What is the initial management for a submandibular gland fistula?

Initial Management of Submandibular Gland Fistula

The initial management of a submandibular gland fistula should focus on surgical excision of the affected submandibular gland, as this has proven to be the most effective definitive treatment with minimal side effects.

Diagnostic Assessment

Before proceeding with treatment, proper diagnosis is essential:

• Imaging studies: Ultrasound is the preferred initial imaging modality for salivary gland disorders 1
• Bimanual palpation: To assess for possible stones or masses in the gland or duct 1
• Evaluate salivary flow: Check for slow or absent flow from the affected duct 1
• Pain assessment: Note if pain is intermittent and characteristically occurs before eating (typical of salivary stones) 1

Management Algorithm

1. Initial Conservative Management (Short-term)

• Reduce stool liquidity: If the fistula is draining, measures to reduce fluid output include:
  • Antisialagogues (medications that reduce saliva production)
  • Local pressure dressings
  • Avoid sialagogues (substances that stimulate saliva production)

2. Definitive Treatment

• Surgical excision of the submandibular gland: This is the standard and most effective treatment for submandibular gland fistulas 2
  • Success rate is high with minimal complications
  • Resolves the underlying problem permanently
  • Prevents recurrence of the condition

3. Special Considerations

• If sialolithiasis (stones) is present:
  • Complete gland removal is still recommended rather than just stone removal 2
  • In cases without inflammatory disease, lithotripsy could be considered as an alternative 2

Rationale for Surgical Approach

The surgical approach is supported by evidence showing that:

1. Extirpation of the affected submandibular gland has been the standard operation (77% of cases) for nonneoplastic diseases of the submandibular gland 2
2. Side effects from submandibular gland removal are rare 2
3. Conservative management often fails to provide permanent resolution
4. A case report demonstrated successful treatment of a submandibular gland fistula by excision of the gland 3

Important Caveats

• Pre-surgical imaging: Consider sialography through the fistulous opening if conventional sialography through Wharton's duct fails 4
• Rule out associated conditions: Some cases may have underlying issues such as enlarged styloid process that could contribute to the condition 5
• Avoid simple procedures: Simple closure of the fistula without addressing the underlying gland pathology typically leads to recurrence

By following this management approach, the underlying cause of the fistula is eliminated, providing the best chance for complete resolution and preventing recurrence.