Treatment Options for Salivary Gland Issues
Treatment depends on the specific salivary gland disorder: for malignant tumors, complete surgical excision is the cornerstone of therapy; for dry mouth from gland dysfunction, treatment is stratified by residual gland function using either non-pharmacological stimulation, pharmacological muscarinic agonists, or saliva substitutes; for salivary stones, intraoral surgical removal is standard; and for infections, antibiotics combined with hydration and sialagogues are first-line. 1, 2, 3
Malignant Salivary Gland Tumors
Diagnostic Staging
- Complete surgical excision is the fundamental treatment for all salivary gland malignancies, with or without postoperative radiation based on stage and histological grade 1
- Staging requires cervico-facial CT scan or high-resolution ultrasound (by trained teams only), with histopathological confirmation via excision biopsy with frozen section for major glands or simple biopsy for minor glands 1
- TNM AJC/UICC classification guides treatment decisions, with histological grading (low vs. high grade) being critical 1
Stage-Specific Treatment Algorithm
Stage I (T1a-T2a N0 M0):
- Major glands: complete gland excision 1
- Minor glands: wide radical resection 1
- No adjuvant radiotherapy if resection is macroscopically and microscopically complete, even for high-grade tumors 1
- Postoperative radiotherapy with photons (±electrons) is mandatory if excision margins are positive 1
- Routine neck dissection is not recommended for Stage I 1
Stage II-IV High Grade Tumors:
- Surgery plus postoperative radiotherapy is standard for all Stage II, III, and IV high-grade tumors 1
- Postoperative radiotherapy is also standard for low-grade Stage III and IV tumors 1
- Ipsilateral neck dissection is standard for T2a high-grade tumors 1
- Nerves should not be conserved at the expense of tumor clearance 1
Inoperable or Advanced Disease:
- Neutron therapy alone is the treatment of choice for inoperable tumors, regardless of stage and grade 1
- Neutron therapy is an alternative for locally advanced disease (Stage III-IV) where surgery would cause significant functional sequelae 1
- Postoperative neutron therapy is only indicated for large-volume residual disease 1
Chemotherapy Considerations
- Chemotherapy has no established role as routine treatment and should only be given within multicenter therapeutic trials 1
Dry Mouth (Xerostomia) from Salivary Gland Dysfunction
Initial Assessment
- Baseline measurement of salivary gland function is mandatory before starting treatment, not the patient's subjective feelings, since environmental factors may not correlate with objective glandular function 1
- Measure whole salivary flows and rule out unrelated conditions (candidiasis, burning mouth syndrome) 1
- Salivary scintigraphy may be considered 1
Treatment Algorithm Based on Gland Function
Mild Glandular Dysfunction:
- Non-pharmacological glandular stimulation is the preferred first-line approach 1
- Use gustatory stimulants: sugar-free acidic candies, lozenges, xylitol 1
- Use mechanical stimulants: sugar-free chewing gum 1
- Ideal preparations have neutral pH, contain fluoride and electrolytes mimicking natural saliva 1
- Saliva substitutes available as oral sprays, gels, and rinses 1
Moderate Glandular Dysfunction:
- Pharmacological stimulation with muscarinic agonists (pilocarpine or cevimeline) may be considered 1
- Pilocarpine is FDA-approved for dry mouth from radiotherapy for head/neck cancer and for Sjögren's syndrome 4
- Pilocarpine dosing: 5 mg three times daily increases unstimulated salivary flow with onset at 20 minutes, peak at 1 hour, duration 3-5 hours 4
- Greatest improvement occurs in patients with no measurable salivary flow at baseline 4
- Common adverse events increase with dose: sweating (most common cause of withdrawal at 10 mg TID = 12%), nausea, rhinitis, diarrhea, chills, flushing, urinary frequency 4
Severe Dysfunction:
- When glands cannot be stimulated, focus on saliva substitutes and oral comfort agents 1, 5
- Conservative measures: hydration, salivary massage, warm compresses, oral hygiene optimization 3, 6
Systemic Disease Management
- For Sjögren's syndrome with systemic features, immunosuppressive therapy may be considered after careful organ-by-organ evaluation 1
- Management follows a two-stage regimen: intensive induction to restore organ function, followed by maintenance therapy 1
Salivary Stones (Sialolithiasis)
Diagnosis and Treatment
- Salivary stones under the tongue should be surgically removed through an intraoral approach, with technique determined by stone size and location 2
- Characteristic symptoms: intermittent pain and swelling just before eating 2
- Diagnosis confirmed by bimanual palpation, with ultrasound (by trained personnel) to confirm location and size 2
- CT scan may be considered if adjacent structure involvement is suspected 2
- Sialendoscopy is a gland-sparing technique for both obstructive and non-obstructive disorders 6
Post-Procedure Care
- Clean wound with 0.1% chlorhexidine solution 2
- Oral rinses with 0.1% chlorhexidine for 1 minute after procedure and daily during healing 2
- Avoid spicy, acidic, or hot foods 2
- Maintain regular oral hygiene 2
Salivary Gland Infections (Sialadenitis)
Acute Bacterial Sialadenitis
- Acute suppurative sialadenitis requires antibiotics, salivary massage, hydration, and sialagogues (lemon drops or vitamin C lozenges) 3
- Most common bacterial cause is Staphylococcus aureus 6
- Conservative measures include treating underlying etiology, controlling pain, increasing salivary flow, and medication adjustment 6
Viral Infections
- Mumps is most common viral cause in children globally; juvenile recurrent parotitis in vaccinated populations 6
- Treatment directed at underlying viral disease 3
Chronic/Recurrent Sialadenitis
- More likely inflammatory than infectious 3
- Management directed at relieving obstruction (stones, duct stricture) 3
- Goal is gland preservation when possible 7