Conditions of the Salivary Glands

We have three paired major salivary glands, the parotid, the submandibular, and the sublingual glands, as well as thousands of minor salivary glands.  Various conditions, described below, may occur within these glands.

Anatomy

Obstruction of a salivary duct

Stones in the salivary ducts are most frequently the cause of saliva gland obstruction. Other less frequent causes are impaction of the duct orifice, trauma to the orifice, idiopathic inflammatory stenosis, and radioiodine-induced stenosis. The symptoms of an obstructed salivary duct are usually very characteristic, consisting of recurrent swelling of the affected gland, particularly with meals, because that is when saliva production peaks and the backup of saliva is therefore greatest.

salivary Stones (saliolithiasis)

Salivary stones, also known as sialoliths, form due to calcifications in the salivary glands. These solid crystal aggregates consist mainly of calcium, with possible inclusion of minerals like magnesium and phosphate. The size of these stones can range from that of a grain of sand to that of a marble. Salivary stones may be solitary or multiple, and may block flow of saliva in the ducts, resulting in swelling and pain that occurs with eating because this is when saliva flow is maximal. Because of the backup of saliva, salivary stones also predispose to bacterial infection (sialoadenitis), described below. Increased blood calcium may predispose to the formation of salivary stones as well as urinary tract stones, and may be the result of hyperparathyroidism.

Infections

Infection of a salivary gland, called sialoadenitis, may be caused by a bacteria or, less commonly, by a virus.

Bacterial

Bacterial sialadenitis, is characterized by inflammation of the salivary glands due to bacterial infection. Staphylococcus aureus is the most common causative organism, although other bacteria such as Streptococcus species can also be responsible. The condition typically presents with symptoms such as pain, swelling, and tenderness in the affected gland, usually the parotid gland.

Viral

Viral sialadenitis is most commonly affects the parotid salivary gland, located near the ear and is usually caused by either the mumps virus, cytomegalovirus, or coxsackievirus. The mumps virus (paramyxovirus) has a vaccine that is routinely given in childhood in most developed countries, and a history of mumps immunization makes mumps sialoadenitis very unlikely. Symptoms of viral sialoadenbitis typically include pain and swelling in the affected salivary gland. In some cases, individuals may experience fever, difficulty swallowing, and dry mouth.

Tumors

Salivary gland tumors are abnormal growths that develop in the tissues of the salivary glands, which are responsible for producing saliva in the mouth. These tumors can be either benign or malignant, with the majority being benign. Symptoms of salivary gland tumors may include a lump in the mouth or neck, numbness in the face, difficulty swallowing, or facial paralysis. Diagnosis often involves imaging tests, such as MRI or CT scans, followed by a biopsy for confirmation. Treatment options may include surgery, radiation therapy, or chemotherapy, depending on the type and stage of the tumor.

Mucocoele

An oral mucocoele, also known as a mucous cyst, is a painless bump that forms on the inside of the lip or the floor of the mouth. It is usually caused by a blockage of the salivary gland ducts, leading to the accumulation of saliva and mucus. Oral mucocoeles appear as fluid-filled sacs that are translucent, though often with a bluish color, and vary in size. While they are typically harmless and tend to resolve on their own, larger mucocoeles may cause discomfort or interfere with speaking and eating. In such cases, treatment may involve draining the fluid or surgical removal.

Trauma

A sialocele is a collection of saliva that has leaked from a damaged salivary gland duct and become trapped under the skin. This condition typically presents as a painless, soft swelling in the mouth or neck area. Sialoceles are caused by some form of trauma to the salivary gland, including surgery and non-medical traumatic injury. A sialocoele is typically not painful unless it becomes infected. Treatment for sialoceles usually involves reducing the accumulation of saliva by drainage or medicine to decrease saliva production (e.g. Botulinum toxin or glycopyrrolate) and and repair of the damaged duct(s). Small duct branches may heal spontaneously, but larger duct injury or for sialocoeles that persist despite more conservative therapy, surgical exploration may be necessary.

A salivary fistula is similar to a sialocoele, but is characterized by an abnormal connection between a salivary gland and the surface of the skin, causing leakage of saliva rather than a contained collection of it under the skin. Salivary fistulas can occur as a complication of surgery, trauma, or infection involving the salivary glands. Treatment may involve medical efforts to decrease salivary flow from the affected gland (e.g. Botulinum toxin or glycopyrrolate), but may require surgical repair.

dry mouth (xerostomia)

Xerostomia is the experience of a dry mouth from a deficiency of oral saliva, Dry mouth is associated with xerogenic medications, dehydration, exposure to radiation, and smoking. Decreased saliva production can affect quality of life by hindering one’s ability to eat, speak, and swallow. In severe instances, xerostomia may even lead to oral infections and promote accelerated dental decay. Effectively managing xerostomia typically involves using saliva substitutes, staying well hydrated, practicing good oral hygiene, possibly using salivary stimulants (e.g., cevimeline (Evoxac®)), and modifying the diet to favor wet foods over dry foods such as bread.

xerostomia from medication

The highly folded, small print paper included with a prescription medication will list potential side effects of the medicine. Common medications frequently causing xerostomia include the following:

• Anticholinergics for overactive bladder (oxybutynin, darifenacin, fesoterodine (Toviaz®), solifenacin (Vesicare®), tolterodine (Detrol®), and trospium

• Antihistamines used for allergies, itching, and swelling, especially “1st generation” antihistamines, such as diphenhydramine (Benadryl®), chlorpheniramine, hydroxyzine hydrochloride, hydroxyzine pamoate (Vistaril®),

• Antidepressants, including those in the serotonin and norepinephrine reuptake inhibitors (SNRIs) and selective serotonin reuptake inhibitors (SSRIs), including venlafaxine (Effexor XR®), duloxetine (Cymbalta®), citalopram (Celexa®), escitalopram (Lexapro®), paroxetine (Paxil®), fluoxetine (Prozac®), sertraline (Zoloft®).

• Tricyclic antidepressants — such as amitriptyline, nortriptyline (Pamelor®), and clomipramine (Anafranil®).

• Stimulants, used for ADHD, including amphetamine salts (Adderall®), methylphenidate (Ritalin®), and (methylphenidate ER®), and Concerta®.

• Opiates, used for pain, including morphine (MS Contin®), oxycodone, (which is in Percocet®), hydrocodone (which is in Vicodin® and Lortab® Tramadol® and hydromorphone (Dilaudid®)

• Benzodiazepines, used for anxiety, including alprazolam (Xanax®) lorazepam (Ativan®) diazepam (Valium®), temazepam (Restoril®)

• Antipsychotics and mood stabilizers, including haloperidol (Haldol®), chlorpromazine, fluphenazine, olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine (Seroquel®), clozapine (Clozaril®) and lithium (Lithobid®).

Xerostomia from radiation

Xerostomia is a prevalent side effect of radiation therapy for head and neck cancer when the salivary glands have been exposed to the radiation. Radiation therapy is a used for multiple types of cancer in the head and neck area, including salivary gland cancers, oral and throat cancers, thyroid cancer, and skin cancer. Salivary glands are highly sensitive to radiation which results in decrease in the volume of saliva produced.

Autoimmune - Sjogren’s disease

Sjogren's disease is a chronic autoimmune disorder that predominantly affects the tear and salivary glands. Typical signs of this condition include dry eyes and dry mouth. Alongside gland-related issues, some patients may also encounter systemic symptoms like fatigue, joint discomfort, and potential organ dysfunction. Diagnosis usually involves a rheumatologist combining information from history, physical exam, blood screenings, and sometimes imaging scans. In some cases, biopsy of a minor salivary gland is required to make the diagnosis. Treatment strategies are centered on symptom relief and may involve the use of artificial tears, medications to enhance saliva flow (and/or minimizing medications that inhibit saliva flow), and for severe disease, use of immune-suppressing medications.

Noninflammatory enlargement- Sialadenosis

Sialadenosis is a noninfectious, noninflammatory gland enlargement usually affecting both left and right parotid glands simultaneously. This swelling is generally painless. Sialoadenitis may result from or be associated with diabetes mellitus, obesity, chronic malnutrition, alcoholism, and liver disease.