Sialadenitis

Sialadenitis is inflammation of a salivary gland, most often the parotid or submandibular gland. Acute bacterial disease is caused by Staphylococcus aureus, streptococci and oral anaerobes ascending the duct when salivary flow falls.

• Dehydration, ductal stones, poor oral hygiene, malnutrition, recent surgery and anticholinergic drugs reduce flow.
• Viral causes include mumps, HIV, Epstein Barr virus and influenza; autoimmune causes include Sjogren syndrome and IgG4 related disease.
• Elderly and debilitated patients and neonates are most at risk.

Painful, tender swelling of the gland, redness of overlying skin, fever, bad taste, and pus at the duct opening on massaging the gland.

• Pain and swelling often worsen with meals when a stone or stricture is present.
• Differential diagnosis: mumps, salivary stone, abscess, tumour, lymphadenitis, dental abscess, Sjogren syndrome, sarcoidosis, HIV related cystic disease, Ludwig angina, tuberculosis.
• Complications: abscess, airway compromise, facial nerve palsy, sepsis, chronic sialadenitis, gland fibrosis.

Diagnosis is clinical with ultrasound.

• Ultrasound for stones, abscess and ductal dilation; CT with contrast for deep infection or suspected tumour.
• Swab of expressed pus for culture; full blood count, CRP, glucose, urea and electrolytes.
• Mumps IgM or PCR, HIV test, and Sjogren antibodies in recurrent or bilateral disease; avoid sialography in acute infection.

Rehydrate, encourage salivary flow and give antibiotics.

• Supportive: oral or intravenous fluids, warm compresses, gentle gland massage toward the duct, sucking sour sweets or lemon, oral hygiene with chlorhexidine 0.2 percent mouthwash, stop anticholinergic drugs, analgesia.
• Pharmacological: flucloxacillin 500 mg four times daily for 7 to 10 days (children 12.5 to 25 mg/kg four times daily); or amoxicillin clavulanate 625 mg three times daily for 7 to 10 days; clindamycin 300 mg four times daily in penicillin allergy. Severe infection: flucloxacillin 1 to 2 g IV every 6 hours with metronidazole 500 mg IV every 8 hours. Paracetamol 1 g every 6 hours and ibuprofen 400 mg every 8 hours.
• Procedures: ultrasound guided aspiration or incision and drainage of abscess; sialendoscopy to clear stones; gland excision for chronic recurrent disease.
• Special groups: neonates, admit for IV antibiotics; pregnancy, amoxicillin clavulanate and hydration; mumps, supportive care and isolation for 5 days; HIV, treat the infection and consider antiretroviral therapy.
• Red flags: airway swelling, trismus, floor of mouth swelling, facial weakness, hard mass, fever with rigors, failure to improve in 48 hours.
• Follow-up: review in 48 hours; ultrasound and ENT referral if recurrent.