What are the typical presentation and management of parotitis?

Parotitis: Presentation and Management

Parotitis presents with unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland lasting ≥2 days, often accompanied by pain and fever. 1

Clinical Presentation

Typical Symptoms and Signs

• Acute onset of unilateral or bilateral parotid swelling and tenderness 1
• Pain on swallowing 1
• Fever, headache, malaise, myalgia, and anorexia may precede parotitis 1
• Purulent discharge from Stensen's duct (parotid duct) may be observed in bacterial parotitis 2
• In mumps, parotitis typically develops 16-18 days after exposure 1

Epidemiology and Risk Factors

• Mumps is most common in children aged 2-9 years 1
• Only 30-40% of mumps infections produce typical acute parotitis; 15-20% are asymptomatic 1
• Bacterial parotitis is more common in:
  • Elderly patients 3
  • Immunocompromised individuals 3
  • Patients with hyposalivation (e.g., Sjögren syndrome) 1, 3
  • Dehydrated patients 2

Differential Diagnosis

Infectious Causes

• Viral: Mumps virus (most common viral cause) 1
• Bacterial: Staphylococcus aureus (accounts for 80% of bacterial cases) 3, 2
• Other bacterial pathogens: streptococci, anaerobes (Prevotella, Porphyromonas, Fusobacterium), and gram-negative bacilli 2

Non-infectious Causes

• Sjögren syndrome (may present with recurrent parotitis) 1, 3
• Sialolithiasis (salivary stones) 4, 5
• Ductal strictures 4, 5
• Medication-induced hyposalivation 3
• Immune-related adverse events from checkpoint inhibitors 1

Diagnostic Approach

Laboratory Testing

• For suspected mumps:
  • Serum mumps IgM antibodies (positive in acute infection) 1
  • Paired acute and convalescent serum for mumps IgG (4-fold rise indicates recent infection) 1
  • Buccal swab around affected parotid gland and Stensen's duct for viral culture or NAAT 1

Imaging

• Sialography remains the investigation of choice for chronic parotitis 5
• CT with IV contrast is useful for evaluating parotid inflammation and possible abscess formation 1
• MRI with and without contrast provides comprehensive information about extent of disease 1
• Ultrasound can differentiate between parotid and extraparotid masses 1

Management

Viral Parotitis (Mumps)

• Supportive care with hydration 1
• Analgesics for pain relief 1
• Isolation of infected individuals to prevent spread 1
• Vaccination is the primary preventive measure 1

Bacterial Parotitis

• Broad-spectrum antibiotics targeting Staphylococcus aureus and anaerobes 2
• Maintain adequate hydration 2
• Local application of moist heat 3
• Massage of the gland to promote drainage 3
• Surgical drainage if abscess formation occurs 2

Chronic/Recurrent Parotitis

• Conservative management:

  • Periodic drainage of pus 3
  • Gland massage 3, 5
  • Sialogogues to stimulate salivary flow 5
  • Adequate hydration 2

• Interventional procedures:

  • Removal of stones with Dormia basket 4
  • Balloon catheter dilation of strictures 4
  • Sialoendoscopy for diagnosis and treatment 5

• Surgical options (for refractory cases):

  • Ductal ligation or ductoplasty 5
  • Tympanic neurectomy 5
  • Parotidectomy (ultimate surgical option but has significant morbidity) 6, 5

Complications

• Orchitis in up to 38% of postpubertal men with mumps 1
• Aseptic meningitis in 4-6% of clinical mumps cases 1
• Sensorineural deafness (can be sudden, bilateral, and permanent) 1
• Abscess formation in bacterial parotitis 2
• Facial nerve damage (risk with surgical intervention) 4, 5

Prevention

• MMR vaccination is highly effective in preventing mumps 1
• Good oral hygiene and adequate hydration help prevent bacterial parotitis 2
• Early treatment of oropharyngeal infections may reduce occurrence of suppurative parotitis 2