A 55-year-old man comes to the office for follow-up due to recurrent episodes of jaw pain. The patient's most recent episode was a week ago. He had pain that worsened with eating, accompanied by a tender mass under the left jaw and fever. All symptoms resolved within a few days with oral antibiotic treatment. This was the third episode in the past year. Which of the following is the most likely underlying reason for this patient's recurrent episodes of jaw pain?

Question

A 55-year-old man comes to the office for follow-up due to recurrent episodes of jaw pain.  The patient's most recent episode was a week ago.  He had pain that worsened with eating, accompanied by a tender mass under the left jaw and fever.  All symptoms resolved within a few days with oral antibiotic treatment.  This was the third episode in the past year.  Which of the following is the most likely underlying reason for this patient's recurrent episodes of jaw pain?

Quizplus · Accepted Answer

This patient with episodes of jaw pain and swelling (eg, tender mass) that are exacerbated by eating, are associated with fever, and resolve with antibiotics likely has recurrent sialadenitis (salivary gland infection). Sialadenitis is caused by salivary stasis that leads to retrograde seeding of bacteria (eg, Staphylococcus aureus, oral flora) from the oral cavity. Salivary stasis can be seen in elderly postoperative patients or in those with obstruction of the outflow duct. In this patient with no other known risk factors, salivary stasis is likely due to ductal obstruction by salivary stones (sialolithiasis). Salivary stones most often form in the submandibular, rather than the parotid, glands because saliva from the submandibular glands has a higher mucus content and the duct travels against gravity, resulting in decreased salivary flow. These stones are most commonly made of calcium and are visible on CT scan. Sialolithiasis typically presents with pain and swelling exacerbated by eating. In some patients, management with hydration, moist heat, milking of the gland, and sialagogues is sufficient to control symptoms and even flush out the stone. However, in other patients (such as this one), ductal obstruction leads to secondary infections (sialadenitis). Although these episodes typically respond to nonsteroidal anti-inflammatory drugs and antibiotics, patients with recurrent infections should be referred to otolaryngology for stone removal. (Choice A) Giant cell arteritis can present with jaw pain exacerbated by eating. However, pain due to jaw claudication would worsen during chewing and improve shortly after cessation. In addition, pain would not resolve with antibiotic treatment, and a tender submandibular mass would not be present. (Choice C) Sjögren syndrome can present with salivary gland enlargement (typically painless) due to lymphocytic infiltration of the glands. However, patients are typically women, it more often affects the parotid glands, and secretions are significantly decreased, resulting in both xerostomia and dry eyes. (Choice D) Temporomandibular joint disorder can present with episodic pain exacerbated by eating with intervening asymptomatic periods. However, patients would not have fever or a submandibular mass. (Choice E) Trigeminal neuralgia can present with recurrent pain in the jaw (V2 and V3 branches of the trigeminal nerve) often triggered by minor stimuli like eating or brushing teeth. However, episodes last several seconds rather than a few days, and fever and a submandibular mass would not be present. Educational objective: Salivary stones occur most often in the submandibular glands and can present with recurrent sialadenitis due to obstruction of the duct. References: Human immunodeficiency virus and salivary gland pathology: an update. (http://www.ncbi.nlm.nih.gov/pubmed/30827854) Algorithms for treatment of salivary gland obstructions. (http://www.ncbi.nlm.nih.gov/pubmed/19962014)

A 55-Year-Old Man Comes to the Office for Follow-Up Due