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parotitis

Inflammation of the parotid gland. Etiology: 1) bilateral a) viruses - Epstein-Barr virus [2] - human herpes virus type 6 [2] - mumps - parainfluenza virus type 3 - coxsackievirus - influenza A [3] - HIV1 infection [9] (generally painless, asymptomatic) b) metabolic disorders - diabetes mellitus - uremia c) pharmaceutical agents [8] - phenylbutazone - propylthiouracil - iodides - heavy metals [9] 2) unilateral - tumor - cyst - sialolithiasis - suppurative parotitis (Staphylococcus aureus) - Staphylococcus aureus including MRSA [5] - Streptococcus species - gram-negative bacteria (rare) - anaerobic bacteria mostly Peptostreptococcus & Bacteroides - pigmented Porphyromonas, Prevotella - beta-Lactamase-producing organisms common [4] - predisposing to suppurative infection - dehydration, malnutrition, oral neoplasms, immunosuppression, sialolithiasis, medications that diminish salivation - tuberculosis (rare), non-tender lump in gland [7] - candidiasis [9] 3) disease affecting the salivary glands generally cause chronic parotitis a) see salivary gland disease b) chronic parotid swelling - sarcoidosis - Sjogren's syndrome - rheumatoid arthritis - systemic lupus erythematosus (SLE) - human immunodeficiency virus - IgG4 disease c) cystic fibrosis [9] 4) juvenile recurrent parotitis [10] Epidemiology: - equally likely in males & females - more common in elderly - accounts for 0.01 to 0.02% of hospital admissions [9] Pathology: - parotid duct obstruction (sialolithiasis) - infection (viral infection or bacterial infection) - inflammation (Sjogren syndrome, rheumatoid arthritis, SLE, sarcoidosis) - lymphoepithelial cysts occur in HIV1 parotitis - noncaseating granulomata are present in sarcoid parotitis - lymphocytic invasion with acinar destruction can be seen with lymphoma [9] Clinical manifestations: - bilateral parotid involvement is typical for viral & inflammatory disorder - unilateral parotid swelling, pain, & fever suggest bacterial cause - jaw pain aggrevates chewing - parotid gland enlargement & swelling - dry mouth - fever may be noted * also see Etiology Laboratory: - gram stain of aspirate if bacterial causes suspected - culture of aspirate - plated on media supportive for growth of aerobic & anaerobic bacteria, mycobacteria, & fungi [4] - antimicrobial sensitivity of any cultured growth - histopathology of incisional or fine needle biopsy - laboratory values generally elevated, supportive, but nonspecific - serum amylase - serum C-reactive protein (CRP) - erythrocyte sedimentation rate (ESR) Special laboratory: - sialendoscopy is useful in chronic parotitis & juvenile recurrent parotitis - incisional or fine-needle biopsy of the parotid tail - care to avoid the facial nerve - send for culture &/or histopathology Radiology: - rarely necessary - scintigraphy may play a role in diagnosis of chronic obstructive parotitis [9] - parotid ultrasonography - might confirm sialolithiasis - can identify abscesses, differentiate between solid & cystic masses & & identify hypoechoic areas seen in punctate sialectasis - plain radiographs or computed tomography without contrast, can confirm sialolithiasis & multiple parotid calcifications in chronic parotitis [9] - magnetic resonance imaging (MRI) - can differentiate chronic parotitis & neoplastic changes within the parotid - can demonstrate multiple cyst formation of HIV1 parotitis [9] - sialography is the gold standard - can provide detailed visualization of the parotid ductal system & acini - not commonly performed [9] Complications: - includes parotid procedures [9] - facial nerve palsy [6,9] - osteomyelitis - Lemierre syndrome - sepsis Differential diagnosis: - sialadenosis Management: - symptomatic control - local application of heat - gentle massage from posterior to anterior - sialagogues - adequate hydration - acetaminophen &/or ibuprofen generally sufficient for pain - if purulent drainage is expressed during the glandular massage, swab or fine needle aspiration with culture & sensitivity - empiric therapy is directed against both aerobic & anaerobic bacteria - community-acquired parotitis - nafcillin, oxacillin or cefazolin (1st line) - IV vancomycin or clindamycin for MRSA may be prudent [5] - nosocomial parotitis - cefoxitin, ertapenem, or ampicillin/sulbactam - levofloxacin, clindamycin, or piperacillin-tazobactam as alternatives - dental infection parotitis - clindamycin or metronidazole (anaerobic coverage) + ceftriaxone - piperacillin-tazobactam as an alternative - surgical drainage may be indicated when pus has formed [4] - consult otolaryngology early for incision & drainage for cases of acute parotitis refractory to hydration, sialagogues & antibiotics - see sialolithiasis for removal of salivary stone - parotidectomy is usually the last resort for chronic parotitis - surgery may be necessary for facial nerve paralysis [9] - treat underlying condition

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parotid gland

General

sialadenitis

References

  1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 186, 1128
  2. Barskey AE et al. Viruses detected among sporadic cases of parotitis, United States, 2009-2011. J Infect Dis 2013 Dec; 208:1979 PMID: 23935203
  3. Rolfes MA, Millman AJ, Talley P et al. Influenza-associated parotitis during the 2014-2015 influenza season in the United States. Clin Infect Dis 2018 Aug 15; 67:485 PMID: 29617957 https://academic.oup.com/cid/article/67/4/485/4957003 - Elbadawi LI, Talley P, Rolfes MA et al. Non-mumps viral parotitis during the 2014-2015 influenza season in the United States. Clin Infect Dis 2018 Aug 15; 67:493. PMID: 29617951 https://academic.oup.com/cid/article/67/4/493/4957004 - Pavia AT. Is parotitis one more complication of influenza? The ongoing challenge of determining causal associations. Clin Infect Dis 2018 Aug 15; 67:502 PMID: 29617960 https://academic.oup.com/cid/article-abstract/67/4/502/4957005
  4. Brook Diagnosis and management of parotitis Arch Otolaryngol Head Neck Surg. 1992 May;118(5):469-71 PMID: 1571113
  5. Richards W, Steehler M MRSA parotitis Ear Nose Throat J. 2013 Jun;92(6):E66 PMID: 23780611 Free article
  6. Campbell E, McLaren O Facial nerve palsy secondary to parotitis BMJ Case Rep. 2021 Feb 4;14(2):e241001 PMID: 33541969 PMCID: PMC7868194 (available on 2023-02-04)
  7. Catano JC, Robledo J. Tuberculous Lymphadenitis and Parotitis. Microbiol Spectr. 2016 Dec;4(6). PMID: 28084205 Free article. Review.
  8. Brooks KG, Thompson DF. A review and assessment of drug-induced parotitis. Ann Pharmacother. 2012 Dec;46(12):1688-99. PMID: 23249870 Review.
  9. Wilson M, Pandey S StatPearls. NCBI Bookshelf. Aug 28, 2022 https://www.ncbi.nlm.nih.gov/books/NBK560735/
  10. NEJM Knowledge+ Otolaryngology