Children with cervical adenitis may present with an acutely tender and inflamed cervical lymph node that will appear as neck swelling, similar to this case presentation. It is usually related to a recent upper respiratory infection and mainly affects the submandibular or anterior cervical lymph nodes.3 Pus is usually not visible in the roof of the mouth, unlike with sialadenitis.
Brachial cleft cysts may present as a painless, unilateral neck mass, unless they have become secondarily infected. Although present at birth, many cases of brachial cleft cysts do not become evident until later in childhood or adolescence.4
Finally, sialolithiasis are salivary stones that can occlude the salivary ducts and lead to inflammation and infection, or sialadenitis. These patients present with neck swelling, pain, fevers, and occasionally drainage from the salivary ducts. Sialolithiasis causing sialadenitis was diagnosed in this patient due to classic presentation and supporting lab work and imaging.
Diagnosis: sialadenitis and sialolithiasis
Sialadenitis is defined as inflammation of the salivary glands and can be caused by infection, obstruction, or less commonly autoimmune or allergic processes. Sialadenitis in the pediatric population accounts only for up to 10% of all salivary gland disease.5 A multitude of factors contribute to inflammation of the salivary glands including viral or bacterial infections, genetics, immunologic diseases, congenital abnormalities, dehydration, and allergies.6 Additional predisposing factors include sialolithiasis (or salivary stones), mucus plugs, stenosis, or foreign bodies.5 Sialolithiasis is a common etiology in the adult population. However, the prevalence of sialolithiasis in the pediatric population is thought to be as low as 3% of all cases.7
Sialadenitis is a multifactorial process with multiple etiologies. Francis and Larsen composed a list of sialadenitis etiologies (Table 2) and included major causes such as viral, bacterial, immune, or traumatic.6 Prior to the measles/mumps/rubella (MMR) vaccine, viral sialadenitis was most commonly caused by mumps and affected the parotid gland. This has become less common with immunization efforts. Less common viral etiologies include Epstein-Barr virus (EBV), parainfluenza, and human immunodeficiency virus (HIV). Bacterial sialadenitis is most commonly caused by Staphylococcus aureus and Streptococcus species and presents with acute swelling, presence of pus, fever, and leukocytosis.8 Ductal stenosis can lead to obstructive sialadenitis and is more common in the parotid ductal system.9 Juvenile recurrent parotitis (JRP) is an important immunologic cause of sialadenitis and is thought to be the third-most common salivary disease in children, after mumps and viral infection.
While discussing sialolithiasis, it is important to understand the mechanism that leads to sialadenitis. Obstruction via a salivary stone causes inflammation, salivary stasis, postobstructive dilation, tissue damage, and remodeling that causes further inflammatory changes. Several theories have been proposed on how the salivary stone forms. One theory, proposed by Bodner and colleagues, states salivary mucin, bacteria, and desquamated epithelial cells form an initial organic nidus in which material deposits, forming a salivary stone.10,11 Another theory states the initiating factor is an infection, which changes salivary composition and leads to stone formation.12
The most common location for stone formation in the pediatric population is the submandibular gland. A study by Chung and colleagues of 29 pediatric patients demonstrated that the submandibular gland was affected in more than 90% of cases.12 This finding is similar to studies in adults. Another study by Lustmann and colleagues revealed the submandibular gland was affected in 94% of patients of all ages.7 Possible reasons why the submandibular gland is most often affected may be due to slower flow of secretions as well as higher calcium content.13 The parotid gland is the second-most common location and rarely the sublingual and minor salivary glands are involved.14 Sialolithiases in children are usually smaller, occur distally within the duct, and present with shorter symptoms duration.12,15
1. Chou YK, Lee CY, Chao HH. Upper airway obstruction emergency: Ludwig angina. Pediatr Emerg Care. 2007;23(12):892-896.
2. Garcia-Salido A, Unzueta-Roch JL, Garcia-Teresa MÀ, Sirvent-Cerdá S, Martinez de Azagra-Garde A, Casado-Flores J. Pediatric disseminated Lemierre syndrome in 2 infants: not too young for an ancient disease. Pediatr Emerg Care. 2017;33(7):490-493.
3. Margileth A. Cervical adenitis. Pediatr in Rev. 1985;7(1):13-24.
4. Chavan S, Deshmukh R, Karande P, Ingale Y. Branchial cleft cyst: a case report and review of literature. J Oral Maxillofac Pathol. 2014;18(1):150.
5. Jabbour N, Tibesar R, Lander T, Sidman J. Sialendoscopy in children. Int J Pediatr Otorhinolaryngol. 2010;74(4):347-350.
6. Francis CL, Larsen CG. Pediatric sialadenitis. Otolaryngol Clin North Am. 2014;47(5):763-778.
7. Lustmann J, Regev E, Melamed Y. Sialolithiasis: a survey on 245 patients and a review of the literature. Int J Oral Maxillofac Surg. 1990;19(3):135-138.
8. Brook I, Frazier EH, Thompson DH. Aerobic and anaerobic microbiology of acute suppurative parotitis. Laryngoscope. 1991;101(2):170-172.
9. Faure F, Querin S, Dulguerov P, Froehlich P, Disant F, Marchal F. Pediatric salivary gland obstructive swelling: sialendoscopic approach. Laryngoscope. 2007;117(8):1364-1367.
10. Bodner L, Azaz B. Submandibular sialolithiasis in children. J Oral Maxillofac Surg. 1982;40(9):551-554
11. McCullom C 3rd, Lee CY, Blaustein DI. Sialolithiasis in an 8-year-old child: case report. Pediatr Dent. 1991;13(4):231-233.
12. Chung MK, Jeong HS, Ko MH, et al. Pediatric sialolithiasis: what is different from adult sialolithiasis? Int J Pediatr Otorhinolaryngol. 2007;71(5):787-791.
13. Wallace E, Tauzin M, Hagan J, Schaitkin B, Walvekar RR. Management of giant sialoliths: review of the literature and preliminary experience with interventional sialendoscopy. Laryngoscope. 2010;120(10):1974-1978.
14. Bodner L, Fliss D. Parotid and submandibular calculi in children. Int J Pediatr Otorhinolaryngol. 1995;31(1):35-42.
15. Nahlieli O, Eliav E, Hasson O, Zagury A, Baruchin AM. Pediatric sialolithiasis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(6):709-712.
16. Williams MF. Sialolithiasis. Otolaryngol Clin North Am. 1999;32(5):819-834.
17. Orlandi MA, Pistorio V, Guerra PA. Ultrasound in sialadenitis. J Ultrasound. 2013;16(1):3-9.
18. Rice DH. Diseases of the salivary glands–non-neoplastic. In: Bailey BJ, Johnson JT, Kohut RI, et al, eds. Head and Neck Surgery—Otolaryngology. Vol 1. Philadelphia, PA: JB Lippincott; 1993:475-484.
19. Iro H, Zenk J, Koch M. Modern concepts for the diagnosis and therapy of sialolithiasis [article in German]. HNO. 2010;58(3):211-217.
20. Woo SH, Jang JY, Park GY, Jeong HS. Long-term outcomes of intraoral submandibular stone removal in children as compared with adults. Laryngoscope. 2009;119(1):116-120.