Summary

To define the specification of patients with sialoadenitis a retrospective study was carried out on 119 patients admitted in Imam Khomeiny and Amir Aalam Hospitals from 1992 to 1996.  The main objective of this study was to look at age, sex, involved gland and also chief complaint by descriptive and analytic statistical methods. The result showed that men suffered twice as often as females and the mean age of the patients was 32.6 years which was significantly different from what reported in other references.  Sex distribution was found to be inverse in parotid gland involvement versus sub maxillary gland involvement.  81% of sialoadenitis was found to involve males and 19% to involve female. The details of the results and proposal are explained as follows.

Key words: sialoadenitis, salivary gland, parotid gland, submandibular gland, swelling of salivary glands.

Introduction

Infections of salivary glands including acute and chronic infections are a subgroup of salivary glands inflammatory diseases.  Primary infection of parenchyma of salivary glands is due to invasion of bacteria from oral cavity.  Bacterial infection can happen in any of the salivary glands, but is more often in parotid gland due to the little bacteriostatic activity of its secretions. 

Stasis is one of the most important factors in occurrence of the infection; the other factors include dietary factors, dehydration, fluid and electrolyte disturbance, and poor oral hygiene. It is more common in immunodeficient patients like patients who received chemotherapy for malignancy or have had organ transplantation.  Sixth and seventh decades of life are common ages for the disease and male and female ratios are equal.  Patients suffering from a chronic disease or post operative patients are also at higher risk for the disease (1).

Chronic sialoadenitis presents with recurrent pain and swelling of the salivary gland.  It usually will cause tissue damage which will be replaced by fibrosis tissue consequently.  Most of the patients give a history of an episode of severe acute infection of the gland which has progressed to a chronic state.  Factors like obstruction or dilatation of the duct and decrease in secretions of the gland are important in establishing and recurrence of the infection (2).

In a research study on two groups of 10 dogs, they made complete and partial obstruction in submandibular gland duct.  All of these dogs ended up with chronic sialoadenitis.  This showed that either partial or complete obstruction can cause chronic obstruction (6).

Surgical removal of the salivary gland is only necessary when the other conservative treatments have failed.  Surgical maneuver in chronic sialoadenitis is a difficult procedure generally because due to tissue fibrosis, glandular dissection without damage to facial nerve is difficult.  In one study they used conservative surgery in treatment of 128 patients with chronic sialoadenitis.  In these patients the chronic infection was due to narrowing of the duct orifice of submandibular gland or too much curvature of parotid duct.  These defects were operated and then conservative measures including electrophoresis and ultra sonography were used.  The removal of the gland's calculus reduced the inflammation (7).  In 103 of the patients relative recovery was achieved after the surgery and almost all the patient recovered eventually.

The complicated events that happen during acute and chronic inflammation of salivary glands can facilitate calculus formation.  This happens especially in case of submandibular and parotid gland inflammation.  Also whatever decreases or changes the quality and consistency of salivary secretion can cause stone formation.  Salivary calculi are usually accompanied by chronic sialoadenitis.  Calculi formation is one of the evidences for the chronisity of the process of inflammation. 75% of patients with chronic sialoadenitis are in their 5^th to 8^th decade of their lives (3).

The objective of this study was a statistical analysis on different variables retrieved from patient's files.  The variables included are, sex, the involved gland, chief complaint at the first visit, the etiology of the disease according to diagnostic measures, radiology results and calculus formation.

Materials

This study was performed using patient's files, as a retrospective study.  All the files of the patients with the diagnosis of sialoadenitis who were admitted in Amir Aalam and Imam Khomeiny Hospitals were searched for the needed information which in turn was put in pre designed forms.  These forms were analysed with statistical methods.  The study took 5 months to be completed.

The definition of the variables

1.      Age of the patient:  The patients were put in 4 age groups, <10, 11-18, 19-24 and >25 years old.

2.      Sex: The patients were divided into two male and female groups.

3.      The involved gland: Parotid gland, Submandibular gland and Sublingual gland.

4.      The chief complaint at the referral: The patients were put in 5 groups.

5.      The etiology of the disease after diagnostic methods (diagnosis at the time of discharge:

6.      Radiology results:

7.      Salivary calculus.

Method

The study was a descriptive, retrospective and analytic study.  The reason for choosing this method was the low number of infectious sialoadenitis cases which is about 7-8 cases per year.

We used the archive of two major ENT centers (Imam Khomeiny an Amir Aalam Hospitals) to find our cases.  As a result we found and studied 119 patients who have been admitted in those hospitals between 1992 and 1996.

Findings

From 100% of the patients admitted with the diagnosis of sialoadenitis:

1. 61% were male and 38.7% were female which is similar to other references (Table 1).

Table 1: Frequency and relative frequency of two sex groups in patients with sialoadenitis admitted in Amir Aalam and Imam Khomeiny Hospitals, 1992-1996

2. In terms of the involved salivary gland, 17.6% of the cases were in parotid gland and 82.4% located in submandibular gland.  There was no case involving sublingual gland (Table 2).

Table 2: Frequency and relative frequency of involvement of different types of salivary glands in patients admitted in Imam Khomeiny and Amir Aalam Hospitals, 1992-1996.

3. 80% of the patients complained from pain and swelling at their first visit, 5% had a chief complaint of pain, swelling and salivary calculus, 8% with pain, swelling and dry mouth, 5.9% with pain and lymphadenopathy and 7.6% only with swelling (Table 3).
4. 11.8% of the patients discharged with the final diagnosis of acute sialoadenitis, 76.5% as chronic sialoadenitis, 1.7% with the diagnosis of Sjogren's disease, 8% as viral disease, 5.9% as tumor cases and 3.4% were cases of tuberculosis (Table 4).

Table 3: Frequency and relative frequency of the chief complaint of the patients with sialoadenitis admitted in Imam Khomeiny and Imam Aalam Hospitals, 1992-1996.

Table 4: Frequency and percentage of final diagnosis of the patients admitted in Imam Khomeiny and Amir Aalam Hospitals with the impression of sialoadenitis, 1992-1996

5. In terms of radiology results, 26.9% of the cases showed radio opacity, 12% were radiolucent and for 61% of the cases there weren't any radiology results in their files (Table 5).

Table 5: Frequency and relative frequency of radiology results in patients admitted in Imam Khomeiny and Amir Aalam Hospitals with sialoadenitis, 1992-1996.

6. Among our 119 cases, 58 (48.7%) had a salivary gland calculus.  It was negative for stone (Table 6).

Table 6:  Frequency and relative frequency of calculi formation in patients with sialoadenitis admitted in Imam Khomeiny and Amir Aalam Hospitals, 1992-1996.

7. Age analysis showed that 4.2% of the patients were in the first age group (0-10), 18.7% of them in the second group (11-19), 42.9% in the third age group (19-24) and 34.5% in the last age group (above 25).  The youngest patient was 1 year old and the oldest was 83 y/o; the mean age was 32.6 y/o.  In the first age group male frequency was 5.5%, in the second age group 15.12%, in the third age group 46.6% and in the fourth age group 32.9%.  In the first age group the frequency of the disease in female was 2.2%, in the second age group it was 23.9%, in the third age group 37% and in the 4^th age group it was 37% (Table 7).

Table 7:  The frequency and relative frequency of the patients' gender according to the defined age groups in patients admitted with sialoadenitis in Imam Khomeiny and Amir Aalam Hospitals, 1992-1997.

8. In the first age group there wasn't any radiology report on the file.  In the second age group 21.9% were radio opaque and 20% were radio lucent.  In the third age group 43.8% were radio opaque and 60.3% were radio lucent.  In the 4^th age group 34.4% were radio opaque and 20.4% were radio lucent.
9. Parotid gland involvement, in the first age group was 4.8% in the second age group was 23.8%, in the third age group 22.2% and in the fourth age group it was 38.1%. 

Submandibular gland involvement was 4.1% in the first age group, 17.3% in the second age group, 44.9% in the third age group, and 33.7% in the fourth age group.

10. Parotid gland was involved in men in 23.8 of the cases and in women in 76.2%
11.  Radio-opacity was found in parotid gland in 3.1% of the cases and in submandibular gland in 96.9%.  Radio-lucency on the other hand was in parotid gland in 13.2% of the cases and in submandibular gland in 86.7% of the cases.
12. 81.3% of the radio opaque calculi were in male while in female it was 18.8%.  On the other hand 60% of the radio lucent stones were in men and 40% in women.
13. Stone formation was 81% in men and 19% in women.  Non stone forming disease was 42.6% in male and 57.4% in female.
14. Stone formation was in parotid gland in 2.4% and in submandibular gland in 96.6% of the cases. Non stone formation was in parotid gland in 21% of the cases and in submandibular gland in 68.9%.
15.  Stone formation was none in the first age group, 17.2% in the second age group, 55.2% in the third age group and 27.6% in the fourth age group.

Non stone formation was 8.2% in the first age group, 19.7% in the second age group, 31.3% in the third age group and 42% in the fourth age group.

Discussion

1. Sialoadenitis was seen in men in 61.3% and in women in 38.7% of the cases. This is similar to other references (1).
2. The type of the involved gland was parotid gland in 17.6% of the cases and submandibular gland in 82.4%.  This is also similar to other references (2).
3. From the patients admitted originally with the impression of sialoadenitis, 11.8% were discharged with the final diagnosis of acute sialoadenitis, 76.5% with chronic sialoadenitis, 1.7% were diagnosed as Sjogren's disease, 0.8% as viral infection, 5.9% was found to have a tumor and 3.4% had tuberculosis.  This shows that in 12% of the cases the original impression was wrong.
4. The mean age obtained in this study was 32.6 years which is lower than what is mentioned in text books (1,2).
5. In the analysis of the relationship between sex of the patient and the type of the involved gland, parotid gland male involvement was 23.8% and female involvement 76.3%; while in the case of submandibular gland male involvement was 63.9% and female involvement was 30.6%.  This reverse relationship with p<0.05 is significant statistically.
6. 3.4% of the salivary calculi were in parotid gland and 96.16% in submandibular gland.  This is different from other reports i.e. in other studies 80% of the calculi were found in submandibular gland and 19% in parotid gland (1,2).
7. 81% of the calculi were found in men while women had only 19% of the stones.  This difference wasn't mentioned in other references and is significant statistically with p < 0.05. 
8. The most common age for calculi formation was 19-24. This is different from other references in which 75% of the salivary calculi were reported to happen in the 5^th -8^th decades of life.  This is also significant statistically with

      p < 0.05 (1,7,8).

References:

1. Paparell A: "Otolaryngology and Head and neck surgery" 27 Saunders USA, pp. 2085, 1991.
2. Commings, A: "Otolaryngology and head and neck surgery", 24 Saimeres USA, pp. 1120,H224, 1992.
3. Ballenyer. JR: "Otolaryngology 1, 15, William and Wilkins USA, PP. 713, 714.
4. Robin's Basic Pathology, 1,15, Saunders, USA, pp. 498-501, 1992.
5. Van-der-val, JE, Subacute necrotizing sialoadenitis, a new entity, Br-J-aral. Maillofac-surgery, 1995 oct. 33(5) 302-2.
6. Robrts, DN, Parotid duct stenosis, Inter; 33(5) 302-3 ventional. Radiology to the sescue, Ann-R-Coll, Surgery, England, 1995 Nov. 77(6): 444-6.
7. Gudziol-H, Salivary gland diseased, Ther-umsch 1995 Nov: 52(11): 774-9.
8. Seifert-G, Ethilogy and differential diagnosis of sialoadenitis, Laryngo rhinootologie, 1995 may 74(5): 274-81.
9. John son-FB, Sial adenitis with crystalloid formation, a report of six cases diagnosed by fineneedle aspiration, Diagn-cytopathol. 1995 (Feb) 12(1) 76-80.
10. Harkness, P, Submandibular. Salivary disease, J. Laryngeal-atol 1995 Jan-109(1) 66-7.

Published in: The Iranian journal of Otolaryngology, No 1-2, Vol. 9, December 1995, Serial No. 19.
By: E. Razmpa, MD., B. Malakooti, MD., M. Mirzaii, MD. Tehran University.