Caring for children in the ED can be challenging for certain.  Managing the critically ill child requires a lot of skill and action (ex, Can’t Intubate, Can’t Ventilate and Hypercyanotic Spell).  Remaining vigilant for the subtly sick takes a lot of energy and contemplation (ex, Subtle Signs of Heart Failure, Osteosarcoma, and Inborn Errors in the ED).  While these two groups make our job challenging, often I find the relatively “simple” conditions to be surprisingly challenging;  they can generate a number of questions that perhaps I wasn’t ready to answer.  As many of us (in the USA anyway) salivate over our Thanksgiving meals, let us consider the “seemingly simple” condition of Sialadenitis and Parotitis.

Sialadenitis: Basics

• Sialadenitis = inflammation of the salivary glands.

• Saliva is important! It plays a role in:
  • Digestion, lubrication, and taste
  • Tooth intergrity
  • Defense against bacterial (secretion of IgA)

• There are Numerous Salivary Glands
  • Parotid Gland
    • Largest of the glands
    • Stensen duct travels parallel to the zygoma, ~1cm inferior to it, and exist opposite the 2nd mandibular molar. [Francis, 2014]
    • Produces two-thirds of stimulated salivation.
    • Lower rate of secretion.
    • Produces primarily serous, watery saliva
    • More likely to become inflamed due to infectious and autoimmune reasons.
  • Submandibular Gland
    • 2nd largest of the glands
    • Wharton duct exits the floor of the mouth near the frenulum of the tongue. [Francis, 2014]
    • Produces two-thirds of the constant salivation.
    • Produced mixture of mucinous and watery saliva.
      • Mucinous saliva aids in lubrication, mastication, and swallowing.
    • More likely to become inflamed by obstructive processes, like stones.
  • Sublingular Glands
    • Multiple smaller glands.
    • Have very small ducts without a dominant duct. [Francis, 2014]
  • Minor Salivary Glands
    • Scattered in the oral cavity and oral pharynx.

Sialadenitis: Causes

• Variety of factors can lead to sialadenitis and often due to multi-factorial processes leading to a “salivary gland inflammatory cycle”.  [Francis, 2014]
  • Sequence of events that decrease saliva flow, increase inflammation, generate ductal dysfunction, and increase mucinous saliva.
  • Predisposing factors = infection, structural abnormality, immune factors, dehydration.

• Infectious
  • Viral
    • Mumps
      • Vaccination has made this much less common, but outbreaks do occur.
      • Systemic illness… so look for other systems that may be involved.
    • EBV
    • HIV
    • Parainfluenza
  • Bacterial
    • Staph, Strep, H. flu, E. coli, Bacteroides
    • Most commonly occurs in the Parotid Gland. [Francis, 2014]
• Immunologic
  • Sjogren Syndrome [Baszis, 2012]
    • Chronic inflammatory disease of the exocrine glands.
    • Dry mouth and dry eyes are common.
  • HIV
    • Can cause bilateral involvement (think of this with bilateral parotitis)
    • Often glands are NOT tender.
  • IgA deficiency
  • Juvenile rheumatoid arthritis
  • Ankylosing spondylitis
  • Sarcoidosis [Banks, 2013]
  • Ulcerative colitis
  • Bulimia Nervosa Sialadenosis (unclear etiology, but may be first presentation)
• Trauma
  • Local obstruction from stones
    • Relatively uncommon in children.
    • Submandibular gland involved in majority of cases (higher amount of mucoid saliva production).
  • Penetrating injuries
  • Blunt injuries
  • Radiation injury

Sialadenitis: Presentation

• Swelling, pain, fever, and erythema of the affected gland.
• Trimus and Pain with mastication
• Purulence may be expressed from the associated duct.  [Francis, 2014]
• Inspissated mucus may also mimic purulence.

Sialadenitis: Recurrent?

• Recurrent or chronic sialadenitis has been associated with several autoimmune disorders.   [Francis, 2014; Baszis, 2012]
• Causes are, again, likely must-factorial (structural, infectious, obstruction, inflammatory, etc).
• Juvenile Recurrent Parotitis is a common cause.
  • True incidence is unknown, but thought to be the second most common cause of salivary disease in children worldwide (after Mumps).  [Francis, 2014; Patel, 2009]
  • Has two peaks in age of presentation: ages 2-6 years and at age of puberty.
  • Self-limited and resolves spontaneous after puberty.  [Francis, 2014]
• Diagnostic sialendoscopy can be useful to help diagnose and manage. [Ramakrishna, 2015]

Sialadenitis: Management

• Diagnosis is primarily a clinical one!  (It’s awesome when you don’t need to order tests!)
• Treatment is typically conservative:  [Francis, 2014]
  • Pain management 
  • Adequate hydration
    • Dehydration exacerbates inflammatory process.
    • Dehydration makes mucoid saliva more prominent.
  • Warm massage
  • Sialogogues
  • Treat underlying autoimmune / inflammatory disorder.
  • Appropriate antibiotics
    • While bacterial infection may not have initiated the condition, it is difficult to deny the possibility of its involvement.
    • If able to express material from duct, send purulence / inspissated mucus for Gram Stain and Culture.  [Francis, 2014]
    • Antistaphylococcal penicillinases-resistant antibiotics should be started while awaiting culture results.
  • Patients with co-morbidities, fever, or leukocytosis may benefit from inpatient, IV antibiotics. [Stong, 2005]

• If medical therapies fail, or there is concern for localized complication: [Stong, 2005]
  • May need to image:
    • Ultrasound
      • Considered 1st line option by many.
      • Can help evaluate the gland and abscess formation.
      • May illustrate a stone, but may still miss smaller stones. [Francis, 2014]
    • CT
      • Likely needed if surgical options need to be considered.
  • Surgical options:
    • Stone retrieval and ballon dilation
    • Lithotripsy
    • Gland excision – has become less common
    • Sialendoscopy – has become preferred option

Moral of the Morsel

• The “seemingly simple” conditions occurring in a complex organism (like us Humans) can be less than straight forward.
• Don’t dismiss sialadenitis as a simple infection and throw antibiotics at it. It is multifactorial and may not merely be an antibiotic deficiency. Keep other etiologies in mind, especially when educating families about it.
• Recurrent parotitis / sialadenitis warrants additional consideration and referral.

References