8-24: Acute Inflammatory Salivary Gland Disorders

1. SIALADENITIS

Acute bacterial sialadenitis most commonly affects either the parotid or submandibular gland. It typically presents with acute swelling of the gland, increased pain and swelling with meals, and tenderness and erythema of the duct opening. Pus often can be massaged from the duct. Sialadenitis often occurs in the setting of dehydration or in association with chronic illness. Underlying Sjögren syndrome and chronic periodontitis may contribute. Ductal obstruction, often by an inspissated mucous plug, is followed by salivary stasis and secondary infection. The most common organism recovered from purulent draining saliva is S aureus. Treatment consists of intravenous antibiotics, such as nafcillin (1 g intravenously every 4–6 hours), and measures to increase salivary flow, including hydration, warm compresses, sialagogues (eg, lemon drops), and massage of the gland. Treatment can usually then be switched to an oral agent based on clinical improvement and microbiologic results to complete a 10-day treatment course. Less severe cases can often be treated with oral antibiotics with similar spectrum. Complete resolution of parotid swelling and pain can take 2–3 weeks. Failure of the process to improve and ultimately resolve on this regimen suggests abscess formation, ductal stricture, stone, or tumor causing obstruction. Ultrasound or CT scan may be helpful in establishing the diagnosis. In the setting of acute illness, a severe and potentially life-threatening form of sialadenitis, sometimes called suppurative sialadenitis, may develop. The causative organism is usually S aureus, but often no pus will drain from Stensen papilla. These patients often do not respond to rehydration and intravenous antibiotics and thus may require operative incision and drainage to resolve the infection. In patients with bilateral parotid sialadenitis, mumps should be considered.

2. SIALOLITHIASIS

Calculus formation is more common in the Wharton duct (draining the submandibular glands) than in the Stensen duct (draining the parotid glands). Clinically, a patient may note postprandial pain and local swelling, often with a history of recurrent acute sialadenitis. Stones in the Wharton duct are usually large and radiopaque, whereas those in the Stensen duct are usually radiolucent and smaller. Those very close to the orifice of the Wharton duct may be palpated manually in the anterior floor of the mouth and removed intraorally by dilating or incising the distal duct. Those more than 1.5–2 cm from the duct are too close to the lingual nerve to be removed safely in this manner. Similarly, dilation of the Stensen duct, located on the buccal surface opposite the second maxillary molar, may relieve distal stricture or allow a small stone to pass. Sialoendoscopy for the management of chronic sialolithiasis is superior to extracorporeal shock-wave lithotripsy and fluoroscopically guided basket retrieval. Repeated episodes of sialadenitis are usually associated with stricture and chronic infection. If the obstruction cannot be safely removed or dilated, excision of the gland may be necessary to relieve recurrent symptoms.