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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