Inflammatory and infectious pathology of the salivary glands

Inflammatory and infectious pathology of the salivary glands

Salivary gland pathology is very diverse, with stones being the most common condition after mumps. However, salivary tumors occupy a very important place in salivary pathology due to their frequency.

1. Sialites
   1. Sialadenitis
      1. Viral sialadenitis: Mumps sialadenitis

This is the most common viral infection. It affects children and young adults (between 5 and 15 years old).

-The causative agent is an RNA paramyxovirus. It is transmitted by direct contact and saliva droplets. The incubation period is 18 to 21 days.

1.  Clinic: The invasion lasts 24 to 36 hours, it is a phase of high contagiousness.

• Spontaneous pain in the ear and when chewing.
• Parotid swelling raises the earlobe, initially unilateral, becoming bilateral in 2 or 3 days.
• Redness around the ostium of the Steno canal, but without suppuration.
• Saliva rare at the ostia, remains clear, never purulent.

2.  Diagnosis:

The diagnosis is based on:

• clinical data:

-bilaterality,

-the concept of contagion and the incubation period of approximately 3 weeks.

• Isolation of the virus from biological fluids (CSF, saliva) which shows an increase in antibody levels within a week of the onset of the disease.

3.  Treatment and prognosis:

– Isolation (15 days of school exclusion), bed rest.

-The prescription:

• Analgesics, NSAIDs,
• Sialogogues (Jaborandi tincture; Geneserin): to shorten salivary deficit and ductal stasis.

-Healing occurs spontaneously in about ten days.

Vaccine prophylaxis:

Vaccination at 12 months: triple Measles-Mumps-Rubella vaccine: due to serious complications (meningitis, encephalitis, deafness).

2. Bacterial sialadenitis
   1. Acute suppurative parotitis in adults (with common pyogenic bacteria) They mainly affect the parotid gland , more rarely the submandibular gland. The infection can be:

ascending canal pathway (Preponderant)	polymicrobial, predominantly streptococcal
hematogenous route	Monomicrobial

Poor hygiene, dehydration, hyposialia and immunodeficiency (HIV, immunosuppressive drugs, diabetes) are contributing factors.

1. Clinic: Sudden or gradual onset

• Fever, parotid pain, earache worsened by chewing, moderate trismus.
• Parotid swelling under erythematous or purplish skin adhering to the deep layers.
• the ostium of the Steno canal is red and turgid, oozing pus or mucopurulent saliva.

2.  Bacteriological sampling :

With culture, it is possible to identify the flora and perform an antibiogram.

3. Treatment :

Preventive Treatment :

– eliminate the causes of oral infection.

Curative Treatment:

• Antibiotic: mono or bi-antibiotic therapy, which can be adjusted with an antibiogram.

-Humidification of the oral cavity in bedridden patients

• Stimulation of salivary secretion by:

a sialagogue (Généserine 2 to 3 granules three times/day or in oral solution 30 to 45 drops 3 times/day).

-Lavage of the gland with antibiotics instilled through the duct.

-Drainage: in case of purulent collection.

4. Evolution :

-Under antibiotics: favorable progress and complete recovery in a few days.

-In the absence of treatment: suppuration and cutaneous fistulization if drainage does not occur through the canal.

2. Acute suppurative submaxillitis in adults
   • They are exceptional in adults.
   • Ultrasound can be helpful in distinguishing what is glandular from what is lymph node and cellular.

3. Chronic recurrent parotitis in children:
4.  Clinical 

• The first ^episode often occurs around the age of 5 ; it is then taken for mumps, but the unilateral nature and purulent saliva help with the diagnosis.

-The 2nd ^episode occurs a few months later.

• The onset of each acute episode is marked by the rapid onset, often during meals, of a partial, painful, firm unilateral parotid swelling. The discharge of a little mucoid saliva, sometimes lumpy;

Each acute episode generally progresses spontaneously to sedation within 3 to 10 days.

2. Additional examinations

• Bacteriological examination of saliva with an antibiogram.
• Ultrasound : inhomogeneous parenchyma with multiple small hypoechoic images.
• Sialography: small round cavity images in the middle of the parenchyma, attached to images of canaliculi corresponding to the dilations of the canaliculi in metaplasia.

This is the “lead grain” appearance. They are pathognomonic.

3.  Treatment :

General treatment:

– Antibiotic therapy is the same as for acute parotitis. Medication will be continued after clinical recovery.

-Sialalogue cures: (jaborandi tincture; Geneserin)

Local treatments:

-Lavage of the gland through the duct with penicillin can be carried out from the age of 5 years. Series of

3 washes, a few days apart, systematically repeated every three months, contribute to the regression of lesions.

Parotidectomy: indicated exceptionally in severe cases.

4.  Evolution: recurrent. Some authors claim that patients reaching the age of 13 to 15 recover spontaneously.

4. Chronic recurrent parotitis in adults:
5. Etiopathogenesis : It is organized on

-Repeated salivary retention accidents (sialodochitis, megacanals)

-Chronic parotitis in children that has not healed by puberty

– calcinosis,

2.  Clinical

-Repeated inflammatory parotid swelling, more often unilateral than bilateral.

-The pain remains moderate and fairly localized. Saliva is rarely cloudy or purulent.

-Acute episodes with parotid swelling and pain resolve within 3 to 10 days.

3.  Sialography:

The lesions observed are:

-Parenchymatous: (large drops of Lipiodol); image of shot.

-Canals: irregular dilations of the canals.

4. Treatment :

– general antibiotic therapy is only justified in acute episodes.

– Washing the canals with penicillin is useful provided that it is repeated 2 or 3 times a few days apart.

-Surgical excision : as a last resort, complete excision of the gland can be considered;

3. Specific bacterial sialadenitis:
   1. Tuberculous sialadenitis: rare, parotid locations are more numerous than submandibular locations, most often unilateral. This is always secondary tuberculosis. (Koch’s bacillus reaches the gland by hematogenous or lymphatic route),
4. Clinic:

-It is revealed by a cold nodule, often pre-tragic. There is no pain, no fever and the saliva is not purulent.

-The diagnoses mentioned: common chronic adenitis, pleomorphic adenoma.

– Without treatment, caseous necrosis can develop into cutaneous fistulization.

2. Sialography:

-Inhomogeneous opacification of the parenchyma and delays in the evacuation of the contrast product.

-There is often the image of a lacuna, often peripheral to the upper pole of the gland (resembling the “imprint” image of a ganglion in an inflammatory parenchyma).

-At the stage of caseous necrosis/extravasation of the contrast product “lipiodol” gives fairly characteristic images of “puddles”.

3.  The intradermal tuberculin reaction : is positive,
4. Puncture of a caseous shingles and culture on Lewenstein-Jensen medium gives the diagnosis of tuberculous sialadenitis.
5.  Treatment :
   • Treatment is carried out in specialized centers.
   • Surgery: often complements medical TRT to remove nodules and fistulas.
6. Syphilitic sialadenitis: exceptional these days

-Inflammatory swelling, generally bilateral, almost asymptomatic

-At the tertiary stage (gum): very hard nodular swelling the size of a hazelnut.

1.  Diagnosis : based on serology: search for Treponema Pallidum
2. Treatment: Benzathine-penicillin G and other ATBs as needed.
3. Allergic and toxic sialadenitis:

• Allergy is considered when there is bilateral or multiglandular parotid swelling of a subacute appearance, without suppuration, persistent or recurring.
• A positive intradermal test for the allergen guides the diagnosis.

1. Nonsteroidal anti-inflammatory drugs:
   • Phenylbutazone derivatives are often the cause.

-Salivary involvement from the 3rd ^to the 5th ^day of treatment is announced by asialia,

• salivary swelling occurring the next day: It is bilateral, moderate, a little painful, It disappears after stopping treatment,

2. Toxic sialadenitis:

-They appear as toxic accidents.

-Parotid swelling and drooling usually associated

-phosphoric esters of certain pesticides and insecticides, as well as industrial iodides, cause salivary intumescences with drooling.

– biology : blood and salivary eosinophilia.

1. 2. Sialodochites
2. Reflex ductal dilations (salivary dyskinesias):

These are non-lithiasic salivary canal dilations acting as a reflex phenomenon to severe dental pain and mucosal ulcerations.

1.  Clinic:
   • Salivary hernia confused with lithiasis (differential diagnosis);
2.  Sialography: global non-lithiatic dilation.
3. Treatment: it is etiological, removal of the oral-dental cause.
4. Idiopathic bilateral salivary megaducts:

Starts after age 40. Indefinitely recurring

1.  Clinic:

-Transient increase in the volume of a major gland.

-the ostium is inflamed, saliva is often abundant with mucoid plugs.

-The finding of the same sign at the contralateral ostium is pathognomonic.

-Evacuation is rapid, in 1 to 2 minutes, which confirms both ductal dilation and functional activity of the gland.

2.  Sialography:

– Dilations that affect the entire length of the canal.

– Sometimes: An image with alternating expansions and contractions (string of sausages).

-The bilaterality of these images allows us to confirm the diagnosis of megacanals.

3. Treatment :

-Manual expression of saliva, by massaging the canal from back to front, repeated several times a day.

3. Sialolithiasis: +++

Salivary stones are concretions of calcareous origin which are located in the excretory ductal system of the salivary glands.

Etiopathogenesis:

-Submandibular saliva, due to its richness in mucin and calcium, which promotes the formation of stones.

-The ascending direction of the Wharton canal => Salivary stasis

-Submandibular stones are three times more common than parotid stones.

1. Submandibular lithiasis
2.  Clinic:

The presence of calculus leads to mechanical or infectious manifestations

1. Mechanical accidents:
   • Salivary hernia :
     • during meals: A swelling suddenly appears under the basilar edge of the mandible
     • then at the end of the meal the swelling disappears while the patient feels saliva flow.
   • Salivary colic :

• reflects the total retention of saliva.
• Severe, sudden pain in the floor of the mouth, tongue, radiating towards the ear,
• Pain and swelling disappear quickly after a brief drooling.

2. Infectious manifestations:
   • Whartonite:

-floor pain radiating to the ear

• Dysphagia
• Swollen, red salivary ridge,
• Turgid ostium, pus.
• Periwhartonite:

-It is the periductal abscess of the floor

• Complicated Whartonite, all signs are accentuated

-Trismus, fever

• The edema pushes the tongue upwards and towards the contralateral side,

-Suppuration at the ostium confirms its salivary origin.

• Acute submandibulitis

-It is the abscess of the submandibular lodge: the infection extends upstream of the canal

-Painful inflammatory swelling, dysphagia, suppuration at the ostium and sometimes cutaneous fistulization.

• Variable general signs: often related to a large posterior lithiasis.

2. Clinical examination

• inspection: endo and exo-oral.

-bidigital palpation: hard stone, more or less painful

3.  Radiological Exploration:

• Standard X-ray:

Occlusal image – Panoramic image

-Ultrasound: Size and number of stones

• CT and MRI
• Sialography : It has the advantage of highlighting small stones as well as stones with little calcification.

4. Positive diagnosis: by

• Discovery of calculus: by bi-digital palpation.
• Paraclinical examinations.

5. Treatment
   • Medical Treatment:

• Analgesic (paracetamol, paracetamol-codeine): relieves pain.
• Nonsteroidal anti-inflammatory drugs (Contraindicated in cases of infection)
• Antispasmodics (Spasfon), 6 tablets/day: increase the diameter of the ostium, improving canal drainage.

– Sialogogues:

Promotes the expulsion of small stones: Pilocarpine (Salagen) is the most effective sialogogue. – (Sulfarlem S 25) 12.5 and 25 mg tablets, 3 tablets/day

• Antibiotics: prescribed in cases of infection, antibiotic therapy is adapted to the polymicrobial flora of the oral cavity (amoxicillin) or is for preferential salivary elimination (macrolides).
• Surgical treatment of submandibular stones:

Essential except in cases of stones expelled spontaneously or with the help of medical treatment.

• Transmucosal stone removal:

under local anesthesia; mucosal incision, begins a few mm behind the ostium. Indicated especially for stones of the antrum and middle third.

• Submandibulectomy:
• It is performed under general anesthesia, via the cervical skin.

-This intervention is indicated when the stone is very posterior, and it cannot be removed orally or by sialoscopy.

-Sialoscopy

It is performed under local anesthesia. Sialoscopy is used for small stones (less than 4 mm in diameter). Stones larger than 4 mm require prior fractionation, externally (extracorporeal lithotripsy).

2. Parotid lithiasis

-Rare: Because saliva is low in mucin and mineral salts, the stones are small and not very calcified. The saliva flows horizontally.

1. Clinic:

a1. Infectious complications are predominant and revealing:

• stenonite

-Jug pain

-Gapy, red, swollen ostium. Pus

-Palpation: dilated canal in the form of a hardened cord, sometimes a stone.

• Parotitis: Ascending
• Damage to cellular tissue: Masseter or Genian cellulitis.

a2. Mechanical accidents: less frequent but significant

-Less frequent hernia and salivary colic:

• Hernia: sudden parotid swelling, slightly painful during meals.
• Salivary colic: during meals, making eating difficult.

2. X-ray:

• Plain X-ray.
• Sialography: Upstream ductal dilation

3.  Positive diagnosis: all the paraclinical examinations described in submandibular lithiasis can be used to search for the stone and therefore make a positive diagnosis.
4. Treatment:

Spontaneous or medically assisted expulsion of the stone is common.

• Medical: similar to that of submaxillary stones.

-Sialogogues and antispasmodics

• Sténon duct lavages with penicillin accelerate healing and promote the migration and expulsion of parotid stones 🡺 often small, rounded, not very hard
• Surgical:

• Removal of stones close to the ostium : excision by the endo-oral route
• Superficial or partial parotidectomy is indicated for posterior stones, sometimes total if the stone is intraglandular.

3. Sublingual Lithiasis:

Exceptional,

1.  Clinic: inflammatory pelvic-oral swelling (sublingualitis).

The stone (sometimes multiple small stones), if visible, is located further outward than in a Wharton stone.

2. Occlusal image: calcification of the floor.
3. Sialography:

Calculations located between the Wharton and the external table of the horizontal branch.

4.  Treatment :

Infectious complications may lead to sublingualectomy.

4. Lithiasis of the accessory salivary glands:

Rare. It occurs preferentially in the elderly.

1.  Clinic:

• Inflammatory swelling of a gland (lip, palate, cheek).

Pressure on the affected gland may cause some purulent saliva to ooze out.

• Endo-oral film: calcification.

2. Treatment: removal of the stone or gland under local anesthesia.

1.4. Salivary calcinosis

Multiple, bilateral parenchymal concretions , they only affect one group of salivary glands: the parotids+++

a.clinical : (Clinical picture of chronic bilateral sialitis).

• painful, intermittent bilateral or tilting glandular swellings,
• cloudy or purulent saliva.

2. Sialography:

Parenchymal images in drops of lipiodol, irregular ductal dilations.

3. Diagnosis is based on the discovery of calcifications by:

– unprepared X-rays,

• ultrasound

4. Treatment: Inflammatory flare-ups require systemic antibiotic therapy or injection of antibiotics into the canal.
5. Sialosis

Sialosis is a non-inflammatory disease of the salivary glandular parenchyma, caused by metabolic and secretory disorders of the parenchyma,

2. 1. Functional disorders of salivary secretion: Hyposialia and sialorrhea

1. Chronic hyposialia and asialia, xerostomia:

a. The causes of hyposialia : are dominated by

• Drug causes:

neuropsychotropics (psycholeptics, anxiolytics), antihypertensives, antiarrhythmics, cholinergic antiulcers.

• Cervicofacial irradiations.
• Sjögren’s disease, sarcoidosis and other sialoses;

b. Interrogation :

-Age, profession, lifestyle, notion of medication intake.

-Duration, variations of dry mouth.

-Estimate the degree of discomfort caused by dryness during meals.

-Notion of other locations of drought.

3.  Clinical 

• Difficulty speaking, chewing, swallowing,

-Need to moisten the mouth, suck on candy…

4. Diagnostic tests for dry mouth :

-Sugar test: The sugar cube normally melts in 3 minutes.

-Measurement of intraoral pH : Dryness → acidic pH < 6.5.

5. Additional examinations:

• Panoramic and occlusal radiographs:

• Search for lithiasis and calcinosis.
• Dental and periodontal assessment.
• Sialograhiy:

-Ductal and parenchymal morphology of the salivary glands.

-Functional evacuation disorders.

• Biological tests: Look for a systemic etiology.
• Ophthalmological and psychological examinations.

6.  Complications :

Alteration of dental condition, mucosal alterations and mycotic superinfections (angular cheilitis; red, depapillated oral mucosa).

7.  Treatment

• Preventive TRT for complications :

– Rigorous oral hygiene,

-1.4% baking soda mouthwash

• Etiological TRT:
• Replacement of a sialoprive drug.
• TRT for total xerostomia :

• Artificial saliva.
• artisial ®) spray or Bioxtra ®) 8 to 10 f/d gel for humidification.
• Stimulation by sialogogues (pilocarpine), combined with small measures (sweets, acids, lemon juice, etc.).

2. Drooping:

Sialorrhea = Excessive salivary secretion

1.  etiology :

• Gastric causes: gastritis, ulcer.
• Oropharyngeal causes: tonsillitis and stomatitis, dental eruptions, dental pulpitis, ulcerations.
• Esophageal causes: spasms, foreign bodies, cancers.
• Neurological causes: lesion affecting the salivary secretory centers (Parkinson’s disease).
• Drug poisoning.

2.  Clinic :

– Mouth congestion with saliva, Passive flow of saliva outside the mouth.

-Suprahyoid muscle fatigue.

-Alkaline salivary pH.

-Sugar test below 2 min.

3.  Treatment :

Etiological treatment ; (removal of drug causes, treatment of a digestive lesion, etc.).

Surgical treatment: extreme and chronic cases

• Canal ligation (Wharton and Steno)
• Posterior tunneling plasty of the orifices of the Steno ducts with or without simultaneous excision of the submandibular glands.

2. 2. Nutritional sialosis:

-Excess of starchy foods (bread, potatoes): Causes moderate and silent parotid hyperplasia.

-hyperlipoproteinemia and hypertriglyceridemia are responsible for moderate salivary deficits with parotidomegaly. TRT is dietary.

-Alcoholism: Hyperplasia, in the pre-cirrhosis phase.

-Severe malnutrition and sialosis of protein deficiencies

Expl: Kwashiorkor (protein-calorie malnutrition in young African children) combines parotidomegaly with hepatosplenomegaly,

– Neurotic dysorexia: causes large parotidomegaly

These are neurotic and depressed young women, thin because they are malnourished,

-Diabetes mellitus: is often associated with moderate sialomegaly.

2.3. Sjögren’s syndrome or myoepithelial sialadenitis (MS)

1.  Definition :

– Autoimmune exocrinopathy , systemic, chronic, slowly progressive, characterized by a

lymphocytic infiltration of exocrine glands .

-It can be:

• isolated (primitive SGS),
• or associated with other autoimmune diseases: rheumatoid arthritis; systemic lupus erythematosus; scleroderma.

-It occurs mainly in women between 40 and 60 years old.

2.  Clinic:

b1. Glandular manifestations:

-Dry mouth (xerostomia): results in

• Difficulty swallowing, speaking without interruption; wearing prostheses.
• Sometimes, increase in the volume of the main glands (parotid).
• Dry, erythematous oral mucosa.
• Atrophy of the lingual filiform papillae.
• Multiple cavities.

-Dry eyes (xerophthalmia)

• Sensation of sand or gravel under the eyelid; burning sensation.
• Occurrence of keratoconjunctivitis.

-Affecting other exocrine glands

• Nasal, tracheal, skin and genital dryness.

b2. Extra-glandular (systemic ) manifestations

• Joint manifestations: rheumatoid arthritis; myalgia.
• pulmonary and renal interstitial damage.
• Vasculitis can manifest as a recurring and progressive neurological condition. The main and most serious complication of SS is the development of lymphoma.

3.  Positive diagnosis :

Tear dryness is assessed using the Shirmer test:

A strip of blotting paper is placed in the lower lacrimal sac. The test is considered pathological if the area of ​​the blotting paper moistened by tears is less than 5 mm after 5 min.

Dry mouth:

Sugar cube melting test: an average sugar cube placed under the tongue melts on average in 3 minutes.

4. Sialography : it can have 3 aspects

• At the beginning: Punctate opacification of the parenchyma
• Advanced stage: Ball images with dilation of the afferent ducts.
• Final stage: Parenchymal destruction 🡺 image of dead tree.

5.  Biopsy of accessory salivary glands

– It is performed under local anesthesia on the mucosa of the lower lip. At least three glands must be removed. (Lymphocytic infiltration).

6. Treatment

-Sialogogues: (jaborandi tincture; Geneserin, Sulfarlem S25)

-Saliva substitute sprays, sour candies, chewing gum (sugar-free).

-Corticosteroid therapy: brief for edema and lymphocytic reaction 🡺 temporary results. Disadvantages of this treatment : candidiasis.

-For infected forms: antibiotic washes ( penicillin ) of the salivary ducts.

Inflammatory and infectious pathology of the salivary glands

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Inflammatory and infectious pathology of the salivary glands