What is the initial management for an infected salivary gland?

Initial Management of Infected Salivary Gland (Sialadenitis)

Begin treatment immediately with conservative medical therapy including hydration, gland massage, warm compresses, sialagogues (lemon drops or sour candies), and empiric antibiotics targeting Staphylococcus aureus—the most common bacterial pathogen. 1

Immediate Conservative Measures

• Hydration: Aggressive oral or IV fluid resuscitation to optimize salivary flow and reduce stasis 2, 1
• Gland massage: Manual massage of the affected gland from posterior to anterior to promote drainage 2, 3
• Warm compresses: Applied to the affected gland to reduce inflammation and promote drainage 2, 4
• Sialagogues: Lemon drops, sour candies, or other agents to stimulate salivary flow 1, 4
• Oral hygiene: Maintain meticulous oral care to reduce bacterial load 1

Antibiotic Selection

First-line antibiotics should be cephalosporins or fluoroquinolones, as these achieve the highest bactericidal concentrations in saliva and cover the full spectrum of bacteria implicated in sialadenitis (S. aureus, Viridans streptococci, gram-negatives, and anaerobes). 5

Specific Antibiotic Recommendations:

• Intravenous cephalosporins: Achieve the highest salivary concentrations and exceed minimal inhibitory concentrations for all relevant pathogens 5
• Oral cephalosporins or fluoroquinolones: Appropriate for outpatient management with favorable pharmacokinetics in saliva 5
• Avoid phenoxymethylpenicillin and tetracyclines: These do not achieve bactericidal levels in saliva 5

Clinical Pitfalls to Avoid

• Do not use penicillins or tetracyclines as first-line agents, as they fail to reach therapeutic concentrations in salivary tissue 5
• Do not delay antibiotics while awaiting culture results in acute bacterial sialadenitis 1
• Recognize that S. aureus is the most common bacterial cause, not oral flora 1

When Conservative Management Fails

If symptoms persist or worsen after 48-72 hours of conservative therapy, or if there is inadequate response (occurs in up to 40% of patients), proceed to imaging and consider interventional options. 4

Escalation Options:

• Ultrasound or CT imaging: To identify abscess formation, sialolithiasis, or ductal stenosis requiring intervention 1
• Sialendoscopy: Minimally invasive diagnostic and therapeutic option for gland-sparing management of obstructive and inflammatory disorders 4
• Surgical drainage: Reserved for frank abscess formation unresponsive to medical management 2, 3
• Gland excision: Only for recurrent chronic infection refractory to all other measures 3

Special Considerations

• Viral etiologies (mumps, juvenile recurrent parotitis in children): Supportive care without antibiotics 1
• Medication review: Identify and adjust anticholinergic or diuretic medications that reduce salivary flow 1
• Underlying systemic disease: Address predisposing factors such as dehydration, malnutrition, or chronic illness 1