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MedicineToday PEER REVIEWED ARTICLE CPD 1 POINT

A guide to salivary
gland disorders
The salivary glands may be affected by a wide range of neoplastic and inflammatory

disorders. This article reviews the common salivary gland disorders encountered in

general practice.

RON BOVA The salivary glands include the parotid glands, examination are often adequate to recognise and
MB BS, MS, FRACS submandibular glands and sublingual glands differentiate many of these conditions. A wide
(Figure 1). There are also hundreds of minor sali- array of benign and malignant neoplasms may also
Dr Bova is an ENT, Head and vary glands located in the mucosa of the hard and affect the salivary glands and a neoplasia should
Neck Surgeon, St Vincent’s soft palate, oral cavity, lips, tongue and oro- always be considered when assessing a salivary
Hospital, Sydney, NSW. pharynx. The parotid gland lies in the preauricular gland mass.
region and extends inferiorly over the angle of the
mandible. The parotid duct courses anteriorly Inflammatory disorders
from the parotid gland and enters the mouth Acute sialadenitis
through the buccal mucosa adjacent to the second Acute inflammation of the salivary glands is usu-
upper molar tooth. The submandibular gland lies ally of viral or bacterial origin. Mumps is the most
in the submandibular triangle and its duct passes common causative viral illness, typically affecting
anteriorly along the floor of the mouth to enter the parotid glands bilaterally. Children are most
adjacent to the frenulum of the tongue. The sub- often affected, with peak incidence occurring at
lingual glands are small glands that lie just beneath approximately 4 to 6 years of age. The parotid
the mucosa in the lateral floor of mouth region. swelling is accompanied by constitutional symp-
The salivary glands may be affected by a range toms such as fever and malaise, but many cases are
of neoplastic and inflammatory disorders. Inflam- mild and subclinical in nature. Treatment is symp-
matory disorders may be due to viral or bacterial tomatic. In addition to the mumps virus, other
infections, granulomatous conditions or autoim- viruses that may manifest as acute viral sialadenitis
mune diseases. A thorough history and physical include cytomegalovirus, coxsackievirus, echovirus,

• Salivary gland disorders represent a heterogeneous group of conditions ranging from


IN SUMMARY

inflammatory disorders to a diverse group of benign and malignant neoplasms.


• Acute inflammation of the salivary glands is usually of viral or bacterial origin; mumps is
the most common causative viral illness.
• Chronic inflammation and fibrosis most often affect the parotid gland.
• Most salivary stones (80%) occur in the submandibular gland; 20% occur in the parotid
gland.
• Salivary gland neoplasms are relatively uncommon, comprising only about 2% of all
head and neck neoplasms. The histopathology of these tumours is incredibly diverse,
with most (80%) occurring in the parotid gland.

44 MedicineToday ❙ February 2006, Volume 7, Number 2

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parainfluenza virus and HIV.
Acute suppurative bacterial sialadenitis most
often affects the parotid gland and, to a lesser
extent, the submandibular glands. Acute reduction © copyright
in salivary flow from dehydration or chronic
reduction as a result of psychotropic medications,
combined with poor oral hygiene, may predispose
to parotitis. Fever, painful unilateral gland swelling,
trismus and purulent sialorrhoea are the typical
signs of this potentially serious infection. Staphy-
lococcus aureus is the most common pathogen.
Treatment includes rehydration, warm com-
presses, repeated gland massage and antibiotic
therapy. If an abscess develops, incision and Parotid
gland
drainage may be required once the exact location
of the collection is localised radiologically. Parotid
duct

Chronic sialadenitis

© CHRIS WIKOFF, 2006


Sublingual
Chronic inflammation and fibrosis most com- gland Submandibular
monly affect the parotid gland, often resulting from gland
repeated acute infections with progressive damage Submandibular
duct
to the ductal epithelium leading to stricture forma-
tion and acinar atrophy.
Patients experience recurrent low grade infec- begins between 7 and 9 years of age, and the fre- Figure 1. Salivary glands,
tions in one or both glands, characterised by inter- quency of attacks often subsides after puberty. The showing position of the
mittent swelling, pain or discomfort precipitated cause is thought to be bacterial infection ascend- parotid, sublingual and
by eating. Streptococcus viridans is the usual organ- ing from the oral cavity, and hence treatment with submandibular glands.
ism responsible and penicillin is the antibiotic of a penicillin based antibiotic is indicated for severe
choice. Maintaining adequate hydration and gland acute attacks.
massage are adjunctive measures that facilitate
resolution of this often frustrating condition. If Sjögren’s syndrome
conservative measures fail, excision of the gland Sjögren’s syndrome is an autoimmune disorder
may be required; however, the chronic inflamma- that results in immunologically mediated destruc-
tory changes and fibrosis can make surgical resec- tion and inflammatory enlargement of the lacrimal
tion challenging. and salivary glands. Sjögren’s syndrome occurs
Sometimes an enlarged gland raises the possibil- predominantly in postmenopausal women and
ity of malignancy and both CT scanning and fine presents with dryness of the eyes and mouth, lead-
needle aspiration (FNA) biopsy are required to ing to chronic mouth and ocular discomfort.
exclude a neoplastic process. Sialography can also Patients may develop slowly progressive symmetri-
support the diagnosis of sialadenitis by demonstrat- cal enlargement of the salivary glands. Sudden
ing strictures and dilatation of the relevant salivary increased swelling of the parotid gland should alert
ductal system. the GP to the possibility of lymphoma, which is
40 times more likely to occur in patients with
Juvenile recurrent parotitis Sjögren’s syndrome than in the general population.
Juvenile recurrent parotitis represents the second Treatment for salivary gland disease in Sjögren’s
most common inflammatory salivary gland disease syndrome is symptomatic and supportive. Some-
of childhood after mumps. Patients usually pre- times superficial parotidectomy is required for
sent with unilateral recurrent swelling of the markedly enlarged glands that are causing cos-
parotid gland, often with associated pain, fever metic concern, or if recurrent infections become
and malaise. This interesting condition generally problematic.

MedicineToday ❙ February 2006, Volume 7, Number 2 45

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Salivary gland disorders
continued

Figure 3. CT scan demonstrating a large stone impacted in the


hilum of the submandibular gland. Stones are typically smaller
than this and in the majority of cases can be readily identified with
Figure 2. Enlarged submandibular gland. standard plain x-rays.

Chronic granulomatous sialadenitis Noninflammatory disorders suspected but is impalpable, x-rays of


Granulomatous disorders may present Salivary calculi the submandibular region with intraoral
with acute or chronic salivary gland Most salivary stones (80%) occur in the views may identify the offending calcu-
swelling. This group of disorders is often submandibular gland; 20% occur in the lus; however, 20% of stones are radiolu-
painless and includes tuberculosis, cat parotid gland. Stone formation is thought cent and thus will be missed with plain
scratch disease, sarcoidosis, actinomycosis to be more common in the submandibular x-rays. Sialography, where contrast is
and Wegener’s granulomatosis. CT scan- gland as a result of the higher mucin and injected into the salivary duct, is techni-
ning and FNA biopsy can often assist with calcium content of its saliva. Interest- cally challenging and usually unnecessary
the diagnosis. ingly, there is no association between but is the most accurate imaging method
serum calcium and phosphorous levels to detect salivary calculi. Both CT scan-
and the formation of calculi. Calculi may ning and ultrasound can also be used to
be found within the ductal system itself identify calculi with a high degree of
or within salivary gland parenchyma. accuracy. They are particularly useful for
Submandibular duct stones most often identifying stones in the hilum or
present with intermittent salivary gland parenchyma of the affected salivary gland
swelling and discomfort associated with (Figure 3).
eating (Figure 2). Sometimes mucopuru- Treatment of small stones is initially
lent saliva can be expressed from the duct conservative. It includes adequate hydra-
in the floor of the mouth and the offend- tion, sialagogues such as lemon juice,
ing calculus may be palpable. Most sub- heat, massage, and appropriate anti-
mandibular duct stones can be palpated biotics for established infection. Although
bimanually. The index finger of one small stones often extrude spontaneously,
hand is placed in the floor of the mouth surgical removal is sometimes required.
with the other hand palpating the sub- Stone removal may be performed trans-
mandibular region. The normal sub- orally for calculi located distally within
mandibular gland will feel soft to firm in the duct; however, adequate removal of
Figure 4. Submandibular gland removed consistency, while stones will feel hard. larger stones located more proximally
and sectioned, demonstrating numerous If a stone is palpable, radiological studies often requires submandibular gland
stones filling the hilum of the gland. are usually not necessary. If a stone is resection (Figure 4).

46 MedicineToday ❙ February 2006, Volume 7, Number 2

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Benign lymphoepithelial lesion
Benign lymphoepithelial lesion is also
known as Mikulicz’s syndrome. It has a
predilection for women in the fifth and
sixth decades of life and also occurs com-
monly in HIV-infected populations.
Patients present with unilateral firm or
cystic swelling of the parotid gland, with
bilateral involvement in 20% of cases.
Ultrasound or CT scanning reveals multi-
ple cystic lesions, and FNA demonstrates
acinar atrophy and diffuse lymphocytic
infiltration. Treatment is supportive unless
parotid enlargement is severe enough to Figure 5. Ranula appearing as a floor of mouth Figure 6. Plunging ranula appearing as a
warrant parotidectomy. swelling. submandibular neck mass.

Sialadenosis and systemic diseases chronic infection and autoimmune dis- malignant parotid tumour in Australia.
Sialadenosis is the term used to describe orders. It also often occurs after radia- Similarly, malignant melanoma may also
the non-neoplastic, noninflammatory tion therapy used to treat patients with metastasise to the parotid, and hence a
enlargement of the salivary glands that head and neck cancer. The salivary high index of suspicion is required when
occurs in association with many systemic glands are extremely sensitive to the assessing parotid lumps, especially in
disorders. The cause is unknown and the effects of radiation and irreversible aci- patients with sun-damaged skin.
disease most often presents with bilateral nar cell damage is an inevitable conse- A list of the common benign and
asymptomatic parotid gland swelling. quence of radiation therapy. Xerostomia malig nant salivary gland tumours is
Associated disorders include: may also be secondary to the use of cer- shown in the Table.
• obesity tain medications, especially those with Most salivary gland tumours present
• malnutrition anticholinergic side effects. Treatment is as slow-growing, painless, firm, non-
• alcoholic cirrhosis symptomatic, including increased tender masses. Symptoms and signs that
• hypothyroidism hydration, sialagogues and artificial saliva.
• diabetes Recommended sialagogues include
Table. Salivary gland tumours
• other endocrine abnormalities. lemon with ice, sugarless candies and
Salivary gland enlargement usually chewing gum.
resolves with treatment of the underlying Benign
condition. Neoplastic salivary gland disease Pleomorphic adenoma
Salivary gland neoplasms are relatively Warthin’s tumour
Ranula uncommon and constitute only about 2% Oncocytoma
A ranula is a benign cystic lesion that of all head and neck neoplasms. The Monomorphic adenoma
occurs in the floor of mouth as a result histopathology of these tumours is incred- Malignant
of mucous extravasation that originates ibly diverse with most (80%) occurring in Metastatic cutaneous squamous cell
from the sublingual gland. It appears as the parotid gland, while the remaining carcinoma
a bluish cystic lesion in the anterior floor 20% occur in the submandibular and Mucoepidermoid carcinoma
of mouth (Figure 5). A plunging ranula minor salivary glands. About 80% of Adenoid cystic carcinoma
occurs when a ranula penetrates through parotid tumours are benign; however, the Adenocarcinoma
the floor of mouth muscles and presents incidence of malignancy in submandibu- Acinic cell carcinoma
as a submandibular or submental mass lar tumours is approximately 50%. Lymphoma
(Figure 6). Australia has the highest incidence of
cutaneous squamous cell carcinoma Miscellaneous
Xerostomia (SCC) and melanoma in the world. Haemangioma
Xerostomia (dry mouth) may be secon- Metastatic SCC to the parotid gland from Cysts
dary to systemic disorders such as diabetes, a facial or scalp SCC is the most common

MedicineToday ❙ February 2006, Volume 7, Number 2 47

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Salivary gland disorders
continued

structures. FNA cytology is a safe and rence. The multidisciplinary approach for
highly reliable test for differentiating managing salivary gland malignancies is
between neoplastic and non-neoplastic similar to treatment paradigms for other
disorders. FNA allows the surgeon to head and neck cancers. This has been cov-
counsel patients preoperatively about the ered in a recent article in Medicine Today.2
extent of resection required to optimally
manage their tumour type. As with other Conclusion
head and neck masses, open biopsy Inflammatory disorders of the salivary
should be avoided because tumour glands are relatively common, and usually
spillage may compromise future curative respond to medical management. Patients
surgical procedures. with salivary gland masses require further
Treatment of benign neoplasms invol- investigation and appropriate referral.
ves resecting the affected salivary gland. While most salivary gland tumours are
As most benign tumours occur in the benign, malignancy needs to be consid-
Figure 7. Malignant parotid mass. superficial lobe of the parotid, superficial ered for all salivary masses. The high inci-
parotidectomy is the most common oper- dence of cutaneous cancers in Australia
may indicate a malignancy include: ation performed. Careful dissection of the warrants a high index of suspicion when
• pain facial nerve is mandatory for all parotid patients present with a persistent salivary
• rapid growth resections. Temporary partial facial weak- gland lump. MT
• hard mass ness occurs in about 5 to 10% of patients
• fixation to overlying skin or having superficial parotidectomy for References
underlying structures (Figure 7) benign tumours, while the incidence of
• facial nerve palsy. permanent nerve damage is less than 1%.1 1. Bova R, Saylor A, Coman WB. Parotidectomy:
Generally, all salivary gland masses Sometimes the facial nerve is invaded by review of treatment and outcomes. ANZ J Surg
warrant further investigation. A CT scan tumour and requires sacrifice as part of the 2004; 74: 563-568.
is the preferred radiological modality as tumour resection. 2. Bova R. Head and neck cancer: a guide to
it provides excellent anatomical detail High grade salivary gland malignancies diagnosis and an overview of management.
that helps the surgeon determine the may also require neck dissection and post- Medicine Today 2005; 6(4): 54-61.
exact location of the tumour as well as operative radiotherapy to minimise the
demonstrating infiltration of surrounding chance of locoregional tumour recur- DECLARATION OF INTEREST: None.

48 MedicineToday ❙ February 2006, Volume 7, Number 2

Permission granted for use by Entthyroid.com.au for educational purposes. © Medicine Today 2006. Copyright for illustrations as stated.