Acute viral and bacterial infections of the salivary glands

Parotid Enlargement as a Rare First Site of Manifestation in Extramedullary Acute Lymphoblastic Leukemia: A Case Report

Parotid neoplasm in children is very rare, and most of these tumors are benign. Parotid enlargement in children is usually caused by infection or inflammation. We report a case of a 12-year-old boy who presented with the initial manifestation of bilateral parotid enlargement. He complained of two weeks of parotid swelling, during which the tumor gradually increased in size as he battled a monthlong on-and-off fever. An intravenous antibiotic was administered, as the first diagnosis was infection. Imaging studies of the swelling displayed features of infection, which was not resolved by the antibiotic. Fine-needle aspiration cytology was initially planned to establish a diagnosis. However, due to other findings in the clinical examination, such as bilateral scrotal swelling with abnormal blood work, the child was referred to other specialists for further assessment. Eventually, he was diagnosed with B-cell acute lymphoblastic leukemia by a hematology team.

Beware: Sialadenitis as a Rare Post Neurosurgical Complication: A Single-Institution Clinical Case Series

OBJECTIVE

Acute postoperative sialadenitis is a potentially life-threatening complication of cranial neurosurgery characterized by swelling of the face and neck due to obstruction of salivary ducts by either mechanical obstruction or, potentially, pharmacologic stasis or gland obstruction. Given the paucity of literature surrounding this rare phenomenon, we sought to report our experience with acute sialadenitis after cranial neurosurgery.

METHODS

Retrospective review of patients with acute sialadenitis after neurosurgical craniotomy or craniectomy from a single institution from January 1, 2011, through December 31, 2021.

RESULTS

Seven patients (median age: 27 years; 6 female) identified meeting our inclusion criteria out of 10,014 patients who underwent craniotomy and/or craniectomy procedures during last 11 years (∼0.006%), 5 of these cases were considered skull base procedures. Five (71%) patients required emergent airway management either via intubation or tracheostomy and 5 (71%) were treated with steroids. Additional supportive care included sialagogues, warm compress, massage, analgesics, and intravenous hydration for all 7 patients. Three patients (43%) developed concomitant transient focal neurologic deficits attributable to the sialadenitis. No mortalities occurred as a result of this complication.

CONCLUSIONS

Acute post-neurosurgical sialadenitis spans a range of severity, with some patients requiring emergent airway management and prolonged ventilator support whereas other patients only require conservative supportive care. Early recognition of acute sialadenitis after cranial neurosurgery can prevent fatal outcomes and provide complete recovery from this condition. Therefore, all neurosurgeons, anesthesiologists, and intensivists should be aware of this rare, but potentially life-threatening, complication.

Contralateral sialadenitis after resection of a right cerebellar metastasis: illustrative case

BACKGROUND

Acute postoperative sialadenitis is a rare and potentially morbid complication of cranial neurosurgery. This rapidly progressive, unilateral neck swelling often presents within hours of extubation. Diagnosis is made by imaging and exclusion of other causes of etiologies, such as neck hematoma, sialolithiasis, and dependent soft tissue edema.

OBSERVATIONS

The authors presented a case of acute postoperative sialadenitis after suboccipital resection of a right cerebellar metastasis. Shortly after extubation, extensive left-sided neck swelling was apparent in the postanesthesia care unit. No central lines were placed during the procedure. Imaging revealed submandibular gland edema and fluid accumulation in the surrounding tissue. The patient was managed conservatively with steroids, antibiotics, and warm compresses, with complete resolution of symptoms 2 weeks after the procedure.

LESSONS

This case emphasizes the broad differential of acute neck swelling after cranial surgery. Physical examination of the neck and airway protection should guide initial treatment. If a patient is stable, bedside ultrasound and computed tomography can be helpful with the differential diagnosis. Here the authors proposed an algorithm for diagnosis and treatment of acute neck swelling after cranial surgery.

A case of progressive systemic sclerosis/lupus overlap syndrome: Presenting with parotid swelling

An overlap syndrome is a medical condition which shares features of at least two more widely recognized disorders. Autoimmune connective tissue diseases include systemic lupus erythematosus (SLE), scleroderma, polymyositis, dermatomyositis, rheumatoid arthritis and Sjögren's syndrome where overlap syndrome most commonly seen in combination with SLE and systemic sclerosis (SSc). Sjogren's is an autoimmune exocrinopathy, in which systemic diseases such as arthritis, interstitial lung disease and renal disease may develop in addition to the pathognomonic features such as dry eyes and mouth. The other associated disease with Sjogren's includes sialadenitis. Sialadenitis of the parotid gland is one of the major disorders of salivary gland. This article presents a rare case report of a patient diagnosed with sialadenitis of the parotid gland and associated with progressive SSc/lupus overlap syndrome and secondary Sjogren's.

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.

Clinical implications of aberrant neurovascular structures coursing through the submandibular gland

Background

Variation within the submandibular triangle, including variant paths of facial neurovasculature, could increase risk of neurovascular derangement during submandibular gland (SMG) dysfunction, enlargement, interventions, or removal.

Methods

Frequency of anatomical variants enveloped within or piercing the SMG, including facial artery, vein, or branches of CN VII, were assessed in 70 cadaveric submandibular glands (39M/31F).

Results

Eighteen of 70 SMGs (25.7%) were pierced by at least one aberrant neurovasculature structure: Facial artery most frequently (n = 13), followed by facial vein (n = 2), inferior labial artery and vein (n = 1), and CN VII cervical branch (n = 1). This study demonstrated the high variability of neurovasculature within submandibular parenchyma. These aberrant neurovascular structures, especially facial artery, are in danger of compromise during surgical and other medical procedures on the SMG. To avoid potential neurovascular compromise, ultrasonographic or other imaging is recommended prior to procedures involving the SMG.

Expression of ETS1 and LEF1 in salivary glands of Sjögren syndrome patients

OBJECTIVE

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease affecting exocrine glands, thereby causing dry mouth and eyes (sicca). Our objective was to determine the expression of pSS pathogenic biomarker MMP9 and its putative transcription factors ETS1 and LEF1, in labial salivary glands of pSS patients.

METHODS

Sicca patients were assigned to three groups based on focus score (FS): non-pSS sicca (i.e., GR1 [FS = 0] and GR2 [0 < FS < 1]) and pSS (i.e., GR3 [FS ≥ 1]). We determined the mRNA and protein expression of MMP9, ETS1, and LEF1 in salivary gland biopsies. Also, ETS1-CD4 and LEF1-CD4 co-expression analyses were performed.

RESULTS

The mRNA expression of MMP9, ETS1, and LEF1 was upregulated in GR3 compared to GR1 (p < 0.01). Most GR3 salivary gland areas had moderate to high MMP9, ETS1, and LEF1 protein expression compared to GR1 and GR2. Further, ETS1-CD4 and LEF1-CD4 dual staining demonstrated that both salivary gland epithelial cells and lymphocytic infiltrates had increased levels of ETS1 and LEF1. Moreover, there was a strong correlation between ETS1(+)-CD4(-) and LEF1(+)-CD4(-) cells.

CONCLUSION

These results suggest, for the first time, a concerted increase in ETS1 and LEF1 expression in salivary gland epithelial cells of pSS patients that is reflective of the etiopathogenesis of pSS.

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.

Influenza-Associated Parotitis During the 2014-2015 Influenza Season in the United States

Background

During the 2014-2015 influenza season in the United States, 256 cases of influenza-associated parotitis were reported from 27 states. We conducted a case-control study and laboratory investigation to further describe this rare clinical manifestation of influenza.

Methods

During February 2015-April 2015, we interviewed 50 cases (with parotitis) and 124 ill controls (without parotitis) with laboratory-confirmed influenza; participants resided in 11 states and were matched by age, state, hospital admission status, and specimen collection date. Influenza viruses were characterized using real-time polymerase chain reaction and next-generation sequencing. We compared cases and controls using conditional logistic regression. Specimens from additional reported cases were also analyzed.

Results

Cases, 73% of whom were aged <20 years, experienced painful (86%), unilateral (68%) parotitis a median of 4 (range, 0-16) days after onset of systemic or respiratory symptoms. Cases were more likely than controls to be male (76% vs 51%; P = .005). We detected influenza A(H3N2) viruses, genetic group 3C.2a, in 100% (32/32) of case and 92% (105/108) of control specimens sequenced (P = .22). Influenza B and A(H3N2) 3C.3 and 3C.3b genetic group virus infections were detected in specimens from additional cases.

Conclusions

Influenza-associated parotitis, as reported here and in prior sporadic case reports, seems to occur primarily with influenza A(H3N2) virus infection. Because of the different clinical and infection control considerations for mumps and influenza virus infections, we recommend clinicians consider influenza in the differential diagnoses among patients with acute parotitis during the influenza season.

Incidence of Acute Suppurative Sialadenitis in End-Stage Cancer Patients: A Retrospective Observational Study

CONTEXT

Acute suppurative sialadenitis (hereafter referred to as sialadenitis) is accompanied by pain and fever and can diminish the quality of life in end-stage cancer patients; however, its incidence is not clear.

OBJECTIVES

We conducted this study to elucidate the incidence of sialadenitis in end-stage cancer patients.

METHODS

Retrospective review and observational study based on patients' medical records.

SUBJECTS

About 726 consecutive cancer patients who died on the palliative care unit of our hospital between April 2012 and November 2016 were included.

MEASUREMENTS

Median duration between sialadenitis onset and death, concomitant treatment, average infusion volume per day, site of onset, symptoms, effectiveness of antibiotic treatment, and mean duration until symptomatic relief.

RESULTS

The incidence of sialadenitis was 2.9% (21 of 726 cases). The median duration from onset to death was 20 days (range 2-112); concomitant treatment included opioids in 11 patients (55%), anticholinergic drugs in six patients (28%), steroids in three patients (14%), and oxygen inhalation in five patients (23%); average infusion volume per day was 588 ± 307 mL; site of onset was submandibular gland in 12 patients (57%) and parotid gland in nine patients (42%); and symptoms were pain in 18 patients (85%) and fever in 13 patients (61%). Antibiotic treatment was administered in 18 patients (85%), and the mean duration until symptomatic relief was 4.0 ± 1.5 days.

CONCLUSION

Sialadenitis is a rare complication in end-stage cancer patients; however, it is important to recognize that it can be associated with severe symptoms, including fever and pain.

Acute Parotitis after Lower Limb Amputation: A Case Report of a Rare Complication

Background

Postoperative parotitis is a rare complication that occurs usually after abdominal surgery. Parotitis has never been described as a complication of vascular operations, in literature. In the present article, we describe a case of a postamputation parotitis along with its management and its possible pathogenesis.

Case Report

An 83-year-old diabetic man was emergently admitted to hospital because of gangrene below the right ankle and sepsis. The patient underwent a lower limb amputation above the knee. On the 5th postoperative day, he was diagnosed with right parotitis probably because of dehydration, general anesthesia, and immunocompromisation. A CT scan confirmed the diagnosis. He received treatment with antibiotics and fluids. His condition gradually improved, and he was finally discharged on 15th postoperative day.

Conclusions

Postoperative parotitis can possibly occur after any type of surgery including vascular. Clinicians should be aware of this complication although it is rare. Several risk factors such as dehydration, general anesthesia, drugs, immunocompromisation, head tilt during surgery, and stones in Stensen's duct may predispose to postoperative parotitis. Treatment consists of antibiotics and hydration.

Mumps: An Emergency Medicine-Focused Update

BACKGROUND

Mumps is a Paramyxoviridae virus. This disease was rampant prior to introduction of the measles, mumps, and rubella vaccine, resulting in decreased incidence. This disease has demonstrated several outbreaks.

OBJECTIVE

This review provides a focused evaluation of mumps, an update on outbreaks, management recommendations, and ways to decrease transmission.

DISCUSSION

Clusters of mumps outbreaks continue to occur. The virus is a paramyxovirus, a single-stranded RNA virus. The vaccine can provide lifelong immunity if administered properly, though prior to 1967 and introduction of the vaccine, the virus was common. In the past decade, there have been several notable outbreaks. Humans are the only known hosts, with disease spread through exposure to droplets and saliva. Factors affecting transmission include age, compromised immunity, time of year, travel, and vaccination status. Upper respiratory symptoms, fever, and headache are common, with unilateral or bilateral parotitis, and the virus may spread to other systems. Diagnosis is clinical, though polymerase chain reaction and immunoglobulin testing are available. This review provides several recommendations for vaccine in pregnancy, patients living in close quarters, health care personnel, and those immunocompromised. Treatment is generally supportive, with emphasis on proper isolation to prevent widespread outbreaks. Although reporting regulations and procedures vary by state, mumps is reportable in most states.

CONCLUSIONS

Mumps is an easily spread virus. Although vaccination is the most effective way to prevent transmission, early recognition of the disease is crucial. As an emergency physician, it is important to recognize the clinical presentation, recommended testing, treatment, and isolation procedures.

Cellular and humoral immunity after vaccination or natural mumps infection

BACKGROUND

This study measured cell-mediated immunity (CMI) and serum antibody to clarify the basis of breakthrough after vaccination and reinfection after mumps.

METHODS

From a pool of 54 college students, 17 seronegative subjects and 14 subjects with intermediate level of antibodies against mumps were vaccinated with a monovalent mumps vaccine, and CMI was assessed using interferon-γ release assay.

RESULTS

CMI positivity according to pre-existing antibody level, defined as titer <2.0 index units, negative; 2.0-3.9 index units, intermediate; and ≥4.0 index units, positive, was 8/17 (47.1%), 9/14 (64.3%) and 19/23 (82.6%) before vaccination, respectively. Of the 17 seronegative subjects, seven (41.2%) had a history of vaccination and/or natural infection, four (57.1%) of whom were CMI positive or intermediate. Ten (71%) of 14 subjects with intermediate antibody level had a history of vaccination or natural infection, eight (80%) of whom were CMI positive or intermediate. After vaccination the interferon (IFN)-γ and antibody titers increased significantly, but seven (41.2%) of the 17 seronegative subjects and 13 (92.9%) of the 14 intermediate-level subjects tested positive for both antibody and CMI. In a comparison of the natural infection group (confirmed as IgG seropositive and/or CMI positive without vaccination) versus the vaccination group, IgG antibody titer (mean ± SD) was 14.4 ± 8.0 versus 3.6 ± 2.4 index units (P < 0.01) and IFN-γ was 122.7 ± 90.0 pg/mL versus 59.5 ± 37.8 pg/mL (P > 0.05), respectively.

CONCLUSION

Vaccination or even natural mumps infection did not always induce both cellular and humoral immunity.

Acute submaxillitis: Etiological data and etiological management

OBJECTIVES

The objective of the present study was to test the hypothesis that acute submaxillitis involves salivary duct obstruction. Obstacle characteristics and treatment were analyzed.

MATERIAL AND METHODS

Patients presenting with an episode of acute submaxillitis between 2009 and 2015 were retrospectively included. All underwent salivary duct imaging and/or sialendoscopy, with pathologic examination if the salivary gland was removed for etiologic diagnosis. For etiological treatment, if the causal lesion could not be treated by isolated sialendoscopy, surgery used a direct approach assisted by sialendoscope. In case of failure of these procedures, submaxillectomy was indicated.

RESULTS

Twenty-nine patients were included, 28 of whom showed salivary duct abnormality. At least 1 calculus was found in 27 patients; calculi were usually single (n=20), situated in the mid-third (n=21), and large (mean 7.7mm). Ten patients showed stenosis, associated with salivary calculus in 9 cases. Twenty-five patients with salivary duct obstruction underwent sialendoscopy. Isolated sialendoscopy was used in 5 cases, and a combined approach in 13 cases.

CONCLUSION

An episode of submaxillitis requires salivary duct exploration by sialendoscopy, to enable early treatment given the prevalence of associated calculi and high success rate of conservative management by sialendoscopy.

[Swelling of the submandibular and parotid glands : A description of possible differential diagnoses]

Swelling of single or multiple major salivary glands can be caused by various local or systemic diseases. In differential diagnosis, congenital cystic or vascular malformations should be considered, as well as infectious or tumorous alterations. Salivary duct obstructions due to sialolithiasis or stenosis can cause salivary gland enlargement. Multiple systemic diseases can have manifestations in the parotid or submandibular glands. As therapy varies from cause to cause, knowledge of the different potential diagnoses is crucial.

ALX/FPR2 Modulates Anti-Inflammatory Responses in Mouse Submandibular Gland

Activation of the G-protein coupled formyl peptide receptor 2 (ALX/FPR2) by the lipid mediators lipoxin A4 and resolvin D1 (RvD1) promotes resolution of inflammation. Our previous in vitro studies indicate that RvD1 activation of ALX/FPR2 resolves cytokine-mediated inflammatory responses in mammalian cells. However, the impact of ALX/FPR2 activation on salivary gland function in vivo is unknown. The objective of this study was to determine whether submandibular glands (SMG) from ALX/FPR2(-/-) mice display enhanced inflammatory responses to lipopolysaccharides (LPS) stimulation. For these studies, C57BL/6 and ALX/FPR2(-/-) mice at age 8-12-week-old were treated with LPS by i.p for 24 h. Salivary gland structure and function were analyzed by histopathological assessment, saliva flow rate, quantitative PCR, Western blot analyses and immunofluorescence. Our results showed the following events in the ALX/FPR2(-/-) mice treated with LPS: a) upregulated inflammatory cytokines and decreased M3R (Muscarinic Acetylcholine receptor M3) and AQP5 (Aquaporin 5) protein expression, b) decreased saliva secretion, c) increased apoptosis, d) alteration of tight junction and neuronal damage. Overall, our data suggest that the loss of ALX/FPR2 results in unresolved acute inflammation and SMG dysfunction (xerostomia) in response to LPS that is similar to human salivary gland dysfunction induced by bacterial infection.

Salivary gland disorders

Patients with salivary gland disease present with certain objective and/or subjective signs. An accurate diagnosis for these patients requires a range of techniques that includes the organized integration of information derived from their history, clinical examination, imaging, serology, and histopathology. This article highlights the signs and symptoms of the salivary gland disorders seen in the Salivary Gland Center, and emphasizes the methodology used to achieve a definitive diagnosis and therapy.

Suppurative parotitis and submandibular sialadenitis

Suppurative involvement of salivary gland in neonates is a rare disorder. Parotid gland being the most commonly involved. We described a case of suppurative parotitis leading to abscess formation and subsequent involvement of the submandibular gland. Incision and drainage of the abscess was performed, most of the purulent material was drained. Symptoms and signs resolved within 2 days. Pus culture grew Staphylococcus aureus.

An Algorithm Approach to Diagnosing Bilateral Parotid Enlargement

Objective

This contemporary review aims to categorize the disease entities that cause bilateral parotid enlargement and to develop a question-based algorithm to improve diagnosis of bilateral parotid masses.

Data Sources

A PubMed search for bilateral and parotid showed 818 results. Of these, 68 relevant studies were reviewed to compile a list of disease processes that can cause bilateral parotid enlargement.

Review Methods

A total of 22 diseases entities were reviewed. The disease processes were initially grouped into 6 categories based on etiology: sialadenosis, infection, neoplasm, autoimmune, iatrogenic, and miscellaneous. For each lesion, the incidence, history, and physical examination were compiled in a matrix.

Conclusion

After reviewing the matrix, it was clear that grouping diseases based on specific history and physical findings limits the differential diagnosis. The most important factors included disease incidence, timing of onset, nodular or diffuse, pain, and overlying skin changes. With this algorithm, the differential diagnosis can be limited from 28 to 7 or fewer likely diagnoses for a given presentation.

Implications for Practice

Bilateral parotid disease has a wide differential diagnosis with an expanding number of available tests. An algorithm, based solely on data obtained from the history and physical examination in the first patient encounter, may reduce the differential and aid the clinician in deciding on further workup and treatment. Following the algorithm presented here should allow the clinician to arrive at a diagnosis rapidly without ordering unnecessary tests and wasting resources.

Acute parotitis induced by trimethoprim/sulfamethoxazole

Adverse drug reactions to the sulfonamide antibiotics are uncommon. When they do occur, they usually manifest as a rash or urticaria. Our review of the recent literature found that while sialadenitis is listed as a possible side effect of sulfonamide use, no actual case has ever been reported until now. We describe a case of acute bilateral parotitis that arose as a side effect of sulfonamide antibiotic treatment. We also examine the relevance of such pathology to the proposed mechanisms of sialadenitis, and we briefly discuss sulfonamide-induced pancreatitis. Lastly, we review the controversy over the possibility that some adverse drug reactions may be caused by cross-reactivity among different classes of sulfonamides.

Postoperative acute sialadenitis after skull base surgery

During retrosigmoid and far-lateral skull base surgical approaches, the head may be positioned at the extreme limits of rotation and flexion. In rare instances, patients may develop acute sialadenitis after surgery as a result of this positioning technique. Over a 4-year period, five patients developed postoperative sialadenitis after undergoing either a retrosigmoid craniotomy in the supine position (n = 4) or a far-lateral craniotomy in the park-bench position. Based on all the retrosigmoid and far-lateral approaches performed by the senior author (RFS), the incidence of sialadenitis was 0.84%. In all five patients, the acute sialadenitis was not clinically apparent at the conclusion of the operation. However, the diagnosis was evident within 4 hours of surgery. In each case, the neck swelling in the vicinity of the submandibular gland was contralateral to the craniotomy site. All patients were treated with intravenous hydration and antibiotic therapy. One patient was extubated immediately after surgery with no obvious evidence of sialadenitis. However, she required emergent reintubation due to airway compromise. The mechanism of acute sialadenitis in these patients was obstruction of the salivary duct caused by surgical positioning. This previously unreported observation in patients undergoing skull base surgery deserves consideration during perioperative and postoperative management.

Fine needle aspiration of salivary gland masses in HIV-infected patients

Salivary gland disease is an important manifestation of HIV-infection. The aim of this study was to evaluate the cytologic findings of salivary gland fine needle aspiration (FNA) in South African human immunodeficiency virus (HIV)-infected patients. A retrospective review was performed on confirmed HIV-positive patients who underwent FNA of various body sites, including salivary glands, over a 5-year period. There were 495 (14.1%) salivary gland FNAs out of a total of 3,501 HIV-positive patients. This included 260 (52.5%) parotid, 226 (45.7%) submandibular, 2 (0.4%) sublingual, and 7 (1.4%) specimens labeled as a salivary gland aspirate, exact site not provided. Patients were of average age 34 years (range 9 months to 63 years) with a female: male ratio of 1:0.6. There were 37 (7.5%) inadequate FNAs and 22 (4.4%) that contained normal gland constituents only. Most diagnoses were benign and comprised 168 (33.9%) reactive lymphadenopathy, 115 (23.2%) benign lymphoepithelial cysts, 62 (12.5%) mycobacterial infections, and 52 (10.5%) abscesses, of which 10 had associated mycobacterial infections. Neoplasms accounted for 31 (6.7%) diagnoses including 11 pleomorphic adenomas, 13 lymphoma, 3 Kaposi sarcoma, 1 squamous cell carcinoma, 1 metastatic carcinoma, and 1 rhabdomyosarcoma. There were four epidermoid inclusion cysts, three non-specific sialadenitis, one mucocele, and one spindle cell lesion not able to be further characterized. FNA is a useful procedure to evaluate salivary gland lesions in an HIV-infected population, allowing prompt management to be undertaken and obviating the need for surgery in many instances, an important consideration in an underfunded public health care system.

Diagnosis and management of salivary gland infections

Salivary gland infections are frequently encountered entities that are acquired in community and hospital settings. These infections have many causes and may be treated with a diverse array of modalities ranging from conservative medical therapy to removal of the affected salivary gland. Minimally invasive techniques employing diagnostic and interventional sialoendoscopy exist between these two extremes. If possible, the goal of management of such infections is to preserve the gland. It is the purpose of this article to review the diagnosis and treatment of acute and chronic salivary gland infections.

Difficulty with mumps diagnosis: what is the contribution of mumps mimickers?

BACKGROUND

Mumps is a vaccine preventable disease that typically presents with unilateral or bilateral parotitis. In February 2007, mumps re-emerged in university students in Nova Scotia. Despite highly sensitive methods for mumps virus detection, only 14% (298/2082) of cases during the peak of the outbreak were laboratory confirmed.

OBJECTIVES

Due to the low positivity rate, this study investigated whether infection with other viral pathogens caused mumps-like presentations during the outbreak.

STUDY DESIGN

148 buccal specimens from patients who presented with unilateral or bilateral parotitis but had negative laboratory tests for mumps virus were tested for Epstein-Barr virus (EBV) and cytomegalovirus (CMV) by quantitative PCR and 21 different viral markers using the Luminex xTAG Respiratory Virus Panel (RVP). Companion sera to each buccal specimen were available for EBV and CMV serology to differentiate acute infection from reactivation.

RESULTS

No correlation was observed since viral pathogens were detected in both the parotitis and non-parotitis groups.

CONCLUSION

Although there was co-circulation of other viral pathogens during the mumps outbreak, no difference was observed in the prevalence between patients who presented with or without parotitis. The low positivity rate for specimens submitted for mumps diagnostics was likely the result of increased Public Health messaging and physician inexperience in recognizing mumps infection, suggesting the clinical acumen for mumps diagnosis based solely on clinical presentation is low.

Laboratory diagnosis of mumps in a partially immunized population: The Nova Scotia experience

BACKGROUND

In 2007, Atlantic Canada experienced a large outbreak of mumps predominately in university students who had received a single dose of measles, mumps and rubella vaccine. The present study describes the performance characteristics of reverse transcriptase polymerase chain reaction (RT-PCR) on buccal and urine specimens and immunoglobulin M (IgM) serology in this partially immune population.

METHODS

Patients presenting with symptoms suspicious for mumps had a serum, urine and a buccal swab collected for diagnostic testing. Persons were classified as a 'confirmed' case according to the Public Health Agency of Canada's definition. Sera were tested using an enzyme-linked immunoassay. Detection of mumps virus in buccal swabs and urine samples was performed by RT-PCR.

RESULTS

A subset of 155 cases and 376 non-cases that had all three specimens submitted was used for calculating the performance characteristics. The sensitivity of RT-PCR on buccal swabs, urine specimens and IgM serology were 79%, 43% and 25%, respectively. The specificity of RT-PCR on buccal swabs, urine specimens and IgM serology was 99.5%, 100% and 99.7%, respectively. Only 12 of 134 (9%) patients had positive urine specimens in the presence of negative oral swabs.

CONCLUSION

RT-PCR on buccal swabs is the ideal specimen for diagnosis. Testing an additional urine sample in an outbreak setting did not increase the diagnostic yield significantly, but doubled testing volume and cost. In addition, the data suggest that, in this partially immune group, IgM serology has little value in the diagnosis of acute infection.

Surgical removal of mouse salivary glands

Surgical removal of the salivary glands is a simple procedure aimed at providing glandular tissues for studies in histopathology, immunohistology, DNA and RNA analysis, cytokine production, and virus detection and isolation. This unit describes the surgical removal of the salivary glands in mice, but a similar protocol is applicable to rats and other rodents.

Pediatric soft tissue lesions

Soft tissue oral and perioral lesions in the pediatric population are numerous and occur in various clinical presentations. Some conditions observed in children share characteristics with adult-onset disease. Other oral lesions are limited to the pediatric population. This article focuses on the more common soft tissue manifestations in children. Rather than a comprehensive review of pediatric oral pathology, the article offers an overview of selected clinical conditions often encountered in young patients.

A downward spread in acute parotitis

Acute parotitis occasionally spreads rapidly down the neck with severe symptoms of swelling and pain. However, the inflammatory course of parotitis with extraglandular spread has seldom been described. On CT images, we have noticed a unique area just below the parotid gland that is surrounded by the platysma muscle and the superficial layer of the deep cervical fascia (DCF). In this case report, we describe the CT imaging features of acute parotitis, focusing on this area.

Acute Parotitis Following Sitting Position Neurosurgical Procedures

Acute bacterial parotitis subsequent to major abdominal surgery is well documented, reportedly occurring in as many as 0.1% of patients. Postoperative parotitis has been reported between 1 to 15 weeks after surgery, commonly appearing within 2 weeks of the procedure. However, postoperative parotitis has not been reported previously after neurosurgical procedures. The authors report five cases of postoperative parotitis after neurosurgical operations in the sitting position with mild flexion and rotation of the head. This group of patients accounted for 0.16% of all craniotomy and 1.9% of all sitting position neurosurgical procedures performed in the authors' institution from 1996 through 2001. Neck flexion and head tilt in the sitting position might have an influence on acute parotitis. The authors found that the side of the parotitis was on the opposite side of the head rotation. Dehydration therapy may also be a contributing factor. The objective of this paper is to state that parotitis is a possible complication in neurosurgical patients operated on in sitting position and to discuss its pathophysiology and treatment options.

Microbiology and Management of Sialadenitis

Acute and chronic inflammatory diseases of the major and minor salivary glands constitute the most common clinical syndrome of salivary glands. During the past decade, the use of antibiotics along with fluid hydration and electrolyte management has almost eliminated the development of fulminating acute suppurative parotitis in hospital surgical patients. Although acute bacterial and viral sialadenitis persists, the clinical challenge has changed, with more focus on the chronic inflammatory group of diseases. The pathogenesis of the chronic salivary inflammatory disease spectrum has also changed, with the interplay between sialadenitis, sialectasia, and sialolithiasis. There also exists a heterogeneous group of disorders in chronic inflammatory sialadenitis, which include the group of specific and nonspecific granulomatous diseases.

Comparison of the sonographic features of acalculous and calculous submandibular sialadenitis

OBJECTIVE

The purpose of this study was to compare the sonographic features of acalculous and calculous sialadenitis of the submandibular gland.

METHODS

A retrospective review of sonograms of the neck was performed in 25 patients with submandibular sialadenitis: 8 with acalculous and 17 with calculous disease. The submandibular glands were assessed for size, shape, border, and echogenicity; presence of dilated ducts or other intraglandular lesions; inflammatory changes in adjacent tissues; lymphadenopathy; and involvement of other salivary glands.

RESULTS

In the group with acalculous sialadenitis, 4 (50%) of the 8 patients had unilateral disease, and 11 (92%) of 12 glands were rounded. In all cases (100%), multiple hypoechoic lesions were diffusely distributed throughout the submandibular glands against a heterogeneous parenchymal background. The lesions ranged from 3 to 15 mm and were oval or round. Confluent lesions were noted in 2 glands (17%). There was no sonographic evidence of duct dilatation, calculi, or abnormal lymph nodes. All patients with calculous sialadenitis had unilateral disease; 9 had a main duct calculus (53%), 7 had intraglandular calculi (41%), and 1 had both (6%). In 14 (82%) of 17 glands, normal shape was maintained, and 11 (65%) of 17 had duct dilatation.

CONCLUSIONS

Acalculous submandibular sialadenitis differs from the calculous form of the disease. The former has characteristic sonographic features, including a round gland with numerous hypoechoic lesions in a heterogeneous parenchymal background. Sonographic imaging in conjunction with fine-needle aspiration is useful for detection of this disorder.