Parotid enlargement

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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230 Parotid enlargement

Instruction

Look at this patient’s face.

Salient features

History

• Ask the patient whether the parotids are painful and dry mouth

• Ask the patient about dry eyes or use of artificial tears

• History of sarcoidosis

• History of lymphoma, leukaemia.

Examination

• Bilateral parotid enlargement (Fig. 230.1).

image

Fig. 230.1 Sjögren syndrome with moderate parotid swelling.

(With permission from Firestein et al. 2008.)

Proceed as follows:

• Look for the following conditions:

• Dry mouth
• Lupus pernio
• Rheumatoid arthritis.

• Tell the examiner that you would like to know whether the patient has gritty eyes or dry mouth.

Remember: Unilateral parotid enlargement with associated facial nerve palsy is more likely to be malignant tumour of the parotids; it is very rare for facial weakness to occur with benign tumours.

Diagnosis

This patient has parotid enlargement, which is painless, and has a dry mouth (lesion) probably caused by Sjögren syndrome (aetiology). The dry mouth is making swallowing difficult (functional status).

Questions

What are the causes of painless bilateral parotid enlargement?

• Sarcoidosis

• Sjögren syndrome or keratoconjunctivitis sicca

• Lymphoma and leukaemia.

How would you test objectively for dry eyes?

Schirmer’s test: filter paper is hooked over the lower eyelid; in normal people at least 15 mm is wet in 5 min whereas a value of <5 mm is seen in sicca syndrome.

What do you know about keratoconjunctivitis sicca?

It is a condition characterized by decreased production of tears by lacrimal glands.

Advanced-level questions

Mention a few causes of keratoconjunctivitis sicca

• Primary keratoconjunctivitis sicca is common and characterized by involvement of the lacrimal gland alone.

• Primary Sjögren syndrome is an autoimmune disorder that is usually positive for rheumatoid factor, anti-nuclear antibodies and hypergammaglobulinaemia. Less frequently, autoantibodies to DNA, salivary gland, smooth muscle and gastric parietal cells are present. There may be associated dry mouth and bronchial epithelium, and the vagina may also be affected. Histopathogically the glands show intralobar ductal epithelial hyperplasia and lymphocytic infiltration of the gland.

• Secondary Sjögren syndrome is the presence of keratoconjunctivitis sicca in association with a systemic disorder such as the following:

• Rheumatoid arthritis
• Psoriatic arthritis
• Connective tissue disorder
• Sarcoidosis
• Crohn’s disease.

How would you manage such patients?

• Artificial tears (e.g. hypromellose) are instilled frequently for dry eyes

• Artificial saliva for dry mouth.

Which are the other salivary glands?

These include submandibular, sublingual and minor salivary glands in the oral cavity, pharynx and larynx.

What do you know about superficial anatomy of the salivary gland?

The gland lies on the lateral surface of the ramus of the mandible and folds itself along the posterior mandibular border. It is usually not palpable as a discrete structure. Clenching the teeth tenses the masseter and makes the anterior border of the gland more prominent (as the gland lies just behind the masseter muscle).

How are parotid secretions carried into the oral cavity?

By Stensen’s duct, which opens just opposite the upper second molar tooth.

What is Mikulicz’s disease?

It is the enlargement of salivary and lacrimal glands (caused by sarcoidosis, lymphoma or TB) associated with dry mouth and dry eyes but not arthritis.

Which neoplasm may be associated with Sjögren syndrome?

Usually B cell-derived non-Hodgkin’s lymphoma.

OWA Schirmer (1864–1917) a German ophthalmologist.

J von Mikulicz-Radecki (1850–1905) was successively Professor of Surgery at Könisberg and Breslau.

HSC Sjögren (1899–1986), Swedish Professor of Ophthalmology in Gothenburg.

N Stensen (1638–1686), Danish anatomist and Professor of Anatomy at Copenhagen. He was then appointed the Catholic Bishop of Titioplis in 1677 and was an international authority on geology. He described the tetralogy of Fallot before Fallot, in 1672.

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