Sialadenitis

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Sialadenitis(Sialoadenitis)
Micrograph showing chronic sialadenitis. H&E stain.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2]

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Overview

Sialadenitis is a condition of inflammation of a salivary gland. The causes of sialadenitis include bacterial and viral infections such as mumps and HIV, obstruction from stones or radiation, and autoimmune disorders such as Sjogren's syndrome. The complications of sialadenitis include recurrence, abscess, and chronic sialadenitis. Sialadenitis must be differentiated from other diseases that cause swelling in salivary glands, such as sialolithiasis, human immunodeficiency virus, radiation, and systemic diseases such as, sarcoidosis, and sjögren's syndrome. History from the patient will reveal symptoms of sialadenitis that include fever, and difficulty in opening the mouth. The diagnosis of choice is a high resolution CT scan. Sialoendoscopy can be used in the diagnosis of small stones and differentiate them from polyps. Conservative treatment is the first line of therapy in the most patients and it involves Hydration, applying moist heat, massaging the gland, duct milking, discontinuation of medication that decrease the saliva flow, such as the TCAs because of their anticholinergic effects, and antibiotics usage for the infection. Preferred regimen Dicloxacillin 500 mg q 6h PO for 7 to 10 days or Cephalexin 500 mg q 6h PO for 7 to 10 days.

Historical Perspective

The historical perspective of sialadenitis is as follows:[1]

  • In 17th century, major salivary gland ductal system in anatomical human studies was first reported.
  • In 1990, , Konigsberger et al. performed the first successful salivary endoscopy.[2]
  • In 2004, Zenk et al. reported the use of semirigid sialendoscope in different types of obstructive salivary disorders.[3]
  • In 2006, Nahlieli et al. described sialendoscopy in the management of radioiodine sialadenitis.[4]

Classification

  • There is no established system for the classification of sialadenitis, but may be classified according to location of the stone.[5]
Gland Percent of stones
Submandibular glands 80 to 90 
Parotid glands 6 to 20
Sublinguals or minor salivary glands 1 to 2

Pathophysiology

  • Sialadenitis is a condition of inflammation of a salivary gland. [6]
  • Swelling is usually present in this condition.
  • Acute sialadenitis may be caused by viral or bacterial infection[7]
    • Parotid and submandibular glands are more involved in acute sialadenitis. approximately 10% sialadenitis cases are related to involvement of submandibular gland.
  • Chronic sialadenitis is caused by repeated episodes of inflammation and finally it progresses in to salivary gland dysfucntion.

Causes

Common causes of sialadenitis include the following:

Bacterial and viral infections[8]

  • Mumps
  • HIV
  • Staph aureus
  • Streptococci
  • Pseudomona aeruginosa
  • Escherichia coli
  • Moraxella catarrhalis
  • Tuberculosis[9]

Obstruction

  • Stones
  • Radiation
  • Strictures
  • Sarcoidosis

Autoimmune disorders

  • Sjogrens

Differentiating sialadenitis from Other Diseases

Diseases Symptoms and sign Laboratory Findings Other Findings
Onset Unilateral/Bilateral Pain Swelling Tenderness Purulent discharge Common site of involvement ESR Leukocytosis
Sialolithiasis Acute Unilateral + + + - Submandibular gland ↑/NL ↑/NL Radio-opaque in X-ray
Acute bacterial sialadenitis Acute Unilateral + + + + Parotid Other sign of infection may be present
Chronic bacterial sialadenitis Chronic Unilateral + + - +/- Parotid Other sign of infection may be present
Viral sialadenitis Acute Bilateral + + + - Parotid Coryza symptoms
Human immunodeficiency virus Acute Bilateral + + - - Parotid NL NL Other systemic findings of HIV/ check ELIZA
 Radiation sialadenitis Acute Unilateral + + + - Depends on the treatment field NL NL History of radiation in the salivary gland site
Salivary gland tumors Subacute Unilateral - + - - Parotid ↑/NL ↑/NL Advance age
Sarcoidosis Gradual Bilateral - + - - Parotid Systemic findings in other organs
Sjögren's syndrome Gradual Bilateral +/- + - - Parotid or submandibular glands ↑/NL ↑/NL Dry eye/dry mouth
Malnutrition Gradual Bilateral +/- + - - Parotid NL NL Systemic findings in other organs

Epidemiology and Demographics

  • The exact prevalence of submandibular sialadenitis is unclear.
  • The incidence of acute sialadenitis is approximately 27.5 per 1,000,000 individuals in United Kingdom.[18]
  • Patients of all age groups may develop sialadenitis.
  • Sialadenitis commonly affects older, dehydrated patients.

Risk Factors

Common Risk Factors

Common risk factors in the development of sialolithisis which can lead to sialadenitis include:[19]

Screening

There is insufficient evidence to recommend routine screening for sialadenitis.

Natural History, Complications, and Prognosis

Natural History

  • If left untreated, patients with sialadeitis may progress to develop secondary infection and chronic sialadenitis including gland atrophy.[21]

Complications

  • Common complications of sialadenitis include:[22]
    • Recurrence
    • Abscess
    • Cellulitis

Prognosis

  • Prognosis is generally good with fluid management and antimicrobial therapy, but edema in the gland may persist for several weeks. [16]

Diagnosis

Diagnostic Criteria

Computed tomography
  •  High resolution noncontrast computed tomography (CT) scanning is the study of choice for the diagnosis of sialadenitis.[23]
    • Most stones contain enough calcium, so they can be visible on noncontrast CT scan.
  • The following results are seen in acute obstructive due to sialolithiasis after administration of contrast:
    • The gland may appear enlarged
    • Hyperdensity of gland with stranding
  • In chronic sialolithiasis, fatty atrophy and reduction in salivary gland parenchymal volume may be seen.

The comparison table for diagnostic studies of choice for sialolithiasis

The sensitivity and specificity of CT scan and ultrasonography in a patient with sialadenitis is given below:[24]

Sensitivity Specificity
CT scan 98% 88%
Ultrasound 65% 80%

History and Symptoms

A positive history of swelling of the affected gland and pain is suggestive of acute sialadenitis. The most common symptoms of sialadenitis include fever and difficulty in opening the mouth.[22]

  • A positive history of pain, swelling, overlying skin redness, and hard lump is suggestive of sialadenitis.

Common symptoms of chronic sialadenitis are similar to acute sialadenitis but with less intensity.

Physical Examination

Vital Signs

  • Vital signs are usually normal, but fever may be seen in sialadenititis as a complication of sialolithiasis.[7]

HEENT

Normal salivary gland is spongy.

In sialadenitis:[25][26]

  • Tenderness of the involved gland
  • Palpable hard lump near the end of the involved duct or under the tongue in submandibular duct stone.
    • Stones, sometimes may be felt smooth or irregular.
  • In total obstruction, no saliva is being produced from the duct.
  • Erythema of the floor of the mouth
  • Pus discharging from the duct
  • Stone in the minor salivary glands can be felt as a small nodule
  • Stones are typically rock hard and small; they may be smooth or irregular. They are most commonly felt within the ductal system.

Neck

  • Cervical lymphadenitis in cases of infection

Laboratory Findings

Electrocardiogram

There are no ECG findings associated with sialadenitis.

X-ray

  • An x-ray may be helpful in the diagnosis of sialadenitis. Findings on an x-ray suggestive of sialadenitis include:[27]
    • Radiopaque stones: 43-60% of the parotid stones and 80-95% of the submandibular stones are radiopaque and can be seen in x-ray.

Ultrasound

  • Ultrasound may be helpful in the diagnosis of sialadenitis. Findings on ultrasound diagnostic of sialadenitis include:[28][29][30]
    • Hyperechoic points or lines with distal acoustic shadowing.
      • Small stones less than 2 mm may not have shadow
    • Ultrasound can detect stones that are radiolucent
    • In acute obstructive cases due to sialolithiasis, ther excretory duct may be dilated.
  • Ultrasound is done with intra oral probes.

CT scan

Head and neck CT scan is the study of choice for the diagnosis of sialadenitis.[23][24][27]

  • Most stones contain enough calcium, so they can be visible with noncontrast CT scan.
  • The following results are seen in acute obstructive due to sialolithiasis after administration of contrast:
    • The gland may appear enlarged
    • Hyperdensity of gland with stranding
  • In chronic sialolithiasis, fatty atrophy and reduction in salivary gland parenchymal volume may be seen.

MRI

  • Magnetic resonance sialography may be helpful in the diagnosis of sialadenitis. Findings on magnetic resonance sialography suggestive of sialadenitisinclude:[31][32][28]
    • Stones are visible as low signal regions outlined by saliva (high signal regions) on T2 weighted images.
  • Acute from chronic obstruction can be distinguished by magnetic resonance sialography on T1 signals:
    • In acute obstruction, enlargement of the gland and inflammatory changes may be seen as reduced signal compared to other side.
    • In chronic cases, size of the gland is decreased and fatty atrophy may be seen as an increased signal compared to the other side.

Other Imaging Findings

Conventional sialography may be helpful in the diagnosis of sialadenitis. Findings on sialography suggestive of sialadenitis include:[28][33]

  • Filling defect within the duct
  • In complete obstruction, contrast can not pass beyond the stone

Sialography is contraindicated in active infection of the involved gland.

Sialography is replaced by CT scan and ultrasound.

Other Diagnostic Studies

  • There are no other diagnostic studies associated with sialadenitis.

Treatment

=Medical Therapy

  • Certain individuals with chronic bacterial infections not responding to appropriate conservative and antibiotic measures may require either radiation or removal of the affected gland to control its symptoms.The prognosis of acute sialadenitis is very good. Most cases are easily treated with conservative medical management, and admission is the exception, not the rule. Acute symptoms resolve within 1 week; however, edema in the area may last for several weeks

Conservative treatment is the first line of therapy in the most patients. The most commonly used treatment options are:[10]

  • Hydration
  • Apply moist heat
  • Massage the gland
  • Duct milking
  • Using agents that increase the saliva flow, such as lemon drops.
  • Discontinue of the medication that decrease the saliva flow, such as the TCAs because of their anticholinergic effects.
  • Pain control with NSAIDs, or opioid analgesics, if needed.
  • Antibiotics usage in the case of superimposed infection:
    • Preferred regimen(1): Dicloxacillin 500 mg q 6h PO for 7 to 10 days.
    • Preferred regimen(2): Cephalexin 500 mg q 6h PO for 7 to 10 days.
  • If the patients clinics did not change in five days of using above antibiotics, change to:
  • Duct discharge should be used for culture.
  • Many cases of sialadenitis can not be cured by using medical therapy alone; invasive, or open surgery methods can be used for salivary gland stones. The interventional methods are discussed in the sialadenitis surgery page.

Surgery

The mainstay of treatment for acute siladenitis is medical therapy. Surgery is not the first-line treatment option for patients with acute siladenitis. Surgery is usually reserved for patients with abscess that do not respond to medical therapy.[34]

Surgical resection of involved gland in chronic bacterial sialadenitis may be considered if it does not respond to medical therapy. [22]

Minimally invasive management

Sialoendoscopy

  • Sialoendoscopy can be used in the diagnosis of small stones, and differentiate them from polyps.[35]
  • In the case of no response to medical management, sialoendoscopy can be done. The treatment result using sialoendoscopy, mostly depends on the size of the stone.

Laser lithotripsy

  • Can be used before sialoendoscopy in order to fragment salivary stones.[12]

Stone removal with wire baske

  • Removal of stones using a wire basket extractor under fluoroscopic guidance.[36]

Surgical intervention 

If all of above methods fails, surgical intervention can be used.[13]

  • For the submandibular stones, a transoral approach can be used.
  • In some proximal submandibular stones, a combination of sialoendoscopic and open intraoral techniques, may be used.
  • For parotid stones, if sialoendoscopy did not worked, open surgery should be done.

Primary Prevention

  • Effective measures for the primary prevention of sialadenitis include:[19]
    • Healthy oral care regimen ( brushing teeth)
    • Increased water intake
  • There are no available vaccines against sialolithiasis

Secondary Prevention

Effective measures for the secondary prevention of acute sialadenitis include hygiene and repeated massaging of the gland when tenderness had subsided. [22][17][1]

References

  1. Erkul, Evren; Gillespie, M. Boyd (2016). "Sialendoscopy for non-stone disorders: The current evidence". Laryngoscope Investigative Otolaryngology. 1 (5): 140–145. doi:10.1002/lio2.33. ISSN 2378-8038.
  2. Lydiatt, Daniel D.; Bucher, Gregory S. (2012). "The historical evolution of the understanding of the submandibular and sublingual salivary glands". Clinical Anatomy. 25 (1): 2–11. doi:10.1002/ca.22007. ISSN 0897-3806.
  3. Zenk, J; Koch, M; Bozzato, A; Iro, H (2004). "Sialoscopy—initial experiences with a new endoscope". British Journal of Oral and Maxillofacial Surgery. 42 (4): 293–298. doi:10.1016/j.bjoms.2004.03.006. ISSN 0266-4356.
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  20. Ship JA (2002). "Diagnosing, managing, and preventing salivary gland disorders". Oral Dis. 8 (2): 77–89. PMID 11991308.
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  23. 23.0 23.1 Ellies, Maik; Laskawi, Rainer; Arglebe, Christian; Schott, Anngrit (1996). "Surgical management of nonneoplastic diseases of the submandibular gland". International Journal of Oral and Maxillofacial Surgery. 25 (4): 285–289. doi:10.1016/S0901-5027(06)80058-5. ISSN 0901-5027.
  24. 24.0 24.1 Thomas WW, Douglas JE, Rassekh CH (2017). "Accuracy of Ultrasonography and Computed Tomography in the Evaluation of Patients Undergoing Sialendoscopy for Sialolithiasis". Otolaryngol Head Neck Surg. 156 (5): 834–839. doi:10.1177/0194599817696308. PMID 28457224.
  25. Hupp, James (2008). Contemporary oral and maxillofacial surgery. St. Louis, Mo: Mosby Elsevier. ISBN 9780323049030.
  26. Neville, Brad (2002). Oral & maxillofacial pathology. Philadelphia: W.B. Saunders. ISBN 0721690033.
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  29. Witt, Robert (2005). Salivary gland diseases : surgical and medical management. New York: Thieme. ISBN 1588904148.
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  31. Sumi M, Izumi M, Yonetsu K, Nakamura T (1999). "The MR imaging assessment of submandibular gland sialoadenitis secondary to sialolithiasis: correlation with CT and histopathologic findings". AJNR Am J Neuroradiol. 20 (9): 1737–43. PMID 10543651.
  32. Becker M, Marchal F, Becker CD, Dulguerov P, Georgakopoulos G, Lehmann W, Terrier F (2000). "Sialolithiasis and salivary ductal stenosis: diagnostic accuracy of MR sialography with a three-dimensional extended-phase conjugate-symmetry rapid spin-echo sequence". Radiology. 217 (2): 347–58. doi:10.1148/radiology.217.2.r00oc02347. PMID 11058627.
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  34. Gallo A, Benazzo M, Capaccio P, De Campora L, De Vincentiis M, Fusconi M, Martellucci S, Paludetti G, Pasquini E, Puxeddu R, Speciale R (2015). "Sialoendoscopy: state of the art, challenges and further perspectives. Round Table, 101(st) SIO National Congress, Catania 2014". Acta Otorhinolaryngol Ital. 35 (4): 217–33. PMC 4731883. PMID 26824208.
  35. Drage NA, Brown JE, Escudier MP, McGurk M (2000). "Interventional radiology in the removal of salivary calculi". Radiology. 214 (1): 139–42. doi:10.1148/radiology.214.1.r00ja02139. PMID 10644113.



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