​Kembara Xtra - Medicine - Salivary Gland Calculi / Sialadenitis

​Kembara Xtra - Medicine - Salivary Gland Calculi / Sialadenitis 
One or more salivary glands are inflamed.
 It can be autoimmune, obstructive, or infectious. When eating, the affected gland experiences a painful swelling known as "sialolithiasis" that is brought on by a blockage of the salivary glands or ducts by a stone.
"Sialadenitis" is an inflammation of the salivary gland that can be either acute or chronic. A primary infection (viral/bacterial) or secondary infection may be the source of acute. Repeated episodes of inflammation that lead to a progressive decrease of salivary gland function are what cause chronic sialadenitis. Sialadenitis frequently affects the submandibular glands and the parotid gland. However, acute suppurative sialadenitis is the main cause of parotid gland inflammation. Due to the higher mucinous content of saliva, longer Wharton duct course, and slower salivary flow against gravity, the submandibular gland is more frequently (80–90% of cases) impacted by stones than the parotid gland.

Peak incidence is between the ages of 30 and 60; children are rarely affected. Patients who are weak and dehydrated are more likely to develop salivary stones, which are 70% solitary and 30% bilateral.

Pathophysiology and Etiology 
Elevated calcium concentrations and stagnation of salivary flow are suggested to be significant.
 Reduced salivary output brought on by anticholinergic medications, dehydration, or radiation
.
Predisposing factors for salivary calculi include inflammation of the salivary gland or duct, salivary stasis, retrograde bacterial contamination from the oral cavity, increased salivary alkalinity, and physical trauma to the salivary duct or gland. Salivary calculi are composed of calcium phosphate and hydroxyapatite with smaller amounts of magnesium, potassium, and ammonium.
 
The development of salivary stones and gout. Sialoliths in gout are made of uric acid.
Staphylococcus aureus, Streptococcus viridans, Streptococcus pyogenes, Haemophilus influenzae, Escherichia coli, Pseudomonas aeruginosa, and group B streptococci (neonates and children) are the most common bacteria to cause sialadenitis.
Because of the mumps, CMV, Epstein-Barr virus, HIV, and enteroviruses, viral sialadenitis frequently has several foci.
The use of radioiodine, positive pressure ventilation  when under anesthesia, Sjögren syndrome, and sarcoidosis are some additional common reasons.



Child Safety Considerations

Idiopathic juvenile recurrent parotitis and the mumps are frequent causes of sialadenitis in kids.

Anticholinergic usage, poor oral hygiene, hunger, smoking, dehydration, and head-and-neck radiation are risk factors.


Prevention 
Avoid anticholinergics and other xerostomia triggers, and practice good oral hygiene.


Associated Conditions 
Sjögren syndrome, Mikulicz syndrome, radiation or medication-induced xerostomia, and hypercalcemia

Diagnosis 
The submandibular glands account for the majority (80%) of salivary gland stones, followed by the parotid gland (6–20%) and the sublingual or small salivary glands (1–2%).
The duct is where submandibular stones are more frequently found.
Stones in the parotid gland are internal to the gland itself, more numerous, and often smaller than stones in the mandible.


History 
Acute onset of pain and swelling over the affected salivary gland, especially postprandial or following the anticipation of eating; dental pain, discharge, bad breath (halitosis); hypersalivation; and pain with chewing; review history for: alcoholism, bulimia, malnutrition; radiation therapy, past malignancy; TB or HIV exposure;
Xerostomia Worsening discomfort, erythema, and/or fever may indicate secondary infection Pus drainage from the gland duct into the mouth 33% of patients with submandibular sialolithiasis present with painless swelling and 10% with pain but not swelling.

Clinical evaluation 
Visual examination of the glands and ducts may reveal a stone in the Wharton duct or close to the tongue's frenulum in the case of the submandibular gland.
A stone for the parotid glands may be felt in the Stensen duct or observed at the aperture.
 Bimanual examination of the oral cavity, including palpation of all salivary glands, the tongue, the floor of the mouth, and the neck to determine symmetry, tenderness, induration, edema, the presence of stones, lymphadenopathy, and the number of affected glands. Typically, an active gland is elastic and spongy.
Check the duct apertures for saliva and purulent discharge. It is possible to have acute bacterial sialadenitis if there is a purulent discharge from the opening.
Gently palpate the gland to check for normal, thin, nonexistent, or diminished saliva production and to feel for bubbling or purulent outflow.
Look into interstitial keratitis in the eyes.
 An assessment of the facial nerve's (CN VII) health, which could be jeopardized if the parotid gland is affected.
Child Safety 


Considerations
Children's stones 
frequently occur within the distal duct.
In sialendoscopy, ultrasound is both diagnostic and therapeutic.

Differential diagnosis include salivary gland cancers, lymphoma, cystic fibrosis, bacterial parotitis, idiopathic juvenile recurrent parotitis, the measles, and tularemia.

Laboratory Results 

Sialolithiasis is diagnosed clinically based on a distinctive history and physical exam. When eating or anticipating eating, the afflicted gland often experiences an abrupt onset of pain and swelling. At the damaged salivary duct's opening or throughout its length, a stone could be palpable.

Initial examinations (lab, imaging)
Think about CBC.
Culture and sensitivity of any expressed pus.
Up to 90% of stones 2 mm or larger can be found with ultrasound.
The CT scan with IV contrast is more sensitive, but it exposes you to radiation.
 MR sialography without intraductal contrast for patients with an inconclusive ultrasound and persistent symptoms.
 Sonopalpation, which combines transoral palpation with ultrasound, has a sensitivity and specificity of 96.6% and 90% for detecting calculi, respectively.


Tests in the Future & Special Considerations
 
Request rheumatoid factor (RF) and antinuclear antibodies (ANAs) tests if an autoimmune disease is suspected.
 
Diagnostic Procedures/Other: Salivary gland biopsy
.Sialography to assess obstructive lesions such as sialolithiasis.
Sialoliths can be found and removed through sialendoscopy. In one investigation, sialendoscopy verified 812 (93%) submandibular stones and 221 (79%) parotid stones.
According to one study, sialendoscopy, cone beam CT, and sonography all exhibited great specificity and positive predictive value when it came to identifying stones.
A unique ultrasound-guided needle localization method has been suggested when sialendoscopy fails.
Patients with sialolithiasis had decreased gland excretion and decreased absorption, according to technetium-99m pertechnetate scintigraphy.

Management 
Keep yourself hydrated.
Use hot compresses.
Milk the duct while massaging the gland.
Sialagogues, or substances that encourage salivation, may be beneficial. Examples include tart, lemon juice, and hard candies (lemon drops). Use as tolerated throughout the day.
 Practice proper oral hygiene.
By using mouthwash containing chlorhexidine 0.12% three times a day, you can improve oral hygiene and lessen the amount of germs that live in your mouth.
 Stop using drugs that have anticholinergic effects and lower saliva production.

Prescription drugs include NSAIDs for pain relief and antibiotics for any secondary infections (fever, purulent discharge).

Initial Line
A culture of the duct discharge should be collected, and the antibiotic coverage should be expanded by switching to amoxicillin/clavulanate or clindamycin if there is no improvement after 5 to 7 days. Antistaphylococcal antibiotics such dicloxacillin or cephalexin 500 mg QID for 7 to 10 days.
Clindamycin 300 mg PO every 8 hours if you are allergic to penicillin.
 Fluoroquinolones or third-generation cephalosporins for Gram-negative bacteria
Metronidazole or clindamycin for anaerobic bacteria

Next Line

For empiric coverage, first-generation cephalosporins (cephalexin or cefazolin) or clindamycin are also recommended.
Vancomycin in the event of MRSA


If you have a dental abscess or poor dentition, consult a dentist.
 ENT if symptoms recur or don't go better with conventional treatment

Further Treatment 
Consider placing a sialostent in the case of chronic sialadenitis with strictures.

Surgical Techniques 
Submandibular stones in the hilum require gland excision, but those on the anterior floor of the mouth can be removed intraorally (sialodochoplasty). Parotidectomy is typically necessary for parotid stones.
Sialadenitis and sialolithiasis treated by sialendoscopy have shown promising results in terms of symptom reduction, patient quality of life, and safety. Strictures, ranulas, and lingual nerve damage are complications. Sialendoscopy is not advised in cases of severe sialadenitis.
A combination strategy employing sialendoscopy and a small intraoral incision had an 86% success rate.
When conventional treatment for a parotid abscess fails after three to five days, surgery is required to drain the abscess.
● In about 80% of instances, sialoliths larger than 4 mm and stenoses can be successfully treated using radiologically, fluoroscopically, or sialendoscopically based techniques. Up to 50% of patients who undergo extracorporeal shock wave lithotripsy (ESWL) are successful.
 90% success rate with transoral duct cutting for extraparenchymal submandibular stones

Alternative Therapies 
To encourage salivation, consider using lemon drops or other sialogogues. In one study, sialogogue use after surgery nearly cut sialadenitis incidence in half.

Admission 

Parotid abscess  and inability to tolerate PO intake

Avoid recommending drugs that contribute to xerostomia. Keep an eye on patients with chronic sialadenitis since acute exacerbations might result from diminished salivary gland function brought on by fibrosis and acini loss.


Diet 
Avoid sialogogues during acute bouts, and drink enough water.


Modification of Lifestyle 

preserving healthy dental and hydration habits


With the right care, acute symptoms will often go away in about a week. Following cautious outpatient care, full recovery is anticipated.
Due to systemic involvement, patients with autoimmune etiology may experience a longer course.
18% of individuals who have transoral surgery to remove stones have reported experiencing a recurrence.


Complications 

Localized infection that spreads, leading to cellulitis or Ludwig's angina; facial nerve impingement; hypoglossal and lingual nerve injuries; and dental decay because salivary gland hypofunction reduces teeth's ability to fend off acid erosion and decay. 

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