What is the treatment for parotitis?

Treatment of Parotitis

The treatment of parotitis should include adequate hydration, antimicrobial therapy targeting Staphylococcus aureus and anaerobic bacteria, and surgical drainage if an abscess has formed. 1

Types of Parotitis and Diagnosis

Parotitis is inflammation of the parotid gland, which can be classified as:

1. Viral parotitis: Commonly caused by mumps (paramyxovirus), Epstein-Barr virus, coxsackievirus, and influenza viruses 2

2. Acute bacterial suppurative parotitis: Characterized by sudden onset of pain, swelling, and erythema over the parotid gland

3. Chronic parotitis: Characterized by repeated episodes of inflammation and infection 3

Diagnosis should include:

• Assessment of swelling, pain, and erythema over the parotid gland
• Evaluation for purulent discharge from Stensen's duct
• Identification of risk factors: dehydration, malnutrition, immunosuppression, medications that reduce salivation 2

Treatment Algorithm for Parotitis

1. Acute Bacterial Suppurative Parotitis

First-line treatment:

• Hydration: Maintain adequate fluid intake to promote salivary flow 1
• Antimicrobial therapy: Parenteral antibiotics targeting the most common pathogens 1
  • Coverage for Staphylococcus aureus, Streptococcus species, and anaerobic bacteria
  • Recommended empiric regimens:
    • Amoxicillin-clavulanate or
    • Clindamycin (for penicillin-allergic patients) or
    • Combination therapy with anti-staphylococcal agent plus anaerobic coverage

Additional measures:

• Warm compresses to the affected area
• Oral hygiene maintenance
• Massage of the gland to promote drainage
• Sialogogues (lemon drops, sugar-free candies) to stimulate salivary flow

For abscess formation:

• Surgical drainage is required once an abscess has formed 1
• Ultrasound examination may help in diagnosis and monitoring 4

2. Viral Parotitis

• Supportive care with adequate hydration
• Analgesics for pain relief
• Warm compresses to reduce discomfort
• No antibiotics needed unless secondary bacterial infection occurs

3. Chronic Parotitis

• Conservative management initially with:
  • Hydration
  • Sialogogues
  • Warm compresses
  • Gland massage
• For recurrent episodes:
  • Antibiotics during acute exacerbations
  • Consider surgical parotidectomy for refractory cases 3

Microbiology and Antibiotic Selection

The most common pathogens in acute bacterial parotitis are:

• Staphylococcus aureus (predominant)
• Anaerobic bacteria (Peptostreptococcus, Bacteroides, Prevotella, Porphyromonas)
• Streptococcus species
• Gram-negative bacilli (especially in hospitalized patients) 1, 5

Beta-lactamase-producing organisms can be isolated in approximately three-fourths of patients 2, which should guide antibiotic selection.

Special Considerations

• Neonatal parotitis: Requires prompt antimicrobial therapy; S. aureus is the most common pathogen 4
• Hospitalized patients: Higher risk of gram-negative infections; broader antimicrobial coverage may be needed
• Immunocompromised patients: More aggressive therapy and closer monitoring required

Prevention

Prevention strategies include:

• Maintaining good oral hygiene
• Adequate hydration
• Early and proper treatment of bacterial infections of the oropharynx 1
• Management of conditions that reduce salivary flow

Pitfalls and Caveats

1. Failure to obtain appropriate cultures before initiating antibiotics may lead to inadequate treatment
2. Overlooking the need for surgical drainage when an abscess has formed can prolong recovery
3. Not addressing underlying predisposing factors may lead to recurrent infections
4. Inadequate hydration can worsen the condition and delay recovery
5. Delaying treatment may lead to complications including abscess formation, facial nerve involvement, or spread to deep neck spaces

By following this structured approach to the diagnosis and management of parotitis, clinicians can effectively treat this condition and minimize complications.