Ear, Nose & Throat
Question 178 of 300
A 73 year old woman presents to the Emergency Department complaining of intermittent facial pain and associated swelling occurring on the right side. She has noted that symptoms usually appear after eating. She is afebrile and her observations are normal. What is the most likely diagnosis?
Answer:
Obstructing stones cause glandular swelling and pain, particularly after eating, which stimulates saliva flow. Symptoms may subside after a few hours. Relief may coincide with a gush of saliva. Some stones cause intermittent or no symptoms. If a stone is lodged distally, it may be visible or palpable at the duct’s outlet. Persisting or recurrent stones predispose to infection of the involved gland.Salivary Gland Disease
Ear, Nose & Throat
Last Updated: 12th February 2021
The three major pairs of salivary glands are the parotid glands, the submandibular glands and the sublingual glands. In addition to these major glands, many tiny salivary glands are distributed throughout the mouth. All of the glands produce saliva, which aids in breaking down food as part of the digestive process.
Causes of salivary gland disease:
- Salivary gland malfunction resulting in xerostomia
- Salivary gland stones (sialolithiasis)
- Salivary gland infection (sialadenitis)
- Salivary gland tumours
- Other causes:
- Prescription drugs (for example, thiazide diuretics, phenothiazines, thiouracil, iodide contrast media).
- Metabolic disorders (for example, diabetes mellitus, cirrhosis, uraemia).
- Autoimmune disease (for example, sarcoidosis, Sjogren's syndrome, Wegener's granulomatosis).
Xerostomia (dry mouth)
- Xerostomia is dry mouth caused by reduced or absent flow of saliva. Xerostomia is usually caused by the following: drugs (e.g. anticholinergics, antiparkinsonian drugs, chemotherapy agents), radiation to the head and neck for cancer treatment and systemic disorders (e.g. Sjogren syndrome, HIV, uncontrolled diabetes mellitus). Assessment of the patient should include assessment for any of these risk factors.
- Physical examination is focused on the oral cavity, specifically any apparent dryness (e.g. whether the mucosa is dry, sticky, or moist; whether saliva is foamy, thick, stringy, or normal in appearance), the presence of any lesions caused by Candida albicans, and the condition of the teeth. If there appears to be dryness, the submandibular, sublingual, and parotid glands should be palpated while observing the ductal openings for saliva flow.
- Xerostomia is diagnosed by symptoms, appearance, and absence of salivary flow when massaging the salivary glands. No further assessment is required when xerostomia occurs after initiation of a new drug and stops after cessation of that drug or when symptoms appear within several weeks of irradiation of the head and neck. Xerostomia that occurs with abrupt onset after head and neck trauma may be caused by nerve damage. Concomitant systemic features may prompt further investigation. For patients in whom the presence or cause of xerostomia is unclear, sialometry or salivary gland biopsy may be appropriate.
- When possible, the cause of xerostomia should be addressed and treated. Causative drugs should be stopped where possible. Further management includes cholinergic drugs to increase existing saliva, saliva substitutes and regular oral hygiene and dental care to prevent tooth decay.
Salivary stones
- Eighty percent of stones originate in the submandibular glands and obstruct the Wharton duct. Most salivary stones are composed of calcium phosphate with small amounts of magnesium and carbonate. Patients with gout may have uric acid stones. Stone formation results from salivary stasis, which occurs in patients who are debilitated, dehydrated, have reduced food intake, or take anticholinergics.
- Obstructing stones cause glandular swelling and pain, particularly after eating, which stimulates saliva flow. Symptoms may subside after a few hours. Relief may coincide with a gush of saliva. Some stones cause intermittent or no symptoms. If a stone is lodged distally, it may be visible or palpable at the duct’s outlet. Persisting or recurrent stones predispose to infection of the involved gland.
- If a stone is not apparent on examination, the patient can be given a sialagogue (e.g. lemon juice, hard candy, or some other substance that triggers saliva flow). Reproduction of symptoms is almost always diagnostic of a stone. CT, ultrasonography, and sialography are highly sensitive and are used if clinical diagnosis is equivocal.
- Analgesics, hydration, and massage can relieve symptoms. Antistaphylococcal antibiotics can be used to prevent acute sialadenitis if started early. Stones may pass spontaneously or when salivary flow is stimulated by sialogogues; patients are encouraged to suck a lemon wedge or sour candy every 2 to 3 hours. Stones right at the duct orifice can sometimes be expressed manually by squeezing with the fingertips. Dilation of the duct with a small probe may facilitate expulsion. Surgical removal of stones may be required if other methods fail.
Salivary gland infection
- Sialadenitis usually occurs after hyposecretion or duct obstruction but may develop without an obvious cause. Sialadenitis is most common in the parotid gland and typically occurs in: patients in their 50s and 60s, chronically ill patients with xerostomia, patients with Sjogren syndrome, young people with anorexia. The most common causative organism is Staphylococcus aureus; others include streptococci, coliforms, and various anaerobic bacteria.
- Fever, chills, and unilateral pain and swelling develop. The gland is firm and diffusely tender, with erythema and oedema of the overlying skin. Pus can often be expressed from the duct by compressing the affected gland and should be cultured. Focal enlargement may indicate an abscess.
- CT, ultrasonography, and MRI can confirm sialadenitis or abscess that is not obvious clinically, although MRI may miss an obstructing stone. If pus can be expressed from the duct of the affected gland, it is sent for Gram stain and culture.
- Initial treatment is with antibiotics active against S. aureus, modified according to culture results. Chlorhexidine 0.12% mouth rinses three times a day will reduce bacterial burden in the oral cavity and will promote oral hygiene. Hydration, sialogogues (e.g. lemon juice, hard candy, or some other substance that triggers saliva flow), warm compresses, gland massage, and good oral hygiene are also important. Abscesses require drainage. Occasionally, a superficial parotidectomy or submandibular gland excision is indicated for patients with chronic or relapsing sialadenitis.
- Other infections that may involve the salivary gland should be considered including: mumps, HIV, cat-scratch disease (Bartonella infection), atypical mycobacterial infections (TB) and other viral causes of parotitis (e.g. Epstein–Barr virus, parainfluenza, adenovirus, influenza type A, coxsackievirus, parvovirus B19 and lymphocytic choriomeningitis virus).
Salivary gland tumours
- About 85% of salivary gland tumors occur in the parotid glands, followed by the submandibular and minor salivary glands. About 75 to 80% are benign, slow-growing, movable, painless, usually solitary nodules beneath normal skin or mucosa. The most common type of benign tumour is a pleomorphic adenoma (mixed tumor). Malignant tumors are less common and can be characterised by rapid growth or a sudden growth spurt. They are firm, nodular, and can be fixed to adjacent tissue, often with a poorly defined periphery. Eventually, the overlying skin or mucosa may become ulcerated or the adjacent tissues may become invaded. Mucoepidermoid carcinoma is the most common type of malignant salivary gland tumour.
- Most benign and malignant tumors manifest as a unilateral painless mass. However, malignant tumors may invade nerves, causing localised or regional pain, numbness, paraesthesia, causalgia, or a loss of motor function.
- CT and MRI locate the tumor and describe its extent. Fine-needle aspiration biopsy of the mass confirms the cell type. A search for spread to regional nodes or distant metastases in the lung, liver, bone, or brain may be indicated before treatment is selected.
- Treatment of benign tumors is surgery. For malignant salivary gland tumors, surgery, sometimes followed by radiation therapy, is the treatment of choice for resectable disease. Currently, there is no effective chemotherapy for salivary cancer.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
