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Neonatal submandibular sialadenitis
7. Bloomer, H. H., and Hawk, A. H.: Speech considerations: speech disorders associated with ablative surgery of the face, mouth and pharynx - - ablative approaches to learning. In Orofacial Anomalies: Clinical and Research Implications: Proceedings of the Conference. ASHA Rep., 8, 1973. 8. Skelly, M., Donaldson, R. C., Fust, R. S., and Townsend, D. L.: Changes in phonatory aspects of glossectomee intelligibility through vocal parameter manipulation. J. Speech Hear. Dis., 37:379-389, 1972. 9. Shedd, D. P.: Rehabilitation problems of head and neck cancer patients. J. Surg. Oncol., 8:11-21, 1976.
10. Minifie, F. D., Hixon, T. J., and Williams, F.: Normal Aspects of Speech, Hearing, and Language. Englewood Cliffs, New Jersey, Prentice-Hall, Inc,, 1973. 11. Lindau, M.: Vowel features. Language, 54:541-563, 1978. 12. West, D. W.: Social adaptation patterns among cancer patients with facial disfigurements resulting from surgery. Arch. Phys. Med. Rehab., 58:473-479, 1977.
Volume 1 Number 3 May 1980
Department of Linguistics California State University Fresno, California 93740 (Dr. Weitzman)
Neonatal Submandibular Sialadenitis WILLIAM W. BANKS, M.D.,* STEVEN D. HANDLER, M.D.,t GORDON B. GLADE, M.D.,* AND H. DIXON TURNER, M.D.§
Abscess of the salivary glands in the neonatal period is a rare occurrence and almost always involves the parotid gland. A case of suppurative sialadenitis and abscess involving the submandibular gland in a neonate is presented. The diagnosis and management of this uncommon disease are discussed. A review of the literature revealed only three cases of isolated submandibular sialadenitis in neonates.
S u p p u r a t i v e sialadenitis in the neonatal period is a rare o c c u r r e n c e and almost always involves the parotid gland. Nearly 100 cases reported in the literature were recently reviewed; however, only three cases of s u b m a n dibular sialadenitis o c c u r r i n g as an isolated lesion in the neonatal period have been r e p o r t e d ) This article describes a fourth case of this unc o m m o n disease.
CASE
REPORT
A 2.35 kg. (5 lb., 3 oz.) w h i t e female was born at 34 w e e k s ' gestation. The p r e g n a n c y was unc o m p l i c a t e d except for c h r o n i c sinusitis for w h i c h the m o t h e r was treated with an antibiotic and d e c o n g e s t a n t d u r i n g the first trimester. The baby was delivered by cesarean section because of the b r o w p r e s e n t a t i o n and r u p t u r e of the
Accepted for publication December 12, 1979. Presented at the Pennsylvania Academy of Otolaryngology and Ophthalmology, Bedford Springs, Pennsylvania, May 18, 1979. *Resident, Department of Otorhinolaryngology and Human Communication, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. tAssistant Professor, Department of Otorhinolaryngology and Human Communication, Children's Haspital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. *Resident, Division of Pediatrics, Department of Medicine, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. ~Assistant Physician, Division of Pediatrics, Department of Medicine, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. American Journal of Otolaryngology- Volume 1, Number 3, May 1980
261
American Journal of Otolaryngology
membranes four days earlier. The mother did not have fever or other signs of sepsis. The infant developed hyperbilirubinemia and remained in the hospital for two weeks for ultraviolet therapy and to insure weight gain. The patient received no blood transfusions. There was no evidence of infection in the infant or infections in the nursery. After going home, the patient appeared to be well for one week, at which time her mother noted a swelling in the right side of the neck. This mass increased in size and was associated with a temperature of 38.1 ° C. The infant, however, continued to take her bottle feedings well in spite of the febrile course. The infant was admitted to another hospital for evaluation. The white blood count was reported as 18,000 with a differential of 68 per cent polymorphonuclear leukocytes and 2 per cent band cells. No therapy was started. After one day the patient was transferred to the Children's Hospital of Philadelphia because of a continued increase in the size of the neck mass. On admission the patient was active, feeding well, and in no acute distress. The rectal temperature was 38.2 ° C., the pulse was 140 beats per minute, and the weight was 2.65 kg. Examina-
Figure 2. Purulent fluid flowing from the duct of the right submandibular gland (arrow).
fion of the ears, nose, and throat showed normal findings. There was a fluctuant tender erythematous mass 4 cm. in diameter in the right submandibular area (Fig. 1). The leukocyte count was 17,000 with 37 per cent polymorphonuclear leukocytes and 4 per cent band cells. Cultures of the blood showed no growth. Needle aspiration of the submandibular mass was performed, and 1 ml. of pus was obtained. Gram staining showed gram positive cocci in clusters. These micro-organisms were identified as Staphylococcus aureus on culture. The patient was given oxacillin, 100 mg. intravenously every six hours, and warm soaks were applied to the right side of the neck. On the day after admission pus was noted oozing from the right submandibular duct and was easily expressed by compression of the submandibular gland (Fig. 2). Culture of the exudate grew Staphylococcus aureus. Given antibiotic therapy, the infant became afebrile within 48 hours, and the submandibular mass showed a steady decrease in size over the one week hospital stay. The patient was discharged and given oxacillin, taken orally, and at a six month follow-up showed no evidence of infection.
COMMENT
Figure 1. Neonate with swelling in the right submandibular triangle (arrow}.
262
Suppurative sialadenitis involving the submandibular gland in the neonate is u n c o m m o n and is usually considered to be a complication of suppurative parotitis. 1 Wells ~ in 1975 reported the first three cases of neonatal submandibular
NEONATAL SUBMANDIBULAR SIALADENITIS
gland infection occurring as an isolated lesion. Our case was the only one noted in a 10 year review of the hospital records of the Children's Hospital of Philadelphia. The etiology of the submandibular suppurative sialadenitis is unclear. The submandibular gland is composed of both mucous and serous elements. The mucus has a bacteriostatic effect and tends to protect the gland from infection. 1 This production of mucus may be the reason infections of the submandibular gland are much less common than those of the parotid gland. The submandibular gland duct is longer than the parotid gland duct, and its ascending course predisposes to the formation of calculi. When the submandibular gland duct is obstructed with sialoliths, the protection by the mucus is apparently less effective, and stasis of the glandular secretion favors the development of infection. In the case presented no ductal stones were demonstrated by palpation or radiographically. On physical examination there was no anatomical deformity of the oral cavity that might predispose to an infection. Dehydration is a common cause of salivary stasis and secondary sialadenitis. Leake and Leake 1 state that only a moderate amount of dehydration is needed in the infant to produce stasis and infection. In our case, however, the infant was feeding well and there was no clinical evidence of dehydration. As in many reported cases, our patient was premature, being born at 34 weeks' gestation. Thirty to 40 per cent of the patients with suppurative parotitis are premature.1 The reason for the association of prematurity and salivary gland infection is not known. Although Staphylococcus aureus is the most common responsible micro-organism, other bacteria have been cultured in neonatal sialadenitis. Streptococci, Escherichia coli, Pseudomanas aeruginosa, and Neisseria catarrhalis have been reported as causative agents. 1 It is therefore imperative that Gram staining and cultures with antibiotic sensitivities be obtained to ensure proper treatment. The source of the staphylococcus is unclear. The skin of neonates commonly becomes colonized with staphylococcus within a few hours after birth, yet staphylococcal infections are uncommon in neonates. 3" 4 The mother had no evidence of staphylococcal infection and did not nurse the infant. The presence of ruptured membranes for four days prior to delivery could have
WILLIAM W. BANKS ET AL.
been a cause of neonatal infection. However, the micro-organisms that usually cause neonatal sepsis under such circumstances are gram negative rods. 4 The infant's prolonged hospital stay could have contributed to the infection, although no staphylococcal infection was reported in the newborn nursery or delivery room. Our case is illustrative that dissemination of the infection is uncommon and signs of systemic response are minimal in neonates with salivary gland infection. The temperature elevation was slight, no growth occurred on the blood cultures, and the infant continued to feed well. The diagnosis of submandibular sialadenitis can easily be made on clinical grounds. As in the case described, the patient presents with a warm erythematous mass in the submandibular area. The diagnosis is confirmed by expressing purulent material from the duct of the submandibular gland with compression of the submandibular mass. Wells, 2 however, admonishes that manipulation of the involved gland should be done with care to prevent septicemia. With appropriate antibiotic therapy, the clinical course is one of steady improvement with resolution usually occurring in one week. Only occasionally are incision and drainage required. Recurrence of the infeciton is uncommon.
Volume 1 Number 3 May 1980
SUMMARY A case of submandibular sialadenitis and abscess in the neonatal period is presented. The diagnosis can easily be made on clinical grounds. The most common micro-organism cultured is Staphylococcus aureus. The infection resolves quickly following appropriate antibiotic therapy.
References 1. Leake, D., and Leake, R.: Neonatal suppurative parotitis. Pediatrics, 46:203-207, 1970. 2. Wells, D.: Suppuration of the submandibular salivary glands in the neonate. Am. J. Dis. Child., 129:628-630, 1975. 3. Wilson, M. G., Armstrong, D. H., Nelson, R. C., and Boak, R. A.: Prolonged rupture of fetal membranes. Am. J. Dis. Child., 107:138-146, 1964. 4. Alojipan, L. C., and Andrews, B. F.: Neonatal sepsis. Clin. Pediatr., 14:181-185, 1975. Department of Otolaryngology and Human Communication Children's Hospital of Philadelphia 34th Street and Civic Center Boulevard Philadelphia, Pennsylvania 19104 (Dr. Handler)
263
10. Minifie, F. D., Hixon, T. J., and Williams, F.: Normal Aspects of Speech, Hearing, and Language. Englewood Cliffs, New Jersey, Prentice-Hall, Inc,, 1973. 11. Lindau, M.: Vowel features. Language, 54:541-563, 1978. 12. West, D. W.: Social adaptation patterns among cancer patients with facial disfigurements resulting from surgery. Arch. Phys. Med. Rehab., 58:473-479, 1977.
Volume 1 Number 3 May 1980
Department of Linguistics California State University Fresno, California 93740 (Dr. Weitzman)
Neonatal Submandibular Sialadenitis WILLIAM W. BANKS, M.D.,* STEVEN D. HANDLER, M.D.,t GORDON B. GLADE, M.D.,* AND H. DIXON TURNER, M.D.§
Abscess of the salivary glands in the neonatal period is a rare occurrence and almost always involves the parotid gland. A case of suppurative sialadenitis and abscess involving the submandibular gland in a neonate is presented. The diagnosis and management of this uncommon disease are discussed. A review of the literature revealed only three cases of isolated submandibular sialadenitis in neonates.
S u p p u r a t i v e sialadenitis in the neonatal period is a rare o c c u r r e n c e and almost always involves the parotid gland. Nearly 100 cases reported in the literature were recently reviewed; however, only three cases of s u b m a n dibular sialadenitis o c c u r r i n g as an isolated lesion in the neonatal period have been r e p o r t e d ) This article describes a fourth case of this unc o m m o n disease.
CASE
REPORT
A 2.35 kg. (5 lb., 3 oz.) w h i t e female was born at 34 w e e k s ' gestation. The p r e g n a n c y was unc o m p l i c a t e d except for c h r o n i c sinusitis for w h i c h the m o t h e r was treated with an antibiotic and d e c o n g e s t a n t d u r i n g the first trimester. The baby was delivered by cesarean section because of the b r o w p r e s e n t a t i o n and r u p t u r e of the
Accepted for publication December 12, 1979. Presented at the Pennsylvania Academy of Otolaryngology and Ophthalmology, Bedford Springs, Pennsylvania, May 18, 1979. *Resident, Department of Otorhinolaryngology and Human Communication, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. tAssistant Professor, Department of Otorhinolaryngology and Human Communication, Children's Haspital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. *Resident, Division of Pediatrics, Department of Medicine, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. ~Assistant Physician, Division of Pediatrics, Department of Medicine, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. American Journal of Otolaryngology- Volume 1, Number 3, May 1980
261
American Journal of Otolaryngology
membranes four days earlier. The mother did not have fever or other signs of sepsis. The infant developed hyperbilirubinemia and remained in the hospital for two weeks for ultraviolet therapy and to insure weight gain. The patient received no blood transfusions. There was no evidence of infection in the infant or infections in the nursery. After going home, the patient appeared to be well for one week, at which time her mother noted a swelling in the right side of the neck. This mass increased in size and was associated with a temperature of 38.1 ° C. The infant, however, continued to take her bottle feedings well in spite of the febrile course. The infant was admitted to another hospital for evaluation. The white blood count was reported as 18,000 with a differential of 68 per cent polymorphonuclear leukocytes and 2 per cent band cells. No therapy was started. After one day the patient was transferred to the Children's Hospital of Philadelphia because of a continued increase in the size of the neck mass. On admission the patient was active, feeding well, and in no acute distress. The rectal temperature was 38.2 ° C., the pulse was 140 beats per minute, and the weight was 2.65 kg. Examina-
Figure 2. Purulent fluid flowing from the duct of the right submandibular gland (arrow).
fion of the ears, nose, and throat showed normal findings. There was a fluctuant tender erythematous mass 4 cm. in diameter in the right submandibular area (Fig. 1). The leukocyte count was 17,000 with 37 per cent polymorphonuclear leukocytes and 4 per cent band cells. Cultures of the blood showed no growth. Needle aspiration of the submandibular mass was performed, and 1 ml. of pus was obtained. Gram staining showed gram positive cocci in clusters. These micro-organisms were identified as Staphylococcus aureus on culture. The patient was given oxacillin, 100 mg. intravenously every six hours, and warm soaks were applied to the right side of the neck. On the day after admission pus was noted oozing from the right submandibular duct and was easily expressed by compression of the submandibular gland (Fig. 2). Culture of the exudate grew Staphylococcus aureus. Given antibiotic therapy, the infant became afebrile within 48 hours, and the submandibular mass showed a steady decrease in size over the one week hospital stay. The patient was discharged and given oxacillin, taken orally, and at a six month follow-up showed no evidence of infection.
COMMENT
Figure 1. Neonate with swelling in the right submandibular triangle (arrow}.
262
Suppurative sialadenitis involving the submandibular gland in the neonate is u n c o m m o n and is usually considered to be a complication of suppurative parotitis. 1 Wells ~ in 1975 reported the first three cases of neonatal submandibular
NEONATAL SUBMANDIBULAR SIALADENITIS
gland infection occurring as an isolated lesion. Our case was the only one noted in a 10 year review of the hospital records of the Children's Hospital of Philadelphia. The etiology of the submandibular suppurative sialadenitis is unclear. The submandibular gland is composed of both mucous and serous elements. The mucus has a bacteriostatic effect and tends to protect the gland from infection. 1 This production of mucus may be the reason infections of the submandibular gland are much less common than those of the parotid gland. The submandibular gland duct is longer than the parotid gland duct, and its ascending course predisposes to the formation of calculi. When the submandibular gland duct is obstructed with sialoliths, the protection by the mucus is apparently less effective, and stasis of the glandular secretion favors the development of infection. In the case presented no ductal stones were demonstrated by palpation or radiographically. On physical examination there was no anatomical deformity of the oral cavity that might predispose to an infection. Dehydration is a common cause of salivary stasis and secondary sialadenitis. Leake and Leake 1 state that only a moderate amount of dehydration is needed in the infant to produce stasis and infection. In our case, however, the infant was feeding well and there was no clinical evidence of dehydration. As in many reported cases, our patient was premature, being born at 34 weeks' gestation. Thirty to 40 per cent of the patients with suppurative parotitis are premature.1 The reason for the association of prematurity and salivary gland infection is not known. Although Staphylococcus aureus is the most common responsible micro-organism, other bacteria have been cultured in neonatal sialadenitis. Streptococci, Escherichia coli, Pseudomanas aeruginosa, and Neisseria catarrhalis have been reported as causative agents. 1 It is therefore imperative that Gram staining and cultures with antibiotic sensitivities be obtained to ensure proper treatment. The source of the staphylococcus is unclear. The skin of neonates commonly becomes colonized with staphylococcus within a few hours after birth, yet staphylococcal infections are uncommon in neonates. 3" 4 The mother had no evidence of staphylococcal infection and did not nurse the infant. The presence of ruptured membranes for four days prior to delivery could have
WILLIAM W. BANKS ET AL.
been a cause of neonatal infection. However, the micro-organisms that usually cause neonatal sepsis under such circumstances are gram negative rods. 4 The infant's prolonged hospital stay could have contributed to the infection, although no staphylococcal infection was reported in the newborn nursery or delivery room. Our case is illustrative that dissemination of the infection is uncommon and signs of systemic response are minimal in neonates with salivary gland infection. The temperature elevation was slight, no growth occurred on the blood cultures, and the infant continued to feed well. The diagnosis of submandibular sialadenitis can easily be made on clinical grounds. As in the case described, the patient presents with a warm erythematous mass in the submandibular area. The diagnosis is confirmed by expressing purulent material from the duct of the submandibular gland with compression of the submandibular mass. Wells, 2 however, admonishes that manipulation of the involved gland should be done with care to prevent septicemia. With appropriate antibiotic therapy, the clinical course is one of steady improvement with resolution usually occurring in one week. Only occasionally are incision and drainage required. Recurrence of the infeciton is uncommon.
Volume 1 Number 3 May 1980
SUMMARY A case of submandibular sialadenitis and abscess in the neonatal period is presented. The diagnosis can easily be made on clinical grounds. The most common micro-organism cultured is Staphylococcus aureus. The infection resolves quickly following appropriate antibiotic therapy.
References 1. Leake, D., and Leake, R.: Neonatal suppurative parotitis. Pediatrics, 46:203-207, 1970. 2. Wells, D.: Suppuration of the submandibular salivary glands in the neonate. Am. J. Dis. Child., 129:628-630, 1975. 3. Wilson, M. G., Armstrong, D. H., Nelson, R. C., and Boak, R. A.: Prolonged rupture of fetal membranes. Am. J. Dis. Child., 107:138-146, 1964. 4. Alojipan, L. C., and Andrews, B. F.: Neonatal sepsis. Clin. Pediatr., 14:181-185, 1975. Department of Otolaryngology and Human Communication Children's Hospital of Philadelphia 34th Street and Civic Center Boulevard Philadelphia, Pennsylvania 19104 (Dr. Handler)
263