What is the best approach for managing bilateral submandibular abscesses?

Management of Bilateral Submandibular Abscess

Bilateral submandibular abscesses require prompt surgical drainage combined with broad-spectrum antibiotic therapy to prevent life-threatening complications such as airway compromise and systemic infection. 1

Diagnosis

• Clinical presentation: Pain, swelling in submandibular region, trismus (limited mouth opening), fever, and possible systemic symptoms
• Physical examination: Look for bilateral fluctuant masses, erythema, warmth, and assess for signs of systemic infection
• Imaging:
  • Intraoral periapical X-ray if dental origin is suspected
  • CT with IV contrast is preferred for deep or complex infections to determine extent and identify potential complications 2
  • Ultrasound can help distinguish cellulitis from abscess

Treatment Algorithm

1. Airway Management (Priority)

• Assess for signs of airway compromise (stridor, respiratory distress)
• For cases with significant airway concerns, consider:
  • Awake fiberoptic intubation in cases of trismus or distorted anatomy 3
  • Tracheostomy may be necessary in severe cases

2. Surgical Intervention

• Immediate surgical drainage is the cornerstone of treatment 1
• Approach options:
  • External cervical approach: Traditional method with skin incision in submandibular area
  • Intraoral approach: May be considered in selected cases for better cosmetic outcome 4
• Technique:
  • Multiple counter incisions rather than a single long incision to prevent step-off deformity and delay in wound healing 1
  • Identify and drain all loculations
  • Consider placing drains for continued drainage

3. Antimicrobial Therapy

• Empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria 1
• Recommended regimens:
  • Amoxicillin-clavulanic acid (875/125 mg PO every 12 hours) 2
  • For penicillin allergy: Clindamycin or combination of ciprofloxacin plus metronidazole 2
  • For severe infections requiring IV therapy: Vancomycin (30-60 mg/kg/day in 2-4 divided doses) plus coverage for Gram-negatives and anaerobes 2
• Consider MRSA coverage if risk factors present or high local prevalence 1, 5
• Duration: 5-7 days, with reassessment after 48-72 hours 2

4. Source Control

• Identify and address the source of infection:
  • Dental: Extraction or root canal therapy if odontogenic origin
  • Salivary gland: Treat underlying sialadenitis if present

5. Supportive Care

• IV fluids for hydration
• Pain management
• Nutritional support
• Close monitoring for complications

Special Considerations

Risk Factors for Complications

• Anterior visceral space involvement (highest risk factor) 6
• Diabetes mellitus (significantly increases risk) 6
• Other comorbidities
• Bilateral submandibular swelling 6

Potential Complications

• Airway obstruction
• Spread to deep neck spaces
• Ludwig's angina
• Mediastinitis
• Septicemia
• Cavernous sinus thrombosis

Follow-up

• Daily clinical assessment during hospitalization
• Reassess need for continued drainage
• Consider repeat imaging if clinical improvement is not observed
• Transition to oral antibiotics when clinically improved
• Outpatient follow-up within 1-2 weeks after discharge

Pitfalls to Avoid

• Delayed surgical intervention: Early drainage is crucial, especially in diabetic patients or those with comorbidities 6
• Inadequate drainage: Ensure all loculations are drained
• Overlooking airway management: Maintain high vigilance for potential airway compromise
• Insufficient antibiotic coverage: Ensure coverage for mixed aerobic and anaerobic flora
• Missing the underlying cause: Identify and address the source of infection to prevent recurrence

For patients with bilateral submandibular abscesses, a high index of suspicion for potential life-threatening complications should be maintained, particularly in those with comorbidities such as diabetes mellitus 6.