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Acute Sialadenitis 

Overview
Acute sialadenitis represents acute inflammation of one or more of the major salivary glands and, while usually medically managed, is a common consult for Otolaryngologists. Sialadenitis has many causes including autoimmune processes, salivary outflow obstruction, granulomatous diseases, and various infections both viral and bacterial. Common symptoms include swelling and tenderness of the involved gland(s) while bacterial sialadenitis commonly presents additionally with fever, leukocytosis, and purulent drainage from the duct of the affected gland (most commonly the parotid). Bacterial or suppurative sialadenitis occurs most commonly in the setting of dehydration, malnutrition, or post-operatively in elderly patients with Staphylococcus aureus and Streptococcus pneumoniae the most common isolated bacteria though most cases are polymicrobial. Viral causes of sialadenitis most commonly include influenza, adenoviruses, and Epstein-Barr virus (EBV). While the incidence of mumps-induced parotitis has decreased dramatically after the implementation of the MMR vaccine, this cause should still be on the differential diagnosis for patients with multiple gland involvement who have not been immunized. Sialoliths may lead to sialadenitis with or without infection by causing salivary duct obstruction. Sialoliths are predominantly found in the submandibular duct due to the longer course of the submandibular duct as well as the higher viscosity of the mucus-rich saliva. Approximately 80% of sialoliths are radiopaque in the submandibular glands, compared to approximately 60% in the parotid glands. Hospitalized patients may suffer from sialadenitis secondary to dehydration. Acute suppurative sialadenitis of the salivary glands can lead to abscess formation which may require drainage and may be difficult to distinguish on palpation alone making imaging with CT or ultrasound necessary. In addition to abscess identification, both CT and ultrasound have a high sensitivity for detection and localization of sialoliths. The physical examination for sialadenitis remains imperative for diagnostic purposes. Importantly, massaging the gland and visualizing saliva pass through the duct lumen is important for both diagnostic purposes and is also therapeutic for bacterial infections or in cases of small sialoliths.

Key Supplies for Sialadenitis Consultation

  • Appropriate PPE including masks, eye protection, gloves, gown

  • Headlight

  • Tongue depressors

  • Culture swabs

  • If drainable abscess, for ultrasound guided FNA

    • Alcohol swab (for skin cleansing)

    • 1% lidocaine with 1:100,000 epinephrine

    • 27-gauge and 18-gauge needle

    • 10cc syringe

    • Ultrasound with ultrasound gel

Management

  • Basic complete medical history with attention to similar previous episodes (suspect sialolithiasis or in pediatric patients juvenile recurrent parotitis), history of risk factors such as autoimmune conditions, immunosuppression, sicca, current medications (many can cause xerostomia), and recent surgeries

  • Full head and neck physical exam with detailed cranial nerve exam (facial nerve paralysis is highly suspicious for underlying parotid malignancy, rarely Heerfordt syndrome with sarcoidosis presents with uveitis, facial paralysis, and parotid swelling), bimanual massage may express purulence from the associated duct as well as palpation of the ducts for sialoliths

    • If purulence is expressed, collect and send for aerobic and anaerobic bacterial cultures

  • Basic laboratory analysis including CBC and BMP

  • If suspecting autoimmune or specific infectious causes can consider targeted labs such as HIV, ESR, CRP, ANCA, RF, Ro/SS-A, La/SS-B, IgG to B. henselae, PPD, etc.

  • Imaging in cases where abscess is suspected or failure to improve after antibiotic and supportive care trial

    • CT with contrast: sensitive and specific, may show sialolithiasis as well as abscess

    • Ultrasound: slightly less sensitive than CT for abscess and sialolithiasis, but good first line imaging in children or in uncomplicated cases

    • Sialogram: contraindicated in acute sialadenitis as can worsen inflammation

  • If inflammation alone without signs of infection

    • Conservative medical management with massage of the gland, warm compress, analgesics, sialogogues (bitter or acidic drops such as lemon or orange juice or candies), and hydration

  • If suspected bacterial sialadenitis (purulence expressed from involved gland, leukocytosis, fever)

    • Conservative management as above except no gland massage in neonates (may lead to septicemia)

    • Initiate empiric beta-lactamase resistant anti-staphylococcal antibiotics, for adults consider clindamycin or amoxicillin-clavulanate; can also consider vancomycin if risk of MSRA (history of prior MRSA, nursing home or hospitalized patient)

  • Response to antibiotics is expected within 2-3 days, consider imaging vs change in antibiotics if unimproved

  • In cases of sialolithiasis:

    • Submandibular duct calculi within 2cm of Wharton’s duct may be removed with manual massage, papillary dilation, or intraoral excision with or without sialodochoplasty

    • Calculi beyond 2cm from duct papilla may require sialendoscopy (stones up to 5mm in size may be mechanically removed with baskets or graspers, >5mm in size typically need additional maneuvers such as laser fragmentation or external lithotripsy followed by endoscopic removal vs surgical gland excision)

    • Parotid duct calculi are generally orally accessible if in segment medial to masseter muscle or proximal to the first branching ductal segment

  • If imaging reveals an abscess, can trial medical therapy or proceed directly to needle aspiration with surgical drainage with drain placement reserved usually for cases without improvement after needle aspiration

  • Patients with systemic symptoms such as fever, malaise, and significantly elevated WBC should be admitted with IV antibiotics

  • Close follow-up with primary care

    • ENT follow-up in cases of recurrent disease for consideration of gland excision or sialendoscopy

    • Rheumatology referral if suspicion of underlying autoimmune condition

 

References

1. Abdel Razek, A., & Mukherji, S. (2017). Imaging of sialadenitis. The neuroradiology journal, 30(3), 205–215. https://doi.org/10.1177/1971400916682752

2. Jackson, N.M., et al (2020). Inflammatory Disorders of the Salivary Glands. In Flint, P.W., et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 1157-1170). Philadelphia, PA: Elsevier.

3. Roland, L. T., Skillington, S. A., & Ogden, M. A. (2017). Sialendoscopy-assisted transfacial removal of parotid sialoliths: A systematic review and meta-analysis. The Laryngoscope, 127(11), 2510–2516. https://doi.org/10.1002/lary.26610 

4. Walvekar, R.R., Bowen, M.A. (2013). Nonneoplastic Disease of the Salivary Glands. In J.J. Johnson, C.A. Rosen. (Eds.), Bailey’s Head and Neck Surgery-Otolaryngology 5e (pp. 702-716). Baltimore, MD: Lippincott Williams & Wilkins.