The Management of Salivary Gland Infection - Essay Example

The management of salivary gland infection Introduction Salivary glands are the three pairs of glands ly parotid, submandibular and sublingual that secretes saliva. Saliva is essential for the breaking down of carbohydrates and lubrication of food from mouth to esophagus into the stomach. Sometimes bacteria and virus infect the salivary gland and leads to salivary gland infection. The name given to the infection of parotid gland is Parortis while that of the other two pairs of salivary gland is Salandenitis. Salivary gland infection is common and in rare cases leads to complications. The salivary gland infection is of two types-Bacterial salivary gland infection and viral salivary gland infection. The management of these two types of salivary gland infection is possible with certain preventive measures and treatments. In certain cases, treatment is not required for curing these infections. Bacterial infection of the Salivary glands. The acute bacterial infection of the salivary glands occurs because of two important physiological mechanisms. Firstly, there are certain bacteria present in the oral cavity. Due to poor oral hygiene, the salivary duct and parenchyma tissue inhabited by these bacteria is contaminated which results in the infection. Secondly, the obstruction of salivary gland results in the stasis of salivary flow through the ducts and parenchyma promotes acute suppurative infection. The bacterial infection can affect any of the three pairs of the salivary glands however the most commonly affected gland is the Parotid gland. Several physiological and anatomic factors attribute to the predilection of the Parotid gland's infection. The composition of the Parotid gland secretion is completely different from that of the submandibular and sublingual glands. The saliva secreted by the Parotid gland is serous while that of the other two glands have higher proportion of mucinous material. The kind of saliva secreted by the other two glands contains lysosomes and IgA antibodies, which serve an antimicrobial function in protecting these glands from the bacterial infection. Mucins also contain sialic acid, which agglutinates bacteria, preventing its adherence to host tissues. Finally, specific glycoproteins found in mucins bind epithelial cells, competitively inhibiting bacterial attachment to these cells. There are certain anatomic factors as well that contribute to the predilection of the parotid gland's infection. Stensen's duct lies adjacent to the upper mandibular molars, whereas Wharton's ducts rests on the floor of the mouth near the tongue. Tongue mobility may prevent salivary stasis in the area of warton's ducts, reducing the rate of infections involving the submandibular gland. The submandibular gland is more prone to bacterial infection rather than the sublingual gland in spite of its composition. Sialothiasis can produce mechanical obstruction of the duct, resulting in salivary stasis and subsequent bacterial infection. Calculus formation is associated frequently with acute bacterial infections of the submandibular gland because Wharton's duct is far more likely to harbor a calculus than stensen's duct.85 % to 90% of salivary calculi is located in the submandibular duct. Submandibular secretions are more mucinous than parotid secretions and therefore more viscid. They are also more alkaline containing a higher percentage of calcium phosphates. These characteristics contributes to the formation of submandibular calculi, despite the submandibular gland's predisposition for calculus formation. The parotid gland remains the most common site of acute suppurative salivary infection. Sialography, a method used for diagnosis of the internal structure of the salivary gland can also result in the infection of the submandibular glands rather than sublingual glands. There are small and numerous sublingual ducts which may not allow the catheter to enter unless there are anatomic variations.[ Bailey, Byron , Healy, Gerald ., Johnson, Jonas , Jackler, Robert , Calhoun, Karen , Pillsbury, Harold , Tardy and Eugene, 2001].Ultrasonography is a preferred method of diagnosis rather than sialolithiasis since it does not indicate the development of calculus formation. The various types of bacterial salivary gland infections are acute bacterial parotitis, acute bacterial sialadenitis and acute bacterial submandibular sialadenitis. Acute bacterial parortis is the bacterial infection of the parotid gland, which causes erythema, pain, tenderness along with the formation of pus over the parotid glands. Acute sialadenitis is the bacterial infection or the inflammation of the salivary glands that causes tender swelling of the salivary gland, enlargement of lymph nodes, fever and malaise. Acute bacterial submandibular sialadenitis is the bacterial infection of the submandibular glands caused by simple infection or autoimmune etiologies. The term generally used to describe acute bacterial parortis traditionally was nosochomial postoperative infection. It generally occurred in dehydrated patients who have undergone abdominal surgery and resulted in higher rate of death among such patients. A study conducted by the experts in this field for five years revealed that it generally occurred in patients who have undergone neurosurgical procedures in the sitting position. During sitting position, mild flexion and rotation of the head result in drainage of Stenson's duct causing stasis in the contralateral parotid gland. This results in swelling and inflammation of the parotid glands. However, certain experts think that this cause of infection is exaggerated. The study also revealed that 0.1 percent of the patients who have undergone abdominal surgery suffered from this infection after two weeks. This infection occurred most commonly in postoperative patients who have undergone neurosurgical procedures in the sitting position. This group of patients accounted for 0.16% of all craniotomy and 1.9% of all patients who have undergone neurosurgical procedures in the sitting position. Progression of this infection leads to massive swelling of the neck, respiratory obstruction, septicemia, and osteomyelitis of the adjacent facial bones. [Mustafa, 2003]. This kind of infection mainly affects the elderly, malnourished, dehydrated, or postoperative patients. The pathogens causing this infection are Staphylococci, Enterobacteriaceae, other gram-negative bacilli and anaerobes however Staphylococci is the common pathogen. Acute bacterial sialadenitis occurs also in nosochomial patients who are not critically ill. A study conducted on the salivary discharge of 17 patients with acute bacterial parortis and 12 patients with acute bacterial submandibular sialadenitis has revealed Staphylococcus aureus in 53% and viridans streptococci in 31%. [Raad, Sabbagh and Caranasos, 1990]The most common pathogen causing this infection is Staphylococcus aureus. This kind of infection is not fatal and patients recover with appropriate treatment. Acute bacterial submandibular sialadenitis is caused because of diabetes and immunosuppression. The clinical features of this infection include fever, pain, erythematic, tender swelling, and discharge of pus from the duct, dry mouth and dehydration. The lack of appropriate treatment in case of acute bacterial submandibular sialadenitis leads chronic or recurrent infection. It may also result in non-functional glands. [The salivary glands, 2005]. Treatment There are various types of treatment for bacterial infection depending its kind. The treatment in case of acute bacterial parortis is antibiotic therapy, which includes antistaphylococcal agent. The medications also include antihypertensives, antihistamines, and antidepressants, have been associated with acute bacterial sialadenitis. It contributes to oral or systemic dehydration by a variety of mechanisms, including anticholinergic and diuretic effects. The patients receive mannitol during the surgery. The administration of this medicine occurs orally and if the patient fails to respond within 48 hours then intravenous antibiotics are given. Specific antibody therapy helps in curing this infection. The identification of the pathogens occurs by the study of the samples of the salivary gland secretion attained from the Stensen's or Wharton's duct or from needle aspiration of the gland. Sometimes, the addition of a third generation cephalosporin in recalcitrant infections helps to enhance gram-negative coverage. Some even advocate the addition of an aminoglycoside in critically ill patients. The preponderance of methicilline - resistant s. aureus particularly in nosocomial and nursing home environments, has prompted the recommendation of vancomycin for the patients in these groups. Historically, radiation therapy helped in the treatment of acute suppurative parotitis however it did not show great benefit, hence no longer advocated. Treatment of acute sialadenitis mainly involves the reversal of the underlying medical conditions responsible for the infection and initiation of appropriate antimicrobial therapy. Antisialogogic medications are discontinued whenever possible. There are attempts made to reverse salivary stasis and stimulate salivary flow by application of warm compress, maximization of oral hygiene and mouth irrigations, and administration of sialogogous, such as lemon drops or orange juice. External or bimanual massage of the gland both intraorally and externally helps if the patient can tolerate these measures. The serial dilation of the duct with lacrimal probes can establish ductal patency if neither saliva nor pus is expressed from stensen's duct. The utilization of Antimicrobial therapy initially toward the gram- positive and anaerobic organisms was identified as common causes of acute bacterial sialadenitis. Over 70 % of organisms cultured produce beta-lactamase or penicillinase. Augmented penicillins contain beta-lactamase inhibitors, whereas antistaphylacocal penicillins and second-generation cephasporins are penicillinase resistant. The utilization of any one of these antibiotics helps in the treatment of acute sialadenitis. Some authors have suggested combining these agents with metronidazole or alternatively using clindamycin to broaden coverage against anaerobic organisms. The role of surgery in the treatment of acute bacterial sialadenitis is limited. The surgical drainage helps in treatment in case of the identification of a descrete abscess. A small population of patients without descrete abscess who are refractory to nonoperative interventions may be candidates for surgical exploration, if their medical condition permits. The gland is approached with standard, anteriorly based facial flap, and multiple, superficial, radial incisions are created in the parotid fascia parallel to the facial nerve branches. The wound is loosely approximated over a drain. The central aspect of the wound is often allowed to heal by secondary intention. Surgery occasionally is indicated for tissue diagnosis in a select group of patients not responding to standard therapy to identify one of the conditions mimicking acute sialadenitis. The treatments of acute bacterial submandibular salinities are antibiotics, rehydration, analgesia, and correction of any systemic conditions, e.g. diabetes. If there is an obstruction found, e.g. stone, then it is removed to enable drainage. The prevention of the infection from progressing and to maintain a flushing effect gland massage, especially after meals, and 'lemon drops' to stimulate salivary flow, helps to a great extend. The Abscesses are incised and drained immediately to prevent the infection from progressing. The removal of glands occurs if the infection persists, usually done in case of no active infection. [The salivary glands, 2005]. Viral infection of the salivary glands The viral infection of the salivary glands is systematic from the onset in contrary to the bacterial infection. The virus is endemic in the community, spread by air- born droplets and enters the body through the upper respiratory tract. Patients experience a 2-3 week incubation period after exposure, during which the virus multiplies in the upper respiratory tract or parotid gland, followed by a 3- 5 day of viremia. The virus then localizes to biologically active tissue, such as the salivary glands, germinal tissues and the central nervous system.The most commonly caused viral infection is mumps, which usually appears in children between the ages of 2 to 12. The virus is endemic in the community, spread by air- born droplets and enters the body through the upper respiratory tract. Although the viruses causing the mumps syndrome demonstrate a strong predilection for parotid tissue, the infection can involve the submandibular or sublingual glands. The cause of mumps is a type of paramyxovirus, which spreads through coughs, sneezes and saliva and through contaminated items and surfaces. The mumps virus enters the blood stream and spreads to different glands and brains. It initates in the salivary glands and affects other parts of the body such as testis, ovaries, pancreas and brains. In a pregnant woman, it can cause fetal death and miscarriage if it affects the mother in the first trimester however, it does not cause any birth defects. People with mumps are contagious within 48 hours of the infection and the spreading of this disease can end by 6 to 9 days after the beginning of the mumps symptoms. Mumps are asymptomatic initially, the symptoms appear only after 14 to 18 days, and by then those who are in contact with the mumps patients already contract this kind of infection. The symptoms of mumps include fever, headache, sore throat, muscle aches, poor appetite and malaise (a general feeling of sickness). The mumps virus causes pain and swelling in front of the earlobe, called parotitis. The pain results in difficulty while chewing and swallowing. In certain cases, it results in swelling and pain of one or both the testis in men, which leads to sterility, and lower abdominal pain in women. In certain rare cases, it can also lead to complications in both the sexes such as Mumps pancreatitis, Aseptic (not bacterial) meningitis or Mumps encephalitis. Mumps pancreatitis, causes pain in the upper abdomen, Aseptic (not bacterial) meningitis, causes headache, stiff neck and drowsiness and Mumps encephalitis, causes high fever and unconsciousness, although this occurs in less than one in 1,000 patients with mumps. The symptoms of mumps last for about 10 days. The diagnosis mainly occurs by analyzing the patient's medical history and further confirmed by blood test. Treatment Treatment of viral salivary gland infection is primarily supportive, including rest and adequate hydration, because the disease is self- limited. The utilization of Antipyretics and anti-inflammatory medications also help in the treatment of this infection. The most significant advancement in the treatment of mumps parotitis is prevention by vaccination. The live attenuated Jeryl Lynn vaccine became available in 1967 commonly combined with the measles and rubella vaccines. The administration of mumps vaccine occurs in a single, subcutaneous dose after 12 months of age. It produces measurable antibody titers in 90 % of recipients. No deaths and very few side effects have been associated with the vaccine. The case of mump parotitis occurs rarely in immunized patients, and likely represents salivary infection with a nonparamyxovirus or rarely failed vaccination. The symptoms of mumps are treated in healthy patients with Acetaminophen (Tylenol) to reduce fever and relieve general body discomfort.Warm and cold compresses are also utilized to relieve pain and swelling in the parotid glands. In men infected with mumps of the testicles cool compresses and support for the scrotum helps in reducing pain and swelling of the testicles. Aspirin is not administered for children since it leads to Reye's syndrome which is a serious brain problem Soft diet with lot of fluids is recommended to reduce the need for chewing.Fruit juices and tarts are avoided since it aggravates the pain of the salivary glands. Children are recommended from not attending the schools during the persistence of this illness since it is contagious. Conclusion There are various kinds of salivary gland infections. There are treatments and preventive measures available for the management of this kind of infection. In certain rare cases, it leads to complications. Therefore, the knowledge of causes and symptoms is mandatory for the appropriate management of this kind of infections. There are various methods by which such infection are diagnosed and this is the first step towards identifying an appropriate treatment. Salivary gland is an important gland that secretes saliva, which is essential for various digestions process hence its infections, should be properly treated to avoid further complications. References Bailey, Byron J., Healy, Gerald B., Johnson, Jonas T., Jackler, Robert K., Calhoun, Karen H., Pillsbury, Harold C., Tardy, M. Eugene. Head & Neck Surgery - Otolaryngology.2001 Berker, Mustafa MD, PhD; Sahin, Altan MD; Aypar, Ulku MD; Ozgen and Tuncalp MD. Acute Parotitis Following Sitting Position Neurosurgical Procedures: Review of Five Cases. 3rd Jul 2003 Cain. A. "Parortis". 14th Oct 2005.net doctor. co. uk. 25th Jan 2006 retrieved from http://www.netdoctor.co.uk/diseases/facts/parotitis.htm Raad II. Sabbagh MF. Caranasos GJ. Acute bacterial sialadenitis: a study of 29 cases and review. Reviews of Infectious Diseases. 1990. Triantafyllopoulou.A and Barland.P. "Dry Another Day". 2006. The doctor will see you now. 25th Jan 2006 retrieved from http://www.thedoctorwillseeyounow.com/articles/arthritis/sjogren_10/ The salivary glands. 25th Jan 2006 retrieved from http://72.14.203.104/searchq=cache:S5XThXFb5MUJ:www.oup.co.uk/pdf/0-19-852910-4.pdf+cause+of+acute+submandibular+sialadenitis++&hl=en&gl=in&ct=clnk&cd=3 Infection mumps. 2006.Nemours foundation. 25th Jan 2006 retrieved from http://kidshealth.org/parent/infections/bacterial_viral/mumps.html Read More