Indian Pediatrics 2001; 38: 87-89
Suppurative Submandibular Sialadenitis in a Neonate
Acute suppurative infection of the salivary glands is a rare entity during the neonatal period and it almost always involves the parotid glands(1). Infection of the sub-mandibular gland is rare(2). Till 1999, only six cases of submandibular suppurative sialade-nitis have been reported in the neonatal period(3). No case has been reported from India. We here report a neonate with staphylo-coccal sialadenitis of the submandibular gland.
A ten-day-old male child was brought with history of poor feeding and lethargy for 4 days. He was born at home at 30 week’s gestation, by vaginal route and was on breast feeds since birth. At admission, he weighed 1.3 kg and was hypothermic. Neonatal reflexes were sluggish. Rest of the systemic examina-tion was unremarkable. Investigations revealed a positive C reactive protein and neutrophilic leukocytosis. Radiograph of the chest and CSF examination were unremark-able. Along with supportive treatment, he was started on intravenous cefotaxime (100 mg/kg) and gentamicin (5 mg/kg) for suspected sepsis. After initial correction of hypothermia, he developed fever and at about 8 hours of admission, he was noticed to have swelling of the right submandibular gland. Examination of the oral cavity revealed pus oozing from the opening of the right Whartons duct below the tongue. There was no involvement of the parotid gland. Inspite of receiving antibiotics, size of the swelling continued to increase and it became fluctuant. Incision and drainage of the abscess yielded about 10 ml of pus and it grew Staphylococcus aureus, which was sensitive to cefotaxime and netilmycin. Blood culture was sterile and HIV serology was negative. Swelling decreased significantly by 10 days of admission and he was discharged after 14 days of antibiotic therapy. There is no recurrence of submandibular swelling during follow up.
Bacterial sialadenitis occurs frequently in adults, but it is also known to occur in neonates and children(1). The parotid being a serous gland is more susceptible to infection due to stasis of salvia. By contrast, submandibular gland produces both mucous and serous secretions and the former is thought to be baceriostatic, hence submandibular gland is less susceptible to infections compared to parotid gland(4). Although, involvement of submandibular glands as a complication of suppurative parotitis was known for many years, isolated submandibular suppurative sialadenitis in neonates was first reported in 1975(5).
The disease is usually seen during the first two weeks of life. Various predisposing factors for sialadenitis in adults and older children are poor oral hygiene and post operative state. In neonates, prematurity, congenital anomalies and prolonged orogastric feeding have been associated with suppurative parotitis(5), the same may be true for suppuration of sub-mandibular glands. Long term exclusive orogastric feeding may result in reduced reflex salivary gland stimulation, decreased saliva production and thus ductal clearance of saliva, causing functional ductal obstruction and local inflammation(6). The index case was preterm and was not taking feeds properly for a few days. Other than these factors, septicemia may have been responsible for sialadenitis. In a review of 20 cases of suppurative parotitis in children, no case was post-operative and none of the neonates had recurrent attacks of sialadenitis(7). Therefore, it can be concluded that sialastasis rather than sialolithiasis plays an important role in the causation of sialadenitis in neonates.
Submandibular sialadenitis usually presents as swelling, induration and erythema over the gland. The submandibular salivary glands are present in the submaxillary triangle, medial and inferior to the ramus of the mandible. The ducts of these glands open in the floor of mouth, just lateral to the frenulum of the tongue. Therefore, a diagnosis of submandibular sialadenitis can be confirmed by visualizing purulent material coming from the Wharton’s duct(5). During examination, the salivary gland should be massaged gently to decrease the chances of seeding organisms into the blood stream.
Various organisms known to cause sialade-nitis are Staphylococcus aureus, Streptoco-ccus pyogenes, Streptococcus viridans, Escherichia coli, Pseudomonas aeruginosa and Neisseria catarrhalis(4). Most of the cases of sialadenitis respond well to antibiotics and response usually starts within a week. If improvement is not prompt or there is increasing fluctuation, surgical incision and drainage should be done. Infection with S. aureus carries good prognosis(5). While 54% cases of sialadenitis in a series(4) were due to S. aureus, all those who died (5/15) had infection with organisms other than S. aureus.
Any premature neonate, who is dehydrated, septicemic or is on prolonged orogastric feeds, should be observed carefully for evidence of sialadenitis.
Contributors: MS worked up the case and drafted of the paper. BP helped in drafting the paper. KC and DS helped in data collection and writing of the manuscript.