Overview
Definition:
Submandibular sialadenitis refers to the inflammation and infection of the submandibular salivary gland, typically caused by bacterial pathogens
In children, it often presents as acute swelling and pain in the floor of the mouth and submandibular region.
Epidemiology:
While less common than parotid sialadenitis, submandibular sialadenitis can occur in children of all ages, with a slightly higher incidence in infants and toddlers
It is often associated with dehydration, poor oral hygiene, or obstruction.
Clinical Significance:
Prompt diagnosis and management are crucial to prevent complications such as abscess formation, gland destruction, and recurrent episodes
Understanding the underlying causes and appropriate treatment is vital for pediatric residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Sudden onset of unilateral or bilateral swelling in the submandibular region
Pain, tenderness, and erythema over the affected gland
Fever, malaise, and irritability
Difficulty with mastication and swallowing
Purulent discharge from the Wharton's duct may be present
In infants, feeding difficulties and fussiness are common.
Signs:
Palpable, tender, and indurated submandibular gland
Redness and warmth over the gland
Possible crepitus if an abscess has formed
Trismus may be present due to pain and inflammation
Examination of the oral cavity may reveal purulent exudate from the submandibular duct orifice.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on characteristic history and physical examination findings
Laboratory investigations and imaging support the diagnosis and help identify complications
No universally established formal diagnostic criteria exist, but a combination of clinical features is used.
Diagnostic Approach
History Taking:
Detailed history including onset, duration, and progression of swelling and pain
Associated symptoms like fever, difficulty feeding or swallowing
Recent history of dehydration, viral illness, trauma, or surgery
Previous episodes of similar symptoms
Vaccination status
Nutritional status and hydration.
Physical Examination:
Thorough head and neck examination
Palpation of the submandibular glands for tenderness, size, consistency, and presence of fluctuance
Examination of the oral cavity, including the floor of the mouth and the orifices of Wharton's ducts for purulent discharge
Assessment of vital signs, hydration status, and general well-being.
Investigations:
Complete blood count (CBC) may show leukocytosis with a neutrophilic predominance
C-reactive protein (CRP) levels can be elevated
Ultrasound of the submandibular region is the imaging modality of choice, identifying inflammation, abscess formation, ductal dilation, or calculi
Computed tomography (CT) scan may be considered for extensive disease or suspected complications
Bacterial culture and sensitivity of any purulent discharge can guide antibiotic therapy.
Differential Diagnosis:
Mumps (bilateral parotid swelling often present), other viral sialadenitis, bacterial parotitis, reactive lymphadenopathy, cervical lymphadenitis, dental abscess, peritonsillar abscess, ranula, cellulitis of the floor of the mouth, and benign or malignant salivary gland tumors (rare in children).
Management
Initial Management:
Aggressive fluid resuscitation if dehydrated
Analgesics for pain relief
Warm compresses to the affected area
Sialagogues (e.g., lemon drops, sucking on ice chips) to promote salivary flow, provided there is no complete ductal obstruction.
Medical Management:
Empiric antibiotic therapy is essential for suspected bacterial sialadenitis
Broad-spectrum antibiotics covering common oral flora (e.g., Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae)
Common choices include amoxicillin-clavulanate (e.g., 20-40 mg/kg/day divided q12h for children 3 months to 12 years
adults 875/125 mg q12h), clindamycin, or cefuroxime
Duration typically 7-10 days
Adjust antibiotics based on culture and sensitivity results.
Surgical Management:
Surgical intervention is indicated for abscess formation or persistent sialadenitis unresponsive to medical management
Incision and drainage of abscesses are performed, often through an intraoral approach to minimize external scarring
Duct exploration or lysis of obstruction may be necessary in recurrent cases.
Supportive Care:
Close monitoring of vital signs, hydration status, and pain control
Nutritional support may be required if feeding is significantly impaired
Education on oral hygiene practices
Advise to avoid mastication of hard foods during acute episodes.
Complications
Early Complications:
Abscess formation in the submandibular gland or surrounding tissues
Sepsis and bacteremia, particularly in immunocompromised children
Spread of infection to adjacent structures like the pharynx or neck spaces.
Late Complications:
Chronic sialadenitis with recurrent swelling and pain
Glandular fibrosis and atrophy leading to chronic salivary insufficiency
Stricture formation of Wharton's duct
Osteomyelitis of the mandible in severe, untreated cases.
Prevention Strategies:
Maintaining adequate hydration, especially during febrile illnesses
Good oral hygiene practices
Prompt treatment of dental infections
Prophylactic antibiotics in specific high-risk situations, though this is controversial.
Prognosis
Factors Affecting Prognosis:
Promptness of diagnosis and initiation of treatment
Virulence of the causative pathogen
Presence and extent of complications like abscess formation
Underlying host immune status
Presence of ductal obstruction.
Outcomes:
With appropriate antibiotic therapy and supportive care, most cases of acute submandibular sialadenitis resolve completely
Abscesses require drainage
Recurrent episodes can occur and may necessitate further investigation and management.
Follow Up:
Follow-up is recommended to ensure complete resolution of infection and symptoms
In cases of recurrent sialadenitis or suspected ductal pathology, referral to a pediatric ENT specialist for further evaluation, potentially including sialography, may be warranted.
Key Points
Exam Focus:
Distinguish submandibular sialadenitis from parotid sialadenitis and cervical lymphadenitis
Recognize the role of ultrasound in diagnosis and abscess detection
Understand empiric antibiotic choices and the importance of hydration and oral hygiene
Know indications for surgical intervention.
Clinical Pearls:
Always examine Wharton's duct for purulent discharge
Ultrasound is your best friend for visualizing the gland and ruling out abscess
Prompt antibiotic therapy can often prevent the need for surgical drainage
Consider sialagogues cautiously if there is no evidence of complete obstruction to avoid worsening symptoms.
Common Mistakes:
Delayed initiation of antibiotics, leading to abscess formation
Insufficient hydration support
Overlooking the need for surgical drainage in fluctuant abscesses
Misdiagnosing as simple cervical lymphadenitis without palpating the gland itself.