k Infections of the Salivary Glands 81 (a) (b) k k (c) (d) Figure 3.10. The miniature endoscope for diagnostic and interventional sialoendoscopic procedures (a – Karl Storz Endoscopy, Germany). The instrumentation seen here is utilized for diagnostic procedures only. The endoscope may be connected to an operating sheath for interventional procedures (see Chapter 5). A series of duct dilators (b) are inserted in the Stensen duct prior to placing the sialoendoscope (c). A representative image is noted in (d) that demonstrates normal findings in a patient with chronic parotid pain. The sialoendoscopy procedure, including dilatation and irrigation of the duct, resulted in resolution of symptoms. A 76-year-old-man (e) with a chronic history of right parotid swelling. His symptom of right facial swelling waxed and waned (f and g) and he was noted to have the forced expression of pus from the right Stensen duct (h). He underwent imaging studies (i and j) due to the chronicity of his diagnosis of chronic parotitis. A sialoendoscopy was performed (k) that identified thick mucus in his main Stensen duct (l) and strictures in his distal ductwork withinthe gland (m). ACUTE BACTERIAL SUBMANDIBULAR Wharton duct and therefore presents as swelling SIALADENITIS associated with the submandibular gland. That said, physical examination of the patient with Acute bacterial submandibular sialadenitis (ABSS) submandibular swelling may not immediately dis- is usually associated with physical obstruction of close whether the swelling is related to sialadenitis k k 82 Chapter 3 (e) (f) k k (g) (h) (i) (j) Figure 3.10. (Continued). k k Infections of the Salivary Glands 83 (k) (l) k k (m) Figure 3.10. (Continued). of the submandibular gland, to neoplastic dis- findings alone (Figure 3.12a). This notwithstand- ease of the submandibular gland, or due to a ing, sialolithiasis, the likely cause of obstruction process extrinsic to the submandibular gland. of the duct with resultant submandibular gland As such, CT scans become required when the swelling, is discussed in Chapter 5 so it is only distinction cannot be made entirely on physical briefly mentioned here. Suffice it to say that the k k 84 Chapter 3 (a) (b) k k (c) Figure 3.11. A 35-year-old man with a 2-year history of left parotid pain and swelling (a and b). Computerized tomograms (c) showed sclerosis of the parotid parenchyma as well as a suspected abscess. The patient underwent left superficial parotidectomy with a clinical and radiographic diagnosis of chronic bacterial parotitis with abscess formation. The superficial parotidectomy was accessed with a standard incision (d). A nerve sparing approach was followed (e) that allowed for delivery of the specimen (f). Histopathology showed chronic sialadenitis with abscess formation (g). At 3 years postoperatively (h and i) he displays resolution of his disease. submandibular ductal system is prone to stone dehydration and hospitalization as compared to formation. The common features of ABSS are ABP. Purulence may be expressed from the opening swelling in the submandibular region associated of the Wharton duct, but in many cases complete with prandial pain. ABSS is a community acquired obstruction to pus and saliva occurs. As in the disease that less frequently is associated with case of APB, imaging studies are also obtained in k k Infections of the Salivary Glands 85 (d) (e) k k (f) (g) (h) (i) Figure 3.11. (Continued). k k 86 Chapter 3 (a) (b) Figure 3.12. The CT scan (a) of a 73-year-old man with a one year history of right submandibular swelling. Physical exami- nation of the neck identified a mass with a differential diagnosis of submandibular gland mass versus enlarged lymph node in the submandibular region. This CT scan was obtained due to the equivocal nature of the finding on physical examination. Fine needle aspiration biopsy of this mass led to a diagnosis of low-grade lymphoma. By distinction, a 24-year-old woman k with right submandibular swelling and pain who underwent a CT scan that identified intense uptake of intravenous contrast k of the right submandibular gland indicative of acute bacterial submandibular sialadenitis (b). Fat stranding in the left neck indicative of inflammation is also noted. patients with clinically unequivocal acute bacte- sialolithiasis. Chronic recurrent submandibular rial submandibular sialadenitis when signs and sialadenitis occurs more commonly than chronic symptoms are of a magnitude to justify acquiring recurrent bacterial parotitis. Initial treatment CT scans (Figure 3.12b). for chronic recurrent submandibular sialadenitis begins with antibiotic therapy, sialogogues, and hydration. Sialolithotomy is required if diagnosed. Treatment of Acute Bacterial Sialoendoscopic intervention may also be of benefit Submandibular Sialadenitis in the treatment of chronic recurrent submandibu- Treatment of ABSS consists of antibiotic ther- lar sialadenitis prior to subjecting the patient to apy, hydration, avoidance of antisialogogues, submandibular gland removal. Ultimately, removal and removal of a sialolith, if one is identified of the submandibular gland is often necessary (Figure 3.13). Empiric antibiotics used to treat ABSS (Figure 3.14). are similar to ABP, including an extended spectrum penicillin, a first generation cephalosporin, clin- damycin, or a macrolide. Patients are also encour- BARTONELLA HENSELAE aged to use sialogogues, such as sour ball candies. (CAT SCRATCH DISEASE) Cat scratch disease (CSD) is a granulomatous CHRONIC RECURRENT lymphadenitis that most commonly results from SUBMANDIBULAR SIALADENITIS cutaneous inoculation caused by a scratch from a domestic cat. The causative microorganism is Chronic recurrent submandibular sialadenitis usu- Bartonella henselae, a gram negative bacillus. ally follows ABSS and is associated with untreated Approximately 90% of patients who have cat k k Infections of the Salivary Glands 87 Submandibular swelling CT scan Diffuse submandibular Discrete mass Yes gland enlargement associated with Submandibular gland neoplasm submandibular gland No Purulent drainage at Wharton duct? Leukocystosis? Elevated temperature? See chapter 10 Discrete mass adjacent to submandibular gland Yes No Community acquired ABSS Fine needle aspiration biopsy to rule out metastatic adenopathy vs. lymphoma Culture and sensitivity if pus present Empiric oral antibiotics Oral hydration Sour ball candies Control medical comorbidity Submandibular gland excision Stone present on panoramic radiograph k or CT scans? k Yes No No Consider sialoendoscopy No resolution Remove – See chapter 5 Resolution of swelling with conservative therapy? Monitor Yes Figure 3.13. Algorithm for diagnosis and management of acute bacterial submandibular sialadenitis (ABSS). scratch disease have a history of exposure to cats antibody (IFA) and the enzyme immunoassay and 75% of these patients report a cat scratch (EIA). When tissue is removed for diagnosis, or bite (Arrieta and McCaffrey 2005). Dogs have histologic examination might demonstrate bacilli been implicated in 5% in these cases. This disease with the use of Warthin–Starry staining or a process begins in the preauricular and cervical Steiner stain. Lymph node involvement shows lymph nodes as a chronic lymphadenitis and reticular cell hyperplasia, granuloma formation may ultimately involve the salivary glands, most and occasionally a stellate abscess. commonly the parotid gland by contiguous spread In most cases, no active therapy is required. (English, et al. 1988). The patient should be reassured that the lym- The diagnosis of CSD has changed with phadenopathy is self-limited and will sponta- advances in serologic and molecular biologic neously resolve in 2–4 months. Antibiotic therapy techniques. These methods have replaced the is indicated when patients are symptomatic. Antibi- need for the Rose Hanger skin test previously otics reported to be most effective include rifampin, used. Testing for the presence of antibodies to erythromycin, gentamycin, azithromycin, and B. henselae is now the most commonly used test ciprofloxacin. Surgery becomes necessary when to confirm the diagnosis. The two methods used the diagnosis is equivocal, or when incision and for antibody detection are the indirect fluorescent drainage is indicated (Figure 3.15). k k 88 Chapter 3 (a) (b) k k (c) (d) Figure 3.14. A 52-year-old man (a) with a 1-year history of vague discomfort in the left upper neck. Screening panoramic radiograph (b) showed no evidence of a sialolith. His diagnosis was chronic submandibular sialadenitis and he was prepared for left submandibular gland excision (c). The surgery was carried through anatomic planes, including the investing layer of the deep cervical fascia (d). The dissection is carried deep to this layer since a cancer surgery is not being performed that would require a dissection superficial to the investing fascia. Exposure of the gland demonstrates a small submandibular gland due to scar contracture (e). Inferior retraction of the gland allows for identification and preservation of the lingual nerve (f). The specimen (g) is bivalved (h) which allows for the appreciation of scar within the gland. The resultant tissue bed (i) shows the hypoglossal nerve which is routinely preserved in excision of the submandibular gland. Histopathology shows a sclerosing sialadenitis (j). The patient’s symptoms were eliminated postoperatively, and he healed uneventfully, as noted at 1 year following the surgery (k). k k Infections of the Salivary Glands 89 (e) (f) k k (g) (h)