Salivary gland disorders

SALIVARY
GLAND
DISORDERS
Thilanka Umesh Sugathadasa(D/10/064)

Thilanka Umesh Sugathadasa Page 1
Non-neoplastic diseases of salivary glands including dry mouth
Classification
Non- neoplastic SG disorders
Congenital/
Developmental
Inflammatory
/Traumatic/
Ischemic
Infective Endocrine/
Metabolic
(Sialosis)
Autoimmune/
Benign
lymphoepithelial
Obstructive
Drug induced
 Aplasia/
Hypoplasia
 Agenesis
 Atresia of the
duct &
congenital
strictures
 Aberrancy
 Accessory
ducts & lobes
 Haemangioma
s
 Polycystic
disease of
parotid
 Stomatitis
nicotina
 Necrotizing
sialometapla
sia
 Cheilitis
glandularis
 Mucocele &
other cystic
lesions
 Bacterial
- Acute (Ascending)
sialadenitis
- Chronic non-specific
Sialadenitis(with or
without sialolithiasis)
- Chronic specific
sialadenitis(TB/
syphilis/ Sarcoidosis) &
granulomatous
inflammation.
- Recurrent subacute/
chronic sialadenitis(eg-
juvenile parotitis)
 Viral
- Mumps
- Mumps like diseases
(Cytomegalic inclusion
disease/ Coxaskie A
infection/ ECHO or
Lymphocytic
Choriomeningitis viral
infection)
- HIV induced SG
disease.
Painless
salivary
swellings
 Alcoholic
cirrhosis
 DM
 Acromegaly
 Malnutrition
 Chronic renal
failure
 Cystic fibrosis
 Sjogren’s
syndrome
 Chlorhexidin
e
 Isoprenaline
 Iodine
 Phenyl
butazone
 Sialolithiasis
 Strictures

Dry Mouth/ Xerostomia
Introduction
 This is significantly a patient perception.
 Dry mouth & Oral dryness are general terms that encompasses 2 medical entities
- Xerostomia (This is a symptom) – subjective complaints
- Hyposalivation – Objective reduction in salivary secretion
 Mainly occur due to decreased salivary flow or decrease composition of the saliva.
& there are many of other causes.
 So this is a subjective clinical condition due to absolute or relative reduction in amount of saliva
 Advancing of the age also increasingly associated with the dry mouth. But this is usually due to
medications & diseases.
Causes
Causes
Iatrogenic
1.Drugs
-Atropine
-Antidepressants : Tricyclic(eg:
Amitriptyline, Nortriptyline),
Selective serotonin reuptake
inhibitors
-Antihypertensive : Can also cause
the compositional changes of the
saliva as well as the changes of the
flow rate.
- Antihistamines
- Opioids
- Cytotoxic drugs
-Antiemetics
2.Irradiation(External irradiation
doses above 40 Gy & Iodine 131)
3.Graft versus host reaction
Physiological Diseases of Salivary
glands
Dehydration
Psychogenic(Anxiety,
Depression)
Post exercise/ mouth breathing
 Salivary aplasia
 Sjogren’s syndrome
 Sarcoidosis
 Parotidectomy
 Cystic fibrosis
 Ectodermal
dysplasia
 Infections
 Controlled
diabetes
 CRF
Mouth breathing due to nasal
polyp, etc
When doing presentation or
social speech.

Clinical features of dry mouth
Symptoms
1. Sensation of burning.
2. Swallowing difficulty(Eating difficulty of dry foods “cracker sign”)
3. Stability & retention of dentures become low
4. Speaking difficulty(Clicking quality speech due to tongue sticking to
the palate)
5. Sensation of taste reduction
6. Increase incidence of dental caries & periodontal disease.
7. Infection
8. Recurrent ulceration
9. Tongue or check getting accidental bitten frequently.
Signs
1. Dryness of the lips & oral mucosa.
2. Pale & corrugated buccal mucosa.
3. Lack of salivary pooling in floor of the mouth.
4. Atrophy/ inflammation/ fissuring/ cracking/ of tongue
5. Erythema/ Ulceration
6. Infections
7. Lipstick sign
8. Crackers sign
9. Tongue blade sign
10. Increase levels of dental caries & periodontal disease.
11. Mucosa tends to stick to the dental mouth mirror & dry
Complications of dry mouth
Soft tissue changes Hard tissue changes Other
 The mucosal tissues may
become painful,
“Burning”, dry & atrophic.
 Cracked lips.
 Soreness & redness due to
candidosis.
 Ascending suppurative
sialadenitis.
 Tingling sensation of the
mouth.
 Angular cheilitis
 Severe & uncontrolled
dental caries
 Marked increase in erosions
especially in the non-
carious risk areas & the root
surfaces, & even in the cusp
tips.
 Caries may be progressive
even with the excellent oral
hygiene.
 Difficulty in speaking.
 Difficulty in swallowing especially
dry foods.
 Reduced denture retention.
 Reduced taste sensation.
 Painful salivary gland enlargement.
 Increased thirst.
 Increase uptake of the fluids when
eating.
 Periodontal disease?
 Halitosis
Dry mouth
patient can be
classified in to
3 types
Those having
asymptomatic
hyposalivation,ie reduction
in the salivary secretion
not significant enough to
cause xerostomia.
Those with
symptomatically significant
hyposalivation, thus
suffering from xerostomia.
Those suffering from
xerostomia but with no
evident decrease in salivary
secretion

Diagnosis & Ix
Diagnosis is mainly by the combination of the
- Hx
- Ix
- Clinical features.
Investigations
Salivary function studies
1. Salivary flow rate
2. Sialography
3. Salivary scintiscanning
Other
1. Lacrimation flow – exclude sjogren's syndrome
2. Urinanalysis – exclude DM
3. Blood tests
ESR – exclude Sjorgren’s syndrome or sarcoidosis
antinuclear antibodies – exclude Sjorgren’s syndrome or sarcoidosis.
Rheumatoid factor – Exclude Sjorgren’s syndrome
Serology – Viral disease
Serum calcium & phosphate – exclude hyperparathyroidism.
4. Imaging
CXR –exclude Sarcoidosis
Ultrasonography – exclude Sjorgren’s syndrome or Neoplasia
MRI –exclude Sjorgren’s syndrome
5. Bx
Biopsy is taken if there is a suspicion about the organic disease of the salivary glands. Here
always possible to take biopsy from the major salivary glands but usually perform the minor SG
Bx due to risks of nerve damage, scars. So usually preferable site is the lower labial mucosa.
Management
Can divide in to 3 categories
1. Symptomatic Rx
2. Preventive Rx
3. Curative Rx
Salivary flow over a 24-hour period
Sleep
40 ml saliva will be produced over 7 hours
Awake
300 ml of unstimulated saliva over 16 hours
200 ml of stimulated saliva during meals over 54 minutes

Symptomatic Rx Preventive Rx Curative Rx
(- Directed at alleviating or minimizing complaints associated
with decreased salivation. Range from simple methods of
hydration & lubrication to systemic secretagogues to stimulate
the salivary function)
 Non sugar containing fluids & frequent small
sips of them. Helps to hydrate the mucosa &
removal of retained debris
 Avoids fluids containing sugars.
 Humidifiers specially closer to bed at night
(Can use jug of water)
 Lip moisturizers & emollients.
 Penetrating creams are preferred over the
petroleum based products.
 Avoid dry foods.
 Avoiding spicy foods, alcohol & strong
flavoring may reduce oral mucosal sensitivity.
 Avoid mouth rinses with high alcohol content.
(Listerine), which can induce mucosal
irritation & sensitivity.
 Mechanical, local saliva induce with sugarless
candy, gums or rinses.
disadvantages of local stimulants
- short lived
- Frequent application can be inconvenient.
- Citric acid may irritate the oral mucosa.
- continue use may contribute to
demineralization.
 Systemic sialologues
- Only use for the patients who have salivary
tissues that can be stimulated.
- Pilorcarpine hydrochloride-
parasympathomimetic agonist that increase
exocrine output.
- Most widely tested sialagogue.
- Recommended dose = 5mg tds
- Cevimeline hydrochloride – similar to
Pilorcarpine. (This product can’t use in high in
high conc as it containing metals.)
 Salivary replacement products (Substitute)
commonly containing Carboxymethylcellulose
or hydroxycellulose as lubricants, artificial
sweeteners, preservatives, chloride &
Fluorides
(- To limit the consequences of
salivary gland hypofunction on oral
& dental tissues)
 Increase oral hygiene
measures.
 Professional care.
 Oral application of topical
fluorides to minimize the
dental caries risk.
 If bacterial infection is
identified, appropriate
antibiotics should be
identified. It may require
prolonged therapy.
 If swelling which is not
due to infection a short
course of steroids are
beneficial.
 NSAIDs are not helpful
 If candidal infection
presents use topical or
systemic antifungals
prolongly
those antifungals should
not contain sugars.
Composition of the
artificial saliva
- Carboxymethylcellulose
10g/L(Keep the watery
content of saliva)
- Sorbitol 30mg/L
- Sodium chloride
- Magnesium chloride
- Calcium chloride
- Dipotasium hydrogen
phosphate
 Disadvantages
- Regular use is
inconvenient.
- More viscous than the
natural saliva so feel odd.
- Expensive
- No antimicrobial & other
protective functions.
(Managing underlying cause
or symptoms)
 If dry mouth is due
to drugs,
stopping/changing
drugs if possible, in
consultation with
patient’s physician.
 If possible
alternative drug.
 Identify the cause
by history,
examination &
further
investigations & Rx
- Secretagogues can
provide transient
relief but will not
address the
underlying cause.
- Patients may leave
with gradual
decline in function
over time &
worsening the
symptoms & signs.

Mx of the Xerostomia can be presents as
1. Replacement of saliva
2. Avoidance of harmful effects.
3. Prevention of oral disease
4. Stimulation of the residual secretory capacity.
5. Curative Rx.
Replacement of saliva
 Frequent sips of water
 Glycerol & Thymol or Glycerol & lemon
 Luborant- Methyl cellulose based products
 Glandosane - ;;
 Above having enough hydration but not enough lubrication
 Saliva orthana is having (Mucin- based products) better
lubrication properties
Avoidance of harmful effects
 Dry and cariogenic foods.
 Tobacco smoking and alcohol intake
 Alter treatment with medicaments if there are any medicines
which cause dry mouth.
 Avoid wearing dentures at night
Prevention of oral disease
 Meticulous (careful) oral hygiene.
 Dietary advice
 Topical F-
 Chlorhexidine mouth wash 0.2%
 Antifungal agents
Stimulation of the residual secretory capacity
 Sugar free chewing gums
 Saliva orthana lozenges(release Mucin)
 Pilorcarpine tablets 5mg tds
 Pilorcarpine eye drops 0.5- 1% also can be swallowed (2-4 drops)
every 4 hours.
 Other drugs (Anethole trithione, yohimbine, neostigmine)

Condition Features & etiology Clinical features/ Ix &
Diagnosis
Mx
Sjogren’s
syndrome
 An autoimmune inflammatory
disorder
 Immunologically mediated chronic
inflammatory disorder of exocrine
glands mainly affecting salivary,
lacrimal glands.
 Common in the middle aged Females.
 Two types present
- Primary SS (sicca syndrome)-:
Dry eyes (Keratoconjunctivitis/
xerophthalmia) & dry mouth.
- Secondary SS-:
Dry eyes, Dry mouth & connective
tissue disorder (RA, SLE, Systemic
sclerosis, mixed CT disease, primary
biliary cirrhosis)
 Causes
- Genetic predisposition
- Hormones
- Inflammatory events
- Auto antibodies
- Liver disease
- Processes mediating salivary gland
dysfunction.
-Viruses
 A benign autoimmune inflammatory
exocrinopathy (epithelitis) directed
against alpha fodrin, a cytoskeletal
protein involved in actin binding, with
lymphocyte-mediated destruction of
salivary, lacrimal and other exocrine
glands. Tumor necrosis factor (TNF),
interferon (IFN) and B cell activating
factor (BAFF) are implicated. A viral
etiology, possibly human retrovirus 5
(HRV-5), and a genetic predisposition
May be implicated. A SS type of
disease may follow HIV, EBV, HCV, or
Helicobacter pylori infection, or graft-
versus-host disease.
Symptoms
Mouth
 Xerostomia is the main
problem. But only some
have unpleasant taste.
 Angular cheilitis
 Pus discharge from the
ductal orifices.
 Unilateral/ Bilateral
intermittent enlargement
of salivary glands mainly
parotids.
 Thick frothy saliva, later
stage with loss of saliva
pooling.
 Glazed, dry mucosa that
tend to form wrinkles.
 Redness/soreness of the
mucosa due to candida
infection.
 Lobulated, reddish,
partial/complete
depapillated tongue with
reduced no of taste buds
 Gross accumulation of
plaque
 Several dental caries
including root caries.
 Periodontal diseases
 Recurrent attacks of the
acute bacterial
sialadenitis: SS is the most
common cause for the
acute bacterial
sialadenitis.
 Enlarged tender regional
lymph nodes.
Signs
 Unpleasant taste
 Difficulty in eating
 Soreness of the mouth.
 Difficulty in speech.
 Most patients
are treated with
symptomatically
 Oral hygiene
improvement
 Mx of dry mouth
 Mx of dry eyes
 Agents against
CD20(B
lymphocyte
surface antigen)
SS is
characterized by
glandular
lymphocytic
infiltration
 As curative Rx
most of the time
Systemic
steroids,
cyclosporines,
Methotrexate,
etc…using

Rheumatic Diseases associated with
Sjogren’s’ syndrome
- RA
- SLE
- Progressive systemic sclerosis
- Mixed CT disease.
- Dermatomyositis.
- Polyarteritis nodosa.
- Reynaud’s phenomenon.
Immunologically related diseases
associated with SS
- 1ry biliary cirrhosis
- Chronic active hepatitis
- Autoimmune thyroid disease
- Pemphigus vulgaris
- Coeliac disease
- Myasthenia gravis
- Graft versus host disease
Eye
 Sensation of dryness
 Burning sensation
 Redness
 Frequent conjunctival
infections
 Ulceration
 Also dryness of pharynx,
larynx, and genital areas
also may present.
 CT disorders clinical
features also can present
in the 2ry SS.
Radiological features
1. Multiple sialectasias
(snow storm app) in
sialogram with atrophy
of ductal system
delayed emptying of
dye.
2. Impaired salivary
activity seen in salivary
scintiscanning
Reduced sialometry &
abnormal sialochemistry.
Positive ose Bengal staining
test & schirmer test

Diagnosis
Dry mouth
Reduced salivary flow (measured by sialometry)
with dry eyes (measured by Schirmer test)
Biopsy of labial salivary glands
(> 1 focus of lymphocytes in 4 mm2
Laboratory test
ANA, ENA ,SS-A and SS-B
No Yes
Sicca syndrome
and
Positive Negative
Sjögren’s syndrome
Others, autoimmune
diseases associates
No Yes
2ry SS
If biopsy of labial salivary
glands – positive(> 1 focus
of lymphocytes
in 4 mm2)
review some months later
syndrome and ask for
laboratory test in a
Consider an incomplete
form of Sjogren’s
Primary SS

Diagnostic criteria (American-European) for Sjögren’s syndrome.
I
Ocular symptoms
A positive response to at
least one
of the following questions:
(1) Have you had daily ocular symptoms or
persistent, troublesome dry eyes
For more than three months?
(2) Do you have a recurrent sensation of
sand or gravel in the eyes?
(3) Do you use tear substitutes more than 3
times a day?
II
Oral symptoms
A positive response to at
least one
of the following questions
(1) Have you had a daily feeling of dry mouth
for more than 3 months?
(2) Have you had recurrently or persistently
swollen salivary glands as an adult?
(3) Do you frequently drink liquids to aid in
swallowing dry food?
III
Ocular signs
That is, objective evidence
of ocular
involvement defined as a
positive
result for at least one of:
In minor salivary glands
(obtained
through normal-appearing
mucosa).
(1) Schirmer test, performed without
anesthesia (< 5 mm in 5 minutes).
(2) Rose-Bengal score or other ocular dye
score (> 4 according to van
Bijsterveld’s scoring system).
Focal lymphocytic sialadenitis evaluated
by an expert histopathologist, with
a focus score > 1, defined as a number
of lymphocytic foci (which are adjacent
to
normal-appearing mucous acini and
contain more than 50 lymphocytes)
per 4 mm2 of glandular tissue.
IV
Histopathology
V
Salivary gland
Involvement
Objective evidence of
salivary gland
involvement, defined by a
positive
result for one of the
following:
(1) Unstimulated whole salivary flow ≤
1.5 ml in 15 minutes.
(2) Parotid sialography showing the presence
of ductal sialectasis (punctate,
cavitary or destructive pattern) without
evidence of obstruction in the major
ducts.
(3) Salivary scintigraphy showing delayed
uptake, reduced concentration and/or
delayed excretion of tracer.
VI
Autoantibodies
Presence in the serum of the
following autoantibodies:
Antibodies to Ro (SS-A) or La (SS-B) antigens,
or both

For the diagnosis of primary SS:
In patients without any potentially associated disease, primary SS may be defined as follows:
 The presence of any 4 of the 6 items is indicative of primary SS, as long as either item IV
(histopathology) or VI (serology) is positive
 The presence of any 3 of the 4 objective criteria items (that, is items III, IV, V, VI)
 The classification tree procedure represents a valid alternative method of classification,
although it should be more properly used in clinical “epidemiological survey
For the diagnosis of secondary SS:
 In patients with a potentially associated disease (for instance, another well-defined connective
tissue disease), the presence of item I or item II plus any 2 from among items III, IV, and V may
be considered as indicative of secondary SS
Exclusion criteria:
1. Past head and neck radiation treatment
2. Hepatitis C infection
3. Acquired immunodeficiency disease (AIDS)
4. Pre-existing lymphoma
5. Sarcoidosis
6. Graft versus host disease
7. Use of anticholinergic drugs (since a time shorter than 3-fold the half-life of the drug).

Obstructive disorders
Condition Features & etiology Clinical features/ Ix & Diagnosis
Sialolithiasis(S
alivary gland
calculi or
stones)
 Calculi composed of
laminated layers of
organic materials covered
with concentric shells of
calcified materials.
 Mainly hydroxyapatite
crystals containing
octacalcium phosphate.
 Etiology & pathogenesis
Nuerohumoral
mechanisms
Metabolic
mechanisms(eg: presence
of existing inflammation)
 Common in the
submandibular
glands(80%)
10% in the parotid gland.
 Reasons for higher
prevalence of sialoliths in
the SMG
Physiological factors
- Saliva more alkaline
- Presence higher conc of
Calcium & Phosphate
- Higher mucus content
- Richness in phosphatase
enzyme.
- Low content of Co2
Anatomical factors
- Longer duct
- anti gravity flow(position
of the gland)
- Smaller orifice than the
ductal luman.
- Irregular course of duct.
 Middle aged people with slight male predilection
 Size can vary from few mm to several cm.
 Intraglandular sialoliths cause less problems to the
patients than extraglandular/ ductal sialoliths.
 Symptoms
- Sometimes there are no any symptoms
- Meal time swelling (due to increase demands)
- Moderate pain(due to increase pressure)
- fever & malaise due to infections (If untreated)
 Signs
- Pus discharge through the orifice
- Severe inflammation in the soft tissues.
- Overlying mucosa may be ulcerated.
- Sialoliths may be palpated if it presents in the
extraglandular portion.
- Reduce salivary flow
- Enlargement of the glands.
 Radiological features
- Radiolucent calculi(Here 80-90% of SMG calculi are
radio-opaque & 50-80% of parotid calculi are
radiolucent.)
- Solitary or Multiple(30% of the SMG stones are
multiple & 60% of the parotid stones are multiple)
- Usually oval shape & is cylindrical with multiple layers
of calcifications.
 Sialography is indicated when sialoliths are radiolucent,
Here we can see easily the ductal dilatation & the
sialodochitis.
 Radiological DD
- Hyoid bone
- Myositis ossificans
- Phleboliths
- Calcific submandibular lymph nodes
- Gas bubble in sialography
 Plain radiographic views
Parotid
- DPT
- Oblique lateral/ Rotated PA or AP
Intraoral view of the cheek to show the duct using an
occlusal radiographs
SMG
-DPT/ Oblique lateral
- Lower 900
occlusal
- Lower oblique occlusal(to show the gland)

Diagram of submandibular sialogram.
The subsidiary duct descending from the angle of the
jaw to join the angle of the main duct is very
constant.
Sialolithiasis.
Diagram of parotid sialogram. There are usually
three ascending ducts as well as the duct of the
socia, if present, and one or two descending ducts
depending on the size of the gland. Several small
retromandibular ducts drain the deep, part
of the gland.
Sialolithiasis.
Sialadenitis showing pus from Stensen duct
.
Dormaia basket
Tiny apparatus consisting of four
wires that can be advanced
through an endoscope to the body
cavity or tube, manipulated to trap
a calculus or other object,&
withdrawn
Used in the bile duct & the ureter

Management of the sialolithiasis
Traditional Mx of the
sialolithiasis
Non-surgical Mx of the sialolithiasis
 Ductal dilatation
 Incision & dissection
 Sialadenectomy(Do
when the gland has
fibrosed)
Side effects of the
sialoendoscopy
1. Transient glandular
swelling
2. Ductal strictures
3. Lacerations
4. Basket block
5. Infections
6. Temporary parasthesia
7. Bleeding
8. Ranula formation
 Interventional radiology
Various techniques are using
- coronary angioplasty
balloon
- Wire loop
- Embolectomy catheter
Under fluoroscopy guidance
Best method is the
fluoroscopically guided stone
retrieval (success rate 40-100%)
Main complications are
Gland swelling
Infections
Main limitation is the
administration of ionizing
radiation.
 Antibiotics if acute infection is present
 Increase salivation & allow stone to come out through
orifice.
 Manual manipulation(milking)
E/O & I/O palpation behind the calculi in to the orifice.
 Lithotripsy(shock wave)- sialolithotripsy
- Introduced in 1989
- Noninvasive method of fragmenting the stones in to
smaller portions to allow possible flushing out
spontaneously.
- stone fracture by producing a compressive wave that
spread through calculus & expansive wave that pit stone &
induce cavitations
- shock wave can be generated
Extra-corporeally using piezoelectric or
electromagnetic techniques
Intra-corporeally using electro-hydrolic, pneumatic or
laser endoscopic techniques
 Sialoendoscopy
- First used to diagnosis but now also used for the calculi
removal.
- First describe in 1991
- Rigid, semi rigid, or moderately flexible endoscopes
presents with different diametres.
- Equipped with working channels & irrigation ports
- Main problem is the entering through orifice
- this problems are overcome by
Dilatation with lacrimal probes/ guiding wires
Papillotomy with CO2 laser
Microsurgical dissection of anterior duct(ductal cut
down)
Graspers, miniforceps, dormaia baskets & balloons to
remove stone
- Not indicated if the calculi is located deeply inside the
gland or embedded in wall.
- Success rate is around 89% for submandibular & 83-86%
for parotid calculi
- Also effective in removing mucus plugs, foreign bodies,
polyps & granulation tissue.
- Contraindicated if there is complete distal obliteration of
duct.
- insertion of the sialostent averts recurrences

Infective conditions
Condition Features & etiology Mx & Diagnosis
Acute bacterial
sialadenitis(Ascen
ding)
 Definition
Sialadenitis due to bacterial infection
ascending from the oral cavity.
 Prevalence (approximate): Rare.
 Age mainly affected: Older adults.
 Gender mainly affected: M = F.
 Etiopathogenesis: The organisms most.
commonly isolated in ascending sialadenitis
are Streptococcus viridans and
Staphylococcus aureus
(often penicillin-resistant). The parotid glands
are most commonly affected
 Causes
Host factors
- Decreased host resistance
- salivary secretion & bacterial effects
- Composition of the saliva
- Calculi, Mucus plugs, duct strictures
Other predisposing factors
- After radiotherapy to the head & neck.
- In Sjogren’s syndrome
- Occasionally in the GI surgery due to
dehydration & dry mouth.
 Clinical features
Symptoms
- Painful & tender enlargement in the gland
-Trismus
- Pain in TMJ region.
-Fever
- Taste disturbances
Signs
- The overlying skin can be redded.
- Pus exuding from, or in milked form through
the parotid duct orifice
- Become hot, indurated & tender on
percussion.
- Can spread to the surrounding tissues also.
- Leucocytosis
- Malaise
 Diagnosis
Pus should be sent for a
culture & ABST
 DD
Parotitis/ Submasseteric
abcess
Deep parotid abcess vs Otitis
media
 Mx
- Must treat aggressively as
it can cause death in
debilitated patient, even
with antibiotics
- Improvement of oral
hygiene
- Pus for culture & ABST
- High dose of parental
antibiotics against
staphylococcus.
(flucloxacillin or
amoxicillin/ clavulanate if
staphylococcus and not
allergic to penicillin;
erythromycin or
azithromycin in penicillin
allergy).)
- Improve hydration
- Maintain electrolyte
balance.
- Analgesics.
- soft diet as chewing is
painful to the patient.
- Stimulate salivation to
facilitate drainage of pus
- If there is no improvement
drainage of the affected
gland.
- Lemon juice suction for
promote salivary flow.

Chronic bacterial
sialadenitis
 Definition: Chronic salivary gland infection.
 Prevalence (approximate): Rare.
 Age mainly affected: Older adults.
 Gender mainly affected: M = F.
 Etiopathogenesis: May develop after salivary
calculus formation or acute sialadenitis,
particularly if inappropriate antibiotics are
used, or predisposing factors not eliminated.
Serous acini atrophy when salivary outflow is
chronically obstructed, further reducing saliva
secretion.
 Usually caused by streptococcus viridans
 Recurrent forms are due to duct obstruction,
congenital stenosis, Sjogren’s
syndrome,Allergy or previous viral infection
 Salivary flow is accompanied by the flecks of
purulent material
 Fibrosis of gland after several recurrences
causing reduced salivary flow
-Single, swollen, firm , non-tender salivary
gland
 Differential diagnosis:
Calculus, neoplasm.
 Diagnosis is from clinical
features, and imaging
(radiography, MRI,
ultrasonography).
 Mx
- Intraductal injection of
antibiotics
- Ligation of duct to induce
fibrosis.
- Radiotherapy to induce
fibrosis but this increase the
risk of head & neck cancers.
- Total removal of the gland
Radiological features
- Multiple ectasias &
dilatations of main excretory
duct in sialogram
- Multiple cavitations in the
USS
Juvenile recurrent
parotitis
 Definition
Repeated parotitis &sialectasis in a child,
associated with a sialographic pattern of
sialectasis
 Prevalence (approximate): Uncommon.
 Age mainly affected: Usually begins in pre-
school children.
 Gender mainly affected: M > F.
 Etiopathogenesis: Congenital or autoimmune
duct defects.
 Symptoms
- Intermittent pain,
- Unilateral parotid swelling which lasts
< 3weeks with spontaneous regression.
- It may occur simultaneously or alternately
contra- laterally.
- fever
 Signs
- parotid swelling
 DD
Sjorgren’s syndrome
 Diagnosis is mainly on
clinical grounds but serum
anti-SS-A and SS-B
antibodies are indicated to
exclude Sjögren's syndrome,
and imaging
with ultrasonography and CT
scan or sialography showing
sialectasis is confirmatory
 Mx
 In- patients hospital
admission if condition
warrants
 Culture & ABST(from salivary
exudate)
 Appropriate antibiotics.
 High fluid intake.
 Lemon juice suction to
promote salivary flow

Chronic sclerosing
sialadenitis(Kuttn
er’s tumor)
 Commonly seen in SMG
 Is a chronic inflammatory disease of major
salivary glands causing fibrosis & firm tumor
like enlargement of the gland.
 Due to ductal calculi causing subsequent
bacterial infection resulting chronic
inflammation, acinar destruction &
replacement fibrosis.
 Radiological features
- Multiple globular
sialectasias in sialogram.
- Sialodochitis (sausage like
appearance of ducts) in
sialogram.
- Absence of terminal
branches & presence of
constricted ductal lumens.
- Multiple cavitations with
reduced echogenicity in USS.
Granulomatous
diseases of
salivary
glands(Chronic
specific
sialadenitis)
 Main one is Sarcoidosis which produce Heerfordt’s syndrome
 Features of the Heerfordt’s syndrome are
- Uveitis of the eye
- Salivary gland swelling
- Facial palsy
Mumps
 This is the most commonest & important
condition.
 Acute contagious viral infection
 Characterized by bilateral/ unilateral gland
enlargement.
 Mainly affects the major salivary glands but
also can affects testis, meninges, pancreas,
heart & mammary glands.
 Also called endemic parotitis
 Caused by paramyxovirus
 Endemic in most urban population
 Airborne infection
- more common in boys & often between 5-15
years of age.
- Incubation period is 2-3 weeks
- Prodromal symptoms(Onset of headache,
chills, moderate fever, vomiting, pain below
ear & last about 1 week)
- Parotids are usually affected & mostly
bilateral.
- SMG is less commonly involved & when
affected have less swelling & pain.
 Symptoms – Prodromal symptoms followed by
sudden onset of painful salivary gland swelling
without purulent discharge from duct.
 Signs- Elevation of ear lobe, Firm/ rubbery/
elastic gland enlargement., Puffy & reddened
papilla.
 No antiviral therapy or
antibiotics advocated.
 Bed rest & isolation
 Hydration with plenty of
fluid intake.
 NSAIDs(ibuprofen)
for children’s: Ibuprofen
syrup 100mg/5ml

Asymptomatic
enlargement
(Sialosis/
Sialadenosis)
 Non- neoplastic, non- inflammatory enlargement of the salivary glands
 Usually bilateral & may presents as recurrent painless enlargements.
 Commonly in parotids in males.
 Associated with systemic conditions such as cirrhosis, diabetes, thyroid
insufficiency, alcoholism & malnutrition
 Alteration occurs in the chemical composition of saliva.
 Significant elevation of salivary potassium & decrease in sodium.
Sialorrhea
(Ptyalism)
 Increase salivary secretions occurs.
 2 types
- True Sialorrhea: Rare, may be due to rabies,
metal poisoning, inflammatory lesion in the
mouth
- Pseudo Sialorrhea: Common in
infants(drooling), Neuromuscular problems,
Down’s syndrome, paralysis, Mental handicaps
 Etiology
- Drugs
- Local factors such as stomatitis, erythema
multeforme & ANUG
- Systemic disease such as rabies, paralysis,
alcoholic neuritis, epilepsy, Down’s syndrome,
Neuromuscular disorder
- Miscellaneous causes such as psychic
factors, metal poisoning & facial paralysis
- Excessive production or inadequate
swallowing due to neuromuscular in-
coordination.
- Affected individuals may need several cloths
- Emotional & physical impairment.
- Infections due to chronic exposure to saliva
- Ulceration & cheek scarring due to recurrent
infections & necrosis of tissues.
 Botulinum toxin injection is
an effective method
 Cause selective chemical
denervation by blocking
neurotransmitter release at
the cholinergic
parasympathetic nerve
terminals of the salivary
glands. So secretory
capacity of the gland is
reduced.
 Botulinum toxin therapy is
also used to treat sialocele
& chronic & recurrent
parotitis.
Diseases of minor salivary
glands
 Mucocele
 Nicotinic Stomatitis
 Necrotizing
sialometaplasia
 Neoplasms

Tree in winter appearance(normal appearance of the parotid gland)

Brush in winter appearance (SMG)
Sjorgren’s syndrome
Sialadenitis
Sialadochitis(Sausage link appearance)

Salivary gland disorders

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