Treatment of Chronic Sialadenitis by Intraductal Penicillin or Saline

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J Oral Maxillofac Surg 62:431-434, 2004

Treatment of Chronic Sialadenitis by Intraductal Penicillin or Saline

Demetrios Antoniades, MD, PhD,*

John D. Harrison, PhD, FRCPath,†

Apostolos Epivatianos, DDS, PhD,‡

and Panayotis Papanayotou, MD, PhD§

Purpose: We sought to describe the treatment of chronic sialadenitis by intraductal penicillin or saline.

Patients and Methods: The study group consisted of 32 males and 23 females with chronic submandibular sialadenitis aged 12 to 65 years and 16 males and 11 females with chronic parotitis aged 8 to 65 years who were treated by intraductal instillation of penicillin or saline.

Results: In the patients with submandibular sialadenitis, 44 patients treated with penicillin and 11 treated with saline became symptom free; symptoms recurred in 3 treated with penicillin, of whom 2 became symptom free after further instillations and 1 after removal of a sialolith at the ductal orifice; and follow-up of 22 patients verified that 18 treated with penicillin and 4 with saline had been symptom free for 1 to 15 years and 1 to 3 years, respectively. In the patients with parotitis, 18 patients treated with penicillin, 8 treated with saline, and 1 treated with both became symptom free;

symptoms recurred in 1 treated with penicillin and 1 with saline, both of whom became symptom free after further instillations; and follow-up of 15 patients verified that 11 treated with penicillin, 3 with saline, and 1 with both had been symptom free for 1 to 14 years, 2 to 12 years, and 3 years, respectively.

Conclusion: The intraductal instillation of penicillin or saline is a simple and surprisingly successful technique for the treatment of chronic sialadenitis.

Interest in therapies other than sialadenectomy for the treatment of chronic sialadenitis is burgeoning because of the high cost of sialadenectomy in terms of morbidity and economics.^1-6The ability of the glands to recover functionally or to be symptom free after the removal of obstruction has been shown experimentally

and clinically,^1-5,7-10 and many of the submandibular glands removed because of sialadenitis are normal his- tologically.^6,11Recent experimental and clinical investigations have described the etiologic importance of secretory inactivity, obstruction by normally occurring microsialoliths, ascending infection and inflammatory obstruction, and the successful adaptation of the parenchyma to the adverse environment.^11-14

Requests from patients in Thessaloniki, Greece, for conservative treatment of chronic sialadenitis led to the adaptation of a technique that had been reported by Quinn and Graham¹⁵ in 1973 and involved the intraductal instillation of antibiotics for the treatment of recurrent suppurative parotitis, which had been successful in all of their 10 patients without recurrence for follow-ups of up to 100 months. The appli- cation of this technique to the treatment of chronic submandibular sialadenitis and chronic parotitis in Thessaloniki was so successful that its use was con- tinued. There is now a sufficient number of patients with sufficiently long follow-ups, as well as some surprising findings, to call for the present communi- cation. The purpose of this study was to assess the long-term outcome of this method.

*Professor, Department of Oral Medicine and Oral Pathology, Dental School, Aristotle University of Thessaloniki, Thessaloniki, Greece.

†Reader, Department of Oral Pathology, GKT Dental Institute, King’s College, London, England.

‡Associate Professor, Department of Oral Medicine and Oral Pathology, Dental School, Aristotle University of Thessaloniki, Thessa- loniki, Greece.

§Professor, Department of Oral Medicine and Oral Pathology, Dental School, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Address correspondence and reprint requests to Dr Harrison:

Department of Oral Pathology, Floor 28, Guy’s Tower, Guy’s Hos- pital, London SE1 9RT, England; e-mail: [email protected]

doi:10.1016/j.joms.2003.07.007

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Patients and Methods

PATIENTS

The patients were treated in the Department of Oral Medicine of the University of Thessaloniki and consisted of 55 patients with chronic submandibular sialadenitis and 27 patients with chronic parotitis.

Diagnosis was established by clinical history and ex- amination that included radiography and sialography.

The symptoms included discomfort and swelling that were often related to meals and discharge of mucopus; plain radiographs were often successful in reveal- ing sialoliths, and sialographic changes included ductal dilatation and reduced filling of secondary and tertiary ducts. Penicillin was instilled into Wharton’s duct in 44 patients, in 2 of whom it was instilled bilaterally, and into Stensen’s duct in 18 patients. The results were such that saline alone was instilled into Wharton’s duct in 11 patients and into Stensen’s duct in 8 patients, and penicillin and subsequently saline were instilled into Stensen’s duct in 1 patient.

INTRADUCTAL INSTILLATION

The orifice of the duct was dilated with a lacrimal probe and the duct cannulated with No. 19 polyeth- ylene tubing for the submandibular gland and No. 21 for the parotid. The solution consisted either of 1 million IU of penicillin G in 5 mL of normal saline or of normal saline alone and was instilled until the patient was aware of discomfort or enlargement of the gland was observed. Reflux of the solution was prevented by pressure of the fingers of the free hand on the orifice of the duct during the instillation and subsequently for 5 to 10 minutes depending on the tolerance of the patient. The volume of the solution varied from 0.5 to 1.5 mL for the submandibular gland and from 1.5 to 2 mL for the parotid gland.

The number and frequency of the instillations were determined initially by the clinical symptoms and subsequently by the therapeutic response.

OTHER TREATMENT

Acute symptoms were treated with oral antibiotic before the instillations were started. Accessible ductal sialoliths were intraorally removed surgically.

FOLLOW-UP

Patients were discharged once free from symptoms and were requested to return if there was any return of symptoms. Follow-up was undertaken in 2002 by telephone and the patients contacted were asked if they had experienced any further symptoms since their last visit to the clinic.

Results

CHRONIC SUBMANDIBULAR SIALADENITIS

The ages of the 55 patients with chronic submandibular sialadenitis ranged from 12 to 65 years at the start of treatment (32 males and 23 females), and the duration of symptoms ranged from 4 days to 20 years.

In 2 patients, the disease was bilateral.

The 44 patients treated with instillation of penicillin were given 2 to 19 instillations (average, 7.1 instillations) over periods of 1 to 36 weeks (average, 6.8 weeks). The 11 patients treated with instillation of saline were given 1 to 10 instillations (average, 4.0 instillations) over periods of up to 8 weeks (average, 3.1 weeks).

Radiopaque sialoliths were identified in 35 patients and, after the start of the course of instillations, were discharged spontaneously in 13 and surgically removed at the orifice of the duct in 7.

The time of clearance after sialography was mea- sured before and after the instillations, which were of penicillin, in 24 patients and clearance varied from 5 to 45 minutes before and from 1 to 5 minutes after, which was always a reduction from clearance before.

Three patients presented with recurrent symptoms at 27 months, 29 months, and 5 years after instillations of penicillin. They were treated by 4 instillations of penicillin over 10 weeks, surgical removal of a sialolith at the orifice of the duct, and 6 instillations of saline over 44 weeks, respectively.

Contact was made with 22 of the 55 patients whose submandibular glands had been treated. Twenty had been symptom free since the original course of instillations, which were of penicillin in 16 and of saline in 4, for between 1 and 15 years (average, 11.8 years) and 1 and 3 years (average, 1.5 years), respectively.

The other 2 had been symptom free since the recur- rences at 27 months and 5 years for 8 and 2 years respectively.

CHRONIC PAROTITIS

The ages of the 27 patients with chronic parotitis ranged from 8 to 65 years at the start of treatment, 16 were male and 11 were female, and the duration of symptoms ranged from 1 day to 10 years.

The 18 patients treated with instillation of penicillin were given 2 to 28 instillations (average, 8.4 instillations) over periods of 1 week to 2 years (average, 15.6 weeks). The 8 patients treated with instillation of saline were given 4 to 10 instillations (average, 6.9 instillations) over periods of 1 to 12 weeks (average, 6.4 weeks). The 1 patient who was treated with instillation of penicillin and saline was given 4 instillations of penicillin followed by 2 of saline over a period of 3 weeks.

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One patient developed sensitivity to penicillin after 5 instillations that were given over a period of 4 weeks, which nevertheless successfully treated the sialadenitis.

Radiopaque sialoliths were identified in 8 patients, and after the start of the course of instillations, 1 was surgically removed at the orifice of the duct.

The time of clearance after sialography was mea- sured before and after the instillations, which were of penicillin, in 3 patients and was 30 minutes before and 2 minutes after in 1 and 1 minute both before and after in the other 2.

One patient presented with recurrent symptoms 18 months after instillations of saline and was treated with 1 instillation of saline, and 1 patient presented with recurrent symptoms 8 years after instillations of penicillin and was treated with 6 instillations of penicillin over 3 weeks.

Contact was made with 15 of the 27 patients whose parotid glands had been treated. Fourteen had been symptom free since the original course of instillations, which were of penicillin in 10, of saline in 3, and of both in 1 for between 1 and 14 years (average, 9.3 years) and 2 and 12 years (average, 6.0 years) and for 3 years, respectively, although 1 patient reported that a sialolith had been discharged from the duct but that there had been no other symptoms. The other one had been symptom free since the recurrence at 8 years for 3 years.

Discussion

Recent clinical and experimental investigations^11-13,16 have supported the original notion of Ku¨ttner¹⁷that sialoliths are secondary to chronic sialadenitis. How- ever, these investigations have revealed that microsialoliths, which are unrelated to sialoliths, are important in the etiology of chronic sialadenitis. Microsialo- liths have now been extensively investigated; a mi- crosialolith is defined as “a concretion that is only seen microscopically and is most often calcified.”¹² They have been found to occur in normal salivary glands and may become impacted in small intraglan- dular ducts and cause foci of obstructive atrophy.

These foci are havens for ascendant microbes that proliferate there to cause surrounding inflammation, the edema of which compresses and thereby ob- structs the secretory parenchyma to cause further atrophy that becomes associated with further infection until chronic sialadenitis is present. Then sialoliths are able to form in the stagnant mixture of secretion rich in calcium and debris in the large in- terlobular ducts that are partially obstructed by the inflammatory edema. This etiology explains the surprising discovery that many cases of chronic submandibular sialadenitis are of normal histologic appear-

ance,^6,11 because these are glands that appear to be sensitive to small increases of pressure caused by focal inflammation, which is nevertheless seen in most symptomless glands as focal collections of inflammatory cells that are part of the normal histologic appearance.¹¹Thus, the finding of a normal histologic appearance in many cases of chronic sialadenitis is no more than a manifestation of the wide variation in sensory perception in the glands.

The good results with instillation of penicillin in the present investigation could be considered to be ex- plained by the opinion of Quinn and Graham¹⁵ that intraductal instillation allows the antibiotic to reach microbes remaining in the parenchyma, whereas systemic antibiotic is adequate for resolution of the acute symptoms but cannot remove infected purulent ma- terial in the ducts that remains to cause subsequent exacerbation of symptoms. However, the equally good results after instillation of saline cast doubt on this and indicate that irrigation itself is the more important factor. Quinn and Graham¹⁵ also stressed the therapeutic value of irrigation, which may explain the therapeutic value of diagnostic sialography, which was recently confirmed.¹⁸Further support for the value of irrigation is given by Baurmash,¹⁹ who found irrigation with saline together with systemic steroid to be a most successful therapy for chronic parotitis. Furthermore, Baurmash¹⁹presented strong evidence that plasma proteins leak into the lumina of the inflamed glands and the albumin forms a coagu- lum, which is often mistaken for mucopus, and will of itself cause obstruction. Therefore, there are several possible ways to explain the effectiveness of the instillate of saline: it could 1) flush out the obstructing coagulated albumin, 2) dilute and flush ascendant microbes out of fibrotic atrophic foci into regions where the microbicidal capacity of the gland is effec- tive against these avirulent commensals, 3) dilate ducts and thus allow small sialoliths to be passed, and 4) dislodge sialoliths adherent to the walls of ducts.

Quinn and Graham¹⁵ instilled local anesthetic before and with the antibiotic, which was not done in the present investigation in order to decrease the possibility of significant overfilling of an anaesthetized gland. The increase in size of the glands observed during instillation is likely to be due not only to dilatation of the lumina of the ducts and acini but also to passage of fluid between acinar cells into the inter- stitium, which has been found to occur during ductal instillation of fluids into salivary glands²⁰and indicates that the instillate is likely to reach all parts of the gland.

The improved functional response to sialography after the courses of ductal instillation is likely to be a manifestation of a loss of the obstruction caused by the inflammatory edema, which appears to be of par-

ANTONIADES ET AL 433

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ticular importance in chronic sialadenitis.¹¹ Such a loss of obstruction is the likely cause of the sponta- neous expulsion of sialoliths. However, some of the glands were symptomless despite the persistence of sialoliths and a persistence of sialoliths after lithotripsy and other conservative treatment has been found to be compatible with freedom from symptoms,^1-3,5,7as has lack of normal function.^1,7

There is an increased likelihood of an accumulation of microsialoliths and resultant obstructive foci as well as an ascent by microbes in an inactive gland,^11,13 which indicates the importance of the maintenance of good salivary secretory activity not only as a therapy but also as a prophylactic against sialadenitis.

The intraductal instillation of antibiotic or saline has much to offer in the treatment of chronic sialadenitis. It would be interesting to further investigate the surprising effectiveness of saline as the instillate and the role of irrigation and systemic steroid¹⁹in the treatment of chronic sialadenitis.

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