The Laryngoscope

C 2018 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Case Report

Acute Sialadenitis Associated With 2017–2018 Influenza A Infection:

A Case Series

John A. Stafford, MD ; Charles A. Moore, MD; Jonathan R. Mark, MD

The influenza A virus has accounted for the majority of influenza infections in the 2017 to 2018 flu season, with the typical
clinical presentation including fever, myalgias, malaise, and nonproductive cough. Notably this season, we have recognized a
cluster of influenza A cases presenting as severe neck and facial swelling, with the subsequent diagnosis of sialadenitis.
Whereas previous authors have demonstrated isolated case reports of sialadenitis associated with influenza A infection,
herein we describe the clinical history, laboratory values, and radiographic findings of four patients presenting to our institu-
tion in January 2018 with acute sialadenitis and influenza A infection.
Key Words: Sialadenitis, influenza, submandibular, salivary glands, parotid.
Laryngoscope, 00:000–000, 2018

INTRODUCTION patient was diagnosed with acute upper respiratory

Each year, influenza outbreaks generate seasonal
epidemics of acute viral respiratory illness resulting
from influenza A or B viral infection. The typical clinical
presentation of flu includes fever, myalgias, headache,
malaise, and accompanying upper respiratory infection
symptoms such as cough, rhinorrhea, and sore throat.1
In 2017, Fujiwara et al. published a case report of bilat-
eral submandibular sialadenitis following influenza A
infection, an association not previously described.2 Dur-
ing a month in 2018, we recognized a series of four
patients presenting with significant sialadenitis follow-
ing influenza A infection and here aim to present this
series in an effort to better describe this association.
CASE REPORT
Patient A
A 50-year-old female with a past medical history of
asthma presented to the emergency department (ED)
with a 2-day history of bilateral neck swelling, severe
neck pain, and cough. One week prior, the patient was
seen by the family physician for cough, headache, rhi-
norrhea, nasal congestion, and shortness of breath. The
From the Department of Otolaryngology–Head and Neck Surgery,
University of Cincinnati (J.A.S., C.A.M., J.R.M.), Cincinnati, Ohio, U.S.A.
Editor’s Note: This Manuscript was accepted for publication on
March 5, 2018.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Dr. Jonathan R. Mark, Assistant Profes-
sor, Otolaryngology–Head and Neck Surgery, University of Cincinnati
Medical Center, Department of Otolaryngology–Head and Neck Surgery,
University of Cincinnati College of Medicine, Medical Sciences Building
Room 6507, 231 Albert Sabin Way, Cincinnati, OH 45267-0528. E-mail:
jonathan.mark@uc.edu
DOI: 10.1002/lary.27202
infection, sinusitis, and asthma exacerbation, for which
the patient received doxycycline, benzonatate, and pred-
nisone. The patient did not experience improvement in
the symptoms and subsequently developed severely ten-
der and enlarged bilateral submandibular glands with
overlying erythema of the anterior neck. Clear saliva
without purulence was expressed from bilateral subman-
dibular and parotid glands.
The patient had the following relevant vital signs
and laboratory results: temperature 36.7 8 C; white blood
cell count (WBC) 12,100/mL; normal electrolytes; creati-
nine 0.76 mg/dL; blood glucose 115 mg/dL; influenza A-
positive; and influenza B-negative. Computed tomogra-
phy scan demonstrated significant enlargement of the
bilateral submandibular glands with overlying cellulitis
and surrounding soft tissue inflammation (Fig. 1). While
in the ED, the patient received a one-time dose of ste-
roids and was subsequently started on clindamycin due
to a concern for deep neck space infection and also was
started on ceftriaxone and azithromycin due to a concern
for possible community-acquired pneumonia.
The patient continued the above-mentioned antibi-
otics, along with adequate intravenous hydration, siala-
gogues, and massage of the submandibular glands. The
neck swelling significantly improved over the course of
the next 24 hours, and the patient was discharged the
following day.
Patient B
A 47-year-old female with a past medical history of
type II diabetes and asthma presented to the ED with a
2-day history of left-sided facial and neck swelling. One
week prior to presentation, the patient was hospitalized
elsewhere with fever, myalgias, and shortness of

Laryngoscope 00: Month 2018 Stafford et al.: Sialadenitis and Influenza A

1

Fig. 1. Axial computed tomography neck with IV contrast demon-
strating enlarged bilateral submandibular glands with inflammation
of the glands, thickening of the platysma, and fat-stranding of the
overlying soft tissues correlated clinically with cellulitis.
breath—and was found to be influenza A-positive and
influenza B-negative. The patient was discharged after
receiving oseltamivir and encouraged to remain
hydrated. The patient subsequently developed painful
left-sided facial and neck swelling worsening over 2
days, prompting transfer to our institution for evalua-
tion and management.
Computed tomography scan of the neck demonstrated
inflammatory changes to the left submandibular and
parotid glands with inflammation of the overlying soft tis-
sues of the neck. Pertinent laboratory findings included
the following: temperature 37.2 8 C; WBC 7,700/mL; normal
electrolytes; blood glucose 120 mg/dL; and creatini-
ne < 0.5 mg/dL. On examination, the patient was noted to
have significant left-sided facial edema and erythema,
with an underlying firm, tender left submandibular gland.
Clear saliva was expressed from the salivary ducts.
The patient was treated with warm compress,
hydration, sialagogues, gland massage, oral care, and
clindamycin. After overnight observation in the ED, the
patient was discharged after improvement of symptoms
and reduction in facial swelling and tenderness.
Patient C
A previously healthy 20-year-old female presented
to an outside hospital ED with 3-day history of fever,
cough, myalgias, and malaise. At that time, the patient
was found to be influenza A-positive and influenza B-
negative and was discharged with instructions to remain
hydrated. Two days later, the patient presented at our
institution with complaints of right-sided face and neck
swelling, as well as shortness of breath.
Pertinent laboratory results and vital signs at that
time include the following: temperatures 37.7 8 C; WBC
Laryngoscope 00: Month 2018
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5,200/mL; creatinine 1.03 mg/dL; mumps IgM-negative;
and blood glucose 92 mg/dL. Computed tomography
scan at that time demonstrated right parotid gland
hyperemia and inflammation. The patient received
intravenous fluids, pain medications, ondansetron, and a
prescription for prednisone.
On physical examination, the patient was noted to
have right-sided facial, parotid, and submandibular
swelling with clear saliva expressible from the salivary
ducts. The patient was instructed to continue the pre-
scribed course of prednisone, along with aggressive
hydration, parotid and submandibular massage, warm
compresses, and sialagogues.
Patient D
A 43-year-old female with hypothyroidism and
hypertension presented to an outside ED with bilateral
submandibular swelling and tenderness. The patient
had been diagnosed 5 days earlier with presumed bron-
chitis, for which the patient was subsequently treated
with a steroid taper and azithromycin. The patient com-
pleted both courses 1 day prior to secondary ED presen-
tation. The patient reported new neck swelling that
developed overnight and progressed to bilateral neck
pain and odynophagia with findings of significant bilat-
eral submandibular swelling, tenderness to palpation,
and overlying erythema of the anterior neck. Clear
saliva was expressed from the patient’s salivary ducts.
The computed tomography (CT) scan demonstrated bilat-
eral submandibular gland inflammation with overlying
fat stranding and cellulitic changes. Pertinent laboratory
findings included the following: temperature 37.4 8 C;
WBC 5,400/mL; creatinine 0.69 mg/dL; normal electro-
lytes; Monospot-negative; mumps IgM-negative; influ-
enza A-positive; and influenza B-negative.
The patient received intravenous steroids;
amoxicillin-clavulanate; and conservative measures
including use of sialagogues, salivary gland massage,
and aggressive intravenous and oral hydration. The
patient was observed overnight and noted to signifi-
cantly improve prior to discharge.
DISCUSSION
During the 2014 to 2015 influenza season, the Cen-
ters for Disease Control and Prevention (CDC) report-
edly received hundreds of confirmed influenza cases
with associated parotitis, primarily occurring following
influenza A (H3N2) infection.3 Subsequent CDC influ-
enza reports have not carried similar advisories regard-
ing parotitis and influenza. Our institution has
recognized this recent cluster of sialadenitis cases follow-
ing influenza A infection. Notably, the CDC recently
reported that 86.6% of documented influenza infections
this season have resulted from the influenza A virus,
with 89.4% of those infection specifically resulting from
the H3N2 strain.4 This series aims to highlight the asso-
ciation between sialadenitis and influenza A in the 2017
to 2018 season in order to facilitate better recognition of
such cases in the future.
Stafford et al.: Sialadenitis and Influenza A
 The relationship between sialadenitis and influenza
infection remains a poorly described clinical association.
Whereas the mumps virus is the classic viral cause of
parotitis, the influenza virus has been recognized as a
rare cause of nonsuppurative parotitis.5 Within the pedi-
atric population, the H3N2 strain of influenza A has
been detected in the saliva of children with sialadenitis
who were suspected to have mumps infection.6 Despite
these associations, the majority of literature addressing
sialadenitis in the setting of influenza A infection
remains limited to isolated case reports, such as those of
Fujiwara et al. and Krilov et al.2,7
The cause of this association is unclear. Dehydra-
tion secondary to preceding respiratory infection may
predispose the patient to salivary stasis and subsequent
development of sialadenitis. Alternatively, the influenza
A virus itself has been detected within the salivary
gland tissues after respiratory exposure in animal mod-
els, supporting direct viral sialadenitis secondary to the
influenza virus as a potential mechanism.8 Despite ini-
tially demonstrating evidence of severe neck swelling,
patients within our series appear to respond to largely
supportive therapy, with the addition of steroids for
inflammation reduction and antibiotics for treatment of
associated soft-tissue infections.
CONCLUSION
This series demonstrates a cluster of cases of acute
nonsuppurative sialadenitis presenting as new-onset
Laryngoscope 00: Month 2018
neck and/or facial swelling in the setting of previously
unrecognized Influenza A infection. This association has
not been previously well characterized and represents
an atypical presentation for influenza A infection in the
2017 to 2018 flu season. Earlier recognition of influenza
A infection in patients with sialadenitis this season may
allow for reduced interpersonal spread of disease,
prompt initiation of treatment, and potential limitation
of CT scans ordered for such patients.
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