From the Guidelines
The approach to bilateral parotid swelling should prioritize a systematic evaluation to determine the underlying cause, considering infectious, inflammatory, autoimmune, metabolic, or neoplastic conditions, with a focus on minimizing morbidity, mortality, and improving quality of life 1.
Key Considerations
- Begin with a thorough history and physical examination, focusing on onset, duration, associated symptoms like pain, fever, dryness of mouth, and systemic manifestations.
- Laboratory investigations should include complete blood count, inflammatory markers, autoimmune antibodies (anti-SSA/Ro, anti-SSB/La), amylase, lipase, and metabolic panel.
- Imaging studies are essential, with ultrasound being the first-line modality due to its accessibility and lack of radiation, followed by CT or MRI for more detailed evaluation if needed, as suggested by the American College of Radiology 1.
Diagnostic Approach
- Fine needle aspiration cytology may be performed for suspicious lesions.
- Common causes of bilateral parotid swelling include viral infections (mumps, HIV), Sjögren's syndrome, sarcoidosis, alcoholism, malnutrition, diabetes, and medication side effects.
Management
- Treatment depends on the underlying cause - antimicrobials for infections, corticosteroids for inflammatory conditions, immunomodulators for autoimmune diseases, and supportive measures like hydration, warm compresses, and sialagogues to stimulate saliva production.
- Surgical intervention is rarely needed for bilateral swelling unless there's a neoplastic process, as outlined in the management of salivary gland malignancy guidelines 1.
- Symptomatic relief can be provided with analgesics like acetaminophen or NSAIDs.
Follow-Up
- Regular follow-up is recommended following treatment of malignant salivary gland neoplasms, with a focus on surveillance imaging or follow-up imaging for suspected or known recurrence, as emphasized in the ACR appropriateness criteria for staging and post-therapy assessment of head and neck cancer 1.
- The majority of recurrences of high-grade malignant salivary gland tumors occur in the first 3 years following treatment, highlighting the importance of close monitoring during this period.
From the Research
Approach to Bilateral Parotid Swelling
Bilateral parotid swelling can be caused by various conditions, including Sjögren's syndrome and parotitis. The approach to diagnosis and management involves:
- Evaluating symptoms and extraglandular manifestations 2
- Conducting a thorough medical history and physical examination to differentiate between local primary parotid infection and systemic infection 3
- Considering laboratory tests, such as blood work and imaging studies, to confirm the diagnosis
Diagnostic Considerations
Diagnostic considerations for bilateral parotid swelling include:
- Sjögren's syndrome, an autoimmune disorder characterized by sicca and systemic manifestations 4, 2, 5
- Parotitis, an inflammatory process that can be caused by viral or bacterial infections 3
- Other conditions, such as dehydration, malnutrition, and immunosuppression, which can predispose to suppurative infections 3
Management Options
Management options for bilateral parotid swelling depend on the underlying cause and may include:
- Topical agents to improve moisture and decrease inflammation 5
- Systemic therapy, such as steroidal and non-steroidal anti-inflammatory agents, disease-modifying agents, and cytotoxic agents 5
- Antimicrobial therapy, which may be required to prevent suppuration 3
- Surgical drainage, which may be indicated when pus has formed 3
- Biologic agents, such as rituximab, which may be used in selected clinical settings for oral and ocular dryness and for certain extraglandular manifestations 6