Sialolithiasis and sialadenitisMANAGEMENT

ENT AND MAXILLOFACIAL PRESENTATIONS · 12 SECTIONS

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647 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Acute laryngitis Acute pharyngitis Auricular hematoma Bezold's Abscess Cerumen impaction Dry socket Ear foreign body Epistaxis (anterior)Epistaxis (Posterior)Labyrinthitis Ludwig's Angina Malignant Otitis Externa Marcus Gunn Pupil Mastoiditis Meniere's Disease Nasal Bone Fracture Nasal foreign body Nasal Septal Hematoma Otitis externa Otitis Media Post-tonsillectomy hemorrhage Sialolithiasis and sialadenitis Sinusitis Sudden Sensorineural Hearing Loss TMJ dislocation Tympanic membrane perforation Vestibular Neuronitis

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp40

Immediate airway assessment

›Floor-of-mouth swelling with tongue elevation is the airway emergency in this topic

›Submandibular and sublingual space infection (Ludwig angina) can arise from an infected submandibular stone

›Brawny bilateral floor-of-mouth induration, tongue pushed up and back, pooled saliva, drooling

›Muffled "hot potato" voice, stridor, tripod posture, and inability to handle secretions are late signs

›Sit the patient upright and do not force a supine position

›Supine positioning and blind instrumentation can precipitate complete obstruction

›Keep the patient calm and limit repeat oropharyngeal exams once the diagnosis is evident

›Call anesthesia and ENT early for any floor-of-mouth or deep neck involvement

›Plan for awake fiberoptic intubation with a double setup for a surgical airway

›Do not give a paralytic until the airway is secured or a surgical airway is immediately available

›Apply humidified oxygen titrated to SpO2 94% or higher

›Target 88 to 92% in COPD or known chronic hypercapnia

›Nebulized racemic epinephrine can temporize mucosal edema as a bridge, not a definitive measure

Recognition of systemic sepsis

›Acute suppurative sialadenitis in a dehydrated, debilitated, or postoperative patient can present as undifferentiated sepsis

›Rigors, temperature 38.0 C or higher, tachycardia, hypotension, altered mentation

›The elderly septic patient may be afebrile with delirium as the only sign

›Screen with qSOFA and a full set of vitals including a lactate

›qSOFA 2 or more (systolic 100 mmHg or less, respiratory rate 22/min or more, altered mentation) prompts escalation

›Lactate 2 mmol/l or more indicates hypoperfusion; 4 mmol/l or more is severe

›Start broad-spectrum antibiotics within 1 hour of recognizing sepsis

›Do not wait for imaging or cultures to give the first dose

›Draw two sets of blood cultures first if it does not delay treatment

›Establish intravenous access and begin balanced crystalloid resuscitation

›Reassess perfusion after each fluid bolus

›Escalate to a monitored bed for any airway symptom or rising vasopressor need

02History/hx54

Presenting symptoms and time course

›Unilateral facial or submandibular swelling

›Location: submandibular (angle and below the jaw) versus parotid (preauricular, over the ramus, parotid tail)

›Onset over hours (obstruction or suppuration) versus weeks to months (chronic, autoimmune, neoplastic)

›Whether the swelling has ever completely resolved between episodes

›Gland pain

›Severity and radiation to the ear or floor of the mouth

›Constant versus provoked by eating

›Associated symptoms

›Fever, rigors, malaise

›Bad taste or pus in the mouth

›Dry eyes and dry mouth (sicca symptoms)

›Prior history

›Previous identical episodes, prior imaging, prior stone passage, prior gland surgery

›Known salivary, autoimmune, or head and neck cancer history

Obstructive and mealtime features

›Prandial swelling and pain, the hallmark of ductal obstruction

›Swelling begins within minutes of eating, or with the sight or smell of food, then subsides over 1 to 2 hours

›Sour foods provoke it most strongly

›Swelling that never fully resolves between episodes argues against simple obstruction

›Sensation of a stone or gritty fragment passing from the duct

›Symptom relief after a palpable fragment passes

›Prior documented stone passage or prior sialendoscopy

›Recurrent, self-limited episodes over months favor a stone over infection

›Number and frequency of prior episodes

›Any interval imaging and its findings

Infectious and deep-space features

›Local infective features

›Fever, rigors, malaise

›Purulent taste or visible pus at the duct orifice

›Increasing, constant, non-prandial pain and swelling with overlying erythema

›Deep-space and airway warning features

›Trismus (reduced mouth opening)

›Dysphagia, odynophagia, drooling, or voice change

›Dyspnea, stridor, or a sensation of throat tightness

›Rapidly spreading neck erythema crossing the midline or extending below the mandible

›Neck stiffness, chest pain, or dyspnea suggesting retropharyngeal or mediastinal extension

›Alternative or contributing sources

›Dental pain, recent extraction, or known dental infection

›Skin infection or trauma over the gland

Risk factors, comorbidities, and redirecting features

›Predisposing factors for stones and sialadenitis

›Dehydration or reduced oral intake

›Xerostomic medications: anticholinergics, antihistamines, tricyclics, antipsychotics, diuretics

›Recent general anesthesia or a prolonged nil-by-mouth state (postoperative parotitis)

›Radioactive iodine therapy for thyroid disease; head and neck radiotherapy

›Gout or hyperuricemia (radiolucent urate stones); nephrolithiasis or disordered calcium metabolism

›Host factors raising the risk of suppuration and sepsis

›Diabetes mellitus, immunosuppression, HIV, chronic kidney disease, hepatic failure, malnutrition

›Alcohol use disorder and bulimia (also cause painless sialadenosis)

›Anticoagulant or antiplatelet therapy, relevant if drainage is planned

›Features that redirect away from simple sialadenitis

›Painless, firm, fixed, slowly enlarging mass suggests neoplasm

›Ipsilateral facial nerve weakness suggests malignancy or deep parotid abscess, not simple sialadenitis

›Bilateral parotid enlargement suggests mumps, HIV, Sjögren, sarcoidosis, IgG4 disease, or sialadenosis

›Weight loss and night sweats suggest lymphoma, tuberculosis, or metastatic disease

›Overlying skin sinus with yellow granules suggests actinomycosis

›Immunization history and mumps exposure or recent travel

03Physical Exam/exam43

Vital signs and general appearance

›Vital signs

›Temperature; record fever as 38.0 C or higher

›Heart rate, blood pressure, respiratory rate, SpO2

›SpO2 target 94% or higher; 88 to 92% in COPD or chronic hypercapnia

›Adult tachypnea is 22/min or more; use age-specific norms in children (see Pediatrics)

›General appearance

›Degree of distress and ability to swallow secretions

›Posture: tripod or sniffing position

›Voice quality: muffled or "hot potato" voice signals floor-of-mouth or supraglottic involvement

›Hydration status

›Dry mucous membranes, reduced skin turgor, capillary refill over 2 seconds

›Postural pulse and blood pressure change

Salivary gland and duct examination

›Localize and characterize the swelling

›Submandibular triangle versus preauricular parotid versus parotid tail

›Tender, warm, firm; discrete fluctuant area versus diffuse induration

›Intraoral and ductal examination

›Bimanual palpation of the floor of mouth along Wharton duct for a palpable stone

›Palpate the buccal mucosa along Stensen duct opposite the second maxillary molar

›Inspect the duct papilla for erythema, edema, or a protruding calculus

›Milk the gland and observe the duct orifice

›Frank pus confirms suppurative sialadenitis and provides a culture specimen

›Clear saliva with a palpable stone favors uncomplicated obstruction

›No expressible saliva suggests complete obstruction

Airway, neck, and deep-space findings

›Floor of mouth and tongue

›Induration and elevation of the floor of mouth

04Differential Diagnosis/ddx53

Airway-threatening and life-threatening diagnoses

›Ludwig angina and submandibular space infection

›Bilateral floor-of-mouth induration, tongue elevation, rapid progression, airway loss

›Most often odontogenic but can complicate an infected submandibular stone

›Deep neck space abscess (parapharyngeal, submandibular, masticator, retropharyngeal)

›Trismus, dysphagia, neck swelling, febrile toxicity

›Risk of extension to the mediastinum (descending necrotizing mediastinitis) and the carotid sheath

›Lemierre syndrome (septic internal jugular thrombophlebitis)

›Persistent fever, neck pain, and septic pulmonary emboli after oropharyngeal infection

›Necrotizing soft tissue infection of the face or neck

›Pain out of proportion, rapidly advancing erythema, bullae, crepitus, systemic toxicity

›Acute suppurative sialadenitis with sepsis, particularly parotid, in the frail elderly

›Postoperative or profoundly dehydrated patient

›Rapidly enlarging, exquisitely tender gland with expressible pus

›Salivary gland malignancy presenting with facial nerve palsy

›Progressive, painless, firm mass with new facial weakness

›Fixed skin or deep attachment

Common infectious and obstructive diagnoses

›Sialolithiasis with ductal obstruction

›Most common cause overall; roughly 80 to 90% arise in the submandibular gland

›Prandial swelling with a palpable duct stone

›Acute bacterial (suppurative) sialadenitis

›Staphylococcus aureus (including MRSA), viridans streptococci, oral anaerobes

›Gram-negatives in hospitalized or immunocompromised patients

›Chronic recurrent sialadenitis with ductal stenosis or sialectasis

›Repeated self-limited episodes with incomplete resolution

›Viral parotitis

›Mumps, Epstein-Barr virus, cytomegalovirus, influenza, parainfluenza, coxsackievirus

05Laboratory Tests/lt37

Inflammatory markers and sepsis workup

›Complete blood count with differential

›Leukocytosis with left shift supports bacterial infection

›A normal white cell count does not exclude serious infection in the elderly or immunocompromised

›Inflammatory markers

›C-reactive protein for severity and trend; a normal early value does not exclude abscess

›Erythrocyte sedimentation rate where locally used

›Sepsis workup

›Venous lactate (2 mmol/l or more abnormal; 4 mmol/l or more severe)

›Blood cultures, two sets, before antibiotics if febrile or toxic

›Cultures drawn after antibiotics are frequently falsely negative

›Procalcitonin is not required and must not delay antibiotics or drainage

Metabolic panel and hydration assessment

›Basic metabolic profile (report electrolytes in mmol/l)

›Sodium, potassium, urea, creatinine, glucose

›Acute kidney injury from dehydration alters NSAID and antibiotic dosing

›Vomiting and poor intake cause hypokalemia and hypomagnesemia, which prolong the QT interval

›Additional chemistry

›Magnesium and albumin-corrected calcium (normal calcium roughly 2.2 to 2.6 mmol/l)

›Serum amylase is often mildly elevated in parotitis

›Do not misread an isolated amylase rise as pancreatitis when the picture is parotid

›Order lipase if pancreatitis is genuinely being considered

›Glucose and hydration

›Capillary or serum glucose in any lethargic or poorly feeding patient; treat glucose below 3.9 mmol/l

›Targets differ in known diabetes with chronic hyperglycemia; treat symptomatic hypoglycemia regardless of baseline

›HbA1c if diabetes is newly suspected; coagulation profile if anticoagulated or drainage is planned

Microbiology and cause-specific tests

›Direct microbiology

06Diagnostic Tests/dt64

Scoring Systems

›No disease-specific emergency severity score exists for sialadenitis or sialolithiasis

›Decisions rest on airway assessment, presence of a drainable collection, and systemic toxicity

›Pharyngitis scores (Centor, McIsaac) do not apply to this presentation

›Sepsis screening tools apply

›qSOFA 2 or more (systolic 100 mmHg or less, respiratory rate 22/min or more, altered mentation) predicts poor outcome

›SIRS and NEWS2 support disposition but are nonspecific

›LRINEC score if necrotizing neck infection is considered

›Components: C-reactive protein, white cell count, hemoglobin, sodium, creatinine, glucose

›A score of 6 or more raises suspicion and 8 or more is strongly predictive; a low score does not exclude it

›Necrotizing infection is a clinical and operative diagnosis; a low score must not delay exploration

›Stone size and spontaneous passage

›Calculi under about 2 mm usually pass with conservative measures

›Calculi over 4 to 5 mm usually require sialendoscopic or surgical removal

Ultrasound

›First-line imaging; bedside point-of-care ultrasound is appropriate

›No ionizing radiation, repeatable, and the preferred initial test in children and pregnancy

›Guides diagnostic aspiration and drainage

›Positive findings

›Hyperechoic focus with posterior acoustic shadowing indicates a calculus

›Ductal dilatation proximal to an obstructing stone

›Diffuse hypoechoic gland with increased colour Doppler flow in acute sialadenitis

›Hypoechoic or anechoic collection with posterior enhancement and peripheral hyperemia indicates abscess

›Limitations

›Small stones without shadowing and distal intraductal stones can be missed

›Operator dependent; deep parapharyngeal extension is poorly seen

›Non-contrast CT for calculi

›Most sensitive test for salivary stones, including those radiolucent on plain film

›Thin sections through the floor of mouth and the gland

›Contrast-enhanced CT of the neck for significant infection

›Distinguishes phlegmon from a rim-enhancing drainable abscess

›Defines deep neck space and mediastinal extension, airway narrowing, and vascular complications

›Gas within a collection suggests gas-forming organisms or necrotizing infection

›Practical cautions

›Assess and secure the airway first; send an unstable patient only with an escort able to intubate

›Correct hypovolemia before iodinated contrast and check for prior severe contrast reaction

›CT is the practical emergency choice for suspected abscess and for surgical planning

MRI

›Role

›Not first-line in the emergency setting

›Use when CT is contraindicated or when neoplasm or perineural spread is suspected

›Techniques and advantages

›MR sialography shows ductal anatomy and strictures without contrast or radiation

›Superior soft tissue detail for a salivary mass and for adenoid cystic perineural invasion

›Preferred cross-sectional test in pregnancy when ultrasound is insufficient; avoid gadolinium unless essential

›Limitations

›Long acquisition time and limited access make it unsuitable for an unstable airway

›Motion sensitive and often not available after hours

Plain radiography, sialography, and procedural diagnostics

›Plain radiography

›Occlusal and panoramic films detect roughly 70 to 80% of submandibular stones but only about 40% of parotid stones

›A normal plain film never excludes a radiolucent calculus

›Contrast studies

›Conventional and CT sialography are contraindicated during acute infection

›Deferred until inflammation settles, then useful for ductal strictures

›Procedural diagnostics

›Sialendoscopy (ENT, subacute) is both diagnostic and therapeutic for ductal disease

›Diagnostic needle aspiration of a fluctuant collection provides Gram stain and culture and can be therapeutic

›Fine-needle aspiration cytology is an outpatient test for mass lesions; open biopsy risks fistula and facial nerve injury

ECG

›Baseline ECG before QT-prolonging drugs in at-risk patients

›Ondansetron, macrolides, and fluoroquinolones (for example moxifloxacin) each prolong the QT interval

›At-risk: known long QT, structural heart disease, bradycardia, older age, other QT-active drugs

›Electrolyte-driven QT change from this illness

›Vomiting and poor intake cause hypokalemia and hypomagnesemia, prolonging the QT interval and risking torsades de pointes

›Recheck potassium and magnesium and repeat the ECG after repletion and after giving QT-active drugs

›Sinus tachycardia is expected with pain, fever, and hypovolemia

›Look for another cause if it persists after analgesia and rehydration

›New irregular rhythm or ischemic changes warrant a separate cardiac workup

07Disposition/dispo37

Discharge criteria

›Clinical criteria for safe discharge

›Well-appearing, no airway symptoms, no floor-of-mouth or deep neck involvement

›Tolerating oral fluids and oral analgesia with pain controlled

›Afebrile or low-grade fever only, no hemodynamic compromise

›Immunocompetent, no poorly controlled diabetes

›Practical criteria

›Able to obtain and take oral antibiotics if suppurative sialadenitis is diagnosed

›Reliable social situation, transport, and understanding of return precautions

›Documented ENT or primary-care follow-up within 48 to 72 hours

›Antibiotic decision at discharge

›Uncomplicated obstruction without infection needs no antibiotic, only conservative measures

›Mild suppurative sialadenitis: oral amoxicillin-clavulanate (see Treatment)

Admission, observation, and ICU criteria

›Short-stay observation

›Dehydration requiring intravenous rehydration

›Pain or vomiting preventing oral intake

›Diagnostic uncertainty or a trial of intravenous antibiotics before deciding

›Inpatient admission

›Systemic toxicity or sepsis

›Suppurative parotitis in an elderly, diabetic, or immunocompromised patient

›Failure of adequately dosed outpatient therapy

›Abscess requiring drainage or significant comorbidity

›ICU or airway-monitored bed

›Any stridor, voice change, or difficulty managing secretions

›Floor-of-mouth swelling, trismus with dysphagia, or Ludwig angina

›Deep neck space abscess with airway narrowing

›Rapid progression despite therapy, or an awake surgical airway on standby

08Treatment/t156

Critical illness: airway, deep neck space, and sepsis

›Airway management in Ludwig angina and deep neck abscess

›Sit the patient upright; give humidified oxygen to SpO2 94% or higher (88 to 92% in COPD or chronic hypercapnia)

›Mobilize anesthesia and ENT immediately; awake flexible fiberoptic intubation is the preferred technique

›Prepare a double setup for a surgical airway (cricothyrotomy or tracheostomy under local anesthesia)

›Do not give neuromuscular blockade unless the airway is secured or a surgeon is scrubbed for a surgical airway

›Avoid blind nasotracheal intubation: it can rupture an abscess, cause bleeding, or create a false passage

›Temporizing measures while the airway team assembles

›Nebulized racemic epinephrine

›0.5 ml of 2.25% solution in 3 ml sodium chloride 0.9%, nebulized

›May repeat after 20 minutes with continuous cardiac monitoring

›Caution in tachyarrhythmia and ischemic heart disease; it does not replace a definitive airway

›Dexamethasone

›10 mg IV once, then 4 mg IV every 6 hours as an airway-edema adjunct

›Unproven benefit; must not delay intubation or drainage

›Glycopyrrolate 0.2 mg IV as an antisialagogue to improve the view for awake intubation, may repeat 0.1 to 0.2 mg (maximum about 0.8 mg in 24 hours)

›If rapid sequence intubation is unavoidable and a surgical airway is prepared

›Ketamine 1 to 2 mg/kg IV preserves respiratory drive and supports blood pressure

›Rocuronium 1.2 mg/kg IV for rapid, dense paralysis if a paralytic is used

›Have a smaller-diameter tube, bougie, and video laryngoscope ready; anticipate distorted anatomy

›Operative drainage of a deep neck abscess in the operating room once the airway is controlled

›Do not rely on needle aspiration alone for a multiloculated deep-space collection

›Re-image and re-explore if fever and sepsis persist after drainage

›Sepsis recognition and antibiotics

›Screen with qSOFA (systolic 100 mmHg or less, respiratory rate 22/min or more, altered mentation) and lactate

›Give broad-spectrum antibiotics within 1 hour of recognizing sepsis (see the antibiotic subsection)

›Draw two sets of blood cultures first, but do not delay antibiotics to obtain them

›Fluid resuscitation in septic shock

›30 ml/kg balanced crystalloid for hypoperfusion or lactate 4 mmol/l or more, then reassess

›Give in 250 ml aliquots with reassessment in heart failure, end-stage renal disease, or known pulmonary hypertension

›Reassess with focused cardiac and lung ultrasound, capillary refill, and a repeat lactate

›Vasopressors for fluid-refractory hypotension

›Noradrenaline (norepinephrine)

›Start 0.05 microgram/kg/min IV; titrate every 5 minutes toward mean arterial pressure 65 mmHg or higher

›Decelerate to smaller increments as the target is approached to avoid overshoot, then wean once stable

›No absolute maximum; a rising requirement should prompt vasopressin and a search for an undrained source

›Prefer central venous administration; short-term peripheral use through a large proximal vein is acceptable

›Vasopressin 0.03 unit/min IV, fixed dose, added when the noradrenaline requirement is escalating

›Target mean arterial pressure 80 to 85 mmHg in chronic hypertension; individualize in dialysis patients

›Monitoring during resuscitation

›Mean arterial pressure and vasopressor rate at least every 5 minutes during titration, then hourly

›Hourly urine output, mental status, and lactate clearance

›Source control within 6 to 12 hours: drain any abscess and relieve the obstructing focus when feasible

›Iatrogenic harms to anticipate in this condition

›Intubation: distorted, friable anatomy; awake fiberoptic preferred, blind nasotracheal contraindicated, always a double setup

›Sedation: benzodiazepines and propofol can abolish the tone holding a marginal deep-neck airway open

›Neuromuscular blockade: removing respiratory drive before a secured airway risks a can't-intubate can't-oxygenate emergency

›Fluid loading: over-resuscitation worsens airway and oropharyngeal edema; give what perfusion needs and no more

›Oxygen: titrate to SpO2 94% or higher (88 to 92% in COPD); high-flow oxygen does not substitute for a definitive airway

›Vasopressors: for septic shock after fluids only, and not a substitute for source control

›Anticoagulation and antiplatelet agents: hold when drainage or a surgical airway is anticipated; septic internal jugular thrombophlebitis (Lemierre) may itself warrant anticoagulation

›Fibrinolysis and mechanical circulatory support, including intra-aortic balloon pump: no role in this condition

›Analgesia: NSAIDs only after hypovolemia is corrected; opioids depress airway reflexes and should be minimized with deep-space infection

›Corticosteroids: not therapeutic for bacterial sialadenitis; only an airway-edema adjunct and must not delay drainage

Fluid resuscitation and conservative gland measures

›Rehydration for the dehydrated but not shocked patient

›Balanced crystalloid (for example Ringer lactate) or sodium chloride 0.9%, 1 to 2 litres IV titrated to heart rate, blood pressure, and urine output

›Transition to oral intake as soon as swallowing allows

›Smaller aliquots with reassessment in heart failure, end-stage renal disease, or pulmonary hypertension

›Conservative gland measures that resolve most uncomplicated stones and mild sialadenitis

›Oral hydration target 2 to 3 litres per day unless fluid-restricted

›Sialogogues: sour or citrus hard candy, lemon drops, or xylitol gum several times daily and before meals

›Warm compresses over the gland for 15 to 20 minutes, 3 to 4 times daily

›Gland massage from posterior to anterior, milking toward the duct orifice, after each compress

›Chlorhexidine gluconate 0.12% mouthwash, 15 ml swished for 30 seconds twice daily, plus routine oral hygiene

›Medication review

›Stop or substitute xerostomic drugs (anticholinergics, antihistamines, tricyclics, diuretics) where feasible

›Do not attempt blind duct probing or dilatation during acute infection

›What to expect

›Stones under about 2 mm usually pass within 1 to 2 weeks on these measures

›Persistent or enlarging swelling despite 48 to 72 hours of conservative care needs imaging and ENT referral

Analgesia and antiemetics

›Non-opioid analgesia (first line)

›Paracetamol (acetaminophen) 1000 mg PO or IV every 6 hours; maximum 4 g in 24 hours

›Cap at 3 g in 24 hours for age over 65, weight under 50 kg, chronic alcohol use, or hepatic impairment

›Advise a 3 g daily limit for unsupervised outpatient use

›Ibuprofen 400 to 600 mg PO every 6 to 8 hours with food; maximum 2400 mg in 24 hours

›Outpatient over-the-counter limit is 1200 mg in 24 hours without medical advice

›Withhold until hypovolemia is corrected; avoid in acute kidney injury, chronic kidney disease, active GI bleeding, and from 20 weeks of pregnancy

›Ketorolac 15 to 30 mg IV or IM every 6 hours; maximum 120 mg in 24 hours; maximum 5 days

›Reduce to 15 mg every 6 hours with a 60 mg daily maximum for age over 65, weight under 50 kg, or renal impairment

›Same contraindications as other NSAIDs

›Opioids for severe pain not controlled by the above

›Morphine 0.05 to 0.1 mg/kg IV, titrated in 2 mg increments every 10 minutes to effect

›Oxycodone 5 mg PO every 4 to 6 hours as needed, short course only

›Reduce the dose and monitor closely when deep-space infection threatens the airway; opioids blunt protective reflexes

›Antiemetics

›Ondansetron 4 mg IV or orally disintegrating every 8 hours as needed; maximum 8 mg per IV dose

›Avoid with congenital long QT, uncorrected hypokalemia or hypomagnesemia, or other QT-prolonging drugs

›Obtain an ECG first in cardiac patients or those on interacting drugs

›Correct potassium and magnesium before repeat dosing

Antibiotic therapy for acute suppurative sialadenitis

›Antibiotics are not indicated for uncomplicated ductal obstruction without signs of infection

›Reserve antibiotics for fever, expressible pus, cellulitis, or systemic features

›Overuse selects for resistant oral flora

›Empiric target organisms

›Staphylococcus aureus, including MRSA where prevalent

›Viridans and other streptococci

›Oral anaerobes (Prevotella, Fusobacterium, Peptostreptococcus)

›Add gram-negative cover in hospitalized, elderly, diabetic, or immunocompromised patients

›Outpatient, mild, immunocompetent

›Amoxicillin-clavulanate 875/125 mg PO every 12 hours for 7 to 10 days

›Clindamycin 300 to 450 mg PO every 6 to 8 hours for 7 to 10 days for penicillin allergy (anaerobes and many community MRSA strains)

›If MRSA is likely and clindamycin is not used, add trimethoprim-sulfamethoxazole 160/800 mg (one double-strength tablet) PO every 12 hours, or doxycycline 100 mg PO every 12 hours

›Inpatient or systemically ill

›Ampicillin-sulbactam

›3 g IV every 6 hours

›Extend the dosing interval in renal impairment per creatinine clearance

›Alternative: ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 8 hours

›Add vancomycin for MRSA risk, sepsis, or healthcare association

›15 to 20 mg/kg IV every 8 to 12 hours

›Target AUC24/MIC 400 to 600 (or trough 15 to 20 mg/l); check a level before the third or fourth dose

›Hold and redose by level in acute kidney injury; monitor renal function daily

›Piperacillin-tazobactam 4.5 g IV every 6 hours for hospital-acquired infection or immunocompromise (covers Pseudomonas)

›Severe beta-lactam allergy: vancomycin plus aztreonam 2 g IV every 8 hours plus metronidazole 500 mg IV every 8 hours; or moxifloxacin 400 mg IV or PO every 24 hours (anaerobic cover, prolongs the QT interval)

›Duration and de-escalation

›De-escalate to culture-directed therapy once susceptibilities are known

›Total course usually 10 to 14 days depending on drainage and response

›When therapy is not working (no improvement or worsening at 48 to 72 hours)

›Obtain or repeat contrast-enhanced CT to find a drainable abscess or deep-space extension

›Broaden to cover MRSA and resistant gram-negatives and confirm anaerobic cover

›Arrange ENT drainage or sialendoscopy and ensure any obstructing stone is addressed

›Reconsider the diagnosis: neoplasm, mycobacterial or actinomycotic infection, IgG4 disease, lymphoma

›Check adherence, absorption, and whether xerostomic drugs were stopped

Source control and definitive stone management

›Incision and drainage of a fluctuant abscess

›Parotid: incisions parallel to facial nerve branches, performed by ENT

›Submandibular or floor of mouth: intraoral drainage where feasible

›Ultrasound-guided needle aspiration can temporize and provides culture

›Deep neck space and Ludwig angina

›Operative drainage in the operating room after the airway is controlled

›Re-image and re-explore if sepsis persists

›Definitive stone treatment (non-emergent, ENT)

›Distal palpable submandibular stone: transoral duct slitting or stone delivery

›Proximal or hilar stone: sialendoscopy, endoscopic-assisted transoral removal, or basket retrieval

›Small parotid stones: extracorporeal shock wave lithotripsy or sialendoscopy

›Recurrent disease with a damaged, non-functioning gland: gland excision as a last resort

›Bedside measures

›Manual expression only for a stone already visible or palpable at the duct orifice

›Do not probe or dilate an acutely infected duct

Non-bacterial, chronic, and adjunctive management

›Viral parotitis, including mumps

›Supportive care: hydration, analgesia, and antipyretics (paracetamol, dosed as above); no antibiotics

›Droplet precautions and isolation for 5 days after parotitis onset; report to public health

›Watch for orchitis, aseptic meningitis, pancreatitis, and rarely encephalitis or sensorineural deafness

›Autoimmune and infiltrative disease

›Sjögren, sarcoidosis, and IgG4-related disease: outpatient rheumatology referral

›Systemic corticosteroids only under specialist direction

›Persistent unilateral gland enlargement in Sjögren needs biopsy to exclude MALT lymphoma

›Chronic xerostomia predisposing to recurrent sialadenitis

›Pilocarpine 5 mg PO every 6 to 8 hours (maximum 30 mg per day)

›Cevimeline 30 mg PO three times daily as an alternative

›Both contraindicated in uncontrolled asthma, narrow-angle glaucoma, and significant bradyarrhythmia

›Refractory chronic recurrent sialadenitis

›Sialendoscopy with ductal irrigation and, where indicated, steroid instillation by ENT

›Botulinum toxin into the gland, specialist-administered, approximately 15 to 30 units onabotulinumtoxinA per gland, for selected cases

›Radioiodine sialadenitis

›Hydration, sialogogues, gland massage, and NSAIDs at the doses above

›Refer for sialendoscopy if symptoms persist beyond a few weeks

›No role in ordinary bacterial or obstructive sialadenitis

›Systemic corticosteroids

›Routine antivirals

09Special Populations/sp70

Pregnancy

›Imaging

›Ultrasound is first line and sufficient for most stones and abscesses

›Use CT only for a suspected deep neck or airway-threatening infection; do not withhold a needed CT for fear of radiation

›MRI without gadolinium is the preferred cross-sectional test if ultrasound is inadequate

›Antibiotics considered acceptable in pregnancy

›Amoxicillin-clavulanate 875/125 mg PO every 12 hours; cephalosporins; ampicillin-sulbactam 3 g IV every 6 hours

›Clindamycin 300 to 450 mg PO every 6 to 8 hours, or 600 to 900 mg IV every 8 hours

›Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours when MRSA cover is required

›Antibiotics to avoid

›Doxycycline and other tetracyclines (fetal tooth staining and effects on bone)

›Trimethoprim-sulfamethoxazole in the first trimester (folate antagonism, neural tube defects) and near term (kernicterus risk)

›Fluoroquinolones including moxifloxacin (relative contraindication)

›Metronidazole is generally avoided in the first trimester and acceptable later when needed

›Analgesia

›Paracetamol 1000 mg every 6 hours is the preferred analgesic; keep to 3 g in 24 hours

›Avoid NSAIDs (ibuprofen, ketorolac) from 20 weeks (oligohydramnios, ductus arteriosus constriction); limited early use only if essential

›Ondansetron 4 mg IV or orally disintegrating every 8 hours: data are largely reassuring, with a small possible first-trimester cleft signal, so use shared decision-making

›Airway and physiology

›Reduced functional residual capacity and mucosal edema shorten safe apnea time; have the difficult-airway team and smaller tubes ready

›Dehydration from nausea and vomiting of pregnancy promotes salivary stasis; treat it aggressively

Geriatric

›Who is at risk and how it presents

›Acute suppurative parotitis classically affects the dehydrated, debilitated, or postoperative elderly patient

›Higher sepsis and mortality risk than in younger patients

›Presentation is often atypical: delirium or a fall may be the only sign and fever may be absent

›Contributing factors

›Polypharmacy with anticholinergics, diuretics, antihistamines, and antidepressants reduces salivary flow

›Age-related salivary hypofunction

›Prescribing adjustments

›Avoid NSAIDs where possible; if used, ketorolac maximum 60 mg in 24 hours and 5 days or fewer

›Renally dose vancomycin, piperacillin-tazobactam, aztreonam, and trimethoprim-sulfamethoxazole

›Review QT-prolonging combinations before ondansetron, macrolides, or fluoroquinolones

›Disposition and follow-up

›Lower threshold to admit for intravenous fluids and antibiotics

›A firm, persistent gland mass carries higher malignancy risk; ensure ENT follow-up and cross-sectional imaging even after infection settles

›Aspiration risk is increased with oral pain, trismus, and pooled secretions

Pediatrics

›Viral parotitis, especially mumps, is the most common cause in children

›Suspect mumps in the incompletely immunized child; look for bilateral parotitis, orchitis, and aseptic meningitis

›Droplet isolation for 5 days after parotitis onset and public health notification

›Juvenile recurrent parotitis

›Recurrent unilateral or bilateral parotid swelling, typically ages 3 to 6 years, usually self-limited

›Manage conservatively (hydration, massage, sialogogues, analgesia); refer for sialendoscopy if frequent or refractory

›Neonatal suppurative parotitis is rare but serious

›Usually Staphylococcus aureus in a premature or dehydrated neonate; admit for intravenous antibiotics

›Ampicillin monotherapy is inadequate at this age; combine an antistaphylococcal agent with a gram-negative agent

›Nafcillin 25 mg/kg IV every 8 hours (term neonate over 7 days old; every 12 hours if younger or preterm), or vancomycin 15 mg/kg IV every 8 to 12 hours if MRSA is a concern

›Plus cefotaxime 50 mg/kg IV every 8 to 12 hours, or gentamicin 4 to 5 mg/kg IV every 24 hours with level monitoring

›Verify against current neonatal guideline before use

›Other points

›Salivary stones are uncommon in children but do occur; ultrasound is the imaging test of choice

›Bilateral parotid enlargement in a child: test for HIV

›Smaller pediatric airway: lower the threshold for imaging and observation in deep neck infection

›Weight-based supportive dosing

›Isotonic crystalloid bolus 10 to 20 ml/kg, reassess after each bolus

›Verify against current pediatric guideline before use

›Paracetamol 15 mg/kg PO or IV every 6 hours (maximum 75 mg/kg per day, not exceeding 4 g)

›Ibuprofen 10 mg/kg PO every 6 to 8 hours if older than 6 months and well hydrated (maximum 40 mg/kg per day)

›Amoxicillin-clavulanate 45 to 90 mg/kg per day (amoxicillin component) PO divided every 12 hours for mild bacterial sialadenitis

›Clindamycin 30 to 40 mg/kg per day PO or IV divided every 6 to 8 hours for penicillin allergy

›Dextrose 10% 2 to 5 ml/kg IV for glucose below 3.9 mmol/l in a lethargic or poorly feeding child

›Verify against current pediatric guideline before use

›If pediatric rapid sequence intubation is required for airway compromise

›Ketamine 1 to 2 mg/kg IV and rocuronium 1.2 mg/kg IV, with a surgical airway plan sized to the child

›Verify against current pediatric guideline before use

›Nebulized racemic epinephrine 0.05 ml/kg (maximum 0.5 ml) of 2.25% solution in 3 ml sodium chloride 0.9% as a temporizing measure

›Verify against current pediatric guideline before use

›Age-based respiratory rate norms

›Infants under 1 year 30 to 53/min

›Children 1 to 5 years 22 to 37/min

›Children 6 to 12 years 18 to 25/min

›Interpret tachypnea against age, not a single adult threshold

10Background/b39

Epidemiology

›Sialolithiasis is the most common non-neoplastic disorder of the salivary glands

›Estimated annual incidence roughly 1 in 15,000 to 30,000; symptomatic prevalence about 0.45% and autopsy prevalence around 1.2%

›Roughly 80 to 90% arise in the submandibular gland, 5 to 20% in the parotid, and 1 to 7% in the sublingual or minor glands

›Demographics and stone characteristics

›Peak incidence in the third to sixth decades, with a male predominance of about 1.5 to 2 to 1

›Most stones measure 2 to 10 mm; "giant" calculi over 15 mm are rare

›About 70 to 80% of submandibular calculi are radiopaque; roughly 60% of parotid calculi are radiolucent

›Sialadenitis and related conditions

›Acute suppurative sialadenitis accounts for an estimated 0.01 to 0.02% of hospital admissions

›Postoperative parotitis historically carried mortality as high as 20 to 40%; with antibiotics and source control it is much lower but still significant in frail septic patients

›Mumps incidence fell by more than 99% after vaccination, but outbreaks persist in close-contact settings such as universities

›Juvenile recurrent parotitis is the second most common salivary condition in children after mumps, with onset between ages 3 and 6

Pathophysiology

›Stone formation

›Salivary stasis, ductal microinflammation, and altered saliva composition allow an organic nidus to mineralize with calcium phosphate (hydroxyapatite) in concentric layers

›The submandibular gland is predisposed because Wharton duct is long, runs uphill against gravity, and drains more viscous, alkaline, calcium- and phosphate-rich mucous saliva

›Urate stones, which are radiolucent, occur in gout and hyperuricemia

›Obstruction and secondary infection

›A stone obstructs outflow, raising intraductal and intraglandular pressure with acinar atrophy and ductal dilatation

›Stasis permits retrograde migration of oral flora, producing suppurative sialadenitis

›Acute bacterial sialadenitis without a stone

›Reduced salivary flow (dehydration, xerostomic drugs, postanesthetic state, duct obstruction) is the common precondition

›Parotid serous saliva lacks the bacteriostatic mucins, lysozyme, and IgA concentration of submandibular saliva, so the parotid is the gland most prone to ascending infection without a calculus

›Usual organisms are Staphylococcus aureus, streptococci, and anaerobes; gram-negatives and Pseudomonas in hospitalized or immunocompromised patients

›Deep space extension follows fascial planes

›The submandibular space communicates with the sublingual and submental spaces, producing Ludwig angina and airway obstruction by posterosuperior tongue displacement

›Parotid and pharyngeal spaces communicate with the parapharyngeal and carotid spaces and the mediastinum

11Patient Discharge Instructions/pdi32

copy discharge instructions

›What you have

›You have a blocked or inflamed salivary gland (a saliva-making gland in your face or under your jaw), sometimes caused by a small stone in the gland's duct

›Most small stones pass on their own within 1 to 2 weeks with the measures below

›Fluids and gland care

›Drink 2 to 3 litres of water a day unless your doctor has told you to limit fluids

›Suck on lemon drops or sour hard sweets several times a day, especially just before meals, to get the saliva flowing

›Hold a warm compress on the swollen area for 15 to 20 minutes, 3 to 4 times a day

›After the compress, gently massage the gland from back to front, toward your mouth

›Keep your mouth clean: brush your teeth and rinse with warm salt water (half a teaspoon of salt in a cup of water) after meals

›Medicines

›If you were given an antibiotic, take every dose and finish the whole course; take amoxicillin-clavulanate with food

›For pain, paracetamol up to 1000 mg every 6 hours, and no more than 3 g (3000 mg) in 24 hours

›You may add ibuprofen 400 mg with food every 8 hours if your kidneys are healthy and you are not more than 20 weeks pregnant; no more than 1200 mg in 24 hours without medical advice

›Avoid over-the-counter medicines that dry the mouth, such as sedating antihistamines (for example diphenhydramine)

›Come back now or call emergency services if you have

›Difficulty breathing, noisy breathing, or a feeling of your throat closing

›Difficulty swallowing your own saliva, drooling, or a muffled voice

›Swelling of the floor of your mouth or your tongue being pushed up

›Inability to open your mouth

›Rapidly spreading redness or swelling of the neck, or swelling below the jaw on both sides

›Fever above 39 C, shaking chills, neck stiffness, or confusion

›Come back within 24 hours if

›You are no better, or worse, after 48 hours of antibiotics

›Pain or swelling is increasing, or pus is increasing

›You cannot keep down fluids

›Fever continues beyond 48 to 72 hours

›Follow-up

12References/r22

Guidelines and society statements

›Infectious Diseases Society of America

›Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections, 2014 update (Stevens et al.) — principles for Staphylococcus aureus and MRSA coverage and for abscess drainage

›Surviving Sepsis Campaign

›International Guidelines for Management of Sepsis and Septic Shock, 2021 — antibiotics within 1 hour, 30 ml/kg crystalloid for hypoperfusion, noradrenaline first line, mean arterial pressure target 65 mmHg

›Difficult Airway Society

›Guidelines for management of unanticipated difficult intubation in adults, 2015 — approach to the distorted airway in deep neck infection

›Centers for Disease Control and Prevention

›Advisory Committee on Immunization Practices recommendations for MMR vaccine, and the Manual for the Surveillance of Vaccine-Preventable Diseases (Mumps) — case definition, testing, and isolation for 5 days after parotitis onset

›American College of Radiology

›ACR Appropriateness Criteria, Neck Mass–Adenopathy — imaging selection for salivary and neck masses

›American Academy of Otolaryngology–Head and Neck Surgery

›Clinical resources and patient education on salivary gland stones and sialadenitis

Landmark and foundational literature

›Marchal F, Dulguerov P

›Body of work establishing sialolithiasis pathophysiology and sialendoscopy as gland-preserving therapy (Archives of Otolaryngology–Head and Neck Surgery, 2000s)

›Nahlieli O and colleagues

›Case series defining interventional sialendoscopy technique and outcomes for ductal stones and strictures

›Escudier MP, McGurk M

›United Kingdom series on minimally invasive management of submandibular calculi and reduction in the need for gland excision

›Brook I

›Microbiology studies of suppurative parotitis and salivary gland abscess documenting Staphylococcus aureus and anaerobic predominance

›Wong CH and colleagues

›Derivation of the LRINEC score for necrotizing fasciitis, 2004 — used here only as an adjunct, not a rule-out

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.