Images in Emergency Medicine
Article Outline
[Ann Emerg Med. 2007;50:13.]
An 18-year-old man presented for swelling and pain in the left submandibular region, associated with fever. Physical examination demonstrated prominent swelling of the left submandibular region, with redness, warmth and tenderness to palpation (Figure 1). No intraoral swelling or protrusion of the tongue was noted. Total WBC count was increased, at 15,000 cells per cubic millimeter with 75% neutrophils. Bedside ultrasonography was performed (Figure 2). Subsequent intravenous contrasted computed tomography of the neck was obtained (Figure 3).
Figure 1.
Left submandibular swelling and erythema.
Figure 2.
Bedside ultrasonography of left submandibular swelling.
Figure 3.
Intravenous contrasted computed tomography of the neck. Used with permission of Justin B. Williams, MD, San Antonio Uniformed Services Health Education Consortium Emergency Medicine Residency Program, Brooke Army Medical Center, Fort Sam Houston, TX.
Diagnosis
Acute submandibular sialadenitis with infected sialocele. Sialadenitis is acute inflammation of the salivary gland, predominantly infectious in origin but occasionally autoimmune in cause. The parotid gland is much more commonly affected than the submandibular salivary glands.1 Frank cellulitis may be present, potentially complicated by an obstructed salivary gland, resulting in formation of a sialocele or abscess.
Treatment of these patients may be altered by bedside ultrasonography by determining the presence or absence of a fluid collection.2 If a fluid collection is present, surgical drainage is indicated. If one is absent, antibiotics with close follow-up is indicated.1
Staphylococcus aureus is the most commonly cultured organism in sialadenitis, but other intraoral aerobes, anaerobes, and viruses have been implicated.3 Patients with acute sialadenitis may appear toxic, and the condition may be life threatening, with abscess formation or infectious involvement of the deep spaces of the neck.
Our patient underwent surgical drainage and resection of the submandibular salivary gland, complicated by subsequent development of a submandibular phlegmon. Methicillin-resistant staphylococcus aureus was the causative agent. The patient recovered completely after administration of intravenous antibiotics.
References
- . Inflammatory disorders of the salivary glands. In: Cummings CW editors. Otolaryngology Head and Neck Surgery. 4th ed.. St. Louis, MO: Mosby; 2005;p. 1323–1324
- Sonography of the salivary glands. Eur Radiol. 2003;13:964–975
- . Acute viral and bacterial infections of the salivary glands. Otolaryngol Clin North Am. 1999;32:793–811
For the diagnosis and teaching points, see page 24.To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com
The conclusions and opinions reported by the authors do not necessarily reflect the official position of the US Department of Defense or the United States Army.
PII: S0196-0644(06)02541-8
doi:10.1016/j.annemergmed.2006.11.017
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
