Infected salivary gland

Red flags

  • Abscess of the salivary glands may rarely progress into the deep neck spaces as a parapharyngeal abscess or Ludwig’s angina.
  • Lower motor neurone facial nerve palsy with parotid swelling is usually not a sign of infection but rather one of a malignant tumour.

 

  Figure 1 Salivary glands. Souce: Blausen gallery 2014. Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010, with thanks.

 

Figure 1 Salivary glands. Souce: Blausen gallery 2014. Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010, with thanks.

Why is this important?

The main salivary glands are the parotids (two in total), submandibulars (two in total) and sublinguals (two in total) with numerous other minor glands spread around the oral cavity.

 

When to involve the ENT registrar

  • If infection has progressed to deep neck spaces and is comprising the airway.
  • If patients are in septic shock

 

Who to admit

  • Patient with tenderness, swelling, erythema in the parotid or submandibular region that has not resolved with a one week course of oral antibiotics 
  • Spreading overlying cellulitis
  • Abscess formation (tender, warm and fluctuant swelling) over salivary gland areas
  • Patients who cannot eat and drink

 

  Figure 2. Right submandibular duct stone. Source: James Heilman MD, Wikimedia Commons, with thanks.

 

Figure 2. Right submandibular duct stone. Source: James Heilman MD, Wikimedia Commons, with thanks.

Assessment and recognition

Infections are commoner in the parotid ('parotiditis', or 'parotitis' if you say 'appendectomy') and submandibular glands. Dependent patients tend to have poorer oral hygiene and get dehydrated, despite the best efforts of carers, and they are at higher risk.

Most salivary gland infections are viral in nature and usually settle with conservative management. This includes adequate oral hygiene and hydration. Some bacterial infections may require oral antibiotics, which can be administered on an outpatient basis.

Many submandibular swellings will be dental: always ensure dental examination and imaging have been undertaken to rule out a tooth abscess.

Patients with repeated salivary gland infections may have an underlying cause (see below), which will require further investigation.

A thorough history of duration, onset and nature of infection is vital. Patients usually complain of swelling, dry mouth, foul taste in the mouth and difficulty in eating and drinking. Pay good attention to co-morbidities and medications as these could be related to the underlying pathology.

 

Common causes of salivary gland swellings

  • Viral causes – Mumps, Coxsackie, Parainfluenza, Influenza A
  • Bacterial causes – staphylococcus aureus, anaerobic bacteria
  • Stones (sialolithiasis)
  • Chronic scarring and strictures (sialectasis)
  • Benign and malignant tumours
  • Granulatomous conditions - Sjogren’s syndrome, Sarcoidosis, Wegeners granulomatosis
  • HIV-related lymphocytic infiltration (usually parotid gland)
  • Medical causes – chemotherapy agents and radiotherapy (controversial!)

Examination of the neck and oral cavity is vital. This includes bimanual palpation for feeling stones and trying to express pus from the glands.

 

Immediate and overnight management

If patients meet the criteria for admission:

  • IV access, bloods (including cultures if temp >38) and IV hydration
  • Start antibiotics, ensuring adequate cover for anaerobes eg co-amoxiclav, clarithromycin or penicillin and metronidazole: do follow your local/Trust protocol
  • Encourage good oral hydration if tolerated and oral hygiene: this has to be stressed to the nursing staff
  • Citrus fruits / drinks or other forms of sialogogues can help promote salivary outflow to encourage expulsion of pus or stones
  • Some patients attempt milking the duct for stones but this is painful

 

Further management

The patient should be seen on the ward round and usually an ultrasound scan of the salivary gland is requested to determine the nature of the infection as well as the underlying cause.

If there is a possibility of an abscess or deep neck space infection, this may require urgent drainage in theatre.

Depending on the underlying cause, patients may undergo sialoendoscopy or sialography. This is usually on an outpatient basis once the immediate infection has settled.

 

 

 

Page last reviewed: 23 September 2016