acute suppurative sialadenitis
Monday 18 March 2013
Acute suppurative sialadenitis is most commonly bacterial in origin and most often involves the parotid, and to a lesser extent, the submandibular glands.
The more mucinous saliva produced by the submandibular glands is felt to confer more bacteristatic properties than the serous saliva of the parotids. The causative agent most frequently implicated is Staphylococcus aureus.
Other aerobic organisms isolated are Streptococcus pneumoniae, Hemophilus influenzae, and Escherichia coli. Anaerobic bacteria such as Bacteroides have been involved as well. Stasis of saliva, often as a result of dehydration, is thought to be an integral component in the pathogenesis of this condition perhaps secondary to obstruction or decreased production.
Common clinical settings in which this entity may occur include the elderly postoperative patient after cardiothoracic or gastrointestinal surgery and perhaps more frequently the elderly nursing home patient.
Onset is typically heralded by unilateral abrupt diffuse swelling of the parotid perhaps with accompanying induration and tenderness.
Mucopurulent material may be expressed from the opening of Stensen’s duct with massage of the gland, and a sample should be obtained for Gram stain and culture. Fluctuance is often not present due to the multiple fascial investments with the substance of the parotid gland.
Therapy is initially conservative with adequate hydration, sialogogues, heat, massage of the affected gland, and the administration of an appropriate intravenous antibiotic, usually a penicillinase-resistant antistaphylococcal antibiotic. Improvement is expected within the first 24 to 48 hours. If this does not occur, operative intervention may be indicated.
This usually consists of a standard parotidectomy skin incision and flap followed by creation of several openings within the substance of the gland parallel to the course of the facial nerve. A drain is then placed over the gland and the wound closed.
Complications include possible septicemia or deep space neck infection.
Mortality has been reported as high as 20% and is likely related to the severity patient’s underlying medical condition.