BMN Blog

Saliva is produced by three paired “major” salivary glands in the head and neck – Parotid, Submandibular, and Sublingual as well as ~400 “minor” salivary glands throughout your oral cavity and oropharynx. Saliva is usually plentiful (your mouth makes between one pint and one liter per day) and is important in the enzymatic digestion of food, providing an immunologic barrier for dental protection, and to foster ideal oral mucosal health. Salivary glands may be affected by several different disorders that disrupt their important normal function:

• Salivary gland inflammation (Sialadenitis) – inflammation or infection of the gland, often secondary to bacterial overgrowth or dehydration, usually identified in elderly, hospitalized, or immunocompromised patients.
• Salivary Gland Stones (Sialolithiasis) – similar to kidney stones, producing stasis of flow and subsequent bacterial infection (Sialadenitis).
• Autoimmune disorders: Sjogren’s syndrome, sarcoidosis
• Neoplasms: Primary Salivary gland tumors (benign & malignant), as well as Lymphoma or other metastatic cancer to intraparotid lymph nodes.

Identification and appropriate referral for management of Salivary Gland pathology is important, as treatment is dependent on timely and accurate diagnosis. Imaging studies in the form of ultrasound versus contrasted CT scanning provide information about potential neoplastic versus inflammatory processes. Rapid referral to Otolaryngologists with a special interest in head and neck pathology is imperative for appropriate management.

Inflammation or Infection

Symptomatic management in association with antibiotic therapy (Augmentin vs Clindamycin) is important for management of sialadenitis. In general, the mainstays of therapy relate to appropriate hydration, warm compresses, sialogogues (sour candies to promote salivary flow), and NSAIDs.

Gland Enlargement or Mass

Enlargement of salivary glands in the absence of signs/symptoms of inflammation is concerning for neoplasm or autoimmune disease. Laboratory testing for autoimmunity is often performed in tandem with definitive imaging and/or Fine Needle Aspiration (FNA). Performing FNA may precipitate secondary inflammatory response within the salivary glands, so the benefit of this procedure is weighed against the potential for creating a temporary worsening of symptoms. Alternatives to FNA for a primary salivary gland neoplasm include surgical gland removal. This is a safe, effective, and rapid (< one hour) outpatient procedure to definitively remove the affected gland.

If salivary gland or duct stones are identified on imaging or physical exam findings, intraoral extraction of the stone may be attempted if the stone is palpable, or endoscopic removal (sialoendoscopy) may be performed – akin to removal of kidney stones.

Removal of salivary glands is performed for suspected neoplasm, and is undertaken with careful preservation of surrounding structures, which are vital for normal facial function, speech, and swallow.

• Parotidectomy entails removing the largest salivary gland from the lateral aspect of the face. Utilizing a “facelift” incision, hidden in a preauricular skin crease or along the tragal edge, the skin and soft tissue are elevated off of the parotid gland, with subsequent identification and preservation of the facial nerve and its five main divisions. This is almost always performed in conjunction with intraoperative facial nerve monitoring.
• Submandibular gland excision involves a small incision approximately two fingerbreadths below the jawbone, with dissection and removal of the gland and ligation of the duct and nerve (ganglion). Care must be taken to preserve the hypoglossal nerve (tongue mobility) and lingual nerve (taste, sensory).
• Sublingual gland excision is often performed through an intraoral incision for treatment of ranula (collection of mucus within the anterior floor of mouth), dissection is carried down through the intrinsic musculature with identification and preservation of the lingual nerve.
• Minor Salivary gland biopsy is often performed for pathologic identification of autoimmune disease, and is a simple clinic procedure involving a small ~five mm incision on the inside of the lower lip.

Salivary gland neoplasms are characterized as either benign or malignant, and there are multiple pathologies within each class. Overall, the management includes wide local excision of the mass, with preservation of the surrounding nerves, vessels, and muscles, as allowable to obtain negative margins. If there is malignant pathology, adjuvant therapy in the form of cervical lymphadenectomy (neck dissection) with or without postoperative chemoradiation may be required. Otolaryngologists will use the pathology obtained from surgery and present the patient to a multidisciplinary cancer conference (tumor board) for comprehensive management.

Christopher Clark, MD is Board Certified in Otolaryngology – Head and Neck Surgery and is Fellowship Trained in Rhinology and Allergy. He practices with ENT Associates of Alabama.