cephalosporin, clindamycin, or a macrolide. Patients are also encouraged to use sialogogues, such as sour ball candies.
CHRONIC RECURRENT SUBMANDIBULAR SIALADENITIS
Chronic recurrent submandibular sialadenitis usually follows ABSS and is associated with untreated sialolithiasis. Chronic recurrent submandibular sialadenitis occurs more commonly than chronic recurrent bacterial parotitis. Initial treatment for chronic recurrent submandibular sialadenitis begins with antibiotic therapy, sialogogues, and hydration. Sialolithotomy is required if diagnosed. Sialendoscopic intervention may also be of benefit in the treatment of chronic recurrent submandibular sialadenitis prior to subjecting the patient to submandibular gland removal. Ultimately, removal of the submandibular gland is often necessary (Figure 3.15).
BARTONELLA HENSELAE (CAT‐SCRATCH DISEASE)
Cat‐scratch disease (CSD) is a granulomatous lymphadenitis that most commonly results from cutaneous inoculation caused by a scratch from a domestic cat. The causative microorganism is Bartonella henselae, a Gram negative bacillus. Approximately 90% of patients who have cat‐scratch disease have a history of exposure to cats, and 75% of these patients report a cat scratch or bite (Arrieta and McCaffrey 2005). Dogs have been implicated in 5% in these cases. This disease process begins in the preauricular and cervical lymph nodes as a chronic lymphadenitis and may ultimately involve the salivary glands, most commonly the parotid gland by contiguous spread (English et al. 1988).
Figure 3.15. A 52‐year‐old man (a) with a one‐year history of vague discomfort in the left upper neck. Screening panoramic radiograph (b) showed no evidence of a sialolith. His diagnosis was chronic submandibular sialadenitis and he was prepared for left submandibular gland excision (c). The surgery was carried through anatomic planes, including the investing layer of the deep cervical fascia (d). The dissection is carried deep to this layer since a cancer surgery is not being performed that would require a dissection superficial to the investing fascia. Exposure of the gland demonstrates a small submandibular gland due to scar contracture (e). Inferior retraction of the gland allows for identification and preservation of the lingual nerve (f). The specimen (g) is bivalved (h), which allows for the appreciation of scar within the gland. The resultant tissue bed (i) shows the hypoglossal nerve, which is routinely preserved in excision of the submandibular gland. Histopathology shows a sclerosing sialadenitis (j). The patient's symptoms were eliminated postoperatively, and he healed uneventfully, as noted at one year following the surgery (k).
The diagnosis of CSD has changed with advances in serologic and molecular biologic techniques. These methods have replaced the need for the Rose Hanger skin test previously used to establish the diagnosis of CSD. Testing for the presence of antibodies to B. henselae is now the most commonly used test to confirm the diagnosis. The two methods used for antibody detection are the indirect fluorescent antibody (IFA) and the enzyme immunoassay (EIA). When tissue is removed for diagnosis, histologic examination might demonstrate bacilli with the use of Warthin–Starry staining or a Steiner stain. Lymph node involvement shows reticular cell hyperplasia, granuloma formation, and occasionally a stellate abscess.
In most cases, no active therapy is required. The patient should be reassured that the lymphadenopathy is self‐limited and will spontaneously resolve in two to four months. Antibiotic therapy is indicated when patients are symptomatic. Antibiotics reported to be most effective include rifampin, erythromycin, gentamycin, azithromycin, and ciprofloxacin. Surgery becomes necessary when the diagnosis is equivocal, or when incision and drainage is indicated (Figure 3.16).
TUBERCULOUS MYCOBACTERIAL DISEASE
Tuberculosis is a chronic infectious disease with worldwide distribution, although more commonly seen in developing countries. While primarily noted in the lungs and characterized by caseous necrosis, extrapulmonary forms of the disease account for approximately 20% of active tuberculosis and can affect any organ in the body (Maurya et al. 2019). The most common head and neck manifestation of mycobacterium tuberculosis is infection of the cervical lymph nodes. Tuberculous infection of the salivary glands is very rare and generally seen in older children and adults. Parotid tuberculous constitutes 2.5–10% of salivary gland tuberculosis (Maurya et al. 2019). Salivary glands are thought to resist the growth of mycobacterium tuberculosis due to the continuous flow of saliva that prevents colonization of the bacteria. The infection is believed to originate in the tonsils or gingiva and most commonly ascends to the parotid gland via its duct (Arrieta and McCaffrey 2005). Secondary infection of the salivary glands occurs by way of the lymphatic or hematogenous spread from the lungs. Clinically, tuberculous salivary gland infection presents in two different forms. The first is an acute inflammatory lesion with diffuse glandular edema that may be confused with an acute sialadenitis or abscess. The chronic lesion occurs as a slow‐growing painless mass with or without cervical adenopathy that mimics a tumor. Patients with tuberculous parotitis have been further classified into three groups: group 1 – patients with asymptomatic unilateral preauricular swelling; group 2 – patients with recurrent swelling with fistula; and group 3 – acute inflammatory swelling/abscess. Diagnosis by fine needle aspiration biopsy may elude surgeons and cytologists such that surgery may be required for definitive diagnosis. If the diagnosis is established by nonsurgical means, treatment of the tuberculous sialadenitis is accomplished with medical therapy against the tuberculous infection.
Figure 3.16. A 21‐year‐old woman (a) with a two‐week history of left submandibular pain and swelling. A history of animal scratch was provided. Computerized tomograms (b) revealed a mass of the left submandibular gland. The patient was taken to the operating room where excision of the submandibular gland and mass was performed. Wide access was afforded (c) and the mass was exposed (d). The specimen is noted in (e). Histopathology showed a stellate abscess (f). A Steiner stain (g) showed Bartonella (Gram negative bacillus). Her disease resolved without long‐term antibiotics as seen in five‐year postoperative images (h and i).
NONTUBERCULOUS MYCOBACTERIAL DISEASE
Nontuberculous mycobacterial disease has become an important entity in the pediatric population. It has been estimated that greater than 92% of mycobacterial cervicofacial infections