Initial Management of Parotiditis
The initial approach to treating parotiditis should include adequate hydration, warm compresses, sialogogues, analgesics, and empiric antibiotics targeting Staphylococcus aureus and anaerobic bacteria, typically with amoxicillin-clavulanate or clindamycin plus a fluoroquinolone for severe cases. 1
Diagnosis and Assessment
When evaluating a patient with suspected parotiditis, focus on:
- Unilateral or bilateral parotid swelling
- Pain and tenderness over the parotid gland
- Erythema of the overlying skin
- Purulent discharge from Stensen's duct when massaging the gland
- Fever and other systemic symptoms
- Risk factors: dehydration, poor oral hygiene, immunosuppression, hospitalization
Diagnostic Imaging
- Ultrasound is the initial imaging modality of choice for evaluating parotid inflammation 2
- CT with IV contrast may be needed to identify abscess formation, appearing as discrete fluid-filled areas 3
Treatment Algorithm
Step 1: Initial Conservative Management
- Hydration: Ensure adequate fluid intake to promote salivary flow 1
- Warm compresses: Apply to the affected area 3-4 times daily
- Sialogogues: Use sugar-free lemon drops or similar to stimulate salivary flow
- Analgesics: NSAIDs or acetaminophen for pain management
- Oral hygiene: Regular gentle mouth rinses with warm salt water
Step 2: Antimicrobial Therapy
For acute bacterial parotiditis, initiate empiric antibiotics targeting the most common pathogens:
First-line therapy (mild-moderate disease):
- Amoxicillin-clavulanate 875/125 mg orally twice daily for 7-10 days 1
Alternative options (for penicillin-allergic patients):
- Clindamycin 300-450 mg orally four times daily for 7-10 days 1
For severe cases or hospitalized patients:
- Combination therapy with clindamycin plus a respiratory fluoroquinolone (e.g., levofloxacin) 2
- Consider IV therapy initially with transition to oral therapy when improving
Step 3: Management of Complications
For abscess formation:
- Surgical drainage or CT-guided percutaneous drainage with catheter placement 3
- Continue antibiotics for 10-14 days
For recurrent parotiditis:
- Consider sialography to identify ductal strictures or stones 4
- Interventional radiology procedures may be beneficial:
- Removal of stones with Dormia basket
- Dilation of strictures with balloon catheter
Special Considerations
Chronic or Recurrent Parotiditis
More challenging to manage than acute cases 5
Consider underlying causes:
- Ductal strictures
- Sialolithiasis (stones)
- Autoimmune disorders
- Sjögren's syndrome
Treatment options:
- Longer courses of antibiotics during acute exacerbations
- Sialendoscopy for stone removal or stricture dilation
- Surgical parotidectomy may be required for refractory cases 5
Pediatric Considerations
- Neonatal suppurative parotiditis is rare but requires prompt treatment 6
- Risk factors include prematurity and dehydration
- Empiric antibiotics should cover Staphylococcus aureus
Monitoring and Follow-up
- Reassess within 48-72 hours of initiating treatment
- If no improvement after 72 hours, consider:
- Changing antibiotic therapy
- Additional imaging to identify complications
- Surgical consultation
Prevention Strategies
- Maintain good oral hygiene
- Ensure adequate hydration
- Prompt treatment of oropharyngeal infections
- Regular dental care
By following this approach, most cases of acute parotiditis will resolve without complications. However, recurrent or chronic cases may require more specialized interventions and multidisciplinary management.