1. Approach to Parotid Gland Enlargement Iraj Salehi-Abari MD
Approach to Parotid Gland Enlargement Iraj Salehi-Abari MD., Internist Rheumatologist

2. In the name of God the merciful the compassionate

3. The Parotids are one of salivary glands The causes of parotid gland swelling # 43

4. Approach to Parotid gland enlargement:
Acute versus Chronic Swelling
Unilateral versus Bilateral Swelling
Painful versus Painless Swelling
Obstructive versus non-Obstructive Swelling
Granulomatous versus non-Granulomatous
Isolated Swelling versus Swelling with systemic features
Childhood versus Adulthood Swelling
Febrile versus non-Febrile Swelling
Suppurative versus non-Suppurative Swelling

5. Classification of Parotid gland enlargement:
Infective
Inflammatory
Immune mediated (autoimmune)
Neoplastic
Non-inflammatory Non-neoplastic
Congenital

6. Important Comments:
Unilateral parotid swelling is more common than Bilateral
The causes of Bilateral swelling: numerous
The causes of Unilateral swelling: a few

7. Unilateral parotid enlargement:

8. Bilateral parotid enlargement: Chipmunk-like cheeks

9. Important Comments:
In Bilateral parotid swelling with systemic features, for diagnosis usually:
Do not require Imaging of parotid gland
Do not require Biopsy of Parotid gland
In Unilateral parotid swelling without systemic features, for diagnosis usually:
require Imaging of parotid gland
require Biopsy of Parotid gland

10. Parotid gland Imaging:
MRI
CT scan
Ultrasonography
Scintigraphy
Sialography

11. Unilateral Parotid gland swelling:
Acute:
Bacterial (Suppurative) parotitis
Stones (Sialolithiasis)
Chronic:
Chronic bacterial parotitis
Tumors (Neoplasms)
Stones
Actinomycosis

12. Bilateral parotid gland swelling:
Painful, Inflammatory:
Acute
Chronic
Painless, non-Inflammatory, non-Neoplastic:
Sialadenosis

13. Acute painful, inflammatory bilateral parotid gland swelling:
Viral Parotitis:
Mumps
Coxsackie virus
Echovirus
EBV
CMV

14. Chronic painful (or little painful), inflammatory bilateral parotid gland swelling:
Sjogren’s syndrome
Chronic granulomatosis diseases:
Sarcoidosis (Heerfordt’s syndrome)
Tuberculosis
Leprosy
Cat scratch fever
Granulomatosis with polyangiitis (WG)

15. Chronic painful (or little painful), inflammatory bilateral parotid gland swelling:
IgG4 related systemic disease
IgE related systemic disease:
Kimuras’S disease
Chronic viral disease
HCV
HIV
Recurrent parotitis of childhood

16. Chronic painless, non-inflammatory Non-neoplastic bilateral parotid gland swelling:
Eating disorder
Anorexia
Bulimia
Malnutrition and Alcoholism
Hyperlipoproteinemia
Malabsorbtion: Celiac
Cirrhosis
Chronic Pancreatitis

17. Chronic painless, non-inflammatory Non-neoplastic bilateral parotid gland swelling:
Amyloidosis
Diabetes mellitus
Acromegaly
Myxedema
Gonadal hypofunction
Cushing’s syndrome

18. Bilateral parotid swelling with dry eyes:
Sjogren’s syndrome
Sarcoidosis
Amyloidosis
IgG4-related systemic disease

19. Bilateral parotid swelling with dry mouth:
Sjogren’s syndrome
Sarcoidosis
Amyloidosis
IgG4-related systemic disease
Diabetes mellitus
HCV
HIV

20. Bilateral parotid swelling with dry mouth and dry eyes:
Sjogren’s syndrome
Sarcoidosis
Amyloidosis
IgG4-related systemic disease

21. Bilateral parotid swelling with Macroglossia:
Amyloidosis
Sarcoidosis
Acromegaly
Hypothyroidism

22. Parotid swelling with Facial n. paralysis:
Unilateral parotid swelling:
Malignant neoplasm of parotid
Bilateral parotid swelling:
Sjogren’s syndrome
Sarcoidosis

23. Parotid glands swelling with lacrimal glands enlargement:
Sjogren’s syndrome
Sarcoidosis:
Scintigraphy using Gallium-67 citrate may produce the classic “Panda sign” owing to bilateral increased uptake by the lacrimal and parotid glands

24. Parotid G. enlargement + bihilar adenopathies:
Sarcoidosis
Tuberculosis
Lymphoma
Parotid G. enlargement + ILD:
Sjogren’s syndrome
Parotid G. enlargement + bihilar adenopathies + ILD:

25. Heerfordt’s syndrome: (Uveoparotid fever)
Uveitis
Parotid swelling
Facial nerve paralysis
Fever

26. Causes of parotid glands swelling in Sjogren’s syndrome:
Parotid stones
Bacterial infection of parotid
Viral (Mumps, EBV, CMV) trigger
Non-Hodgkin’s lymphoma
Hypothyroidism
Pancreatitis
Cirrhosis
HCV

27. There are three key findings: Salivary gland swelling Dry eyes
Amiralam Hospital Guideline for General Practitioner to approach to patients suspected to have primary Sjogren’s syndrome:
There are three key findings:
Salivary gland swelling
Dry eyes
Dry mouth
If there are at least 2 items of above in a patient, he/she has to be referred to a Rheumatologist by GP.

28. In a patient with parotid G. enlargement:
If there is chronic or recurrent bilateral parotid enlargement and at least one of below features:
Pathologic dry eyes
Pathologic dry mouth
He/she has to be evaluated for sjogren’s syndrome

29. Items must be done for patients suspected to have primary Sjogren’s syndrome: (I)
Hx. and Ph. Ex. By Rheumatologist
Schirmer test and Slit lamp examination (Rose Bengal test) by Ophthalmologist
At least one test to quantifying the amount of saliva
CBC, ESR, CRP, FBS, SGOT, SGPT, BUN/Cr, U/A
Anti-Ro, Anti-La, RF and FANA
PA-CXR

30. Items must be done for patients suspected to have primary Sjogren’s syndrome: (II)
Labial Gland Biopsy (LGB) by ENTman or General Surgeon
Pathologic evaluation and looking for Focus score > 1 by Pathologist
In suspected states: Plasma IgG4 level, ACE
In suspected states: HIV, HBsAg, Anti HCV
If we need: CT scanning or MRI, Scintigraphy or Sialography of salivary glands and Biopsy of them by ENTman may be done

32. Diagnosis of Sjogren’s synd.:
American-European classification criteria:
Ocular symptoms
Oral symptoms
Ocular signs:
Schirmer’s test
Rose bengal staining
Pathology:
> 1 focus score(50 lymphocytes /4 mm2)
Salivary gland involvement
Salivary flow < 1.5 ml in 15 min
Parotid sialography
Salivary scintigraphy
Autoantibodies:
Anti-Ro & or Anti –La
4 of 6 ; Definite Sjogren’s syndrome

33. Diagnosis of Sjogren’s synd.:
American-European classification criteria:
Ocular signs:
Schirmer’s test
Rose bengal staining
Pathology:
> 1 focus score(50 lymphocytes /4 mm2)
Salivary gland involvement
Salivary flow < 1.5 ml in 15 min
Parotid sialography
Salivary scintigraphy
Autoantibodies:
Anti-Ro & or Anti–La
3 out of 4  Sjogren’s syndrome

35. Diagnosis: Secondary Sjogren’s syndrome:
A connective tissue disease plus
Ocular or Oral dryness and
At least 2 items out of below 3 items:
Ocular sign
Positive LGB (Biopsy)
Abnormal tests of salivary gland function

36. In a patient with bilateral Parotid G. enlargement:
If no dry eyes and no dry mouth:
 very low probability of Sjogren’s
If no lung involvement and no skin involvement:
 low probability of Sarcoidosis

43. Chest radiograph in Sarcoidosis:
Stage 0: Normal: 5%
Stage I: Bilateral hilar adenopathy: 50%
Stage II: Bihilar adenopathy + ILD: 25%
Stage III: ILD: 15%
Stage IV: Fibrosis: 5%

45. Evaluation of the patients with suspected Sarcoidosis:
Hx and Ph. Examination
Ophthalmologic Examination
PA-CXR, PFTs
CBC, ACE, LFT, serum Ca, U/A
PPD
HRCT of Lungs
Biopsy: noncaseating Granulomas
Lofgren’s and Heerfordt’s syndrome: no Biopsy

47. A patient with Bilateral Parotid G. enlargement and :
Black eyes sign
Shoulder pad sign
Symmetric CTS
Hepatosplenomegaly
Cardiomyopathy
Proteinuria
Skin petechia and purpura is a case of Amyloidosis
Biopsy and Congo red staining are necessary for documentation of DX.

51. A patient with benign tumor of Parotid G.:
Chronic unilateral diffuse swelling of parotid
No skin involvement
No lymphadenopathy
No facial n. paralysis

52. A patient with malignant tumor of Parotid G.:
Chronic unilateral local swelling of parotid gland with rapid growth
Skin retraction
Lymphadenopathy
Facial n. paralysis

53. A student of school of medicine has:
Acute painful bilateral parotid swelling
Sore throat
Fever
Maculopapular rash
Diagnosis: Infectious mononucleosis

54. Typical feature of Mumps:
A children with
Acute painful bilateral parotid swelling
Fever

55. Chronic bilateral parotid enlargement with Dactylitis:
Sarcoidosis
Tuberculosis

56. Chronic bilateral parotid enlargement with lacrimal gland enlargement and facial n. palsy without dry eyes and without dry mouth:
Diagnosis: Sarcoidosis

57. A boy of 8 years old with history of recurrent parotid gland stones has an older brother with the same history. Recently his parotid has been fistulized with yellow creamy discharge:
Diagnosis: HGPRT deficiency  Hyperuricemia