From the Guidelines
For a left submandibular swelling that hasn't responded to Augmentin and conservative measures for sialadenitis, the next appropriate step is to refer the patient to oral/maxillofacial surgeons for further management, as indicated by the presence of potential salivary stones or other salivary gland disorders 1. The patient's symptoms of left submandibular swelling refractory to treatment with Augmentin and conservative measures for sialadenitis suggest the need for a more detailed evaluation. Key considerations in the workup include:
- Advanced imaging, such as ultrasound, to visualize potential stones, ductal dilation, or abscesses in the submandibular gland, as these are common causes of pain and swelling in this area 1.
- Laboratory tests, including complete blood count and inflammatory markers, to assess for signs of infection or inflammation.
- Consultation with specialists, such as oral/maxillofacial surgeons, who can provide further guidance on management, including potential surgical intervention. Given the potential for salivary stones or other salivary gland disorders, as discussed in the British Journal of Anaesthesia study 1, referral to a specialist is crucial for appropriate management and to prevent potential complications. The use of broader-spectrum antibiotics, such as clindamycin or amoxicillin-clavulanate, may also be considered if there is ongoing suspicion of infection, but this should be guided by specialist advice. Ultimately, the goal is to identify the underlying cause of the swelling and develop an effective treatment plan to improve the patient's quality of life and reduce morbidity and mortality.
From the Research
Next Steps for Left Submandibular Swelling
The patient's left submandibular swelling that is refractory to treatment with Augmentin and conservative measures for sialadenitis requires further evaluation.
- Imaging studies can be helpful in detecting the underlying cause of the swelling, such as abscesses, stones, or ductal dilation 2, 3, 4.
- Ultrasonography (US) and computed tomography (CT) are commonly used imaging modalities for evaluating sialadenitis, with CT having a higher sensitivity and specificity than US 3.
- Surgeon-performed ultrasound (SP-US) can also be useful in predicting sialendoscopic findings and outcomes in patients with chronic obstructive sialadenitis 5.
- The choice of imaging modality depends on the clinical presentation and the suspected underlying cause of the swelling, as well as considerations of reliability, side effects, accessibility, and cost 4.
- Red flags such as suspected abscess formation, signs of respiratory obstruction, facial paresis, and fixation of a mass to underlying tissue should prompt urgent referral to head and neck surgery or a visit to the emergency department 6.
Possible Diagnostic Steps
- Perform imaging studies such as US or CT to evaluate the left submandibular gland and detect any underlying abnormalities 2, 3, 4.
- Consider SP-US to predict sialendoscopic findings and outcomes in patients with chronic obstructive sialadenitis 5.
- Review the patient's history and physical examination to direct management and identify any red flags that require urgent attention 6.