What is the appropriate treatment for parotitis?

Treatment of Parotitis

For viral parotitis (mumps), provide supportive care only without antibiotics, while bacterial parotitis requires parenteral antimicrobial therapy targeting Staphylococcus aureus and anaerobes, with surgical drainage if abscess formation occurs. 1, 2

Distinguishing Viral from Bacterial Parotitis

The etiology determines treatment approach entirely:

• Viral parotitis (mumps) presents with bilateral or unilateral swelling developing 16-18 days after exposure, often preceded by fever, headache, malaise, myalgia, and anorexia 1
• Only 30-40% of mumps infections produce typical acute parotitis; 15-20% are asymptomatic and up to 50% present with nonspecific respiratory symptoms 1
• Bacterial parotitis typically presents with acute onset of unilateral painful swelling, purulent discharge from Stensen's duct, fever, and signs of systemic toxicity 2
• The most common bacterial pathogens are Staphylococcus aureus and anaerobic bacteria (pigmented Prevotella, Porphyromonas, Fusobacterium, and Peptostreptococcus species) 2

Treatment Algorithm for Viral Parotitis

Viral parotitis is self-limited and requires only supportive care—antimicrobial therapy is not indicated. 1

Oral Hygiene Measures

• Clean the mouth daily with warm saline mouthwashes to reduce bacterial colonization 1
• Use antiseptic oral rinses containing 0.2% chlorhexidine digluconate or 1.5% hydrogen peroxide twice daily to decrease microbial load 1

Pain Management (Stepwise Approach)

• First-line: Apply benzydamine hydrochloride oral rinse or spray every 3 hours for anti-inflammatory and analgesic effects 1
• Second-line: Add topical anesthetic preparations such as viscous lidocaine 2% if pain control is inadequate with anti-inflammatory agents alone 1
• Third-line: Escalate to systemic analgesics following the WHO pain management ladder for severe pain unresponsive to topical measures 1

Additional Supportive Measures

• Apply white soft paraffin ointment to the lips every 2-4 hours if perioral involvement is present 1
• Use mucoprotectant mouthwash three times daily to protect ulcerated mucosal surfaces if oral mucositis accompanies parotitis 1
• Treat secondary candidal infection with nystatin oral suspension or miconazole oral gel if fungal overgrowth develops 1

Monitoring for Complications

• Monitor for orchitis, aseptic meningitis, and rarely meningoencephalitis or sensorineural deafness 1

Treatment Algorithm for Bacterial Parotitis

Bacterial parotitis requires parenteral antimicrobial therapy and surgical drainage once abscess formation occurs. 2

Antimicrobial Therapy

• Maintain adequate hydration and administer parenteral antimicrobial therapy targeting both Staphylococcus aureus and anaerobic bacteria 2
• The choice of antimicrobial depends on the etiologic agent; gram-negative organisms are often seen in hospitalized patients 2
• Common pathogens also include Streptococcus species (including S. pneumoniae) and gram-negative bacilli (including Escherichia coli) 2

Surgical Intervention

• Once an abscess has formed, surgical drainage is required 2

Preventive Measures

• Maintenance of good oral hygiene, adequate hydration, and early and proper therapy of bacterial infection of the oropharynx may reduce the occurrence of suppurative parotitis 2

Imaging Considerations

• Ultrasound is commonly used to evaluate palpable parotid region abnormalities, usually in the setting of suspected acute inflammation 3
• CT performed without IV contrast may be helpful in a small number of cases, particularly for delineating sialoliths and bony details 3
• MRI sialography may provide assessment of the parotid ducts if there is clinical concern for acute parotitis in the setting of duct obstruction 3

Common Clinical Pitfalls

• Do not prescribe antibiotics for viral parotitis—this is the most common error, as viral parotitis requires only supportive care 1
• Avoid petroleum-based lip products as they promote mucosal dehydration and create an occlusive environment increasing secondary infection risk 4
• Do not use alcohol-containing mouthwashes as they cause additional pain, irritation, and impair healing 4
• Inadequate pain management can impact nutrition and hydration—escalate pain control systematically rather than allowing patients to suffer 1