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Nonsurgical Management of Amlodipine International Journal of Dental and Health Sciences Case Report Volume 02, Issue 05 SUBMANDIBULAR BACTERIAL SIALADENITIS: A CASE REPORT R. Pradeepalakshmi Ganesh1, Ramasamy2, Ravi David Austin3 1. Post Graduate student, Department of Oral Medicine and Radiology, Rajah Muthiah Dental College and Hospital, Annamalai University 2. Professor, Department of Oral Medicine and Radiology, Rajah Muthiah Dental college and Hospital, Annamalai University. 3. Professor & Head, Department of Oral Medicine and Radiology, Rajah Muthiah Dental college and Hospital, Annamalai University. ABSTRACT: Acute bacterial Sialadenitis, a painful and inflammatory infection preferentially affects parotid and submandibular gland. Though commonly caused by bacteria, the etiology ranges from simple infection to autoimmune disorders. Though it affects both parotid and submandibular gland, submandibular sialadenitis is an uncommon condition with an infrequent discussion in literature, unlike sialadenitis of the parotid gland. The management belies mainly on early administration of antimicrobial therapy and surgical drainage if deemed necessary. This case report describes a case of acute suppurative submandibular sialadenitis without a common predisposing factor, and its management. Key words: Submandibular gland, Bacterial sialadenitis, Suppurative sialadenitis, infection. INTRODUCTION: opening the mouth and pus exudation through duct orifice in suppurative A variety of factors affect the conditions. susceptibility of the salivary glands to bacterial infection, among them salivary CASE DETAIL: flow rate, composition of saliva and A 35 year old female patient reported to varying damage to their ductal systems the Department of Oral Medicine and are the most common predisposing Radiology, Rajah Muthiah Dental College, factors [1]. Deterioration of host defence Annamalai University, Chidambaram, inevitably renders the salivary glands Tamil Nadu with a complaint of painful susceptible to haematogenous infections. swelling in the left side of neck region, The common factors are older age, since 10 days. The swelling was gradual in debilitation and dehydration. The site and onset, initially smaller and progressed size of parotid and submandibular glands slowly to attain the present status. She renders them prone to infection. The had a similar swelling before one month in suggested proportion of submandibular the same site, with concurring pain irt 38, sialadenitis incidence is about 10% of all which was treated with antibiotics and 38 cases of sialadenitis [2]. The common was extracted. Then the swelling subsided features are swelling of the gland, pain and she remained normal for two weeks. and tenderness, occasionally difficulty in *Corresponding Author Address: Dr R.Pradeepalakshmi Ganesh.Email: [email protected] Ganesh P. et al., Int J Dent Health Sci 2015; 2(5): 1345-1349 Thereafter, the present swelling started the swelling was normal. On palpation, it before 10 days. A moderate and was firm in consistency and tender, and intermittent pain was present that temperature was not raised. aggravates on eating. She reported a Intraorally, diffuse swelling was yellowish discharge from the floor of the seen in the left floor of the mouth, with a mouth on pressing the swelling. No size of approximately 2.5cm diameter. history of fluctuations in size was Anteroposterior extension was from revealed. There was concurrent fever with lingual frenum to lingual vestibule of 36 swelling, but the fever had subsided region, from vestibule to midline medio- before one week by the medications laterally. The mucosa over the swelling prescribed by her dentist. However, the appeared erythematous. Wharton’s duct swelling remained unresponsive to the orifice was inflamed. medications. Figure 2: Erythematous, inflamed Wharton’s duct With all those clinical findings, following entities were considered in our differential diagnosis—acute or chronic sialadenitis, sialolith, space infections, Figure 1: Image of left submandibular benign lymphoepithelial lesion, swelling. lymphadenitis, and benign salivary gland neoplasms. On clinical examination, a single well defined swelling was present in the Routine hematological investigations were left submandibular gland region, below within normal limit. The occlusal view of the lower border of body of the mandible, left side of mandible revealed normal elliptical in shape, with a diameter of morphological structure of alveolus. No 2×3cm in size approximately. It extends soft tissue calcifications seen in the anteroposteriorly from 1cm behind the submandibular region. No aspirate was parasymphysis to 1cm beyond the angle obtained with wide bore needle. of mandible and superioinferiorly, below the inferior border of mandible to the level of second thyroid cartilage. Skin over 1346 Ganesh P. et al., Int J Dent Health Sci 2015; 2(5): 1345-1349 Based on the history, clinical examination and investigations the case was diagnosed as acute bacterial sialadenitis. Broad spectrum antibiotics (amoxicillin and clavulanic acid) and anti- inflammatory were prescribed and Figure 3: Occlusal view of left side of reviewed after 5 days. The swelling mandible. reduced in size and there was no pus discharge and pain. Ultrasonography of left and right submandibular gland revealed normal right submandibular gland, of size of about 28×14mm approximately, with no evidence of nodes. Left submandibular gland revealed mixed echogenecity with increased vascularity and the gland is enlarged in size of about 35×20mm Figure 6: Mid-Treatment review` ` approximately. No calcifications seen. Medications were continued till the total Ultrasonography was suggestive of disappearance of the swelling. Post enlarged left submandibular gland with treatment ultrasonography revealed infection. essentially normal study of both the glands in size, shape, echotexture and vascularity. Thus, a final diagnosis of acute submandibular sialadenitis was confirmed. Figure 4: USG scan showing enlarged left submandibular gland. Figure 5: Color doppler showing increased vascularity. Figure 7: Post –treatment USG showing normal study of the gland 1347 Ganesh P. et al., Int J Dent Health Sci 2015; 2(5): 1345-1349 DISCUSSION: poor oral hygiene potently increases the vulnerability of the gland to infection. Sialadenitis is characterized by an inflammatory enlargement of one or more Most often the diagnosis of salivary glands, caused by virus or submandibular sialadenitis is made by the bacteria. It exits in both acute and chronic history and clinical features of the lesion. forms. Though it preferentially affects Further investigations like radiograph and parotid and submandibular glands, the ultrasound helps to rule out sialolithiasis, submandibular sialadenitis is uncommon wharton’s duct abnormalities and [2]. The common predisposing factors of glandular neoplasm. submandibular sialadenitis are sialolithiasis and xerostomia [1]. Although The microscopic features in the sialoliths frequently occur in earliest stages of sialadenitis are submandibular gland, bacterial vasodilatation, with increased neutrophils sialadenitis occurs frequently in parotid in the vessels, emigrating into the gland because the submandibular gland is parenchyma and ducts. Colonies of protected putatively by high level of bacteria is seen particularly in the ducts. mucin (antimicrobial) in saliva and In the advanced stages of infection, the protective role of tongue by cleaning the ducts become dilated with neutrophils. floor of the mouth. The causative The destruction of duct epithelium and organisms include Staphylococcus aureus, acini occurs, leading to formation of streptococci, pseudomonous aeruginosa, microabscesses. With impairement of Escherichia coli. Amongst them host immune responses, parenchymal staphylococcus aureus is the frequently destruction progresses and fusion of isolated strain [3]. microabscesses leads to gross abscess formation and destruction of gland. Often The clinical signs and healing occurs by fibrosis of the gland [3]. symptoms of sialadenitis include fever, chills, localized painful firm swelling of the Ultrasonogram helped us to rule affected gland area, with redness of the out the anatomical abnormalities of overlying skin. Other constitutional Wharton’s duct, mechanical obstruction features include a foul taste in the mouth, of salivary duct secondary to a sialolith dry mouth, decreased mobility of the and confirmed as submandibular gland jaw, and a general ill feeling. Pus drainage swelling discerned from lymph node through the gland duct may also present. pathology. The increased size and Debilitating condition, dehydration, vascularity of the gland gave us a malnourishment, autoimmune diseases, suspicion of adenoma. The good and recovery after surgery, certain prognosis to antibiotic treatment and the medications increase the risk normal study of gland in post-operative considerably. The salivary duct stone and ultrasonogram confirmed our diagnosis of bacterial sialadenitis. 1348 Ganesh P. et al., Int J Dent Health Sci 2015; 2(5): 1345-1349 More interestingly, in our case Sometimes abscess formation may there is no any predisposing factor but require surgical drainage [6]. The long-term there was an antecedent alveolar abscess, outlook (prognosis) for sialadenitis is quite the relationship between them has to be good with the prompt diagnosis and an ascertained. appropriate treatment. The treatment for sialadenitis is the CONCLUSION: administration of antibiotics specifically Submandibular
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