Книга_4440_Библиотеки_им_академика_М_И_Перельмана

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364

11 History andExamination ofThyroid andParathyroid Gland Disease…

• Neuromuscular and psychologic manifestations include fatigue, muscle weakness, depression, inability to concentrate, and memory problems or subtle decits that are often characterized poorly and may not be noted by the patient, a common description being ‘brain fog’

(b) Duration of complaints (c) Associated symptoms/history of thyroid

surgery, autoimmune disease like Addison disease, H/o radiation treatment, family H/o hypoparathyroidism, MEN type 1

2. Examination (a) General examination

• Muscle weakness, depression, hypertension, bradycardia

• Signs of hypercalcemia—Hypotonia, hyporeexia, paresis, coma, memory disturbance, muscle twitch and cramps, swelling of feet and ankle

(b) Systemic examination

• Cardiovascular system— Hypertension, arrhythmia

• Abdomen—Epigastric tenderness (pancreatitis)

• A palpable mass in neck

History andExamination ofSalivary Gland Diseases (Exocrine Glands ofHead andNeck)

12.1 History/Presentation ofSalivary Glands Diseases

1. Chief complaints/symptoms of salivary

glands—The salivary gland disease is of three

types like infection, mucocele, sialolithiasis and tumours and presented as:

(a) General chief complaints/symptoms of

salivary gland diseases

• Oral dryness

• Halitosis (foul breath)

• Fever

• Burning sensation in mouth

• Loss of taste or bizarre taste

• Difculty in rst phase of swallowing

• Tongue tends to stick to palate

• Decreased retention of denture

(b) Gland-specic complaints

• Parotid gland – Swelling/lump

Generalized swelling—parotitis, xerostomia, abscess, mumps Localized swelling or lump— tumours, abscess, tumours

– Pain—parotid abscess, acute par-

otitis, mumps

– Swelling in throat—tumour of deep

lobe of parotid

– Symptoms of facial nerve paraly-

sis—deviation of angle of mouth, unable to blow and whistle, etc.—

This suggests the malignant lesions

of parotid gland. – Sinus in parotid area – Gustatory sweating—sweating

over parotid area while having meal

or eating, drinking. This is symp-

tom of Fray’s syndrome. – Discharge of side of mouth

• Submandibular gland – Swelling in submandibular

triangle

Generalized—sialadenitis, sialolithiasis, abscess, Ludwig’s angina Localized—tumour

– Swelling while taking meal—This

suggests the sialolithiasis in duct of

gland. – Pain—infection, abscess – Discharge in oor of

mouth—Infection – Deviation of angle of mouth—This

is due to the involvement of

marginal mandibular nerve and is

an indication of malignancy.

• Sublingual gland – Swelling on oor of mouth – Pain—oor of mouth

• Minor salivary gland – Swelling over lip, hard palate, etc. – Pain

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025 S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck Surgery, https://doi.org/10.1007/978-981-96-1765-4_12

365

366

12 History andExamination ofSalivary Gland Diseases…

• The symptoms of sialolithiasis include – Painful lump below tongue – Pain that aggravates when eating – Painful swelling in submandibular

area—This is a common symptom of submandibular sialolithiasis. This is caused by a collection of saliva in the salivary gland due to obstruction of Stensen’s duct.

• Sialadenitis symptoms include – Lump on side of cheek—this is a

symptom of parotid diseases.

– Lump below chin—submandibular

gland diseases

– Lump below tongue—sublingual

gland disease

– Lump over palate—minor salivary

gland disease

– Pus that drains into your mouth

below the tongue is due to submandibular sialadenitis or abscess.

– Pus drains into mouth through the

opening in cheek due to parotitis, parotid abscess.

– Strong or foul-smelling pus—This

may be found in infection of both submandibular and parotid glands.

– Fever—This is a symptom of

infection.

• Cysts that grow in salivary glands can

cause

– Yellow mucus that drains when the

cyst bursts.

– Pain while eating, speaking and

swallowing.

• Tumour of salivary gland – Lump/mass on side of cheek, facial

nerve weakness—This is a symptom of parotid tumour

– Lump/mass below chin—subman-

dibular gland diseases

– Lump/mass below tongue—sublin-

gual gland disease

– Lump/mass over palate—minor

salivary gland disease

• Viral infections in the salivary glands,

such as mumps, can cause

– Fever – Muscle aches – Joint pain – Swelling on both sides of the face – Headache – Symptoms of Sjögren’s syndrome

include: – Dry mouth – Dry eyes – Tooth decay – Sores in the mouth – Joint pain or swelling – Dry cough – Unexplained fatigue – Swollen salivary glands – Frequent salivary gland infections

(d) Duration of symptoms

• Short duration—abscess, acute sialadenitis, mumps

• Long duration—benign tumour, sialolithiasis, chronic sialadenitis

(e) Mode of onset

• Sudden—acute sialadenitis, abscess, viral infection (mumps)

• Gradual—chronic sialolithiasis, benign tumours, sialolithiasis

(f) Associated symptoms/history of

• Modiable risk factors include dehydration, malnutrition, sialolithiasis, recent surgery and medications (anticholinergics, diuretics and chemotherapy). Nonmodiable risk factors include age (elderly), anorexia nervosa, cystic brosis, diabetes, HIV/ AIDS, hepatic/renal failure and prior radiation.

• Patients with sialolithiasis typically present with painful salivary glands, exacerbated by eating foods that precipitate saliva production.

• Sialosis refers to bilateral symmetric painless enlargement of the salivary glands often due to diabetes, alcohol, obesity, or medications.

• Clinically, mumps sialadenitis begins with a prodromal period followed by acute bilateral salivary gland swelling typically affecting the parotid glands.

12.1 History/Presentation ofSalivary Glands Diseases

367

12.1.1 Examination ofSalivary Gland

1. Surgical anatomy—The salivary glands are exocrine glands that are part of the digestive system and include three major paired glands: the parotid, the submandibular and the sublingual glands. There are also many smaller minor glands in the oral cavity, pharynx and larynx (Table12.1).

Difference between minor and major sali-

vary glands (Table12.2)

2. Physiology and functions of salivary glands— The salivary glands produce saliva, which plays an important role in mastication, speech, protection, deglutition, digestion, excretion, repair, antimicrobial action, maintenance of tooth integrity, taste, buffering

3. Examination of patients/signs

(a) General signs of salivary gland diseases

• Halitosis

Table 12.1 Clinical anatomy salivary glands

Parotid gland—These are the largest salivary glands located on the lateral surface of the mandibular ramus and fold themselves around the posterior border of the mandible, just behind the masseter in the retromandibular area. They are two in numbers. The parotid gland has two lobes supercial and deep. It drains into oral cavity via Stenson’s duct opposite the second upper molar

Submandibular gland—They are two in numbers located in submandibular triangle below body of mandible. These are the second largest salivary glands

Sublingual glands—They are two in numbers located on either side of the tongue deep under the oor of the mouth, deep to the body of the mandible within the sublingual space. These are the smallest of the major salivary glands

Minor salivary glands—They are numerous in number and located whole mouth and nasal cavity.They are labial and buccal gland, glossopalatine gland, and palatine and lingual glands

Table 12.2 The difference between major and minor salivary glands

Major salivary gland Minor salivary gland They are big in size, they

have their own duct, three pairs in numbers

They are called minor because of their size, no envelope around them, no own duct, present all over mouth and throat

• Saliva pool disappear

• Dry mucosa

• Glossitis and ssured tongue

• Atrophy of papilla

• Angular cheilitis

• Periodontitis

• Candidiasis

(b) Gland-specic examination/signs

Parotid gland examination

• Inspection (Fig.12.1) – Extraoral inspection—Parotid is

inspected for swelling/lump/mass, stula, and face is inspected for any paresis. The anterior border of the gland may be better dened by having the patient clench his or her teeth together, which tenses the masseter muscle.

– Intraoral inspection—The ana-

tomic landmarks intraorally for

Stensen’s duct (usually at the

maxillary second molar tooth on the inner surface of the buccal mucosa at the parotid papilla).

Parotid secretions are carried to the oral cavity by Stensen's duct, which enters the oral cavity in the cheek just opposite the upper second molar tooth. It is visible as a small papilla in the buccal mucosa. Careful observation of this papilla done for pus, mucus or particulate matter in the secretion suggest infection of parotid gland. The normal saliva from the parotid gland is usually clear, thin and colourless.

– Displacement of lateral oropharyn-

geal wall—The deep lobe of parotid gland may displace the tonsil medially if enlarge.

• Palpation (Fig.12.2) – Extraoral palpation—There are

two methods of palpation of parotid gland one is anterior and another is posterior method. In posterior method, examiner stands behind the patient, puts 2 to 3 ngers over posterior border of ramus and

368

Fig. 12.1 (a, b) Inspection of parotid gland swelling from lateral side, (c) Opening of parotid duct, (d) Bulging of lateral oropharyngeal wall (Deep lobe of parotid tumours)

12 History andExamination ofSalivary Gland Diseases…

c d

Fig. 12.2 Intraoral and extraoral palpation of parotid gland

moves backward and inward. The normal parotid gland is generally soft and is not usually palpable as a discrete gland. its consistency may be appreciated by pressing the gland on its lateral surface against the vertical mandibular ramus. The

Parotid gland

swelling is palpated for tenderness, raised temperature and consistency

– Intraoral palpation—The

Stensen’s duct should be palpated bimanually and look for the type of saliva that comes out. The parotid gland is palpable or not.

12.1 History/Presentation ofSalivary Glands Diseases

369

– Salivary duct and ow exam—To

perform a ow assessment at Stensen’s ducts by rst positioning your light correctly, pulling the buccal mucosa out to expose the duct, and then drying all uid from the buccal mucosa area. Next, compress the parotid gland externally

with the other hand moving from posterior to anterior across the

gland. This should produce an expression of uid from the duct. In case of xerostomia, a gauze piece is placed near Stensen’s duct opening.

– Bimanual palpation—The parotid

gland is bimanually palpated around the anterior border of the ramus of mandible.

– Interpretation of parotid exami-

nation (Table 12.3)

– Parotid gland examination—

inspection (Fig.12.1)

– Examination of parotid gland—

Bimanual Palpation (FIg. 12.2)

• Submandibular gland—Physical examination should begin with the gland itself, which resides in submandibular triangle just under the inferior border of the mandibular body between the anterior and posterior belly of digastric muscle.

Table 12.3 Interpretation of parotid gland examination

Interpretation of parotid examination Tender swelling/lump/mass—Infection, blockage,

carcinoma parotid, mumps, parotitis, parotid abscess Non-tender swelling/mass/lump—Alcoholism,

diabetes, Sjogren’s syndrome, HIV infection, benign tumour (pleomorphic adenoma)

Dry oral cavity mucosa—Post radiotherapy, Sjogren’s syndrome

Facial nerve paresis or paralysis—Trauma, carcinoma of parotid

Pus or thick saliva through Stenson’s duct—Parotid infection, parotid abscess, stone in parotid duct

Medially displaced tonsil and lateral oropharyngeal wall—Tumour in deep lobe of parotid

– Inspection—The inspection of

submandibular gland includes the extraoral and intraoral inspection.

Extraoral inspection—The submandibular gland lies in submandibular triangle which is located below the body and angle of mandible. This area should be inspected for:

• Swelling/mass/lump: – Solid—Tumour – Firm—Sialadenitis – Cystic—Lymphangioma,

haemangioma, cystic hygroma, abscess Ludwig’s angina

• Deviation of angle of

mouth—It suggests the malignant tumour of submandibular gland

• Scar—It can be due to previ-

ous surgery, and tubercular lympahdenitis

• Colour of skin of subman-

dibular triangle

• Discolouration of skin over

submandibular fossa

Intraoral inspection (Fig.12.3a)

The submandibular duct or Wharton's duct runs superiorly and anteriorly to empty adjacent to the frenulum of the tongue. The small duct orice is visible at the top of a papilla in this area.

Observation of the salivary ow during palpation is most helpful.

Type of secretion—mucoid or serous.

Purulence—pus discharging from duct opening.

Stone in duct—The submandibular gland is more commonly associated with stone formation than the other glands

370

12 History andExamination ofSalivary Gland Diseases…

because the gland's secretion is more mucoid and because the gland lies in a dependent position.

– Palpation—The gland should be

palpated for the presence of calculi.

Extraoral palpation—It is done with either anteriorly or posteriorly.

examination is done in sitting position of patient. The examiner either stands or sits in front of patient. First, stabilize the head of patient with one hand

Fig. 12.3 Examination of submandibular gland. (a) Intraoral inspection of Wharton’s duct, (b and c) Posterior palpation, (d and e) Bimanual palpation

Anterior approach—This

and ask to ex the head. Now, examiner use his ngers of other hand to palpate the submandibular gland in submandibular triangle one by one.

Posterior approach—Examiner stands behind the patient and rst, stabilizes the patient’s head with thumb over parietal bone. The palpation is done with nger’s pad. Palpation of both submandibular triangles should be done at the same time. The palpation of tringle is done for swelling, mass, it’s consistence, tenderness (Fig.12.3b, c).

Sub-mandibula gland

12.1 History/Presentation ofSalivary Glands Diseases

371

Bimanual palpation—It is best palpated bimanually with one hand on the lateral oor of the mouth and the other on the submandibular gland. The gland is usually soft and mobile and should not be tender to palpation.The examiner stands in front of patient who is seated on stool. Now, examiner wears the gloves, for examination of left submandibular triangle, and index nger of left hand should be placed intra-orally on oor of mouth and ngers of right hand placed externally on submandibular triangle. Now, examiner pushes the swelling up if it can be felt by nger inside the mouth too. The enlarged submandibular gland is palpable bimanually but enlarged submandibular lymph node not (Fig.12.3d, e).

Salivary duct and ow exam—

To perform a ow assessment at

the light, push the tongue poste-

rior with a mirror or tongue blade, and dry all uid from the oor of the mouth with gauze. Then, compress the submandibular gland with the other hand from beneath the mandible to produce uid from the duct.

• Sublingual glands—It lies just beneath the mucosa on the oor of the mouth and empty directly into the mouth or into the submandibular duct. The gland is not discretely palpable, nor are the duct openings usually visible.

• Examination of neck—The neck should be examined for other swellings like lymphadenopathy.

• Examination of cranial nerve VII— The angle of mouth should be inspected for any deviation.

• Examination of hypoglossal nerve— This is checked by the movement of tongue.

12.1.2 Two Practical Collection Methods forClinicians (Table12.4)

Table 12.4 The methods of collection of saliva

Unstimulated saliva collection Stimulated saliva collection

1. Patient is instructed to adopt a sitting position with head hanging forwards slightly.

2. A large glass funnel that sits inside an empty glass

beaker or test tube will be given to a patient.

3. Before starting the test, patient has to swallow saliva, which he/she has in the mouth.

4. During the next ve minutes of the test, the subject remains relaxed and with eyes closed and drools into the funnel for 5 minutes.

5. The volume of saliva generated is then weighed and measured in ml

1. Stimulated saliva collection with parafn wax involves the subject drooling into a funnel while chewing the wax for 3 minutes.

2. Stimulated saliva collection with sugar-free lemon drop candy involves the subject drooling into a funnel while chewing the candy for 3 minute

372

12 History andExamination ofSalivary Gland Diseases…

12.1.3 Causes ofInammation ofSubmandibular Gland (Table12.5)

Table 12.5 The D/D of inammatory causes of submandibular gland swelling

Type of inammation Causes Acute sialadenitis: Usually with

duct calculus

Chronic sialadenitis Recurrent SMG inammation with reduced saliva ow, Stasis of secretions,

Secondary SMG sialadenitis Ductal obstruction from oor of mouth squamous cell carcinoma, enlarged,

Sialolithiasis Concretions within SMG ductal system, salivary stagnation, precipitation of

Autoimmune sialadenitis Sjögren syndrome Chronic sclerosing sialadenitis Küttner tumour—brosis & inammation with IgG4-related systemic disease;

Sialadenosis Non-inammatory SMG swelling, causes include: Diabetes, cirrhosis,

Staphylococcus aureus infection (most often) Others: Streptococcus viridans, Haemophilus inuenzae, and Escherichia coli

calculi; swelling without acute infection

swollen SMG often mistaken for malignant node

calcium salts ± epithelial injury along duct leading to sialoliths

SMG > > parotid

hypothyroidism

Most common parotid neoplasm (80%)

ease in str Slo R R Malignant transf Long standing tumour

(C PA Incr Benign metastasizing pleomorphic adenoma - metastasis

12.2 Histopathological Classication of Salivary Gland Tumours

373

12.2 Histopathological Classication ofSalivary Gland Tumours (Table12.6)

Table 12.6 Histopathological classication of salivary gland tumours

Benign epithelial Malignant epithelial Others Pleomorphic adenoma

Myoepithelioma Basal cells adenoma Warthin’s tumours Oncocytoma Canalicular adenoma Sebaceous adenoma Lymphadenoma Non sebaceous adenoma Ductal papilloma Inverted ductal papilloma Intraductal papilloma Cystadenoma

Fig. 12.4 Characteristic features of pleomorphic adenoma

Acinic cell carcinoma Mucoepidermoid carcinoma Adenoid cystic carcinoma Adenocarcinoma Epithelial myoepithelial CA Basal cell adenocarcinoma Sebaceous carcinoma Sebaceous lymph adenocarcinoma Salivary gland carcinoma Carcinosarcoma Myoepithelial carcinoma Carcinoma ex pleomorphic adenoma Metastatic pleomorphic adenoma Large cell carcinoma Small cell carcinoma

oliferation of epithelial and myoepithelial cells of the ducts and an incr

omal components

w growing, lobular, and not well encapsulated ecurrence rate of 1-5% with appropriate excision (parotidectomy) ecurrence possibly secondary to capsular disruption during surgery***

Carcinoma in pleomorphic adenoma- common

arcinosarcoma also occurs)

in younger patient-higher chance of tumor recurrence

eased growth during pregnancy

12.2.1 Characteristics ofPleomorphic Adenoma ofParotid Gland (Fig.12.4)

Soft tissue tumours

Haemangioma

Lymphoid tumours

Hodgkin’s Lymphoma Large B cell lymphoma

ormation occurs in 2-10% of adenomas

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