Disorders of the Salivary Glands
The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, be-neath the lips. About 1200 mL of saliva are produced daily. The glands’ primary functions are lubrication, protection against harmful bacteria, and digestion.
Parotitis (inflammation of the parotid gland) is the most commoninflammatory condition of the salivary glands, although inflam-mation can occur in the other salivary glands as well. Mumps (epi-demic parotitis), a communicable disease caused by viral infection and most commonly affecting children, is an inflammation of a salivary gland, usually the parotid.
Elderly, acutely ill, or debilitated people with decreased sali-vary flow from general dehydration or medications are at high risk for parotitis. The infecting organisms travel from the mouth through the salivary duct. The organism is usually Staphylococcusaureus (except in mumps). The onset of this complication is sud-den, with an exacerbation of both the fever and the symptoms of the primary condition. The gland swells and becomes tense and tender. The patient feels pain in the ear, and swollen glands in-terfere with swallowing. The swelling increases rapidly, and the overlying skin soon becomes red and shiny.
Preventive measures are essential and include advising the pa-tient to have necessary dental work performed before surgery. In addition, maintaining adequate nutritional and fluid intake, good oral hygiene, and discontinuing medications (eg, tranquilizers, di-uretics) that can diminish salivation may help prevent the condi-tion. If parotitis occurs, antibiotic therapy is necessary. Analgesics may also be prescribed to control pain. If antibiotic therapy is not effective, the gland may need to be drained by a surgical procedure known as parotidectomy. This procedure may be necessary to treat chronic parotitis.
Sialadenitis (inflammation of the salivary glands) may be causedby dehydration, radiation therapy, stress, malnutrition, salivary gland calculi (stones), or improper oral hygiene. The inflam-mation is associated with infection by S. aureus, Streptococcusviridans, or pneumococcus. In hospitalized or institutionalizedpatients the infecting organism may be methicillin-resistant S. aureus (MRSA) (McQuone, 1999). Symptoms include pain,swelling, and purulent discharge. Antibiotics are used to treat infections. Massage, hydration, and corticosteroids frequently cure the problem. Chronic sialadenitis with uncontrolled pain is treated by surgical drainage of the gland or excision of the gland and its duct.
Sialolithiasis, or salivary calculi (stones), usually occurs in the sub-mandibular gland. Salivary gland ultrasonography or sialography (x-ray studies filmed after the injection of a radiopaque substance into the duct) may be required to demonstrate obstruction of the duct by stenosis. Salivary calculi are formed mainly from calcium phosphate. If located within the gland, the calculi are irregular and vary in diameter from 3 to 30 mm. Calculi in the duct are small and oval.
Calculi within the salivary gland itself cause no symptoms un-less infection arises; however, a calculus that obstructs the gland’s duct causes sudden, local, and often colicky pain, which is abruptly relieved by a gush of saliva. This characteristic symptom is often dis-closed in the patient’s health history. On physical assessment, the gland is swollen and quite tender, the stone itself can be palpable, and its shadow may be seen on x-ray films.
The calculus can be extracted fairly easily from the duct in the mouth. Sometimes, enlargement of the ductal orifice permits the stone to pass spontaneously. Occasionally lithotripsy, a proce-dure that uses shock waves to disintegrate the stone, may be used instead of surgical extraction for parotid stones and smaller sub-mandibular stones. Lithotripsy requires no anesthesia, sedation, or analgesia. Side effects can include local hemorrhage and swelling. Surgery may be necessary to remove the gland if symptoms and calculi recur repeatedly.
Although they are uncommon, neoplasms (tumors or growths) of almost any type may develop in the salivary gland. Tumors occur more often in the parotid gland. The incidence of salivary gland tumors is similar in men and women. Risk factors include prior exposure to radiation to the head and neck. Diagnosis is based on the health history and physical examination and the results of fine needle aspiration biopsy.
Management of salivary gland tumors evokes controversy, but the common procedure involves partial excision of the gland, along with all of the tumor and a wide margin of surrounding tissue. Dis-section is carefully performed to preserve the seventh cranial nerve (facial nerve), although it may not be possible to preserve the nerve if the tumor is extensive. If the tumor is malignant, radiation therapy may follow surgery. Radiation therapy alone may be a treatment choice for tumors that are thought to be contained or if there is risk of facial nerve damage from surgical intervention. Chemotherapy is usually used for palliative purposes. Local re-currences are common, and the recurrent growth usually is more aggressive than the original. It has also been observed that pa-tients with salivary gland tumors have an increased incidence of second primary cancers (Bull, 2001).
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