructive Sialadenitis (Bacterial Sialadenitis)
Evaluate for Sialolithiasis (intraductal stone or stenosis, or external compression)
Sialogram
Computed Tomography (CT)
Sialendoscopy
What is Mumps (Epidemic parotitis)
Mumps is an acute, contagious, viral disease that causes painful enlargement of the salivary or parotid glands. After a 12- to 24-day incubation period, most people develop headache, anorexia, malaise, and a low- to moderate-grade fever. The salivary glands become involved 12 to 24 hours later, with fever up to 39.5 to 40° C. Fever persists for 24 to 72 hours. Glandular swelling peaks on about the 2nd day and lasts 5 to 7 days. Involved glands are extremely tender during the febrile period. Parotitis is usually bilateral but may be unilateral, especially at the onset. Pain while chewing or swallowing, especially while swallowing acidic liquids such as vinegar or citrus juice, is its earliest symptom. It later causes swelling beyond the parotid in front of and below the ear. Occasionally, the submandibular and sublingual glands also swell and, more rarely, are the only glands affected. Submandibular gland involvement causes neck swelling beneath the jaw, and suprasternal edema may develop, perhaps because of lymphatic obstruction by enlarged salivary glands. When sublingual glands are involved, the tongue may swell. The oral duct openings of the affected glands are edematous and slightly inflamed. The skin over the glands may become tense and shiny.
Statistics on Mumps (Epidemic parotitis)
Unvaccinated children between the ages of 2 and 12 are most commonly infected, but the infection can occur in other age groups.
Risk Factors for Mumps (Epidemic parotitis)
The mumps are caused by a virus which is spread from person-to-person by respiratory droplets or direct contact with articles that have been contaminated with infected saliva. Avoiding this contact would subsequently greatly reduce the chance for the infection to take hold.
Progression of Mumps (Epidemic parotitis)
Mumps is spread by droplet infection, direct contact or through fomites.
The disease is infective for 2-3 days before the onset of the parotitis and for 3 days after onset. There is an 18 day incubation period.
How is Mumps (Epidemic parotitis) Diagnosed?
Mumps is usually diagnosed on the basis of clinical features.
Mumps would also cause a 4-fold rise in antibodies detected by complement fixation or indirect haemagglutination or neutralisation tests on acute and convalescent sera. Prognosis of Mumps (Epidemic parotitis)
The probable outcome is good, even if other organs are involved. After the illness, life-long immunity to mumps occurs.
Mumps may involve organs other than the salivary glands, particularly in postpubertal patients. Such complications include
Orchitis or oophoritis
Meningitis or encephalitis
Pancreatitis
About 20% of infected postpubertal males develop orchitis (testicular inflammation), usually unilateral, with pain, tenderness, edema, erythema, and warmth of the scrotum. Some testicular atrophy may ensue, but testosterone production and fertility are usually preserved. In females, oophoritis (gonadal involvement) is less commonly recognized, is less painful, and does not impair fertility. Meningitis, typically with headache, vomiting, stiff neck, and CSF pleocytosis, occurs in 1 to 10% of patients with parotitis. Encephalitis, with drowsiness, seizures, or coma, occurs in about 1/5000 to 1/1000 cases. About 50% of CNS mumps infections occur without parotitis. Pancreatitis, typically with sudden severe nausea, vomiting, and epigastric pain, may occur toward the end of the first week. These symptoms disappear in about 1 week, leading to complete recovery. Prostatitis, nephritis, myocarditis, hepatitis, mastitis, polyarthritis, deafness, and lacrimal gland involvement occur extremely rarely. Inflammation of the thyroid and thymus glands may cause edema and swelling over the sternum, but sternal swelling more often results from submandibular gland involvement with obstruction of lymphatic drainage.
How is Mumps (Epidemic parotitis) Treated?
Treatment is supportive.
Adequate nutrition and mouth care should be monitored. Analgesics may be used to relieve pain.
Mumps can be prevented by immunisation with the MMR vaccine. However, vaccination is not recommended in immunosuppressed individuals, during pregnancy or those with severe febrile illnesses.
5. MATERIALS FOR SELF-CONTROL: A. Questions for self-control: 1. Scheme and algorithm of basic and additional investigations at pathology of salivary glands. 2. Sialograms of different forms of chronic and calculous sialoadenitis.
B. Tasks for self-control: Task 1. A 38-year-old female patient complains of recurrent pain in the right submandibular region, which intensifies during meals, especially acute and salty. There is swelling in the right submandibular region. The mouth opens freely. Cloudy saliva is secreted from the orifice of the duct of the right submandibular salivary gland. Bimanual examination: the right submandibular salivary gland is enlarged, of dense consistency. Along the course of the duct at the level of tooth 4.6 - compaction. On palpation, moderate pain is determined. On the X-ray of the floor of the mouth, a dense oval shadow of 0.5x0.8 cm is determined. What diagnosis can be assumed? Answer options: A. Salivary stone disease of the right submandibular salivary gland. B. Polymorphic adenoma of the right submandibular salivary gland. C. Adenophlegmon of the right submandibular region. D. Odontogenic phlegmon of the right submandibular triangle. E. Acute suppurative lymphadenitis of the right submandibular region. Correct answer: A. Salivary stone disease of the right submandibular salivary gland. Solution algorithm: The patient's complaints: intermittent pain in the right submandibular region, which intensifies during meals, especially acute and salty. Physical examination data: swelling in the right submandibular region is determined, the mouth opens freely, cloudy saliva is released from the orifice of the duct of the right submandibular salivary gland. Bimanual examination: the right submandibular salivary gland is enlarged, of dense consistency; along the duct at the level of tooth 4.6 - a seal, the palpation of which is painful. X-ray: a dense oval shadow of 0.5x0.8 cm. Thus, the correct answer is A. Task 2. Patient, 21 years old, two days ago had an increase in body temperature to 38.0 C. On the second day there was a swelling in the parotid region on both sides. The skin above the swelling is tense and has a normal color. On palpation, enlarged, painful parotid salivary glands are determined. Disturbance of salivation from the ducts of the parotid glands, the mouths of the ducts are hyperemic. Pain on palpation in the angle of the lower jaw, at the apex of the mastoid process, in front of the tragus of the auricle. What is your diagnosis? Answer options: A. Purulent-necrotizing parotitis. B. Herzenberg pseudoparotitis. C. Viral mumps. D. Acute bacterial parotitis. E. Sjogren's syndrome. Correct answer: C. Viral mumps. Solution algorithm: It is necessary to pay attention to the patient's complaints: an increase in body temperature to 38.0 0 C, swelling in the parotid region on both sides. Physical examination data: the skin over the swelling is tense, has a normal color; on palpation - enlarged painful parotid salivary glands; violation of salivation from the ducts of the parotid glands, the mouths of the ducts are hyperemic; pain on palpation in the corner of the lower jaw, at the apex of the mastoid process, in front of the tragus of the auricle. From the condition of the problem - the correct answer is C.
Task 3. The patient is 30 years old. On the seventh day after surgery in the abdominal cavity, there was pain and swelling in the area of the left parotid salivary gland, body temperature 39.0 0 С, restriction of mouth opening, dryness, when massaging the gland, purulent exudate appears from its duct. What disease can be diagnosed? Answer options: A. Acute mumps. B. Phlegmon of the chewing space. C. Acute non-epidemic parotitis. D. Parenchymal parotitis. E. Phlegmon of the parotid-masticatory region. Correct answer: C. Acute non-epidemic parotitis. Solution algorithm: It is necessary to pay attention to the anamnesis: 7 day after the operation on the abdominal cavity and the data of an objective examination: pain and swelling in the area of the left parotid salivary gland, body temperature 39.0 0 С, restriction of opening the mouth, dryness, when massaging the gland, purulent exudate appears from it duct. Thus, the correct answer is C. Task 4. A 22-year-old female patient complained of severe pain and swelling in the left parotid gland, general weakness, fever up to 38.5 ° C, difficult and painful mouth opening, clicking and crunching in the left temporomandibular joint region. Has been ill for 6 years. Associates the onset of the disease with transient mumps. For two years, nothing bothered. Then she noticed a swelling in the left parotid region. The swelling went away 3 days after the warming compresses. Further exacerbations of the disease were 4-5 times a year. Exacerbations are associated with hypothermia and Acute Respiratory Viral Infections. Each exacerbation had a more pronounced course, pain appeared. The patient continued to use the warming compresses, but there was no relief. She took antibiotics on her own and the inflammation disappeared. During the last exacerbation, I went to the doctor. The left parotid salivary gland is enlarged, dense, its surface is finely bumpy, palpation is painful, inactive. The soft tissues above the gland are swollen, the skin is not changed in color, it is limitedly gathered in a fold. Opening the mouth up to 3 cm, painful. With the movements of the lower jaw, a crunch in the TMJ is determined on both sides, but more on the left. The movements of the lower jaw are stepped. In the left submandibular region, an enlarged, painful, movable lymph node is palpable. The mouth of the duct of the left parotid gland is dilated, the mucous membrane around it is hyperemic, edematous. When massaging the gland, a significant amount of pus with loose inclusions is released from the duct. 1. Justify the diagnosis. 2. What treatment measures should be applied in this case? 3. What signs are not essential for this disease and what can they be associated with? Solution algorithm: 1. Diagnosis: exacerbation of chronic parenchymal parotitis on the left. Typical signs indicating this disease: anamnesis (frequent exacerbations with significant inflammation) painful enlargement of the gland with symptoms of lymphadenitis, collateral edema; tuberous surface of the gland; discharge of pus from the duct. 2. Local treatment consists in carrying out: a) introduction of proteolytic enzymes into the duct to liquefy pus, washing with antiseptic solutions; b) massage of the gland to evacuate secretions; c) Physiotherapy; d) compresses with Dimexide. 3. Insignificant signs: crunching and clicks in the temporomandibular joint, stepped movements of the lower jaw. This may be due to the presence of TMJ arthrosis in the patient. To clarify the diagnosis, a comprehensive study should be carried out.
Task 5. A 47-year-old patient was hospitalized with complaints of pain in the right submandibular region, numbness in the right corner of the mouth and lower lip on the right. On examination, a compaction of the right submandibular gland was found, in the lower sections - a stony density. Saliva is practically not released from the duct. 1. What diseases can be assumed? 2. What data is missing to establish a definitive diagnosis? 3. What information in this case is insignificant and with what can they be connected?
Solution algorithm: 1. The following diseases can be assumed: a) salivary stone disease (localization of calculus in the lower pole); b) benign tumor of the salivary gland; c) malignant tumor of the salivary gland; d) specific inflammation of the salivary gland; chronic lymphadenitis of the submandibular lymph node. 2. Lack of anamnestic data: the duration and nature of the development of the disease. Was any examination and treatment carried out. The data on the nature of pain are insufficiently presented, which is associated with their intensity. Whether the appearance of pain is accompanied by the presence of swelling. There is a lack of objective data: soreness of the gland, mobility, adhesion with the surrounding tissues, the nature of saliva. There are no data on additional examination methods: X-ray and morphological. 3. The feeling of numbness of the lower lip on the right is insignificant, indicating the phenomena of neuritis of the III branch of the right trigeminal nerve. To find out the causes of neuritis, a comprehensive examination is necessary. LITERATURE: Basic:
1. Oral and maxillofacial surgery: textbook / Ed. by prof. V. Malanchuk / part one. – Vinnytsia: Nova Knyha Publishers, 2011. – 424 p. 2. Avetikov D.S. Using of modern methods of diagnostics in the practice of oral surgery: Text-book / Avetikov D.S, Skikevych M.G., Lokes K.P., Bojchenko O.M.-Poltava-2018 -122p. 3. Avetikov D.S. Precancerous diseases of maxillofacial area: Text-book / Avetikov D.S, Aipert V.V., Lokes K.P.-Poltava-2017 - 125p. 4. Avetikov D.S. Modern methods of treatmentof cysts of jaws: Text-book/ Avetikov D.S, Lokes K.P., I.V. Yatsenko, S.o. Stavicij.-Poltava-2014-83p. 5. S.I. Danylchenko Operative surgery and topographical anatomy: Text-book/ S.I. Danylchenko, E.N. Pronina, D.S.Avetikov .- Poltava-2011-239p. 6. Skikevych M.G. Maxillofacial surgery. Benign tumours and precancer diseases: Text-book/ Avetikov D.S, Khalaf A.A.-Poltava-ASMI, 2014.-199p. 7. Tkachenko P.I. Propaedeutics of surgical stomatology and inflammatory diseases of maxillofacial region / P.I. Tkachenko, A.I. Pan’kevich, K.Yu. Rezvina. – Poltava. – ASMI, 2001. – 283 p.
Additional:
1. Peterson’s Principle of oral and maxillofacial surgery. 3rd Edition / M. Miloro, G.E. Ghali, P.E. Larsen, P.D. Waite. – Hamilton London, BC Decker Inc, 2012. – 1664 p. 2. Oral and Maxillofacial Surgery / J. Pedlar, J. Frame. – Edinburg, London, New York, Philadelphia, Sydney, Toronto: Churchill Livingstone, 2003. – 325 p. 3. Principle of oral and maxillofacial surgery / Ed. by U.J. Moore. – Blackwell Science, 2001. – 276 p. 4. Textbook of general and oral surgery / D. Wray, D. Stenhouse, D. Lee, A. Clark. – Edinburg, London, New York, Philad
Web source: Witt (2012) Laryngoscope 122(6): 1306-11 [PubMed] Luers (2012) Head Neck 34(4): 499-504 [PubMed]
Methodological recommendations were prepared by Associate Professor
Skikevych M.G.