Diffuse Parotid Gland Enlargement
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1 Non-Neoplastic Parotid Gland Disorders David W. Eisele, M.D., F.A.C.S. Head and Neck Surgery and Oncology UCSF Helen Diller Family Comprehensive Cancer Center University of California, San Francisco Diffuse Parotid Gland Enlargement Variety of clinical disorders - Primary gland disorder - Systemic disorder with gland involvement Local symptoms +/- systemic or asymptomatic Diagnosis generally dependent on clinical evaluation and diagnostic studies Treatment largely guided by diagnosis and patient complaints 1
2 History Determine if solitary parotid or more generalized salivary gland involvement Progression of enlargement Inciting factors for enlargement Nature and duration of symptoms Pain: character, severity, frequency History Associated Symptoms - Head and Neck - Systemic Review of Systems Medications Past Medical History Social History (eg. alcohol use) Family History 2
3 Physical Examination Complete Head and Neck Exam Inspection / Palpation of Salivary Glands - enlargement (unilateral/bilateral) - consistency - tenderness - mobility Differentiate diffuse gland enlargement from discrete mass or anatomic anomaly Physical Examination Oral Cavity -Moisture level -Dentition status -Salivary duct output amount character -Palpate for sialoliths, masses Salivary duct probing 3
4 Team Approach Radiology Pathology / Cytopathology Internal Medicine Rheumatology, Endocrinology Infectious Diseases Pediatrics Psychiatry Nutrition CT Scan / MRI Useful to rule-out neoplasm or extrinsic mass Extent of glandular enlargement - localized or diffuse - unilateral, bilateral, or generalized Nature of enlargement - parenchyma density -fat, fibrosis - presence of cysts 4
5 Laboratory Studies Order selectively based on information gleaned from history, physical examination, and imaging studies Useful for diagnosis or exclusion of systemic disorders: - Infectious - Granulomatous - Metabolic - Autoimmune - Hormonal Laboratory Studies HIV test Angiotensin converting enzyme (Sarcoid) Autoantibodies (Sjogren s) - Rheumatoid factor - Antinuclear antibodies - Anti-SSA, Anti-SSB Antineutrophil cytoplasmic antibody;anca (Wegener s) Hormone levels (eg. TSH) 5
6 Fine Needle Aspiration Biopsy Valuable to exclude neoplasm or lymphoma Accurate for diagnosis of non-neoplastic enlargement Acinar size measurement may be helpful (sialadenosis) Clinicopathological correlation important Diagnostic Salivary Gland Biopsy Lower lip minor salivary glands - obtain multiple glands Sjogren s - greater than one focus (>50 lymphocytes in area) in 4 mm 2 Sarcoid - noncaseating granulomas 6
7 Sialendoscopy for Evaluation of Glandular Swelling of Unclear Etiology Koch M et al; OHNS, patients with chronic gland swelling Imaging studies (esp. U/S) No clear etiology of swelling 97% success Findings: stones 20% stenosis/ foreign body 56% sialodochitis 10% normal 10% Diffuse Parotid Gland Enlargement Classification Inflammatory Non-Inflammatory 7
8 Inflammatory Enlargement Acute Sialadenitis Viral Bacterial Radiation Medication Chronic Sialadenitis Obstructive Granulomatous Autoimmune HIV-associated Acute Viral Sialadenitis (Mumps) Acute viral infection -Paramyxovirus predominates Unusual due to two-dose MMR vaccine Spread by cough, sneeze; 2-3 wk incubation 2006 Midwest outbreak (1 st in 20 years) Iowa and surrounding states Over 2500 cases (usually 265/year) 8
9 Acute Viral Sialadenitis (Mumps) Bilateral or unilateral painful parotid swelling Fever, headache, cough, malaise Clinical diagnosis; serologic test Symptomatic and supportive treatment Usually resolves in several weeks Deafness, meningitis, orchitis Acute Bacterial Sialadenitis Acute bacterial infection of ducts and parenchyma, usually unilateral Debilitated and dehydrated patients Polymicrobial: Staph aureus, H. flu, gram neg. anaerobes Painful diffuse gland enlargement, tenderness Antibiotics, hydration, gland massage, oral care Surgical drainage for medical therapy failure 9
10 Sialolithiasis Common parotid gland obstructive disorder Exact etiology unknown Theory: deposition of calcium salts around a nidus of : - desquamated cells - microorganism - foreign body -mucous plug Reduced fluid intake; smoking Sialolithiasis Recurrent painful parotid gland swelling Episodes of acute bacterial sialadenitis Abscess formation Chronic sialadenitis Gland atrophy 10
11 Radiation Sialadenitis Inflammatory process due to radiation effect on gland parenchyma, dose-related injury Serous glands and acini most susceptible External beam radiation Radioactive iodine Painful, tender glands; swelling; xerostomia Chronic injury can result Some benefit with sialendoscopy Chronic Sialadenitis Non-granulomatous chronic inflammatory condition Etiology may be unclear by history - primary obstruction / secondary infection - primary infection / secondary obstruction Recurrent painful gland enlargement common - exacerbation with eating Relief of duct obstruction, sialogogues, glandular massage, warm heat Gland resection for medical therapy failure 11
12 Chronic Sialadenitis - Parotidectomy Failure of medical management Effective Extent of parotidectomy - lack of consensus (superficial vs. total) Technically challenging Facial nerve sometimes thin Temporary facial paresis common (30-60%) Sarcoidosis Systemic granulomatous disease, unclear etiology < 1/3 patients - painless salivary gland swelling Nontender and multinodular glands; xerostomia ACE elevation (50-80%) Most patients have pulmonary involvement CXR- hilar nodes, adenopathy, parenchymal infiltrates Noncaseating granulomas on histopathology Treatment supportive; steroids in select patients 12
13 Wegener s Granulomatosis Necrotizing granulomatous inflammation and vasculitis; etiology unknown Affects upper and lower respiratory tracts, kidney Parotid and submandibular gland involvement (5%) causes persistent gland swelling Dx: Antineutrophil cytoplasmic antibody (ANCA) Biopsy - histopathological triad: granulomatous inflammation, necrosis, and vasculitis Treatment corticosteroids, cyclophosphamide Sjogren s Syndrome Autoimmune disease Exocrine gland dysfunction with lymphocytic glandular infiltration Xerostomia, keratoconjunctivitis sicca Bilateral or unilateral nontender parotid swelling - most pts.with primary form; 1/3 secondary - intermittent or persistent Diagnosis- clinical, autoantibodies, gland biopsy Treatment supportive Salivary secretagogues - pilocarpine;cevimeline 13
14 Sjogren s Syndrome Lymphoma Risk Ioannidis et al; Arthritis Rheum, 2002 Probability of lymphoma: 2.6% at 5 years 3.9% at 10 years HIV-Associated Cystic Sialadenitis Bilateral parotid multicystic enlargement Lymphocytic (T cell) infiltration of gland Persistent, nonprogressive May be mildly painful Enlarged adenoids, cervical nodes common Diagnosis largely clinical Positive HIV test Must exclude lymphoma or other neoplasm 14
15 HIV-Associated Cystic Sialadenitis - Management Anti-retroviral medications Injection sclerotherapy doxycycline, bleomycin Surgery not recommended, despite patient enthusiasm Non-Inflammatory Enlargement Acute Enlargement Neoplasm Miscellaneous: Trauma Pneumoparotitis Anesthesia/ Endoscopy Chronic Enlargement Obesity Sialadenosis - Endocrine - Nutritional - Medication - Idiopathic Amyloidosis 15
16 Sialadenosis (Sialosis) Non-inflammatory, non-neoplastic gland parenchyma enlargement Bilateral parotid enlargement most common Can be recurrent or persistent Wide variety of systemic conditions causative Unifying factor - neuropathic alteration of the autonomic innervation of salivary acini (Batsakis) Diagnosis primarily clinical, exclusion of others Complete metabolic and endocrine evaluation Sialadenosis - Etiologies Endocrine Disorders - Diabetes Mellitus (1/4) - Hypothyroidism Alcoholism (autonomic neuropathy) Nutritional Disorders - Bulimia (1/3) - Deficiency condition eg. protein (alcoholism) vitamin (niacin, thiamine, vit. A) 16
17 Sialadenosis - Etiologies Medications - Direct effect on gland eg. iodine compounds - Drug side-effect (adrenergic, cholinergic) eg. antihypertensives (guanethidine) antiemetics (phenothiazine) antiepileptics (phenobarbital) bronchodilators (isoproterenol) Idiopathic - diagnosis of exclusion Sialadenosis - Treatment Correct underlying disorder Pilocarpine - Bulimia Mehler,Wallace; Arch OHNS, 1993 Consider parotidectomy only for unacceptable cosmetic deformity unresponsive to medical therapy 17
18 Summary Variety of clinical disorders are responsible for diffuse parotid gland enlargement Clinical evaluation and selective use of diagnostic studies are key to diagnosis Multidisciplinary team approach helpful Diagnosis and patient symptoms guide treatment recommendations 18
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