What is the treatment for a submandibular gland abscess?

From the Guidelines

The treatment for a submandibular gland abscess involves prompt surgical drainage combined with antibiotic therapy. Incision and drainage should be performed as soon as possible to remove the purulent material, typically done through an external approach under local or general anesthesia, with careful attention to avoid injury to the marginal mandibular nerve 1.

Key Considerations

• Antibiotics should be started immediately, usually with broad-spectrum coverage such as amoxicillin-clavulanate (875/125 mg twice daily) or clindamycin (300-450 mg four times daily) for 7-10 days if the patient has penicillin allergies 1.
• For severe cases, initial intravenous antibiotics may be necessary, such as ampicillin-sulbactam (3 g every 6 hours) or piperacillin-tazobactam (4.5 g every 6 hours) 1.
• Supportive measures include adequate hydration, pain management with acetaminophen or NSAIDs, and warm compresses to improve blood circulation to the area 1.
• Patients should maintain good oral hygiene and may benefit from saline mouth rinses 1.

Pathogenesis and Complications

• The abscess develops from bacterial infection, often originating from obstructed salivary ducts or spread from adjacent oral infections, with common pathogens including Staphylococcus aureus, Streptococcus species, and anaerobes 1.
• Without proper treatment, the infection can spread to deep neck spaces, potentially causing airway compromise or sepsis 1.

Recent Guidelines

• Recent guidelines from the Infectious Diseases Society of America recommend incision and drainage as the primary treatment for cutaneous abscesses, with antibiotic therapy recommended for abscesses associated with severe or extensive disease, systemic illness, or immunosuppression 1.
• The 2018 WSES/SIS-E consensus conference recommends surgical therapy for abscesses, including incision and drainage, and broad-spectrum antibiotics effective against aerobic and anaerobic organisms 1.

From the Research

Treatment Options for Submandibular Gland Abscess

• The treatment for a submandibular gland abscess depends on the severity of the infection and the patient's overall health 2.
• Patients with cellulitis and small abscesses can respond to antibiotics alone, while surgical drainage is recommended for patients with larger abscesses, Ludwig's angina, or those who do not respond to antibiotic treatment 2.
• In cases where airway management is a concern, awake fibreoptic intubation may be a suitable option for securing the airway before surgical drainage 3.
• Sialendoscopy is also a viable treatment option for submandibular gland abscesses, particularly in patients with a history of radiotherapy or other comorbidities that make traditional surgical approaches risky 4.
• Intra-oral drainage is a minimally invasive technique that has been shown to be effective in managing isolated submandibular space abscesses, with benefits including reduced operative time and improved cosmetic outcomes 5.

Airway Management Considerations

• Airway obstruction is a potential complication of submandibular gland abscesses, and securing the airway is a critical step in treatment 2, 3, 6.
• Awake fibreoptic intubation and tracheostomy are options for airway management in patients with difficult airways due to submandibular abscesses 3, 6.

Surgical Approaches

• Trans-cervical surgical drainage is a traditional approach for managing submandibular gland abscesses, but it may be associated with longer operative times and increased risk of complications 5.
• Intra-oral drainage is a minimally invasive alternative that can reduce operative time and improve cosmetic outcomes, but it may not be suitable for all patients 5.