Treatment of Sialadenitis
The treatment of sialadenitis should include antibiotics that achieve high concentrations in saliva, with cephalosporins and fluoroquinolones being the first-line choices due to their superior pharmacokinetics in saliva and coverage of common causative bacteria. 1
Etiology and Diagnosis
Sialadenitis is inflammation of the salivary glands that can be acute, chronic, or recurrent. The parotid gland is most commonly affected, followed by the submandibular gland 2, 3.
Common causes include:
- Bacterial infection (most frequently Staphylococcus aureus)
- Viral infection
- Ductal obstruction (stones, strictures)
- Dehydration
- Medication-induced (xerogenic drugs)
- Autoimmune conditions
Treatment Algorithm
1. Antimicrobial Therapy
First-line antibiotics:
- Intravenous cephalosporins - highest concentration in saliva 1
- Oral cephalosporins - good salivary penetration 1
- Fluoroquinolones - excellent salivary penetration 1
Antibiotics to avoid:
- Phenoxymethylpenicillin and tetracyclines - inadequate salivary concentrations 1
Duration:
- 7-10 days for uncomplicated cases
- 14 days for severe or complicated cases
2. Supportive Measures
- Hydration - crucial to increase salivary flow 2
- Warm compresses - to reduce pain and swelling
- Analgesics - for pain management
- Salivary stimulants - to increase flow and clear ducts
- Sialagogues - such as lemon drops or sugar-free candies to stimulate saliva
3. Management of Specific Complications
Abscess Formation:
- Surgical drainage if fluctuant collection identified
- Consider ultrasound guidance for drainage
Ductal Obstruction:
- Sialendoscopy - both diagnostic and therapeutic for removing stones or relieving strictures 4
- Massage of the gland toward the duct orifice
4. Special Considerations
Recurrent Sialadenitis:
- Consider long-term, low-dose antibiotic prophylaxis in selected cases
- Evaluate for underlying causes (stones, strictures, autoimmune disorders)
Medication-Induced Sialadenitis:
- Review and modify medications that cause xerostomia when possible 2
Pediatric Sialadenitis:
- Sialendoscopy has emerged as the leading diagnostic and therapeutic intervention 4
- Consider viral etiology more commonly than in adults
Prevention of Recurrence
- Maintain adequate hydration
- Regular gland massage
- Good oral hygiene
- Treat underlying conditions (e.g., Sjögren's syndrome)
When to Consider Specialist Referral
- Failure to respond to initial therapy after 48-72 hours
- Recurrent episodes
- Suspicion of abscess formation
- Need for sialendoscopy or other interventional procedures
- Concern for malignancy
Pitfalls and Caveats
- Failure to identify and address underlying causes can lead to recurrence
- Inadequate antibiotic selection (choosing antibiotics with poor salivary penetration)
- Missing complications such as abscess formation
- Overlooking systemic conditions that may present with sialadenitis (e.g., IgG4-related disease, Sjögren's syndrome)
- Delay in surgical intervention when indicated can lead to increased morbidity
By following this evidence-based approach to the management of sialadenitis, clinicians can effectively treat the condition while minimizing complications and recurrence.