What is the best course of treatment for unilateral swelling below the mandible with associated pain and tongue pain?

Unilateral Submandibular Swelling with Pain and Tongue Pain

This presentation most likely represents an acute infectious process—either sialadenitis (submandibular gland infection), dental abscess with extension, or less commonly a tongue abscess—and requires immediate evaluation for airway compromise, empiric broad-spectrum antibiotics covering oral anaerobes, and urgent imaging to guide definitive management.

Immediate Assessment Priorities

Airway Evaluation

• Assess for signs of airway compromise immediately: difficulty breathing, drooling, stridor, or inability to swallow secretions 1
• Tongue abscesses and deep space infections can rapidly progress to airway obstruction and require emergency surgical intervention 1
• If airway compromise is present or imminent, secure the airway and transfer to the operating room urgently 1

Physical Examination Findings to Document

• Examine for fluctuance in the submandibular or tongue swelling, which indicates abscess formation requiring drainage 1
• Palpate for lymphadenopathy in the neck, which may indicate infectious or malignant processes 2
• Assess tongue mobility and appearance: fixed tongue due to pain, erythematous borders, or visible lesions suggest abscess or other pathology 1, 2
• Evaluate for trismus (difficulty opening mouth), fever, and ability to swallow 1

Differential Diagnosis by Likelihood

Most Likely: Acute Infectious Causes

• Submandibular sialadenitis: bacterial infection of the submandibular gland, typically unilateral with pain and swelling below the angle of mandible 3
• Dental abscess with extension: odontogenic infection from decayed teeth can cause submandibular swelling and referred tongue pain 4
• Tongue abscess: rare but serious, presents with tongue swelling, severe pain, pain radiating to ears, fever, and dysphagia 1
• Ludwig's angina: bilateral but can start unilaterally, involves floor of mouth with potential for rapid airway compromise 1

Less Common but Important

• Submandibular lymphadenitis: from dental, tonsillar, or upper respiratory infections 3
• Submandibular gland stone (sialolithiasis): causes pain with eating, but typically less acute presentation 3

Red Flags Requiring Urgent Specialist Referral

• Malignancy: unilateral pain with induration, ulceration, or non-healing lesions, especially in patients >40 years with tobacco/alcohol use 2, 3
• Osteonecrosis: in patients with history of head/neck radiation or bisphosphonate use, presents with jaw swelling and pain 5

Diagnostic Workup

Laboratory Studies

• Complete blood count with differential to assess for leukocytosis indicating bacterial infection 1
• Blood cultures if patient appears septic or has high fever 4
• ESR/CRP if chronic osteomyelitis is suspected 6

Imaging

• CT scan with IV contrast of the neck and floor of mouth is the gold standard to identify abscess, define extent, and guide surgical planning 1
• Ultrasound can identify submandibular gland stones or abscesses as a bedside alternative 3
• Panoramic dental radiograph to identify odontogenic source 4

Treatment Algorithm

Initial Management (All Patients)

• Start empiric broad-spectrum antibiotics immediately covering gram-positive, gram-negative, and anaerobic organisms 1
  • Recommended regimen: ampicillin-sulbactam or clindamycin plus a fluoroquinolone 1
  • Alternative: piperacillin-tazobactam for severe infections 1
• Ensure adequate hydration and pain control 1
• NPO status if surgical intervention anticipated 1

If Abscess Identified

• Incision and drainage under general anesthesia is definitive treatment 1
• Irrigate pocket with normal saline and 2% hydrogen peroxide 1
• Send purulent material for gram stain, culture, and sensitivities 1, 4
• Continue IV antibiotics for 48-72 hours post-drainage, then transition to oral therapy 1

If Dental Source Identified

• Extract offending tooth after acute infection controlled 4
• Chlorhexidine mouth rinses to reduce bacterial load 4, 7
• Dental referral for definitive management 4

If Osteonecrosis Suspected (History of Radiation/Bisphosphonates)

• Conservative management initially: broad-spectrum antibiotics and daily saline or chlorhexidine irrigations 5
• Refer to oral surgeon, maxillofacial surgeon, or head/neck surgeon for evaluation 5
• Avoid aggressive debridement unless conservative measures fail 5

If Malignancy Suspected

• Biopsy is mandatory for any suspicious lesion, particularly with risk factors 2
• Urgent referral to otolaryngology or oral surgery 2

Common Pitfalls to Avoid

• Do not dismiss as simple sialadenitis without imaging if patient has systemic symptoms, severe pain, or tongue involvement—deep space infections require surgical drainage 1
• Do not delay antibiotics while awaiting imaging or specialist consultation in acutely ill patients 1
• Do not assume psychogenic etiology for tongue pain without thorough evaluation and exclusion of organic pathology 2
• Do not overlook malignancy in patients >40 years with unilateral symptoms, especially with tobacco/alcohol use 2, 3
• Do not perform dental extractions during acute infection phase without adequate antibiotic coverage—risk of spreading infection 4

Disposition

• Admit for IV antibiotics and observation if patient has systemic symptoms, airway concerns, or abscess requiring drainage 1
• Discharge with oral antibiotics only if mild infection, no abscess, reliable follow-up, and patient can tolerate oral intake 1
• Follow-up within 24-48 hours to reassess response to antibiotics 1