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Salivary Swelling (Parotid and Submandibular Glands)

last modified on: Wed, 02/21/2024 - 14:55

Click for: Patient information about salivary swelling (sialadenitis) at the University of Iowa 

see also: Salivary Gland Swelling - Classification by Disease Processes Affecting the Glands

(downloadable questionnaire for patient information: Salivary Gland Swelling Patient Questionnaire)

Differential Diagnosis

  1. Obstructive Sialadenitis
    1. Sialolithiasis (salivary stones) see also: Pneumatic Lithotripsy
    2. Ductal stenosis (stricture or narrowing of drainage tubes)
    3. Sialectasis (chronic changes in the salivary glands)
    4. Pressue on the distal Wharton's duct from the lingual flange of a denture (Aframian 2001)
    5. Evaluated (at the University of Iowa) by ultrasound (Lecture Ultrasound Assisted Surgical Techniques (Hoffman) Mt Sinai May 5 2018) and frequently by sialography (Sialograms and Sialography)
  2. Autoimmune
    1. Sjogren's (primary, secondary = associated with other autoimmune disorder) (see: Sjogren's Syndrome)
    2. Graft v Host Disease aka "Sjogren's - like syndrome"
      1. Complication after transplantation: interaction of immunocompetent donor cells with recipient. Xerostomia similar to Sjogren's - may use lip biopsy to monitor
  3. Granulomatous Sialadenitis (Non-caseating)
    1. Sarcoidosis; parotid commonly affected. Heerfordt's: uveoparotid fever
    2. Crohn's disease
    3. Melkersson-Rosenthal syndrome
      1. "cheilitis granulomatosa Miescher"
    4. Granulomatous giant cell sialadenitis
    5. Xanthogranulomatous sialadenitis
    6. Wegener's granulomatosis
    7. Churg-Strauss granulomatosis
    8. Inflammatory pseudotumor
  4. Sialadenosis (Sialosis) see also: Sialosis or sialadenosis Case example of surgical treatment; and Sialosis - Radiology 
    1. Endocrine/Metabolic
      1. Acromegaly, Alcoholism, Diabetes insipidus, Diabetes mellitus, Hypothyroidism, Cirrhosis of the liver, Uraemia. 
    2. Drug induced
      1. Antihypertensives, Guanacline, Iodine, Isoprenaline, Lead, Mercury, Naproxen, Oxphenbutazone, Phenylbutazone, Sulfisoxazole, Thiocyanate, Thiouracil, Valproic acid
    3. Nutritional
      1. Beriberi, bulimia, gastrointestinal disease, malnutrition, pellagra, amylophagia, vitamin A deficiency
  5. Viral Sialadenitis
    1. Mumps (note recent article identifying that "72.3% of sporadic suspected mumps cases were not mumps cases" (Barrabeig et al 2015)
      1. Paramyxovirus: swelling 2-7 days/ systemic effects (orchitis in 25% of adult males)
      2. Mimics mumps
        1. Influenza, parainfluenza, coxsackie, CMV, adenovirus
        2. EBV (Barrabeig et al 2015)
        3. Human immunodeficiency virus
        4. Hepatits C virus
    2. Gland enlargement due to multiple lymphoepithelial cysts
  6. Bacterial Sialadenitis
    1. Parotid more commonly affected than SMG (?more bacteriostatic saliva in SMG)
    2. Related to decreased salivary flow / dehydration
  7. Paraglandular node infection
    1. Mycobacterial tuberculosis
    2. Atypical mycobacteria - M. avium-intracellulare and M. scrofulaceum.
  8. Tumor
    1. See Further Reading (below) for detailed discussion of benign/malignant process arising in parotid
      1. note occasional clinical presentation of Warthin's tumor or cystic mucoepidermoid carcinoma with a presentation that is more consistent with infection or ductal obstruction than tumor
      2. see Parotidectomy with Facial Nerve Dissection 
      3. see Submandibular Gland Resection
    2. Metastatic to periglandular nodes
    3. Lymphoma - MALT associated
  9. Masseter hypertrophy
    1. Impression of parotid swelling from underlying masseter enlargement
  10. Radiation (I131) I131 sialadenitis (Radioiodine Sialadenitis)
         i.   I-131 hones in on the salivary glands where it is concentrated and secreted into the saliva. May be associated with xerostomia and taste alteration.
  11. Miscellaneous (see Chen 2013)
    1. Iodide mumps
    2. Kimura disease
    3. General anesthesia
    4. Polycystic parotid disease
    5. Amyloidosis
    6. Pneumoparotitis
    7. Juvenile Recurrent Parotitis (see Schneider 2014 and Canzi 2013)
  12. IgG4 disease

History

  1. Non painful swelling versus painful (acute infectious, sialadenitis)
  2. Chronic versus acute swelling (inflammatory)
  3. Aggravating factors: Eating (Sialadenitis)
  4. Constitutional "B type symptoms" (HIV)
  5. Unilateral versus Bilateral (Viral parotitis, Sialadenosis)
  6. History of radioactive iodine treatment
    1. Radioactive iodine (I 131) targets the thyroid gland is utilized in the treatment of differentiated papillary and follicular cancers. Dose related damage to the salivary glands occurs secondary to 131I irradiation. Salivary gland swelling and pain may develop acutely or months later. Xerostomia with concomitant increase in dental caries, changing taste, infection, facial nerve involvement, stomatitis, and candidiasis. Treatment of the varied complications that may develop encompass numerous approaches and include gland massage, sialogogic agents, duct probing, antibiotics, mouthwashes, good oral hygiene, and adequate hydration
  7. History of Radiation treatment: sialadenitis
  8. History of Measles, mumps, rubella vaccine:
    1. Mumps associated with sensorineural hearing loss, infertility, encephalitis, pancreatitis, nephritis.
  9. History of Sarcoidosis:
    1. Heerfordt syndrome: uveitis, fever, parotid enlargement, facial palsy
  10. History of Sjogren's:
    1. Associated with dry mouth (xerostomia), dry eyes (keratoconjunctivitis sicca), abnormal taste, intermitted unilateral or bilateral salivary gland enlargement
    2. Can be in association with another connective tissue disorder such as Rheumatoid Arthritis, Systemic Lupus Erythematous, or Polyarteritis Nodosum.
  11. History of Tuberculosis:
  12. History of Gout: associated with sialolithiasis

Physical

  1. Inspection
    1. Unilateral or bilateral gland enlargement
    2. Skin/Mucosal lesions: cancer metastasis to glands
    3. Facial nerve involvement would increase malignant potential
  2. Palpation
    1. Warm skin: sialadenitis
    2. Tender: inflammatory condition is tender
    3. Salivary gland massage:
      1. purulent saliva: inflammatory, sialadenitis
      2. Decreased saliva
    4. Lymphadenopathy of neck

Diagnostic Imaging and Tests

  1. Salivary Ultrasound (see very detailed page with multiple links for examples including: Salivary ultrasound standardized diagnostic approach and report
    1. Distinct margins vs. Indistinct margins (suspicious for malignancy)
    2. Echogenicity - increased with malignancy, decreased with inflammatory lesions
  2. Fine Needle Aspirate:
    1. Indicated for discrete nodules: differentiates benign, malignant
    2. Controversial use: multiple passes dangerous to tumor seeding.
  3. Core needle biopsy
    1. Alternative if FNA cytology has failed to give a definitive diagnosis. Higher sensitivity, positive predictive value, and diagnostic accuracy compared to FNA in both benign and malignant lesions. Also decreased non diagnostic rates with low risk. ??Facial nerve?
  4. CT/MRI for dimensions
    1. Pre-operative evaluation
    2. CT: deep lobe parotid tumors
    3. MRI: parapharyngeal space, may differentiate neoplastic from inflammatory
  5. Sialograms and Sialography: Water soluble contrast injection into cannulated ducts to evaluate size, functional characteristics and ductal anatomy.
    1. Most accurate imaging method to detect calculi
    2. Contraindicated in acute infections
    3. Radiosialography evaluated dynamic activity via radioisotopic concentration in gland
      1. Increased uptake with Warthin's tumor, oncocytoma
  6. Sialendoscopy
    1. Minimal morbidity: Intraoral extraction without transverse cervical incision.  Also can be therapeutic.
  7. Blood Studies - directed by clinical presentation, can consider viral studies (mumps/EBV,HIV)
    1. Serologic tests for viral parotiditis: viral culture from urine, saliva, cerebrospinal fluid
    2. Sjogren's Syndrome: Rheumatoid factor, anti-nuclear antibody, autoantibodies SS-A, SS-B, ANA, ESR
    3. Wegener's Syndrome: Cytoplasmic antineutrophil cytoplasmic antibody (C-ANCA)

Surgical treatment

  1. Sialendoscopy
  2. Parotidectomy with Facial Nerve Dissection
  3. Case example Submandibular Gland Resection

Non Surgical Treatment

  1. Recurrent Parotitis
    1. Calculi or strictures produce sialectasis (dilation of salivary duct) with pain/swelling with eating
    2. May require parotidectomy if symptomatic
  2. Sialolithiasis:
    1. Caused by salivary stones, usually the submandibular gland because of longer length duct and salivary content
    2. Pain and swelling worse at mealtime
    3. Stones composed of hydroxyapatite, +/- radiolucency
    4. History of xerostomia or gout
    5. Colic relived by conservative management to increase salivary flow: rehydration, salivary gland massage, warm compress, sialogogues, and oral irrigations
    6. Stones within duct: sialodochoplasty
    7. Symptomatic with stone situated toward hilum: Sialendoscopy or submandibular gland resection.
  3. Chronic Recurring Sialadenitis:
    1. Risk Factors: repeat acute infections, trauma, radiation, immunocompromised state, smoking
    2. Exclude malignancy with CT scan
    3. Conservative management to increase salivary flow: rehydration, salivary gland massage, warm compress, sialogogues, and oral irrigations
    4. Salivary duct dilation, sialendoscopy
  4. Sjogren's Syndrome: Benign lymphoepithelial lesion, myoepithelial sialadenitis:
    1. Salivary gland swelling with xerostomia and keratoconjunctiva sicca sometimes in association with another connective tissue disease.
    2. Diagnosis with minor salivary gland biopsy with laboratory tests for autoantibodies.
    3. Symptomatic relief of xerostomia and xerophthalmia.
    4. Primary Sjogren's at high risk for development of malignant lymphoma
  5. Chronic Granulomatous Sialadenitis
    1. Sarcoidosis
      1. non-caseating granulomas
      2. Heerfordt syndrome: Uveoparotid syndrome
        1. Parotid enlargement, facial palsy, uveitis
    2. Wegener's Granulomatosis
      1. Acute unilateral mass +/- pain
  6. Sialadenosis
    1. Chronic, bilateral, diffuse, non-inflammatory, non-neoplastic, painless enlargement
    2. Associated with many other metabolic/medical conditions, see above.
    3. Treat underlying medical condition.
  7. Infectious Disease
    1. Acute Suppurative Sialadenitis:
      1. Salivary stasis caused by stones, dehydration, leads to stricture or obstruction of the ducts.
      2. Pain, erythema, swelling, with fever
      3. Post operative or elderly patients with chronic comorbidities. History of radiation or chemotherapy.
      4. Conservative management to increase salivary flow: rehydration, salivary gland massage, warm compress, sialogogues, and oral irrigations
      5. Antimicrobials (anti-staphylococcal) and culture if purulent discharge
      6. Submandibular abscess can mimic Ludwig's angina
    2. Viral Parotitis or Mumps:
      1. Bilateral painful swelling, malaise and trismus
      2. Supportive care with hydration and analgesics, usually self-limited
      3. Other manifestations: orchitis, pancreatitis, nephritis, encephalitis, meningitis, cochleitis
      4. Follow up: audiology, vaccine,
    3. Chronic Granulomatous Sialadenitis
      1. Tuberculosis:
        1. diagnosis: acid-fast staining for organisms, culture saliva, PPD skin test
        2. multi-drug anti-tuberculous medications
      2. Syphilis
      3. Benign Lymphoepithelial lesion (HIV association)
        1. also known as Godwin tumor, Mikulicz syndrome
        2. Inflammatory condition of parotid gland
        3. May present as painless bilateral salivary cysts possibly with associated cervical lymphadenopathy
        4. Known risk factors
        5. Treatment with fine needle aspiration: amylase in cyst fluid confirms diagnosis
      4. Actinomycosis
        1. May be acute or chronic, usually with history of dental trauma
        2. Anaerobic culture for diagnosis
        3. Treat with long-term penicillin therapy
      5. Cat-scratch disease: Bartonella henselae periparotid lymph nodes
        1. self-limited disease with supportive treatment

References

Fox PC, Hong CH, Brun AG and Brennan MT: Ch12 Diagnosis and Management of Autoimmune Salivary Gland Disorders" pp 201-219 in Salivary Gland Disorders eds Myers EN and Ferris RL Springer, Berlin 2007

Hoffman HT, Funk G, Endres D. Evaluation and Surgical Treatment of Tumors of the Salivary Glands, Chapter 54 (pp 1147-1182). In Comprehensive Management of Head and Neck Tumors, 2nd ed. 1999.

Ogren FP, Huerter JV, Pearson PH et al (1987) Transient salivary gland hypertrophy in bulimics. Laryngoscope 97:951-953

Susan J. Mandel, Louis Mandel. Radioactive Iodine and the Salivary Glands Thyroid. March 1, 2003, 13(3): 265-271.

Pratap R, Qayyum A, Ahmed N, Jani P, Berman LH. Ultrasound-guided core needle biopsy of parotid gland swellings. J Laryngol Otol.2008 Sep 30:1-4.

Pape SA, MacLeod RI, McLean NR, Soames JV.  Sialadenosis of the salivary glands.  British Journal of Plastic Surgery. (1995) 48:419-422.

Scully C, Bagan JV, Eveson JW, Barnard N, Turner F.  Sialosis: 35 cases of persistent parotid swelling from two countries.  British Journal of Oral and Maxillofaical Surger (2008) 46: 468-472

Fritsch MH: Algorithms for Treatment of Salivary Gland obstructions Without access to Extracorporeal Lithotripsy. Otolaryngologic Clinics of North America Volume 42, Issue 6, December 2009, pages 1193-1197 mfritsch@iupui.edu

Vitali C: Immunopathologic differences of Sjogren's syndrome versus sicca syndrome in HCV and HIV infection Arthritis Res Ther. 2011 Aug 19;13(4):23
KB, HH 11-29-08

Chen S, Benjamin C and Myssiorek D: An Algorithm Approach to Diagnosing Bilateral Parotid Enlargement  Otolaryngology – Head and Neck Surgery 148(5) 732-739

Canzi P, Occhini A, Pagella F, Marchal F, Benazzo M: Sialendoscopy in jurvenilt recurrent parotitis: a review of the literature. Acta Otorhinolaryngol Ital. 2013 Dec;33(66):367-73

Schneider H, Koch M, Kunzel J, Billespie MB, Grundtner P, Iro H, and Zenk J: Juvenile Recurrent Parotitis: A Retrospective Comparison of Sialendoscopy Versus Conservative Therapy Laryngoscope, 124:451-455,2014

Barrabeig I, Costa J, Rovira A, Marcos MA, Isanta R, Lopex-Adalid R, Cervilla A, Torner N, and Dominguez A:Viral etiology of mumps-like illnesses in suspected mumps cases reported in Catalonia, Spain. Hum Vaccin Immunother. 2015;11(1):282-7

Aframian DJ, Lustmann J, Fisher D, and Markitziu A: An unusual cause of obstructive sialadenitis. Dentomaxillofacial Radiology (2001) 30, 226-229