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Sialectasis

last modified on: Thu, 05/02/2019 - 03:33

return to: Salivary SwellingParotid Sialogram - Sialectasis

 

  1. GENERAL CONSIDERATIONS
    1. Definition
      1. "Dilation of a salivary duct" (ptyalectasis) from [sial- + Gr. ektasis, a stretching]
      2. A condition resulting from duct obstruction of the parotid or submandibular glands associated with pain and swelling. (see also: Salivary Swelling)
  2. Etiology
    1. Recurrent sialadenitis
    2. Multifactorial cause for recurrent sialadenitis
      1.  Primary pathophysiological process is a decrease in the parotid salivary secretion, both volume and flow rate.(ref Motamed 2003)
      2. Causes of reduction in saliva
        1. Obstruction: Stones,strictures of the duct or, external pressure on the main duct (tumor), mucus plugging, and congenital abnormalities of the duct.
        2. Other: Radiation damage and immune-mediated diseases.
      3. A decrease in salivary secretion results in stasis with retrograde bacterial contamination of the ductal system.
      4. Bacterial infection may lead to destruction and fibrosis of gland architecture of acinar elements and ductal ectasia.
        1. Acute suppurative sialadenitis - singular acute event may precipitate others or progress to chronic sialadenitis 
        2. Chronic sialadenitis is more common and often progressive
          1. Sialolithiasis is both a cause and a consequence of chronic recurring sialadenitis (ref Travis 1977)
  3. Diagnosis
    1. History of recurrent painful parotid swelling
    2. Physical exam: swollen gland, 'milking the gland' may produce thickened secretions from duct orifice.
    3. Consider blood studies to evaluate auto-immune evaluation: rheumatoid factor, ANA, SS-A, SS-B antibodies.
    4. Radiographic imaging  (see: Parotid Sialogram - Sialectasis)
      1. Ultrasound: advantages - potential for concurrent U/S guided FNA; absence of radiation exposure; inexpensive
      2. MRI: advantages: best study for anatomic definition of salivary glands for tumor, absence of radiation exposure; evolving technology permits 'MRI sialogram"
      3. CT: controversy w/ or w/o contrast - currently at UIHC: employ contrast; best for defining lymphadenopathy
      4. Sialogram: useful to identify stones - best definition of intraductal architecture; occasionally proves therapeutic as well as diagnostic (duct dilation, 'flushing out gland') (ref Gerry RG 1955)
    5. Sialendoscopy
  4. Management 
    1. Conservative management
      1. Antibiotics / analgesics / mouthwashes / sialogogues / massaging the gland
        1. Antibiotic options cover Staph aureus: Augmentin, clindamycin (ref Motamed 2003)
        2. Mouthwashes? 
    2. Failing conservative management
      1. Decision to intervene surgically is dependent on the requests of an informed patient and the clinicians successful correlation of symptoms with the pathologic process of sialectasis. Facial pain in the absence of classic swelling associated with meals may be caused by processes other than salivary disorders.
        1. Option: Have the patient keep a log book of the swelling episodes and pain intensity.  
        2. Counsel re: gland removal as an invasive but usually (not always) successful approach with an emphasis on alternatives
    3. Published alternative approaches not currently in common use
      1. Duct ligation
      2. Methyl violet (one percent solution) instillation into gland (ref Zou 1992)
      3. Radiotherapy
      4. Tympanic neurectomy. (ref Vasama 2000)
    4. Sialendosocpy with duct dilation and instillation of steroid/antimicrobial
    5. Botulinum toxin type A injection to the gland.
      1. Successful case report from Europe (employing (Dysport) injection under ultrasonographic control into 10 separate injection sides into the left parotid gland. (ref Guntinaas-Lichius O 2002)
      2. Long-lasting, possible irreversible atrophy of parotid gland acini by chemodenervation with botox conclude: "successful alternative for the tx of chronic parotid sialectasis"
    6.  Parotidectomy is a reasonable option with published reports indicating complete resolution of symptoms in 8 out of 10 patients with improvement, but minor persistence of symptoms in 2 out of 10 (ref Sadeghi 1996)
      1. Supeficial parotidectomy
      2. Total parotidectomy
      3. Near-total parotidectomy
  5. SUGGESTED READING
    1. Guntinaas-Lichius O, Jungehulsing M: Treatment of chroinic parotid sialectasis with botulinum toxin A Laryngoscope 2002 Mar;112(3):586-7.
    2. Sadeghi N, Black MJ, Frenkiel S: Parotidectomy for the treatment of chronic recurrent parotitis. J Otolaryngol 1996 Oct;25(5):305-7.
    3. Motamed M, Laugharne D, and Bradley: Management of chronic parotitis: a review. J Laryngol Otol  2003 Jul;117(7):521-6.
    4. Travis LW, Hecht DW. Acute and chronic inflammatorydiseases of the salivary glands: Diagnosis and management. Otolaryngol Clin North Am 1977;10:329--38.
    5. Gerry RG, Seigman EL. Chronic siladenitis and sialography. Oral Sur 1955;8,453-78
    6. Zou ZJ, Wang SL, Zhu JR, Wu QG, Yu SF. Chronic obstructive parotitis. Report of ninety-two cases. Oral Surg Oral Med oral Path 1992;73:434-440
    7. Vasama JP. Tympanic neurectomy and chronic parotitis. Acta Otolaryngol 2000;120:995-8
    8. Bates D, O'Brien CJk, Tikaram K, Painter DM. Parotid and submandibular sialadentitis treated by salivary gland excision. Aust New Zealand J Surg 1998;68:120-4