Management of Blocked Salivary Glands
Begin with conservative medical management including hydration, salivary massage, warm compresses, sialogogues (lemon drops or vitamin C lozenges), and antibiotics if infection is present, reserving sialendoscopy or surgical intervention for cases that fail conservative therapy after 48-72 hours. 1, 2
Initial Conservative Management
Hydration and mechanical measures form the foundation of treatment: aggressive oral hydration, manual massage of the affected gland from posterior to anterior, warm compresses applied to the gland, and oral hygiene optimization 1, 2, 3
Sialogogues should be prescribed to stimulate salivary flow: lemon drops, vitamin C lozenges, or other sour candies to increase saliva production and help dislodge obstructions 1, 2
Antibiotics are indicated when infection (sialadenitis) is present: The most common causative organism is Staphylococcus aureus 2. First-line therapy should be a cephalosporin rather than ampicillin-sulbactam due to superior salivary penetration 4
For MRSA-suspected cases, escalate to vancomycin 30 mg/kg/day IV in 2 divided doses or clindamycin 600-900 mg every 8 hours IV 4
When Conservative Management Fails
Up to 40% of patients have inadequate response to conservative measures and require intervention 5. Failure is defined as persistent symptoms after 48-72 hours of appropriate treatment 4.
Sialendoscopy (Preferred Minimally Invasive Option)
Sialendoscopy offers gland-preserving diagnosis and treatment for both obstructive and non-obstructive chronic inflammatory disorders when conservative measures fail 5, 2
This minimally invasive technique allows direct visualization, stone removal, stricture dilation, and irrigation of the ductal system while preserving gland function 5, 2
Surgical Intervention Indications
Abscess formation requires incision and drainage regardless of antibiotic response 4
Recurrent or chronic sialadenitis unresponsive to sialendoscopy necessitates total excision of the salivary gland and its duct 3
Sialolithiasis management depends on stone size and location: Conservative management for small stones, sialendoscopy for accessible stones, and surgical removal of the gland for large stones or those causing recurrent obstruction 6
Location-Specific Considerations
Submandibular gland stones (84% of all sialoliths) are most commonly located in Wharton's duct (90%) and are associated with salivary stasis due to the long duct that flows against gravity 2, 6
Parotid gland stones (13% of sialoliths) are more often located within the gland itself rather than the duct 6
Critical Pitfalls to Avoid
Do not delay imaging if a mass is present: While inflammatory conditions are common, neoplasms can present similarly and require ultrasonography, CT, or MRI for differentiation 1, 2
Do not use ampicillin-sulbactam monotherapy for sialadenitis due to poor salivary penetration; cephalosporins are superior 4
Do not perform partial gland excision for recurrent infection—total excision of the gland and duct is necessary to prevent recurrence 3
Submandibular masses warrant high suspicion as nearly 50% are malignant, requiring fine needle aspiration biopsy if conservative management fails or if clinical features are concerning 7