Salivary Gland Disorders

The salivary glands are paired as the parotid, submandibular and sublingual glands along with a large number of minor salivary glands.

This section will look at stones, swelling and infection. Salivary gland tumours, benign or malignant is dealt with elsewhere. The parotid and submandibular glands drain into a single duct each but the sublingual glands drain into between 8 and 20 ducts and so obstruction by a stone is rare.

The most likely diagnosis will depend upon features such as the age of the patient, whether the problem is bilateral or unilateral and the history.

The risk of infection is greatest when the flow of saliva is poor. This includes people, usually elderly, who take drugs that inhibit the production of saliva.

Most tumours of the sublingual and minor salivary gland are malignant.

Symptoms

• Which gland or glands are affected? Most common is the parotid
• Unilateral or bilateral?
• Pain or painless swelling?
• Duration
• Affected by eating? (Production of saliva)
• Malaise, pyrexia or other associated features?
• Facial weakness , asymmetry or associated pain? (Highly suggestive of malignancy)
• Dry eyes? (Sjogren's syndrome ) It is often under-diagnosed.¹
• Pain may be referred to the ear or throat.

Signs

A swollen parotid gland emerges just behind the jaw between the angle and the TMJ. It is important to differentiate this from cervical lymphadenopathy which may also be present. Usually it is possible to feel in front of lymph nodes but it is impossible to get in front of the parotid.

• Which gland or glands are involved?
• Are they salivary glands of lymph glands?
• If the problem is unilateral is the other side normal?
• Size, any tenderness and mobility of the mass.
• Regional lymphadenopathy?

Some causes are common to both parotid and submandibular. Others tend to affect just the parotid.

Causes of parotid swelling

• Mumps, usually bilateral but can be unilateral at first. The swelling lasts 5 to 9 days with pyrexia and general malaise.
• Stone in salivary duct,² gland swells with salivation.
• Various tumours of the parotid gland.
• Sjogren's disease affects females in 90% of cases, often with arthritis, a microcytic, hypochromic anaemia, raised ESR and mild fever. The age group is typically 40 to 60. It is an autoimmune phenomenon with an increased risk of non-Hodgkin's B cell lymphoma developing.³
• Sarcoidosis affects the parotid gland in 10% of cases. The Heerfordt-Waldenstrom syndrome consists of sarcoidosis with parotid enlargement, fever, anterior uveitis, and facial nerve palsy.
• Bacterial parotitis occasionally occurs in dehydration or where drugs have reduced flow of saliva. There is progressive, painful swelling, aggravated by chewing.
• Wegener's Granulomatosis can presenting as unilateral parotid enlargement.⁴
• Chronic bacterial parotitis may occur with calculi or stenosis of the ducts. In most cases, the chronic disease is autoimmune with superimposed bacterial infections and should not be designated as a chronic bacterial infection. Chronic parotitis often first presents to a dentist.⁵
• Rarely lymphocytic infiltration of the parotid can occur in HIV. It is commoner in children than adults.

Causes of submandibular swelling

• Stone in the salivary duct. Most masses in the submandibular gland are due to chronic obstruction and infection rather than neoplasia but it must not be forgotten.
• Sjogren's disease is less common in the submandibular gland.
• Various tumours of the submandibular gland

• FBC may suggest infection or inflammation
• ESR and CRP will be elevated in inflammation
• Rheumatoid factor is positive in about 90% of Sjogren's syndrome.
• Mumps is a notifiable disease and viral studies will be performed to confirm or refute the diagnosis
• If sarcoidosis is suspected, CXR may show bilateral hilar lymphadenopathy (BHL).
• Plain x-ray may show a radio-opaque stone in a salivary duct

Non-Drug

If a stone obstructs the salivary duct encourage good fluid intake and avoid strong flavours whilst awaiting for the stone to pass spontaneously. Shock wave lithotripsy has been used but seems more popular abroad.⁶

Encourage fluids and possibly antiseptic mouthwash where the mouth is dry. Oral toilet is important in terminal care.

Drugs

When pain and fever occur antipyretic analgesics are required.

Antibiotics may be required for bacterial infection.

Surgical

Where conservative treatment fails the parotid duct may need to be probed to release a stone.

Acute bacterial parotitis that does not respond to antibiotics and rehydration may require drainage. Rarely in chronic parotitis, bacterial infection become so frequent that parotidectomy is performed

Prognosis depends upon cause. People who have formed stones in the salivary ducts are more likely to produce them again.

A high uptake of MMR vaccine is essential to prevent resurgence of mumps. This is not a trivial disease.

A good intake of fluid will aid the production of saliva and reduce the risk of stones or infection.