PANCE Blueprint EENT (7%)

Sialadenitis (Lecture)

Patient will present as → a 39-year-old female complaining of episodic left-sided jaw pain and swelling. The symptoms are typically aggravated by eating or by the anticipation of eating. Over the last 2-days, the patient has been experiencing worsening pain, redness, and fever. On physical exam, the left salivary gland is exquisitely tender. High-resolution noncontrast computed tomography (CT) scanning reveals a left-sided salivary gland stone. 

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*** Sialadenitis is a bacterial infection of a salivary gland usually caused by sialolithiasis which is an obstructing stone in the salivary gland

I. Sialadenitis - is a bacterial infection of a salivary gland, usually due to an obstructing stone (sialolithiasis) or gland hyposecretion. Symptoms are swelling, pain, redness, and tenderness. Diagnosis is clinical. CT, ultrasonography and MRI may help identify the cause. Treatment is with antibiotics.

  • Bacterial infection of the parotid or submandibular salivary glands (often caused by prior sialolithiasis and blockage of salivary ducts).
  • Most common pathogen is Staphylococcus Aureus. 
  • Patients with Sjögren syndrome
  • Treat with antibiotics (cephalosporin) and dilation of the salivary duct.
    • Increase salivary flow with sialogogues (have the patient suck on lemon drops).

II. Sialolithiasis - stones composed of Ca salts often obstruct salivary glands, causing pain, swelling, and sometimes infection. Diagnosis is made clinically or with CT, ultrasonography, or sialography. Treatment involves stone expression with saliva stimulants, manual manipulation, a probe, or surgery.

  • Salivary stones – most common in Wharton's duct (submandibular gland). Stenson's (parotid glands)
  • Pt will present with postprandial salivary gland pain and swelling. 
  • Treatment: Cephalosporin and dilation of salivary gland duct along with increased oral hydration and the use of sialogogues (as above)
  • May require surgical marsupialization of duct (removal of stone)
Sialadenitis: CT, ultrasonography, or MRI: CT, ultrasonography, and MRI can confirm sialadenitis or abscess that is not obvious clinically, although MRI may miss an obstructing stone. If pus can be expressed from the duct of the affected gland, it is sent for Gram stain and culture.

Sialolithiasis: Clinical diagnosis is usually adequate but sometimes CT, ultrasonography, or sialography is needed.

 

Salivary duct stones affect about 1 out of 100 adults, twice more men than women, and many people with the condition have multiple stones.

Salivary duct stones (Sialolithiasis) affect about 1 out of 100 adults, twice more men than women, and many people with the condition have multiple stones.

Sialadenitis

Antibiotics: Initial treatment is with IV antibiotics active against S. aureus (eg, dicloxacillin, 250 mg PO qid, a 1st-generation cephalosporin, or clindamycin), modified according to culture results. With the increasing prevalence of methicillin-resistant S. aureus, especially among the elderly living in extended-care nursing facilities, vancomycin is often required.

  • Local measures (eg, sialagogues, warm compresses): Hydration, sialagogues (eg, lemon juice, hard candy, or some other substance that triggers saliva flow), warm compresses, gland massage, and good oral hygiene are also important. Abscesses require drainage.

Sialolithiasis

  • Many stones pass spontaneously or with use of sialagogues and manual expression, but some require endoscopic surgical removal or lithotripsy
Question 1
A 28-year-old presents with acute swelling of the cheek, which worsens with meals. Examination reveals an erythematous and edematous tender parotid duct; purulent material is expressed with massage. What is the most appropriate next step?
A
fine-needle biopsy
Hint:
Fine-needle biopsy is indicated in a patient with an asymptomatic salivary gland mass.
B
IV antibiotics
C
lithotripsy
Hint:
Lithotripsy has been successful in the treatment of sialolithiasis.
D
supportive care
Hint:
Supportive care alone is insufficient in sialadenitis.
Question 1 Explanation: 
Treatment of sialadenitis includes IV antibiotics (i.e., nafcillin) and increasing salivary flow (hydration, warm compresses, sialagogues, gland massage).
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