Salivary Gland Disorders

What Is It?

The salivary glands make saliva and release it into the mouth. There are three pairs of relatively large, major salivary glands:

• Parotid glands. Located in the upper part of each cheek, close to the ear. The duct of each parotid gland empties onto the inside of the cheek, near the molars of the upper jaw.
• Submandibular glands. Under the jaw. They have ducts that empty behind the lower front teeth.
• Sublingual glands. Beneath the tongue. They have ducts that empty onto the floor of the mouth.

In addition to these major glands, 600 to 1,000 very tiny, minor salivary glands are scattered throughout the mouth and throat. They are located under the moist skin that lines the:

• Inner lips
• Inner cheeks
• Palate
• Back of the throat
• Back portion of the tongue
• Pharynx
• Sinuses

Some of the most common salivary gland disorders include:

• Sialolithiasis (salivary gland stones). Tiny, calcium-rich stones sometimes form inside the salivary glands. The exact cause of these stones is unknown. Some stones may be related to:
  • Dehydration, which thickens the saliva
  • Decreased food intake, which lowers the demand for saliva
  • Medications that decrease saliva production, including certain antihistamines, blood pressure drugs and psychiatric medications

Some stones sit inside the gland without causing any symptoms. In other cases, a stone blocks the gland's duct, either partially or completely. When this happens, the gland typically is painful and swollen, and saliva flow is partially or completely blocked. This can be followed by an infection called sialadenitis.

• Sialadenitis (infection of a salivary gland). Sialadenitis is a painful infection that usually is caused by bacteria. It is more common among elderly adults with salivary gland stones. Sialadenitis also can occur in infants during the first few weeks of life.
  

  Without proper treatment, sialadenitis can develop into a severe infection, especially in people who are debilitated or elderly.

• Viral infections. Systemic (whole-body) viral infections sometimes settle in the salivary glands. This causes facial swelling, pain and difficulty eating. The most common example is mumps.

• Cysts (tiny fluid-filled sacs). Babies sometimes are born with cysts in the parotid gland because of problems related to ear development before birth. Later in life, other types of cysts can form in the major or minor salivary glands. They may result from traumatic injuries, infections, or salivary gland stones or tumors.

• Benign tumors (noncancerous tumors). Most salivary gland tumors occur in the parotid gland. The majority are benign. The most common type of benign parotid tumor usually appears as a slow-growing, painless lump at the back of the jaw, just below the earlobe. Risk factors include radiation exposure and possibly smoking.

• Malignant tumors (cancerous tumors). Salivary gland cancers are rare. They can be more or less aggressive. The only known risk factors for salivary gland cancers are Sjogren's syndrome and exposure to radiation. Smoking also may play some role.

• Sjogren's syndrome. Sjogren's syndrome is a chronic autoimmune disorder. The body's immune defenses attack the salivary glands, the lacrimal glands (glands that produce tears), and occasionally the skin's sweat and oil glands.

  Most people with this disease are women who first develop symptoms during middle age. In about half of cases, the illness occurs together with rheumatoid arthritis, systemic lupus erythematosus (lupus), scleroderma or polymyositis.

• Sialadenosis (nonspecific salivary gland enlargement). Sometimes, the salivary glands become enlarged without evidence of infection, inflammation or tumor. This nonspecific enlargement is called sialadenosis. It most often affects the parotid gland, and its cause remains unknown.

Symptoms

Symptoms vary, depending on the specific type of salivary gland disorder:

• Sialolithiasis. The most common symptom is a painful lump, usually in the floor of the mouth. Pain may worsen during eating.

• Sialadenitis. Symptoms may include:
  • A tender, painful lump in the cheek or under the chin
  • A foul-tasting discharge of pus from the duct into the mouth
  • In severe cases, fever, chills and general weakness

• Viral infections. The first symptoms often include:
  • Fever
  • Headache
  • Muscle aches
  • Joint pain
  • Poor appetite
  • Malaise

  These symptoms are followed by swelling in the parotid glands, usually on both sides of the face. It may be difficult to fully open the mouth.

• Cysts. A cyst causes a painless lump. It sometimes grows large enough to interfere with eating.

• Tumors. A slow-growing lump is the most common symptom of both cancerous and noncancerous salivary gland tumors. The lump is sometimes painful. This lump may be found in the cheek, under the chin, on the tongue or on the roof of the mouth.

• Sjogren's syndrome. The main features of Sjogren's syndrome are swelling of the salivary glands, dry eyes and a dry mouth.

• Sialadenosis. This condition typically causes painless swelling of the parotid glands on both sides of the face.

Diagnosis

You will describe your symptoms. The doctor will review your:

• Medical history
• Smoking history
• Current medications
• Diet

The doctor also may ask whether you:

• Have recently been hospitalized for surgery. Decreased intake of food and liquids after surgery can increase the risk of salivary gland stones and infections.
• Have ever received radiation treatments for cancer of the head or neck
• Were ever diagnosed with mumps or immunized against mumps
• Have recently been exposed to anyone with the flu or another viral illness
• Have any autoimmune condition, such as rheumatoid arthritis

Next, your doctor will examine your head and neck, including the area inside your mouth. The doctor will press gently on areas of your cheeks to feel for swelling of the parotid gland. He or she also will feel under your jaw for enlarged salivary glands. Tell your doctor if there is any tenderness during the exam.

Depending on your symptoms, history and physical findings, the doctor may order one or more of the following tests:

• Blood tests. To look for a high white blood count that would suggest a bacterial infection. Other blood tests might include testing for Sjogren's syndrome, nutritional deficiencies and viral infections.
• X-rays. To detect salivary gland stones
• Magnetic resonance imaging (MRI) or computed tomography (CT) scans. These tests can detect tumors and stones that are not visible on X-rays.
• Fine-needle aspiration. This test uses a thin needle to remove cells from the salivary gland to determine whether a tumor is cancerous.
• Sialography. Dye is injected into the gland's duct so that the pathways of saliva flow can be seen.
• Salivary gland biopsy. This is removal of a small piece of tissue to diagnose a cyst, tumor or Sjogren's syndrome.
• Salivary function test. To help diagnose Sjogren's syndrome.
• Eye tests. To look for evidence of Sjogren's syndrome.

Expected Duration

How long a salivary gland problem lasts depends on the specific disorder.

• Sialolithiasis. Small stones sometimes pass out of the duct on their own. However, larger stones usually stay in the gland until they are removed.
• Sialadenitis. Symptoms usually begin to subside within 48 hours of treatment with antibiotics.
• Viral infections. With mumps, symptoms usually last about 10 days.
• Cysts. A small, shallow cyst can be a short-term problem that drains on its own. Large cysts often grow larger until they are removed surgically.
• Tumors. Tumors last until they are removed.
• Sjogren's syndrome. This is a lifelong illness.
• Sialadenosis. Sialadenosis related to a medical problem generally persists as long as the medical problem does.

Prevention

You can lower your risk of viral infections of the salivary glands. To do so, get immunized against mumps and influenza.

There are no specific guidelines to protect against other types of salivary gland disorders. However, it is helpful to:

• Avoid smoking.
• Eat a healthy diet.
• Drink six to eight glasses of water daily to avoid dehydration.
• Practice good oral hygiene, with regular tooth brushing and flossing.

Treatment

The treatment varies, depending on the disorder:

• Sialolithiasis. If the stone is located near the end of the duct, your doctor may be able to press it out gently. Deeper stones can be removed with surgery.

• Sialadenitis. Treatment includes:
  • Drinking fluids or receiving fluids intravenously
  • Antibiotics
  • Warm compresses on the infected gland
  • Encouraging saliva flow by chewing sour, sugarless candies or by drinking orange juice

  If these methods do not cure the infection, surgery can drain the gland.

• Viral infections. These infections almost always go away on their own. Treatment focuses on relieving symptoms through:
  • Rest
  • Drinking fluids to prevent dehydration
  • Taking acetaminophen (Tylenol) to relieve pain and fever

• Cysts. A small cyst may drain on its own without treatment. Larger cysts can be removed using traditional surgery or laser surgery.

• Benign tumors. Noncancerous tumors usually are removed surgically. In some cases, radiation treatments are given after surgery to prevent the tumor from returning.

• Malignant tumors. Smaller, early stage, low-grade tumors often can be treated with surgery alone. However, larger, high-grade tumors usually require radiation following surgery. Inoperable tumors are treated with radiation or chemotherapy.

• Sjogren's syndrome. The main symptom related to the salivary glands is a dry mouth. Options include:
  • Medication to stimulate more saliva secretion, such as pilocarpine (Salagen) and cevimeline (Evoxac)
  • Sugarless gum and candy to stimulate saliva production
  • Avoiding medications that can make dry mouth worse
  • Not smoking

  Good oral hygiene is a must. People with Sjogren's have teeth and gum problems because of low saliva secretion.

• Sialadenosis. Treatment is aimed at correcting any underlying medical problem. Once the medical problem improves, the salivary glands should shrink to normal size.

When to Call a Professional

Contact your doctor or dentist if you develop a persistent lump or swelling anywhere in your neck, jaw, cheek, tongue or hard palate.

Call your doctor or dentist immediately if the lump:

• Is painful, red or tender
• Occurs together with fever and chills
• Interferes with your ability to open your mouth, speak, chew or swallow

Prognosis

The outlook depends on the disorder:

• Sialolithiasis. If a stone is removed promptly, the prognosis is usually excellent. About one in five people have stones return.

• Sialadenitis. With prompt antibiotic treatment, the prognosis is usually very good. The highest risk of complications is in elderly people and those with chronic, debilitating illnesses.

• Viral infections. Most people recover fully without complications.

• Cysts. In most cases, the prognosis is good. Cysts develop again in some people. But these usually can be removed without complications.

• Benign tumors. The prognosis is usually very good. However, tumors develop again in some people as late as 10 to 15 years after the first tumor was removed.

• Malignant tumors. The prognosis is usually best for parotid tumors. It is poorest for:
  • Cancers of the sublingual or minor salivary glands
  • Cancers that have invaded the nearby facial nerve
  • Bulky cancers that have spread

• Sjogren's syndrome. The prognosis varies. Some people have only mild symptoms. Others have more severe forms of the illness that affect the quality of life.

• Sialadenosis. Once any underlying illness is treated, the salivary glands usually return to their normal size.

Additional Info

National Institute of Dental and Craniofacial Research
National Institutes of Health
Bethesda, MD 20892-2190
Phone: 301-496-4261
http://www.nidcr.nih.gov/

American Academy of Otolaryngology -- Head and Neck Surgery
One Prince St.
Alexandria, VA 22314-3357
Phone: 703-836-4444
http://www.entnet.org/

American Association of Oral and Maxillofacial Surgeons
9700 West Bryn Mawr Ave.
Rosemont, IL 60018-5701 
Toll-Free: 1-800-822-6637
Fax: 847-678-6286
http://www.aaoms.org/

National Cancer Institute (NCI)
U.S. National Institutes of Health
Public Inquiries Office
Building 31, Room 10A03
31 Center Drive, MSC 8322
Bethesda, MD 20892-2580
Toll-Free: 1-800-422-6237
http://www.nci.nih.gov/

American Cancer Society (ACS)
1599 Clifton Rd, NE
Atlanta, GA 30329-4251
Toll-Free: 1-800-227-2345
http://www.cancer.org/

Sjogren's Syndrome Foundation
6707 Democracy Blvd.
Suite 325
Bethesda, MD 20817
Toll Free: 1-800-475-6473
Fax: 301-530-4415
http://www.sjogrens.org