Salivary benign disoders

Question 1

Which salivary gland is most susceptible to acute bacterial sialadenitis?

Answer 1

The parotid gland

Question 2

Which population groups are most commonly

affected by acute suppurative sialadenitis?

Answer 2

Patients who are medically debilitated, postoperative, and/

or patients with severe dehydration

Question 3

Which surgical patients are most commonly

affected by acute suppurative sialadenitis?

Answer 3

Patients who have undergone major abdominal surgery and
hip replacement/repair, likely a result of poor oral intake attributable to their debilitated state, are most commonly
affected.

Question 4

Why does the saliva produced by the parotid gland
make this gland more prone to sialadenitis
compared with the submandibular and sublingual
glands?

Answer 4

Parotid saliva is mostly serous compared with the mucinous
saliva produced by the submandibular and sublingual
glands. Serous saliva lacks antibodies, acid, and enzymes
with antimicrobial properties.

Question 5

In hospitalized patients, what is the most commonly cultured organism in acute suppurative sialadenitis?

Answer 5

Staphylococcus aureus

Question 6

When is imaging of acute suppurative parotitis recommended?

Answer 6

Imaging is indicated after failure to respond to antibiotics or
if signs, symptoms, and physical examination raise concern
for a parotid abscess.

Question 7

What is the best initial treatment of acute

suppurative sialadenitis?

Answer 7

Empiric antibiotics with both aerobic and anaerobic coverage, sialagogues, warm compresses, parotid massage, pain medication, and rehydration

Question 8

What is the recommended treatment of a parotid

abscess?

Answer 8

Surgical drainage through a standard parotidectomy
exposure is recommended. When making incisions in the parotid fascia, it should be done parallel to facial nerve
branches to minimize risk of damage to the nerve.

Question 9

What is the most common symptom that raises concern for sialolithiasis?

Answer 9

Pain and swelling of the salivary glands, especially associated with eating.

Question 10

Which salivary gland carries the highest risk for salivary calculi formation?

Answer 10

The submandibular gland is the most common location of salivary calculi as a result of increased calcium concentration, higher pH, more mucinous saliva, and potential anatomical factors (e.g., length, gravity).

Question 11

What imaging options are available for diagnosis of sialolithiasis?

Answer 11

There are many choices. Plain X-ray offers little extra
information other than the presence of a radiopaque stone.
Sialography can give information on strictures, dilations, or
filling defects of the ductwork. Ultrasound can be done if a
radiolucent stone is suspected. CT often offers the most
complete information.

Question 12

Which salivary calculi are most often radiopaque on standard X-ray?

Answer 12

Submandibular stones. 80% of parotid stones are radiolucent.

Question 13

What are the treatment options for sialolithiasis?

Answer 13

Conservative treatment is a valid option. This includes
sialagogues, heat, massage, and increased hydration. For larger stones that will not pass with conservative measures,
bedside sialotomy, sialendoscopy, or lithotripsy are options.
Gland excision is final treatment option for refractory disease.

Question 14

What is the number one cause of chronic

sialadenitis?

Answer 14

Parotid duct obstruction secondary to sialolithiasis

Question 15

What is the best treatment for chronic sialadenitis?

Answer 15

No treatment is consistently successful. Antibiotics, massage, warm compresses, and sialagogues may be tried.
Ultimately, if conservative measures fail, the affected gland
should be surgically resected.

Question 16

Patients with chronic sialadenitis should be monitored for what serious condition?

Answer 16

Patients with chronic sialadenitis are at an increased risk for
salivary duct carcinoma.

Question 17

When should sialorrhea be managed as an abnormal condition in the pediatric population?

Answer 17

Sialorrhea is associated with the balance of oral control of secretions and swallowing. Up until about 18 months of age, sialorrhea is a normal event because of poor neuromuscular control. If it is still present by 4 years of age, a patient should undergo further workup.

Question 18

What other medical conditions are associated with

sialorrhea?

Answer 18

Conditions associated with poor neuromuscular control,
which cause difficulty swallowing secretions, can be associated with sialorrhea, most commonly in children with cerebral palsy. It is also seen in adults with amyotrophic
lateral sclerosis, Parkinson disease, and history of stroke.

Question 19

How can sialorrhea be treated medically?

Answer 19

Anticholinergics such as oral glycopyrrolate and topical scopolamine can be helpful with careful consideration of
the many side effects of these medications. Botulinum injections of the salivary glands are also used but require
repeated injections.

Question 20

Describe the side effects of anticholinergic medications.

Answer 20

Urinary retention, increased body temperature/decreased
perspiration, tachycardia, xerostomia (increased risk of dental caries), vision changes, confusion, respiratory suppression, mydriasis, and constipation are all common side effects of anticholinergics.

Question 21

What are the surgical options for treatment of sialorrhea?

Answer 21

Removal of salivary tissue can be done via bilateral submandibular gland excision and parotid duct ligation.
Transection of the chorda tympani can also decrease
salivary output. The submandibular and parotid ducts can
be rerouted to decrease output into the oral cavity.

Question 22

Define the difference between sialorrhea and ptyalism.

Answer 22

These terms are often used interchangeably. By strict definition, though, sialorrhea means excessive flow of saliva.
Usually, it is secondary to administration of medications such as antipsychotics, anticonvulsants, anticholinesterases,
or other parasympathomimetic medications. Excessive flow can also be related to medical conditions such as pregnancy, gastroesophageal reflux disease, and oral
ulceration/irritation. Ptyalism is the act of drooling and the
excessive production of saliva. Historically, it is most commonly used in pregnancy as ptyalism of pregnancy.

Question 23

What is the most common cause of xerostomia?

Answer 23

By far, the most common cause is medication side effect.

Question 24

What is one of the most important preventative
treatments to reduce complications of xerostomia
from head and neck radiation?

Answer 24

Topical fluoride and excellent oral hygiene are used to

prevent the formation of dental caries because saliva is protective of the teeth.

Question 25

What drug is used to treat xerostomia?

Answer 25

Pilocarpine, a parasympathomimetic drug that acts on the M3 acetylcholine muscarinic receptor

Question 26

Describe the three stages of radiation-induced sialadenitis.

Answer 26

● Stage 1: Acute response of salivary glands to lower dose
(20 to 30 Gy). Self-resolution is expected.
● Stage 2: Functional loss of glandular tissue with higher
doses (up to 75 Gy). Nonrestorative.
● Stage 3: Chronic changes with high-dose radiation
(> 75 Gy). Cirrhotic changes with complete glandular
atrophy. Nonrestorative.

Question 27

Describe Mikulicz syndrome.

Answer 27

Mikulicz syndrome involves bilateral salivary gland swelling
that is not associated with another systemic disease.
Specifically, it is distinct from salivary swelling associated
with Sjögren syndrome.

Question 28

What are the clinical signs and symptoms of

sialadenosis?

Answer 28

Sialadenosis is characterized by bilateral, recurrent, painless
parotid gland swelling, unrelated to food intake.

Question 29

What are the histologic findings in sialadenosis?

Answer 29

On histology, one would expect to find enlarged acinar cells
(up to three times normal), degenerative neural changes,
and myoepithelial atrophy.

Question 30

What are the three categories for the development of sialadenosis?

Answer 30

● Endocrine-related sialadenosis (e.g., diabetes mellitus, acromegaly, adrenal disorders, hypothyroidism, pregnancy)
● Dystrophic-metabolic sialadenosis (e.g., pellagra, beri-
beri, kwashiorkor, anorexia nervosa, bulimia, alcoholism)
● Neurogenic sialadenosis (e.g., anticholinergic medications)

Question 31

What differentiates a mucous retention cyst?

Answer 31

It is a true cyst with a complete epithelial lining.

Question 32

From what salivary gland does a ranula develop?

Answer 32

Ranulas are mucoceles that develop from the sublingual gland.

Question 33

What is the common appearance of a ranula on physical examination?

Answer 33

Ranulas often appear as a bluish, translucent mass on the floor of mouth.

Question 34

What is the difference between a ranula and a plunging ranula?

Answer 34

A ranula is extravasated mucus that forms a pseudocyst
between the mucosa of the floor of mouth (superior border) and mylohyoid muscle (inferior border). A plunging ranula is a ranula that extends inferior to the mylohyoid muscle into the neck.

Question 35

What are the routes in which a plunging ranula can pass to reach the neck?

Answer 35

Extravasated mucus from a ranula typically passes around
the posterior border of mylohyoid or passes through
dehiscent areas of the mylohyoid.

Question 36

What are the prevalence and location of mylohyoid muscle dehiscence?

Answer 36

Studies show that up to 50% of mylohyoid muscles are

dehiscent in the anterior two-thirds of the muscle.

Question 37

What are the treatment options for ranulas, and which is most successful?

Answer 37

Conservative treatment options include injection of scle-
rosing agents, intraoral marsupialization, or excision of the ranula alone. The most effective treatment, with a recurrence rate of 1 to 2%, is excision of the sublingual gland and ranula together.

Question 38

Name the most common cause of nonsuppurative

acute parotitis?

Answer 38

The mumps virus is the most common cause of non-

suppurative acute parotitis.

Question 39

The virus that causes mumps is in what family?

Answer 39

Paramyxovirus (RNA)

Question 40

What are the most common initial symptoms of

mumps?

Answer 40

Children between the ages of 5 and 10 years have
nonspecific symptoms of headache, fever, myalgia, and
anorexia, followed by bilateral parotid gland swelling.

Question 41

Name several viruses that have been associated

with viral parotitis.

Answer 41

Influenza, coxsackievirus, echovirus, rabies, mumps, and

hepatitis viruses can be associated with viral parotitis.

Question 42

How is cat-scratch parotitis diagnosed?

Answer 42

Diagnosis is suggested by a history of exposure to cats and confirmed by elevated titers of Bartonella henselae immunoglobulin (Ig)G and IgM.

Question 43

How is actinomycosis of the parotid gland

diagnosed?

Answer 43

Diagnosis is achieved using FNA or tissue biopsy.