MINISTRY OF HEALTH OF UKRAINE UKRAINIAN MEDICAL STOMATOLOGICAL ACADEMY Department of Pediatric surgical stomatology

Approved of the meeting of department of Pediatric surgical stomatology 29.08.2019 protocol number 1 The Head of the Department profesor______Tkachenko P.I.

Reapproved Minutes № 1, 28.08.2020, Head of the Department profesor______Tkachenko P.I.

METHODOLOGICAL RECOMMENDATION for the lecture

Discipline Pediatric surgical stomatology Module number № 1 Anesthesia and exodontia in children, inflammatory and traumatic diseases of maxillofacial area Theme of lesson Regularities of the clinical course, diagnosis, differential diagnosis end complex treatment of inflammatory processes of soft tissues of the maxillofacial region. Year of study IV Faculty Faculty of Foreign StudentsTraining

Poltava-2019 Number of training hours - 2 1. Scientific and methodological justification of the theme Lymph nodes, in conjunction with the spleen, tonsils, adenoids, and Peyer patches, are highly organized centers of immune cells that filter antigen from the extracellular fluid. Lymphadenitis is the and/or enlargement of a lymph node. Lymph node enlargement is common in children. Most cases represent a response to benign, local, or generalized infections, usually viral. Lymphadenitis may affect a single node or a localized group of nodes (regional adenopathy) and may be unilateral or bilateral. The onset and course of lymphadenitis may be acute, subacute, or chronic. The lymphadenitis of maxillofacial region in children has polymorphism of clinical findings, it is necessary to know for effective differential diagnostics and treatment. The inflammatory diseases of salivary glands pretty often meet in practice of child's surgeon- stomatology. Knowledge of etyopathogenesis this group of diseases is a necessity for timely diagnostics correct planning and choice of methods treatment and warnings of complications. 2. Learning objectives of the lecture:  anatomotopographical features of large salivary glands and their conclusions channels; etiology and pathogeny of sharp viral and bacterial inflammatory diseases of salivary glands, their characteristic clinical displays.  to collect anamnesis of disease; to recognize the symptoms of diseases; to set a diagnosis and to appoint necessary treatment.  an understanding of the importance of prevention, identification, assessment and treatment of oral diseases, as opposed to the episodic management of symptomatic oral problems;  accurate examination and accurate records, diagnoses and treatment plan prior to commencement of care of the young person;  an accurate production, interpretation and critique of intra-oral and extra-oral radiographs of the young patient;  appreciation of the value of maintenance of oral health after treatment of child and adolescents including those with advanced or complicated problems;  appreciation of the need for specialist referral for those patients who cannot be successfully managed in general practice;  management of the behavioral aspects of young patients in the dental setting.

3. Development of personality of future specialist (educational purpose) To bring to students the basic principles of ethics and deontology in the specific examples. During the lectures students to form a sense of professional responsibility for the correctness of rendering surgical dental care for children.

4. Learning outcomes. According to the requirements of the Standard discipline ensures the acquisition of competences by students: Competence and learning outcomes, the formation of which is facilitated by discipline (integral, general, special, matrix of competencies). In accordance with the requirements of the Standard discipline ensures the acquisition of competences by students: Integral: Ability to solve complex problems and problems in the field of health care in the field of "Dentistry" in professional activity or in the process of study, which involves conducting research and / or innovations and characterized by uncertainty of conditions and requirements.

General: 1. The ability to abstract thinking, analysis and synthesis. 2. Knowledge and understanding of the subject area and understanding of the professional activities. 3. Ability to apply knowledge in practical situations. 4. Skills in the use of information and communication technologies. 5. Ability to search process and analyse information from different sources. 6. Ability to adapt and act in a new situation. 7. Ability to identify put and solve problems. 8. Ability to be critical and self-critical. 9. Ability to work in a team. 10. Ability to act in a socially responsible and conscious manner.

Special (professional, subject): 1. The ability to collect medical information about a patient and analyze clinical data. 2. The ability to interpret the results of laboratory and instrumental studies. 3. The ability to diagnose: determine the preliminary, clinical, final, concomitant diagnosis, urgent conditions. 4. Ability to plan and conduct measures for the prevention of diseases of organs and tissues of the oral cavity and maxillofacial area. 5. Ability to design the process of medical care: to determine the approaches, plan, types and principles of treatment of diseases of organs and tissues of the oral cavity and maxillofacial area. 6. The ability to determine the rational mode of work, rest, diet in patients with the treatment of diseases of organs and tissues of the oral cavity and maxillofacial area. 7. The ability to determine the tactics of managing patients with diseases of organs and tissues of the oral cavity and maxillofacial region with concomitant somatic diseases. 8. The ability to perform medical and dental manipulations. 9. The ability to treat major diseases of the organs and tissues of the oral cavity and maxillofacial area. 10. Ability to determine tactics, methods and provision of emergency medical care. 11. Ability to organize and conduct screening examinations in dentistry. 12. The ability to assess the environmental impact on the health of the child (individual, family, population). 13. Ability to maintain regulatory medical records. 14. Ability to process state, social and medical information. 15. Ability to organize and conduct rehabilitation activities and care for patients with diseases of the oral cavity and maxillofacial area. 16. The ability to provide legal support for their own professional activities.

5. Interdisciplinary integration Discipline To know To be able Anatomy Structure of major salivary glands, To define the external scopes of their topographical liking for near-by major salivary glands, place of fabrics and organs. opening of their conclusions channels in the cavity of mouth. Infectious diseases Commons clinical displays and terms To collect epidemiology of flow of epidemic . anamnesis.

Topographical Placement of major salivary glands in To represent the layers of soft anatomy and thickness of soft tissues tissues of masticatory, operative surgery submandibular, sublingual regions. Surgical diseases Signs of the formed abscess. To interpret the results of methods of diagnostics for his confirmation.

6. Plan and organisation structure lectures C.N. Main parts of lecture Type of lecture, means of students Time and their contents enhance, materials for methodological distribut providing ion 1 Inflammatory processes Chronic may be nonspecific 5-10% involving the salivary glands are resulting from ductal obstruction due to caused by a multitude of etiological or external radiation or factors. The process may be acute may be specific, caused by various and may result in an abscess infectious agents and immunologic formation particularly as a result of disorders. bacterial infection. The involvement can be unilateral or bilateral as in viral infections.

2 Content 1. To name major salivary glands and 85% Histology, anatomy and physiology their functions. of major salivary glands 2. To name the terms of morphological 1.1 Parotid Glands maturity of salivary glands. 1.2 Submandibular Glands 3. Ways of infection of salivary glands. 1.3 Sublingual Gland 4. Basic diagnostic signs of epidemic 1.4 Innervation parotitis. 2.Diagnostic investigation 3. Classification of inflammation of salivary glands 4. . 5. Chronic sialadenitis.

3 1. Recurrent parotitis is 1. To name the large salivary 5-10% probably caused by a congenital glands. abnormality of the 2. Classification of chronic ducts with recurrent attacks of sialadenitiss. ascending infection, perhaps aided by 3. Etiology and pathogeny of dehydration. The is chronic sialadenitiss. predominantly affected probably 4. Diagnostic signs of chronic because of its lower rate of secretion interstitial sialadenitis. compared with the submandibular 5. Diagnostic signs of chronic gland. parenchymatous sialadenitis. 2. The condition mainly 6. Diagnostic signs of sialodochitis. affects children between the ages of 3 7. Methods of investigation of and 6, with males being more children with the diseases of commonly affected. The symptoms salivary glands. peak in the first year of school, and 8. Principles and methods of usually, but not invariably, begin to treatment of different forms of subside at puberty. By the age of, chronic sialadenitis at children. most patients are completely symptom-free. When the disease starts after puberty, females are predominantly affected.

7. The content of the lecture material The lymphadenitis (lymphadenopathy) occupies one of the first places among the inflammatory diseases in children, because lymphatic system is unaccomplished during first years of life. The common infectious diseases, staphylococcal pyoderma, odontogenic infection are more frequent causes of lymphadenitis in maxillofacial region and neck. The acute and exacerbation of chronic apical periodontitis, periostitis, osteomyelitis, abscesses and phlegmon of soft tissues are accompanied by lymphadenitis. In lymphatic nodus microbes penetrates on lymphatic or hematogenous ways. The staphylococcus and streptococcus are basic nonspecific exciters of lymphadenitis. In other cases, a process can be caused by virus (example as infectious mononucleosis) or specific infection. Etiology (infectious agents):

o Acute, one-sided, pyogenic adenitis is most common. The involved node may be firm and tender, with erythema of the overlying skin. Etiologic agents include group A beta- hemolytic streptococcus, staphylococcal organisms (especially Staphylococcus aureus,), and viruses. o Tularemia may be accompanied by regional adenopathy, most commonly cervical, with local tenderness, pain, and fever. Generalized lymphadenopathy also may develop. o In a child with tuberculosis, generalized lymphadenopathy may indicate hematogenous spread of tubercle bacilli. Localized involvement is most common in the mediastinal, mesenteric, or anterior cervical nodes. Initially, the nodes are discrete, firm, mobile, and tender. If the patient remains untreated, the nodes soften, become fluctuant and matted, and adhere to overlying skin, which may become erythematous. Bilateral involvement is characteristic of this condition. Pulmonary disease is common. o Atypical mycobacteria can manifest cervical or submandibular involvement identical to that of tuberculosis, except the involvement is usually unilateral. o Group B streptococcal cellulitis and adenitis may occur in infants younger than 2 months. o Brucellosis may accompany chronic or intermittent lymphadenopathy. o Y enterocolitica may be associated with cervical lymphadenitis. o Salmonella infection can correspond to generalized adenopathy. o Bubonic plague is caused by Y pestis. o In patients with catscratch disease, the site of the scratch determines if axillary, epitrochlear, supraclavicular, femoral, inguinal, or submaxillary lymph nodes are involved. The nodes are nontender, discrete, mobile, and moderately or greatly enlarged. Occasionally, tenderness, redness, warmth, and suppuration may occur. Bartonella henselae is the organism causing catscratch disease. o Patients with infectious mononucleosis typically present with discrete, firm, nontender lymph nodes. Usually, anterior cervical nodes are involved. Generalized lymphadenopathy may occur, and hepatosplenomegaly is common. o Cytomegalovirus or toxoplasmosis may cause a mononucleosislike syndrome with generalized adenopathy, fever, atypical lymphocytes, and hepatosplenomegaly. o Gianotti-Crosti syndrome accompanies generalized lymphadenopathy, hepatomegaly, splenomegaly, nonicteric hepatitis, and crops of papular lesions that persist for 2-8 weeks.

CLASSIFICATION OF UNSPECIFIC LYMPHADENITIS: a) by clinical course: 1. Acute: - serous - purulent 2. Chronic: - destructive-purulent - hyperplastic-productive b) by localization: - isolated - regional (group) - widespread - generalized. c) by morphological structure of lymphonodus (chronic lymphadenitis): - hyperplastic (follicular) - desquamative (sinus) - mixed (hyperplastic-desquamative) - productive (vascular).

In children under 5 years old lymphadenitis more frequent has nonodontogenic origin. In age from 6 to 14-years the odontogenic infection is dominant cause. The submandibularis, submental, cheek and parotid lymph nodes are most often affected. The acute serous and chronic hyperplastic lymphadenitis are widespread forms of lymphadenopathy. PATIENT AGE Acute unilateral cervical lymphadenitis in the newborn is caused by S aureus in most cases. Another important cause of neonatal acute cervical lymphadenitis is late-onset group B streptococcal infection—the “cellulitis-adenitis” syndrome. Affected patients are between 3 and 7 weeks of age; are male in 75% of cases; and have fever, poor feeding, and neck swelling with overlying cellulitis that responds quickly to appropriate antibiotic therapy. Approximately 80% of cases of acute pyogenic cervical lymphadenitis caused by group A strep and S aureus occur in children younger than 5 years of age, as do most cases of NTM lymph node infection. School-age children and adolescents are more likely to present with chronic cervical lymphadenitis than with acute pyogenic disease, and infection with EBV, CMV, Toxoplasma gondii, anaerobic bacteria, M tuberculosis, and Bartonella henselae is seen more frequently. Acquired Toxoplasma infection, when symptomatic, generally presents as cervical lymphadenopathy and fatigue without fever. Adenopathy may be localized or generalized, tender or nontender, and may persist for many months. This disease usually is benign and self-limited and should be considered in patients in whom infectious mononucleosis is suspected but who have negative EBV serology.

Pathophysiology. The increased size of a node may be caused by the following:

 Multiplication of cells within the node, including lymphocytes, plasma cells, monocytes, or histiocytes  Infiltration of cells from outside the node, such as malignant cells or neutrophils  Draining of a source of infection by lymph nodes If the cause of adenopathy is not evident, consider congenital or neoplastic causes.

Case history

 Upper respiratory symptoms, sore throat, earache, coryza, conjunctivitis, and impetigo  Fever, irritability, and anorexia  Contact with animals, especially kittens  Dental care: Submaxillary adenopathy may develop secondary to , dental caries, or a .  Risk factors for tuberculosis o Generalized lymphadenopathy in a child with tuberculosis may indicate a hematogenous spread of tubercle bacilli. o Localized involvement is most common in the mediastinal, mesenteric, or anterior cervical nodes.  Acute or chronic onset o Usually, bilateral acute cervical adenitis is caused by either viral pharyngitis or infectious mononucleosis. o Chronic localized adenopathy can be attributed to a persistent regional infection.  Skin and scalp conditions: Occipital and postauricular adenopathy may accompany scalp infections, seborrheic dermatitis, or scalp pediculosis. Epitrochlear and axillary lymphadenopathy may result from infections on the arms. Inguinal and femoral adenopathy may be due to infections on the lower extremities.  Periodicity: Periodic fever, , pharyngitis, and cervical adenitis (PFAPA) syndrome usually results in adenopathy associated with the other findings every 3-6 weeks.  History of travel: When adenopathy is caused by Yersinia pestis (bubonic plague), the patient may have visited a rural area in the western United States 1 week prior to the onset of illness.  Medication use o Hydantoin o Mesantoin  Age: Atypical mycobacteria typically cause adenopathy in toddlers.

Clinical findings

 Location o Tularemia may be accompanied by regional adenopathy, most commonly cervical. o Yersinia enterocolitica infection may cause cervical or abdominal adenopathy. o Salmonella infections may accompany generalized lymphadenopathy. o Rubella and parvovirus infection is characterized by enlarged and tender posterior auricular, posterior cervical, and occipital lymph nodes. o Atypical (environmental) mycobacteria may cause submandibular or submental adenopathy. o Mediastinal or infectious hilar adenopathy may occur in patients with tuberculosis, chronic sinusitis, histoplasmosis, tularemia, infectious mononucleosis, candidiasis, coccidioidomycosis, and bronchiectasis.  Size: Lymph nodes that are noted to increase rapidly in size may indicate potential malignancy.  Shape: Confluent lymph nodes may be indicators of malignancy.  Consistency o Descriptors may include soft, fluctuant, firm, rubbery, or hard. o In early stages, nodes in tuberculosis are well-demarcated, mobile, nontender, and firm. If the infection remains untreated, the nodes soften, become fluctuant, and adhere to the skin, which may be erythematous. o In Hodgkin disease, nodes are initially soft. They later become firm and rubbery.  Fixation of lymph nodes to the skin and soft tissue may indicate malignancy.  Tenderness o Lymph nodes of infectious etiology are usually tender. o Bubonic plague, caused by Y pestis, may cause extremely tender lymph node enlargement and erythema of overlying skin in the inguinal, femoral, axillary, or cervical area. o Hodgkin lymphoma may present initially as painless lymph node enlargement, especially of the cervical and supraclavicular region.  Overlying skin o The overlying skin may be erythematous in infectious etiologies. o Draining sinuses may develop in patients with tuberculous adenopathy. o Infants with atopic eczema may have generalized lymphadenopathy.  Systemic signs o Group B streptococcal cellulitis and adenitis, which may occur in infants younger than 2 months, are characterized by sudden onset of fever, anorexia, irritability, and submandibular swelling. Usually, a blood culture test demonstrates positive results. o Hepatosplenomegaly is common in patients with infectious mononucleosis.  Conjunctivitis o Preauricular adenopathy (Parinaud oculoglandular syndrome) secondary to uniocular granulomatous conjunctivitis may be caused by catscratch disease, chlamydial conjunctivitis, listeriosis, tularemia, or tuberculosis. o Adenovirus type 3 causes pharyngeal conjunctival fever. Symptoms associated with adenovirus type 3 are follicular conjunctivitis with enlarged preauricular and/or posterior cervical nodes. Adenovirus type 8 causes epidemic keratoconjunctivitis, which causes preauricular adenopathy.  Aphthous stomatitis and pharyngitis are associated with PFAPA syndrome.  Number: A single node or multiple nodes may be involved.  In catscratch disease, usually only a single node is involved.

Procedures: 1) Needle aspiration, 2) Partial or excisional biopsy, 3) Incision and drainage Inflammatory diseases of salivary glands at children Content Histology, anatomy and physiology of major salivary glands 1.1 Parotid Glands 1.2 Submandibular Glands 1.3 Sublingual Gland 1.4 Innervation 2.Diagnostic investigation 3. Classification of inflammation of salivary glands 4. Mumps. 5. Chronic sialadenitis.

The glands are enclosed in a capsule of connective tissue and internally divided into lobules. Blood vessels and nerves enter the glands at the hilum and gradually branch out into the lobules. In the duct system, the lumens formed by intercalated ducts, which in turn join to form striated ducts. These drain into ducts situated between the lobes of the gland (called interlobar ducts or secretory ducts). All of the human salivary glands terminate in the mouth, where the saliva proceeds to aid in digestion. The saliva that salivary glands release is quickly inactivated in the stomach by the acid that is present there. The parotid glands are a pair of glands located in the subcutaneous tissues of the face overlying the mandibular ramus and anterior and inferior to the external ear. The secretion produced by the parotid glands is serous in nature, and enters the oral cavity through the Stensen's duct after passing through the intercalated ducts which are prominent in the gland. Despite being the largest pair of glands, only approximately 25% of saliva is produced by the glands. Saliva contains a mixture of enzymes like salivary amylase (ptyalin), maltase(trace amounts), lysozyme (which disinfect and kills bacteria and germs which enter the mouth), salts and water. Saliva helps converting starch into maltose which is then converted patially to glucose by the maltase.

The submandibular glands are a pair of glands located beneath lower jaws, superior to the digastric muscles. The secretion produced is a mixture of both serous and mucous and enters the oral cavity via Wharton's ducts. Approximately 70% of saliva in the oral cavity is produced by the submandibular glands, even though they are much smaller than the parotid glands. The sublingual glands are a pair of glands located beneath the tongue to the submandibular glands. The secretion produced is mainly mucous in nature, however it is categorized as a mixed gland. Unlike the other two major glands, the ductal system of the sublingual glands do not have striated ducts, and exit from 8-20 excretory ducts. Approximately 5% of saliva entering the oral cavity come from these glands.

Salivary glands are innervated, either directly or indirectly, by the parasympathetic and sympathetic arms of the autonomic nervous system. Both result in increased amylase output and volume flow. Parasympathetic innervation to the salivary glands is carried via cranial nerves. The parotid gland receives its parasympathetic input from the glossopharyngeal nerve (CN IX) via the otic ganglion, while the submandibular and sublingual glands receive their parasympathetic input from the facial nerve (CN VII) via the submandibular ganglion. These nerves release acetylcholine and substance P, which activate the IP3 and DAG pathways respectively. Direct sympathetic innervation of the salivary glands takes place via preganglionic nerves in the thoracic segments T1-T3 which synapse in the superior cervical ganglion with postganglionic neurons that release norepinephrine, which is then received by β-adrenergic receptors on the acinar and ductal cells of the salivary glands, leading to an increase in cyclic adenosine monophosphate (cAMP) levels and the corresponding increase of saliva secretion. Note that in this regard both parasympathetic and sympathetic stimuli result in an increase in salivary gland secretions.[2] The sympathetic nervous system also affects salivary gland secretions indirectly by innervating the blood vessels that supply the glands.

Etiological and histological classification of sialadenitis  Bacterial sialadenitis is divided into acute and chronic subtypes. Acute bacterial sialadenitis has a predilection for the parotid glands of children and the elderly with 2 distinct presentations: nosocomial and community-acquired. View image Chronic infection may result in recurrent sialadenitis.  Chronic recurrent sialadenitis mainly presents in adults (only 10% of patients are children). It is typically tender, unilateral swelling of a major salivary gland of an episodic nature. It represents recurrent episodes of acute sialadenitis. This may be due to unresolved infection or underlying ductal anomalies.

 Chronic sclerosing sialadenitis has a predilection for submandibular glands. Typically, it is a unilateral enlargement that may be symptomatic and clinically difficult to differentiate from a tumor.

 Obstructive sialadenitis has a predilection for submandibular and parotid glands. Typically, it is a unilateral painful enlargement occurring in connection with eating.

 Autoimmune sialadenitis mainly occurs in adult women and is characterized by bilateral painless and stable swellings.

 Subacute necrotizing sialadenitis is a rare condition affecting the palatal salivary glands. May be an early form of necrotizing sialometaplasia. Presents as a lump on the hard or soft , usually painful but only occasionally ulcerated. Etiology is unknown and resolves within a few weeks.

Laboratory investigations  In evaluating the patient with sialadenitis, steps should be taken in the following order: history, physical examination, culture, laboratory investigation, radiography, and if indicated, fine-needle aspiration biopsy.  Laboratory investigations should begin with culture of the offending gland (if possible, prior to the administration of antibiotics).  Blood cultures should be obtained in the patient exhibiting bacteremia or sepsis.  As a rule, needle aspiration of a suspected abscess is not indicated.  Routine electrolytes and complete blood cell count with differential should be obtained to assess for any evidence of dehydration or systemic infection.  If a diagnosis of autoimmunity is entertained, serum analysis for antinuclear antibody, SS-A, SS-B, and erythrocyte sedimentation rate should be conducted CYTOLOGY.Salivary smears of normal children are acellular. In contrast, saliva in the presence of revealed large amounts of granulocytes, some lymphocytes, and in about 50% of cases, bacteria. The bacteria were mixed, and included aerobic and anaerobic cocci. Imaging studies  Numerous radiologic techniques are available in submandibular imaging. Deciding which study to obtain first is often difficult. Examination selection should be based in part on the suspected cause of the problem. The authors' institution tends to begin with plain radiography, followed by the use of computed tomography scanning with combined .  Of all the radiologic examinations available, one of the simplest is conventional plain radiography. Anteroposterior, lateral, and oblique intraoral occlusal views are used. This technique is particularly valuable in evaluating the presence of calculi, which are radio- opaque in approximately 70% of cases. These radiographs are limited in that they do not provide any information about the ductal system or soft tissues. Sialography can be used to evaluate sialolithiasis or other obstructive entities, as well as inflammatory and neoplastic disease.  In this technique, a water-soluble medium such as meglumine diatrizoate is injected into the Wharton duct and lateral, oblique, and anteroposterior plain radiographs are obtained in order to assess the ductal arborization.  Contraindications for this test are iodine allergy and acute sialadenitis.  Any filling defects (eg, calculi), retained secretions (eg, chronic sialadenitis), stricture formation (eg, inflammation), extravasation (eg, Sjögren disease), or irregularly contoured borders (eg, neoplasm) are noted. Ultrasonography can be used to differentiate between solid versus cystic lesions of the gland. It can also be used to differentiate intrinsic from extrinsic disease and can be helpful in identification of abscess formation. Computed tomography scanning is an excellent modality in differentiating intrinsic versus extrinsic glandular disease. It is also extremely valuable in defining abscess formation versus phlegmon. It is limited in evaluating the ductal system unless combined with simultaneous sialography. Magnetic resonance imaging is of little utility in sialadenitis or sialadenosis. It does not allow evaluation of the ductal system, and it is not helpful in defining calcifications. It is an excellent tool for soft tissue definition and is invaluable in instances of suspected neoplasia. Sialendoscopy. This is a minimally invasive interventional endoscopic technique. It is an outpatient technique which is performed under local anesthetic, very similarly to what one may experience when visiting a dentist. With the patient sitting or lying down the area of the duct opening is injected with local anesthetic.

Acute viral parotitis (mumps)  Mumps, also known as infectious or epidemic parotitis, is an acute viral disease caused by a paramyxovirus. It causes painful enlargement of the salivary or parotid glands. It may also infect other organs, such as the testes, the central nervous system (CNS), and the pancreas. The prognosis for complete recovery is good, although mumps sometimes causes complications.  Background: Mumps is a systemic illness caused by the paramyxovirus. It is a human disease that occurs worldwide. The mumps vaccine was introduced in 1967, and the disease became nationally reportable in 1968. The incidence has decreased substantially with vaccination, but periods of resurgence have occurred in recent years.  Pathophysiology: The mumps virus is transmitted by respiratory droplets. It has an incubation period of 14-25 days after which time prodromal symptoms occur and last anywhere from 3-5 days. After the prodrome, the symptoms of the virus depend on which organ is affected. The most common presentation is a parotitis, which occurs in 30-40% of patients. Other reported sites of infection are the testes, pancreas, eyes, ovaries, central nervous system, joints, and kidneys. A patient is considered infectious from about 3 days before the onset and up to 4 days into active parotitis. Infections can be asymptomatic in up to 20% of persons. Clinical examination of patient  Low-grade fever is common.  Usually, parotid gland swelling that is not warm or erythematous is present.  The swollen parotid gland may lift the earlobe upward and outward.  The patient may complain of an earache and have tenderness over the angle of the .  Opening of stenson duct can be edematous and erythematous.  The patient may have .  Submandibular and sublingual glands may also be involved and swollen.  A morbilliform rash may be present.

During a mumps outbreak, diagnosing mumps is a fairly straightforward process. When a mumps case is more isolated, the doctor will consider several other medical conditions that can have similar signs or symptoms. Some of these conditions include:

 Influenza (the flu)  Bacterial infection of the parotid glands  Drug reaction, including a reaction to iodine known as "iodine mumps"  Parotitis caused by other viruses  Mononucleosis (mono)  Cat-scratch disease  Cellulitis  Parotid gland tumor  Tuberculosis  Leukemia  Hodgkin's disease  Systemic (SLE or lupus)  Sarcoidosis  Lymphoma  Diabetes  Pregnancy  Sjogren's syndrome.

Common complications Common complications of mumps include:  pain and swelling of the testicles (orchitis ) - which affects 20% of all males who get mumps after puberty,  pain and swelling of the ovaries (oophoritis ) - which affects 5% of all females who get mumps after puberty,  inflammation of the pancreas (pancreatitis) - which occurs in 5% of cases, and  viral meningitis - which occurs in as estimated 1-10% of all cases.

Treatment of mumps  There is currently no treatment for mumps that can kill the mumps virus. Because mumps is caused by a virus, antibiotics or other medications for mumps are not effective. Therefore, treatment focuses on providing relief from symptoms as the body fights the virus. This is called supportive care. Supportive care can include:  Medications (such as acetaminophen or ibuprofen) to control fever or pain  Warm, moist towels to help with swelling  Fluids  Rest until the fever improves  Soft, bland diet. Mumps prevention begins with the mumps vaccine. The vaccine contains live, attenuated (weakened) mumps virus. In the United States, the vaccine is licensed and available as a single preparation (Mumpsvax®) or combined with both live attenuated measles and rubella vaccine (MMR vaccine, also known as measles, mumps, rubella vaccine). Typically, mumps vaccine in the United States is administered as the MMR vaccine.

Acute suppurative parotitis  Acute suppurative infection of parotid glands is usually unilateral and most frequently appears in patient more 60 years of age, although it may also occur during childhood. Staphylococcus aureus, Streptococcus viridans, and other bacteria of the oral flora are uaually responsible for the infection, which may be hematogenous or spread by the bacteria via the ducts.  Clinically, the disease is characterized by induration, tenderness, and painfull swelling of the parotid gland. Stenson’s papilla is inflamed and pus may be discharged from the duct opening, particularly after pressure on the parotid gland. Low-grade fever and weakness may be present.  Differential dignoses includes obstructive parotitis, mumps, chronic specific inflammation, Sjogren’s syndrome, Heerfordt’s syndrome, leukemia, lymphomas, and neoplasms of parotid glands.

Chronic sialadenitis Inflammatory processes involving the salivary glands are caused by a multitude of etiological factors. The process may be acute and may result in an abscess formation particularly as a result of bacterial infection. The involvement can be unilateral or bilateral as in viral infections. Chronic sialadenitis may be nonspecific resulting from ductal obstruction due to sialolithiasis or external radiation or may be specific, caused by various infectious agents and immunologic disorders. Recurrent parotitis is defined as recurrent parotid inflammation, generally associated with non- obstructive sialectasis of the parotid gland. Also known as juvenile recurrent parotitis, this disease is characterised by recurring episodes of swelling and/or pain in the parotid gland, usually accompanied by fever and malaise.

Treatment Management of sialadenitis involves a wide range of approaches, from conservative medical management to more aggressive surgical intervention.  Acute sialadenitis:  Medical management - Hydration, antibiotics (oral versus parenteral), warm compresses and massage, sialogogues  Surgical management - Consideration of incision and drainage versus excision of the gland in cases refractory to antibiotics, incision and drainage with abscess formation, gland excision in cases of recurrent acute sialadenitis  RADIOTHERAPY.  DUCT LIGATION.  PAROTIDECTOMY. Parotidectomy has always been the gold standard for obtaining permanent relief. With this operation, however, one is faced with the risk of facial nerve injury; this is especially relevant in recurrent parotitis, where repeated infections result in fibrosis of the gland  TYMPANIC NEURECTOMY. This procedure has recently been recom mended as an effective procedure, with good results in 70% cases. Its aim is to destroy secretomotor fibres to the parotid gland thus abolishing/reducing its secretion. 8. Materiale to support students` independent work to prepare for the lecture.

Pediatric Critical Care Medicine Basic Science and Clinical Evidence Wheeler, Derek S.; Wong, Hector R.; Shanley, Thomas P. (Eds.) 2007, XXXVIII, 1805 p. 597 illus., 50 in color., Hardcover ISBN: 978-1-84628-463-2 Question:  Age-dependent properties of the lymphatic system in children.  Etiology and pathogenesis of unspecific lymphadenitis of maxillofacial region and neck in children.  Classification of lymphadenitis.  Clinical findings, diagnostics, differential diagnostics of lymphadenitis of maxillofacial region and neck in children.  Principles of treatment of lymphadenitis in children, technique of incision and drainage of wound.  Complication and consequences of lymphadenitis of maxillofacial region and neck in children, their prophylaxis.  Etiology, pathogenesis, classification of lymphadenitis in maxillofacial region in children. Symptoms and clinical course of odontogenic and nonodontogenic, acute and chronic lymphadenitis. Additional methods of diagnosis (blood tests, ultrasound, puncture). Differential diagnosis. Age peculiarities of the anatomical structure of the lymphatic system in children.  Treatment of lymphadenitis depending on the stage of inflammation. Methods and surgical treatment of acute and chronic lymphadenitis. The clinic, diagnosis, pathogenesis: migrating granuloma, Herzenberg disease, cat-scratch disease, lymphogranulomatosis.  Acute sialadenitis, mumps. Clinical symptoms, methods of examination of patients with pathology of major salivary glands, classification, treatment. Chronic inflammatory diseases of salivary glands in children: etiology, pathogeny, classification, clinical findings, differential diagnostics, prevention of exacerbation, patient rehabilitation.  Odontogenic and nonodontogenic abscesses and phlegmons of maxillofacial region: etiology, pathogeny, classification, features of clinical course, diagnostics. Ambulatory care and treatment of children in surgical department.

9. References:

1. Contemporary Oral and Maxillofacial Surgery, 5th Edition By James R. Hupp, DMD, MD, JD, MBA, Myron R. Tucker, DDS and Edward Ellis, III, DDS, MS Approx. 728 pages Approx. 1910 illustrations (1550 in full color).

2. Pediatric Oral and Maxillofacial Surgery by Leonard Kaban and Maria Troulis ISBN: 0721696910 Publisher: W. B. Saunders, Mar. 2004 - 496 pages, 850 illustrations, Hardcover.

3.Wharton IP, Chaudhry AH, French ME: A case of mumps epididymitis. Lancet 2006 Feb 25; 367(9511): 702. 4.Sonmez FM, Odemis E, Ahmetoglu A, Ayvaz A: Brainstem encephalitis and acute disseminated encephalomyelitis following mumps. Pediatr Neurol 2004 Feb; 30(2): 132-4. 5.Nussinovitch M, Volovitz B, Varsano I: Complications of mumps requiring hospitalization in children. Eur J Pediatr 1995 Sep; 154(9): 732- Kaban L. Infections of the maxillofacial region. In: Pediatric Oral and Maxillofacial Surgery. Philadelphia, Pa: Saunders; 1990:164-188.

Additional Sources:

1.Green M. Lymphadenopathy. In: Pediatric Diagnosis. 5th ed. WB Saunders Co;1992:393-7.

2.Peters TR, Edwards KM. Cervical lymphadenopathy and adenitis. Pediatr Rev. Dec 2000;21(12):399-405.

Methodological recommendations made by associate professor Dolenko O. B.