Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 6, 2010, pp. 963-964

Neurology India, Vol. 58, No. 6, November-December, 2010, pp. 963-964

Letter to Editor

Acute submandibular sialadenitis as a cause of unilateral neck swelling after posterior fossa surgery in sitting position

Krishna Prabhu¹, Ramamani², Shalini Nair¹, Ari G Chacko¹

¹ Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu-632 004, India
² Department of Anaesthesia, Christian Medical College, Vellore, Tamil Nadu-632 004, India
Correspondence Address: Krishna Prabhu, Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu-632 004, India, krishnaprabhu@cmcvellore.ac.in

Date of Acceptance: 31-Jan-2010

Code Number: ni10274

PMID: 21150076
DOI: 10.4103/0028-3886.73772

Sir,

The possible causes for acute postoperative neck swelling include jugular vein compression, jugular vein thrombosis or superficial vein thrombosis. We report a case of acute sialadenitis resulting in immediate postoperative neck swelling and airway obstruction in a patient operated for a vestibular schwannoma in the semi-sitting position.

A 41-year-old male was taken up for surgery for left vestibular schwannoma in a semi-sitting position with the head flexed and turned 20 degrees to the left side. After the tumor excision he was extubated and shifted to ICU for monitoring. Four hours later he developed a swelling in the right submandibular region that progressed rapidly over the next two hours to involve the right side of the face and supraclavicular area [Figure - 1]. There was no crepitus or skin rash. There was no respiratory embarrassment at this point of time. Oral examination ruled out the possibility of Ludwig's angina. An urgent computed tomography (CT) scan of the neck revealed extensive soft tissue and interfacial plane edema, swelling of the submandibular and parotid glands on the right side compressing and shifting the esophagus and trachea to the left side [Figure - 1]. A Doppler study ruled out jugular and subclavian vein thromboses. Due to impending airway obstruction the patient was re-intubated. Fluid aspirated from the swelling and the blood culture did not reveal any bacterial infection but the patient was treated with broad spectrum antibiotics. The swelling gradually subsided over a period of one week following which he was extubated. At this time clinical examination of the neck showed a hard submandibular gland swelling. A week later he was discharged from the hospital and after four weeks the swelling had completely disappeared.

Massive swelling of the face, tongue and neck has been reported in the immediate postoperative period in neurosurgical patients undergoing posterior fossa surgery. ^[1],[2],[3] Although head and neck positioning, particularly rotation and flexion, has been considered a contributing factor to this complication, the precise cause was not known and was attributed to jugular venous obstruction or impaired venous drainage of the tongue. In all these patients the swelling was on the contralateral side of the surgery. Kim et al, ^[1] indicated that contralateral submandibular and neck swelling after retromastoid and far-lateral approaches to the posterior fossa, when the neck is rotated and flexed, is most probably due to sialadenitis. It has been suggested that the acute sialadenitis was due to obstruction of Wharton's duct due to extreme rotation of the head and compression of the endotracheal tube on the tongue causing stasis of secretion and secondary bacterial infection from the oral cavity. In the present patient the diagnosis was also made based on clinical and radiological examination. The most common pathogen causing sialadenitis is usually gram-positive bacteria, such as Streptococcus or Hemophilus. ^[4] As the swelling in our patient subsided gradually over a period of time, ductal dilatation or sialolithotomy was not considered.

Acute submandibular sialadenitis in the immediate postoperative setting in patients undergoing posterior fossa surgery appears to be related to excessive head and neck rotation causing salivary duct obstruction. This seemingly innocuous condition progresses rapidly and in the majority of cases can lead to the devastating consequence of airway obstruction. Awareness of this clinical entity and careful examination of the patient prior to extubation and in the immediate postoperative period should lead the clinician to protect the airway, adequately hydrate the patient and institute antibiotics to obtain a good outcome.

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