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This letter originally appeared in Dr. Hoffman's column on allHealth.com. |
Q: I have Sjogren's syndrome and have been managing my symptoms fairly well. However, I have problems with parotid gland swelling and pain. I drink a lot of water but it doesn't seem to help the swelling and pain. Is there something else I can do?
A: Sjogren’s syndrome is an autoimmune disease (a disease in which the body’s immune system mistakenly attacks itself– not haphazardly, for only particular tissues are affected.) Dry eyes and dry mouth are the hallmark of Sjogren’s syndrome, but dryness of the nose, throat, skin, and vagina are also occasionally noted. As with any autoimmune disease, chronic fatigue troubles some patients.
Sjogren’s syndrome often accompanies other autoimmune diseases (such as rheumatoid arthritis.) It is often suspected when a patient who is known to have another autoimmune disease complains to her physician of dry eyes and/or dry mouth. The diagnosis of Sjogren’s disease is supported by specific blood tests, but a salivary gland biopsy is essential in order to be certain of the diagnosis. This is most commonly done by an ENT surgeon, who can remove a few minor salivary glands through a small incision on the lower lip.
One critical aspect of your question is something that you may not have considered: have you been correctly diagnosed with Sjogren’s syndrome? It is an unfortunate fact of life that, thanks to HMOs and other third party payors, medicine is not always practiced as it should be. If you have not had a biopsy to prove the diagnosis, you should ask your doctor, "How can you be certain that I have Sjogren’s syndrome?"
Recurrent, painful swelling of the parotid gland is known as chronic sialoadenitis, and Sjogren’s syndrome is only one of many possible causes. In all cases, there is obstruction of salivary outflow through the parotid duct (the tube that channels saliva from the parotid gland into the mouth.) With Sjogren’s syndrome, presumably swelling of the gland itself causes obstruction because of pressure on the duct.
Conservative treatment of chronic sialoadenitis involves the following measures:
– Hydration. I recommend that patients drink 8 to 10 eight ounce glasses per day of nonalcoholic, noncaffeinated beverages. Avoidance of alcohol and caffeine is helpful.
– Stimulation of salivary flow. I often recommend that patients suck on sour candies, but this is damaging to the teeth in the long run. A safer course is to chew sugar-free gum frequently throughout the day.
– Massage. FIRM massage of the gland (no bruises, please) can help stimulate salivary flow.
– Warm packs can be soothing when the glands are particularly tender.
– If one or both parotids becomes very swollen, tender and red, I worry about bacterial infection. A Staphylococcus species is the usual culprit. Antibiotics are necessary, and it is imperative that the antibiotic have activity against Staphylococcus. Penicillin, ampicillin, and amoxicillin are inappropriate antibiotics, because Staphylococcus is often resistant to these antibiotics.
If conservative treatment consistently fails to help you, and if more aggressive treatment of your Sjogren’s disease is ineffective (see next paragraph), surgical removal of the parotid(s) is an effective option OF LAST RESORT. This operation (total parotidectomy) carries with it risk to your facial nerve (the nerve that innervates the muscles of facial expression) and will inevitably leave you with a much drier mouth.
If your parotid swelling is related to Sjogren’s syndrome, you may want to ask your doctor about more aggressive treatment of Sjogren’s syndrome. Ask him/her about the drug hydroxychloroquine, and about drugs to suppress the immune system. All of these drugs have associated risks and side effects, so you will need to have a careful discussion with your doctor before you can knowledgeably weigh your options.
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