Salivary glands

The Parotid Gland

History:

    • Swelling- Careful history must be taken as"How did the swelling start?" " where exactly was the swelling first noticed?' ' How long is the swelling present?' ' Has the swelling enlarged uniformly throughout the period?' or 'Has it suddenly enlarged very recently?' So the onset of the swelling are noted. In dehydrated patient with poor oral hygiene if he complains of sudden increase in size of both the parotid glands with considerable pain, the case is probably one of acute parotitis. If there is brawny oedematous swelling of the parotid region with pain, this is probably a case of parotid abscess. When there is generalized enlargement of all major salivary glands including lacrimal glands, it is called Mikulicz's syndrome. If this is associated with dry eyes and generalized arthritis the condition is called Sjogren's syndrome. A slow growing tumour having duration for years or months of the parotid gland is the painful, it is highly suggestive of malignant transformation of this adenoma (mixed parotid tumor). Site is important as adenolymphoma, which is also a slow-growing painless tumour, arises in the lower part of the parotid gland at the level of the lower border of the mandible slightly lower than the usual site of pleomorphic adenoma. 'Does the swelling increase in size, becomes tense and painful during meals?' This is characteristic of obstruction of the parotid duct with stone.

    • Pain- Acute parotitis is a painful condition. It must be remembered that mumps is the commonest cause of bilateral parotitis. Throbbing pain is the characteristic feature of parotid abscess. Excruciating pain, slight swelling and redness in the region of the parotid gland are characteristic feature of the parotid abscess. In case of obstruction of the parotid duct with a stone or stricture patient will complain of colicky pain during meals when the swelling of the parotid gland will also be increased.

    • Watery discharge- from a sinus in the region of the parotid gland or its duct particularly during meals is significant of a parotid fistula.

INSPECTION & PALPATION:

    • Swelling- The students must keep in mind the position of the parotid gland, which is below, behind and slightly in front of the lobule of the ear. A swelling of the parotid gland thus obliterates the normal hollow just below the lobule of the ear. This position of the parotid gland is very important as many of the lymph node swellings are often mistaken for parotid gland tumour and vice versa. While examining the swelling its extent, size, shape, consistency etc. should be noted as in any other swelling. whether the swelling is fixed to the masseter muscle or not is examined by asking the patient to clinch his teeth and the mobility of the swelling is tested over the contracted masseter muscle. Enlargement of the deep lobe of the parotid gland, though occasionally seen is not very easy to diagnose. The examinations detailed above are all for the superficial lobe. A bimanual examination with one finger of one hand inside the mouth just in front of tonsil and behind the 3rd molar tooth and one finger of the other hand externally behind the ramus of the mandible is necessary for palpation of the deep lobe.

    • Skin over the parotid gland- Careful inspection and palpation must be made for the skin over the parotid gland. In case of parotid abscess the skin becomes brawny oedematous with pitting on pressure. It must be remembered that fluctuation is a very late feature of a parotid abscess as there is strong parotid fascia overlying the parotid gland. So the findings of the skin mentioned above should be considered as conclusive evidence for the diagnosis. The skin will also be warm and extremely tender. One should also look for any scar or fistula in this region. When parotid malignancy is suspected careful examination must be made to exclude if there is infiltration of the skin by the tumour.

    • Duct- The parotid (Stensen's) duct starts just deep to the anterior border of the gland and runs superficial to the masseter muscle, then it curves inwards to open on the buccal surface of the cheek opposite the crown of the upper second molar tooth. For its proper inspection, one has to retract the cheek with spatula. if one suspects the case to be one of suppurative parotitis, gentle pressure over the gland will cause purulent saliva to come out of the orifice of the duct. Similar pressure may find blood to come out in case of malignant growth of the gland. While the duct rounds over the masseter muscle one can feel the duct by rolling the finger over the taut masseter muscle. The terminal part of the duct is best palpated bidigitally between the index finger inside the mouth and the thumb over the cheek.

    • Fistula- If there is a parotid fistula, note its position: whether in relation to the gland or the duct (masseteric or premasseteric).

Examine the facial nerve- The facial nerve is not involved in a benign tumour of the parotid gland, but is involved in a malignant growth.

Lymph nodes- Lymph nodes of the neck must be examined as a routine. The preauricular, the parotid and the submandibular groups of lymph nodes are mostly involved.

Movements of the jaw- may become restricted if the growth is malignant and has involved the periarticular tissue of temporomandibular joint.

Sialography- A watery solution of lipiodol (Neohydriol) is injected into the orifice of Stensen's duct and a skiagram is taken. Any obstruction of the duct by a calculus or dilatation of the ducts and acini (sialectasis) may be demonstrated. In parotid fistula, it helps to locate the site of lesion- whether in the main duct or in aductule.

SUBMANDIBULAR SALIVARY GLAND

History-

Local examination-

Inspection-

Palpation-

DIFFERENTIAL DIAGNOSIS (THE PAROTID GLAND):

    • Congenital sialectasis- It is a condition of dilatation of teh ductules and alveoli, occurring in one gland usually. The symptoms commence in infancy and are characterized by attacks of painful swelling of the parotid gland, often accompanied by fever. Some patients show an allergy to certain food-stuffs. Diagnosis is established by sialography.

    • Calculus- is rarely formed in the parotid gland as the secretion is watery.

    • Acute suppurative parotitis- Infection reaches the gland from the mouth and rarely it is blood-borne. There is brawny oedematous swelling over the parotid region with all signs of inflammation. Fluctuation is a late feature owing to the presence of strong fascia over the gland.

    • The Auriculotemporal (Frey's) Syndrome- This condition follows injury to the auriculo-temporal nerve while incising for the suppurative parotitis. At the time of meals, the parotid region and the cheek in front of it become red, hot and painful; very soon beads of perspiration appear on this area. Cutaneous hyperaesthesia is also present over this area and becomes evident to the patient while shaving.

    • Acute Parotitis-due to mumps, is a nonsuppurative condition. It may be unilateral to start with but becomes bilateral within a few days. It is associted with constitutional disturbances and other manifestations of mumps.

    • Subacute & chronic Parotitis-

    • Parotid tumours-

      • Epithelial tumours-

      • Connective tissue tumours-

      • Metastatic tumours-