Swollen Submandibular Gland
The submandibular gland is a type of salivary gland located under the chin and on both sides of the chin. It can enlarge and become visible from the outside for various reasons. One of the terms used in this regard is "sialosis (sialadenosis)", which is a chronic, bilateral, non-inflammatory, non-cancerogen salivary gland swelling that mainly affects the major salivary glands, especially the parotid glands, but sometimes also affects the submandibular glands and rarely the minor salivary glands. The affected salivary gland may be painless or tender in some cases.
There are different uses of the term 'sialosis' in the literature. Some consider 'sialosis' to be synonymous with 'sialadenosis'. Others - According to Katz et al., they use the term "sialosis" to refer to all chronic diseases of the salivary glands that are not caused by infection or tumor (sources >> Clinical ultrasound of the salivary glands - PubMed / https://medicine.uiowa.edu/iowaprotocols/sialosis-or-sialadenosis-salivary-glands).
While sialosis can also occur without cause (idiopathic), other causes can be summarized as follows:
- chronic malnutrition
- obesity
- diabetes mellitus
- alcoholism
- liver disease
- eating disorders
- medications (i.e. antihypertensives)
When the term "itis" is added to the end of an organ's name, it can mean "inflammation" or "infection", and the term "sialadenitis" is used to refer to inflammation or inflammatory swollen salivary glands that occur for various reasons. Submandibular gland sialadenitis here occurs due to autoimmune diseases (diseases in which the body creates an immune response against its own tissues), viral or bacterial infections, or salivary gland stones. Submandibular gland ducts open into the mouth just under the tongue, and since the opening channels are vertical upwards, slowing of the flow and stone formation can often be seen. When a salivary gland becomes inflamed, it can stop functioning. Especially when there is a narrowing or stone in the duct that discharges the salivary gland secretion, its function can stop completely or decrease significantly. When there is a stone in the salivary gland duct, this condition is called "sialolithiasis". Sometimes, even after a simple viral infection, enlargement of the salivary glands and surrounding lymph nodes under the chin may occur. In some patients, simple lymph node enlargement may be mistaken for submandibular gland swelling. In patients with recurrent submandibular gland enlargement, usually due to the presence of stones in the canal, acute swelling, typically during eating, is a characteristic finding. In other words, there is a mechanical blockage in salivary drainage.
Causes
The main causes of infection in the submandibular gland are roughly the thickening and decrease of the secretion or the occurrence of obstruction in the secretion ducts. Salivary hyposecretion can be seen in patients due to drinking less water, using drugs that reduce saliva production, and having various diseases and after surgery. Drugs that reduce saliva flow such as antihistamines, diuretics, chemotherapy drugs and beta blockers can cause a tendency to sialadenitis. Decreased saliva production can be seen in patients with a history of radiation to the head and neck region (salivary glands), long-term xerostomia (e.g. Sjogren syndrome) and chronic diseases. Submandibular salivary gland duct obstruction can usually occur due to sialolithiasis (stones blocking the duct), duct stenosis, duct foreign bodies and external compression of the duct. The submandibular gland duct (Wharton duct) opens under the tongue to the posterior portion of the mylohyoid muscle, and the opening channels are vertical, against gravity. Salivary stasis may be facilitated in this area, and even a small amount of obstruction may block the flow of saliva through the entire duct. Other risk factors for salivary gland swelling and sialadenitis include advanced age, poor oral hygiene, postoperative status, intubation, and use of anticholinergic agents. Acute stagnation of saliva produced by the salivary gland, mechanically directed saliva into a narrow or obstructed duct, may cause saliva to accumulate and trigger an acute suppurative infection. Retrograde contamination of the salivary gland parasites by polymicrobial contents in the mouth is common. Submandibular sialadenitis is usually polymicrobial. Staphylococcus aureus is the most commonly isolated organism. Other bacteria include Streptococcus viridans, Haemophilus influenza, Enterobacteriaceae spp, and anaerobes such as Prevotella, Fusobacterium spp, Peptostreptococcus. Viral sialadenitis may be caused by mumps, parainfluenza, Epstein-Barr virus, and human immunodeficiency virus. In patients, a reddened area at the mouth of Wharton's duct, purulent discharge, and sometimes a stone in the canal mouth can be directly detected on bimanual examination.
Symptoms
When there is a stone blocking the salivary gland duct, sudden swelling and pain under the jaw during meals are typical findings. On examination, the submandibular gland is swollen, hardened, painful and tender. Cervical lymphadenitis may be present in cases of infection. Chronic or recurrent sialadenitis usually causes recurrent attacks of pain and swelling with meals and recurrent infections. Massage of the gland may cause purulent secretion to discharge from the duct orifice. Acute salivary gland swelling due to obstructive sialadenitis is usually the result of salivary gland stones and/or strictures and is characterized by intermittent gland swelling that occurs during meals, causing salivation. Mechanical obstruction of salivary flow in the duct causes swelling of the gland. Viral sialadenitis (e.g. mumps) presents with acute multifocal salivary gland swelling accompanied by constitutional symptoms such as fever, headache, malaise and myalgia. Submandibular sialadenosis presents with painless bilateral submandibular enlargement and may be associated with mild discomfort. Approximately 50% of cases are associated with known risk factors such as diabetes, metabolic syndrome, alcoholism, bulimia, malnutrition, and liver disease.
Physical Examination
During endoscopic ENT examination, swollen and reddened submandibular gland duct orifices may be noted. During bimanual examination, inflammatory discharge may be seen flowing into the mouth. Sometimes a stone obstructing the duct may be felt by hand, or when the submandibular area is massaged, a stone may be felt moving into the mouth due to the pressure secretion. In cases of suppurative sialadenitis, swollen lymph nodes may also be palpated around the gland and in the neck.
Additional tests, imaging tools
In addition to physical examination, evaluation of sialadenitis, laboratory studies in some patients, radiography, biopsy, and other tests to exclude autoimmune etiology may be requested, including:
- Culture antibiogram test of Wharton duct pus discharge. This should be done prior to empirical antibiotic therapy at the time of initiation of treatment. Once results are available, an antibiotic is determined based on sensitivity.
- Complete blood count to exclude infections
Imaging studies
- X-rays: May be useful for detecting sialoliths in chronic sialadenitis; approximately 70% to 80% of submandibular stones are radiopaque.
Ultrasound: Salivary gland stones (>1 mm) if present, salivary gland dimensions and blood supply characteristics, and the presence or absence of abscesses, and lymph nodes in the submandibular region and neck can be evaluated.
- Computed tomography scan: Indicated if conventional plain films are negative or if the clinical presentation is severe and may show sialolith. In chronic sclerosing sialadenitis, the salivary gland may be enlarged or atrophic.
- Sialography
- Magnetic resonance imaging: Magnetic resonance imaging is required if neoplasm is suspected. It may be requested especially when there is progressive enlargement and painless lymph node enlargement.
- Tests associated with Sjögren syndrome: antigen A autoantibodies, SSB/anti-La, antinuclear antibody, rheumatoid factor tests
- Fine needle aspiration cytology of the submandibular gland: Useful in distinguishing tumoral from non-tumorous salivary gland diseases and in establishing a definitive diagnosis.
Treatment
Treatment of acute sialadenitis
Conservative medical treatment is sufficient in the treatment of acute sialadenitis cases. The recommended treatment for patients is hydration (drinking plenty of water orally and preventing the thickening of salivary secretion), warm compresses, massage (can be done in a circular, ellipsoid or anteriorly from the submandibular gland), use of anti-inflammatory drugs and use of sialogogues. Empiric antibiotic treatment starts with amoxicillin/clavulanate or clindamycin, which has spread to the salivary gland. Antibiotic selection should be made according to culture and sensitivity reports. Spiramycin or macrolides can also be used. Intravenous antibiotics may be required in severe cases. If soft tissue swelling is excessive and there are no contraindications, corticosteroid treatment is an option. Rarely, acute suppurative sialadenitis can lead to local and neck-spreading abscess formation; surgical incision and drainage may be required in these cases.
Treatment of chronic sialadenitis and sialadenosis
Chronic sialadenitis: Medical management includes hydration and increasing the amount of water consumed, attention to oral hygiene, painkillers and sialogogues. In cases of infection, broad-spectrum antibiotics are added. In cases of sialolithiasis, salivary gland stone removal should be performed using interventional sialendoscopy or direct surgical removal. Salivary gland duct endoscopy is laborious and sometimes time-consuming. The use of very thin endoscopes and the easy damage of the instruments, difficulties in reaching the narrow and curved pearl salivary gland ducts, difficulties in removing rough and hard stones from the canal can complicate the procedure. I do not perform endoscopic salivary gland stone removal frequently and prefer to refer my patients to a doctor friend who is quite experienced in this regard. However, I perform submandibular gland stone removal, which is performed by incision in the mouth, and I have added a video of the procedure below. Ultrasound-guided extracorporeal shock wave lithotripsy can be used for intraglandular duct stone removal.
Submandibular glant stone removal (sialolitiyazis) video
In the treatment of recurrent sialadenitis (>3 attacks/year) or chronic sclerosing sialadenitis, excision of the salivary gland is recommended.
The approach adopted in the treatment of sialadenosis is to treat the underlying cause.
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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