Sialadenitis

Airway compromise may be due to acute glandular swelling. The establishment of an open airway is essential for any patient with worsening airway compromise. Surgical airway may be required if intubation is unsuccessful. Elevating the head of the bed may help temporarily, but careful monitoring is crucial.

Treatment recommended for ALL patients in selected patient group

Intravenous antibiotics are recommended for the first 48 hours, then consider an oral alternative if clinically improving.

If a patient is intolerant of beta-lactam antibiotics or vancomycin, clindamycin or metronidazole are alternative options. Cephalosporins and fluoroquinolones (e.g., moxifloxacin) have been identified by a systematic review to have particularly favourable pharmacokinetics in saliva.[43]Troeltzsch M, Pache C, Probst FA, et al. Antibiotic concentrations in saliva: a systematic review of the literature, with clinical implications for the treatment of sialadenitis. J Oral Maxillofac Surg. 2014;72:67-75. http://www.joms.org/article/S0278-2391(13)00820-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/23992785?tool=bestpractice.com Fluoroquinolones should be used only when it is considered inappropriate to use other antibacterial agents that are commonly recommended due to the risk of serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[44]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. November 2018 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products [45]Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects. March 2019 [internet publication]. https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-new-restrictions-and-precautions-for-use-due-to-very-rare-reports-of-disabling-and-potentially-long-lasting-or-irreversible-side-effects [46]Food and Drug Administration. FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. December 2016 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-advises-restricting-fluoroquinolone-antibiotic-use-certain

Treatment recommended for ALL patients in selected patient group

Patients with airway compromise will require intravenous replacement therapy to meet their daily requirements and to account for any extra fluid losses due to pyrexia. Normal saline is usually the first choice, but fluid therapy should be tailored to the individual patient and departmental guidelines on the use of colloid and crystalloid fluids.

Empirical broad-spectrum antibiotic therapy should be started pending sensitivity results based on cultures. If a patient is intolerant of beta-lactam antibiotics or vancomycin, clindamycin or metronidazole are alternative options. Cephalosporins and fluoroquinolones (e.g., moxifloxacin) have been identified by a systematic review to have particularly favourable pharmacokinetics in saliva.[43]Troeltzsch M, Pache C, Probst FA, et al. Antibiotic concentrations in saliva: a systematic review of the literature, with clinical implications for the treatment of sialadenitis. J Oral Maxillofac Surg. 2014;72:67-75. http://www.joms.org/article/S0278-2391(13)00820-3/fulltext http://www.ncbi.nlm.nih.gov/pubmed/23992785?tool=bestpractice.com Fluoroquinolones should be used only when it is considered inappropriate to use other antibacterial agents that are commonly recommended due to the risk of serious, disabling, and potentially irreversible adverse effects, including tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.[44]European Medicines Agency. Quinolone- and fluoroquinolone-containing medicinal products. November 2018 [internet publication]. https://www.ema.europa.eu/en/medicines/human/referrals/quinolone-fluoroquinolone-containing-medicinal-products [45]Medicines and Healthcare products Regulatory Agency. Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects. March 2019 [internet publication]. https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-new-restrictions-and-precautions-for-use-due-to-very-rare-reports-of-disabling-and-potentially-long-lasting-or-irreversible-side-effects [46]Food and Drug Administration. FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. December 2016 [internet publication]. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-advises-restricting-fluoroquinolone-antibiotic-use-certain

Either intravenous or oral antibiotics may be used. In significant infection (fever, trismus, or cranial nerve involvement) 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. If the patient is apyrexial and cranial nerves are unaffected, then outpatient antibiotic therapy is usually sufficient, but review at 24 hours is recommended.

Patients with fever, trismus, or cranial nerve involvement will need careful observation for impending airway compromise. All patients treated on an outpatient basis should be re-examined within 24 hours for worsening symptoms or signs.

Treatment course: 7 days total.

Treatment recommended for ALL patients in selected patient group

Acute medical treatment for bacterial sialadenitis includes conservative therapies such as hydration, analgesia, sialogogues (e.g. pilocarpine, cevimeline) to stimulate salivary secretion, and regular, gentle gland massage. Some patients find that the topical application of ice cubes provides some relief. Temporary comfort can be obtained by sipping water and other sugar-free liquids.

Additional treatment recommended for SOME patients in selected patient group

If soft tissue swelling is significant and there are no contraindications, corticosteroid therapy may be given in addition to antibiotics and analgesia.[49]Marchal F, Bradley PJ. Treatment of infections and inflammatory conditions. In: Management of infections of the salivary glands. Berlin, Germany: Springer Berlin Heidelberg. 2007:169-176.

Additional treatment recommended for SOME patients in selected patient group

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.

Acute medical treatment for symptomatic autoimmune sialadenitis includes conservative therapies such as hydration, analgesia, sialogogues (e.g. pilocarpine, cevimeline) to stimulate salivary secretion, and regular, gentle gland massage.

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.

Treatment recommended for ALL patients in selected patient group

Symptoms of autoimmune sialadenitis often improve following medical management of the underlying condition (such as Sjogren syndrome or IgG4-related disease).

Subacute necrotising sialadenitis is rare but once confirmed usually resolves within 2 to 3 weeks and does not require further treatment.

Chronic recurrent sialadenitis and long-standing sialolithiasis may lead to salivary gland atrophy, which predisposes to further episodes of an acute sialadenitis.

In patients with 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]Kraaij S, Karagozoglu KH, Forouzanfar T, et al. Salivary stones: symptoms, aetiology, biochemical composition and treatment. Br Dent J. 2014 Dec 5;217(11):E23. https://www.doi.org/10.1038/sj.bdj.2014.1054 http://www.ncbi.nlm.nih.gov/pubmed/25476659?tool=bestpractice.com