INFECTIOUS DISEASES | CASE REPORT

MANAGEMENT OF LEFT SUBMANDIBULAR ABSCESS

DUE TO SIALOLITH: A CASE REPORT
Rani Septikasari∗,1 , Lucky Riawan∗∗ and Melita Sylvyana∗∗
∗ Resident, Oral and Maxillofacial Surgery Department, RSUP Dr. Hasan Sadikin, College of Dental Medicine, University of Padjajaran, Bandung 40161,
Indonesia., ∗∗ Staff, Oral and Maxillofacial Surgery Department, RSUP Dr. Hasan Sadikin, College of Dental Medicine, University of Padjajaran, Bandung
40161, Indonesia

ABSTRACT Context: Submandibular abscess is an inflammation accompanied by pus formation in the submandibular
region. The source of infection in the submandibular space may be originated from the infection process of the teeth,
the floor of the mouth, pharynx, submandibular lymph nodes, sialadenitis, lymphadenitis, oral laceration or mandible
fracture. Sialolithiasis is the most common cause of salivary gland obstruction leading to painful swelling and recurs
most frequently in the submandibular gland and its ducts. Case report: Reporting a case of submandibular abscess due
to sialolith admitted from Hasan Sadikin Hospital Emergency Room, Bandung; came in with the complaint of swelling in
the left lower jaw, repeatedly occurred since ±2 years prior to admission (PTA), ±2 weeks PTA patient felt the swelling in
the left lower jaw does not disappear even while the patient is not eating, no history of toothache. Management done
includes incision and drainage, tooth extraction, administration of antibiotics and parenteral analgesics. Discussion:
Submandibular abscess caused by sialolith may be occurred due to the presence of substances/debris, bacteria from the
oral cavity that migrated into the salivary duct will be isolated with additional stagnant of saliva for a long time causing
infection, resulting in frequent findings of suppurative secretions from the ductal orifice in the floor of the mouth. Poor
oral hygiene, advanced age, the declining general condition of the patient, and the presence of purulent bacteria are the
causes of transformation from an infection to an abscess. Treatment of submandibular abscess must be adequate, done
with incision and drainage, extraction of the tooth suspected of being the focus of infection, administration of antibiotics
and parenteral analgesics. The next definitive therapy to address the sialolith is sialoadenectomy. Conclusion: Sialoliths
are often found in the submandibular glands, untreated sialoliths can cause widespread infections not only in the gland
itself but spreading into the submandibular space. Submandibular abscess due to sialolith rarely occured. In this case,
the patient developed a significant improvement due to prompt and appropriate initial treatment.
KEYWORDS Submandibular abscess, Sialolith, Antibiotics, Incision and drainage

Introduction

An abscess is a collection of pus which is located in a sac formed

in the tissue caused by an infection process by bacteria, parasites
or other foreign bodies. An abscess is a defence mechanism that
Copyright © 2020 by the Bulgarian Association of Young Surgeons aims to prevent infectious agents from spreading to other parts
DOI:10.5455/IJMRCR.Management-Left-Submandibular-Abscess
of the body. Pus itself is a collection of dead local tissue cells,
First Received: August 07, 2020
Accepted: September 24, 2020
white blood cells, infectious organisms or foreign bodies and
Associate Editor: Ivan Inkov (BG); toxins produced by organisms and blood cells.
1
Resident, Oral and Maxillofacial Surgery Department, RSUP Dr. Hasan Sadikin,
College of Dental Medicine, University of Padjajaran, Bandung 40161, Indonesia;
A submandibular abscess is an inflammation accompanied
Email: drg.raniseptikasari@yahoo.co.id by pus formation in the submandibular region. This condition is

Rani Septikasari et al./ International Journal of Medical Reviews and Case Reports (2020) 4(9):65-68
part of the deep neck infection. In general, the source of infection
in the submandibular space comes from the infection process of
the teeth, the floor of the mouth, pharynx and submandibular
lymph nodes. This may also occur as an extension from another
deep neck infection.[1,2,3]. 70 - 85% of cases are caused by
infection from the teeth, while the rest is caused by sialadenitis,
lymphadenitis, oral laceration or mandible fracture. In addition,
the higher incidence was also found in an areas with incomplete Fig. 1: Preoperative (a, b, and c) extraoral profile showing
health facilities. swelling in the left submandibular area (d) Intraoral images
Sialoliths are the formation of a calcified structure that de- showing remaining root canals.
veloped in the salivary glands or ducts originated from accu-
mulated debris in the calcium-filled duct lumen. Debris in-
cludes mucus, bacteria, ductal epithelial cells or foreign bodies.
Sialolithiasis is a condition characterized by an obstruction of
the salivary glands or its excretory ducts due to the formation of
calcareous sialoliths. The condition is usually associated with
swelling, pain, and infection of the affected glands, which results
in salivary ductal ectasia (Debnath and A.K., 2015). Sialolithiasis
is the most common disease of the major salivary glands after
mumps and causing 30% of all salivary disorders. About 0.01-
1.0% of the population is affected, with a higher incidence in Fig. 2: (a) Thorax x-ray, there was no signs of cardiomegaly with
men aged between 30 and 60 years. More than 80% of salivary no signs of specific pulmonary active processes (b dan c) Soft tis-
sialolithiasis occur in the submandibular ducts or glands, 6-15% sue neck AP-Lateral x-ray, there was an opaque image with soft
occur in the parotid gland, and around 2% are in the sublingual tissue density and lucent image in it in the submandibular area
salivary glands and minor salivary glands (Moghe et al., 2012). supporting diagnosis of mandibular abscess (d) Left Sialography
The condition will cause mechanical blockage and swelling of image.
the salivary glands, which in turn, will cause salivary gland
infection leading to chronic sialadenitis.
The etiology of sialolithiasis is still unknown, but some patho- mandibular region measuring 7cm×2cmx1cm. On palpation, the
genesis can be used to explain the occurrence of this disease. affected area was warm, tender and fluctuating, and redder than
First, the excretion of intracellular microcalculi into the ductal the surrounding tissue. On intraoral examination, there was re-
canal that developed into calcified nidus. Second, the possibil- maining root canals 24.47.48 and cavities 35, 38 and spontaneous
ity of substances and bacteria from the oral cavity that migrate drainage in the floor of the left mouth. (Figure 1)
into the salivary duct developing into calcified nidus. Both of
Laboratory findings showed decrease level of hemoglobin,
these hypotheses act as triggers for organic nidus which then de-
hematocrit and increase level of RBC, platelets and urea. Patient
velop into a buildup of organic and inorganic substances. Other
was then referred to Internal Medicine for consultation.
hypothesis includes the occurrence of a biological process of
stone formation, which is seen from decreased glandular secre- Based on clinical and diagnostics examination, our patient
tion, changes in electrolytes level, and decreased glycoprotein was diagnosed with a left submandibular abscess due to sialolith
synthesis. All of this may happen due to cell membrane decay and chronic apical periodontitis due to gangrene radix tooth
secondary to aging. 24,47,48 and pulp necrosis 38,35. Extraction and incision
drainage were done to the patient with local anasthesia. Prior to
that, pus was aspirated for the purpose of culture and sensitivity
Case report
(Figure 3).
Female patients, 78-year-old, came in with the complaint of
There was a significant improvement of patient’s condition,
swelling in the left lower jaw. The swelling repeatedly occurred
and the patient was discharged on day three hospitalization.
since ± 2 years PTA, occurs when the patient eats and disappears
On post-op day 63 (Figure 4), patient came in for a follow-up
after eating. ± 2 weeks PTA patient complained of swelling in
at Oral and Maxillofacial Surgery Out-patient Clinic RSHS for
the left lower jaw that persisted even after eating. There was no
sialoadenectomy with general anesthesia.
complaint of tooth pain, and the patient did not take any medi-
cations for her complaint. ±3 days PTA patient complained that
the swelling is gradually enlarging accompanied with dyspha-
gia. ± 12 hours PTA patient complained that the swelling was
getting even bigger, accompanied by yellow and salty discharges
coming out of the mouth. The patient then seeks consultation
at Santo Yusuf Hospital, Ahmad Yani, and was given one medi-
cation (Amoxicillin). The patient was referred to the RSHS for
further evaluation and management.
On physical examination, the patient was alert and con-
scious. Vital signs, blood pressure: 120/80 mmHg, pulse
rate: 83×/minutes, temperature: 36,6 C, respiratory rate:
24x/minutes, SpO2:97% room air. On extraoral examination, Fig. 3: (a and b) Intra and extraoral pus aspiration c. Specimen
there was an asymmetrical face with swelling in the left sub- sent for culture and sensitivity.

Rani Septikasari et al./ International Journal of Medical Reviews and Case Reports (2020) 4(9):65-68

Fig. 3: d) Intraoral incision and drainage; e) Intraoral pendrose
drain application.
Fig. 4: Patient’s clinical picture on post-op day 63.
Discussion
In this case, from patient’s history it is known that there was
swelling since two weeks PTA without any history of tooth pain
followed with spontaneous drainage in the oral cavity, excluding
the tooth from the cause of the abscess. Patient’s swelling has
repeatedly occurred since ± 2 years PTA, developed when the
patient eats and disappears again after eating. This occurrence
of the intermittent pain and swelling of the glands are the most
common complaints of a mealtime syndrome. When appetite
increase, increase salivary secretions will followed, while there
is an obstruction in the drainage through the duct resulting in
stagnation that causes pain and swollen glands.
Swelling occurred in the last 2 years, with patient’s age of
78-year-old patient supported one hypothesis of the process of
sialolith formation that there was a biological process of stone
formation, involving decreased glandular secretion, changes in
electrolyte level, and decreased glycoprotein synthesis where
all this occurred due to cell membrane decay secondary to ag-
ing process. Sialolith was found in the left submandibular
gland. There are two important factors for the high incidence
of sialolithiasis in the submandibular gland. First, the salivary
properties produced by the submandibular gland contained a lot
of mucins, organic matter, phosphatase enzymes, calcium, phos-
phate, alkaline pH, and low carbon dioxide. Second, anatomical
factors including long and curved warthon’s duct, the position of
the orifice are higher than the duct, and the duct size is smaller
than the lumen. Both of these factors support the process of
calcification in the submandibular duct, causing sialolithiasis.
Sialolith as the cause of submandibular abscess may be pos-
sible due to the presence of substances/debris, bacteria from
the oral cavity that migrated into the salivary duct that will
be isolated with additional stagnant of saliva for a long time
causing infection, resulting in frequent findings of suppurative
secretions from the ductal orifice in the floor of the mouth. Some-
Rani Septikasari et al./ International Journal of Medical Reviews and Case Reports (2020) 4(9):65-68
times patient’s will also have symptoms of systemic infection.
In the advanced stage, stagnation causes atrophy of the sali-
vary glands, which causes hyposalivation, leading to fibrosis.
Infection that develops into an abscess in this patient is due
patient’s old age and poor general condition causing a decrease
in immune system, poor oral hygiene and the involvement of
purulent bacteria.
Radiological examination done to the patient were Sialo-
graph x-ray, Soft tissue head AP lateral x-ray, and chest x-ray.
Panoramic X-ray was not done because the cause of the sub-
mandibular abscess is not from the teeth. Chest x-ray exam-
ination needs to be done for evaluation of the mediastinum,
subcutaneous emphysema, pushing of the respiratory airway,
and pneumonia due to abscess aspiration. A complete blood
count will detect an increase in leukocytes as a sign of infection.
Arterial blood gas analysis can also be done to assess airway ob-
struction. Culture and sensitivity test must be done to determine
the type of microorganism and the appropriate antibiotics. High-
dose antibiotics for aerobic and anaerobic microorganisms must
be given parenterally. Abscess evacuation may be performed
under local anaesthesia for superficial and localized abscesses
or through exploration with general anesthesia if the location of
the abscess is deep and extensive.[1,4]
The administration of antibiotics should be based on the re-
sults of cultures and sensitivity tests for specific bacteria causing
the infection. However, culture results usually take a long time,
while treatment must be given immediately. Parenteral antibi-
otics should be given as soon as possible without waiting for
the results of the culture. Combination of antibiotics (covering
aerobes and anaerobes, gram-positive and gram-negative) are
the best choice because the microorganism might be a mixture of
various germs. Empirically, the combination of ceftriaxone and
metronidazole is sufficient. Antibiotics may be adjusted after
the results of the sensitivity test is out.[1,4]
Based on the sensitivity test, aerobic bacteria have a high
sensitivity rate to Cefoperazone-sulbactam, Moxifloxacin, Cef-
operazone, and Ceftriaxone, for more than 70% rate. Metronida-
zole and clindamycin have high sensitivity rate, especially for
gram-negative anaerobic bacteria. Antibiotics are usually given
for ± 10 days.[1]
The incision is made where it fluctuates depending on the lo-
cation and area of the abscess. Patients then are hospitalized for
1-2 days until the signs and symptoms of infections subside.[1.4]
Basically, the treatment of abscesses is incision and drainage. The
incision is a surgical way of creating an exit for the pus (with
a scalpel). Drainage is exploratory surgery on the fascial space
involved, removing the pus from the tissue, usually by using
a hemostat. To maintain drainage of the pus, it is necessary to
apply a drain, for example with a rubber drain or Penrose drain,
to prevent closing of the incision wound before the drainage of
the pus is complete (Karasutisna, 2001; Lopez-Piriz et al., 2007).
Supportive management in patients with infections should
be given because usually, patients will have a decrease in the im-
mune system due to the pain and swelling. The pain will cause
the patient not to get enough rest and lack of nutritional intake.
Therefore patients are advised to eat foods high in calories and
high in protein.
After the patient receives intensive surgical approach and
antibiotics, evaluate the results of treatment by monitoring the
patient’s condition, generally the patient is re-examined after
two days of treatment; when therapy is successful, the patient
usually experiences a significant reduction in pain and swelling.
If there is no significant improvement shown in the patient,
some things may need to reassess including whether there is
adequate drainage, whether the tooth can be extracted, whether
the incision that previously could not be done can already be
done.
In this case, to prevent the recurrence of a submandibular
abscess, sialoadenectomy is done as the definitive therapy.
5. Rizzo P, Mosto MCD. Submandibular Space Infection: A Po-
tentially Lethal Infection. International Journal of Infectious
Diseases. 2009;13:327-33.
6. Dewi Trisna, et all, Laporan Kasus Abses Ruang Sub-
mandibula Sinistra dengan Perluasan Ke Ruang Submental,
FK Udayana

7. Wakeel Syed Wakeel, et all., Sialolithiasis and its manage-

Conclusion ment: A clinical study, International Journal of Applied
Dental Sciences 2017; 3(4): 469-471
A submandibular abscess is an inflammation accompanied by
pus formation in the submandibular region. The source of infec- 8. Yuliana L, et all., Submandibular abscess, Jurnal Medical
tion in the submandibular space comes from the infection pro- Profession 2019
cess of the teeth, the floor of the mouth, pharynx, submandibu-
lar lymph nodes, sialadenitis, lymphadenitis, oral laceration or
mandible fracture.
Submandibular abscess caused by sialolith may be occurred
due to the presence of substances/debris, bacteria from the oral
cavity that migrated into the salivary duct will be isolated with
additional stagnant of saliva for a long time causing infection,
resulting in frequent findings of suppurative secretions from
the ductal orifice in the floor of the mouth. Poor oral hygiene,
advanced age, the declining general condition of the patient, and
the presence of purulent bacteria are the causes of transformation
from an infection to an abscess.
Management of submandibular abscess due to sialolith in-
cluding administration of high dose of antibiotics for aerobes
and anerobes given parenterally, incision and drainage of the
abscess, and also supportive measures gave significant improve-
ment in patient’s condition. To prevent recurrence of sub-
mandibular abscesses, patient is further treated surgically in
the form of sialoadenectomy.

Consent for publication:

A written informed consent was obtained from the patient en-
abling the publication of her case.

Funding
This study received no funding.

Conflict of interest
There are no conflicts of interest to declare by any of the authors
of this study.

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4. R.E. Bridwell, J.J. Oliver, S.A. Griffiths, et al.,

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Rani Septikasari et al./ International Journal of Medical Reviews and Case Reports (2020) 4(9):65-68