Overview
An abscess of the submandibular gland is a serious infection that can arise from various etiologies, including dental factors, surgical complications, and underlying infections. Common causes include chronic irritation from dental appliances like dentures, foreign body migration post-surgery, and specific bacterial pathogens such as Eikenella corrodens. This condition often presents with significant local symptoms and can lead to systemic complications if not promptly addressed. Understanding the pathophysiology, clinical presentation, diagnostic approach, and management strategies is crucial for effective patient care.
Pathophysiology
The development of a submandibular gland abscess often stems from chronic irritation and subsequent infection within the submandibular space. A notable case involved a 71-year-old female who developed a left submandibular space abscess due to extensive calculus accumulation on the lingual flanges of her lower denture, which had remained in place for 54 years [PMID:27164742]. This prolonged exposure to dental plaque and calculus can lead to chronic inflammation and subsequent bacterial proliferation, culminating in abscess formation. Similarly, surgical interventions, such as orthognathic surgery, can introduce foreign bodies like a detached bonded molar tube that may embed in soft tissues, fostering localized infections and abscess development [PMID:23631975]. These scenarios underscore the importance of meticulous oral hygiene and careful surgical technique to prevent such complications.
Bacterial pathogens play a pivotal role in the pathogenesis of submandibular abscesses. Eikenella corrodens, a slow-growing, facultative anaerobic gram-negative bacillus commonly found in the oral flora, has been identified as a significant pathogen in both immunocompromised and immunocompetent hosts [PMID:9283774]. This organism is particularly adept at causing suppurative lesions, including submandibular abscesses, due to its ability to thrive in low-oxygen environments and resist phagocytosis. Clinicians should maintain a high index of suspicion for Eikenella corrodens in patients presenting with suppurative head and neck infections, especially when dental or surgical etiologies are present.
Clinical Presentation
Patients with a submandibular gland abscess typically present with a constellation of local and systemic symptoms. Local manifestations often include significant swelling in the submandibular region, which can extend to the neck and face, leading to difficulty in mouth opening and speech. In the case described, the patient could not remove her lower denture due to calculus locking it under lingual undercuts, necessitating surgical intervention to section the denture [PMID:27164742]. This scenario highlights the mechanical obstruction and discomfort that can accompany abscess formation.
Another clinical presentation involves complications arising from surgical interventions. A case report detailed a submandibular abscess following the migration of a bonded molar tube into soft tissues post-orthognathic surgery [PMID:23631975]. Such cases underscore the need for vigilant postoperative monitoring and early detection of foreign body-related infections. Patients may also report pain, fever, and systemic signs of infection such as malaise and leukocytosis. Early recognition of these symptoms is crucial for timely intervention and to prevent potential complications like airway compromise or sepsis.
Diagnosis
Diagnosing a submandibular gland abscess involves a combination of clinical assessment and diagnostic imaging. Clinicians must consider Eikenella corrodens as a potential pathogen when evaluating suppurative lesions of the head and neck, particularly in the context of dental or surgical etiologies [PMID:9283774]. Laboratory findings often include elevated white blood cell counts and inflammatory markers, supporting the presence of an active infection. Imaging studies, such as computed tomography (CT) scans or magnetic resonance imaging (MRI), are essential for confirming the extent of the abscess and identifying any associated complications like involvement of adjacent structures or vascular compromise.
Fine-needle aspiration or incisional biopsy may be necessary to obtain cultures for definitive pathogen identification and antibiotic sensitivity testing. This approach is particularly important given the potential for anaerobic infections, as highlighted by the role of Eikenella corrodens. Accurate diagnosis guides appropriate management, ensuring targeted antibiotic therapy and effective surgical intervention when required.
Management
The management of a submandibular gland abscess typically involves both medical and surgical approaches, tailored to the severity and extent of the infection. Surgical drainage is often necessary to evacuate the purulent material and alleviate pressure on surrounding tissues. In the case described, surgical drainage via a neck incision was performed after the denture was sectioned to facilitate its removal [PMID:27164742]. This approach ensures complete decompression and removal of any foreign bodies contributing to the infection.
For less invasive cases, such as those involving foreign bodies like a detached molar tube, removal under local anesthesia can be effective [PMID:23631975]. Randomized clinical trials comparing intraoral versus external approaches for submandibular abscess drainage have shown that the intraoral technique offers comparable outcomes in terms of hospitalization duration and intravenous antibiotic use but with fewer complications like nerve weakness and scarring [PMID:22267495]. Intraoral drainage simplifies postoperative care by reducing the need for daily wound irrigation and dressing changes, thereby enhancing patient comfort and recovery.
Antibiotic therapy is a cornerstone of management, with Eikenella corrodens infections often responding well to second-generation cephalosporins like cefuroxime, as demonstrated in a case study where this regimen, combined with incision and drainage, led to successful treatment [PMID:9283774]. Broad-spectrum coverage should be initiated empirically, with adjustments based on culture and sensitivity results to ensure effective pathogen eradication.
Complications
Despite prompt and appropriate management, submandibular gland abscesses can lead to several complications if not adequately addressed. Chronic use of dentures without proper hygiene, as seen in the 71-year-old patient, can result in severe complications such as abscesses despite the denture providing stability and minimal bone resorption [PMID:27164742]. Surgical complications, including the migration of foreign bodies like bonded molar tubes, pose significant risks of localized infection and abscess formation [PMID:23631975]. These cases emphasize the importance of meticulous postoperative care and monitoring.
Postoperatively, complications such as marginal mandibular nerve weakness and skin scarring are potential risks, particularly with external drainage approaches. However, studies indicate that intraoral drainage significantly reduces these risks, with no reported cases of nerve weakness or scarring in the intraoral approach group [PMID:22267495]. Other systemic complications can include sepsis, airway obstruction, and spread of infection to deeper neck spaces, necessitating vigilant monitoring and timely intervention to prevent life-threatening outcomes.
Prognosis & Follow-up
The prognosis for patients with submandibular gland abscesses is generally favorable with appropriate and timely intervention. Early surgical drainage and targeted antibiotic therapy, as exemplified in the case of the detached molar tube managed successfully under local anesthesia [PMID:23631975], often lead to complete resolution of the abscess and recovery. Postoperatively, patients require close follow-up to monitor for signs of recurrence or complications. Regular dental evaluations are crucial, especially for patients with long-term denture use, to prevent recurrent infections.
Follow-up care typically includes clinical assessments, imaging if necessary, and laboratory tests to ensure clearance of the infection. Patients should be educated on maintaining good oral hygiene and the importance of regular dental check-ups to prevent future occurrences. Long-term management may also involve addressing underlying dental issues or surgical hardware that contributed to the initial infection to mitigate recurrence risk.
Key Recommendations
References
1 Bridgman JB. Case report: a patient who had not removed her lower denture for 54 years. The New Zealand dental journal 2016. link 2 de Queiroz SB, Curioso PA, Carvalho FS, de Lima VN. Submandibular-space abscess from loss of a bonded molar tube during orthognathic surgery. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics 2013. link 3 Ardehali MM, Jafari M, Hagh AB. Submandibular space abscess: a clinical trial for testing a new technique. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2012. link 4 Heymann WR, Drezner D. Submandibular abscess caused by Eikenella corrodens. Cutis 1997. link