What is the appropriate management for a 10-year-old child presenting with parotid swelling and cough?

Management of Parotid Swelling with Cough in a 10-Year-Old Child

The cough should be managed systematically using a pediatric-specific algorithm based on whether it is wet/productive versus dry, while the parotid swelling requires evaluation for infectious versus non-infectious etiologies, with mumps, bacterial parotitis, and recurrent parotitis of childhood being the primary considerations. 1, 2

Initial Evaluation of the Cough

Determine Cough Characteristics and Duration

• Assess whether the cough is wet/productive or dry, as this fundamentally determines the diagnostic and treatment pathway. 1
• Determine if the cough has been present for >4 weeks (chronic) or is acute in nature. 1, 2
• Look for specific cough pointers that indicate serious underlying disease: coughing with feeding, digital clubbing, hemoptysis, failure to thrive, or focal chest findings. 1

Obtain Baseline Investigations

• Obtain a chest radiograph and spirometry (age-appropriate for a 10-year-old) as minimum investigations for any child with chronic cough. 1
• These tests have infinite positive likelihood ratios when abnormal (ruling in disease) but are poor at ruling out disease when normal. 1

Management Based on Cough Type

For Wet/Productive Cough Without Specific Pointers:

• Treat with a 2-week course of antibiotics targeting common respiratory bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis) for presumed protracted bacterial bronchitis (PBB). 1, 2
• If wet cough persists after 2 weeks, administer an additional 2-week course of appropriate antibiotics. 1
• If wet cough persists after 4 weeks of antibiotics, undertake further investigations including flexible bronchoscopy with quantitative cultures and/or chest CT. 1

For Dry Cough:

• Evaluate for asthma if there are associated features: wheeze, exercise intolerance, nocturnal symptoms, or bronchodilator reversibility on spirometry. 1, 2
• Do not use empirical treatment for asthma, GERD, or upper airway cough syndrome unless other features consistent with these conditions are present. 1
• Consider post-viral cough if following a recent respiratory infection; these typically resolve with watchful waiting over 2-4 weeks. 1

Evaluation of Parotid Swelling

Key Clinical Features to Assess

• Determine if the swelling is unilateral or bilateral, painful or painless, and whether there is fever or constitutional symptoms. 3, 4
• Check for purulent discharge from Stensen's duct, which indicates bacterial suppurative parotitis. 3, 5
• Assess for recurrent episodes, as recurrent parotitis of childhood typically presents with 8 episodes per year lasting 2-7 days each. 4

Differential Diagnosis Considerations

Mumps Parotitis:

• The UK and other regions have experienced mumps epidemics, and mumps should be considered even in vaccinated children. 6
• Mumps typically presents with bilateral parotid swelling (though can be unilateral), fever, and constitutional symptoms. 6
• Obtain mumps serology if clinically suspected. 6

Acute Bacterial Suppurative Parotitis:

• Most commonly caused by Staphylococcus aureus and anaerobic bacteria (Prevotella, Porphyromonas, Peptostreptococcus). 5
• Presents with painful unilateral swelling, fever, and often purulent discharge from Stensen's duct. 3, 5
• Requires intravenous antibiotic therapy covering S. aureus and anaerobes; surgical drainage is indicated if abscess formation occurs. 3, 5
• Ultrasound is the initial diagnostic method of choice to identify abscess formation. 3

Recurrent Parotitis of Childhood:

• Presents with recurrent episodes of parotid swelling (usually unilateral), pain (92.5%), and fever (41.5%), lasting 2-7 days. 4
• Diagnosis is often delayed >1 year in 70% of patients. 4
• Ultrasound or sialogram showing sialectasis confirms the diagnosis. 4
• Antibiotics do not have a role in treatment of recurrent parotitis of childhood. 4
• Screen for Sjögren's syndrome (antinuclear antibodies) and immunodeficiency (immunoglobulin levels). 4

Pneumoparotid:

• Rare condition from air insufflation through Stensen's duct, typically painless swelling. 7
• CT shows air in the parotid gland and Stensen's duct. 7
• Often stress-related behavior in children; requires supportive treatment and avoidance of insufflation maneuvers. 7

Integrated Management Approach

Address Environmental Factors

• Determine and eliminate exposure to environmental tobacco smoke and other pollutants, as these exacerbate cough regardless of etiology. 1, 2

Address Parental Expectations

• Explore and address specific parental concerns and expectations, as chronic cough significantly impacts quality of life for both children and parents. 1
• Parents often fear serious illness, permanent lung damage, or that the child will die from choking. 1
• Provide education specific to the child's condition rather than general information. 1

Common Pitfalls to Avoid

• Do not empirically treat for asthma, GERD, or upper airway cough syndrome without specific clinical features supporting these diagnoses. 1
• Do not use over-the-counter cough medications, as they lack efficacy in children. 2
• Do not delay diagnosis of recurrent parotitis by repeatedly treating as "infection" or mumps. 4
• Do not use antibiotics for recurrent parotitis of childhood, as they are ineffective. 4
• If empirical treatment is attempted, limit the trial to 2-4 weeks and discontinue if no response occurs. 1, 2

When to Refer or Investigate Further

• Refer to pediatric pulmonology if wet cough persists after 4 weeks of appropriate antibiotics. 1
• Refer to ENT if parotid abscess requires surgical drainage or if recurrent parotitis causes persistent symptoms despite conservative management. 3, 4
• Investigate for immunodeficiency if recurrent infections or unusual pathogens (tuberculosis, atypical mycobacteria) are present. 5, 4