Salivary Gland Pathology. Группа авторов

abundance of IgG4 plasma cells, and mild to moderate tissue eosinophilia (Puxeddu et al. 2018). The increase of IgG4 seems to be a reactive phenomenon rather than the primary etiology of the disease. Involvement of the salivary glands is seen in 27–53% of patients with IgG4‐related disease (Puxeddu et al. 2018). Unlike classic autoimmune diseases such as systemic lupus erythematosus and Sjögren syndrome that affect mainly females, IgG4‐related disease occurs in a subacute form in most patients without the rapid onset of general symptoms such as fever. Mikulicz disease affecting the lacrimal and parotid glands and Kuttner tumor affecting the submandibular glands are two examples of IgG4‐related disease of the salivary gland.

Summary

       Sialadenitis is an infection of salivary glands that has numerous etiologies including microorganisms, and autoimmune diseases.

       Staphylococcal and streptococcal species are involved in community acquired acute bacterial parotitis, and Pseudomonas, Klebsiella, Prevotella, Fusobacterium, Haemophilus, and Proteus species are cultured from hospital acquired cases of acute bacterial parotitis. Methicillin‐resistant Staphylococcus aureus may be cultured from cases of community acquired and hospital acquired acute bacterial parotitis.

       The clinician must rule out a neoplastic process in a prompt fashion while diagnosing and treating the sialadenitis.

       The presence of a sialolith must be considered in the initial workup of patients with a clinical diagnosis of sialadenitis. A screening panoramic radiograph or occlusal radiograph should be obtained. If identified, the expedient removal of a sialolith may permit functional recovery of the salivary gland.

       The parotid and submandibular glands are the most commonly affected salivary glands by sialadenitis.

       The purpose of initial treatment for sialadenitis is to provide medical therapy for the disorder, with surgical therapy being introduced if the disorder becomes refractory to medical treatment.

       Minimally invasive strategies have a role to play in the surgical treatment of sialadenitis, as well as surgical removal of the salivary gland.

       Sialadenitis in pregnant women is a clinical diagnosis worthy of expert consultation in terms of acquiring special imaging studies and initiating antibiotic therapy.

Case Presentation – Gadzooks

A 71‐year‐old man was transferred from an outside hospital with a large left facial abscess (Figure 3.21a). Prior to urgent intubation due to concern for airway patency, the patient reported a history of recent trauma to the left face related to a trip and fall. He was a resident in a nursing home at the time of his admission.

      Past Medical History

      A review of the patient's medical record and the patient's report revealed a history of coronary heart disease, hypertension, hyperlipidemia, severe left ventricular systolic dysfunction (ejection fraction 15%), and a cardiomyopathy. He was medicated with lisinopril, carvedilol, donepezil, furosemide, and famotidine. The patient reported no known drug allergies. He reported no tobacco history.

      Physical Examination

      The patient was orally intubated at the time of comprehensive examination. There was significant left facial swelling and substantial pus expressed from the left Stensen duct during left parotid massage (Figure 3.21b). The left parotid gland was indurated. There were no oral mucosal or oropharyngeal lesions.

      Imaging

      CT scans were obtained at the outlying hospital that revealed left parotid, masseteric, buccal, submandibular, lateral pharyngeal, and pterygomandibular abscesses (Figure 3.21c and d). The CT scans also demonstrated airway deviation, thereby resulting in urgent intubation in the emergency department.

      Diagnosis

A clinical diagnosis of left suppurative parotitis was established. He was subjected to urgent incision and drainage of the left parotid abscess and multiple fascial space abscesses in the operating room (Figure 3.21e) and three Penrose drains were placed (Figure 3.21f). Final culture and sensitivity identified methicillin‐resistant Staphylococcus aureus sensitive to vancomycin. The patient received one week of intravenous vancomycin postoperatively with monitoring of his peaks and troughs and his renal function. He recovered well and was discharged from the hospital following a one‐week admission. He is noted at six months following the incision and drainage procedure (Figure 3.21g). The left parotid gland swelling resolved and his gland recovered from the suppurative parotitis as noted by the production of saliva.

      

Figure 3.21. A 71‐year‐old man (a) demonstrated significant left facial swelling related to his acute left parotitis. Examination of the oral cavity identified thick pus at the left Stensen duct (b) and the ability to express significant pus at this site by massage of the left parotid gland. (c and d) CT imaging identified obvious abscess of the left parotid gland and involvement of numerous fascial spaces. (e) The patient underwent urgent incision and drainage that liberated substantial pus from the left parotid gland. Three Penrose drains were placed (f). Culture and sensitivity identified methicillin‐resistant Staphylococcus aureus, sensitive to vancomycin. (g) The patient improved in the hospital and resolved his parotitis as noted at six months postoperatively.

      TAKE‐HOME POINTS

      1 Incision and drainage of parotitis is uncommonly required as patients typically resolve their parotitis with antibiotics while investigating for the possible presence of a sialolith.

      2 Incision and drainage is warranted when physical examination demonstrates a significant magnitude of suppurative infection and when CT scans demonstrate the presence of an intraparotid abscess. Under these circumstances, culture‐directed antibiotic therapy is required.

      3 A suppurative parotitis is typically of intrinsic origin, e.g. sialolithiasis or retrograde infections. This case demonstrates a possible extrinsic etiology of the suppurative parotitis due to his recent facial trauma, or possibly both intrinsic and extrinsic etiologies.

References

      1 Andrews JC, Abemayor E, Alessi DM et al. 1989. Parotitis and facial nerve dysfunction. Arch Otolaryngol Head Neck Surg 115:240‐242.

      2 Arrieta AJ, McCaffrey TV. 2005. Inflammatory Disorders of the Salivary Glands. In: Cummings CW (ed.) Cummings Otolaryngology Head and Neck Surgery, 4th edn. Philadelphia, Elsevier Mosby, pp. 1323‐1338.

      3 Baurmash HD. 2004. Chronic recurrent parotitis: A closer look at its origin, diagnosis, and management. J Oral Maxillofac Surg 62:1010‐1018.

      4 Bookstaver PB, Bland CM, Griffin B et al. 2015. A review of antibiotic use in pregnancy. Pharmacotherapy 35:1052‐1062.

      5 Brodie BC. 1834. Inflammation of the parotid gland and salivary fistulae. Lancet 1:450‐452.

      6 Carlson