What is the management approach for acute parotitis?

Management of Acute Parotitis

Immediate Assessment and Initial Management

For acute bacterial suppurative parotitis, initiate parenteral antimicrobial therapy immediately while maintaining hydration, and proceed to surgical drainage once abscess formation is confirmed. 1

Key Clinical Features to Identify

• Assess for suppurative versus non-suppurative parotitis: Look for purulent discharge from Stensen's duct, severe unilateral pain and swelling, fever, and signs of systemic toxicity 1, 2
• Identify high-risk patients: Elderly surgical patients, post-operative dehydration, debilitated states, immunosuppression, and poor oral hygiene significantly increase risk 3
• Examine for complications: Facial nerve palsy, progressive swelling despite antibiotics, and signs of abscess formation require urgent intervention 2

Antimicrobial Therapy

Empiric Antibiotic Selection

Start with broad-spectrum parenteral antibiotics covering both Staphylococcus aureus and anaerobic bacteria, as these are the most common pathogens. 1

• Primary pathogens: S. aureus and anaerobes (including pigmented Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species) 1
• Hospital-acquired cases: Consider gram-negative coverage including Pseudomonas aeruginosa, E. coli, and Klebsiella pneumoniae 1, 2
• Streptococcus species (including S. pneumoniae) are also common 1

Antibiotic Regimen Considerations

• Aminoglycosides alone may be insufficient: Even with appropriate gram-negative coverage, patients may continue to deteriorate without surgical intervention 2
• Adjust based on culture results: Obtain parotid fluid cultures to guide definitive therapy 2

Surgical Management

Proceed to surgical incision and drainage on day 9 or earlier if the patient shows progressive deterioration, persistent severe pain, facial nerve involvement, or failure to respond to antibiotics within 48-72 hours. 2

• Indications for surgery: Abscess formation confirmed on imaging, clinical deterioration despite antibiotics, or development of complications 1, 2
• Timing is critical: Delayed surgical intervention increases morbidity and mortality risk, particularly in elderly debilitated patients 3
• Imaging guidance: CT scanning helps identify abscess formation and extent of disease 3

Supportive Care

• Maintain adequate hydration: Dehydration is a major risk factor and must be aggressively corrected 1, 3
• Optimize oral hygiene: Poor oral hygiene contributes to ascending infection through Stensen's duct 1, 3
• Address underlying conditions: Treat any predisposing factors including immunosuppression and debilitation 3

Critical Pitfalls to Avoid

• Do not delay surgical drainage once abscess forms: Medical management alone is insufficient and may lead to multiple organ dysfunction syndrome and death 3
• Do not underestimate severity in elderly surgical patients: This population has particularly high morbidity and mortality despite aggressive treatment 3
• Do not rely solely on aminoglycosides: Gram-negative coverage must be combined with anti-staphylococcal and anaerobic coverage 1, 2
• Do not miss gram-negative organisms in hospitalized patients: Hospital-acquired cases require broader empiric coverage 1

Prevention Strategies

• Maintain good oral hygiene in hospitalized patients 1
• Ensure adequate hydration, especially post-operatively 1, 3
• Treat oropharyngeal bacterial infections early and appropriately 1
• Monitor high-risk patients closely for early signs of parotitis 3

When to Escalate Care

Refer immediately to ENT or surgical services if: progressive swelling despite 48-72 hours of antibiotics, facial nerve palsy develops, imaging shows abscess formation, or patient shows signs of systemic deterioration 2, 3