What is the treatment approach for parotitis?

Treatment Approach for Parotitis

The treatment of parotitis requires antimicrobial therapy targeting Staphylococcus aureus and anaerobic bacteria, along with supportive care including hydration, oral hygiene, and pain management. 1, 2

Etiology and Diagnosis

• Parotitis is an inflammatory condition of the parotid gland, most commonly caused by bacterial infection with Staphylococcus aureus and anaerobic bacteria (including Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species) 2
• Other pathogens may include Streptococcus species, gram-negative bacilli (particularly in hospitalized patients), and rarely mycobacteria 2
• Chronic parotitis is characterized by recurrent painful swelling of the gland with decreased salivary flow or obstruction 3

Initial Management

• Maintain adequate hydration to promote salivary flow and reduce bacterial colonization 2
• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1
• Use antiseptic oral rinses twice daily, such as 0.2% chlorhexidine digluconate mouthwash or 1.5% hydrogen peroxide mouthwash 1
• Administer parenteral antimicrobial therapy targeting the likely pathogens (S. aureus and anaerobes) 2

Pain Management

• Use anti-inflammatory oral rinses or sprays containing benzydamine hydrochloride every 3 hours, particularly before eating 1
• For inadequate pain control, apply topical anesthetic preparations such as viscous lidocaine 2% 1, 4
• Systemic analgesics following the WHO pain management ladder may be provided for more severe pain 5, 1
• Consider topical NSAIDs (e.g., amlexanox 5% oral paste) for moderate pain 5, 4

Management of Associated Mucositis

• Protect ulcerated mucosal surfaces with a mucoprotectant mouthwash three times a day 1
• Apply white soft paraffin ointment to affected lips 1
• For candidal infection, treat with nystatin oral suspension or miconazole oral gel 1

Management Based on Severity and Type

Acute Bacterial Parotitis

• Administer parenteral antibiotics effective against S. aureus and anaerobes 2
• Surgical drainage is required once an abscess has formed 2
• Maintain good oral hygiene and adequate hydration 2

Chronic Parotitis

• Initial management is conservative with medical therapy 3, 6
• For cases that fail medical management, surgical options may be considered 6, 7
• Diagnostic sialography or sialadenoscopy may be used to evaluate ductal anatomy 8, 6
• Interventional radiology procedures (stone removal with Dormia basket, balloon catheter dilation of strictures) may be beneficial before considering more invasive surgery 8
• Total parotidectomy with facial nerve dissection may be necessary for severe recurrent cases unresponsive to other treatments 7

Special Considerations

• Gram-negative organisms are more common in hospitalized patients and require appropriate antibiotic coverage 2
• For chronic cases, investigate for underlying conditions like Sjögren's disease 7
• Early and proper therapy of bacterial infections of the oropharynx may reduce the occurrence of suppurative parotitis 2

Common Pitfalls to Avoid

• Failing to maintain adequate hydration, which is crucial for preventing stasis and bacterial growth 2
• Delaying surgical drainage when an abscess has formed 2
• Not considering interventional radiological procedures before resorting to more invasive surgery in chronic cases 8
• Waiting too long to consider surgical management in severe recurrent cases, which may lead to complications like fistulae or abscesses 7