What is the treatment approach for parotiditis?

Treatment of Parotiditis

The treatment approach for parotiditis depends critically on distinguishing between viral, acute bacterial suppurative, and chronic forms, with acute bacterial parotitis requiring immediate empiric antimicrobial therapy directed against Staphylococcus aureus and anaerobic bacteria, combined with hydration and surgical drainage if abscess formation occurs. 1, 2

Initial Assessment and Differentiation

The first priority is determining whether the parotiditis is infectious (viral vs. bacterial) or non-infectious (chronic/recurrent):

• Acute bacterial suppurative parotitis presents with unilateral parotid swelling, purulent discharge from Stensen's duct, fever, and systemic toxicity 1, 2
• Viral parotitis (mumps, Epstein-Barr virus, coxsackievirus) typically presents with bilateral swelling and constitutional symptoms without purulent drainage 2
• Chronic/recurrent parotitis manifests as repeated episodes of swelling and pain, often without acute purulent features 3

Acute Bacterial Suppurative Parotitis Management

Immediate Interventions

Hydration is the cornerstone of initial management - dehydration is a primary predisposing factor and must be corrected immediately with intravenous fluids if the patient cannot maintain adequate oral intake 1, 2

Antimicrobial Therapy

Empiric parenteral antimicrobial therapy must cover both Staphylococcus aureus and anaerobic bacteria, as these are the predominant pathogens 1, 2:

• The most common aerobic pathogen is Staphylococcus aureus 1, 2
• Anaerobic bacteria are isolated in the majority of cases, including pigmented Prevotella and Porphyromonas species, Fusobacterium species, and Peptostreptococcus species 1, 2
• Beta-lactamase-producing organisms are present in approximately 75% of patients, necessitating beta-lactamase-stable antibiotics 2

Recommended empiric regimen: A beta-lactamase-stable antibiotic with anaerobic coverage, such as ampicillin-sulbactam or piperacillin-tazobactam, should be initiated immediately 1, 2

Microbiological Sampling

Obtain pus or aspirate from the parotid duct for culture before initiating antibiotics when possible, plating on media supportive for aerobic bacteria, anaerobic bacteria, mycobacteria, and fungi 2

Surgical Intervention

Surgical drainage is required once an abscess has formed - early antimicrobial therapy may prevent suppuration, but once pus accumulates, drainage is mandatory to prevent complications and facilitate recovery 1, 2

Viral Parotitis Management

Viral parotitis is managed supportively with:

• Adequate hydration 2
• Analgesics for pain control 2
• Observation for complications 2

No specific antimicrobial therapy is indicated unless secondary bacterial infection develops 2

Chronic/Recurrent Parotitis Management

Conservative Approach (First-Line)

Initial management should be conservative medical therapy including 3:

• Maintenance of excellent oral hygiene 1
• Adequate hydration 1, 3
• Sialagogues (lemon drops, sour candies) to stimulate salivary flow 3
• Warm compresses and parotid massage 3
• Antimicrobials during acute exacerbations 3

Interventional Radiology Options

For patients with identifiable obstructive pathology, interventional radiology procedures should be considered before surgery 4:

• Dormia basket extraction for sialoliths in the main duct 4
• Balloon catheter dilation for ductal strictures 4
• Sialography (conventional or digital) for diagnosis and therapeutic planning 4

Surgical Management

Parotidectomy is reserved for patients who fail prolonged conservative management and have recurrent debilitating symptoms 3:

• This carries risk of facial nerve damage and should only be pursued after exhausting medical and interventional options 3, 4
• Bilateral disease may require staged procedures 3

Prevention Strategies

Preventive measures are critical to reduce occurrence 1:

• Maintenance of good oral hygiene 1
• Adequate hydration, especially in hospitalized or debilitated patients 1
• Early treatment of bacterial oropharyngeal infections 1
• Avoidance of medications that diminish salivation when possible 2

Key Clinical Pitfalls

Do not delay antimicrobial therapy in acute bacterial parotitis - waiting for culture results can lead to abscess formation and complications 2

Do not use narrow-spectrum antibiotics - coverage must include both S. aureus and anaerobes, with consideration for beta-lactamase production 1, 2

Do not perform surgery prematurely in chronic parotitis - interventional radiology and prolonged conservative management should be attempted first given the risk of facial nerve injury 3, 4

Recognize high-risk populations: dehydrated patients, those with malnutrition, immunosuppression, oral neoplasms, sialolithiasis, or medications reducing salivation require aggressive early intervention 2