Infectious and inflammatory pathologies of the salivary glands

Infectious and inflammatory pathologies of the salivary glands

Plan :

Introduction

Diagnostic approach:

I.1. Anamnesis

I.2. Clinical examination

I.3. Additional examinations

I.3.1. Imaging of the Salivary Glands

I.1.2. Biological and anatomopathological explorations

Clinical forms:

II.1 . Inflammatory pathologies of GS: sialitis

II.1. 1. Sialadenitis

II.1. 1. 1. Viral sialadenitis

II.1. 1.2. Bacterial sialadenitis:

Acute purulent sialadenitis (APS)
Chronic recurrent sialadenitis (CRS)

II.1. 1.3. Specific sialadenitis

II.1. 1.4. Other sialitis: Salivary calcinosis

II .1 . 2. Sialodochites

Reflex ductal dilations (salivary dyskinesias)
Anatomical functional retention syndrome
Idiopathic salivary megaducts
Fibrinous sialodochitis

II.2 . Non-inflammatory pathologies of GS: Sialosis

Sialosis of systemic origin
Non-systemic sialosis: Sialadenosis

Conclusion

Introduction

Salivary gland pathology has multiple origins, infectious and inflammatory conditions (sialitis) are the most frequent.

The diagnosis is clinical, often resulting in swelling and/or pain. Treatment is essentially medical, symptomatic and etiological.

It is up to the dentist to know how to diagnose these conditions and to know the therapeutic methods for each clinical form.

Diagnostic approach:

The diagnosis of salivary pathology will always begin with a clinical examination that will include a questioning and a dedicated clinical examination, exobuccal and endobuccal. If necessary, a complementary examination by imaging or a histological analysis can be carried out.

I.1. Anamnesis:

– Age and gender

– Reason for consultation: induced or spontaneous pain, earache, swelling, inflammatory manifestations, etc.

– Medical and surgical history : Certain general pathologies such as endocrine diseases (diabetes in particular) can promote the development of salivary pathologies.

– Research the concept of therapies (radiotherapy, psychotropic drugs) which have an influence on salivary flow.

– Look for the concept of contagion (mumps, tuberculosis).

– Look for the notion of swelling of a salivary gland by specifying:

Mode of appearance: gradual or rapid;
Its nature: rapid or slow development, sudden or progressive, unilateral or bilateral, related or not to meal times, duration and method of resolution;
Functional signs: pain, trismus, facial paralysis, hernia, suppuration
Saliva characteristics: rare or abundant, liquid or thick, with an unpleasant taste or not;
General signs.

– We must also look for:

A feeling of dry mouth and/or eyes;
Inflammatory joint pain;
Dermatological lesions should also be sought, as they can direct the diagnosis towards a systemic inflammatory condition: primary Sjogren’s syndrome, sarcoidosis, etc.

I.2. Clinical examination:

Inspection and palpation of the cervicofacial region will allow us to assess:

Condition of the integuments (inflammatory appearance or not);
Facial asymmetry related to swelling: it is necessary to specify

– The location (parotid, submaxillary, etc.), the volume, the pain;

– Consistency: hard, soft, inhomogeneous, fluctuating…

The search for adenopathies and facial nerve damage.

The intraoral examination:

Dental infectious foci must be systematically sought, which can promote the occurrence of inflammatory and/or infectious outbreaks of the salivary glands.
The orifices of the Stenon and Wharton canals should be examined and their inflammatory or non-inflammatory nature, the presence of mucous debris, or even frank pus should be noted.
Bidigital palpation of the floor of the mouth and/or the jugal region looks for a hard, localized swelling, “rolling” under the finger which indicates the presence of a stone.
Then the saliva is analyzed:

– Assess the quantity and appearance of saliva (stringy or viscous appearance, clear or cloudy saliva) at the ostium of the canal after massaging the gland.

– The quantity of saliva is assessed by the sugar cube test: a sugar cube of average volume placed in the sublingual cavity of a seated subject whose mouth is closed and who is not swallowing is completely soaked and dissolves in approximately 3 minutes.

Salivary pH measurement should be part of the clinical examination.

A pH is considered acidic below 6.5 and basic above 7.5. It also varies depending on age and time of day, in fact it is more acidic in infants and adults as well as upon waking. A drop in pH below 5.5 is a very suggestive sign of hyposialia.

Infectious and inflammatory pathologies of the salivary glands

I.3. Additional examinations:

I.3.1. Imaging of the Salivary Glands:

Unprepared shots:
Standard clichés:

Standard images can be useful for detecting lithiasis, calcifications of inflammatory pathologies. They are therefore not very informative in non-lithiatic inflammatory pathology. This exploration is mainly aimed at the main salivary glands.

At the level of the parotid gland: the useful incidences are:

The profile incidence (for the gland itself);
The axial incidence of Hirtz (for the pharyngeal extension or deep lobe).

At the level of the submandibular and sublingual glands:

Front and profile incidences in the defiled maxilla;
Occlusal incidences with intraoral film (bitten).

At the level of the accessory glands: a retro-jugal or retro-labial dental film may be useful (especially in the case of lithiasis).

Orthopanthomography is of interest in cases of simultaneous bilateral sialographies.

Ultrasound:

Ultrasound is currently the first examination to be performed following a salivary pathology. It is a quick, non-invasive examination to perform. It studies the parenchyma and the ducts. It allows the diagnosis of stones above 2 mm in diameter. However, the ultrasound image has no specificity, it at least allows the elimination of tumor or lymph node processes.

Sialendoscopy:

This new tool constitutes a simple, minimally invasive alternative, providing a certain answer to the diagnostic question and allowing a therapeutic procedure to be carried out at the same time.

It is performed under local anesthesia, except in children (general anesthesia). It consists of introducing a semi-rigid endoscope into the salivary ducts in order to visualize and diagnose ductal pathologies.

It has diagnostic and therapeutic interest. Proposed in:

Acute submandibulitis or parotitis with the presence of stones on radiological examinations.
Chronic parotitis (and submandibulitis), particularly in the recurrent form in children, requires antibiotic rinsing of the salivary ducts.

Shots with preparation:
Sialography:

Sialography is the oldest method of exploring the salivary glands. It involves the ductal-parenchymal opacification using a water-soluble contrast agent with a high iodine content of a parotid or submandibular gland after ostial catheterization of the Stenon duct or Wharton duct.

It allows to highlight stenoses and ductal dilations and to assess the function of the gland.

A series of images are taken before and at the end of the injection, as well as after removal of the catheter, to assess the evacuation of the gland (evacuation images).

Sialography is contraindicated in acute inflammation and iodine allergy.

Currently, its indications are decreasing, mainly due to its invasive nature, irradiation and allergy risks.

Computed tomography (CT):

It allowed the study of the glandular parenchyma and tumor processes, today it is being abandoned in favor of MRI. (Due to problems related to an allergy to iodine, and artifacts due to dental equipment).

Magnetic Resonance Imaging (MRI) and sialo-MRI:

MRI is very useful for observing the salivary glands but it is quite limited in visualizing the excretory ducts. In the case of a need to explore the salivary ducts, sialo-MRI will be used.

Currently, sialo-MRI is the most effective examination of the salivary glands.

It replaces conventional sialography in the screening of sialitis. It allows the exploration of the ducts and the glandular parenchyma and the highlighting of ductal dilations as well as stenoses, without catheterization of the salivary ducts or injection of contrast product.

Scintigraphy:

It is based on the intravenous injection of a radioactive tracer. It is reserved for certain pathologies such as hyposialia in degenerative diseases. This examination allows the functionality of the salivary glands to be checked.

It is based on the intravenous injection of a radioactive tracer (Technicium) which the parotid and submandibular glands concentrate in the same way as the thyroid.

First, images are taken, in frontal and right and left profile views. The administration of lemon juice allows, by increasing glandular excretion, to study salivary evacuation which must be complete. Fixation and elimination curves can be carried out.

Sialography 3D-Cone Beam Computed Tomography (3D-CBCT)

3D-CBCT in combination with sialography is an effective, safe and easy-to-manage examination to explore the ducts of the main salivary glands in non-tumor pathologies, it allows a precise 3D analysis of the ductal system up to the fourth division of the ducts.

I.1.2. Biological and anatomopathological explorations:

Cytobacteriology and virology:

Saliva is normally sterile. Any bacterial or viral contamination is related to the collection technique (swabbing or catheterization) or to an infection of the gland or duct concerned.

The bacteria most commonly involved are Staphylococcus aureus, Staphylococcus pyogenes, Streptococcus viridans, Streptococcus hemolyticus and Pneumococci. Infections are exceptionally specific (tuberculosis, syphilis).

Salivary infections are mainly of mumps origin (paramyxovirus)

A blood culture will be performed simultaneously, if possible, in acute cases.

Biopsy:

Salivary biopsy is best indicated in non-neoplastic conditions of systematic origin (sarcoidosis, Sjögren’s syndrome), the most accessible site being the inner face of the lower lip, the most reliable site is the sublingual gland.

Sialometry:

A simple sialometry technique consists, after catheterization of a Stenon duct, in measuring the salivary secretion of the glands at rest (the patient must have fasted for three hours before the examination) and after stimulation (10% citric acid solution is placed on the tongue with the catheter already in place). The salivary flow is expressed in millimeters per 15 minutes.

Clinical forms:

II.1 . Inflammatory pathologies of GS: sialitis

When the inflammation of the gland is essentially parenchymal, it is called sialadenitis.

When the inflammation is ductal or secondary to ductal damage, it is then sialadochitis.

II.1. 1. Sialadenitis:

The clinical picture of these conditions varies depending on the etiology.

II.1 . 1. 1. Viral sialadenitis:

Mumps sialadenitis:

Mumps parotitis is the most common viral infection of the salivary glands, caused by a paramyxovirus through direct transmission by contagion.

Formerly the main cause of acute parotitis in children, the introduction of vaccination (MMR vaccine: measles-mumps-rubella) has almost completely eliminated childhood forms.

Clinic:

Incubation lasts about three weeks (fifteen to twenty-four days).

The period of state, lasts about a week, marked by: fever, headache, pain radiating to the ears and dysphagia or odynophagia.

On inspection, there is unilateral or bilateral swelling (classic “piriform facies”) of the parotid glands. Involvement of both parotids may be simultaneous but is often delayed by several days.

This is a parotid swelling, renitent, very sensitive under shiny skin and raised earlobe. There is redness at the ostium of the parotid duct with clear and rare saliva and adenopathies.

The diagnosis is clinical; it is most often unnecessary to require paraclinical examinations.

Evolution

It leads to complete healing in the majority of cases; sometimes, it can leave foci of necrosis which can lead to chronic parotitis.

The disease confers lifelong immunity. Thus, a second episode of acute parotitis in a child eliminates this diagnosis (mumps) and suggests another diagnosis: juvenile recurrent parotitis.

Treatment

Clinical healing occurs after about ten days. Classic forms are treated by:

Bed rest,
Analgesics and antipyretics.
School exclusion is mandatory for 15 days.
Other viral sialadenitis:

These are little-known or rare sialites:

Vesicular pharyngitis of herpangina (coxsackievirus A) may be accompanied by unilateral or bilateral parotitis, turgid ostium, without discharge of pus.
The cytomegalovirus CMV (a herpesvirus) is found in a latent state in salivary cells; it only manifests clinically in immunocompromised people (especially AIDS).

Infectious and inflammatory pathologies of the salivary glands

II.1 . 1.2. Bacterial sialadenitis:

Acute purulent sialadenitis (APS)

Acute purulent sialadenitis is a bacterial inflammation of the salivary glands that usually affects one of the major salivary glands.

– In the newborn:

Salivary gland infections are rare in newborns, but when they do occur they most commonly affect the parotid glands.

The most commonly responsible organism is Staphylococcus aureus which reaches the parotid gland through the Steno duct. However, contamination can sometimes occur by the hematogenous route.

Risk factors for SAP in newborns include: insufficient breastfeeding, prematurity, low birth weight, hot temperatures, and maternal breast abscess.

Clinic : The most common symptoms are the appearance of fever, erythema and swelling in the preauricular region, which may be bilateral. Purulent drainage from the Stenon canal is pathognomonic of the pathology.

Management : Antibiotic therapy adapted to the causative germ is the most effective treatment.

Evolution : The prognosis is very good. However, in very rare cases complications can occur.

– In adults:

SAP most commonly affects the parotid gland and sometimes the submandibular gland (10% of cases). It is common in medically weakened patients, hospitalized or after surgery.

Retrograde bacterial contamination via the Stenon duct is the main etiology of the pathology. Stasis of salivary flow, secondary to dehydration or decreased oral intake, allows bacterial migration into the glandular parenchyma.

The most common bacterial cause of acute sialadenitis is Staphylococcus aureus.

Clinical : Patients with SAP present with acute pain, swelling of the affected gland, and sometimes trismus. Physical examination may reveal induration, edema, and localized tenderness. Massage of the gland induces purulent secretion at its excretory orifice.

Management : Treatment is based on antibiotic therapy, guided by bacteriological sampling at the ostium of Stenon’s canal and strict oral hygiene. The most frequently encountered bacteria are Staphylococcus aureus as well as Gram-positive and anaerobic bacteria. Due to the presence of these germs, it is recommended to potentiate penicillin using beta-lactamase inhibitors (amoxicillin-clavulanic acid combination).

Evolution : After treatment, healing is systematic and complications are almost non-existent.

Chronic recurrent sialadenitis (CRS)

– In children:

Childhood SCR is an inflammatory condition of the parotid gland characterized by recurrent episodes of swelling and pain.

Juvenile SCR is 10 times more common than adult SCR and mainly affects children aged 3 to 6 years, with a male predominance.

Symptoms peak during the first year of school and usually begin to subside by mid-adolescence.

The pathogenesis is not fully established and several etiological factors are cited in the literature (genetics, congenital ductal ectasia, autoimmune).

Clinic : These episodes of acute or subacute parotid gland swelling are usually accompanied by fever, malaise, and pain. Symptoms are usually unilateral, but both sides may be affected. Acute attacks may last from a few days to a few weeks and occur every few months.

Management : Antibiotic therapy, which should be continued for several weeks or even repeated after clinical recovery, helps prevent recurrences for long periods.

– In adults:

SCR is characterized by repeated episodes of pain and inflammation caused by decreased salivary flow and salivary stasis. It most commonly affects the parotid gland and typically occurs between the ages of 20 and 50 with a female predominance.

The etiology being multifactorial:

• reduced salivary flow results in decreased mechanical cleaning, allowing bacteria to colonize and invade the Stenon duct retrogradely.

• metaplasia of the mucus of the ductal epithelium by repetition of acute infections leading to an increase in the mucus content of the secretions, stasis and the recurrence of inflammatory episodes.

Clinical : Physical examination reveals swelling and tenderness of the involved gland. The papilla of the Stenon duct is elevated, salivary flow is reduced, and salivary secretion is viscous and milky.

Sialography can highlight terminal canals with areas of “spots” and “dots” of contrast products indicating sialectasis: canal dilation, and exclude lithiatic pathology (image of a hunting lead or a flowering tree).

Support :

Only acute attacks, where the pain generally remains moderate, justify systemic antibiotic therapy. Prevention of recurrences is based on regular ductal lavage with simple saline solutions, to which it is possible to add antibiotics from the penicillin family. Residual nuclei of chronic parotitis can take on a pseudotumoral appearance and justify parotidectomy for diagnostic and therapeutic purposes.

Infectious and inflammatory pathologies of the salivary glands

II.1 . 1.3. Specific sialadenitis:

Tuberculous sialadenitis

Tuberculosis is a necrotizing granulomatous disease, it affects the parotids and more rarely the submandibular glands. In general, the glandular involvement is unilateral.

– Primary salivary gland tuberculosis can manifest in two ways: an acute inflammatory lesion (mimicking SAP) or a chronic mass lesion (tumor) that may be asymptomatic for several years.

– Secondary involvement of the salivary glands is more common than the primary form and is thought to result from systemic dissemination from a distant focus by hematogenous or lymphatic route, particularly the lungs.

– More rarely an infected source of mycobacteria in the oral cavity, such as the tonsils or teeth, may release bacilli which spread by retrograde inoculation via the salivary duct or afferent lymphatics to associated lymph nodes.

Clinical : Tuberculous sialadenitis has a multitude of clinical presentations. The most common manifestation is the appearance of a painless, slowly growing mass of the affected gland mimicking a neoplasm, which presents a diagnostic dilemma.

Diagnosis : Definitive diagnosis is based on the identification of Koch’s bacillus (cytopuncture).

Radiography is useful when the culture remains negative and the clinical appearance is pseudotumoral:

Ultrasound most often shows the existence of several nodules and makes it possible to objectify caseification.

Sialography may show an “imprint” image in the glandular parenchyma, or extravasations of contrast medium, in a pool, more characteristic of the softening phase.

– Management : We use the classic treatment of tuberculosis which is long and consists of a combination for 6 to 18 months of ethambutol (25mg/kg/day), rifampicin (10mg/kg/day) and isoniazid (8mg/kg/day).

Syphilitic sialadenitis:

Syphilis is a rare, sexually transmitted infection caused by Treponema Pallidum, which can be divided into early and late forms. Salivary gland involvement is found in late syphilis.

The swelling is bilateral and may affect the parotid or submandibular glands and is also very symptomatic in the absence of superinfection. In the event of superinfection, the swelling becomes very painful and drooling may be observed.

The diagnosis is established from serological tests which aim to highlight the presence of anti-treponemal antibodies (TPHA or FTA) often associated with a non-specific VDRL (Veneral Disease Research Laboratory) test.

Management: Treatment consists of appropriate antibiotic therapy (penicillin G).

II.1 . 1.4. Other sialitis: Salivary calcinosis

This is a rare pathology that is characterized by multiple and bilateral parenchymal concretions. It most frequently affects the parotid glands and only affects one group of glands in each patient. It almost exclusively affects the female sex with a predominant onset between 40 and 50 years of age.

Calcifications in the parotid gland are generally smaller and more numerous than in the submandibular gland, which has larger but fewer calcifications.

Clinically , we find the symptoms of a SCR with sometimes purulent saliva. An ultrasound and conventional radiographs must be done before considering sialography. Sialography shows irregular ductal dilatation as well as multiple calcareous concretions at the glandular level.

Treatment is based on antibiotic therapy (systemic or by canal injection) during acute phases. Since treatment is only symptomatic, cure is impossible.

Infectious and inflammatory pathologies of the salivary glands

II.1 . 2. Sialodochites:

Reflex ductal dilations (salivary dyskinesias)

Non-lithiasic salivary canal dilations and disturbances act as a reflex phenomenon to oral-dental disorders such as pulpitis, a wound of the oral mucosa or a canker sore…

Their manifestations are limited to obstruction accidents: salivary hernia sometimes with pain.

The diagnosis between these dyskinesias and salivary lithiasis can be difficult due to the frequency of lithiasis in the non-calcified stage and therefore not detectable.

Sialography shows ductal dilatation in both cases. But lithiatic dilatation has its own characteristics: it is located or predominates around or upstream of the lithiatic obstacle, while non-lithiatic dilatation is global .

Treatment : It must be etiological by removing the irritating bucco-facial spines.

Anatomical functional retention syndrome:

Concerns the submandibular gland. It would be due to compressions of the Wharton canal by the supramylohyoid extension of the gland.

Idiopathic salivary megaducts:

This is a uni- or bilateral pathology which affects only the parotid and submandibular glands with the parotids being twice as frequent.

The reason for the first consultation is most often the temporary increase in the volume of a main salivary gland, sometimes with a painful episode and various salivary disorders such as the presence of jet salivation.

The diagnosis, simple, is generally objectified during the clinical examination. It highlights red and edematous excretory orifices. The salivary flow is generally significant. When pressure is applied to the gland, a salivary jet is observed which highlights the proper functioning of the gland as well as ductal dilation. The observation of the same signs on the contralateral gland is pathognomonic of the pathology.

Sialography shows dilations that affect the entire length of the duct. Thus, we can find an image with alternating dilations and narrowings (in the shape of a string of sausages). The evacuation of Lipiodol is rapid, sometimes total in 1 to 2 minutes, which confirms the functional activity of the gland.

Accidents of stasis and canal infection give way to manual expression of saliva, by canal massage from back to front and, in rebellious cases, antibiotic therapy is proposed by general route (amoxicillin or macrolide) and by canal route (canal washing with penicillin).

Fibrinous sialodochitis:

Fibrinous sialodochitis is a rare disease of the salivary glands affecting the parotid glands or submandibular glands bilaterally. It is characterized by swelling and recurrent pain of the salivary glands, caused by obstruction of the salivary duct system by mucofibrinous plugs.

The etiology is poorly understood but the most accepted hypothesis is that it is an allergic process.

Irregular dilation of the main salivary ducts objectified by sialography or MRI is found.

Treatment is symptomatic. In general, compressive massages of the salivary glands, abundant hydration and the administration of antihistamines with or without corticosteroids are sufficient for healing.

II.2 . Non-inflammatory pathologies of GS: Sialosis

Sialosis is defined by the increase in volume of several major salivary glands and is almost always the result of a general pathology. These are chronic salivary conditions that are neither infectious nor tumoral. Schematically, they are either:

– Systemic sialosis: characterized by a specific infiltration, often lymphoid.

– Sialadenoses: diseases of a dystrophic, nutritional nature.

The majority of sialosis manifests itself by hyperplasia, or sialomegaly, most often bilateral with a functional impact, salivary deficit.

Each affected gland is swollen, painless, firm and elastic in consistency. Accessory salivary glands may participate in the process.

The absence of signs of infection is the rule except in the case of superinfections at a late stage of development.

Sialosis of systemic origin:

They are called systemic because they are conditions that affect an entire tissue or several tissues of the patient.

– Gougerot-Sjögren syndrome (dry syndrome):

Autoimmune, chronic inflammatory disease, characterized by progressive degeneration of the exocrine glands, with lymphoplasmacytic infiltration, leading to dryness of the mucous membranes and conjunctiva.

It affects patients aged 40 to 60 years, most often women.

The syndrome is said to be primary when it only affects the salivary glands. It is said to be secondary when there is an associated autoimmune disease (rheumatoid arthritis++, systemic lupus erythematosus, etc.).

The diagnosis of primary SGS requires the existence of:

dry mouth and eyes
or the presence of a lymphocytic infiltrate on a biopsy of accessory salivary glands or the presence of anti-SSA or anti-SSB autoantibodies.

Clinic :

Xerostomia results in disorders : difficulty swallowing, chronic burning of the oral mucosa, lack of stability of removable dental prostheses, intolerance to spicy or acidic foods, cervical caries.

The oral mucosa becomes dull, sticky and fragile. Candidal infection is very common. The tongue is red, depapillated (atrophy of the filiform papillae) and cracked.

About 1/3 of patients develop swelling of the salivary glands (especially parotids) during the course of the disease, the risk increases with the severity of the glandular dysfunction and inflammation. Most often bilateral, diffuse, firm and not painful or sometimes slightly sensitive.

Three stages are described in sialography:

Stage 1, punctate opacification corresponding to small canalicular ectasias;
Stage 2, teardrop images with moderate periductal extravasations indicating an abundant, nodular or diffuse lymphocytic infiltrate;
Stage 3, called “dead tree” where only the largest canals are opacified, objectifying the destruction and sclerosis of the salivary parenchyma.

It can develop into lymphoma, which should be considered in the event of parotid tumor development.

– Sarcoidosis or Besnier Boeck Schaumann disease (BBS)

It is a systemic granulomatosis of unknown etiology. It appears preferentially in adults between 25 and 45 years of age.

Sarcoidosis can affect only one organ or be diffuse (in which case it is called systemic involvement). It most often affects the lungs in 90% of cases and the accessory salivary glands in 50% of cases and the parotids in less than 5% of cases.

Clinically, we find a rather asymmetrical indolent bilateral parotidomegaly of progressive onset, isolated (rare) or associated with thoracic signs. Hyposialia, inconstant, indicates a more or less diffuse salivary disorder.

The association of bilateral parotid hypertrophy, uveitis (uveoparotitis) and facial paralysis results in Heerfordt syndrome.

Other manifestations are cutaneous, bone, pulmonary, lymph node, visceral, neurological.

Spontaneous healing occurs in the majority of cases.

Infectious and inflammatory pathologies of the salivary glands

Non-systemic sialosis: Sialadenosis or salivary dystrophies

Many factors are responsible for homogeneous, chronic and painless enlargements of the salivary glands . The parotids are most affected.

These are:

Nutritional sialosis:

Excess of starchy foods (bread, potatoes)
Hyperlipoproteinemia (increased blood lipids)
Severe malnutrition is sometimes accompanied by parotid hyperplasia.
Toxic sialosis:

Alcoholism also induces salivary dystrophy + parotidomegaly (bilateral and symmetrical, moderate and painless).

Neurotic dysorexias: Anorexia +++
Hormonal sialosis: diabetes, gout, during amenorrhea…
Allergic, drug-induced sialomegaly: Nonsteroidal anti-inflammatory drugs, antidepressants.

Conclusion:

Inflammatory and infectious pathology of the salivary glands has multiple and variable etiologies, mumps dominates viral infectious pathology, recurrent parotitis in children dominates bacterial infectious pathology, and lithiasis constitutes a very common condition.

Early diagnosis and adequate treatment can help achieve a cure and avoid complications and the progression to chronicity.

The care is multidisciplinary and requires collaboration between the stomatologist and the otolaryngologist or maxillofacial surgeon.

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Bidigital palpation of the submandibular gland