Acute Suppurative Sialoadenitis

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

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II. Epidemiology

  1. Rare, serious infection
    1. [PubMed]

III. 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

IV. Causes: Bacterial

  1. See Viral Sialoadenitis
  2. Staphylococcus aureus (most common, cultured in >50% of cases)
  3. Streptococcus species (esp. Streptococcus Pyogenes, Streptococcus viridans)
  4. Gram Negative Bacteria (e.g. Escherichia coli)
  5. Anaerobic Bacteria
  6. Other rare causes
    1. HaemophilusInfluenzae
    2. KlebsiellaPneumoniae

V. 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

VI. Symptoms

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

VII. 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

VIII. Labs

  1. Gram Stain and culture of Salivary duct discharge

IX. Imaging

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

X. Differential Diagnosis

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

XI. Management

  1. Precautions
    1. Acute Parotitis and other severe Sialadenitis may require initial inpatient ParenteralAntibiotics
  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. Amoxicillin-Clavulanate (Augmentin) 875/125 mg every 12 hours OR
      2. Cefuroxime (Ceftin) 500 mg every 12 hours and Metronidazole 500 mg every 8 hours
      3. Penicillin and Cephalosporin allergy
        1. Clindamycin 300 to 450 mg orally three to four times daily OR
        2. Macrolide (e.g. Azithromycin) with Metronidazole 500 mg every 8 hours
    3. Parenteral agents
      1. Indications
        1. Sepsis or systemic signs
        2. Trismus
        3. Fluctuant abscess
      2. First-line Antibiotics if no risk for Pseudomonas
        1. Ampicillin-Sulbactam (Unasyn) 3 g every 6 hours OR
        2. Ceftriaxone 1 to 2 grams IV daily AND Metronidazole 500 mg every 8 hours OR
        3. Clindamycin 600 to 900 mg IV every 8 hours
      3. First-line Antibiotics if Pseudomonas risk (recent Antibiotics, hospitalized, NH resident, DM, Hemodialysis, Immunocompromised)
        1. Piperacillin-Tazobactam (Zosyn) 3.375 g every 6 hours (or 4.5 g every 8 hours) OR
        2. Meropenem 1 g every 8 hours (os substitute other carbopenem)
      4. Add MRSA coverage if needed
        1. MRSA coverage should be considered in cases failing to improve or Immunocompromised patients
        2. Vancomycin 20 to 25 mg/kg load, then 15 mg/kg every 12 hours (max 3 g/dose) OR
        3. Linezolid 600 mg every 12 hours
  3. Increase Saliva production
    1. Increase fluid intake
    2. Stop Anticholinergics and other Xerostomia causes
    3. Sialologues induce Salivation (help clear stone)
      1. Lemon drops
      2. Vitamin C lozenges
      3. Citric acid or malic acid (lemons, limes, apples, grapes)
  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 of abscess (with culture) may be required
    2. Consider early intervention or if no improvement in 3-4 days

XII. Complications

  1. Acute Suppurative Parotitis mortality can approach 40% in some cohorts
  2. Salivary Gland abscess (rare)

XIII. 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. Kim (2024) Am Fam Physician 109(6): 550-9 [PubMed]
  6. Wilson (2014) Am Fam Physician 89(11): 882-8 [PubMed]

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