SALIVARY GLANDS – WHAT IS NORMAL AND WHAT IS NOT

Where are they?

The salivary glands located around the mouth and throat. The main ones are the parotid, submandibular and the sublingual. They all secrete saliva into the oral cavity through the parotid duct near the upper teeth, submandibular under the tongue and the sublingual through many ducts in the oral cavity.

In addition there are hundreds of tiny glands called minor salivary glands within the mucosa, cheeks and located throughout the oral cavity.

The salivary glands produce saliva which serves to moisten the mouth and begin the process of digestion and also protect teeth from decay.

What causes problems in the salivary glands?

Abnormalities of the salivary glands that cause clinical symptoms can be classified into the following categories:

1. OCCLUSION

Obstruction to the flow of saliva usually occurs in the parotid or submandibular and the main cause is the formation of stones. Symptoms occur during eating. Saliva begins to be produced but as the duct closes, the gland swells and hurts, sometimes causing infection.

2. INFLAMMATION

If the stone does not block the duct completely, then, the gland will swell during eating and then gradually subside to swell again at the next meal. Contamination can occur in saliva that has stagnated leading to even more pain and swelling in the gland. If you neglect this situation it can create an abscess.

3. CONTAMINATION

The most common is mumps which is primarily childhood disease but can also occur in adults. However, if an adult has swelling in the parotid gland on one side only, it’s most likely an obstruction or tumour. It has already been said that contamination can occur in the area of the duct obstructing the flow of saliva. Another way is through the transmission of infection in the salivary glands of the cervical lymph nodes, which are often sensitive to a common throat inflammation. Many of these lymph nodes are located on or in the same gland near parotid and submandibular. When these lymph nodes become inflamed it is perceived by the patient as a red painful swelling of the parotid or submandibular salivary gland. The lymph nodes also swell because of tumours or inflammations.

TUMORS

Benign and malignant tumours of the salivary usually appear as painless swellings. They rarely involve more than one gland and appear as a swelling in the region of the parotid or submandibular gland area or on the cheeks, lips or floor of the mouth. These lumps should be checked by ENT physician.

Malignant tumours can grow quickly, be painful and cause loss of movement of part or all of the affected side of the face. Such symptoms should be investigated immediately.

Salivary bulges observed in autoimmune diseases. Patients often complain of dry mouth or dry eyes. Rheumatoid arthritis, diabetes is sometimes responsible for salivary bulges. Finally bilateral swelling salivary is usually observed in alcoholics.

HOW IS THE DIAGNOSIS MADE?

The diagnosis is based on a careful history, physical examination and laboratory tests. If it’s a probable obstruction, it may necessary to open the blocked salivary duct and place a catheter to expand the pipeline and thus to facilitate passage of the stone. A prior radiological examination will show exactly where the stone is located. If there is some mass, a CT scan will reveal if this mass is part of the salivary gland or lymph node.

In many cases it is helpful to do a fine needle biopsy. The accuracy of this test reaches 80%, about 90%. An open biopsy of the skin is where an incision is made and a small piece of the gland taken for testing. This surgical biopsy is not recommended in a practice because it may injure adjacent nerves, so surgery must be done in theatre.

TREATMENT

Which surgical and medical treatment depends on the specific nature of each case. If the cause is a systemic disease (i.e. a disease that engages the whole body and not just a specific area), then this disease I must be cured, in such cases with a physicians cooperation and other disciplines.

If an infection, antibiotic are used. Sometimes it is necessary to perform a catheterization of resources.

If a mass has developed inside the gland it may require removal. Most masses found in the salivary glands are benign. It takes great care not to damage the facial nerve that passes through this region. Radiotherapy is often recommended after the surgical removal of a malignant tumour. This is approximately 4 to 6 weeks after to allow sufficient healing before irradiation.

The same general principles apply to the submandibular tumours or tumours of minor salivary glands of the oral cavity. Benign tumours are treated surgically and only while malignant usually need additional radiation. If the tumour from lymph node is swollen due to cancer then obviously you will need different treatment.

The tonsils and adenoids are part of a “ring” which is located at the back of the neck (waldeyers ring). The adenoids are located behind the nose and the palate and are not seen by mouth. They can only be seen using special tools. It is located at the entrance of the airways at that point from where they enter the body by various infections. Their role is to identify the various bacteria and viruses and produce antibodies against them activating defenses organisms. The function of adenoids and tonsils occurs early in life and as the years go their function fades. In fact their role stops after the age of three (3) years. The methods used to evaluate the adenoids and the tonsils are:

  • Medical history
  • Physical exam
  • Radiography
  • Endoscopy

Clinical examination of the nose and throat may require the use of special tools like a small mirror or flexible endoscope. Examination is done when a child or adult suffers from frequent tonsillitis, pharyngitis, feverish conditions, breath odor, nasal obstruction and shortness of breath, recurrent ear infections, mouth breathing, snoring and sleep disorders and swallowing problems. All infections of the tonsils and adenoids are treated first with antibiotics. Sometimes they may require removal. The main indications for tonsillectomy and / adenoidectomy is:

  1. Repeated infections despite antibiotic treatment.
  2. Difficulty breathing due to swelling of the adenoids and the tonsils.

It is commonly known that obstruction of the airway causes snoring and sleep disorders resulting in daytime sleepiness in adults and behavioral problems in children. Moreover chronic inflammation can lead to problems of the ears as well as a large bulge that can cause orthodontic problems, especially in children.

JUST SNORING OR SOMETHING MORE?

The disturbance of breathing during sleep can range from minor problems to the health of patients (snoring) to heavy sleep apneas (breathing interruption during sleep) which may be for peripheral reasons (obstructive sleep apnea) or on the rare occasions the central reasons which potentially without treatment may lead to serious cardiovascular problems (pulmonary hypertension, right heart failure, etc.).

The syndrome causes the obstructing of breathing and affects the daily activity of patients including drowsiness, weakness, lack of concentration, irritability, increased risk of accidents, etc.
 
Patients are usually unaware of the risks of these daily difficulties and come to the doctor because of established pressure from their social environment that does not tolerate snoring.
 
Snoring is more common in men and the overweight. 45% of adults snore occasionally, while 25% snore on an everyday basis. Alcohol, smoking, over eating especially during the evening as well as some medications can aggravate the problem.
 
The risks that snoring causes include reduced muscle tone in the tongue & neck, enlarged muscle mass tissue in the nasopharynx e.g. adenoids in the nose, elongated soft palate, or uvula, deviated septum, polyps in nose etc.
 
As for the cause of obstructive sleep apnea, it’s usually a blockage caused by movement of the tongue at the rear of the throat during sleep. This can be seen e.g. in retrognathism (small jaw).
 
There are many patients who may experience 30-300 episodes of apnea at night resulting in the reduction of oxygen in the blood and therefore may require an intensive heart operation.
 
The treatment of snoring and obstructive sleep apnea depends on accurate diagnosis. The patient must undergo a complete and thorough examination. Apart from routine examination, a sleep-recording test should always be done. This examination is necessary before any treatment because it is the only one that can capture the scale of the problem ( apnea, hypopneas,how it gets oxygen during sleep, etc.).
 
After this examination and according to the results of the test, the doctor will decide a more therapeutic sleep pattern to follow. This can be simply lowering body weight, stopping smoking, a surgical therapy. If  still high level of sleep-apnea syndrome may be necessary to implement continuous positive pressure using nasal masks (CPAP).