Salivary Gland Emergencies

Ultrasonographic Study of the Submandibular Gland for Botulinum Neurotoxin Injection

BACKGROUND

Hypertrophied submandibular glands provide a bulky contour to the lower face. Botulinum neurotoxin injection methods are commonly used for facial contouring; however, no studies have suggested injection points because of the lack of delicate anatomical information on the submandibular gland.

OBJECTIVE

The aim of this study was to determine the optimal injection site for botulinum neurotoxin injections in the submandibular gland.

MATERIALS AND METHODS

Anatomical considerations when injecting botulinum neurotoxin into the submandibular gland were determined using ultrasonography. The thickness of the submandibular gland, its depth from the skin surface, and the location of the vascular bundle were observed bilaterally in 42 participants. Two cadavers were dissected to measure the location of the submandibular gland corresponding to the ultrasonographic observation.

RESULTS

The thickest part of the submandibular gland measured 11.12 ± 2.46 in width with a depth of 4.63 ± 0.76. At the point where it crosses the line of the lateral canthus, it measured 5.53 ± 1.83 in width and 8.73 ± 1.64 in depth.

CONCLUSION

The authors suggest optimal injection sites based on external anatomical landmarks. These guidelines aim to maximize the effects of botulinum neurotoxin therapy by minimizing its deleterious effects, which can be useful in clinical settings.

Transdermal scopolamine for the treatment of recurrent parotid sialocele: a case report

Recurrent parotid sialocele is rare and challenging to treat. Treatment options are limited for cases of parotid sialocele that recur despite ductal ligation. This case study presents a patient who underwent wide excision of the right buccal mucosa due to squamous cell carcinoma. During the wide excision, a segment of the parotid duct was excised, and ductal ligation was performed to prevent the occurrence of a sialocele, followed by reconstruction using a folded anterolateral thigh free flap. Twenty-two days after surgery, parotid sialocele occurred despite the initial ductal ligation and subsequent ductal ligation was performed; however, the sialocele recurred. As an alternative therapeutic option, a transdermal scopolamine patch was applied for 3 weeks, with one patch used every 3 days. The results were encouraging, with complete resolution of the sialocele. A transdermal scopolamine offers a noninvasive, convenient method of treating parotid sialocele with minimal side effects. The successful outcome of this case suggests that a transdermal scopolamine can be an effective therapeutic option for recurrent parotid sialocele in conjunction with surgical treatment.

Sublingual floor of Rahmani sheep (Ovis aries): A scanning electron microscopy and histomorphology analysis

The current study investigated the sublingual floor of Rahmani sheep (Ovis aries). Samples from nine healthy adult sheep have been analysed using morphometrical, scanning electron microscopic (SEM), and histological examination. The sublingual floor of the sheep was formed of a rostral prefrenular part (spatula-shaped) and two lateral sublingual recesses. Right and left sublingual caruncles were asymmetrical in length and each one had a serrated border, divided into three papillae. At higher magnifications, the three papillae of the sublingual caruncle's edge were variable in shape, with other two papillae were demonstrated underneath the caruncle. Each sublingual recess had a sublingual fold (plica sublingualis) extended from the level of frenulum linguae till the glossopalatine arch, bordered with caudolaterally directed papillae till the level of first lower molar cheek teeth. The sublingual salivary glands were mixed (seromucoid) type. The glandular lobule consisted of mucous acini and sporadic serous acini, as well as the presence of some mucous acini capped by acidophilic cells, serous demilunes. The mucous acinus was formed of pyramidal mucous cells with pale stained cytoplasm and basally located nuclei. Two ducts; major sublingual and submandibular ducts were observed within the submucosa of the sublingual caruncle. The sublingual ductal pseudostratified columnar epithelium was interspersed by more goblet cells than that of the submandibular duct. Collagen fibres around the glandular lobules, intralobular and interlobular excretory ducts as well as the connective core of the papillae were noticed. By SEM, two epithelium-lined pits on the surface of the sublingual floor mucosa caudal to the central incisive teeth were termed orobasal organ. As the first study to give a comprehensive analysis of the sheeps' sublingual floor, this one serves as a baseline for future clinical studies.

Transoral Complete vs Partial Excision of the Sublingual Gland for Plunging Ranula

OBJECTIVES

Plunging ranula is a pseudocyst of saliva extravasated from the sublingual gland (SLG) to the submandibular space. This is treated by transoral excision of the SLG or transcervical cyst excision that might differently affect surgical morbidity and recurrence. This study compared the clinical outcomes of complete vs partial excision of the SLG for plunging ranula.

STUDY DESIGN

A nonrandomized comparative study.

SETTING

Academic medical center.

METHODS

This study included 42 patients with plunging ranula who underwent complete or partial excision of the SLG with the evacuation of cystic content. Two surgical methods of complete or partial SLG resection were alternatively allocated to consecutive patients without randomization. The primary outcome was a postoperative recurrence. Secondary outcomes were operation time and complications.

RESULTS

Complete and partial excision of the SLG was performed in 22 and 20 patients, respectively, without injury to the Wharton's duct or the lingual nerve. Postoperative complications in 42 patients were minor with temporary events: hematoma, 1 (5%); tongue numbness, 2 (5%); dysgeusia, 4 (9%); and dysphagia, 2 (5%), which did not differ between patients with complete and partial excision of the SLG (P > .1). However, recurrence occurred in only 5 of 20 patients with partial SLG excision but none of 22 patients with complete SLG excision for a median follow-up of 36 months.

CONCLUSIONS

Complete SLG excision is preferred over partial SLG excision to treat plunging ranula for reducing postsurgical risks of complications and recurrence.

Effects of Fluoride on Submandibular Glands of Mice: Changes in Oxidative Biochemistry, Proteomic Profile, and Genotoxicity

Although fluoride (F) is well-known to prevent dental caries, changes in cell processes in different tissues have been associated with its excessive exposure. Thus, this study aimed to evaluate the effects of F exposure on biochemical, proteomic, and genotoxic parameters of submandibular glands. Twenty one old rats (n = 30) were allocated into three groups: 60 days administration of drinking water containing 10 mgF/L, 50 mgF/L, or only deionized water (control). The submandibular glands were collected for oxidative biochemistry, protein expression profile, and genotoxic potential analyses. The results showed that both F concentrations increased the levels of thiobarbituric acid–reactive substances (TBARS) and reduced glutathione (GSH) and changed the proteomic profile, mainly regarding the cytoskeleton and cellular activity. Only the exposure to 50 mgF/L induced significant changes in DNA integrity. These findings reinforce the importance of continuous monitoring of F concentration in drinking water and the need for strategies to minimize F intake from other sources to obtain maximum preventive/therapeutic effects and avoid potential adverse effects.

Excision of Sublingual Gland

There are 2 types of ranulas: oral ranulas and plunging (cervical) ranulas. The management of the cervical ranula involves surgical excision of the oral portion of the ranula along with the associated sublingual salivary gland. The sublingual gland is easily removed from an intraoral approach. Significant anatomic structures associated with the removal of the sublingual gland are the submandibular duct, lingual nerve, and sublingual artery. Knowledge of the anatomy makes the surgery easier and without complications.

Does fasting during Ramadan increase the risk of the development of sialadenitis?

BACKGROUND

Ramadan is a month within the Islamic lunar calendar when Muslims are required to fast (abstain from food and drink) during the daytime (from sunrise to sunset) for the entire month. Due to the established connection between fasting and dehydration and acute sialadenitis, the aim of this study is to determine if there is a higher frequency of sialadenitis among the Muslim population during Ramadan than during other months of the year.

METHODS

We conducted a retrospective study using the medical records of 120 Muslim patients admitted to the emergency room (ER) and diagnosed with acute sialadenitis over a 5-year period at the Baruch Padeh Medical Center, Poriya, and St. Vincent de Paul (French) Hospital, Nazareth, both located in Israel. The study group were Muslim patients, with the aforementioned diagnosis, admitted during Ramadan, while the control group included patients diagnosed with sialadenitis during the rest of the year. We analyzed overall admission frequency as well as descriptive and diagnostic data, including age, sex, gland involved and several blood test results.

RESULTS

During the month of Ramadan, the admission of Muslims with a diagnosis of acute sialadenitis was more than double that during the other months of the year - a difference that was found to be statistically significant (p = 0.001). Additionally, we found that Ramadan sialadenitis patients had significantly higher leukocyte numbers at admission (p = 0.0085) and, importantly, a significantly higher level of dehydration (blood urea nitrogen (BUN)/creatinine ratio) than non-Ramadan sialadenitis patients (p = 0.0001).

CONCLUSION

There is evidence that fasting in Ramadan may increase the risk for the development of acute sialadenitis. Our results suggest that this may be the result of dehydration.

Neurotoxin injection in benign submandibular gland hypertrophy: A first choice treatment

BACKGROUND

Various benign clinical entities with a symptomatology of hypertrophic submandibular glands like sialadenitis, sialadenosis, sialolithiasis, or an ageing neck have been described. Botulinum toxin type A is an elegant tool in the management of these conditions.

METHODS

This article is an original article, describing the Munich Concept of treating persistent submandibular swelling with Botulinum Toxin Type A from aesthetic and functional aspect. To shrink the affected tissue, 15 Units of Botox or Xeomin are applied in a single injection technique and under ultrasound guidance into the glands. Therefore, the 100 Units vial is being diluted with 3.5 of NaCl.

RESULTS

Intraglandular injections, using a specific dilution and dosage of the neurotoxin preparations, are very effective in the management of these swellings, offering safe and long-lasting results, with a high satisfaction rate. Our working group treated in the last 18 months 23 patients with benign, bilateral submandibular gland hypertrophies, which did not have any major complications.

CONCLUSION

As there is not yet described an ideal therapeutic strategy for the management of this symptomatology, we suggest, based on our experience, a concept with very promising results from functional and cosmetic aspect.

Sialolithiasis with abscess: An uncommon presentation of a Ludwig's angina mimic

Sialolithiasis represents the most common issue of the salivary gland, ranging from asymptomatic to airway compromising. In rapidly progressing, completely obstructive salivary stones, the presentation can mimic emergent oropharyngeal diseases, primarily Ludwig's angina. We present a case of a large and obstructive sialolith with abscess whose initial presentation was concerning for Ludwig's angina with impending airway compromise. While a common complaint, emergency providers should be aware of the nefarious presentation of an everyday complaint.

Soft Tissue Disorders of the Mouth

Soft tissue disorders of the mouth encompass a wide expanse of pathophysiology. This article focuses on the identification, etiology, management, and complications of common infectious processes (candidiasis, dental caries, and herpes labialis), inflammatory lesions (sialolithiasis, oral lichen planus, and aphthous ulcer), and benign entities (bony tori and mucocele).

Imaging of Inflammatory Disorders of Salivary Glands

Sialadenitis is among the most common conditions that affect the salivary glands. Inflammation of the salivary glands occurs as the end result of a variety of pathologic conditions, including infectious, autoimmune, and idiopathic causes. Clinically, inflammation of the salivary gland causes pain and localized swelling. The presentation may be acute or chronic, and can be recurrent. Because there is significant overlap of underlying disease mechanisms and clinical presentations, radiologic evaluation often plays a significant role in evaluation. This article is a brief review of sialadenitis, including disease mechanisms, causes, and the practical imaging of the salivary glands.

Diagnostic work-up in obstructive and inflammatory salivary gland disorders

Inflammatory and obstructive disorders of the salivary glands are caused by very different pathological conditions affecting the gland tissue and/or the excretory system. The clinical setting is essential to address the appropriate diagnostic imaging work-up. According to history and physical examination, four main clinical scenarios can be recognised: (1) acute generalised swelling of major salivary glands; (2) acute swelling of a single major salivary gland; (3) chronic generalised swelling of major salivary glands, associated or not with "dry mouth"; (4) chronic or prolonged swelling of a single major salivary gland. The algorithm for imaging salivary glands depends on the scenario with which the patient presents to the clinician. Imaging is essential to confirm clinical diagnosis, define the extent of the disease and identify complications. Imaging techniques include ultrasound (US), computed tomography (CT) and magnetic resonance (MR) with MR sialography.

Viral etiology of sporadic cases of parotitis among children in Korea during 2013-2014

Recent years have seen a high incidence of mumps, which is generally diagnosed based on clinical features, especially parotitis, without laboratory confirmation in Korea. To better understand the epidemiology of mumps in Korean children, we investigated sporadic suspected mumps cases with parotitis. In total, 237 buccal swabs or throat swabs collected from children with parotitis who had been clinically diagnosed with mumps were tested using real-time PCR for the detection of six viruses (Epstein-Barr virus, Human herpesvirus 6, Mumps virus, Human parainfluenza virus-1, -2, -3, Human adenovirus, Human bocavirus). Among 237 parotitis cases, 87 (36.7%) were positive for at least one virus; a single infection was observed in 73 (83.9%) cases, and co-infections were detected in 14 (16.1%) cases. Epstein-Barr virus was most frequent (20.7%), followed by human herpesvirus 6 (8.0%), mumps virus (5.5%), human parainfluenza virus-3 (4.6%), human adenovirus (4.2%), and human bocavirus (0.4%). These data suggested that the sporadic suspected mumps in the children might be related to other respiratory viruses rather than to the mumps virus. Our findings also indicate the limitation of clinical diagnosis without laboratory confirmation for mumps and thus highlight the importance of laboratory testing in suspected mumps cases.

Rigid swelling of sublingual caruncle area due to the salivary gland duct obstruction by a sialolith

Sialolithiasis is the presence of calculus within the ductal system of a salivary gland. Among the diagnostic methods are inspection, palpation, checking the amount of saliva secreted and the identification of a sialolith. The authors present the case of a 37-year-old female patient with edema of the submandibular area and a bulging sublingual caruncle due to a calculus that obstructed the salivary gland ostium.