Management of Parotitis
The management of parotitis depends critically on distinguishing between viral, acute bacterial suppurative, and chronic forms, with acute bacterial parotitis requiring immediate parenteral antibiotics targeting Staphylococcus aureus and anaerobes, while chronic parotitis often responds to conservative measures including hydration, gland massage, warm compresses, and periodic drainage before considering surgical intervention.
Initial Assessment and Etiology Determination
The first step is determining whether parotitis is viral (most commonly mumps), acute bacterial suppurative, or chronic recurrent:
- Viral parotitis (mumps) presents with bilateral or unilateral parotid swelling 16-18 days after exposure, preceded by fever, headache, malaise, and myalgia 1
- Acute bacterial suppurative parotitis presents with tenderness, swelling, and purulent discharge from Stensen's duct, most commonly caused by Staphylococcus aureus (80% of cases) and anaerobic bacteria 2
- Chronic parotitis is characterized by repeated infections with decreased salivary flow or obstruction, occurring on at least three separate occasions 3, 4
Management Algorithm by Type
Acute Bacterial Suppurative Parotitis
Immediate intervention is essential:
- Maintain hydration aggressively, as dehydration and decreased salivary flow are major predisposing factors 2
- Administer parenteral broad-spectrum antimicrobial therapy covering S. aureus and anaerobes (including pigmented Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species) 2
- Obtain culture and sensitivity from purulent discharge to guide antibiotic selection 5
- Perform surgical drainage once an abscess has formed, as antibiotics alone are insufficient 2
- In hospitalized patients, consider gram-negative coverage including E. coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa 2
Chronic Suppurative Parotitis
Conservative management should be attempted first, even in cases refractory to antibiotics:
- Gland massage and manipulation to express purulent material through the duct 5
- Local application of superficial moist heat to promote drainage 5
- Periodic pus drainage at clinical visits without routine antibiotic use 5
- Maintain excellent oral hygiene and adequate hydration to prevent retrograde bacterial colonization 2
- Consider sialography (conventional or digital) to identify stones or strictures amenable to interventional radiology 4
Interventional radiology procedures before surgery:
- Stone removal from the main duct using Dormia basket 4
- Balloon catheter dilation of parotid duct strictures 4
Surgical management is reserved for cases failing conservative and interventional approaches:
- Total parotidectomy with facial nerve dissection is definitive for chronic parotitis unresponsive to medical management 3, 6
- Surgery should be considered earlier rather than waiting for fistula or abscess formation 6
- The complication rate is acceptable given the magnitude of recurrent disease 6
Viral Parotitis (Mumps)
Management is supportive only:
- Maintain hydration 2
- Provide symptomatic pain relief
- Monitor for complications including orchitis (occurs in up to 38% of postpubertal males, typically 10 days after parotitis onset) 1
- Note that 10-18% of mumps complications can occur without preceding parotitis 1
Key Clinical Pitfalls
Common errors to avoid:
- Do not delay surgical drainage once abscess formation is confirmed in acute bacterial parotitis—antibiotics alone will fail 2
- Do not immediately resort to antibiotics in chronic suppurative parotitis; conservative measures (massage, heat, drainage) should be first-line and have shown success even when antibiotics failed 5
- Do not overlook interventional radiology options before proceeding to parotidectomy in chronic cases with identifiable stones or strictures 4
- Do not assume all parotitis is viral—bacterial parotitis requires aggressive antimicrobial therapy and is more common in elderly, immunocompromised, or dehydrated patients 2, 5
Prevention Strategies
Reduce occurrence through: