Chronic Parotitis Research Articles

The surgical management of chronic parotitis

Chronic parotitis is a disorder characterized by recurrent painful swelling of the gland with purulent sialorrhea. Occasionally, the condition fails to respond to medical management and definitive surgical therapy is necessary. Sialolithiasis is the usual etiology in cases of parotitis, although occasionally severe recurrent parotid infections are superimposed on underlying Sjögren's disease. Total parotidectomy with facial nerve dissection has been used in such cases in our department and has proved to be an excellent way to manage this disease. A summary of our results indicate that the recurring infections were eradicated and that the complication rate is tolerable, considering the magnitude of the problem. We feel that it is better to use surgical management early rather than wait for the formation of fistulae or abscesses.

Klinisches Bild und mögliche Ursachen der Funktionsstörungen der Glandula parotis bei der Radiojodtherapie des differenzierten Schilddrüsenkarzinoms*

The parotid gland function was examined in 31 patients with thyroid carcinoma treated with radio-iodine. Beside enhanced values of sodium concentration, protein concentration and alpha-amylase activity following each therapy, a continuous reduction of flow rate and alpha-amylase activity is found according to the cumulative total dose. The importance of glandular kallikrein und phosphohexoseisomerase (PHI) are discussed with regard to their possible role in glandular damage. A comparison is made with chronic recurrent parotitis, and therapeutical aspects are considered. On the whole the present investigation shows that radio-iodine therapy causes damage to the parotid gland, which normally leads to measurable effects after cumulative doses of 470 mCi.

｀９９ｍ´Ｔｃ‐ｐｅｒｔｅｃｈｎｅｔａｔｅによる唾液腺シンチグラフィの有用性

Various diagnostic methods are employed for salivary gland diseases. Among these, salivary gland scintigraphy employing 99mTc-pertechnetate is widely used in determining both morphological and functional statuses. In this paper, we evaluated the diagnostic value of this method.Fifty nine cases were examined in this study: 2 cases of acute sialoadenitis, 12 cases of chronic submandibular sialoadenitis, 14 cases of chronic parotitis, 4 cases of benign submandibular gland tumor, 7 cases of benign parotid tumor, 2 cases of malignant tumor, 3 cases of cyst, 3 cases of Sjogren's syndrome, 8 cases of xerostomia, and 4 cases of sialolithiasis.99mTc-pertechnetate was administered i.v. at a dose of 5-10mCi. After about 10 minutes, antero-posterior, right lateral, and left lateral views of the face were obtained. Bilateral parotid and/or submandibular glands were selected as R.O.I.and time activity curves were obtained. As a stimulation test, lemon juice was administered after another 10 minutes, and anteroposterior views of the face were obtained.An analysis was carried out with three parameters: accumulation patterns (AP), the secretory patterns after the stimulation test (SP) and the stimulatory sacretion ratio (SSR) expressed as the ratio of post-to pre-stimulation counts on the salivary glands.AP were subclassified into five images: defective, decreased, normal, increased and enlarged. SP were also subclassified into five patterns (A-E).The following results were obtained:1) “Defective” images were an aid to differentiation between tumors except Warthin's tumor and other diseases.2) “Increased” image with tumorous swelling were strongly indicative of Warthin's tumor, but more detailed examinations were required.3) Differences in accumulations in Sjogren's syndrome and xerostomia were useful in distinguishing between the two diseases.4) SP was helpful in differentiating between Sjogren's disease and xerostomia.5) The SSR was more effective than SP for evaluation of minuter secretory functions.6) Salivary gland scintigraphy employing 99mTc-pertechnetate therefore appears to be an extremely useful diagnostic method for salivary gland diseases.

Osler and Sarcoidosis

In a recent delightful historical report (Chest 1984; 86:263), Sharma and James discussed the case of Hannah W., who was seen by William Osier in 1894. This 11-year-old child presented bilateral gland enlargement, generalized lymphadenopathy, and an enlarged spleen. These signs gradually improved, and when Hannah died three years later of cavitary tuberculosis, there was no trace of the previous findings at autopsy. Osier considered her a case of chronic parotitis. Now, 90 years later, Sharma and James have re-examined the case and concluded that Hannahs illness was actually a case of sarcoidosis. They bemoan the fact that Osler described a “noble disorder” but was robbed by Nature of the opportunity to describe a new disease.

Long-term follow-up of the effect of tympanic neurectomy on sialadenosis and recurrent parotitis.

We examined the effect of tympanic neurectomy on the clinical symptoms and secretory function of the parotids in 13 patients with chronic parotitis or sialadenosis for 3 years. Each patient had significantly fewer complaints immediately after the surgery. In quite a few patients the improvement was transient only. Three years after neurectomy 3 of the 10 examined patients were free from complaints and 4 further patients had less severe complaints than before the surgery. Neurectomy was followed by a significant decrease in parotid flow rate and an increase in the sodium concentration of parotid saliva, while potassium concentration showed a slight decrease. Three years after the surgery the flow rate and the sodium concentration were moderately higher than before that. There was a significant, long-lasting change in the amylase activity of parotid saliva; 3 years after neurectomy it attained one-third of the preoperative value. A pharmacological test, carried out 3 years after neurectomy in 2 patients, suggested parasympathetic reinnervation of the parotid.

Computed tomography and sialography of chronic pyogenic parotitis.

We performed Computed Tomography (CT) immediately following, or simultaneous with, conventional sialography on a group of 45 patients with parotid gland swellings over a two-year period. Tumours occurred in eight, sarcoidosis in 22, actinomycosis in two and chronic pyogenic parotitis in 13 patients. In the latter group, there were two cases of bilateral disease, for a total of 15 glands. The sialographic and the combined CT-sialographic features were retrospectively analysed. In all cases, ductal pathology was more severe in the main and proximal branches, was better demonstrated on conventional sialography and was diagnostic in 10/14 glands (71%). CT-sialography was the superior modality in the evaluation of the gland parenchyma and the adjacent structures, demonstrating diagnostic features of infection in 8/14 glands (57%). However, a combination of both modalities presented a consistent pattern of infection in all cases, distinctive from tumours and sarcoidosis. CT-directed aspiration was performed on the four glands which were equivocal on conventional sialography, and two of these underwent a simultaneous aspiration-irrigation with antibiotics. Although this report is based on a limited experience, CT-sialography with aspiration appears to be an interventional radiological alternative to the traditional diagnostic superficial parotidectomy. Ultrasonography (two cases) and nuclear scintigraphy (one case) added little useful information in chronic pyogenic parotitis.

T-CELL DEFICIENCY IN AN AFRICAN FAMILY

We report the case of a 19-month old African boy born from parents with clinical and immunological features suggesting prodromal acquired immunodeficiency syndrome (AIDS). He showed early failure to thrive, generalized lymphadenopathy, bilateral parotitis. Later he developped persistent interstitial pneumonia, persistent oral thrush and mild hepatosplenomegaly. Immunological studies showed hyper IgG level (3.2 g/dl), reversed T-helper/T-suppressor (T4/T8) ratio (19/68) and T-cell defect (cutaneous anergy for different antigens, depressed in vitro response for concanavalin, phytohaemagglutinin and Pokeweed mitogens). Open lung biopsy showed interstitial nodular lymphocytic infiltrates on optic microscopy and cytoplasmic particles on electron microscopy which are of uncertain origin. Recently the two older brothers were investigated. The oldest (6 years) showed chronic parotitis, hyper IgG level (4.7 g/dl), reversed T4/T8 ratio (18/49) and depressed in vitro response to mitogens. The second (5 years) showed slight parotitis, reversed T4/T8 ratio (29/32) and depressed in vitro response to mitogens. Both had normal chest X-rays The clinical and immunological presentation of the three children resemble that of infants with AIDS-like syndrome described by others in the USA. We suggest specific modes of transmission could be involved in familial acquiring of AIDS (transplacental-route, breast feeding, or other routine close-contact).

Subtotal parotidectomy in the treatment of chronic sialadenitis.

Chronic recurrent parotitis can be disabling, and often requires surgery for its resolution. Twenty-one patients with chronic sialadenitis treated by subtotal parotidectomy were studied. Two patients developed transient and one significant postoperative recurrent parotitis, and two patients had salivary fistulas. There were no instances of permanent facial nerve weakness. Parotidectomy in patients with severe chronic sialadenitis risks injury to the facial nerve. When the nerve is indistinguishable from surrounding scar, subtotal parotidectomy would appear to be preferable to total parotidectomy in select patients. Total parotidectomy is the procedure of choice for elimination of chronic sialadenitis when it can be performed with minimal risk to the facial nerve.

The surgical treatment of chronic parotitis.

The surgical treatment of chronic parotitis.

Occlusion of Stenon's duct by prolamine: a possible treatment of chronic parotitis? Preliminary experience from animal experiments.

The histological and biochemical (amylase, protein) consequences of occlusion by prolamine of the parotid duct were studied in 5 rabbits. Histological examination 2 weeks after occlusion revealed an a

Presence of carcinoembryonic antigen (CEA) in the normal and inflamed human parotid gland. An immunohistochemical study of 31 cases.

Carcinoembryonic antigen (CEA) was analysed in the human parotid gland. Specimens of 31 normal and inflamed parotid glands were studied by the indirect immunoperoxidase technique. The presence of CEA could be demonstrated at the border of the acinar cells and the intercalated duct cells as well as in the undifferentiated duct cells as observed in chronic obstructive parotitis. These observations may explain the presence of CEA in normal human saliva and may provide a new basis for histogenetic interpretation of pathological lesions of the parotid gland, especially of the tumors of the salivary gland tissue.

Immunoglobulin-containing plasma cells in chronic parotitis and malignant lymphomas of the parotid gland. Comparing immunocytochemical observations of frequency and localization.

IgA-containing plasma cells in the periductal gland tissue are part of the special secretory immune system of the salivary glands. The reaction of Ig-containing plasma cells (localization, frequency, specific Ig-content) was analyzed by the indirect immunoperoxidase method in chronic recurrent parotitis (9 cases), chronic myoepithelial parotitis (benign lymphoepithelial lesion, Sjögren's syndrome; 8 cases), and malignant lymphoma associated with chronic myoepithelial parotitis (11 cases). The following results were obtained: 1. In chronic recurrent parotitis, parallel to the increase in IgA in the salivary secretion, a marked multiplication of IgA-containing plasma cells was found in the inflammatory infiltrate and the remaining non-inflamed periductal parenchyma of the parotid gland. In the marginal zone of inflammation, a slight increase of IgG-containing plasma cells was also observed. 2. In chronic myoepithelial parotitis, the total plasma cellular infiltration was slightly less distinct than in chronic recurrent parotitis. The most remarkable increase in Ig-containing plasma cells developed in the marginal zones--away from the myoepithelial cellular islands--as well as in the area of ductular proliferations, and was characterized by a strong increase of IgG-containing plasma cells. At the same time, a slight increase of IgM-containing plasma cells was observed. No plasma cells were found in the myoepithelial cellular islands. 3. In the malignant lymphomas associated with myoepithelial parotitis, which were mainly highly differentiated lymphomas (immunocytomas, centrocytic-centroblastic lymphomas) and rarely poorly differentiated immunoblastic lymphomas, there was a distinct decrease of IgG-containing plasma cells when compared with the numbers in this group without lymphoma. The differing degrees of prevalence and Ig-content of the plasma cells partly describe the change taking place in the local secretory immune system of the parotid gland. The possible relationships between chronic recurrent parotitis and auto-immune myoepithelial parotitis on one hand and the stages of transition (prelymphoma) to malignant lymphoma on the other, are discussed.

Chronic recurrent parotitis aetiopathogenesis

Summary A retrospective study of 107 patients * with chronic recurrent parotitis and a prospective study of 25 patients with chronic recurrent parotitis and 6 patients with Sjogren's syndrome have been carried out. In most of the patients with chronic recurrent parotitis the main parotid duct is more tortuous and bent under a more acute angle while the ducts of the first and second order form a more obtuse angle than normal. Consequently, the secretion of saliva becomes rather difficult and its flow rate is diminished. In 25 subjects with chronic recurrent parotitis biopsy has been performed and the dominant histological finding was infiltration of the interstitium, while histochemically, mucin has been found both in ducts and acini in 72% of the cases. The parotid glands of subjects from the control group secreted more saliva than the unaffected glands of patients with unilateral parotitis. In the cases of unilateral parotitis the levels of IgA and IgG in the saliva of the affected glands have been statistically significantly higher compared to saliva of the unaffected glands in the same patients. In the course of remission of the disease the level of immunoglobulins in saliva from the affected glands has been decreased. The levels of IgA and IgG of parotid saliva in subjects from the control group have been markedly higher compared to the level of parotid saliva of the unaffected glands in patients with unilateral parotitis. After injecting antigens into the parotid duct the levels of IgA and IgG in saliva of the control group have been significantly increased. We have come to the conclusion that in the aetiopathogenesis of chronic recurrent parotitis the main factors which cause and maintain infection are diminished salivation, the diminished immunological capacity of saliva as well as the histological and anatomo-topographical characteristics of the parotid gland. The pathophysiology of the disease can be summarized as follows: Diminished secretion of the immunologically poor-quality saliva and its reduced flow rate have as their sequelae inadequate selfcleansing and retrograde spread of microorganisms from the mouth into the gland. The infection leads to partial metaplasia of serous cells into mucous cells. — Mucus flows with difficulty through narrow serous ducts and mucous plugs are formed. — Accumulation of saliva, infiltration and swelling of tissue produce inactivity and pressure atrophy of the gland. — Proteolytic ferments lacking alpha 1 antitrypsin lead to the destruction of parenchyma and its replacement by connective and fatty tissue. — Obstruction of ducts by mucous plugs and proliferated tissue leads to still greater retention of salivation, dilatation and sacculation of small ducts and acini which result in further decrease in secretion of saliva and its antibacterial agents. All these favour the invasion by bacteria and thus the establishment of a vicious circle.

Flow rate, protein, amylase, lysozyme and kallikrein of human parotid saliva in health and disease

Flow rate, protein, amylase, lysozyme and kallikrein in human parotid saliva of a normal population (n = 117) were determined and the secretion per minute and the specific activities calculated and compared with the findings in 44 patients suffering from chronic parotitis and 30 patients with sialoadenosis. In chronic parotitis, there were characteristic differences between children and adults. According to their secretion behaviour, sialoadenosis patients could be divided into type A characterized by a sharp increase in enzyme activity and type B which, particularly upon stimulation, showed much reduced protein, amylase and lysozyme secretion.

Sialochemical examinations in non-tumorous parotid enlargements.

Secretion rates and the composition of isolated parotid saliva samples were samples were examined in 51 patients suffering from chronic recurrent parotitis, sialosis, or Sjögren's syndrome, and in 17 healthy controls. Evaluation of the results indicated that sialochemical examination may provide a valuable help in the differential diagnosis of parotid diseases characterized by swelling of the gland. Chronic parotitis is characterized by a significantly decreased flow rate, extremely high sodium and protein concentration and lack of secretory response to stimulation. In Sjögren's syndrome the low flow rate was found to be associated with a decreased potassium secretion rate as well as decreased flow rate and decreased sodium concentration after stimulation. In sialosis, where flow rates display a considerable individual variation, a significant increase in potassium secretion rate could be revealed.

Surgical treatment of chronic suppurative parotitis. A critical review.

AbstractChronic suppurative parotitis, manifest by recurrent acute parotid enlargement and purulent sialorrhea, is usually seen with sialolithasis, sialectasis, or duct strictures. These conditions have a common pathophysiology, the predisposition to infection associated with fluid stasis.Chronic suppurative parotitis can usually be successfully treated with conservative mechanical and medical measures. Occasionally the disease is severe enough to require vigorous surgical treatment. Parotidectomy is currative and provides tissue to confirm the diagnosis. Because of concern about risk to the facial nerve in parotidectomy, tympanic neurectomy and parotid duct ligation—which theoretically cause atrophy of the gland by interruption of secretomotor nerves or pressure effects—are advocated as alternative treatment.Basic physiological and clinical studies do not confirm that tympanic neurectomy consistently interrupts all secretomotor nerves to the gland nor that parasympathetic denervation can induce complete atrophy of the gland. Studies of parotid duct ligation also do not conclusively demonstrate that this procedure will induce complete atrophy of the gland. There is a suggestion that it may have some role in protecting an already functionless gland from ascending infection.Published studies indicate that parotidectomy is the most effective treatment for this disease, and that the risk of permanent facial injury after the operation is slight.A review of 86 consecutive parotidectomies is reported. Fourteen of the surgical specimens showed inflammatory pathology and 6 of the patients had frank chronic suppurative parotitis preoperatively. The patients with chronic parotitis are asymptomatic 2 to 7 years after parotidectomy and there was no instance of permanent facial paresis after operations done for inflammatory disease.Parotidectomy is the treatment of choice for chronic suppurative parotitis when it is resistant to conservative measures. Operations such as tympanic neurectomy and parotid duct ligation, which approach the disease in an indirect manner, are not founded on carefully considered basic or clinical information and are of questionable effectiveness. The risk of permanent facial nerve paresis following parotidectomy for inflammatory disease is an important question. Our review indicates that the risk is well within acceptable limits.

Zur Problematik der Ductus-parotideus-Ligatur

Ligation of the parotid duct in cases with chronic recurrent parotitis, is an easy and often successful method in the treatment of this disorder. Still, some complications and failures of this technique have been observed. These undesirable concomitant circumstances and consequences are discussed. It is suggested, that ligation of the parotid duct, should be performed in combination with radiation therapy, or with excision of the parasympathetic secretomotor nerves of the gland.

Radiosialometry. II. The diagnostic accuracy of different evaluation parameters.

The temporal course of 99TcmO4 accumulation in the parotid gland after fast intravenous injection of the radionuclide was measured quantitatively by radiosialometry in 32 patients suffering from inflammatory or neoplastic diseases of the parotid glands. The diagnostic accuracy of five different evaluation parameters was compared. It was found that without reducing diagnostic accuracy, the method used could be simplified by omitting three of the five evaluation parameters. This implies a shortening of the measuring time from 18 to 10 minutes. The diagnostic accuracy of radiosialometry in 14 cases with a general engagement of the parotid parenchyma (irradiation damage, collagen sialosis and chronic recurrent parotitis) was high. Thus, all these 14 cases had abnormal radiosialometric values. Parotid tumours not causing extensive destruction of the parotid parenchyma were not detected by this method.

Zur chirurgischen Behandlung der chronisch rezidivierenden Parotitis

In 34 cases of chronic parotitis the surgical excision of the gland was performed. The range of indications depends on the severity of the symptoms, the frequency of the recurrence of the acute exacerbations with the diffuse or nodular swelling. Sialography shows very often cavity formation or circumscribed ductal dilatations. The demonstration of the facial nerve is difficult because it is embedded in dense scar tissue, the colour of which resembles the normal nerve. The function of the temporarily paralysed nerve returns within 6 months at the latest. Sometimes however, it will be recognized by the Gustatory sweating syndrome (Frey's syndrome).

Scanning Evaluation of Parotid Gland after Tympanic Neurectomy

Summary--Nine patients suffering from chronic parotitis, gustato sweating syndrome, and gustato lacrymation syndrome underwent tympanic neurectomy. Follow-up showed discrepancies between the good clinical results and the unchanged parotid scans in eight out of nine patients. Parasympathetic bypasses to the parotid gland are discussed.