The clinical presentation of sialadenitis is consistent with the inflammatory state. The most common presenting symptom is swelling, followed by pain.7 Other symptoms include erythema, swelling associated with eating, and tenderness to palpation. Many times, purulence and/or mucus may be expressed by gentle manipulation of the gland and duct. In severe cases, systemic complications can extend into adjacent tissues or spread to distal sites.
Diagnosis of sialolithiasis/sialadenitis can be made by serology or gram stain when viral or bacterial etiologies are suspected. Imaging modalities may be necessary to rule out other life-threatening conditions such as Ludwig angina. These imaging modalities include plain radiographs, ultrasound, computed tomography (CT) with intravenous (IV) contrast, and sialography. In a retrospective case control study by Nahlieli and colleagues, 10 of the 15 cases (67%) of pediatric sialolithiasis were visible as radiopaque objects on radiographic film.15 However, up to 20% of submandibular salivary stones may be radiolucent on plain radiographs.11,16
Ultrasound can confirm the presence of an inflamed gland/duct, identify abscesses, and guide in aspiration, if clinically required.17 Computed tomography is the image modality of choice when abscess formation or systemic complications are suspected. However, information may be limited if the stones are smaller than 2 mm in size, and CT is often discouraged if the stone is palpable on exam.9 However, CT may be used for surgical planning for cases of salivary stones to detect the inflamed gland and identify the size, number of calculi, and location of the stones.17
Sialography is the gold study standard for evaluation of sialolithiasis. It is performed by injecting radiopaque dye into the intraductal system, followed by a plain radiograph. Sialograms are reported to be up to 100% effective in detecting ductal and intraglandular calculi. However, they are contraindicated in the acute phase as a sialogram is thought to aggravate the inflammatory state.8,18
Treatment of sialadenitis is often conservative and targeted toward the suspected etiology. Sialolithiasis causing acute symptoms is initially managed conservatively with broad spectrum antibiotics, analgesics, hydration, warm massage, and sialagogues. Most common bacterial etiologies include gram-positive organisms whereas gram-negatives are less frequently seen. Therefore, penicillin derivatives and cephalosporins will provide appropriate coverage as first-line antibiotics.6 A list of likely organisms is shown in Table 2.
Spontaneous passage is more probable if the salivary stone is small and located in the distal section of the duct.16 In one study, the success rate with conservative management for a period of 3 months was only 10%.19
Surgical removal of salivary stones should be considered if conservative management fails. In a retrospective clinical review by Woo and associates, intraoral submandibular salivary stone removal led to complete recovery in 82.4% of pediatric patients.20 Salivary endoscopy has been validated in pediatrics as a safe and efficacious tool for the diagnosis and treatment of salivary gland disorders.9,15
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