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Chronic recurrent parotitis, chronic sialoadenitis and benign lymphoepithelial lesion: Treatment, symptoms, advice and help

 

Definition


These conditions form part of the spectrum of chronic inflammatory conditions of unknown origin. All share a common precursor event that is reduced salivary secretion rate and subsequent stagnation of salivary flow. These conditions are all more common in the parotid gland because of thicker saliva, which is more susceptible to bacterial infection than submandibular saliva.


Incidence/Age


Chronic recurrent parotitis in infants up to 12 years is more common in males than females. Chronic sialoadenitis occurs in adults and more frequently in females than males. Benign lymphoepithelial lesion is more common in adult females.


Anatomy & Physiology


The parotid gland consists of a superficial (outer) and a deep (inner) part, which are separated by the tree-like terminal branches of the facial nerve, responsible for facial movement. Lymph nodes are present within the gland.


Saliva leaves the gland through Stensen's duct, which pierces the facial muscles and enters the mouth through the cheek opposite the second upper molar tooth. Saliva flow is stimulated by chewing and the presence of food in the mouth, particularly sour substances. The stimulus is mediated via parasympathetic nerve fibres carried on the auriculotemporal nerve to the parotid gland.


The submandibular gland consists of superficial and deep parts separated by the myelohyoid muscle. The duct leaves the deep part of the gland and enters the floor of the mouth and meets its opposite partner. The deep part of the gland is intimately related to the hypoglossal nerve, which moves the tongue, and the lingual nerve, which provides sensation to the front half of the tongue.


Saliva flow is stimulated via parasympathetic (chorda tympani) nerve fibres carried along the lingual nerve.


Causes


The causes are unknown, but both chronic recurrent parotitis and acute suppurative sialoadenitis can progress onto chronic sialoadenitis. Chronic recurrent parotitis may also progress into a benign benign lymphoepithelial lesion or may resolve spontaneously at puberty.


Symptoms/Signs


Initially mild recurrent painful swelling of the glands, often aggravated by eating. It initially lasts for some hours and eventually becomes a more permanent swelling. In advanced cases, a dry mouth may be a problem in up to 80% of adult patients, but almost never in children.


Complications of Disorder


Benign lymphoepithelial lesions may rarely go on to develop lymphomas or carcinomas.


Tests


The aim of tests should be to rule out treatable predisposing factors such as stones in the parotid or submandibular ducts, or the narrowing of the ducts (strictures). This may include:


  1. Plain X-rays to identify radioopaque stones.
  2. Sialography, which involves injecting dye into the salivary duct openings in the mouth to identify non-radioopaque stones and strictures in the ducts.
  3. Computed tomographic (CT) scanning with or without sialography.


A biopsy is only required if clinical distinction from tumour is not possible and then requires either:


  1. Fine needle aspiration cytology (FNAC)
  2. Open biopsy involving a superficial parotidectomy approach


Fine needle aspiration cytology (FNAC) involves inserting a fine bore needle into the lump and aspirating some of its contents into a syringe and the sample is then examined by a cytologist. Although interpretation of salivary cytology can be very difficult, positive results can be a helpful guide to treatment planning. Availability of high quality cytology services is variable. Incisional biopsies of the parotid are usually avoided because of the high risk of damaging the facial nerve. Sometimes the only way of obtaining a reliable diagnosis is to take out the superficial lobe with careful identification of t