Sixteen months ago my daughter had surgery performed to remove a stone in her parotid gland. The gland was also removed. Ever since surgery, she has had to expel a white substance out of the duct to release saliva and now she is suffering with pain and swelling again. Another stone? Can she do anything to prevent this from happening? Is it diet or related to her two recent pregnancies?

Adele

The answer to all of your questions is a very definite MAYBE.

This problem is called chronic sialoadenitis, which means "chronic inflammation of the salivary gland." We have previously discussed this problem, but your letter brings up a new point: What do you do if the same problems persist after surgery?

First of all, I need to point out that she couldn't possibly have had the whole gland removed. If she had had a total parotidectomy, her problem would be gone. She might be having other problems due to this operation (such as oral dryness or facial nerve weakness), but she couldn't have chronic salivary gland inflammation without a salivary gland. Thus, her surgeon most likely performed a partial or superficial parotidectomy.

Next, I would like to assume that before resorting to surgery, your daughter's doctor tried to treat her problem conservatively. Conservative measures that may help ease the pain of sialoadenitis (and may facilitate spontaneous passage of a stone) include the following:

• Excellent hydration is essential. She should try to drink eight to 10 eight-ounce glasses per day of nonalcoholic, noncaffeinated beverages. Alcohol and caffeine should be avoided, as they tend to contribute to dehydration.
  
• She should chew a sugar-free gum between meals. This will help stimulate a constant flow of saliva from the gland, and may help prevent "logjams" of the type she is currently experiencing.
  
• Periodic, firm massage of the gland will also help stimulate the flow of saliva.
  
• As a last resort, if the gland becomes very tender, warm packs can be soothing. If pain and swelling persist, she may also need antibiotics to treat a possible bacterial infection. The most common organism causing such infections is Staphylococcus, so her doctor must choose an appropriate antibiotic.
  

Even though we've discussed these measures before, they're worth repeating, since they may provide your daughter with significant relief. But let's be pessimistic and consider the possibility that she tries all of these things and STILL has problems. What then?

Many cases of chronic sialoadenitis are due to poor plumbing. For example, her problems might be due to narrowing (stenosis) of the parotid duct. Periodic dilation of the duct could give her lasting relief. Similarly, she may have formed another stone within the duct. Dilation of the duct may enable her to pass the stone, thus relieving her problems. Depending on the location of the stone, her surgeon may be able to extract it without having to resort to an invasive operation.

If all else fails, then her only other option (aside from just living with it) is a total parotidectomy. In this operation, the facial nerve (the nerve that works the muscles of facial expression on one side of the face) must be carefully separated from the parotid tissue that lies above and below the nerve. Once the nerve and all of its many branches are worked free, both lobes of the gland can be removed. (That part of the parotid gland that lies between the skin and the facial nerve, and its branches, is the superficial lobe. That part of the gland below the nerve is the deep lobe.)

This operation puts the facial nerve at considerable risk even under ideal circumstances. But these are less than ideal circumstances -- these are outright nasty circumstances. Her parotid gland is chronically inflamed. Inflamed tissue tends to bleed more than healthy tissue, and this will impair visibility during the operation. Worse yet, she has had a previous partial/superficial parotidectomy. Consequently, her surgeon may encounter scar tissue while working on the facial nerve, which will increase the difficulty and risk of this procedure. This is a difficult situation; the only way your daughter will be able to make an informed decision is if she has an excellent grasp of the risks and benefits inherent to all of her options. Needless to say, your daughter should discuss this with her surgeon.