Describe the diseases of the salivary glands.

Anatomy and Inflammatory Disease

• The major salivary glands are the parotid, submandibular and sublingual, with hundreds of minor glands throughout the upper aerodigestive tract.
• Their diseases are obstructive, inflammatory, neoplastic or systemic.
• The parotid is serous, and its duct (stensen’S) opens opposite the upper second molar. It is divided into superficial and deep lobes by the facial nerve.
• The gland has NO true capsule superiorly and is enclosed in the parotid fascia, which is why parotitis causes such severe pain as the gland swells within an unyielding sheath
• The submandibular gland is mixed (seromucous), and its duct (wharton’S) opens at the floor of the mouth beside the frenulum
• Wharton’s duct runs uphill against gravity, is longer, and its secretion is more viscid and alkaline with a higher calcium content — which is exactly why 80% of salivary calculi form in the submandibular system.
• The sublingual gland is mucous and drains by multiple small ducts
• Sialolithiasis (salivary calculi) presents with painful swelling at mealtimes — mealtime syndrome — which settles over an hour or two afterwards. That history is close to diagnostic
• Examine by bimanual palpation of the floor of mouth, which frequently detects a stone that no imaging was needed to find
• Investigation — plain radiograph (80% of submandibular stones are radio-opaque, but only about half of parotid stones); ultrasound; sialography, which is contraindicated in acute infection; and CT or MR sialography
• Treatment — conservative measures first: hydration, sialogogues (lemon drops, chewing gum), gland massage, warm compresses and analgesia.
• Intraoral removal of a palpable distal stone; sialendoscopy with basket retrieval or laser lithotripsy.
• Acute suppurative parotitis occurs in the dehydrated, elderly, postoperative or debilitated patient, with staphylococcus aureus, and presents with a tender, red, swollen gland with pus expressible from the duct
• Treatment — rehydration, which is the key; antistaphylococcal antibiotics; sialogogues and massage; and drainage where an abscess forms, incising parallel to the facial nerve branches
• It is largely preventable by attention to hydration and oral hygiene in the ill and postoperative
• Mumps — paramyxovirus, the commonest cause of bilateral parotid swelling in a child, with orchitis, oophoritis, pancreatitis, meningitis and sensorineural hearing loss as complications; prevented by MMR vaccination
• Other inflammatory conditions — recurrent parotitis of childhood.

Systemic Disease, Xerostomia and Investigation

• Sjogren syndrome — an autoimmune exocrinopathy causing dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia), either primary or secondary to rheumatoid arthritis or another connective tissue disease
• Features — recurrent or persistent parotid swelling, dryness, difficulty with dry food and speech, dental caries, and oral candidiasis
• Investigation — anti-Ro (SSA) and anti-La (SSB) antibodies, ANA and rheumatoid factor; schirmer test; minor salivary gland (labial) biopsy.
• The important complication IS lymphoma — there is a substantially increased risk of malt and other non-hodgkin lymphoma, so a persistently enlarging or hard gland in a patient with Sjogren syndrome must be investigated, not attributed to the disease
• Management — symptomatic: artificial tears and saliva, pilocarpine, meticulous dental care and fluoride, treatment of candidiasis, and management of the systemic disease
• Sialadenosis (sialosis) — painless, bilateral, symmetrical parotid enlargement without inflammation, associated with alcoholism, diabetes, malnutrition, bulimia, acromegaly and drugs; treatment is of the underlying condition
• Xerostomia (dry mouth) deserves separate mention because it is common and under-treated
• Its causes — drugs.
• Its consequences are underestimated — rampant dental caries, candidiasis, difficulty with speech, chewing and swallowing, altered taste, denture intolerance, and a genuine reduction in quality of life
• Management — review and change the drugs where possible.
• FROEY (auriculotemporal) syndrome — gustatory sweating and flushing over the parotid region while eating, following parotid surgery or trauma, caused by aberrant regeneration of parasympathetic secretomotor fibres into the divided sympathetic supply of the sweat glands
• It is confirmed by the minor’S starch-iodine test and treated with topical antiperspirants, topical glycopyrrolate or botulinum toxin.