Salivary Gland Disease
Saliva is produced by three pairs of major salivary glands as well as many minor salivary glands, which are located throughout the oral cavity. The major glands include the parotid glands (in front of the ear), the submandibular glands (just below the jaw) and the sublingual glands (under the tongue). These are all paired glands. In addition to producing a baseline amount of saliva, production increases with food consumption.
Diseases of the salivary glands usually involve infections or tumors. Infections of either the parotid or submandibular glands are marked by swelling in the area of the gland that is made worse during eating. Treatment usually involves fluids, antibiotics, heat, massage, and the use of sour candy to stimulate salivary gland drainage. In younger children, the infections may be recurrent in the parotid glands. In all situations, antibiotics usually resolve the infections but, in a few circumstances, surgery may be necessary to remove a chronically infected gland.
When a tumor is suspected, removal of the gland is often necessary. Specialized X-ray studies may be obtained before surgery, and the use of a needle to perform a biopsy may be an option as well. The risk of malignancy is relatively high in salivary gland tumors, and aggressive management of suspected tumors is encouraged.
Viral upper respiratory tract infections are extremely common in children under the age of 5. In children who are in a day care setting, this number is much higher. Though most of these infections will resolve spontaneously with symptomatic treatment in 10 days, sinusitis is thought to be present in those children who do not improve over this time. This condition may be marked by fever, facial pain, profuse nasal drainage, cough and headache. Acute sinusitis should be differentiated from chronic sinusitis in which symptoms may persist for more than three months.
Though antibiotics are the mainstays of treatment for acute sinusitis, routine use of saline nose drops may be helpful in addition to decongestant therapy and nasal steroid spray. Prolonged therapy is necessary frequently. In children who do not respond to conventional therapy, a CT scan of the sinuses may be obtained. X-rays are not used frequently, as the information they provide is limited. In some children who do not respond to medical therapy, drainage of the sinuses may be appropriate. Adenoidectomy may be helpful in certain individuals as well. In those children who require prolonged medical or surgical treatment, evaluation for allergies may be helpful.
Complications of sinusitis often involve the eye or brain. In these situations, intravenous antibiotic therapy is usually required, as is surgical drainage of the sinuses.
Sleep apnea is a condition where the normal sleep patterns of a child are disrupted. The word “apnea” refers to a condition where breathing stops. This can be due to central causes, where the brain no longer transmits signals to the body to actually breathe, or can be due to an obstruction in the airway where breathing is curtailed because of a blockage. Most causes of central apnea are due to neurologic abnormalities and will not be addressed here as they are usually cared for by neurologists or pulmonologists. Obstructive apnea, however, is most frequently treated by the otolaryngologist (ear, nose and throat specialist).
Within sleep apnea, there is a broad range of sleep disordered breathing abnormalities, including obstructive hypopneas, where the child doesn’t totally stop breathing, but there is enough obstruction in the airway such that the breaths taken are too small and not effective.
The most common cause of sleep apnea in children is due to enlarged tonsils and adenoids. However, any obstruction, from the level of the nose down to the voice box, or larynx, can cause sleep obstruction and apnea.
In adults, obesity has been shown to be a major risk factor for sleep apnea, but this is not always the case in children. Very thin children can have sleep apnea.
Untreated sleep abnormalities can be associated with behavioral problems and learning difficulties. In addition, more serious, irreversible health problems can occur including heart failure and pulmonary hypertension.
Sleep disordered breathing includes snoring, snorting, restless sleeping and pauses in the respiration. Some children can sleep only in a sitting position because of the obstruction. Parents are usually the first to notice that their child is having difficulties breathing during sleep. Sometimes, however, if the problem has been present for a long time, the parents may assume that this is simply “normal” for their child and it is only identified when another family member or a friend sleeps over. Sometimes it’s identified when the family is on vacation at a hotel and everyone sleeps in the same room together.
Once the problem is identified, an examination of the child is needed to determine the cause of the obstructed breathing. If the history is clear by the parents’ description of their child’s breathing, and the examination is consistent (i.e., very large tonsils and adenoids), treatment can proceed. If however, it is unclear whether the obstruction is truly dangerous or of concern, parents can supply a videotape of the child sleeping to their physician. Audiotapes can also be helpful. Sleep fluoroscopy or even the use of cine-MRI can be used in more complicated cases of sleep apnea to determine the exact level in the airway where the obstruction is occurring.
If there is still a question about the diagnosis, further documentation is available with a polysomnogram, or sleep study. This is a study where the child comes to the hospital and sleeps overnight attached to different monitors that record many parameters including obstructive apnea and hypopnea, central apnea and hypopnea, oxygen levels, carbon dioxide levels, heart tracing and brain wave tracings. This study is also helpful for children with underlying medical problems that can be associated with different causes of airway obstruction or in children where the obstruction may occur at different levels in the airway.
Most commonly however, sleep apnea is due to enlarged tonsils and adenoids, and treatment consists of removal of the tonsils and adenoids. Other times it may be due to the adenoids alone or from nasal obstruction from a deviated nasal septum. Surgery is then tailored to fit the child’s specific problem.
Children with craniofacial anomalies, such as Down syndrome or Pierre Robin sequence, will have a higher incidence of sleep apnea. More extensive evaluations will be needed for these children both before and after treatment.
For more information about sleep apnea, visit the Upper Airway Center.
Stridor is noisy breathing in children. It may be due to a narrow or obstructed airway. The obstruction may be above, at, or below the larynx. The doctor begins evaluating stridor by checking the patient’s history for whether the onset of stridor was gradual or sudden, the relationship of stridor to feeding, previous intubation and careful questioning for aspirated foreign bodies. A physical evaluation is given to record the pitch, duration and timing of the stridorous noise, breathing rate and degree of breathing distress. X-rays may be taken of the neck and chest. It is also possible that the doctor may suggest a flexible laryngoscopy.
The therapy options for stridor vary greatly depending on the cause, which is determined by the evaluations performed by the doctor.
Subglottic cysts are fluid-filled lesions that occur in the lower part of the larynx, or subglottis, just below the vocal cords. They are a fairly common cause of airway blockage in children. There may be one or more cysts that block the airway below the larynx. Subglottic cysts are often treatable, but can cause total airway obstruction and even death if they are large enough and not treated immediately.
A hemangioma is the benign overgrowth of small blood vessels. Hemangiomas can appear on the skin, commonly considered birth marks, or in the larynx and trachea (air pipe). Though hemangiomas are benign, they can cause problems when they occur in the larynx or trachea. Hemangiomas of the larynx and trachea can significantly reduce the amount of air that can pass into the lungs. This causes the child to make noise when breathing (“stridor”) and work hard to get a breath of air. Hemangiomas of the airway, for unknown reasons, commonly occur just below the vocal cords in a part of the airway called the subglottis.
If the hemangioma does not significantly compromise or reduce the airway, the child can be treated with a class of medications called steroids. Steroids help reduce the size of the hemangioma. Sometimes, babies are born with large subglottic hemangiomas. In these situations, the baby has considerable difficulty breathing and has to be intubated immediately. A surgical airway (tracheotomy) may have to be placed below the level of the subglottic hemangioma for long-term airway support. In the case of large subglottic hemangiomas or hemangiomas that do not respond to steroids, a surgical procedure can remove the hemangioma. An incision in the neck and the larynx is opened. The subglottic hemangioma is resected and the neck incision is closed. The child is usually intubated for several days after the procedure, until the swelling in the airway resolves.
Subglottic / Supraglottic Stenosis
Our lungs receive air through a pipe-like structure called the larynx and trachea. The larynx begins at the very back of the mouth, below the tongue. The larynx is often referred to as the “voice box.” The voice box connects to the trachea, a tube-like structure, which connects to the lungs. The larynx contains the vocal cords, which help us generate sounds to communicate. The supraglottis is the area directly above the vocal cords, and the subglottis is the area directly below the vocal cords. In children, the subglottis is the narrowest part of the airway.
Some children are born with a narrowing of their supraglottic or subglottic airway. This causes the child to make excessive noise when breathing and appear short of breath. Some children can develop narrowing of the supraglottis or subglottis after birth, usually associated with long-term intubation or previous airway surgery.
The most important part of treatment is to characterize or describe the subglottic or supraglottic narrowing. Temporary treatment may involve the placement of a surgical airway (tracheotomy) below the level of airway narrowing. Definitive treatment is aimed at surgically enlarging the area of narrowing or stenosis. This is accomplished by adding cartilage to the wall of the airway to increase the diameter of the airway. Rib cartilage is routinely used for this reconstruction.