Investigation and Management of Submandibular Sialadenitis
Conservative management with warm compresses, massage of the salivary glands, sialagogues, and adequate hydration is the first-line treatment for submandibular sialadenitis, while monitoring the airway closely for any signs of compromise. 1
Diagnostic Approach
Initial Assessment
- Evaluate for swelling, pain, and tenderness over the submandibular gland
- Check for fever and difficulty opening the mouth
- Assess for signs of airway compromise (respiratory distress)
- Look for neurological symptoms such as brachial plexopathy, facial nerve palsy, or Horner syndrome 1
Imaging Studies
- Plain radiographs as initial screening for radiopaque sialoliths
- Ultrasound: non-invasive method to detect stones, ductal dilation, and gland enlargement
- CT scan: for detailed evaluation of gland architecture, abscesses, and calcifications
- Sialoendoscopy: both diagnostic and therapeutic, especially for radiolucent stones, mucus plugs, or stenosis 2, 3
Management Algorithm
1. Conservative Management (First-Line)
- Warm compresses to the affected area
- Gentle massage of the submandibular gland (use caution in elderly patients or those with carotid stenosis) 4, 1
- Sialagogues (substances that promote salivary flow)
- Aggressive hydration (oral or intravenous) 1
- Oral hygiene measures 5
2. Medical Management
- Antistaphylococcal antibiotics while awaiting culture results 5
- Consider corticosteroids if significant inflammation is present 4
3. Airway Management
- Maintain low threshold for intubation if signs of airway compromise develop 1
- Close monitoring for respiratory distress is crucial 1
- In severe cases with airway compromise, emergency intubation or tracheostomy may be necessary 4
4. Interventional Management
For obstructive sialadenitis:
- Interventional sialoendoscopy for removal of stones <5mm, with success rates of approximately 81% 3
- Surgical removal for larger stones (>5mm) or those located in inaccessible areas, with success rates around 87% 3
- Consider submandibular gland excision for recurrent or chronic cases unresponsive to other treatments
Follow-up and Monitoring
- Schedule follow-up in 4-6 weeks to assess resolution 1
- Instruct patients to return immediately if experiencing:
- Difficulty breathing
- Worsening swallowing
- Increased pain or swelling in the neck 1
Potential Complications
- Airway compromise requiring emergency intervention
- Neurological complications (brachial plexopathy, facial nerve palsy, Horner syndrome)
- Progression to chronic sialadenitis
- Abscess formation 4, 1
Special Considerations
- Foreign bodies must be thoroughly explored as they can cause chronic sialadenitis 6
- In post-surgical cases (especially after skull base surgery), sialadenitis typically presents as submandibular swelling contralateral to the surgical site, beginning within 4 hours following surgical closure 4
- Preventive measures for post-surgical sialadenitis include ergonomic positioning to avoid extreme flexion/rotation of the head and neck 4