Sialadenitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

The treatment of sialadenitis will vary depending on the presentation. Acute bacterial sialadenitis may cause significant enough swelling to compromise the airway. Recurrent episodic swelling on eating is less likely to cause airway compromise, and thus the treatment approach is tailored to the presenting signs. In most cases of sialadenitis, symptomatic management with hydration, analgesia (nonsteroidal anti-inflammatory drugs [NSAIDs]), sialogogues (e.g., pilocarpine, cevimeline, chewing gum) to stimulate salivary secretion, and regular, gentle gland massage provides relief. Empirical broad-spectrum antibiotics should be given if infection is present. Subacute necrotising sialadenitis is rare but once confirmed usually resolves between 2 days and 7 days, with few extrapalatal reports lasting longer than 1 week, and does not require further treatment.[42]

Signs of airway compromise

Any patients with signs of airway compromise, such as stridor, use of accessory muscles, nasal flaring, wheeze, or increased respiratory rate, need definitive airway management. Intubation is ideal, but if unsuccessful a surgical airway may be required. Simple manoeuvres such as tilting the head of the bed up may also help but are not definitive. Antibiotics are usually given intravenously for the first 48 hours and then reassessed. Broad-spectrum antibiotics (e.g., ampicillin/sulbactam or clindamycin) are recommended initially pending culture results. Patients with airway compromise may require intravenous hydration in the absence of adequate or safe oral intake. In addition, the patient may be nil by mouth due to possible surgery and may be on intravenous fluids.

Acute bacterial sialadenitis

Inpatient treatment is typically required in any patient with a high fever, with an inability to fully open the mouth (about 40 mm), or with any signs of cranial nerve involvement (cranial nerves VII [facial], IX [glossopharyngeal], and XII [hypoglossal] may be affected by glandular swelling). These patients need careful observation for impending signs of airway compromise, general supportive care, and empirical broad-spectrum antibiotics after appropriate cultures (blood and pus from ductal orifice if present) have been taken. Intravenous antibiotics are usually given for the first 48 hours, then may be continued or switched to an oral alternative if clinically improved and fever has resolved. Beta-lactams or vancomycin are generally considered first-line options. Clindamycin or metronidazole are acceptable alternatives. Cephalosporins and fluoroquinolones have been identified by a systematic review to have particularly favourable pharmacokinetics in saliva.[43]

The European Medicines Agency (EMA) recommends that fluoroquinolone antibiotics are restricted for use in serious, life-threatening bacterial infections only due to their adverse effects (e.g. tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects). Furthermore, they recommend that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Coadministration of a fluoroquinolone and a corticosteroid should be avoided.[44] The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) support these recommendations.[45] The US Food and Drug Administration (FDA) issued a similar safety communication in 2016, restricting the use of fluoroquinolones in acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections.[46] In addition to these restrictions, the FDA has issued warnings about the increased risk of aortic dissection, significant hypoglycaemia, and mental health adverse effects in patients taking fluoroquinolones.[47][48]

If the patient with sialadenitis is apyrexial and cranial nerves are unaffected, then outpatient antibiotic therapy is usually sufficient, but review after 24 hours is recommended. If the condition is worsening, inpatient treatment with intravenous antibiotics may be necessary. Older patients with significant comorbidity may benefit from a short period of inpatient treatment even in the absence of fever, trismus, or cranial nerve involvement.

Other medical treatments include conservative therapies such as hydration, analgesia (NSAIDs), sialogogues to stimulate salivary secretion, and regular, gentle gland massage (e.g. massage from back/top of gland to express saliva towards the front and main duct in to the mouth). Some patients find the topical application of ice cubes provides some relief.

Corticosteroids can be of benefit in reducing soft tissue swelling.[49]

If an abscess is identified, this may require surgical incision and drainage. Surgical intervention should be considered for mature fluctuant abscesses. Location of the abscess dictates the surgical approach. In the submandibular gland, an intra-oral approach, an extra-oral approach, or a combination of approaches may be appropriate. In parotid abscesses, an external approach is usually necessary. Care must be taken to avoid injury to the facial nerve.

Obstructive sialadenitis

In patients with sialolithiasis, surgical intervention to remove the stone from the ductal system may be necessary. Location of the stone dictates the procedure.

Interventional sialendoscopy using a semi-rigid endoscope with irrigation is increasingly used as a first-line therapy for stones in the distal ducts for both the submandibular and parotid glands.[50] One meta-analysis found that sialendoscopy is safe, efficacious, and gland-preserving.[51] This approach has also been described for retrieval of foreign bodies.[52]
Alternatively, if the sialolith is considered accessible to direct removal, then slitting of the salivary duct with cannulation and direct stone removal should be considered. In the submandibular gland, calculi near the opening of Wharton's duct may be treated by cannulation of the duct and removal of the stone via an intra-oral approach. Approximately 40% of submandibular calculi can be managed this way. In a small number of cases, parotid gland calculi near the opening of Stensen's duct may be treated in a similar manner. However, the duct anatomy is such that postoperative stenosis may occur, so this procedure is rarely appropriate. Furthermore, the majority of parotid stones are more distal or within the intraglandular duct system and are not accessible to this approach.
Extracorporeal shock wave lithotripsy (ESWL) under ultrasonic guidance may be used for stones within the intraglandular duct system.[31]

If infection is present, empirical antibiotic therapy should be given after appropriate cultures have been obtained. If a stone is removed then salivary gland massage should be carried out several times a day, combined with sialogogues to stimulate the salivary flow.[31]

Autoimmune sialadenitis

Acute management is with conservative therapies such as hydration, analgesia (NSAIDs), sialogogues to stimulate salivary secretion, and regular, gentle gland massage. Temporary comfort can be obtained by sipping water and other sugar-free liquids. On an ongoing basis, salivary substitutes (artificial saliva) for improving lubrication and hydration of oral tissues may be used. Other alternatives include gels (fluoride gels), saliva-stimulating lozenges or chewing gums, mouthwashes, and prescription-strength toothpastes. Temporary comfort can be obtained by sipping water and other sugar-free liquids. Cholinergic sialogogues may be of benefit to stimulate salivary secretion. Symptoms of autoimmune sialadenitis often improve following specialist medical management of the underlying conditions such as Sjogren syndrome or IgG4-related disease, which may involve corticosteroid and immunosuppression therapy.

Subacute necrotising sialadenitis

Subacute necrotising sialadenitis is rare but once confirmed usually resolves between 2 days and 7 days, with few extrapalatal reports lasting longer than 1 week, and does not require further treatment.[42]

Recurrent sialadenitis of any cause

Following management of the acute sialadenitis, further surgical treatment may be necessary.

Chronic recurrent sialadenitis and long-standing sialolithiasis may lead to atrophy of the salivary gland, which predisposes to further episodes of acute sialadenitis. If the patient is having frequent (>3 times a year) or severe attacks, surgical excision of the affected gland should be considered.

In patients with symptomatic chronic sclerosing sialadenitis, removal of the affected gland is recommended.

Recovery of function of the salivary gland is related to factors such as extent and severity of glandular infection, the diameter and number of the sialolith (if present), position of stones, and the age of the patients.[31]

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