What is the recommended inpatient management for a hypertensive menopausal woman with known submandibular sialolithiasis presenting with acute painful swelling, progressive dysphagia, and failure of outpatient co‑amoxiclav and celecoxib therapy?

Inpatient Management Plan for Acute Obstructive Sialadenitis with Sialolithiasis

This patient requires immediate hospital admission with aggressive conservative medical management, close airway monitoring, and IV antibiotics given the failure of outpatient therapy and progressive dysphagia.

Immediate Airway Assessment and Monitoring

• Establish continuous airway monitoring as the absolute first priority, as acute sialadenitis can cause life-threatening airway compromise within 4 hours of symptom onset 1, 2
• Maintain an extremely low threshold for emergent intubation or tracheostomy if facial/neck swelling progresses, as 84% of acute sialadenitis cases with significant swelling required emergent airway intervention 1, 2
• Monitor specifically for tongue elevation, floor-of-mouth swelling, and any signs of respiratory distress 1
• Serial examinations every 2-4 hours during the acute phase to assess for progression of submandibular swelling 2

Aggressive Conservative Medical Management

Initiate the following measures immediately upon admission:

• IV hydration with normal saline or lactated Ringer's at 125-150 mL/hour, as aggressive rehydration is critical for patients unable to maintain oral intake and promotes salivary flow 1, 2
• Apply warm compresses to the right submandibular area for 15-20 minutes every 2-3 hours to promote salivary excretion 1, 2
• Gentle gland massage after warm compress application to facilitate drainage (use caution given patient's hypertension and age regarding potential carotid stenosis) 1, 2
• Administer sialogogues such as pilocarpine or cevimeline to stimulate salivary flow and reduce stasis 1, 2
• Encourage oral intake of sour candies (lemon drops) or vitamin C lozenges if dysphagia permits 3

Antibiotic Therapy

Switch from oral co-amoxiclav to IV cephalosporin therapy, as cephalosporins achieve the highest concentrations in saliva and cover the bacterial spectrum implicated in sialadenitis 1

• The patient meets criteria for antibiotic therapy given the failure of outpatient treatment, progressive symptoms, and obstructive pathology with risk of bacterial superinfection 1
• Continue IV antibiotics for at least 48-72 hours or until clinical improvement is evident 1
• Transition to oral antibiotics once dysphagia resolves and clinical improvement is sustained 1

Corticosteroid Therapy

Administer systemic corticosteroids (prednisone 40-60 mg daily or equivalent IV methylprednisolone) for 3-5 days given the moderate-to-severe presentation with significant dysphagia and airway concerns 1, 2

• Corticosteroids were used in 47.4% of acute sialadenitis cases with significant swelling and are particularly indicated when airway compromise is a concern 1, 2
• Monitor blood glucose closely given the patient's family history of diabetes mellitus 1

Pain Management

• Continue celecoxib 200 mg twice daily (or switch to IV ketorolac if unable to swallow) for anti-inflammatory effect 1
• Add opioid analgesia (morphine or hydromorphone IV) as needed for breakthrough pain to ensure patient comfort 1
• Continue esomeprazole 40 mg daily (IV formulation) for gastroprotection and management of reported epigastric symptoms 1

Monitoring for Complications

Watch specifically for the following complications:

• Neurologic sequelae including brachial plexopathy, facial nerve palsy, and Horner syndrome from inflammatory compression of adjacent neural structures (occurs in 15.8% of severe cases) 4, 1
• Signs of abscess formation: fluctuance, increased erythema extending >5 cm beyond the gland, fever >38.5°C, or heart rate >110 bpm 1
• Progression of dysphagia or new-onset drooling suggesting worsening airway compromise 4

Definitive Management Planning

• Obtain CT sialography or ultrasound to confirm stone location and size once acute inflammation subsides 5, 3
• Consult ENT/oral surgery for definitive stone removal via:
  • Interventional sialoendoscopy if stone is accessible (81% success rate for submandibular stones) 5
  • Surgical removal if stone is large, impacted, or endoscopy fails (87% success rate) 5
  • Submandibular gland excision if chronic recurrent sialadenitis or failed conservative measures 6, 7

Expected Outcomes and Disposition

• Most patients (78.9%) achieve complete recovery with appropriate conservative management, though recovery may take weeks to months 1, 2
• Plan for 3-5 day hospital stay with transition to outpatient management once dysphagia resolves, inflammation subsides, and patient tolerates oral intake 1
• Schedule definitive stone removal within 4-6 weeks after acute inflammation resolves to prevent recurrence 5, 3

Critical Pitfall to Avoid

Do not discharge this patient until dysphagia has completely resolved and airway stability is confirmed, as the progressive nature of symptoms and failure of outpatient therapy indicate high risk for rapid deterioration 1, 2