Treatment of Sialadenitis
The treatment of acute sialadenitis centers on conservative measures including hydration, warm compresses, gland massage, and sialogogues to promote salivary flow, with antibiotics reserved for bacterial infections—specifically cephalosporins or fluoroquinolones which achieve superior salivary concentrations. 1
Immediate Assessment and Airway Management
In post-surgical sialadenitis (particularly after skull base surgery), airway stabilization is the absolute priority. 2
- Maintain a very low threshold for reintubation if acute sialadenitis develops postoperatively, as 13 of 15 patients in systematic reviews required deferred extubation, early reintubation, or emergent tracheostomy 2, 3
- Monitor for submandibular swelling, which typically presents within 4 hours following surgical closure 4
- Watch for potential neurologic complications from inflammatory compression including brachial plexopathy, facial nerve palsy, and Horner syndrome 2, 4
Conservative Medical Management (First-Line)
These measures should be initiated immediately for all cases of sialadenitis:
- Apply warm compresses to the affected gland to promote salivary excretion 2, 3
- Perform gentle gland massage to facilitate drainage (use caution in elderly patients or those with suspected carotid stenosis) 2, 3
- Administer sialogogues (lemon drops, sour candies, or pharmacologic agents) to stimulate salivary flow and reduce stasis 2, 3
- Provide aggressive intravenous hydration, particularly critical for patients with compromised oral intake or airway management issues 2, 3
- Restore enteral nutrition as soon as clinically advisable 2
Antibiotic Therapy
Antibiotics are indicated when bacterial infection is suspected, but are NOT routinely necessary for all sialadenitis cases.
Antibiotic Selection Based on Pharmacokinetics:
Cephalosporins (first choice): Achieve the highest concentrations in saliva and exceed minimal inhibitory concentrations for common pathogens (Staphylococcus aureus, Viridans streptococci, gram-negative bacteria, anaerobes) 1
- Intravenous cephalosporins achieve superior salivary levels compared to oral formulations 1
Fluoroquinolones (second choice): Display excellent pharmacokinetics in saliva and provide broad spectrum coverage 1
Avoid phenoxymethylpenicillin and tetracyclines: These do not achieve bactericidal levels in saliva 1
When to Use Antibiotics:
- Clinical suspicion for bacterial superinfection (fever, purulent discharge, systemic signs) 2
- In post-surgical cases, antibiotics do not appear to have a role beyond standard perioperative prophylaxis, though reported practices vary 2
- Intraductal instillation of penicillin or saline has shown success in chronic sialadenitis (symptom-free rates of 80-100% in long-term follow-up) 5
Adjunctive Therapies
- Corticosteroids: Consider for significant airway swelling (used in 47.4% of post-surgical cases) 2, 3
- Anticoagulation: Only if venous thrombosis develops secondary to compression 2
- Surgical intervention: Rarely needed; neck fasciotomy reported in severe cases with compartment syndrome 2
Special Considerations by Etiology
Obstructive Sialadenitis:
- Address mechanical causes including sialoliths, ductal strictures, or compression 4, 6
- Sialendoscopy has emerged as the leading diagnostic and therapeutic intervention, particularly in pediatric cases 7
Chronic/Recurrent Sialadenitis:
- Intraductal instillation of penicillin or saline is highly effective (symptom-free for 1-15 years in follow-up studies) 5
- Sialendoscopy is safe and effective as a gland-preserving treatment 7
Post-Radiation or Radioiodine Sialadenitis:
- Prevention with sialogogues is recommended during treatment 8
- Conservative management with sialogogues and local massage 8
- Sialendoscopy when obstructive symptoms develop 8
Common Pitfalls to Avoid
- Do not delay airway management in post-surgical cases—the risk of life-threatening airway compromise is extremely high 2, 3
- Do not use massage indiscriminately in elderly patients or those with carotid stenosis 2, 3
- Do not assume all sialadenitis requires antibiotics—many cases are obstructive or inflammatory rather than infectious 2
- Do not use antibiotics with poor salivary penetration (phenoxymethylpenicillin, tetracyclines) when bacterial infection is present 1