Download Salivary gland disorders

AD_ 0 1 9 _ _ _ J AN2 8 _ 1 1 . p d f
Pa ge
1 9
2 0 / 1 / 1 1 ,
9 : 4 7
AM
HowtoTreat
www.australiandoctor.com.au
PULL-OUT SECTION
inside
COMPLETE HOW TO TREAT QUIZZES ONLINE (www.australiandoctor.com.au/cpd) to earn CPD or PDP points.
Acute sialadenitis
Chronic
sialadenitis and
sialolithiasis
Systemic disease
affecting salivary
glands
Neoplastic
diseases of
salivary glands
Salivary gland
surgery
The authors
DR CHRIS O’NEILL,
general, endocrine and breast
surgeon, Lake Macquarie Specialist
Centre, Gateshead, NSW.
Salivary gland disorders
ASSOCIATE PROFESSOR
STAN SIDHU,
thyroid, parathyroid, salivary
and adrenal surgeon,
University of Sydney, NSW.
Background
THE spectrum of presentation of salivary gland disorders is wideranging
and includes:
• Acute and chronic infection.
• Systemic inflammatory disorders.
• Benign and malignant neoplasms.
In most cases, clinical assessment
allows distinction between these entities and guides further investigation
and management.
Acute onset of unilateral pain,
swelling and fever suggests acute suppurative sialadenitis. Intermittent unilateral gland swelling and pain is
most commonly associated with
chronic sialadenitis and salivary duct
calculi. Bilateral gland involvement is
more common with viral infections
or systemic disease. The presence of a
painless slow-growing unilateral salivary gland mass is highly suggestive
of a neoplasm.
Figure 1: Differential diagnosis of salivary gland swelling.
Salivary gland swelling
Unilateral
Acute
pain
Swelling
Fever
Acute
bacterial
sialadenitis
Bilateral
Painless,
slow-growing
mass
Recurrent
swelling and
pain
Chronic
sialadenitis
Sialolithiasis
Sjögren’s syndrome
Lymphoma
Neoplasm
(benign or
malignant)
Acute
pain
Swelling
Fever
Systemic
symptoms
Slow course
Viral
sialadenitis
Sjögren’s
syndrome
Lymphoma
Mycobacterial
disease
cont’d next page
www.australiandoctor.com.au
28 January 2011 | Australian Doctor |
19
AD_ 0 2 0 _ _ _ J AN2 8 _ 1 1 . p d f
Pa ge
2 0
2 0 / 1 / 1 1 ,
9 : 4 8
AM
HOW TO TREAT Salivary gland disorders
Anatomy and physiology
THE major salivary glands
include the parotid, submandibular and sublingual
glands. The minor salivary
glands predominantly line
the mucosa of the hard and
soft palate but are also
found throughout the oral
cavity and oropharynx.
Secretion of saliva is moderated by a combination of
the autonomic nervous
system and humoral factors.
The saliva produced in the
parotid gland is predominantly serous, that from the
sublingual and minor salivary glands predominantly
mucoid and that from submandibular gland mixed.
Figure 2: Pes anserinus. The facial nerve enters the
posteromedial surface of the parotid gland, as seen during
superficial parotidectomy. A Warthin’s tumour is seen lying
between the main branches of the facial nerve. (SCM:
sternocleidomastoid, PbD: posterior belly of the digastric
muscle.)
(the pes anserinus). Still within
the substance of the gland,
these trunks then divide into
the terminal branches of the
facial nerve (figures 2, 3). The
parotid duct runs anteriorly
from the parotid gland,
pierces the buccinator muscle
and opens in the mouth opposite the second upper molar.
Figure 3: The terminal branches of the facial nerve are
displayed during the dissection of the parotid gland during
superficial parotidectomy.
Submandibular and
sublingual glands
Parotid gland
The parotid gland is the
largest of the salivary glands
and overlies the masseter
muscle. The inferior pole of
the parotid extends down
into the neck to overlie the
superior portion of the
sternocleidomastoid muscle.
Thus it can be difficult on
clinical examination to dis-
tinguish an inferior-pole
parotid mass from an
enlarged lymph node of the
upper neck.
The facial nerve enters the
posteromedial aspect of the
gland and then within the
gland divides into two trunks
The submandibular gland
occupies the submandibular
triangle then wraps around the
posterior border of the mylohyoid muscle to lie in the floor
of the mouth. The submandibular duct (Wharton’s
duct) courses anteriorly from
the gland to end in the anterior
floor of the mouth.
The sublingual glands are
located in the floor of the
mouth and each gland has
multiple small ducts that open
directly into the mouth.
Acute sialadenitis
Viral sialadenitis
VIRAL sialadenitis is most commonly bilateral and associated with
systemic infection. Mumps (a
paramyxovirus) is the most
common cause of viral sialadenitis.
However other viral infections such
as coxsackievirus, cytomegalovirus,
Epstein–Barr virus, influenza and
HIV can cause sialadenitis.
Management is supportive, with
hydration, oral hygiene, analgesia,
warm compresses and rest. The
inflammation of the gland may take
many weeks to resolve but should
resolve completely.
Acute suppurative sialadenitis
Acute suppurative sialadenitis usually affects only one gland and is
due to retrograde bacterial contamination along the duct of the sali-
vary gland. The parotid gland is
most commonly involved and most
patients are dehydrated and medically debilitated.
Other predisposing conditions
include diabetes mellitus, Sjögren’s
syndrome, poor oral hygiene and
ductal obstruction due to salivary
duct calculi (sialolithiasis), duct
stenosis or foreign bodies.
Patients with acute sialadenitis
usually present with pain, erythema
and swelling over the infected
gland. Fever is common and, when
examining the mouth, purulent
fluid can often be milked from the
affected duct.
In most cases hydration, oral
hygiene and antibiotics are sufficient
treatment. More than 80% of infections are due to Staphylococcus
aureus, so a beta-lactam penicillin
(dicloxacillin or flucloxacillin) or
first-generation cephalosporin are the
antibiotics of choice.
In some patients infections are
mixed, with both aerobic and
anaerobic bacteria, and broader
antibiotic coverage is necessary.
Where there is localised abscess
formation or antibiotics alone fail
to resolve symptoms, surgical
drainage may be required.
Chronic sialadenitis and sialolithiasis
PATIENTS with chronic
sialadenitis experience recurrent pain and swelling of the
affected salivary gland. This is
most commonly due to duct
obstruction, with salivary duct
calculi being the most frequent
cause.
Patients with sialolithiasis
often complain of postprandial pain and swelling and
may have a history of prior
episodes of acute suppurative
sialadenitis. On palpation the
gland is often enlarged, may
be tender and minimal saliva
will be able to be expressed
from the obstructed duct.
Large salivary-duct stones
will usually be palpable with
bimanual examination. If
calculi are palpable in the
floor of the mouth, further
examination of the mouth
and gland massage should
be discouraged, as this may
lead to the stone being
pushed more proximally into
the duct and decrease the
likelihood of a successful
transoral excision.
CT is
complementary
and can provide
superior images
in complex cases
or in patients
with recurrent
disease.
Figure 4: Axial CT demonstrating a calculus of the left
submandibular duct (red arrow). This distal stone was retrieved
via a transoral approach.
Salivary gland calculi
Salivary duct calculi are
composed predominantly of
calcium salts, and form due
to stasis and ductal inflammation.
More than 80% of salivary
duct stones occur in the sub-
20
| Australian Doctor | 28 January 2011
www.australiandoctor.com.au
mandibular gland. This
predilection for stones in the
submandibular gland is due
to the long and torturous
nature of the duct as well as
the mixed mucous and serous
composition of the saliva (in
comparison to the serous
saliva from the parotid gland).
Confirmatory imaging can
include plain X-ray, ultrasound or CT (figure 4). Plain
X-ray is most useful for submandibular calculi, as 80%
are radio-opaque; in contrast,
most parotid duct calculi are
radiolucent.
Ultrasound is increasingly
used, as it is able to give information about the gland, the
presence of duct dilation and
can identify stones as small as
1mm.
CT is complementary and
can provide superior images
in complex cases or in patients
with recurrent disease. However, in some patients artefacts
from dental implants may
limit the usefulness of CT.
The initial management of
sialolithiasis should include
gland massage, stimulation of
saliva production (chewing
gum, lemon drops or other
sialogogues) and anti-inflammatories. Antibiotics should
only be prescribed when signs
of infection are also present.
When symptoms persist,
patients should be referred to
a surgeon. For stones within
the distal submandibular duct,
a transoral excision of the
stone is appropriate. This
involves incising the duct longitudinally in the floor of the
mouth and removing the
stone.
When symptomatic stones
are located more proximally
in the duct or within gland
parenchyma, surgical excision of the gland is performed. Surgical treatment is
almost always curative and
associated with minimal
morbidity.
In recent years newer techniques for the treatment of
salivary-duct calculi have
emerged, allowing for preservation of the salivary gland.
These include duct exploration via sialendoscopy and
external shock-wave lithotripsy. Both these treatments
aim to localise and fragment
salivary duct calculi that are
then either removed endoscopically or fragmented such
that they pass spontaneously.
Despite initial promising
results, the long-term outcomes of these treatments
remain unclear, they fail to
treat any underlying abnormality of the salivary gland
and are yet to be adopted
widely in clinical practice.
AD_ 0 2 1 _ _ _ J AN2 8 _ 1 1 . p d f
Pa ge
2 1
2 0 / 1 / 1 1 ,
9 : 4 9
AM
Systemic disease affecting the salivary glands
SJÖGREN’S syndrome is an
autoimmune condition of the
exocrine glands. The salivary
glands are commonly
involved, and xerostomia (dry
mouth) predisposes these
patients to sialadenitis,
sialolithiasis and oral candidiasis. Bilateral painless salivary
gland enlargement (particularly of the parotid) is
common, although this may
be asymmetric and sometimes
involve only a single gland. It
is important even in a patient
with known Sjögren’s syndrome to consider a neoplasm
in the presence of unilateral
gland enlargement.
Treatment of xerostomia
associated with Sjögren’s syndrome includes:
• Stimulation of salivary secretion.
• Use of saliva substitutes.
• Treatment of oral candidiasis
with antifungals.
Sialogogues
Salivary excretion can be promoted by chewing gum, with
lemon drops or by sucking
sugar-free lollies. Such salivary stimulation with these
simple sialogogues is safe and
can be self-regulated by the
patient.
Pilocarpine is a muscarinic
cholinergic stimulator that
can be used to increase salivary excretion. When taken
three times a day it improves
salivary excretion in most
patients. However, its use is
limited by dose-dependent
side effects, including:
• Excessive sweating.
• Flushing.
• Nausea.
• Diarrhoea.
• Frequent urination.
Use of pilocarpine is also
contraindicated in patients
with asthma and congestive
cardiac failure.
Neoplastic diseases of the salivary glands
TUMOURS of the salivary glands
are relatively rare. Most (75%)
occur within the parotid gland.
Most tumours in the parotid are
benign (75%), while about 50% of
tumours in the submandibular
gland will be malignant.
The isolated swelling of a salivary gland should raise the suspicion of a neoplastic process. Most
tumours grow slowly. However,
patients may report a short history
of noticing the lump.
Neoplasms of the salivary glands
can usually be distinguished from
inflammatory processes, as they
involve a single gland, have a
longer time course of presentation
and are usually painless. Nerve
palsy is rare even with malignant
tumours. However, when this
occurs it is highly specific for
malignancy.
Clinical assessment and
further investigation
Clinical assessment of such patients
should involve a history of the
presentation of the mass and any
associated symptoms such as pain
or weakness (of facial muscles or
the tongue). It is also important to
ascertain any prior history of skin
malignancies of the face or scalp,
and of prior radiation exposure.
Examination should include:
• Bimanual palpation of the gland.
• Examination of the oral cavity.
• Palpation of the neck for cervical lymphadenopathy.
Benign tumours are typically
firm, well circumscribed, mobile
and non-tender. It is important to
note that benign tumours are
common in the inferior pole of the
parotid and that this area extends
inferior to the angle of the mandible
into the upper neck.
Facial nerve paralysis, fixity to surrounding structures, rapid growth,
pain or associated cervical lymphadenopathy should raise the suspicion of malignancy.
It is also extremely important to
examine the face and scalp for a primary skin malignancy, as in Australia
nodal metastases (particularly from
squamous cell carcinoma, [SCC]) are
a common cause of a unilateral
swelling in the parotid region.
Further assessment should be performed with ultrasound-guided fineneedle aspiration (FNA) cytology.
Ultrasound allows the characterisation of the extent of the mass and
assessment of draining lymph node
basins.
Cytology (when adequate samples
are obtained) has reported accuracy
rates of up to 97% for benign neoplasms and 87% for salivary malignancies.1,2 All patients with a salivary
gland mass suspicious for a malignancy should be referred for specialist surgical management.
Table 1: Neoplastic processes involving the salivary glands and
relative incidence in the Australian context
Neoplasm
Incidence
Benign salivary gland neoplasms
• Pleomorphic adenoma
50%
• Warthin’s tumour (specific to parotid)
18%
• Basal cell adenoma
<1%
Malignant salivary gland neoplasms
• Mucoepidermoid tumour
4%
• Acinic-cell tumour
2%
• Adenocarcinoma:
<1%
— adenoid cystic carcinoma
— carcinoma ex-pleomorphic adenoma
— undifferentiated carcinoma
Non-salivary gland neoplasms
• Metastatic tumour:
25%
— squamous cell carcinoma (skin or oropharyngeal)
— melanoma
• Lymphoma
<1%
The incidence of neoplastic
tumours of the salivary glands is
shown in table 1. The most common
cause of unilateral painless salivary
gland swelling is a pleomorphic adenoma. Warthin’s tumour and
metastatic skin malignancy (SCC or
melanoma) are also common.
Primary salivary gland malignancies are uncommon. However,
muco-epidermoid cancer is the
most frequent of these rare
tumours and has a tendency to
metastasise to lymph nodes of the
neck.
Benign salivary gland tumours
Pleomorphic adenomas are the
most common benign salivary
gland neoplasms. They are more
common in the parotid gland and
in 90% of cases lie superficial to
the facial nerve.
Patients with a pleomorphic adenoma typically present with a slowgrowing unilateral parotid mass
that on clinical examination is well
circumscribed, mobile and nontender.
The natural history of pleomorphic adenoma is of continued
growth, so most patients elect for
excision. In patients who choose
an observational approach, malignant transformation is rare
www.australiandoctor.com.au
although has been reported in up
to 10% of tumours after 10-15
years.3
For most patients with pleomorphic adenoma, superficial
parotidectomy is the treatment of
choice. Enucleation of the mass
alone is not advised because,
although macroscopically pleomorphic adenoma may appear well circumscribed, on histopathological
examination pseudopods of
tumour spreading into the surrounding parotid parenchyma are
common.
Hence, when possible the excision of these tumours should
involve a cuff of normal parotid
tissue. Although a wide excision
does minimise the risk of recurrence, it is not always possible;
when the tumour is close to the
facial nerve, preservation of the
nerve is prioritised.
Recurrence of pleomorphic adenoma is uncommon but the risk of
recurrence is increased, particularly if
the resection margin was involved
with neoplasm.
Warthin’s tumour is the second
most common primary salivary gland
neoplasm and is also known as an
adenolymphoma. It is associated
with a history of smoking, is more
common in elderly males and may
be bilateral in up to 10% of cases.
It more frequently occurs in the
inferior pole of the parotid gland
and when located in this area
patients present with a mass in the
upper part of the neck near the angle
of the mandible. Thus it may be clinically indistinguishable from an
enlarged lymph node of the upper
neck. On palpation the mass is nontender, mobile and well circumscribed. Ultrasound will often show
a partially cystic mass and FNA is
usually diagnostic.
The natural history of Warthin’s
tumour is of slow growth over time,
so most are treated with excision.
Surgical excision of Warthin’s
tumours is almost uniformly curative. Although enucleation of the
tumour is sufficient, a formal dissection is usually necessary to identify
and preserve the facial nerve
branches.
Malignant salivary gland
tumours
In Australia metastatic skin malignancy is the most common cause
of a malignant mass in a salivary
gland. There are multiple lymph
nodes within the parenchyma of
the parotid gland, so metastases to
this area are almost always to the
lymph nodes within or adjacent to
the gland rather than to the parotid
gland itself.
Most patients will have a history
of previous malignancy of the face,
scalp or neck; SCC is most
common. However, melanoma and
Merkel-cell carcinoma can also
metastasise to the parotid region.
Diagnosis is usually possible with
FNA cytology, and treatment
includes surgical excision of the
gland (usually with superficial
parotidectomy) and dissection of
any involved lymph node compartments of the neck. Adjuvant radiotherapy is recommended in selected
cases.
The most common, malignant,
primary salivary gland neoplasm is
the muco-epidermoid tumour.
Most occur within the parotid
gland and, although they can occur
at any age, peak incidence is
reported between age 40 and 50.
A history of prior external radiation exposure is associated with an
increased incidence of muco-epidermoid cancer of the salivary
gland. In contrast there is thought
to be little association between
radiation exposure and benign salivary neoplasms.
Treatment of muco-epidermoid
cancer is primarily surgical, with
resection of the involved gland. The
facial nerve is preserved unless
there is direct involvement by
tumour or pre-existing facial nerve
palsy.
Nodal metastases are more
common with high-grade tumours
and, in patients with clinical or
radiological evidence of nodal
metastases, neck dissection of the
involved compartments is recommended.
The role of neck dissection and
adjuvant radiotherapy in salivary
gland malignancies in the absence
of clinical or radiological evidence
of metastases remains controversial. Tumour factors associated
with an increased incidence of
occult nodal metastases include:
• Larger size (particularly >4cm).
• Extension of cancer beyond the
capsule of the salivary gland.
• Higher grade.
In addition, tumours of the submandibular gland are more likely
to metatasise to cervical nodes than
those arising in the parotid. Thus
prophylactic dissection of lymph
node compartments within the
neck may be prudent in patients
with large, high-grade salivary
gland malignancies, particularly
when these originate from the submandibular gland.
Use of adjuvant radiotherapy in
malignant salivary gland tumours is
another area of controversy. Postoperative radiotherapy aims to
reduce the rate of local recurrence
and so is often recommended when:
• Tumours are high grade.
• There are nodal metastases or invasion of surrounding bone or soft
tissue.
cont’d page 24
28 January 2011 | Australian Doctor |
21
AD_ 0 2 4 _ _ _ J AN2 8 _ 1 1 . p d f
Pa ge
2 4
2 0 / 1 / 1 1 ,
9 : 5 0
AM
HOW TO TREAT Salivary gland disorders
from page 21
• Local surgical excision is incomplete.
Common side effects of radiotherapy
include:
• A dry or sore mouth.
• Swallowing difficulty.
• Hair loss within the irradiated field.
• Skin erythema or desquamation in the irradiated field.
Some patients may lose weight due to the
decreased caloric intake associated with oral
symptoms. Most of these symptoms are short
term and resolve within weeks of completion of treatment.
In patients with loco-regional recurrence or
metastatic salivary gland malignancies, systemic chemotherapy is administered. In most
series, reported response rates are modest.
Due to the rare nature of these tumours
there are very few clinical trials. However,
novel therapies such as molecular targeted
agents are being investigated in patients with
progressive disease.
Salivary gland surgery
SALIVARY gland surgery can
usually be achieved with minimal short- and long-term morbidity. Superficial parotidectomy
is performed via an S- or Yshaped incision anterior to the
ear and extending into the superior neck.
The key to the operation is the
identification and preservation of
the facial nerve. Once the trunk
of the facial nerve is identified,
the parotid superficial to this
plane is dissected free of the
branches of the facial nerve and
removed (figure 3). Although
temporary neuropraxia can
occur, long-term nerve damage is
rare with benign tumours.
When tumours are malignant,
nerve branches may need to be
sacrificed for tumour clearance.
This is particularly common
when there is pre-existing facial
nerve palsy. Sensory nerve injury
to the greater auricular nerve can
also occur. This results in numbness of the ear lobe but usually
improves over time.
Complications are uncommon
after parotid surgery but those
that can occur after discharge
include salivary fistula and Frey’s
syndrome. A salivary fistula presents with small amounts of saliva
leaking from the wound. This is
due to disconnection of the salivary acini from the ductal
system. Saliva produced from
these disconnected glands can
then leak from the wound.
Management consists of topi-
cal dressings (changed as
required) and reassurance, as
most salivary fistula settle spontaneously within a few weeks. In
the absence of signs of cellulitis,
antibiotics are not required.
Frey’s syndrome refers to
sweating that occurs in the skin
over the parotid region after surgery during eating. It is due to
autonomic nerves of the salivary
gland growing into the sweat
glands of the skin overlying the
gland.
The submandibular gland is
excised through an incision at
least two fingerbreadths below
the lower border of the
mandible. The entire gland, both
superficial and deep to the mylohyoid muscle, is removed and the
duct ligated. If malignancy is suspected, lymph nodes in this
region are also removed.
The nerve most at risk is the
marginal mandibular nerve.
Injury can cause drooping at the
angle of the mouth but is rarely
permanent. Sensory changes in
the jaw and neck can also occur
postoperatively but are usually
temporary.
Most salivary gland surgery
can be performed with minimal
risk. Patients are usually hospitalised for 1-2 nights and can
resume normal activities within
one to two weeks of surgery.
Although short-term complications can occur, long-term morbidity after salivary gland surgery
for benign conditions is rare.
Summary
SALIVARY gland disorders include
acute and chronic infection, systemic diseases and neoplastic
processes.
Initial differentiation of these
clinical entities depends on history
and examination. Most acute
infections will resolve with antibiotics.
Salivary gland calculi are more
common in the submandibular
gland. Typically patients present
with postprandial pain and
swelling. Once confirmed with Xray or ultrasound, any patients
with persistent symptoms should
be referred for specialist opinion
and stone (or gland) excision.
Any slow-growing painless mass
in a salivary gland should be presumed to be a neoplasm until
proven otherwise. Initial investigation should include ultrasound
and FNA cytology. All patients in
whom a salivary gland neoplasm is
suspected should be referred to a
specialist surgeon for further investigation and management.
Summary
Indications for specialist referral
Acute sialadenitis:
Acute sialadenitis
• Presents with short history of fever,
unilateral pain, erythema and swelling
of affected gland
• Failure to improve with oral antibiotics
• Trismus, threatened airway (send to ED)
Salivary duct calculi:
• Intra-oral submandibular stone
• Large calculus
• Persistent symptoms
• Symptoms without evidence of calculus on
imaging
Salivary duct calculi
• More common in the
submandibular gland
• Most improve with antibiotics and oral
hygiene alone
• Symptoms include
postprandial pain and
swelling
• Surgical drainage may be required if
symptoms fail to resolve with oral
antibiotics
• Initial treatment includes
gland massage and
simple sialogogues
• If there are signs of airway
compromise, refer the patient urgently
to the ED
• If symptoms persist, refer
to specialist surgeon
Salivary gland neoplasms
• Any slow-growing painless
mass in a salivary gland
should raise the suspicion
of malignancy
• Initial investigation should
include ultrasound and
FNA cytology
• All should be referred to a
specialist surgeon for
further investigation and
management
Salivary gland mass:
• Any slow-growing painless mass
• An ultrasound and fine-needle asipration (image
guided) will facilitate further workup
Authors’ case studies
Case study 1
A 70-YEAR-old man presented with a two-month
history of a painless lump in
the region of the left parotid
gland (figure 5). He was an
ex-smoker and reported
prior excision of multiple
SCCs from the face and
scalp.
Twelve months earlier he
had undergone excision of
an SCC form the left inner
canthus. On examination the
mass was non-tender, firm
and fixed. Facial nerve function was normal and there
was no associated cervical
lymphadenopathy.
Ultrasound of the parotid
region revealed a partially
cystic mass within the parotid
(figure 6). Abnormal lymph
nodes were also seen in the
upper neck. Ultrasoundguided FNA cytology of the
mass was suspicious for
malignancy, being consistent
with either metastatic SCC or
primary muco-epidermoid
24
Figure 5: Painless left parotid swelling.
| Australian Doctor | 28 January 2011
Figure 6: Ultrasound-guided fine-needle aspiration of a partially cystic parotid mass.
cancer of the parotid.
Superficial parotidectomy
was undertaken, with preservation of the facial nerve.
www.australiandoctor.com.au
Lymph nodes from the
upper neck (level 2 and 3)
were also dissected. Final
histopathology confirmed
metastatic SCC, and adjuvant radiotherapy was
advised to decrease the risk
of local recurrence.
AD_ 0 2 5 _ _ _ J AN2 8 _ 1 1 . p d f
Case study 2
A 37-year-old woman presented to the ED with a history of 24 hours of progressive swelling and pain in
the right face. She had no
history of prior salivary
gland disease, dry mouth or
poor oral hygiene.
She had massive swelling
of the right side of her face
and on palpation this area
was
indurated
and
extremely tender. In addition she had significant trismus and difficulty swallowing saliva.
Initial treatment included
analgesia, dexamethasone
and IV antibiotics (clindamycin and metronidazole). CT of the face confirmed right parotitis with
abscess formation.
Despite antibiotics the
swelling continued to
increase and CT-guided
drainage of the parotid
abscess was undertaken. An
ultrasound of the parotid
gland revealed a calculus in
the parotid duct with some
dilation of the proximal
duct (figure 7). The culture
of the fluid drained from
the abscess revealed mixed
aerobic and anaerobic bacteria.
After drainage and with
continued IV antibiotics,
the patient began to
improve. A follow-up ultrasound of the parotid has
revealed a normal gland
with no residual duct dilation or calculus (presumably the calculus had
passed spontaneously from
the duct).
Case study 3
Pa ge
2 5
2 0 / 1 / 1 1 ,
9 : 5 1
AM
Figure 7: Ultrasound of inflamed parotid gland, revealing dilated parotid duct (to left of picture) and
probable salivary duct calculus (arrow).
The culture of
the fluid drained
from the abscess
revealed mixed
aerobic and
anaerobic
bacteria.
References
1. Stewart CJ, et al. Fineneedle aspiration
cytology of salivary
gland: a review of 341
cases. Diagnostic
Cytopathology 2000;
22:139-46.
2. Zhang S, et al. Fine
needle aspiration of
salivary glands: 5-year
experience from a single
academic center. Acta
Cytologica 2009; 53:37582.
3. Seifert G. Histopathology
of malignant salivary
gland tumours. European
Journal of Cancer Part B:
Oral Oncology 1992;
28B:49-56.
Further reading
Available on request from
julian.mcallan
@reedbusiness.com.au
Online resources
or metastatic malignancy.
Excision was undertaken,
confirming a Warthin’s
tumour originating from
the inferior pole of the
parotid gland.
Case study 4
A 40-year-old female
reported swelling and postprandial pain in the left
submandibular region. She
had no systemic symptoms
and on examination had a
mildly enlarged and tender
left submandibular gland.
A salivary duct stone was
palpable within the floor of
the mouth.
CT confirmed the presence of a calculus in the
floor of the mouth (figure
4, page 20). The stone was
excised transorally, with
marsupialisation of the left
submandibular duct. She
has since not had recurrent
symptoms.
• American Academy of
Otolaryngology — Head
and neck surgery. Salivary
glands: www.entnet.org/
HealthInformation/
salivaryglands.cfm
• MedlinePlus. Salivary
gland disorders:
www.nlm.nih.gov/medline
plus/salivarygland
disorders.html
• PatientUK. Salivary gland
disorders:
www.patient.co.uk/doctor/
Salivary-GlandDisorders.htm
Figure 8: Coronal CT with mass originating from the inferior pole of the parotid gland.
A 51-year-old woman presented to her local doctor
with a painless lump in her
left upper neck. Other than
being a smoker she had no
other significant comorbidities or constitutional symptoms.
Examination revealed a
firm but non-tender mass
just below the angle of the
mandible in the left neck.
She had no skin lesions on
her head or neck, oropharyngeal examination was
normal and the thyroid was
palpably normal.
Ultrasound of the neck
revealed a cystic mass, and
FNA suggested oncocytic
cells probably of thyroid or
salivary origin. (An oncocyte is an epithelial cell
with an excessive number
of mitochondria, resulting
in an abundant, acidophilic
granular cytoplasm. Oncocytes can be benign or can
undergo malignant transformation.)
The thyroid appeared
normal on ultrasound and
no other abnormal lymph
nodes were identified in the
neck. CT of the region
could not differentiate this
mass as either a lymph
node or mass contiguous
with the parotid (figure 8).
The likely diagnoses
included Warthin’s tumour
www.australiandoctor.com.au
28 January 2011 | Australian Doctor |
25
AD_ 0 2 6 _ _ _ J AN2 8 _ 1 1 . p d f
Pa ge
2 6
2 0 / 1 / 1 1 ,
9 : 5 2
AM
HOW TO TREAT Salivary gland disorders
GP’s contribution
General questions for the
authors
the surgery the surgeon
noted that she had Frey’s
syndrome along the wound.
Her facial nerve function is
normal.
How is ‘gland massage’ performed? Could you please
clarify when this should and
should not be used for salivary gland calculi?
Massage of the gland promotes salivary flow and is
performed by applying pressure and rubbing over the
region of the gland (either
parotid or submandibular
regions).
Where there are large submandibular calculi that are
palpable in the floor of the
mouth any manipulation or
massage of the submandibular gland should be avoided
as this may push the stone
proximally along the duct
and decrease the likely success of a trans-oral excision.
Otherwise gland massage
can be performed and may
assist the passage of small
salivary duct calculi.
Questions for the authors
DR MICHELLE CROCKETT
Riverstone, NSW
Case study
DONNA, 37, has been relatively well in the past but is
extremely anxious. In October 2003 she presented with
a rubbery nodule just below
the angle of the mandible in
the left side of the neck that
was approximately 4 × 3mm
diameter. Physical examination was otherwise unremarkable and she was well.
An ultrasound and biopsy
were organised and a pleomorphic adenoma was diagnosed. She was referred to a
head and neck surgeon who
performed a left parotidectomy in January 2004. The
tumour was completely
excised. Histology confirmed
it to be benign and there
were no significant postoperative complications.
She has remained well
with no evidence of recurrence. A few months after
Is there a peak age when
these tumours occur?
The peak age of incidence
for pleomorphic adenoma is
40-50 years. Warthin’s
tumours have a slightly older
peak age of incidence, at 5060 years of age and malignant salivary gland tumours
are more common in
patients aged over 60 years.
What is Frey’s syndrome and
how common is it?
Frey’s syndrome (gustatory
sweating) is flushing and
sweating of the skin overlying the parotid region during
mastication. The true incidence of Frey’s syndrome in
patients after parotidectomy
is unknown but may be as
high as 50% and depends on
how closely symptoms are
sought (many patients have
subclinical Frey’s syndrome).
It is most commonly detected
within the first year after
surgery but the onset may be
delayed for a few years. It
may also follow trauma,
infection or inflammation in
the region of the parotid.
Treatment in most cases
involves reassurance and the
application of antiperspirant
to the affected skin.
Given that her risk of
recurrence is low, what is
the recommended long-
How to Treat Quiz
term follow-up?
After complete excision,
the risk of recurrence is
extremely low and no longterm follow-up is required.
In the rare circumstance of
recurrence this would likely
present as a clinically palpable lump in the parotid
region.
Is smoking a risk factor for
salivary gland malignancies?
Smoking is associated
with an increased incidence
of Warthin’s tumour. For
other salivary gland tumours
(benign and malignant)
smoking is not thought to be
a risk factor.
INSTRUCTIONS
Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes
by post or fax.
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer.
Salivary gland disorders
— 28 January 2011
1. Which TWO statements are correct
regarding salivary gland symptoms?
a) Acute onset of unilateral pain, swelling and
fever suggests acute bacterial sialadenitis
b) Bilateral gland swelling and pain is most
commonly associated with chronic sialadenitis
due to calculi
c) Bilateral gland involvement is more common
with bacterial infections
d) A painless, slow-growing unilateral salivary
gland mass is highly suggestive of a neoplasm
2. Which THREE statements are correct?
a) The saliva produced in the submandibular
gland is predominantly serous
b) The parotid duct opens into the mouth
opposite the second upper molar
c) The submandibular duct (Wharton’s duct)
opens into the anterior floor of the mouth
d) Viral causes of sialadenitis include mumps,
coxsackievirus, cytomegalovirus and
Epstein–Barr virus
3. Which TWO statements are correct
regarding acute bacterial sialoadenitis?
a) It tends to occur in medically debilitated
patients
b) Risk factors include diabetes mellitus,
ONLINE ONLY
www.australiandoctor.com.au/cpd/ for immediate feedback
Sjögren’s syndrome and ductal obstruction
c) The submandibular is the gland most often
affected by bacterial sialoadenitis
d) Antibiotics against Gram-negative
bacteria are the most appropriate first-line
treatment
4. Which TWO statements are correct?
a) Recurrent postprandial pain and swelling of a
salivary gland is usually due to ductal calculi
b) Ductal calculi associated with chronic
sialoadenitis are rarely palpable
c) Gland massage should be performed when a
calculus is palpated in the floor of the mouth
d) Most submandibular calculi are radio-opaque
on plain X-ray
5. Which TWO statements are correct?
a) Most parotid calculi are radio-opaque on plain
X-ray
b) Ultrasound provides information about the
gland and the presence of duct dilation and
can identify small calculi
c) Initial management for parotid calculi includes
gland massage, stimulation of saliva and
NSAIDs
d) Antibiotics should always be used when there
is a symptomatic salivary calculus
6. Which TWO statements are correct?
a) The dry mouth of Sjögren’s syndrome
predisposes to sialadenitis and salivary calculi
b) Sjögren’s syndrome does not directly affect
the salivary glands
c) The salivary gland enlargement in Sjögren’s
syndrome is usually painful
d) The treatment of xerostomia of Sjögren’s
syndrome includes salivary stimulation and
saliva substitutes
7. Which TWO statements are correct?
a) Neoplasia should be excluded when there is
an isolated painless swelling of a salivary
gland
b) Most salivary gland tumours occur in the
submandibular gland
c) Most parotid tumours are benign
d) Nearly all submandibular tumours are benign
8. Which THREE statements are correct?
a) Nerve involvement by a salivary tumour may
cause weakness of facial muscles or the
tongue
b) Benign parotid tumours are commonly located
inferior to the angle of the mandible in the
upper neck
c) In Australia, nodal metastasis from melanoma
or SCC is the most common cause of
malignant neoplasm in the parotid
d) A slow-growing mass in a single salivary gland
should not be biopsied
9. Which TWO statements are correct?
a) Enucleation of a pleomorphic adenoma of the
parotid is the preferred surgical treatment
b) Pleomorphic adenoma does not recur after
surgical treatment
c) Warthin’s tumour may present with a mass in
the upper part of the neck near the angle of
the mandible
d) Tumours of the submandibular gland are more
likely to metatasise to cervical nodes than
those arising in the parotid
10. Which TWO statements are correct?
a) Postoperative radiotherapy to malignant
salivary tumours aims to reduce the risk of
metastatic spread
b) Specialist referral is recommended if there is
an intra-oral submandibular stone
c) Most salivary fistulae complicating parotid
surgery will require surgical repair
d) In Frey’s syndrome (after parotid surgery),
sweating occurs in the skin over the parotid
region during eating
CPD QUIZ UPDATE
The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2011-13 triennium. You can
complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post or
fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
HOW TO TREAT Editor: Dr Giovanna Zingarelli
Co-ordinator: Julian McAllan
Quiz: Dr Giovanna Zingarelli
NEXT WEEK Stroke is Australia’s second-most common killer after coronary heart disease. In 2011, Australians will experience about 60,000 new and recurrent strokes, which equates to one stroke every 10
minutes. Strokes cost Australia an estimated $2.14 billion a year, underscoring the magnitude of the adverse public health impact and the need to improve outcome after stroke. Next week we have a thorough
review of the latest in transient ischaemic attack and stroke prevention. The authors are Dr Sergio Diez Alvarez, director, medical admissions unit, Coffs Harbour Health Campus, Coffs Harbour, NSW; and
Professor Chris Levi, director, acute stroke services, John Hunter Hospital, and director, centre for brain and mental health research, University of Newcastle and Hunter Medical Research Unit, Newcastle, NSW.
26
| Australian Doctor | 28 January 2011
www.australiandoctor.com.au