granulomatous sialadenitis

Tuberculous and non-tuberculous (atypical) mycobacterial involvement of the salivary glands may occur.

Primary tuberculous infection of the salivary glands is uncommon and most often consists of unilateral parotid gland involvement. The infection is thought to arise in the teeth or tonsils and may result in acute inflammation or a chronic tumorlike lesion.

Secondary tuberculosis more often involves the submandibular or sublingual glands and is accompanied by pulmonary disease. Diagnosis may be made with the application of a PPD skin test and staining for acid-fast bacilli from saliva or fine needle aspiration biopsy.

Atypical mycobacterial infection may be more difficult to diagnose. Therapy consists of administration of the appropriate antituberculous chemotherapeutic agents. Excision may occasionally be required.

Cat scratch disease may involve the parotid gland by direct extension from periparotid lymph nodes. Treatment is symptomatic for this self-limited illness.

Actinomycosis may involve the salivary glands directly from direct extension from a focus of infection in the teeth or tonsils. Treatment consists of incision and drainage with long-term administration of an appropriate antibiotic.

Sarcoidosis is a chronic granulomatous disease of unknown etiology and is characterized by the presence of noncaseating granulomas in the involved tissues.

There is often multisystem involvement typically with prominent pulmonary and cutaneous findings, as well as involvement of the liver, spleen, and various locations in the head and neck. Constitutional symptoms of fever, weight loss, anorexia, fatigue, and night sweats may be noted with evidence of hilar adenopathy on chest roentgenography. The diagnosis is one of exclusion and is made only when other possible etiologies have been ruled out.

Histologically, the noncaseating granulomas are composed of aggregations of epithelioid histiocytes often with the presence of Langhans’ or foreign body-type giant cells. Schaumann bodies (laminated concretions of calcium and proteins) and asteroid bodies (stellate intracytoplasmic inclusions) may also be seen microscopically.

Salivary gland involvement may occur as an isolated head and neck finding or as a component of uveoparotid fever (Heerfordt’s syndrome).

This syndrome consists of uveitis, parotid swelling, and facial nerve paralysis. It usually begins with a prodrome of constitutional symptoms and involvement of the submandibular, sublingual, and lacrimal glands may occur. The swelling may last months to years and usually resolves spontaneously.

Treatment is usually symptomatic with steroids being most beneficial when administered in the acute phase of the illness. They are particularly helpful with regard to the facial paralysis, but in most instances, the paralysis is transient even without treatment. Approximately 65 to 70% of patients may achieve remission with little or no evidence of residual sequelae.