Major salivary glands
- Parotid glands
- Submandibular glands
- Sublingual glands
The major salivary glands produce > 95% of an individual’s saliva.
- Secreted by acinar cells
- Concentration of ions modified by ductal cells
- 99.5% water
- Antibacterial compounds
- Lubricates food to aid in the swallowing process
- Starts digestion of carbohydrates and lipids
- Immunologic defense against microbes in the oral cavity
- Protects the oral mucosa and teeth
- Aids in the sense of taste
Terminology for pathologic conditions
Since sialadenosis, sialadenitis, and sialithiasis are similar-appearing names, understanding the suffix may aid in differentiating the underlying process.
- “-osis”: increase or pathologic condition
- “-itis”: inflammation or infection
- “-lithiasis”: stone formation
Sialadenosis (sialosis) is a chronic, benign, noninflammatory hypertrophy of the salivary glands.
- Most common cause of salivary gland swelling
- Incidence and prevalence are unknown
- Men = women
- Valproic acid
- Vitamin deficiencies and malnutrition
- Endocrine/metabolic disorders:
- Other medical conditions:
- Sjögren syndrome
- The cause of hypertrophy is unknown.
- Potential process: accumulation of secretory granules in acinar cells → acinar enlargement → fatty infiltration of the salivary glands
Patients will present with enlarged salivary glands with the following characteristics:
- Usually bilateral
- No fluctuation in size or progressive enlargement
- Suspected based on history and physical examination
- Diffuse salivary gland enlargement
- Other abnormalities should be ruled out
No treatment is needed, other than addressing the underlying medical condition.
Sialadenitis is inflammation or infection of the salivary glands.
- The exact incidence is unknown.
- No predilection for race or sex
- Tends to occur in older, chronically ill, and dehydrated patients
- Infectious causes (most common):
- Staphylococcus aureus
- Streptococcus viridans
- Haemophilus influenzae
- Streptococcus pyogenes
- Escherichia coli
- Iatrogenic causes:
- Radiation treatment
- Radioiodine or contrast exposure
- Juvenile recurrent parotitis
- Age > 50 years
- Anorexia or bulimia
- Sjögren syndrome
- Bacterial: ductal obstruction or salivary hyposecretion → ascending bacterial contamination → secondary infection
- Radiation or iodine-induced: inflammation or damage to gland parenchyma → acute swelling → may or may not be associated with ductal blockage
- Acute salivary gland swelling:
- Usually unilateral
- Parotid gland is most commonly involved (parotitis)
- Pain and swelling with meals
- Firm and diffusely tender
- Overlying erythema and edema
- Purulent exudate can sometimes be massaged from the duct opening.
- Fever and chills
The diagnosis is clinical. An evaluation can be done if the diagnosis is uncertain or to determine an etiology:
- Gram stain and culture of purulent exudate from the gland (if possible)
- PCR or serology for mumps virus
- Imaging with CT, ultrasonography, or MRI to identify:
- Stones in the duct
- Inflammation of the gland
- Good oral hygiene
- Warm compresses
- Massage of the gland
- Sialagogues (↑ salivary flow):
- Chewing gum
- Lemon drops
For bacterial infection:
- Initial antibiotics:
- Cefuroxime plus metronidazole
- Nafcillin plus ceftriaxone (or levofloxacin) plus metronidazole (or clindamycin)
- Hospital-acquired or immunocompromised: vancomycin plus any of the following:
- Cefepime plus metronidazole
- Abscess drainage
Sialolithiasis is the formation of calculi within the salivary glands or ducts.
- Estimated incidence: 0.3–1 in 10,000 people
- Men > women
- Age range: 30–60 years
- Approximately 80% of stones occur in submandibular glands.
- Stagnation of salivary flow:
- Anatomical duct stenosis
- Medications (e.g., anticholinergics)
- ↑ Salivary calcium
- The pathogenesis of stone formation is not well understood.
- Calculi can obstruct ducts → ↑ pressure within the gland → pain and swelling
- Glandular swelling
- May or may not have associated pain and tenderness
- Pain is worse with eating.
- Digital palpation may reveal the presence of calculus.
- Usually a clinical diagnosis
- The presence of a stone may be confirmed with:
- Sialography (radiopaque dye is injected into the duct for visualization on X-ray)
- Conservative management:
- Hot compresses
- Gland massage
- Analgesia with NSAIDs
- Stones close to the orifice of the duct may be removed with manual expression.
- Other methods:
- Extracorporeal shock-wave lithotripsy
- Laser lithotripsy
- Basket retrieval
- If the obstruction cannot be removed, surgical excision may be necessary.
Salivary Gland Neoplasms
- Salivary gland tumors are rare.
- Incidence: approximately 5.5 cases per 100,000 people per year in the United States
- Represent 6%–8% of all head and neck tumors
- Benign: > 40 years of age
- Malignant: > 60 years of age
- Benign: women > men
- Malignant: men = women
- The parotid gland is the most common site (80%–85% of cases).
- Benign neoplasms (majority):
- Pleomorphic adenoma (most common)
- Warthin tumor (also known as papillary cystadenoma lymphomatosum)
- Sebaceous adenoma
- Basal cell adenoma
- Canalicular adenoma
- Sialadenoma papilliferum
- Ductal papilloma
- Malignant neoplasms:
- Mucoepidermoid carcinoma (most common)
- Adenoid cystic carcinoma
- Acinic cell carcinoma
- Carcinoma ex pleomorphic adenoma (malignant transformation of pleomorphic adenoma)
- Polymorphous low-grade adenocarcinoma
- Salivary duct carcinoma
- Primary squamous cell carcinoma
The following are risk factors for malignant salivary tumors:
- Ionizing radiation exposure
- Environmental exposures:
- Rubber manufacturing
- Nickel compounds
- Hair salon/beauty shop personnel
- Viral infections:
- Presentation based on involved glands:
- Major salivary glands: painless mass or swelling
- Minor salivary glands:
- Submucosal mass
- Mucosal ulceration
- Malignant tumors are characterized by:
- Rapid growth
- Can be fixed to adjacent tissue
- Facial nerve involvement:
- Persistent pain
- Asymmetry of facial motion
- Total facial paralysis
- Associated with cervical lymphadenopathy
- Depending on the location, neoplasms can lead to:
- Dysphagia or odynophagia
- Nasal or airway obstruction
- Vocal hoarseness
- Fine-needle aspiration biopsy establishes the diagnosis.
- Usually an initial test to distinguish characteristics of the mass
- Useful in guiding biopsy
- CT or MRI can be used to define the extent of the tumor:
- Assess the location
- Detect local invasion
- Identify metastatic disease
- Complete surgical excision:
- Treatment of choice for all salivary gland neoplasms
- Facial nerve injury (most common early complication)
- Frey’s syndrome: gustatory sweating and flushing due to abnormal regeneration of parasympathetic nerve fibers
- Adjuvant radiation therapy may be used for malignant neoplasms.
- Branchial cleft cyst: congenital defect resulting from incomplete obliteration of the branchial clefts during embryonic development. Branchial cleft cyst can cause a small, painless neck mass that can become infected, resulting in the cyst becoming tender and inflamed. The diagnosis is typically clinical, and excision can be considered.
- Lymphadenopathy: palpable enlargement of the lymph nodes, which can result from a number of etiologies, including infection and malignancy. If there is concern for malignancy or worrisome physical exam findings, laboratory evaluation, peripheral blood smear, biopsy, or infectious workup should be performed. Management is directed at the underlying etiology.
- Dental abscess: odontogenic infection that often arises because of dental caries. Patients with dental abscess can have severe tooth pain, facial erythema, and fever. The diagnosis is made with physical examination and imaging. Management includes drainage of the abscess, antibiotics, and removal of the infected tooth.
- Cellulitis: common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. Cellulitis can occur anywhere, including the face or neck. The infection presents as an erythematous, edematous area with warmth and tenderness. Diagnosis is usually clinical, and management involves antibiotics.
- Hodgkin lymphoma: malignancy of B lymphocytes originating in the lymph nodes. The disease presents with lymphadenopathy (most commonly involving the neck), night sweats, weight loss, fever, and potentially splenomegaly and hepatomegaly. Diagnostic testing includes lymph node histologic analysis, blood tests, and imaging. Management includes chemotherapy and radiotherapy.
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