Core Curriculum Syllabus: Salivary Gland Disorders

Core Curriculum Syllabus: Salivary Gland Disorders

Inflammatory Diseases

I. Viral - Mumps

Etiology: Contagious systemic myxovirus. Incubation period of 14 to 21 days.
Signs and symptoms
- Prodrome of fever, malaise, and headache may occur
- Painful swelling of one or both parotid glands with erythema of Stenson's duct orifice. Ingestion of sour liquids increases pain.
- Complications may occur due to involvement of other organs
  - Sensorineural deafness
  - Encephalitis
  - Orchitis or oophoritis can lead to sterility
  - Pancreatitis
Treatment - supportive and symptomatic. No specific treatment currently available.
Prevention by mumps vaccine

II. Acute Bacterial Infection

Etiology
- Stasis - secondary to obstruction, decreased flow or dehydration
- Staphylococcus aureus is the most common pathogen in the parotid. Staph aureus and oral flora are seen in submandibular gland.
Signs and Symptoms - pain, tenderness and swelling with increased pain on eating. Orifice of duct is red and swollen, and massage of the gland may express pus.
Treatment
- Antibiotics
- Warm compresses
- Promote drainage by
  - Massage
  - Sialogogues
  - Dilatation of duct
- If condition unresponsive or progressive after above, surgical drainage is indicated.
  - In the parotid gland, care must be taken to avoid the facial nerve. A parotidectomy incision is made and skin over the gland is elevated. The gland is drained bluntly by inserting a clamp and spreading in the direction of the nerve.
  - In draining the submandibular gland, the marginal mandibular nerve must be avoided.

III. Chronic or Recurrent Infections

Etiology -
- Usually related to scarring and inflammation of the duct and/or parenchyma from prior infections
- May also be due to stones
Signs and Symptoms - as in acute infection
Treatment
- Conservative treatment as for acute infection
- In refractory disease, surgical excision is indicated

IV. Autoimmune Diseases - Sjogren's Syndrome

Etiology - collagen vascular disease
Signs and Symptoms -keratoconjunctivitis sicca, xerostomia, and a connective tissue disorder, such as rheumatoid arthritis. Enlargement of salivary and lacrimal glands, often with recurrent sialoadenitis
Diagnosis - biopsy of salivary glands, usually the lower lip, shows lymphoreticular hyperplasia
Treatment
- Treat recurrent infection
- May develop a superimposed malignancy. Therefore, if a mass appears, surgical excision is needed.

Degenerative Diseases

I. Fatty Infiltration

II. Hypertrophy

Alcoholism
Kwashiorkor
Metabolic diseases

Obstructive Disease

I. Sialolithiasis (Salivary Duct Stones) - Common in submandibular gland, uncommon in the parotid

Etiology - Inspirated secretions, ductal debris, and calcium phosphate coalesce, due to inflammation or stasis.
Signs and symptoms
- Submandibular stone may be palpable in the floor of the mouth.
- Partial obstruction causes enlargement and pain on eating, with return to normal as saliva drains
- Total obstruction leads to chronic enlargement and often infection
Treatment
- Stones near the orifice may be removed intraorally
- Deeper stones require excision of the gland

II. Ductal Stenosis

Etiology-Trauma, neoplasm or chronic inflammatory process
Signs and symptoms-Painful swollen gland-Neoplasm usually palpable
Treatment-Dilatation or glandular excision

Cystic Disease

I. Ranula - A sialocele of the floor of the mouth

Types
- Circumscribed - obstruction and cystic dilatation of sublingual gland or submandibular duct.
- Plunging - extravasation of saliva into tissues of the floor of the mouth. May extend deep into floor of the mouth
Signs and Symptoms - cystic submucosal mass in the floor of the mouth; may periodically shrink with discharge of contents into mouth
Treatment
- Circumscribed cyst may be excised, along with involved gland or glands
- Plunging ranulas cannot be excised and should be marsupialized

II. Congenital Cysts

Developmental Diseases

I. Agenesis

II. Branchial Cleft Cysts

First branchial cleft cysts present as cysts or draining sinuses in preauricular area
- Type I cysts track deep into parotid along EAC
- Type II cysts track deep into parotid and are intimately involved with facial nerve
Treatment-surgical excision

Salivary Gland Masses

I. Etiology

Inflammatory scarring or focal obstruction,
Inflammatory lymph node enlargement, secondary to cat scratch disease, scalp or external ear infection, etc.
Metastatic involvement of nodes
Neoplasm
- Benign-75-80% of all parotid tumors are benign
  - Benign mixed tumor
    - 65% of parotid neoplasms
  - Warthin's tumor
  - Lymphangioma, hemangioma
- Malignant - 20% of all parotid tumors are malignant. Submandibular and minor salivary gland tumors have increasing percentage of malignancy, i.e., the smaller the gland, the greater the likelihood of malignancy.
  1. Mucoepidermoid carcinoma
  2. Adenoid cystic carcinoma - associated with high propensity for nerve invasion
  3. Squamous cell carcinoma

II. Diagnosis

Careful examination of scalp, ear and face for infection or malignant lesion
Palpation of other lymph nodes
Persistent salivary gland mass should be assumed to be neoplastic unless proven otherwise
Minimum biopsy of parotid mass is a superficial parotidectomy
Submandibular masses require excision of gland
Minor salivary gland masses require excision with a margin of surrounding normal tissue

III. Treatment - Most salivary gland tumors require surgical excision of involved gland with or without post operative radiotherapy depending on the histology of the tumor and extent of disease. (See section on Head and Neck Tumors for management principles)

Next | Core Curriculum Table of Contents | Department Home page

©2001-2006 Baylor College of Medicine
Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery
Mail: One Baylor Plaza, NA102, Houston, TX 77030
Phone: 713-798-5906
E-mail: oto@bcm.edu

Last modified: Jan. 23, 2006