What is the initial management for a patient with submandibular gland pain, diagnosed with salivary stones and possible infection?

Management of Submandibular Gland Pain with Salivary Stones and Infection

The initial management for submandibular gland pain due to salivary stones with possible infection should include antibiotics, analgesics, hydration, and referral to oral/maxillofacial surgeons for definitive stone removal. 1

Initial Assessment and Management

Diagnostic Confirmation

• Bimanual palpation of the submandibular gland to confirm stone presence
• Check for salivary flow from the duct (will be slow or absent if stone is present)
• Ultrasound is the preferred imaging modality for salivary gland stones 1

Immediate Management Steps

1. Antimicrobial Therapy

   • Initiate antibiotics if infection is suspected (signs include fever, erythema, purulent discharge)
   • Choose antibiotics with coverage for oral flora

2. Pain Management

   • Oral analgesics (NSAIDs or acetaminophen)
   • Topical analgesics may provide temporary relief
   • For severe pain, consider benzydamine hydrochloride oral rinse 1

3. Hydration and Salivary Stimulation

   • Encourage increased fluid intake
   • Use gustatory stimulants (sugar-free acidic candies, lozenges) 1
   • Mechanical stimulation with sugar-free chewing gum may help 1

4. Local Measures

   • Warm compresses to the affected area
   • Gentle massage of the gland (if not acutely infected)
   • Sialagogues to increase salivary flow and potentially help move small stones

Definitive Treatment

The definitive treatment depends on the size and location of the stone:

For Small, Accessible Stones

• Conservative management with gland massage and sialagogues may be sufficient 2, 3
• Basket retrieval techniques may be attempted for stones in the distal duct

For Larger or Hilar/Parenchymal Stones

• Surgical removal is typically required 1, 3
• Referral to oral/maxillofacial surgeons is indicated 1
• Surgical options include:
  • Transoral removal of the stone (preserves gland function) 4
  • Sialadenectomy (complete gland removal) for recurrent or multiple stones

Complications to Monitor

• Chronic sialadenitis if left untreated 5
• Glandular atrophy 5
• Sicca syndrome (dry mouth) as a potential long-term complication 1

Follow-up Care

• Clinical and ultrasonographic follow-up for 3 months after stone removal 4
• Monitor for symptom relief and absence of stones
• Assess for normal salivary flow

Important Considerations

• Submandibular gland is the most common location for salivary stones (84% of cases) 3
• The majority of submandibular stones (90%) are located in Wharton's duct 3
• If untreated, stones can lead to chronic inflammation and irreversible gland damage
• Preservation of gland function should be prioritized when possible to maintain quality of life and prevent complications of dry mouth

By following this structured approach to management, patients with submandibular gland pain due to salivary stones and infection can achieve prompt symptom relief and preservation of gland function, minimizing long-term morbidity.