Submandibular Sialadenitis/Sialadenosis Treatment & Management

Management of submandibular sialadenitis and sialadenosis involves a wide range of approaches, from conservative medical management to more aggressive surgical intervention.

One management scheme is as follows:

• Acute sialadenitis

  • Medical management - Hydration, antibiotics (oral versus parenteral), warm compresses and massage, sialogogues ^[2]

  • Surgical management - Consideration of incision and drainage versus excision of the gland in cases refractory to antibiotics, incision and drainage with abscess formation, gland excision in cases of recurrent acute sialadenitis

• Salivary calculi

  • Medical management - Hydration, compression and massage, antibiotics for the infected gland

  • Surgical management - Duct cannulation with stone removal, gland excision in recurrent case

• Sjögren disease

  • Medical management - Hydration, dental hygiene, rheumatology and dental referral

  • Surgical management - Gland excision not usually needed unless recurrent acute sialadenitis

• Sialadenosis

  • Medical management - Treatment of underlying cause

  • Surgical management - Not indicated

A prospective study by Choi et al indicated that following salivary stimulation therapy, patients with radioactive iodine (RAI)-induced sialadenitis may undergo a subjective reduction in symptoms but will not experience significant improvement in salivary gland function. The study involved 61 patients who were diagnosed with chronic RAI-induced sialadenitis following thyroidectomy and RAI treatment. After salivary stimulation with pilocarpine, significant improvement was seen in the patients’ subjective symptom scores; however, salivary flow rates and salivary gland scintigraphy parameters, as measured in the parotid and submandibular glands, were not significantly different from their prestimulation values. ^[13]

A study by Kim et al of 33 patients (58 salivary glands) with chronic obstructive sialadenitis indicated that intraductal irrigation can relieve symptoms of the condition. As assessed using a numeric rating scale, a set of 3-5 visits for intraductal irrigation reduced the average symptom severity score from 6.0 to 3.3. However, irrigation was not associated with a change in ductal width. ^[14]

Medical management of submandibular sialadenitis and sialadenosis centers on eliminating the causative factor.

• Acute sialadenitis

  • In cases of acute sialadenitis, adequate hydration should be ensured and electrolyte imbalances corrected.

  • Patients are most often treated on an outpatient basis, with the administration of a single dose of parenteral antibiotics in an emergency department, followed by oral antibiotics for a period of 7-10 days. Clindamycin (900 mg IV q8h or 300 mg PO q8h) is an excellent choice and provides good coverage against typical organisms.

  • Patients who exhibit significant morbidity, are significantly dehydrated, or are septic should be admitted to hospital. In this latter group of patients, CT scanning of the area should be performed. If a large abscess is noted, incision and drainage should be considered. Small abscesses typically respond to conservative methods.

  • In cases refractory to antibiotics, viral and atypical bacterial causes should be considered.

• Sialolithiasis

  • Patients with sialolithiasis should be initially treated with hydration, warm compresses, and gland massage.

  • Antibiotics are indicated in patients exhibiting infection.

• Sjögren disease

  • In those patients with Sjögren disease, hydration and prevention of complications should be undertaken.

  • Dental hygiene should be strictly maintained in order to prevent carries, and dental and rheumatology consults should be sought. Gland excision is rarely indicated.

• Sialadenosis: Sialadenosis should be managed expectantly. Treatment should be directed towards managing the underlying problem and achieving homeostasis. Gland excision is not indicated.

Acute sialadenitis

Patients who exhibit significant morbidity, are significantly dehydrated, or are septic should be admitted to hospital. In this latter group of patients, CT scanning of the area should be performed. If a large abscess is noted, incision and drainage should be considered. Small abscesses typically respond to conservative methods.

In patients with recurrent acute attacks, gland excision during a period of quiescence should be considered. Serial CT scanning is often useful.

Endoscopic management of sialadenitis frequently obviates the need for gland removal. Results follow a learning curve. ^[15]

Chronic sialadenitis

A retrospective study described sialendoscopy as a safe and effective means of treating children with recurrent or chronic sialadenitis. Semensohn et al examined the medical records of 12 pediatric patients who underwent diagnostic and therapeutic sialendoscopy for recurrent parotitis (nine patients) or chronic submandibular sialadenitis (three patients). During follow-up, which averaged 16.5 months, only one patient needed additional surgery (salvage parotidectomy), due to repeated recurrences. ^[16]

Sialolithiasis

In patients with calculi in proximity of the opening of the Wharton duct, the duct can be cannulated, dilated, and the stone removed via a transoral approach.

Patients with deep intraparenchymal stones or multiple stones should have their glands excised on an elective basis. Ultrasonic lithotripsy is rarely effective and is not offered at the authors' institution.

A study by Kopeć et al indicated that sialendoscopy and sialendoscopy-assisted surgery are effective treatments for lithiasis of the submandibular glands. The study found that of 175 patients with submandibular gland stones, complete stone removal was achieved in 149 of them, through either sialendoscopy alone (82 patients) or sialendoscopy with surgery (67 patients). The procedures were also effective in the treatment of lithiasis of the parotid glands. ^{[17, 18]}

Similarly, a prospective study by Aubin-Pouliot et al indicated that sialendoscopy-assisted salivary duct surgery is an effective treatment for chronic obstructive sialadenitis, especially that caused by sialolithiasis. In the study’s 40 patients (54 glands), the overall mean score on the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire improved by 22.6 points, falling from 36.1 preoperatively to 13.5 at 3 months postoperatively. For submandibular gland patients specifically, the mean score fell from 38.1 preoperatively to 10.3, while for parotid gland patients the mean score fell from 32.6 to 19.0. The investigators found the greatest COSS score improvement in patients whose condition was caused by sialolithiasis, as opposed to those with radioactive iodine– or inflammatory-related sialolithiasis. ^[19]