The Pennsylvania Academy of
Otolaryngology - Head and Neck Surgery
Thyroid and Other Head and Neck Conditions
Obstructive Salivary Gland Disease
Author(s): Nikolaus Hjelm, MD; David Cognetti, MD.
Overview:
Obstructive salivary gland disease occurs when there is an blockage in the outflow duct from the salivary gland that prevents saliva from traveling out of the gland and into a patient’s mouth. The backflow of saliva behind the blockage results in enlargement of the obstructed salivary gland. This is similar to a clogged sink drain. When a sink drain (the salivary duct) is clogged, the water backs up into the sink (the salivary gland) and overflows the sink (resulting in a swollen salivary gland).
The most common cause of a salivary gland obstruction is a sialolith, also known as a salivary duct stone. Other frequent etiologies include mucus plugging and narrowing of the duct from scarring. The best way to treat obstructive salivary gland disease is to remove the blockage. In the past, treatment was limited to surgically removing the entire salivary gland. However, in the mid 1990s, sialendoscopy emerged in Europe as a gland preserving management option for diagnosing and removing salivary stones. Fortunately, there are several otolaryngologists in Pennsylvania who are experienced with sialendoscopy. Sialendoscopy is a minimally-invasive procedure in which your physician uses a very small camera scope to evaluate the ducts of the salivary glands. The scope passes through your mouth and into the natural entrance of the salivary duct and therefore does not require an incision or result in a scar. The camera ranges from 0.8 mm to 1.6 mm in size, and allows for visualization of the inside of the small salivary ducts. A working channel in the larger endoscopes allows for treatment of salivary stones and scarring with baskets, burrs, balloons, and lasers. The endoscope can also be used to irrigate the duct with saline or steroids to clear mucus plugs and alleviate inflammation.
Symptoms:
Most frequently include but are not limited to:
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Salivary gland swelling with eating
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Discomfort or pain in the salivary glands with eating
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Dry mouth
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Feeling of a hard and possibly tender mass in the mouth, on the face, or under the jaw
What to Expect at Your Otolaryngologist Office Visit:
Your otolaryngologist will ask you about your symptoms including but not limited to when you first noticed them, when they typically occur, how frequently they occur, and any exacerbating or alleviating factors. Careful examination by your physician will include a full head and neck examination to rule out other causes of your symptoms. The exam will include but is not limited to palpation of the affected area as well as palpation inside your mouth to localize the origin of your discomfort. Additional tests may include but are not limited to a CT scan or ultrasound of your head and neck.
Treatment:
If it is determined that sialendoscopy is indicated for assessment and treatment of your salivary problem, your otolaryngologist will schedule you for the procedure. This typically takes place in the operating room. The risks for this minimally invasive procedure are low as it simply involves looking within the duct. In patients with scarring or blockages in the duct, there is a small risk of damage to the duct. Most patients experience swelling of the salivary gland after the procedure. This is expected and subsides within the first few days. Massage of the gland helps with this, and it is important to stay well hydrated. In patients with a large salivary stone, your physician may need to make a small incision within the mouth to remove the stone. This heals very quickly and without scar (if you ever accidentally bit the inside of your cheek you know how quickly the mouth heals). In some rare cases when the stone is in the parotid gland (salivary gland on side of face) and is unable to be reached with the endoscope or an intraoral incision, a small skin incision in front of your ear may be required.
After the procedure, you can resume a normal diet. If an incision was made, you should be careful brushing your teeth in that area. You doctor will likely recommend an oral rinse during the recovery period. Rarely, patients experience numbness along the side of their tongue, which typically improves with time. Occasionally, a stent is placed in the salivary duct at the time of the procedure. This stent is then removed at your postoperative visit after the duct is well healed.
Parathyroid Adenoma
Authors: Robert Saadi M.D., Elizabeth Cottrill M.D.
Overview:
The parathyroid glands are part of the body’s endocrine system and are located in the neck close to the thyroid gland. Most people have four glands, each roughly the size of a pea. These glands are responsible for making parathyroid hormone (PTH), a chemical which controls calcium levels in the blood by altering how it is absorbed in the gut, excreted in the kidney, and deposited in or released from the bones. Calcium is vital to the function of many different types of cells in the body, especially muscle and nerve cells.
A parathyroid adenoma is a benign growth of one or more of the parathyroid glands which results in over production of PTH. Parathyroid adenomas account for the vast majority of what is called “primary hyperparathyroidism”. Primary hyperparathyroidism is about 3 times more common in women than in men and usually occurs in people in their 50’s and 60’s, but can occur at any age. While some genetic mutations are known, and tend to run in families (Multiple Endocrine Neoplasia or “MEN”), the majority of primary hyperparathyroidism is caused by sporadic mutations. There is no known cause, although radiation exposure to the neck may increase the risk. Most cases of primary hyperparathyroidism are due to over-growth of a single gland (about 80%). Less commonly, there is growth of multiple glands at once, termed parathyroid hyperplasia (about 20%). Less than 1% of cases are caused by a cancer (malignancy) of a parathyroid gland. In all of these cases, too much PTH causes the levels of calcium to rise in the blood. This results from more absorption of calcium from the gut, less excretion of calcium by the kidneys, and more calcium release from the bones.
Symptoms:
Many patients with primary hyperparathyroidism do not have any symptoms and, very often, it is diagnosed by routine blood work that incidentally finds a high calcium level. Symptoms that may be caused by elevated calcium in the blood include kidney stones, bone pain and weak bones, abdominal cramping, irritability or depression. When a cancer of the parathyroid gland is present, patients are more likely to have severe symptoms due to very high levels of hormone and, although rare, may also note hoarseness or a neck mass.
What to Expect at Your Otolaryngologist Office Visit:
Prior to seeing your otolaryngologist, you may have already been evaluated by your primary care doctor or an endocrinologist to rule out other diagnoses that are associated with high calcium levels. When the diagnosis of primary hyperparathyroidism is confirmed, additional tests may be necessary. Because parathyroid hormone causes calcium to be absorbed into the blood from bones, you may develop weak bones or osteoporosis which can be determined with a bone density test. If you have symptoms of kidney stones, radiographic imaging of your abdomen may sometimes be necessary. Depending on your medical and family history, your doctor may recommend genetic testing for MEN 1 or MEN2.
Your Otolaryngologist will perform a head and neck examination at your visit. Parathyroid adenomas are generally not able to be felt in the neck, therefore, for surgical planning, your Otolaryngologist will often order certain imaging studies and may perform a bed-side ultrasound in clinic. An ultrasound of the neck, which may also be done by a radiologist, is an inexpensive and radiation-free method for looking for an enlarged gland. Sometimes, a Tc-sestimibi scan, which uses a drug that is taken up by a parathyroid adenoma and is then shown on imaging, will be required to locate the enlarged gland. A specialized CT or MRI scan may be necessary in some cases.
Treatment:
Treatment for primary hyperparathyroidism is often coordinated by a team of doctors including both an Endocrinologist and also an Otolaryngologist. The most common and effective treatment is to remove the enlarged gland or glands, with surgery. For patients who are not having obvious symptoms, there are criteria that help guide when to undergo surgery and when to observe. For patients who are not good candidates for surgery or who have severe kidney failure, a prescription medication may be given to lower the PTH levels.
Surgery can be done with a minimally invasive approach through a very small incision in the neck when a parathyroid adenoma is clearly seen on imaging. Additional imaging may be performed the day of surgery to assist with this. If imaging does not localize the adenoma, a slightly larger incision is planned and all four glands are found and evaluated (“parathyroid exploration”). Removal of multiple over-active glands may be necessary to drop the parathyroid hormone to normal levels. Parathyroid hormone levels drop dramatically after removal of the adenoma and this is can be measured during the operation to confirm that all hyper-secreting glands have been removed. In some cases, the surgeon may have to switch from a minimally invasive approach to look at all four glands if levels do not drop appropriately or if visualization is difficult. Rarely, the location of the parathyroid glands will be abnormal and parathyroid glands may be found inside the thyroid gland, in the chest, or higher in the neck.
The main risks of surgery include hoarseness, bleeding, and long-term low calcium levels. Hoarseness may result from stretch or damage to the nerve that controls the vocal cords. The risk of damage to this nerve is less than 4% for experiences surgeons. If bleeding occurs following surgery, it can result in a collection of blood in the neck, called a hematoma. Often these are small and resolve on their own over time, or they may require a procedure to drain the blood. Low calcium levels are actually expected for a short period after surgery since function of the normal glands is suppressed by the over-functioning gland, however long term low calcium is rare. Calcium and Vitamin D supplements may be needed after surgery for several weeks. Signs of low calcium include numbness and tingling around your lips and fingertips and in extreme cases muscular contractions called tetany.
References
1. Cole DE, Webb S, Chan PC. Update on parathyroid hormone: new tests and new challenges for external quality assessment. Clin Biochem. 2007;40(9-10):585-90.
2. Mourad M, Buemi A, Darius T, Maiter D. Surgical options for primary hyperparathyroidism. Ann Endocrinol (Paris). 2015;76(5):638-42.
Parotid Gland (Salivary Gland) Tumors
Authors: Christopher Pool, MD (Penn State Hershey Medical Center) and Neerav Goyal, MD MPH (Penn State Hershey Medical Center)
Overview:
The parotid gland is a salivary gland located in front of the lower border of the ear. The nerve responsible for facial expression and movement, called the facial nerve, courses through the parotid gland. Tumors (or masses) of salivary glands occur most commonly in the parotid gland although they can occur less frequently in the sublingual (below the tongue) or submandibular gland (below the jaw).1, 2 The majority (75%) of parotid masses are benign (not cancerous) and a visit to your otolaryngologist-head and neck surgeon (ENT) will help determine the nature of the mass.3
Salivary gland tumors are rare, representing six to eight percent (6-8%) of head and neck tumors.1, 2 In the United States, there are approximately 2500 cases per year.1, 2 Although there are no predominant risk factors for salivary gland cancer, smoking has been associated with Warthin’s tumor, a type of non-cancerous salivary gland tumor.4, 5
Possible reasons for a parotid mass include: benign (non-cancerous) or malignant (cancerous) tumors, salivary cysts, salivary gland stones, sarcoid, autoimmune conditions, infections or other inflammatory processes. Many of these reasons present with a single-sided mass, but some conditions can be associated with a mass in both glands.
Symptoms:
Most patients with salivary gland tumors present with painless swelling of the parotid, submandibular (below the jaw), or sublingual (below the tongue) glands. Occasionally, the mass may be associated with facial droop as the facial nerve runs through the gland. Facial weakness or droop is more commonly found in cancerous masses. This droop may sometimes be recognized as a “Bell’s palsy.” Some patients may present with a lump in their neck or cheek.
What to Expect at Your Otolaryngologist Office Visit:
Your doctor will ask you questions to better understand when the swelling began, where it is located, and if you are in pain or discomfort. The physical exam will include an assessment of the mass or salivary glands as well as an assessment of your facial movement and facial function. Several additional tests may be helpful. Tissue diagnosis remains the gold standard for determining the nature of the mass.6 An ultrasound will be used to identify the architecture of the mass and a fine needle (FNA) will be used to collect a sample for pathologic analysis.7 This maybe done in the office by the otolaryngologist or by a radiologist or ultrasonographer at a separate visit. Some practices have someone (a cytopathologist or pathologist) review the slide immediately to ensure there are enough cells to help make the diagnosis. Your surgeon will also likely get a CT (“CAT”) scan or MRI to assess the extent of the parotid mass.9
Treatment:
Surgery is the cornerstone of treatment of this disease, with most benign and low-grade cancers treated with surgery alone.10 Tumors that are high-grade, are treated more aggressively with radiation therapy in addition to surgery.11 Every effort is made to remove the entire tumor while preserving the facial nerve. In experienced hands and in patients with no evidence of facial nerve weakness, the risk to this nerve is usually low. Patients who have tumors that are non-cancerous or benign, can elect to have the masses followed instead of having surgery. However, many of these masses do continue to grow and get larger in size. The surgeon may recommend repeat imaging if you choose to follow the mass instead of surgery. The surgery is usually an outpatient surgery or associated with a short hospital stay. The surgeon may use a drain, or a small plastic tube, connected to a suction bulb to help keep the wound fluid out. The surgeon may also suggest a compressive dressing over the surgical wound. Your surgeon will be able to provide the most relevant information regarding your parotid tumor and how to best address it as well as more details regarding the surgery and associated risks.
Further reading:
Fine Needle Aspiration
Salivary Gland Cancer
References
1. Barnes L EJ, Reichart P, Sidransky D. (Eds). Pathology and Genetics of Head and Neck Tumours: Tumours of the Salivary Glands. World Health Organization.2005: 209.
2. Guzzo M, Locati LD, Prott FJ, Gatta G, McGurk M, Licitra L. Major and minor salivary gland tumors. Critical Reviews in Oncology/Hematology. 2010;74: 134-148.
3. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head and Neck Surgery. 1986;8: 177-184.
4. de Ru JA, Plantinga RF, Majoor MH, et al. Warthin's tumour and smoking. B-ent. 2005;1: 63-66.
5. Pinkston JA, Cole P. Cigarette smoking and Warthin's tumor. American Journal of Epidemiology. 1996;144: 183-187.
6. Liu CC, Jethwa AR, Khariwala SS, Johnson J, Shin JJ. Sensitivity, Specificity, and Posttest Probability of Parotid Fine-Needle Aspiration: A Systematic Review and Meta-analysis. Otolaryngology and Head and Neck Surgery. 2016;154: 9-23.
7. Christensen RK, Bjorndal K, Godballe C, Krogdahl A. Value of fine-needle aspiration biopsy of salivary gland lesions. Head and Neck. 2010;32: 104-108.
8. Maiorano E, Lo Muzio L, Favia G, Piattelli A. Warthin's tumour: a study of 78 cases with emphasis on bilaterality, multifocality and association with other malignancies. Oral Oncology. 2002;38: 35-40.
9. Lee YY, Wong KT, King AD, Ahuja AT. Imaging of salivary gland tumours. European Journal of Radiology. 2008;66: 419-436.
10. Lim YC, Lee SY, Kim K, et al. Conservative parotidectomy for the treatment of parotid cancers. Oral Oncology. 2005;41: 1021-1027.
11. Mahmood U, Koshy M, Goloubeva O, Suntharalingam M. Adjuvant radiation therapy for high-grade and/or locally advanced major salivary gland tumors. Archives of Otolaryngology - Head and Neck Surgery. 2011;137: 1025-1030.
