What is the treatment for parotitis, or inflammation of the parotid gland?

Treatment of Parotitis

For acute bacterial parotitis, initiate immediate empiric antibiotic therapy targeting Staphylococcus aureus and anaerobes, combined with aggressive hydration, gland massage, warm compresses, and sialagogues. 1, 2

Immediate Assessment and Risk Stratification

When evaluating parotitis, immediately assess for:

• Facial nerve function – Any facial weakness or palsy indicates either malignancy or serious complication requiring emergency evaluation 1
• Systemic symptoms – Fever, constitutional symptoms, weight loss, or night sweats suggest severe infection or lymphoma 1, 3
• Pain characteristics – Painful swelling typically indicates infection or inflammation, while painless masses raise concern for malignancy 1
• Bilateral versus unilateral involvement – Bilateral swelling suggests Sjögren's syndrome or systemic autoimmune process 1

Initial Medical Management

For Acute Bacterial Parotitis

Initiate empiric antibiotic therapy immediately targeting the most common pathogens:

• Primary pathogens: Staphylococcus aureus and anaerobic bacteria (including Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species) 2
• Secondary considerations: Streptococcus species and gram-negative bacilli (particularly in hospitalized patients) 2

Concurrent supportive measures are essential 1:

• Aggressive intravenous hydration
• Parotid gland massage
• Warm compresses
• Sialagogues (lemon drops, sugar-free gum) to stimulate saliva flow
• Maintain good oral hygiene 2

For Viral Parotitis (Mumps)

• Supportive care only – Mumps parotitis is self-limited, with onset 16-18 days after exposure 4
• Pain management and hydration
• Monitor for complications (orchitis, aseptic meningitis, meningoencephalitis) which are more common in adults 4

Imaging Algorithm

Order high-frequency ultrasound (≥12 MHz) with color Doppler as the initial imaging study to 1:

• Distinguish parotid versus extraparotid location
• Identify abscess formation
• Characterize suspicious features

Proceed immediately to MRI with and without IV contrast if 1, 5:

• Deep lobe involvement is suspected
• Facial nerve dysfunction is present
• Ultrasound shows indeterminate or concerning features
• Additional palpable neck lymph nodes are identified

Surgical Intervention Criteria

Immediate surgical drainage is required when 1, 2:

• Abscess formation is confirmed on imaging
• Clinical deterioration occurs despite 48-72 hours of appropriate antibiotic therapy
• Facial nerve palsy develops
• Rapidly enlarging mass despite treatment

Monitor closely within 48-72 hours of initiating antibiotics, and obtain ultrasound to assess for abscess or underlying mass if symptoms persist or worsen 1

Tissue Diagnosis Requirements

Perform fine needle aspiration biopsy (FNAB) for any mass that persists beyond acute infection treatment to distinguish between inflammatory, infectious, autoimmune, and malignant causes 1, 5

• Use ultrasound-guided FNA rather than palpation-guided to increase specimen adequacy and target solid components 1, 5
• Any residual mass after infection resolution requires tissue diagnosis 1

Special Populations and Considerations

Autoimmune-Related Parotitis

For patients with recurrent bilateral parotid swelling 1:

• Evaluate for Sjögren's syndrome (check for sicca symptoms)
• Consider sialography or MRI sialography if duct obstruction suspected
• Be aware of increased lymphoma risk (MALT lymphoma) in Sjögren's patients

Chronic/Recurrent Parotitis

• Conservative management first: Hydration, oral hygiene, sialagogues 6, 7
• Sialography may be therapeutic in addition to diagnostic 7
• Interventional radiology procedures (stone removal with Dormia basket, balloon dilation of strictures) should be attempted before surgery 8
• Surgical parotidectomy reserved for refractory cases after prolonged medical management failure 6

Pediatric Considerations

• Recurrent parotitis in children aged 3-6 years typically resolves by puberty 7
• Expectant management is appropriate; aggressive treatment rarely justified 7
• Ultrasound is the appropriate initial investigation 7

Common Pitfalls to Avoid

• Do not delay antibiotics while awaiting imaging or culture results in suspected bacterial parotitis 1, 2
• Do not rely solely on imaging to determine benign versus malignant nature – histologic diagnosis is required 1, 5
• Do not underestimate deep lobe involvement when using ultrasound alone – proceed to MRI when indicated 1, 5
• Do not ignore persistent masses after infection resolution – these require tissue diagnosis 1
• Do not perform open biopsy without attempting FNA first for suspected malignancy 5

Red Flags Requiring Urgent Specialist Referral

Immediate otolaryngology consultation required for 1:

• Facial nerve palsy development
• Abscess formation identified on imaging
• Rapidly enlarging mass despite antibiotic therapy
• Histology confirming malignancy