Salivary Gland Enlargement

Acute Suppurative Sialadenitis

• Pathophysiology: salivary stasis or obstruction, retrograde migration of bacteria, postoperative parotiditis

• Risks: dehydration, postsurgical (GI procedures), radiation and chemotherapy, Sjogren's syndrome

• SSx: sudden onset of erythema, tenderness, warmth, and purulence at ductal orifice, auricle may protrude, trismus

• Dx: clinical history and exam, cultures

• Rx: rehydration, warm compresses, antimicrobial therapy (may require parenteral antibiotics for severe cases), sialogogues, parotid massage, oral irrigations, if no resolution after 2—3 days then consider CT or U/S to evaluate for abscess (may require I&D)

Mumps and Viral Infections

• presents in pediatric population (4-6 years old)

• Pathogen: paramyxoviruses

• SSx: 75% bilateral, painful parotid swelling (may involve submandibular and sublingual glands), malaise, fever, trismus

• Dx: mumps titers; hemoagglutination antigens; virus may be cultured from saliva, urine, or CSF

• Complications: sudden sensorineural hearing loss (SNHL) (CN VIII involvement), infertility (with orchitis), encephalitis, pancreatitis, and nephritis

• Rx: self limiting: requires only supportive care (hydration, analgesics), audiological evaluation, vaccine is available

• Other Viral Infections: CMV (higher mortality in neonates), Coxsackievirus, influenza A

Chronic Inflammation

1. Granulomatous: tuberculosis, atypical mycobacterium, actinomycosis (poor oral hygiene, dental caries), cat scratch fever, sarcoidosis (see pp. 205—212.)

2. Secondary: progression from acute sialadenitis

• SSx: xerostomia, slow painless enlargement, may be recurrent

• Dx: sialography ("tree-leaf" appearance), CT, PPD, serum markers, VDRL, FTA-ABS, cat-scratch antigen test, etc

• Complications: abscess, fistula, ductal destruction

1. Medical: sialogogues, antibiotics, warm compress, massage

2. Conservative Surgical Management: ductal dilatation

3. Destructive Surgical Management: gland excision, ductal ligation, gland irradiation, or neuronectomy

NOTE: incisional biopsy should be avoided because ofhigh risk of fistula formation (especially with mycobacterial infections)

Uveoparotid Fever (Heerfordt's Syndrome)

• more common in women

• Pathophysiology: extrapulmonary form of sarcoidosis

• SSx: self-limited uveitis, parotid enlargement, SNHL, facial palsy, malaise, fever

• Dx: based on clinical history and exam and evidence of sarcoidosis in salivary gland tissue

• Rx: corticosteroids

Kuettner's Tumor (Chronic Sclerosing Sialadenitis of the Submandibular Gland)

• Pathophysiology: may be autoimmune mediated

• SSx: firm, enlargement of submandibular gland (similar to tumor)

• Histopathology: chronic inflammation with destruction of acinar cells, sclerosis, "cirrhotic" changes

• Rx: submandibular excision for diagnosis and treatment

Radiation Sialadenitis

• SSx: xerostomia, hypogeusia, ageusia

• Dx: clinical exam and history of radiation exposure

• Histopathology: interstitial fibrosis

• Rx: symptomatic (pilocarpine drops, artificial saliva, frequent drinks), dental care (fluoride rinses)

Salivary Calculi (Sialolithiasis)

• most common in submandibular gland

• associated with gout (uric acid calculi)

• Pathophysiology: change in the viscosity of the saliva may cause mucous obstruction, calcium phosphate and calcium carbonate form around this center causing obstruction

• SSx: recurrent pain, swelling, worse with meals (salivary colic)

• Dx: stone may be palpable, sialography (90% of submandibular calculi are radiopaque, 90% of parotid calculi are radiolucent, may be multiple), CT, U/S

• Complications: fistulas, acute suppurative sialioadenitis, ductal strictures

• Rx: gland massage, bimanual expression, transoral incision, sialodochoplasty (reconstruct duct), gland excision if recurrent or if stone is lodged within substance of the gland, extracorporeal lithotripsy

Sjogren's Syndrome (Myoepithelial Sialadenitis, Benign Lymphepithelial Lesion)

• most common in middle-aged women

• Pathophysiology: systemic autoimmune destruction of exocrine glands, B-cell hyperactivity

• associated with Non-Hodgkin's Lymphoma

1. Primary: exocrine gland involvement only

2. Secondary: associated with other connective tissue disorders (most commonly rheumatoid arthritis)

• Other Sicca-like Causes: aging, medications (diuretics, anticholenergics, antihistamines, antidepressants), dehydration, hepatitis, other autoimmune disease

• SSx: keratoconjunctiva sicca (filamentary keratitis, sandy sensations in eyes), xerostomia (dental caries, dry mucosa), intermittent bilateral parotid swelling (atrophy at end-stage of disease), achlorhydria, Raynaud's phenomenon, pancreatitis, myositis, anemia, glomerulonephritis, hepatosplenomegaly

• Rx: artificial saliva, frequent small drinks, artificial tears, consider pilocarpine hydrochlorate drops and oral corticosteroids for severe acute exacerbation

Diagnosis

• Clinical History (must have 2 of 3): keratoconjunctiva sicca, xerostomia, or other connective tissue disease

• Biopsy: lip biopsy or minor salivary glands reveals lymphocytic infiltration with glandular atrophy

• Serology: ANA, RF, ESR, SS-A and SS-B (antibodies specific for primary Sjogren's syndrome), decreased IgM (suggest higher risk of progression to malignancy)

• Sialography: globular, multiple contrast collections throughout gland ("pine tree" appearance)

• Schirmer test: evaluates tear production

Mikulicz's Syndrome

• Mikulicz's Disease: all cases of recurrent parotid gland swelling that are nonautoimmune

• Common Causes: amyloidosis, duct stricture, bulimia, lymphadenitis, lead and mercury toxicity, chronic fatty infiltration from alcohol, and hypovitaminosis

Sialadenosis

• Pathophysiology: secondary to underlying endocrine or metabolic pathology (cirrhosis, diabetes, malnutrition, ovarian, thyroid, or pancreatic insufficiency) or medications (hypertensive medications, catecholamines, iodine-containing compounds)

• SSx: recurrent bilateral nontender parotid swelling (painful sialadenosis is associated with antihypertensive medications)

• Dx: clinical history and exam

• Rx: treat underlying disease or change medications

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