Salivary Gland Emergencies

• The three pairs of major salivary glands are the parotid, the submandibular and the sublingual glands. In addition, there are many smaller minor salivary glands spread throughout the oral hemorrhage and oropharyngeal mucosa.
• When evaluating and treating salivary gland disease, it is important to be familiar with the local anatomy in order to prevent injury and rule out involvement of vital surrounding structures.
• The parotid gland lies just anterior and inferior to the ear. It is drained by Stensen’s duct that empties into the oral cavity adjacent to the second maxillary molar. The gland is in close proximity to the lateral pharyngeal space, and its investing fascia is contiguous with the deep fascia of the neck. The facial nerve, facial trauma courses through the gland.
• The submandibular gland is medial to the mandible adjacent to the mylohyoid muscle and above the hypoglossal nerve. The mandibular branch of the facial nerve is in close proximity to the gland. The submandibular duct (Wharton’s duct) runs along the base of the mouth and opens at the floor of the mouth lateral to the frenulum of the tongue.
• The smaller sublingual glands are located in the anterior floor of the mouth just beneath the oral mucosa. These glands are drained by numerous ducts that open into the floor of the mouth. One or more ducts also open into the submandibular duct.

Salivary gland inflammation has numerous etiologies including infection and conditions that lead to salivary stasis or decreased saliva production.

Mumps

• Mumps occurs most frequently in persons < 15 yr of age but is also seen in older adolescents and adults. Younger patients tend to have a more benign course.
• The parotid glands are most commonly affected.

  Etiology of sialoadenitis

  Viral	Mumps (most common viral etiology), CMV, Coxsackie, ECHO, influenza
  Bacterial	S. aureus (most common bacterial etiology), S. pneumoniae, E. coli, anaerobes
  Granulomatous	Tuberculosis, other mycobacteria Actinomycosis Cat-scratch disease Sarcoidosis
  Autoimmune	Sjogren’s syndrome
  Obstruction	Sialolithiasis Neoplasm Ductal strictures
  Decreased saliva	Dehydration/malnutrition/dehabilitation
  Production	NPO/postoperative status Radiation Systemic: endocrine disorders, uremia, CHF Medications
  CMV-cytomegalovirus; ECHO-enteric cytopathic human orphan virus; NPO-nothing by mouth; CHF-congestive heart failure; * Includes analgesics, antihistamines, phenothiazines, anticholinergics, etc.

• Patients experience a prodrome of fever, headache and myalgias followed by unilateral or bilateral parotid pain and swelling. Parotid swelling may not appear until after other prodromal symptoms have completely resolved. Examination reveals tender and enlarged glands. In contrast to bacterial disease, there are no purulent secretions and the saliva will be clear. Patients are infective for up to a week after resolution of symptoms.
• Complications include pancreatitis, meningitis, encephalitis, sensorineural deafness and orchitis. Gonadal involvement in prepubertal patients is rare. However, up to 30% of older males have orchitis. Mumps orchitis is usually unilateral and sometimes occurs in the absence of parotid disease. Infertility is rare even in cases of subsequent testicular atrophy.
• Treatment is supportive with hydration and analgesics.
• Having mumps is thought to confer immunity for future episodes although rare recurrences have been documented.

• As with mumps, bacterial infection usually involves the parotid gland. The other salivary glands are thought to produce saliva with greater bacteriostatic activity.
• Most patients are debilitated elderly with dehydration. A significant number of patients (up to 40%) are postoperative.
• The most common causative organism is S. aureus. Disease is believed to be secondary to salivary stasis with movement of oral flora into the gland.
• Patients complain of acute onset of gland swelling and pain. Bilateral involvement occurs in up to 20% of cases.
• Examination reveals a tender, warm, enlarged gland. Patients are febrile and possibly septic. Purulent secretions are expressed from the involved duct unless it is totally obstructed.
• Initial antibiotic therapy should cover penicillin-resistant S. aureus and anaerobes. Treatment is then tailored as necessary based on results of Gram stain and culture of secretions. Additional treatment includes IV hydration, analgesics, warm compresses and massage of the involved gland. Surgical therapy by ENT should be considered for persistent symptoms.

• Salivary gland calculi occur most frequently in the submandibular gland presumably secondary to higher mucus content of the saliva and the long, upwardly directed duct. Parotid stones are less common, and sublingual stones are rare.
• Most cases are idiopathic although gout is a known cause.
• The majority of patients are middle-aged adults with men being affected more often.
• Patients present with sudden onset of pain and enlargement of the involved gland that begins after food intake. The gland is tender to palpation, and it is sometimes possible to palpate a calculus along the course of Stensen’s or Wharton’s duct. If the obstruction is subacute or chronic, evidence of secondary infection is also noted.
• Diagnosis is made clinically. The majority of submandibular gland calculi are radiopaque. Soft tissue radiographs provide diagnostic confirmation and help localize the calculus. Most parotid calculi are radiolucent. More specialized radiology studies such as contrast sialography, ultrasound or CT scan are available but are rarely indicated in acute cases of uncomplicated disease.
• Treatment consists of analgesics and sialogogues such as lemon drops. When secondary infection is suspected, begin empiric coverage for S. aureus. If the calculus is located in the distal portion of the duct, it may be possible to manually express it from the ductal orifice. Patients with sialolithiasis require prompt ENT follow-up. Surgical excision of the gland is required for recurrent cases or persistent proximally located stones.