Salivary Gland MCQs | Clinical Application

Simple ranula results from mucus extravasation from sublingual gland, common in children. Presents as bluish translucent swelling.

Acute bacterial parotitis requires prompt antibiotic therapy covering S. aureus and adequate hydration. Hospitalization may be needed in young children.

Juvenile recurrent parotitis typically presents with repeated episodes of unilateral or bilateral parotid swelling. Ultrasound showing hypoechoic areas (sialectasis) is diagnostic.

Mumps virus is the most common cause of bilateral parotid swelling in unvaccinated children. Presents with prodromal symptoms followed by bilateral parotid enlargement.

Facial nerve involvement is a key indicator of malignancy in salivary gland tumors. While benign tumors typically present as slow-growing, mobile masses, malignant tumors often show rapid growth, pain, facial nerve involvement, and fixation to surrounding structures.

Patients with Sjögren's syndrome have a significantly increased risk of developing lymphoma, particularly MALT lymphoma, with a much higher risk (up to 16 fold) compared to the general population. Regular monitoring for lymphoma development is essential. Mucosa-associated lymphoid tissue (MALT) lymphoma is a type of non-Hodgkin lymphoma that commonly occurs in patients with Sjögren's syndrome.
SmedbyK. E., Baecklund, E., & Johan Askling. (2006). Malignant Lymphomas in Autoimmunity and Inflammation: A Review of Risks, Risk Factors, and Lymphoma Characteristics. Cancer Epidemiology Biomarkers & Prevention, 15(11), 2069–2077. https://doi.org/10.1158/1055-9965.epi-06-0300

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Ultrasound is the initial imaging modality of choice for suspected sialolithiasis due to its high sensitivity (around 94%) for stone detection, lack of radiation, and ability to assess ductal dilation and parenchymal changes. It can also guide interventional procedures. Neeraja Nina Karwowska, & Turner, M. D. (2021). Etiology, diagnosis, and surgical management of obstructive salivary gland disease. Frontiers of Oral and Maxillofacial Medicine, 3, 17–17. https://doi.org/10.21037/fomm-20-73

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Pleomorphic adenoma is the most common benign salivary gland tumor, accounting for about 60% of all salivary gland tumors. It typically presents as a slow-growing, painless, mobile mass in the superficial lobe of the parotid gland. The characteristic histologic finding is a mixture of epithelial and myoepithelial cells in a chondromyxoid stroma.

HIV-associated salivary gland disease commonly presents as bilateral parotid enlargement, often due to lymphoepithelial cysts or lymphoma. Weight loss and low CD4 suggest advanced HIV.

The submandibular glands produce 65-70% of unstimulated saliva. Radiation damage to these glands significantly impacts baseline salivary flow.

Anti-SSA/Ro and anti-SSB/La antibodies are characteristic of Sjögren's syndrome. Anti-SSA/Ro is more sensitive and specific, present in 60-70% of patients.

Sialolithiasis most commonly affects the submandibular gland (80-90% of cases) due to its tortuous duct course and more viscous, mineral-rich secretions. Classic presentation includes meal-time pain and swelling.

Pleomorphic adenoma is the most common benign salivary gland tumor, typically presenting as a slow-growing, painless, mobile mass in the parotid gland. It accounts for approximately 60-70% of all parotid tumors.

Radioactive iodine causes radiation sialadenitis through direct damage to salivary gland parenchyma, leading to inflammation and reduced function. Arunrat Auttara-atthakorn, Jaruwan Sungmala, Thunyarat Anothaisintawee, Sirimon Reutrakul, & Chutintorn Sriphrapradang. (2022). Prevention of salivary gland dysfunction in patients treated with radioiodine for differentiated thyroid cancer: A systematic review of randomized controlled trials. Frontiers in Endocrinology, 13. https://doi.org/10.3389/fendo.2022.960265

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Minor salivary gland biopsy showing focal lymphocytic sialadenitis with a focus score ≥1 provides the highest diagnostic specificity for Sjögren's syndrome.
"Histopathology in minor salivary gland (presence of focal lymphocytic sialadenitis with a focus score ≥1) is one of the six diagnostic criteria set in the revised international classification for Sjögren’s Syndrome."
P. Varela-Centelles, JM. Seoane-Romero, M. Sanchez-Sanchez, A. Gonzalez-Mosquera, P. Diz-Dios, & Seoane, J. (2013). Minor salivary gland biopsy in Sjogren’s syndrome: A review and introduction of a new tool to ease the procedure. Medicina Oral, Patología Oral Y Cirugía Bucal, e20–e23. https://doi.org/10.4317/medoral.19131

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Anticholinergic medications, commonly used in psychiatric conditions, are the most frequent cause of medication-induced xerostomia through blocking of muscarinic receptors.

Necrotizing sialometaplasia can mimic squamous cell carcinoma clinically and histologically, leading to potential misdiagnosis. It is a self-limiting condition that typically resolves in 6-10 weeks.

Ultrasound is the first-line imaging modality for acute sialadenitis, offering real-time visualization of ductal dilation, stones, and parenchymal changes without radiation. Koch, M., Sievert, M., Iro, H., Mantsopoulos, K., & Schapher, M. (2021). Ultrasound in Inflammatory and Obstructive Salivary Gland Diseases: Own Experiences and a Review of the Literature. Journal of Clinical Medicine, 10(16), 3547. https://doi.org/10.3390/jcm10163547

The facial nerve (CN VII) runs through the parotid gland, dividing it into superficial and deep lobes. This anatomical relationship makes the nerve vulnerable during parotid surgery.

Viral infections, particularly mumps, are most common in children.

The lower lip is a more likely location for malignant tumors, upper lip for benign. Reminder: Lip malignancies typically present as a non-healing ulcer on the vermillion of the lower lip.

Medications are the most common cause, followed by radiation and Sjögren's. [Ogle OE. "Salivary Gland Diseases." Dent Clin North Am (2020)]

Bilal Talha, & Swarnkar, S. A. (2023, March 24). Xerostomia. Retrieved December 3, 2024, from Nih.gov

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MRI is best for tumors due to soft tissue contrast. "For a salivary gland tumor, MRI is recommended with diffusion-weighted and dynamic contrast-enhanced techniques. In the case of histologically proven malignancy or a highly suspicious lesion, a CT scan of the neck and chest is recommended to assess the tumor, lymph nodes and metastases."

Varoquaux, A., Fakhry, N., Baujat, B., Verillaud, B., Jegoux, F., Barry, B., … Terroir-Cassou-Mounat, M. (2024). Diagnostic imaging of salivary gland cancers: REFCOR recommendations by the formal consensus method. European Annals of Otorhinolaryngology, Head and Neck Diseases, 141(1), 27–31. https://doi.org/10.1016/j.anorl.2023.11.007

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A careful history is the first step, before physical exam and imaging. [Ogle OE. "Salivary Gland Diseases." Dent Clin North Am (2020)]

80% of major salivary gland tumors occur in parotid.

[ Schiff, B. A. (2024, September). Salivary Gland Tumors. Retrieved November 19, 2024, from Merck Manual Professional Edition website ]

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Plunging ranulas descend below mylohyoid muscle into neck, while oral remain in floor of mouth. A simple ranula causes swelling limited to the floor of the mouth. Cervical ranulas, also known as plunging ranulas, appear painless, movable, soft, and gradually enlarging mass in the neck, with a fluctuant consistency.

[Muhammad Huzaifa, & Soni, A. (2023, July 24). Mucocele and Ranula. Retrieved November 19, 2024, from Nih.gov website]

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Sialadenosis is a non-inflammatory, non-neoplastic enlargement of the salivary glands, most commonly the parotid glands, presenting as bilateral, painless swelling without signs of infection.

It is often associated with systemic conditions such as diabetes, hypothyroidism, and hormonal changes, as well as nutritional disorders like malnutrition, alcoholism, bulimia, and anorexia. Certain medications, including antihypertensives and psychotropics, can also contribute. Management focuses on addressing the underlying cause and providing supportive care.

Other causes of bilateral parotid swelling:

Mumps, a viral infection which primarily affects children and involves the parotid gland, may occur bilaterally (75%) or unilaterally.

Note: This is unlike Bacterial parotitis which tends to occur unilaterally.

HIV-associated: Parotid gland enlargement occurs in individuals with HIV due to lymphoepithelial cysts or lymphadenopathy.

Sarcoidosis: Bilateral swelling with possible systemic symptoms like pulmonary involvement and uveitis.

Malignant lymphoid proliferation can cause parotid gland enlargement as part of systemic disease or localized involvement.

Eveson, J. W., Cawson, R. A., & Lucas, R. B. (2008). Pathology of the salivary glands. In Cawson's Essentials of Oral Pathology and Oral Medicine (8th ed., pp. 276-278). Elsevier

A Gadodia, Bhalla, A. S., Sharma, R., Thakar, A., & R Parshad. (2011). Bilateral parotid swelling: a radiological review. Dentomaxillofacial Radiology, 40(7), 403–414. https://doi.org/10.1259/dmfr/17889378

Silography is contraindicated in acute conditions due to risks with contrast medium. Other contra-indications include known sensitivity to iodine-containing compounds.

Benson, B. W. (2014). Salivary Gland Diseases. Elsevier EBooks, 542–561. https://doi.org/10.1016/b978-0-323-09633-1.00029-8

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Mumps, cytomegalovirus, and Coxsackie are the main viral causes of SGD.

Key Differences:

• Mumps is vaccine-preventable and primarily affects children, causing notable bilateral parotid swelling.
• CMV often presents in immunocompromised individuals or congenitally, with a broader range of systemic effects.
• Coxsackie virus typically causes mild, self-limited illness with occasional salivary gland involvement

Swelling with meals and gradual relief after is characteristic of stones. [Kraaij S et al. "Salivary stones: symptoms, aetiology." Br Dent J (2014)]