A previously healthy 24-year-old man presented with a palpable 5-cm mass that was inferior to the angle of the right-sided mandible and that had been growing steadily for more than 1 week (Figure 1). The patient stated that the mass first appeared as a small, 3-mm nodule. From the start, the nodule was painful and produced discomfort when the patient opened his mouth, turned his head, or looked up. During the next week, the patient had fever, chills, pharyngeal erythema, headaches, and general malaise. The symptoms worsened with exercise and with eating. The patient had a history of parotitis, but previous episodes had resolved within 2 to 3 days. 

Physical examination was grossly normal, except for the 5-cm movable, nonerythematous neck mass and a small gingival tear on the right-sided second mandibular molar. Results of cranial radiographs showed a radiopaque area near the submandibular gland (Figure 2) and, based on these results, sialadenitis was diagnosed. Routine blood tests and pharyngeal swabs were also obtained, but the results were unremarkable. 

The patient was initially treated with 500 mg of cephalexin, administered every 6 hours for 5 days. However, after 5 days, the mass had continued to grow, so cephalexin was discontinued and the patient was started on 875 mg of amoxicillin/clavulanate, administered twice a day. Three days later, the patient reported no improvement in the right-sided lower neck pain, headaches, fever, or chills. Clindamycin (150 mg every 6 hours) was added for suspected anaerobes, but, within 48 hours, the patient had voluminous, foul-smelling diarrhea. At this point, clindamycin was stopped and the patient was given 500 mg of metronidazole 3 times per day for possible Clostridium difficile–associated diarrheal illness. The metronidazole reduced the diarrhea but did not eliminate it entirely. Three days later, the patient was started on trimethoprim and sulfamethoxazole (160 mg/800 mg 2 times per day). In all, 5 antibiotics were used during a period of 2 weeks, but the patient's symptoms did not abate. 

For the management of possible sialadenitis, the submandibular duct was cannulated to resolve any obstruction. In addition, a contrast-enhanced CT scan was ordered. Results of the CT scan showed a 3-cm mass adjacent to the rightsided submandibular gland, which appeared to be anodal with an area of necrosis. The CT findings were compatible with suppurative adenopathy with abscessed submandibular node (Figure 3). Test results showed no evidence of sialadenitis or sialolithiasis. 

Given the patient's level of discomfort, he was started on methylprednisolone (24 mg/d in 4-mg divided doses), which was tapered by 4 mg per day over the next 5 days. The patient was also continued on amoxicillin/clavulanate and trimethoprim and sulfamethoxazole. During the second day of steroid treatment, the patient underwent lymphatic osteopathic manipulative treatment (OMT). The thoracic duct was opened using myofascial release, and the lymph nodes were stimulated in a downward fashion along the chain using effleurage and pétrissage. Warm compresses were used during this procedure. Within 30 minutes of lymphatic OMT initiation, the patient's visible inflammation had subsided by more than 70%. The improvements persisted into the next day. 

The day after the initial OMT session, the patient was instructed to get 45 minutes of aerobic exercise and return for a second round of lymphatic OMT. By the third day, the mass had reduced in size by more than 90% and was no longer noticeable. During the next 2 weeks, the patient steadily improved until all of his symptoms had resolved. 

We believe that the cause of the patient's symptoms was a perfect storm of upper respiratory tract infection, salivary gland obstruction, stasis of lymphatic fluid, and bacterial infection (possibly anaerobic) through a gingival tear. Presumably, this tetrad led to contiguous spread of infection into adjacent tissues, resulting in lymphadenitis. Given the timing of the presentation and the normal laboratory values, etiologies such as malignancy and connective tissue disease can be excluded. 

Because of this patient's periodontal symptoms, the ideal first line antibiotic was amoxicillin/clavulanate potassium. However, antibiotic monotherapy was not successful in the present case. Resolution of symptoms was achieved by the use of a combination of broad-spectrum antibiotics, corticosteroids, and OMT. The effectiveness of OMT may be because of its substantial effect on lymphatic flow and immune defense, effects that are shared to an extent by aerobic exercise.²¹ 

The authors recommend that previously healthy adults with unilateral, painful, and acutely enlarging cervical lymphadenitis be treated with combination therapy if the first line therapy fails. Given the impressive response to steroid treatment and OMT in combination with antibiotics described in the present case, we recommend that these treatment modalities be exhausted before neck mass aspiration or open incision and drainage are performed.