Download Sialadenitis Inflammation of the salivary glands is known as

Sialadenitis
Inflammation of the salivary glands is known as sialadenitis. Viral infections,
bacterial infections, allergic reactions and systemic diseases are the major causes for
sialadenitis. It may be acute or chronic.
Viral Infections
Mumps (epidemic parotitis) is the most common viral infection at feeling the
salivary glands; which is caused by a paramyxo virus. It is an acute, contagious disease,
usually affecting the parotid gland. Occasionally, the submandibular or the sublingual
glands may also be involved.
This disease is self-limiting one and not dangerous. In these days, the number of
cases is reduced, because of the use of the Mumps vaccine. It is a disease of the
childhood, but when it affects the adults, it leads to greater complications.
Patients suffering from Mumps give the history of local epidemic or contact with
Mumps' patients. This disease has the incubation period of 2-3 weeks.
Clinical features. Initially, the patient may suffer from mild fever, headache,
chills, vomiting, etc. followed by pain below the ear and sudden onset of firm, rubbery
or elastic swelling of the salivary glands, frequently elevating the ear lobe. In viral
parotitis, the glands of both the sides enlarge, which may be simultaneous or one
following the other in 24-48 hrs. There is excruciating ear pain during mastication.
Xerostomia, trismus, cervical lymphadenitis, tender glands, oedema of the overlying
skin may also be present. These symptoms usually last for a week. The disease spreads
through droplet dissemination as the virus is present in the saliva. Because of the
inflammation of the glands, the salivary flow decreases, with the increase in viscosity
and turbidity, which increases the chance of ascending infections.
The diagnosis is easy, when the above mentioned features are present. In the
absence of secondary infection, there is no suppuration and no pus discharge from
Stenson's duct upon pressure on the gland; however, the papilla may be puffy and red.
Complications
1.
In adults, this viral disease may lead to the inflammation of gonads and
central nervous system resulting in meningitis, encephalitis, orchitis, epididymitis,
deafness, myocarditis, thyroiditis, pancreatitis, oophoritis etc.
2.
In case of secondary infection, it leads to bacterial sialadenitis.
Investigations
• In acute phase, the serum amylase level is increased.
• Demonstration of the antibodies may confirm the disease.
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Differential diagnosis. Because the swelling can be near the angle of the
mandible, one should not confuse Mumps for a infectious swelling from lower molars.
Management. It is self-limiting. Symptomatic relief can be given by antipyretics.
Antibiotics can be given to prevent the secondary infection.
Bacterial Infection
Bacterial infection can lead to the inflammation of major salivary glands.
Depending on the onset, it may be acute or chronic/ recurrent. The bacterial
sialadenitis affects the parotid gland more commonly, the submandibular glands are
rarely affected.
Acute Bacterial Sialadenitis (Fig. 37.8 A)
The commensal organisms such as Staph. aureus, Staph. pyogenes, Strep,
viridans, Pnuemococcus, Actinomycetes, etc. can cause the bacterial sialadenitis. It
affects either the neonate and children or debilitated adults with poor oral hygiene.
Some drugs like tranquilizers, anti-parkinson drugs, diuretics, anti histamines, tricyclic
antidepressants, etc. decrease the salivary flow, with increased chance of infection of
salivary glands.
Clinical features. The disease is characterized by sudden onset of pain at the angle
of the jaw, which is unilateral. The affected gland is enlarged and tender and extremely
painful. The inflammatory swelling is very tense and doesn't show much fluctuation.
The overlying skin is warm and red. There is purulent discharge from Stenson's duct,
which can be seen upon pressing the papilla (Fig. 37. 8B). Patient might present with
fever and other symptoms of acute inflammation.
Differential diagnosis. Bacterial sialadenitis can be differentiated from mumps by
the discharge of pus at ductal opening.
Investigation The leucocyte count is high - leucocytosis.
Sialography should not be performed in the presence of suppuration. The pus is
collected from Stenson's duct taking care not to contaminate the swab with oral
microflora, for the culture and sensitivity test.
Management:
1.
Antibiotics.
2.
Palliative
a.
Hydrating the patient.
b.
Stimulate the salivation by chewing sialogogues.
c.
Improve the oral hygiene by debridement and irrigation. If there is no
improvement.
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3.
Surgical drainage may be done using needle aspiration guided by CT scan
or ultrasonography.
Chronic Bacterial Sialadenitis (Figs 37.9A and B)
The chronic or the recurrent type of bacterial sialadenitis may be seen in children
and adults. It may be idiopathic or with factors like duct obstruction, congenital
stenosis, Sjogrens syndrome and viral infection. All these factors except the duct
obstruction by stone are seen commonly in the parotid glands. The microorganisms
may be Strep, viridans, Escherichia coll, Proteus or Pneumococci. Because these have
low virulence, the changes are not sudden.
Clinical features. The disease starts as an unilateral swelling at the angle of the
jaw.
The recurrent sialadenitis shows periods of remissions. The gland may undergo
atrophy, which results in decreased salivary flow.
Management
1.
Antibiotics
2.
Intraductal infusion of erythromycin or tetracycline
3.
Occluding ductal system with a protein solution
4.
In intractable cases, excision of the gland.
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Sialolithiasis (Fig. 37.5)
Sialolithiasis is the formation of sialolith (salivary calculi, salivary stone) in the salivary
duct or the gland resulting in the obstruction of the salivary flow. Sialolith is a calcareous
substance, which may form in the parenchyma or the duct of the major or minor
salivary -glands. Though any of the salivary ducts may be obstructed by the formation
of the sialolith, about 90% of the sialoliths form in the submandibular gland. This is
because the long, curved Wharton's duct has increased chance of entrapment of
organic debris, plus the secretion of this gland is higher in calcium content and thick in
consistency and the position of the gland increases the chances for the stagnation of the
saliva.
The factors like inflammation; local irritation or drugs can cause stagnation of saliva
leading to the build up of an organic nidus, which eventually will calcify. Though the
metabolic cause for their formation is suggested, it is not yet established.
Sialolith: The sialolith is a calcified mass with laminated layers of the inorganic
material. It results from the crystallization of salivary solutes. The sialolith is yellowish
white in color, single or multiple, may be round, ovoid or elongated having the size of 2
cms or more in diameter. The minerals are various forms of calcium phosphate like
hydroxyapatite, octacalcium phosphate etc. Calcium and phosphorus ions are
deposited on the organic nidus, which may be, desquamated epithelial cell, bacteria,
foreign particle or product of bacterial decomposition. It is said that the sialoliths grow
at the rate of 1mm/year.
Clinical Features
Sialolithiasis may occur at any age; common in the middle aged persons. When a duct
of the major gland is involved, there is pain with the psychic stimulation of the salivary
flow. Patients complain of pain and swelling during and after eating the food. The
obstruction of the duct by the sialolith causes prevention of salivary flow and increased
pressure producing the pain.
On examination, the stone can be palpated, especially, if present at the peripheral aspect
of the duct.
Investigation
Radiographs AP view, Lateral, Lateral Oblique or Occlusal view.
Sialography The radiographs demonstrate the presence of salivary calculi; which
can be appropriately I located by the sialography.
Complications
1.
Bacterial infection of the gland may result in the obstruction of long duration.
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2.
Sialoangiectasis: Dilatation of the gland and the duct system can happen because
of the stasis of the saliva. It may be due to a sialolith, a stricture or chronic infection of
the gland.
3.
The retention of the saliva may result in the formation of mucoceles, especially the
mucous retention phenomenon.
4.
Rarely, the complete obstruction of the duct may result in the atrophy of the gland.
Management
There are several techniques available for the removal of the sialolith. A suitable
procedure is selected depending upon the number, size, and site of the stone in the duct
or the gland and age of the patient, etc.
•
The smaller sialoliths, which are located peripherally near the ductal opening, may
be removed by manipulation. (Called milking the gland)
•
Larger sialoliths are surgically removed.
•
Sometimes, the stones, which are not impacted, may be extracted through the
intubation of the duct with fine soft plastic catheter and application of the suction to the
tube.
•
Multiple stones or stones in the gland require the removal of the gland.
•
Some investigators have successfully used modern techniques like Piezoelectric
shockwave lithotripsy to fragment the salivary stones. The fragments pass through the
duct, as the salivary flow is stimulated and enhanced by the use of sialogogues.
Transoral sialolithotomy of the submandibular duct (Figs 37.6 to 37.7A-C) Transoral
sialolithotomy is the best procedure to surgically remove the submandibular duct stones.
This procedure can be carried out under local anesthesia.
The exact site of the stone is located by X-rays and palpation. Following this, a suture
may be placed behind the stone to prevent its backward movement. The tongue is lifted
and held with the help of a gauze.
Incision is made in the mucosa parallel to the duct taking care not to injure the structures
like the lingual nerve and the sublingual glands. After this, blunt dissection is carried out.
The tissues are displaced to locate the duct. Once that part of the duct lodging the stone is
identified, a longitudinal incision is made over the stone. The stone is removed using
small forceps, in case the stone is large, it is crushed with the help of the forceps.
Following this a cannula may be passed to aspirate the pieces of stone, mucin, etc. The
patency of the duct anterior to the surgical area should be ensured by passing a probe.
Sutures are placed at the level of the mucosa.
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