Peritonsillar Abscess: Complication of Acute Tonsillitis or Weber's Glands Infection?

OBJECTIVE: To review the literature concerning the 2 primary hypotheses put forth to explain the pathogenesis of peritonsillar abscess: "the acute tonsillitis hypothesis" (peritonsillar abscess is a complication of acute tonsillitis) and "the Weber gland hypothesis" (peritonsillar abscess is an infection of Weber's glands). DATA SOURCES: PubMed, EMBASE. REVIEW METHODS: Data supporting or negating one hypothesis or the other were elicited from the literature. CONCLUSIONS: Several findings support the acute tonsillitis hypothesis. First, the 2 main pathogens in peritonsillar abscess have been recovered from pus aspirates and bilateral tonsillar tissues with high concordance rates, suggesting that both tonsils are infected in patients with peritonsillar abscess. Second, studies report signs of acute tonsillitis in the days prior to and at the time of peritonsillar abscess. Third, antibiotic treatment reduces the risk of abscess development in patients with acute tonsillitis. However, some findings suggest involvement of the Weber's glands in peritonsillar abscess pathogenesis. First, high amylase levels have been found in peritonsillar pus. Second, the majority of peritonsillar abscesses are located at the superior tonsillar pole in proximity of the Weber's glands. We propose a unified hypothesis whereby bacteria initially infect the tonsillar mucosa and spread via the salivary duct system to the peritonsillar space, where an abscess is formed. IMPLICATIONS FOR PRACTICE: Our findings support the rationale for antibiotic treatment of patients with severe acute tonsillitis to reduce the risk of abscess development. Improved understanding of peritonsillar abscess pathogenesis is important for the development of efficient prevention strategies.

Non-tuberculous mycobacterial head and neck infections in children: Analysis of results and complications for various treatment modalities.

OBJECTIVES: Analyze the results and complications of various surgical interventions in a large cohort of children with non-tuberculous mycobacterial (NTM) head and neck infections and suggest a heuristic treatment protocol for managing this condition while aiming to maximize cure and minimize complications. METHODS: Retrospective chart review of 104 consecutive patients diagnosed with head and neck NTM at a tertiary paediatric hospital between January 1994 and December 2013 inclusive. RESULTS: 104 patients ranged in age between 8 months to 15 years (mean age 27 months) were reviewed and 97 patients were included in the final analysis. 6 patients excluded due to lack of follow-up and one excluded due to systemic immunocompromised condition. Sub-sites of NTM infections were submandibular (n=48, 46%), cervical (n=40, 38%), parotid (n=18, 17%) and submental (n=4, 4%). Some patients had more than one lesion so counted twice. Higher cure rates were demonstrated for primary excision (81%, p<0.01) versus incisional interventions (44%, p<0.01). Marginal mandibular nerve palsy following surgery was seen in 7 patients (7.2%). This was permanent in 4 patients (4%) and temporary in 3 patients (3%). All children who were complicated with marginal mandibular palsies had lesions in the submandibular region. The rate of palsy for submandibular disease alone was 15%, while 8% presented permanent palsy and 6% temporary. Marginal mandibular nerve palsy was more likely following excisional compared to incisional procedures (6 versus 1 patient, p<0.01). Hypertrophic scarring occurred in 7 patients: 3 patients following excision and 4 patients after an incisional procedure. One patient suffered long term spinal accessory nerve damage presented as winged scapula. CONCLUSIONS: Excision of NTM provides better cure rates compared to incision although at the expense of long term post-surgical morbidity. Excision should probably be the first line of treatment when the risk for neural damage is low. Incision and drainage with or without antimycobacterial treatment may be the preferred option for at-risk sub-sites (submandibular or parotid) in order to reduce long term morbidity.

Salivary gland nocardiosis in an immunocompetent patient.

We report a case of nocardiosis in an immunocompetent patient who presented with pain and multiple swellings in the face. Nocardia asteroides was isolated from the parotid and submandibular salivary glands. The patient was successfully treated by surgical drainage and oral administration of trimethoprim and sulfamethoxazole. To the best of our knowledge, this is the first reported case from India on N. asteroides affecting the salivary gland.

Submandibular and sublingual glands involvement in advanced acquired immunodeficiency syndrome (AIDS): an autopsy-based study.

OBJECTIVE: To assess the histopathological, immunohistochemical (IHC), and in situ hybridization (ISH) features found in the submandibular (SM) and sublingual (SL) glands of 105 acquired immunodeficiency syndrome (AIDS) patients at autopsy. STUDY DESIGN: Gender, age, CD4 cell level, and clinical histories were obtained from clinical charts (SM: n = 103; SL: n = 92). Histologic analysis of hematoxylin and eosin, Gomori-Grocott, and Ziehl-Neelsen stained tissues, IHC to detect infectious agents and characterize inflammatory cells in sialadenitis, and ISH for EBER-1/2 were performed. RESULTS: The mean age of the patients and CD4 cell count were 36 years and 76 cells/microL, respectively. Fifty-eight cases (SM: n = 51 [49%]; SL: n = 54 [59%]) were considered to be microscopically normal. The most common infectious conditions were mycobacteriosis (SM: n = 11 [10%]; SL: n = 7 [7%]), followed by cytomegalovirus (CMV) (SM: n = 14 [13%]; SL: n = 2 [2%]), and cryptococcosis (SM: n = 3 [3%]; SL: n = 4 [4%]). Human immunodeficiency virus (HIV) p24 (SM: n = 2 [2%]; SL: n = 1 [1%]) and EBER-1/2 (SM: n = 9 [39%]; SL: n = 4 [20%]) were seen only in macrophages and lymphocytes, respectively. The most prevalent cells seen in chronic nonspecific sialadenitis (SM: n = 25; SL: n = 25) were CD8+ T lymphocytes, whereas CD68+ macrophages were predominant in the mycobacteriosis-associated granulomatous and nonspecific diffuse macrophagic sialadenitis. Concomitant infections occurred in 5 cases (SM: n = 4; SL: n = 1) and non-Hodgkin lymphoma in 1 case. CONCLUSIONS: Infectious diseases and chronic nonspecific sialadenitis were the main alterations found in the SM and SL glands. These alterations were greater in the SM than in the SL glands. CD8+ T lymphocytes and CD68+ macrophages might be relevant to the pathogenesis of the sialadenitis. Clinicians should consider these diseases when assessing the major salivary glands in advanced AIDS patients and follow biosafety procedures to avoid contamination by HIV, CMV, mycobacteriosis, and cryptococcosis.

Diagnosis of major salivary gland tuberculosis: experience of eight cases and review of the literature.

CONCLUSIONS: Tuberculosis of the salivary gland is mostly a medically curable disease entity but early diagnosis is very important to ensure complete remission. In cases with a high index of suspicion, reliable diagnostic methods such as polymerase chain reaction (PCR) should always be considered before surgical intervention to enable differential diagnosis of a salivary gland tumor. OBJECTIVES: To investigate the clinical characteristics of major salivary gland tuberculosis and to review the literature relating to its diagnosis. MATERIAL AND METHODS: Eight patients diagnosed as having major salivary gland tuberculosis between 1994 and 2004 were treated at one of three tertiary referral centers. Medical records, including imaging findings and the results of microbiological tests, Mycobacterium tuberculosis PCR and histopathology, were retrospectively retrieved and the literature was reviewed. RESULTS: The parotid and submandibular glands were involved in 5 (62.5%) and 3 cases (37.5%), respectively. Neck CT demonstrated typical findings of salivary gland tuberculosis in 3 patients (37.5%). Fine-needle aspiration cytology revealed chronic inflammation in 6/7 patients (85.7%), 2 of whom (33.3%) showed caseous necrosis, strongly suggesting tuberculosis. Five of the 8 patients (62.5%) required resection of the affected gland and 3 (37.5%) received open biopsy. PCR was performed in half of the cases and was affirmative in every case. No significant differences were found between the surgically resected and non-resected groups in terms of treatment results or morbidity. All patients received anti-tuberculous chemotherapy for 8-12 months, with no disease recurrence.

Multiple suppurative cystic lesions of the lips and buccal mucosa: a case of suppurative stomatitis glandularis.

Cheilitis glandularis (CG) is a rare inflammatory salivary gland disease that usually affects the lips. Although the etiology of CG is still unknown, it is believed to be a hereditary disease with an autosomal dominant pattern of inheritance. Three clinical presentations of CG are described in the literature: simple, superficial suppurative, and deep suppurative. A case of deep suppurative CG that extended to the buccal mucosa has been previously reported as suppurative stomatitis glandularis (SSG). Here we report a case of SSG in a 64-year-old white female with a history of bilateral renal transplants for adult polycystic kidney disease, who presented with painful swollen lips and bilateral buccal mucosal lesions. The diagnosis and management of the case is discussed. To the best of our knowledge, this is the second report of SSG, a rare condition affecting the minor salivary glands in the oral cavity.

Oral tuberculosis: a clinical evaluation of 42 cases.

OBJECTIVES: A retrospective review of a large series of oro-facial cases of tuberculosis to analyse clinical, histopathological, and radiological aspects, as well as those of chemotherapy. MATERIALS AND METHODS: A total of 42 cases of tuberculosis of the oro-facial region were examined. Thirteen patients had a primary form and 29 a secondary form of the disease. Diagnosis was based on careful clinical examination, Mantoux reaction, histopathological examination, microbiological cultures and immunological investigation with the detection of antibodies against Mycobacteria in the patients' serum (ELISA). RESULTS: Cases examined consisted of 27 males and 15 females. The age range was 3 to 73 years (mean age 31 years). Clinical manifestations comprised oral ulcers in 69.1%, bone involvement in 21.4%, and salivary gland and/or lymph node involvement in 14.3%. A total of 79.4% patients with secondary disease had pulmonary lesions, 15 of whom showed clinical and radiological signs of activity; there was one case of bilateral renal lesions and two of skin lesions. CONCLUSIONS: Oro-facial tuberculosis is often difficult to diagnose and it should be an important consideration in the differential diagnosis of lesions that appear in the oral cavity. The most important diagnostic tools remain a careful clinical evaluation, biopsy for histologic study, as well as acid-fast stains, culture, and immunological assays, and skin testing.

What can transgenic and gene-targeted mouse models teach us about salivary gland physiology?

Thousands of genetically modified mice have been developed since the first reports of stable expression of recombinant DNA in this species nearly 20 years ago. This mammalian model system has revolutionized the study of whole-animal, organ, and cell physiology. Transgenic and gene-targeted mice have been widely used to characterize salivary-gland-specific expression and to identify genes associated with tumorigenesis. Moreover, several of these mouse lines have proved to be useful models of salivary gland disease related to impaired immunology, i.e., Sjögren's syndrome, and disease states associated with pathogens. Despite the availability of genetically modified mice, few investigators have taken advantage of this resource to better their understanding of salivary gland function as it relates to the production of saliva. In this article, we describe the methods used to generate transgenic and gene-targeted mice and provide an overview of the advantages of and potential difficulties with these models. Finally, using these mouse models, we discuss the advances made in our understanding of the salivary gland secretion process.

Absence of Helicobacter pylori DNA in salivary lymphoepithelial lesions.

Helicobacter pylori is a common cause of chronic gastritis and has been implicated as the main agent responsible for the development of lymphomas of mucosa associated lymphoid tissue (MALT) in the stomach. An uncommon cause of salivary gland swelling is salivary lymphoepithelial lesion (SLEL), which shows histological features of acquired MALT and is associated with the development of MALT-type lymphomas. Since H. pylori has been identified in the oral cavity, we hypothesised that this organism might act as a potential antigen for the development of MALT in salivary glands. Routinely processed biopsies of 20 SLEL were screened for H. pylori DNA using a sensitive two-stage PCR technique to amplify the 16S ribosomal RNA gene. Immunoglobulin heavy chain gene monoclonality was determined by amplifying the VDJ gene using a nested PCR technique. All SLEL had histological features of organised MALT and 14 cases showed Ig heavy chain gene monoclonality consistent with MALT lymphoma. None of the SLEL contained H. pylori DNA. In contrast to the putative role of H. pylori as an antigenic stimulus in gastric MALT lymphomas, it appears not to play a role locally in the development of MALT or MALT lymphomas of the salivary gland.

Potential of diagnostic microbiology for treatment and prognosis of dental caries and periodontal diseases.

Most evidence suggests that only a finite number of bacteria are responsible for dental caries and periodontal diseases. This knowledge led to the development of microbial tests which can identify suspected pathogens. Current evaluation of the diagnostic power of microbial tests has shown that they have a low sensitivity and a low prognostic value. Despite these shortcomings, there are valid indications for microbiological-based diagnosis. Salivary microbial tests for the detection of mutans streptococci and lactobacilli may be useful, for example, in young children, oligosialic patients, and orthodontic patients. These tests can be used to monitor the success of chemopreventive measures or compliance with dietary recommendations. Microbial diagnosis, may also be valuable in the treatment of early-onset periodontitis or in subjects who respond poorly to periodontal therapy. The use of microbial tests to monitor the efficacy of chemotherapy or mechanical treatment is of particular interest.

Fine-needle aspiration biopsy of salivary gland mycoses.

This report details the fine-needle aspiration biopsy (FNAB) cytomorphologic features of two cases of salivary gland mycosis. Both patients had acquired immunodeficiency syndrome (AIDS) and presented with parotid gland masses. The first patient had Histoplasmosis with secondary infection by Candida. Cytopathologically, the FNAB smears showed classic features of a deep-seated mycosis characterized by necrosis and scattered fungal forms. The second patient had a colonizing sialadenitis caused by either Asperigillus or Fusarium. Cytopathologically, the findings were similar to those seen in aspergillomas of the lung or paranasal sinuses with numerous hyphal forms and an absence of an inflammatory response. Because mycotic disease can induce a wide spectrum of pathogenic change, other benign or malignant, solid or cystic lesions enter into the differential diagnosis.

Human immunodeficiency virus type 1 replication within cystic lymphoepithelial lesion of the salivary gland.

Cystic lymphoepithelial lesions of salivary glands (CLLSG) are nodular or diffuse salivary gland enlargements that are observed in patients who tested positive for human immunodeficiency virus type 1 (HIV-1). Two cases of CLLSG are reported. Particular emphasis is placed on the presence of HIV-1 major-core protein (P24), HIV-1 RNA sequences, Epstein-Barr virus (EBV) DNA sequences, and lymphocyte receptor gene rearrangement. Lymphoid alterations consisted of explosive hyperplasia with a prominent follicular reticular dendritic cell (DRC) network and numerous intrafollicular CD8+ lymphocytes. Intrafollicular DRC strongly expressed HIV-1 major-core protein and HIV-1 RNA, indicating that most DRCs actively replicated the HIV-1 virus. The presence of active HIV-1 replication within DRC and the absence of clonal EBV infected lymphoid population strongly suggest that CLLSG pathogenesis is primarily induced by HIV-1. The presence of oligoclonal immunoglobulin gene rearrangements in our cases, however, suggest the need of long-term follow-up of such patients to determine whether CLLSG could be a benign prelymphomatous disease.

Experimental Parker's coronavirus infection in Wistar rats.

Specific Pathogen Free (SPF) male Wistar rats were inoculated intranasally with Parker's rat coronavirus (PRC), then killed at various intervals post-inoculation (pi). PRC inoculated rats had transient respiratory signs. Intermandibular swelling was evident in some rats at 6-8 days pi. During the acute stages of the disease, inflammatory lesions were present in the respiratory tract and in the salivary and lacrimal glands. Regenerative lesions were observed in the salivary and lacrimal glands at 2 weeks pi. Inoculated rats seroconverted at 8-14 days pi, and significant coronaviral antibody titers were present in inoculated rats examined at 21 days pi with PRC. Changes in the respiratory tract and salivary and lacrimal glands were identical in incidence, distribution and nature to those observed in sialodacryoadenitis (SDA) virus inoculated Wistar rats. Thus, in the absence of viral isolation and characterization, "rat coronavirus infection" is a more appropriate term than either PRC infection or sialodacryoadenitis (SDA).

Head and neck manifestations of mycobacteria in the absence of pulmonary disease.

Mycobacterial infections, once relatively rare in North America have recently shown an upsurge with the influx of Asian and African immigrants. The infections are usually due to M. tuberculosis and present with pulmonary symptoms. However, an uncommon presentation is that of a mass in the head and neck region without any pulmonary manifestations. Although these infections are usually secondary to invasion by "atypical" mycobacteria, unusual presentations due to mycobacterium tuberculosis have been noted. Case reports depicting the very rare presentations of M. tuberculosis in the thyroglossal duct cyst, parotid, and submandibular lymph node are described. A very unusual case of atypical mycobacteria in the larynx is noted and cervical adenitis is also included. The initial subtle presentation emphasizes the importance of mycobacteria in the differential diagnosis of lesions in the head and neck region.