What is the treatment for parotid swelling?

Treatment of Parotid Swelling

The treatment of parotid swelling depends entirely on the underlying cause, requiring initial diagnostic workup with imaging (MRI preferred) and tissue diagnosis before definitive management, which ranges from conservative medical therapy for infections to surgical excision for malignancies. 1, 2

Initial Diagnostic Approach

The first step is determining whether the swelling is inflammatory/infectious versus neoplastic:

• Obtain MRI with and without IV contrast as the preferred imaging modality to evaluate extent, local invasion, and deep lobe involvement 1, 2
• High-frequency ultrasound (≥12 MHz) with color Doppler can be used as initial imaging to distinguish parotid from extraparotid masses and identify suspicious features, though it has limitations for deep lobe lesions 1
• CT with IV contrast is an alternative when MRI is contraindicated 1, 2

Critical clinical features to assess:

• Acute onset with fever suggests infection requiring antibiotics 3
• Facial nerve palsy indicates possible malignancy or serious complication requiring immediate attention 2, 3
• Constitutional symptoms (fever, weight loss, night sweats) suggest lymphoma or systemic infection 2
• Recurrent bilateral swelling may indicate autoimmune conditions like Sjögren's syndrome 4

Treatment Based on Etiology

Acute Infectious Parotitis

Initial management includes antibiotics, conservative measures (massage, warm compresses, sialogogues), and adequate hydration with close monitoring for abscess formation. 3

• Consider ultrasound if abscess or tumor suspected when symptoms persist 3
• Emergency referral required if facial nerve palsy develops 3

Malignant Parotid Tumors

Open surgical excision is the standard treatment for histologically confirmed salivary gland malignancies. 1

Surgical extent depends on tumor characteristics:

• Low-grade, early-stage (T1-T2) tumors: Partial superficial parotidectomy is sufficient 4, 1
• High-grade or advanced-stage tumors: At least superficial parotidectomy with consideration of total/subtotal parotidectomy due to risk of intraparotid nodal metastases 4, 1
• Facial nerve preservation when preoperative function is intact and dissection plane can be created between tumor and nerve 4, 1
• Facial nerve resection only when preoperative facial nerve movement is impaired or branches are encased/grossly involved by confirmed malignancy 4, 1

Adjuvant therapy considerations:

• Radiation therapy for tumors ≥2 cm, high-grade histology, or positive margins 1
• Sentinel lymph node biopsy or neck dissection for high-grade tumors or clinically positive nodes 1

Sjögren's Syndrome with Parotid Involvement

Rituximab (1 g every 15 days x2) may be considered for severe, refractory systemic disease with parotid swelling, though evidence from RCTs is weak. 4

• Belimumab showed effectiveness in 77% of cases with parotid swelling in uncontrolled studies, including 60% of patients previously refractory to rituximab 4
• Best indications are for vasculitis, cryoglobulinemic-associated MALT lymphoma, and other marginal zone lymphomas 4

Lymphoma Involving Parotid

Treatment should be individualized according to specific histological subtype per WHO 2016 classification, with chemotherapy ± radiation avoiding unnecessary parotidectomy. 4, 2

• Watchful waiting may be appropriate for low-grade lymphoma affecting only exocrine glands without constitutional symptoms or systemic features 4
• Radiotherapy for early-stage (stage I or non-bulky stage II) marginal zone lymphomas 4

Common Pitfalls to Avoid

• Never rely solely on imaging to determine benign versus malignant nature - histologic confirmation through fine needle aspiration biopsy (FNAB) is essential 1, 2
• Do not underestimate deep lobe involvement when using ultrasound alone - proceed to MRI if deep lobe suspected 1
• Avoid making facial nerve sacrifice decisions based on indeterminate diagnoses - only resect when confirmed malignancy with gross involvement 4, 1
• Do not fail to consider intraparotid nodal metastases in high-grade or advanced parotid cancers - perform at least superficial parotidectomy 4, 1
• Remember that intraparotid lymphadenopathy may represent metastatic disease from cutaneous primaries - examine head and neck skin carefully, particularly in elderly patients 1