Treatment of Parotitis
Parotitis treatment requires a combination of supportive care with oral hygiene measures, pain management, and antimicrobial therapy targeting Staphylococcus aureus and anaerobic bacteria, with surgical drainage reserved for abscess formation. 1, 2
Immediate Supportive Care
- Maintain adequate hydration as the cornerstone of initial management, as dehydration is a recognized risk factor for parotitis progression 2, 3
- Use anti-inflammatory oral rinses containing benzydamine hydrochloride every 3 hours, particularly before eating, for pain control 1
- Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1
- Apply antiseptic oral rinses twice daily using either 0.2% chlorhexidine digluconate mouthwash or 1.5% hydrogen peroxide mouthwash 1
Pain Management Algorithm
- First-line: Benzydamine hydrochloride oral rinses every 3 hours 1
- Second-line: If pain control is inadequate, add topical anesthetic preparations such as viscous lidocaine 2% 1
- Third-line: Systemic analgesics following the WHO pain management ladder for more severe pain 1
- Consider topical NSAIDs (e.g., amlexanox 5% oral paste) for moderate pain 1
Antimicrobial Therapy
The microbiology of acute bacterial suppurative parotitis guides antibiotic selection:
- Primary pathogens: Staphylococcus aureus and anaerobic bacteria (including pigmented Prevotella, Porphyromonas spp., Fusobacterium spp., and Peptostreptococcus spp.) 2
- Secondary pathogens: Streptococcus spp. (including S. pneumoniae) and gram-negative bacilli (especially in hospitalized patients, including E. coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae) 2, 4
Empiric parenteral antimicrobial therapy should be initiated promptly, with coverage for both gram-positive organisms (particularly S. aureus) and anaerobes 2, 4
Common Pitfalls in Antibiotic Selection:
- Historically, ASP was attributed only to gram-positive organisms, but gram-negative and anaerobic bacteria are now frequently implicated 4
- In hospitalized or debilitated patients, consider broader gram-negative coverage including Pseudomonas 4
- Neonatal cases most commonly involve S. aureus, but other gram-positive cocci, gram-negative bacilli, and rarely anaerobes should be considered 3
Surgical Intervention Criteria
- Surgical incision and drainage is required once an abscess has formed 2
- Surgery is reserved for organized abscesses and infections not responding to medical management 3
- In cases of persistent symptoms despite appropriate antimicrobial therapy (typically by day 9 of treatment), surgical drainage should be performed to avoid severe morbidity 4
- For chronic recurrent parotitis with repeated exacerbations, parotidectomy may ultimately be required when prolonged medical management fails 5
Adjunctive Measures for Oral Mucositis
If associated oral mucositis is present:
- Protect ulcerated mucosal surfaces with a mucoprotectant mouthwash three times daily (such as Gelclair) 1
- Apply white soft paraffin ointment to the lips if affected 1
- For candidal superinfection, treat with nystatin oral suspension or miconazole oral gel 1
Monitoring and Follow-up
- Ultrasound examination may help in diagnosis and monitoring of clinical course 3
- Early recognition and appropriate management are critical to avoiding serious morbidity and mortality 4
- Advances in antimicrobial therapy have improved outcomes, and complications are now drastically reduced with prompt antibiotic treatment 3