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Acute suppurative parotitis
Updated 2008 Jul 14 03:06 PM: guideline update
review of differential diagnosis of neck masses (Infect Dis Clin North Am 2007 Jun)
case report of acute suppurative parotitis due to Mycobacterium tuberculosis (Kulak Burun Bogaz Ihtis
Derg 2007)
Related Summaries:
Mumps
Chronic recurrent parotitis
General Information (including ICD-9/-10 Codes)
Description:

inflammatory and infectious process of parotid gland

(2 )


Also called:
acute parotitis
sialadenitis
sialoadenitis
surgical parotitis
postoperative parotitis
ICD-9 Codes:
527.2 sialoadenitis
527.3 abscess of salivary gland
ICD-10 Codes:
K11.2 sialoadenitis
K11.3 abscess of salivary gland
Organs involved:

parotid gland
(1 )


Who is most affected:

elderly
(2 )


case report and review of neonatal suppurative parotitis can be found in
Pediatr Infect Dis J 2004 Jan;23(1):76
Incidence/Prevalence:

estimated incidence
(2 )

reported to be 0.01% to 0.02% of all hospital admissions
reported to be 0.002% to 0.04% of postoperative patients

less common due to use of perioperative antibiotics

(2 )

Causes and Risk Factors
Causes:
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gram-positive bacteria most commonly involved

(1 )

Staphylococcus aureus has been cultured in 50-90% of cases
methicillin-resistant Staphylococcus aureus (case report in South Med
J 2004 Nov;97(11):1139)
Streptococcus pneumoniae
Streptococcus pyogenes
Haemophilus influenzae
other bacteria reported less frequently
Escherichia coli
Klebsiella pneumoniae
Pseudomonas aeruginosa
Salmonella
Pseudomonas pseudomallei
Mycobacterium tuberculosis (case report in Kulak Burun Bogaz Ihtis
Derg 2007;17(5):272)
Mycobacterium scrofulaceum (case report in patient with AIDS in Sex
Transm Infect 2005 Dec;81(6):517)
Treponema pallidum (syphilis)
anaerobes
Candida albicans (case report of parotid abscess in Acta Otolaryngol 2006
Mar;126(3):334)
Pathogenesis:

retrograde contamination by oral cavity bacteria

(1 )

salivary stasis
(1 )

parotid predilection may be due to different composition of secretions

(1 )

Likely risk factors:

dehydration
(1 )

postoperative state
(1 )

advanced age
(1 )

prematurity
(1 )

immunocompromise
(1 )

prior radiation therapy

(1 )

medical illnesses
(1 )

hepatic failure
renal failure
diabetes mellitus (type 1, type 2)
hypothyroidism
malnutrition
HIV
Sjogren's syndrome
hyperuricemia
hyperlipoproteinemia
cystic fibrosis (sialectasis)
lead intoxication
Cushing's disease
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psychiatric illness
(1 )

depression
anorexia
bulimia

prescription medications
(1 )

antihistamines
diuretics
tricyclic antidepressants
phenothiazines
beta blockers
barbiturates
anticholinergics

presence of tracheostomy
(1 )

foreign body obstruction or trauma to duct

(1 )

oral cavity neoplasm

(1 )

pneumoparotitis
(1 )

poor oral hygiene

(2 )

Complications and Associated Conditions
Complications:

abscess
(1 )

systemic infection
(1 )

osteomyelitis
(1 )

thrombophlebitis
(1 )

parapharyngeal extension of abscess

(1 )

facial nerve dysfunction

(1 )

extension of infection into deep neck space (case report in Am J Emerg Med
1999 Jan;17(1):46)
Associated conditions:

in parotitis of strict anaerobic etiology

(2 )

Sjogren's syndrome
rheumatoid arthritis
History
Chief Concern (CC):

sudden onset of severe pain

(1 )

pain exacerbated by meals and salivation

(1 )

swelling over affected gland

(1 )

Medication History:

ask about use of anticholinergic drugs or diuretics

(1 )
Past Medical History (PMH):
ask about other comorbid conditions (see Likely risk factors )

ask about recent surgery

(1 )

postoperative parotitis usually within 2 weeks after procedure
peak incidence between postoperative days 5-7
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has been reported up to 15 weeks postoperatively
Physical
General physical:

may appear toxic, with high fever, possibly delirium

(1 )
Skin:

general skin turgor may be decreased, indicating dehydration

(1 )
HEENT:

area of induration, erythema, edema and heat in cheek

(1 )

extreme tenderness over mandibular angle

(1 )

inflammation of Stensen's or Wharton's duct, purulent discharge may be
present
(1 )

dry or crusted oral mucous membranes

(1 )

redness and swelling accompany bacterial but not viral parotitis

(1 )

facial nerve dysfunction rare

(2 )

Diagnosis
Making the diagnosis:

diagnosis based on clinical exam and presentation

(1 )
Rule out:

differential diagnosis should include

(2 )

viral parotitis (mumps)
cystic fibrosis
collagen vascular diseases (connective tissue diseases)
alcoholism
sarcoidosis
sialolithiasis
chronic recurrent parotitis

if no response to medical therapy, consider

(1 )

lymphoma (see Hodgkin's disease or non-Hodgkin's lymphoma)
actinomycosis
cat-scratch disease
cervical lymphadenitis
Sjogren's syndrome
Wegener's granulomatosis
review of differential diagnosis of neck masses can be found in Infect Dis
Clin North Am 2007 Jun;21(2):523
Testing to consider:

white blood cell count

(1 )


needle aspiration and diagnostic culture if abscess present
(1
(1 )
)


CT, MRI or ultrasound to rule out abscess if no improvement after 48 hours
of medical therapy
(1 )

sialography (contraindicated in acute infection)

(1 )

Blood tests:
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white blood cell count - leukocytosis with predominance of neutrophils

(1 )

serum amylase usually normal

(1 )
(case series of 4 patients with acute
parotitis and asymptomatic hyperamylasemia after whole-brain radiation
therapy can be found in Ann Neurol 1980 Apr;7(4):385)
Imaging studies:

computed tomography (CT) with intravenous contrast medium

(2 )

first-choice radiologic evaluation
can differentiate soft tissue densities in gland

ultrasound to show abscess formation

(2 )


sialography contraindicated in acute infection due to risk of ectatic duct
rupture from pressure of injected dye
(2 )

Prognosis
Prognosis:
variable depending on underlying medical condition of patient

sepsis complication associated with poor prognosis

(1 )

resolution likely in healthy patients who receive early aggressive treatment
(1 )

may result in chronic recurrent parotitis due to ductal stenosis

(1 )

Treatment
Treatment overview:

treat underlying medical condition

(2 )

discontinue antisialagogic medications

(2 )

hydration
(2 )

stimulate salivary flow

(2 )

antibiotic therapy based on culture and sensitivity

(2 )

cannulate and dilate duct if complete obstruction of Stensen's duct

(2 )

surgery if medical therapy failure

(2 )

Activity:

methods to stimulate salivary flow

(1 )

warm compresses
mouth irrigations
administer sialagogues (e.g. citrus lozenges or beverages)
external and intraoral bimanual massage of gland if tolerated by
patient
Medications:

antibiotic therapy
(1,2 )

tailor antibiotic therapy to specific organisms based on culture and
sensitivity
10-14 day course
oral therapy if no systemic illness but intravenous therapy indicated if
no response within 48 hours
if due to S. aureus, drugs of choice include
anti-staphylococcal penicillin, such as nafcillin, oxacillin,
ampicillin/sulbactam (Unasyn), amoxicillin/clavulanate
(Augmentin)
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first-generation cephalosporin, such as cefazolin
clindamycin
consider vancomycin if due to methicillin-resistant S. aureus (MRSA)
especially if nursing home or other nosocomial environment
for recalcitrant infection
consider addition of third-generation cephalosporin to enhance gram-
negative coverage
consider addition of aminoglycoside for critically ill patients
Surgery:

surgical drainage
(2 )

indications
no improvement after 3-5 days of antibiotics therapy
facial nerve involvement
involvement of adjacent structures (e.g. lateral pharyngeal
space, deep fascial spaces)
abscess formation within gland parenchyma
standard parotidectomy incision in direction of facial nerve should be
used
Other management:
radiation therapy not shown to be beneficial and no longer recommended
(historically used as adjuvant therapy)
(1 )

Follow-up:

after resolution
(2 )

consider imaging (CT scan or sialogram) to evaluate gland
parenchyma
consider surgical interventions if calculi, mucous plugs, or strictures
develop
evaluation for parotid tumor by routine clinical exam and imaging
when indicated
Prevention and Screening
Prevention:

perioperative hydration to avoid salivary stasis

(1 )
References including Reviews and Guidelines
General references used:
1. McQuone SJ. Acute viral and bacterial infections of the salivary glands.
Otolaryngol Clin North Am. 1999 Oct;32(5):793-811.
2. Fattahi TT, Lyu PE, Van Sickels JE. Management of acute suppurative
parotitis. J Oral Maxillofac Surg. 2002 Apr;60(4):446-8.
Reviews:
review can be found in Pediatric Surgery Update 2003 Mar;20(3):3 full-text
review of management of acute suppurative parotitis can be found in J Oral
Maxillofac Surg 2002 Apr;60(4):446
Guidelines:
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no relevant guideline for "acute suppurative parotitis or sialadenitis" found
2008 May 1 on systematic search of MEDLINE (using guidelines limiter) and
National Guideline Clearinghouse
Patient Information
Patient information:
handout on parotitis from EBSCO Publishing Health Library PDF or in
Spanish PDF
Acknowledgements
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Over 500 journals and evidence-based sources (DynaMed Content Sources) are
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Competing interests:
Each participating member of the DynaMed Editorial Team has declared no
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