Acute Suppurative Sialoadenitis

Aka: Acute Suppurative Sialoadenitis, Acute Suppurative Sialadenitis, Obstructive Sialadenitis, Bacterial Sialoadenitis, Suppurative Parotitis, Acute Parotitis, Parotitis

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II. Pathophysiology

  1. Mechanism
    1. Bacterial Infection with seeding via retrograde infection from the oral cavity
    2. Stasis due to volume depletion or Xerostomia allows for Salivary GlandBacterial parenchymal infection
  2. Most common in age >50 years
    1. Contrast with Viral Sialoadenitis
  3. Parotid Gland is most commonly affected Salivary Gland
    1. Less bacteriostatic secretions than submandibular

III. Causes: Bacterial

  1. See Viral Sialoadenitis
  2. Staphylococcus aureus (most common, cultured in >50% of cases)
  3. Streptococcus species (esp. Streptococcus Pyogenes)
  4. Haemophilus Influenzae
  5. Gram Negative Bacteria
  6. Anaerobic Bacteria

IV. Risk Factors

  1. Advanced age
  2. Volume depletion
  3. Diabetes Mellitus
  4. Hypothyroidism
  5. Renal Failure
  6. Sjogren Syndrome
  7. Debilitated or recently post-operative or post-hospitalization
  8. Anticholinergic Medications causing Xerostomia
  9. Secondary to Salivary Gland Calculus
    1. Known as Obstructive Sialadenitis

V. Symptoms

  1. Acute pain and swelling localized over affected Salivary Gland
  2. High fever with chills often present

VI. Signs

  1. Ill appearing patient
  2. Exquisitely tender, warm, swollen Salivary Gland (usually Parotid Gland)
  3. Regional Lymphadenopathy
  4. Pus at affected Salivary duct orifice
    1. Affected gland may be massaged to express pus for culture
    2. Parotid duct (Stensen's Duct) at upper second molar
    3. Submandibular duct (Wharton's Duct) at frenulum

VII. Labs

  1. Gram Stain and culture of Salivary duct discharge

VIII. Imaging

  1. CT Scan if not improving within 3-4 days
  2. Avoid sialography in acute Bacterial Sialoadenitis

IX. Differential Diagnosis

  1. See Lymphadenopathy of the Head and Neck
  2. Sialolithiasis
  3. Viral Sialoadenitis
  4. Chronic Sialoadenitis

X. Management

  1. Precautions
    1. Acute Parotitis and other severe Sialadenitis may require initial inpatient Parenteral antibiotics (e.g. Nafcillin and metronizadole)
    2. MRSA coverage should be considered in cases failing to improve or Immunocompromised patients (e.g. Vancomycin)
  2. Start antibiotic coverage for Staphylococcus aureus and other Gram Positive organisms (as well as Anaerobes)
    1. Total treatment course: 10-14 days
    2. Oral agents (non-toxic patient)
      1. Augmentin
      2. Dicloxacillin
      3. Clindamycin
    3. Parenteral agents
      1. Use broad spectrum coverage instead for immunosuppressed patients (e.g. Zosyn and Vancomycin)
      2. Clindamycin 600 mg IV every 6-8 hours OR
      3. Nafcillin 2 g IV every 4 hours AND Metronidazole 500 mg IV every 6 to 8 hours
  3. Increase Saliva production
    1. Increase fluid intake
    2. Lemon drops to increase Saliva secretion
    3. Stop Anticholinergics and other Xerostomia causes
  4. Symptomatic therapy
    1. Analgesics
    2. Warm compresses over affected Salivary Gland
    3. Attempt to milk gland of discharge
  5. Otolaryngology Consultation
    1. Surgical drainage may be required
    2. Consider early intervention or if no improvement in 3-4 days

XI. Complications

  1. Salivary Gland abscess (rare)

XII. References

  1. (2018) Sanford Guide, accessed on IOS 12/24/2019
  2. Fedok in Noble (2001) Primary Care Medicine, p. 1770-1
  3. Chow in Mandell (2000) Infectious Disease, p. 699-700
  4. Walner in Cummings (1998) Otolaryngology, p. 5-121
  5. Wilson (2014) Am Fam Physician 89(11): 882-8 [PubMed]

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