What is the initial approach to treating parotitis?

Initial Management of Parotitis

The initial approach to treating parotitis should include adequate hydration, good oral hygiene, pain management, and appropriate antimicrobial therapy targeting Staphylococcus aureus and anaerobic bacteria. 1

Etiology and Diagnosis

• Parotitis is inflammation of the parotid gland, which is the salivary gland most commonly affected by inflammatory processes 2
• Common pathogens include Staphylococcus aureus (most common), anaerobic bacteria (Prevotella, Porphyromonas, Fusobacterium, Peptostreptococcus), Streptococcus species, and gram-negative bacilli 1, 2
• Gram-negative organisms are more commonly seen in hospitalized patients 1
• Predisposing factors include dehydration, malnutrition, oral neoplasms, immunosuppression, sialolithiasis (stones), and medications that reduce salivation 2

Initial Management Approach

Supportive Care

• Maintain adequate hydration to promote salivary flow and prevent worsening of the condition 1
• Implement good oral hygiene measures to reduce bacterial load 1
• Apply warm compresses to the affected area to improve blood flow and reduce pain 2

Pain Management

• Use anti-inflammatory oral rinses or sprays containing benzydamine hydrochloride every 3 hours, particularly before eating 3
• For inadequate pain control, topical anesthetic preparations such as viscous lidocaine 2% (15 mL per application) can be used 3
• Systemic analgesics following the WHO pain management ladder may be provided to treat pain from inflammation 3

Antimicrobial Therapy

• Initiate parenteral antimicrobial therapy that covers both Staphylococcus aureus and anaerobic bacteria 1, 2
• Empiric therapy should be directed against both aerobic and anaerobic bacteria until culture results are available 2
• Consider that β-lactamase-producing organisms can be isolated in almost three-fourths of patients 2
• For severe cases or hospitalized patients, coverage for gram-negative organisms should be included 1

Oral Care for Associated Mucositis

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 3
• Use an antiseptic oral rinse twice daily such as 0.2% chlorhexidine digluconate mouthwash (10 mL twice daily) or 1.5% hydrogen peroxide mouthwash 3
• Protect ulcerated mucosal surfaces with a mucoprotectant mouthwash three times a day (e.g., Gelclair) 3
• Apply white soft paraffin ointment to the lips if affected 3

Monitoring and Further Management

• Obtain pus samples from suppurative parotitis for culture and sensitivity testing to guide definitive antimicrobial therapy 2
• Samples should be plated on media supportive for aerobic and anaerobic bacteria, mycobacteria, and fungi 2
• Ultrasound examination may help in diagnosis and monitoring of the clinical course 4
• If an abscess has formed, surgical drainage is required 1
• For recurrent parotitis, consider interventional radiology procedures such as removal of stones with a Dormia basket or dilation of strictures with a balloon catheter before considering more invasive surgical options 5

Special Considerations

• For chronic or recurrent parotitis, prolonged medical management should be attempted before considering surgical interventions such as parotidectomy 6
• In neonatal parotitis, prompt antibiotic treatment is essential to prevent complications 4
• For patients with candidal infection, treatment with nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel 5-10 mL held in the mouth after food four times daily for 1 week may be necessary 3

By following this algorithmic approach to the management of parotitis, clinicians can effectively treat the condition while minimizing complications and improving patient outcomes.