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Approch to Acute Parotitis in Children
7
Approch to Acute Parotitis in Children
Prepared by Dr.Abdelmoniem Elhedody
Introduction
Defenitions
Defenitions
- Sialadenitis is inflammation of a salivary gland.
- Acute sialadenitis or parotitis is characterized by sudden enlargement and pain of the parotid gland and is usually due to an obstructive, infectious, or inflammatory etiology.
- The size of the affected gland may fluctuate depending on the specific cause and acuity of the inflammation.
Anatomy of parotid gland
Anatomy of parotid gland
- The parotid gland is the largest salivary gland, located lateral and anterior to the masseter muscle, and extends posteriorly over the sternocleidomastoid muscle behind the angle of the mandible. It produces serous secretions, which lack bacteriostatic properties, making it more susceptible to infection than other salivary glands.
- The parotid duct, also called the Stensen duct, pierces the buccinator muscle and enters the buccal mucosa opposite to the maxillary second molar.
- The branches of the facial nerve bisect the gland into lobes.
Etiology
Etiology
Acute unilateral
- Acute unilateral parotitis:
- Acute unilateral parotitis:
Obstructive causes — usually caused by salivary gland stones and/or strictures and is characterized by intermittent gland swelling . The mechanical obstruction of salivary flow within the duct causes swelling of the gland as saliva is produced but is unable to drain normall .
Obstructive causes
Acute unilateral parotitis:Obstructive causes
1-salivary stones is the most common cause of acute, unifocal salivary gland swelling. The clinical presentation of acute obstructive sialadenitis due to stones is variable depending on the degree of obstruction; symptoms may be less severe and episodic or more severe and persistent
salivary stones
Ductal stricture
Acute unilateral parotitis:Obstructive causes
2-Ductal stricture is a narrowing in the salivary duct lumen that impairs normal salivary flow.
Ductal stricture often presents similarly to stones, although the overall course may typically be more of relapsing and remitting symptoms.
Determining the etiology of stricture may be difficult; all disorders associated with salivary duct injury including irradiation, trauma, prior infection, and autoimmune processes may result in duct damage and ultimate stricture. However, the cause for the stricture often remains unknown.
Acute unilateral parotitis:Obstructive causes
3-Ductal foreign body may infrequently enter the salivary ducts in a retrograde fashion from the oral cavity to cause obstruction; fish bones, hair, and toothbrush bristles have been found within salivary ducts . Foreign bodies within the ducts may additionally serve as a nidus for the development of a stone, as seen in a Chinese hospital where in a series of 561 sialendoscopies, 423 stones were identified, 2.8 percent of which were found to contain fish bones.
Rarely, foreign bodies may be introduced percutaneously into the ductal system traumatically .
Ductal foreign body
Pneumoparotitis
Acute unilateral parotitis:Obstructive causes
4-Pneumoparotitis – Sialadenitis may result when air is forced into the duct and gland . It has been described in association with the use of positive pressure ventilation Pneumoparotitis can occur as a result of oronasal CPAP. The obstruction is caused by the air within the duct and should resolve within a few hours after discontinuation of the positive airway pressure ventilation or conversion from oronasal CPAP to nasal CPAP *1.
Other activities that cause increased intraoral pressure, including wind instrument playing , glass blowing, exercising, and behaviors associated with psychiatric abnormalities .
Only 54 cases have been reported in literature. Majorly these cases are in the pediatric population (74%), seen in children as young as five, and are linked to psychological stresses or tic disorders. All cases can be linked to an increase in intraoral pressure either self-induced secondary to stress or iatrogenic/idiopathic *2.
*1 Pneumoparotitis as a complication of long-term oronasal positive airway pressure for sleep apnea.
Goates AJ, Lee DJ, Maley JE, Lee PC, Hoffman HT
Head Neck. 2018;40(1):E5. Epub 2017 Nov 17.
*2 Pneumoparotid and pneumoparotitis: a literary review. Gazia F, Freni F, Galletti C, et al. https://doi.org/10.3390/ijerph17113936 Int J Environ Res Public Health. 2020;17
External compression
Acute unilateral parotitis:Obstructive causes
5-External compression of the duct – Less common causes of obstruction to salivary flow may occur from other processes including pressure from hypertrophied masseter causing kinking of the parotid duct.
Acute unilateral parotitis:Infectios causes
Bacterial sialadenitis is characterized by the sudden onset of pain and swelling of a single gland, with an indurated, tender, and swollen. Massage of the gland may produce purulent material at the duct orifice .
Most common organism is Staphylococcus aureus .Predisposing factors include any process that inhibits salivary flow or causes salivary stasis, such as dehydration, sialolithiasis, ductal stricture and prior irradiation.
Genral prevention by Maintaining adequate hydration and good dental hygiene .
Other less common ,actinomycosis and mycobacteria. While mycobacterial typically involve the cervical lymph nodes, in rare cases the salivary gland itself may become involved.
Infectious causes
Inflammatory causes
Acute unilateral parotitis:Inflammatory causes
Post-radiation sialadenitis – The acute effects of radiation can cause an inflammatory sialadenitis with swelling and pain that usually resolves over a period of months. Following the initial radiation-induced sialadenitis, chronic destructive changes to the glands. The long-term effects of radiation are generally irreversible.
Acute bilateral
- Acute bilateral parotitis:
Acute bilateral parotitis:Viral sialadenitis
Most commonly Mumps is characterized by fever, headache, malaise and myalgia, followed by the development of salivary gland (typically parotid) swelling within 48 hours of symptom onset.
Often unilateral at onset, becomes bilateral in over 90 percent of cases within a few days.
General Prevention by Completing MMR vaccinnation.
Other viral causes (mumps-like) as (EBV) and parainfluenza virus (PIV) were found to be the most common causes of mumps-like viral infections, with adenovirus, enterovirus, parvovirus, and herpes virus type 6 (HHV-6)
acute Viral parotitis
Inflammatory causes
Acute bilateral parotitis:inflammatory
Iodide mumps, or contrast-induced acute sialadenitis, is characterised by rapid, painless enlargement of the salivary glands, following the use of iodinated contrast dye. The underlying mechanism of this adverse reaction is not completely understood.
Juvenile recurrent parotitis
Acute Bilateral parotitis:Juvenile recurrent parotitis
JRP is a recurrent, acute parotitis characterized by intermittent painful swelling of one or both glands and redness of the overlying skin and is often accompanied by fever .last from 24 to 48 hours but may last for 1-2 weeks.
JRP most often occurs in boys between the ages of four months and 15 years and is generally self-limited with spontaneous remission . JRP had been the second most common salivary gland disorder after mumps *.
The pathogenesis of JRP is unclear, with various causes hypothesized, including autoimmune disease, retrograde infection (bacterial or viral) of the ducts, genetic abnormality, and congenital ductal malformation
*Sialendoscopy in juvenile recurrent parotitis: a review of the literature.
Canzi P, Occhini A, Pagella F, Marchal F, Benazzo M
Acta Otorhinolaryngol Ital. 2013;33(6):367.
Drug-induced
and
Bulimia nervosa
Acute Bilateral parotitis:
Drug induced
Drug-induced parotitis is a rare adverse drug reaction associated with l-asparaginase, clozapine, and phenylbutazone . The mechanism of action for drug-induced salivary swelling is largely unknown .
Bulimia nervosa
Although chronic parotid gland enlargement is widely described in patients with bulimia nervosa ,vomiting may result in acute sialadenitis, characterized by painful, bilateral parotid gland swelling.
Epidemiology
Epidemiology
Viral parotitis is the most common cause of parotitis in children; incidence has decreased since introduction of vaccination.But increased overall due to SARS-CoV-2 infections.
Acute bacterial parotitis is less common but occurs more frequently in neonates and postoperative patients.
Juvenile recurrent parotitis (JRP): second most common inflammatory cause of parotitis in children in the United States; first episode usually occurs between ages 3 and 6 years.
Diagnosis and managmanet
Diagnosis and Managmanet
Initial evaluation
Initial evaluation
History
Initial evaluation: History
- Viral parotitis is usually bilateral and accompanied by a prodrome of malaise, anorexia, headaches, myalgias, arthralgias, and fever: typically, overlying skin is not warm or red, and no pus is reported at the opening of Stensen duct.
-Bacterial parotitis is typically unilateral with induration, warmth, and redness over the affected cheek; fever is often present.
- JRP is unilateral or bilateral ; pain and swelling resolve within 2 weeks, and exacerbations occur until puberty; purulent exudate not typical unless superinfection occurs.
-stones is characterized by recurrent acute swelling and pain, exacerbated by eating but affects the submandibular gland more frequently.
- Other reported symptoms include trismus (inability to open mouth). pain exacerbated by chewing or worsened by foods that stimulate production of saliva, dry mouth with abnormal taste, difficulty with drinking/eating, anorexia, or dehydration.
examination
Initial evaluation:examination
Parotitis is characterized by swelling or enlargement of the parotid gland(s) overlying the masseter muscle; may obscure the angle of the mandible or cause the ear to protrude upward and outward .
Palpation is best done by using one hand at the earlobe and palpating anteriorly and inferiorly along the mandibular ramus while the other hand palpates the duct orifice inside the oral cavity. Tender and bilateral suggest viral etiology, whereas tender, erythematous, warm, an unilateral suggest bacterial etiology.
Pus from the duct is suggestive of bacterial parotitis or superinfection while opening of the duct may appear edematous and erythematous in both bacterial and viral parotitis.
In JRP, the duct is often enlarged, dilated,erythematous, and swollen.
Facial nerve palsy can be seen in severe cases.
Investigations
Investigations
Laboratory
Investigations:Laboratory
History and physical exam are usually sufficient for diagnosis.
For suspected mumps, the CDC recommends collecting a oral swab for mumps PCR and a blood specimen for IgM and IgG serologies. Mumps PCR is best obtained within 1 to 3 days of parotitis onset. In areas of high vaccination rates, IgM may be falsely negative necessitating correlation with clinical symptoms. A 4-fold increase of mumps IgG antibody indicates infection. CMV titers should be sent in immunocompromised patients.
Acute bacterial parotitis often demonstrates an elevated white blood cell count and amylase.
Performing aerobic culture and Gram stain of purulent drainage from Stensen duct or from needle aspiration of gland or abscess can be helpful to identify causative organism.
Imaging
Investigations:Imaging
Indicated with unilateral swelling . To evaluate the nature of the swelling (cystic versus diffuse enlargement) . To determine if the salivary gland itself or another structure (lymph node) is enlarged. Typically initial imaging with ultrasound.
Imaging approach in patients with unilateral gland swelling is as follows:
●If ductal dilatation is identified on ultrasound, we proceed with CT with contrast. when parotid stones are identified on CT imaging, we perform sialography to evaluate for strictures; this information helps determine the most appropriate surgical approach .
●If ultrasound is performed and no abnormality is identified, CT with contrast; sialography or sialendoscopy may be then performed if needed.
●If CT with contrast is performed initially and abnormalities are found , sialography and/or sialendoscopy may then be indicated.
●If a mass with features suggesting a neoplasm or vascular etiology is detected on ultrasound or CT, then we obtain an MRI in the majority of cases.
Treatment
Treatment
conservative
Treatment :conservative
-Admission is recommended for patients with comorbidities, systemic involvement, or inability to tolerate PO as, neonates and patients for whom close outpatient up is not feasible.
-Referral to ENT is needed if a mass is seen,or no improvement with antibiotic therapy.
-Usually a self-limiting course that requires supportive and conservative treatment *1 inculding:
-Pain management
-Adequate hydration as Dehydration exacerbates inflammatory process and makes mucoid saliva more prominent.
-Warm massage
- Can stimulate glands to produce saliva by sucking on hard candies .
- Patients diagnosed with mumps should be isolated with droplet precautionsfor 5 days after onset of parotid swelling.
- Underimmunized individuals should get 2 doses of the MMR vaccine separated by at least 28 days. This will not change the disease course if the person is already infected but will help prevent future infection.
- During a mumps outbreak, the CDC supports administration of MMR vaccine even in fully vaccinated individuals. *2
*1 Francis CL1, Larsen CG2. Pediatric sialadenitis. Otolaryngol Clin North Am. 2014 Oct;47(5):763-78. PMID: 25128215.
*2 Cardemil CV, Dahl RM, James L, et al. Effectiveness of a third dose of MMR vaccine for mumps outbreak control. N Engl J Med. 2017;377(10):947–956.
Medications
Treatment : medications
-Viral parotitis: There is no evidence for the role of immunoglobulin .
Antibiotics is used if patient is toxic appearing or has an Acute bacterial parotitis:
-Outpatient management: amoxicillin/clavulanate or Cefuroxime + metronidazole
-hospitalized: ampicillin/sulbactam or ceftriaxone + clindamycin ; if MRSA +ve to consider vancomycin or linezolid.
-There are no data available to guide duration of therapy for suppurative parotitis.For patients with uncomplicated suppurative parotitis who have good clinical response, a total duration of 10 to 14 days is reasonable.
surgical
Treatment : surgical
If medical therapies fail, or there is concern for localized complication the Likely needed Surgical options:
Stone retrieval and ballon dilation
Gland excision – has become less common
Sialendoscopy – has become preferred option
Progosis and complications
Progosis and complications
Viral infection in immunocompetent individuals often resolves with excellent prognosis.
For mumps, potential complications include orchitis, oophoritis, mastitis, aseptic meningitis, encephalitis, pancreatitis, myocarditis, sensorineural hearing loss, and nephritis.
Untreated bacterial parotitis can lead to local extension, abscess formation, and facial paralysis.
case reports
Case 1
Case 1:Acute parotitis in a 4-year-old in association with COVID-19
A healthy 4-year-old boy presented with a day of malaise, diarrhoea, vomiting and mild abdominal pain.nasopharyngeal swab was positive for SARS-CoV-2 by PCR.
Four days later, child was admitted with right-sided facial swelling and pain, especially
in the pre-auricular area and cheek, with difficulty swallowing.Serology was negative for mumps, measles, rubella,hepatitis A, hepatitis C, CMV, EBV and HIV. Neck ultrasonography showed diffuse enlargement of the parotid gland, compatible with acute parotitis.
Cases of COVID-19-associated parotitis in children are rare. In a case series of 15 patients only 3 were children (10 , 13 and 4 years old)
The occurrence of COVID-19 related acute parotitis has been suggested in a recent case report *
Celebi University Faculty of Medicine, _Izmir, Turkey
Journal of Paediatrics and Child Health 57 (2021) 958–959
© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).
* Acute parotitis: a possible precocious clinical manifestation of SARS-CoV-2 infection? Otolaryngol Head Neck Surg. 2020;194599820926992;
Case 2
Case 2:Acute parotitis in a newborn:
An 8-day-old, full-term boy (40 weeks with NVD delivery, and BTW 3150 g ,developed fever 39°C and a swelling in the left parotid region with local inflammatory signs. There were no perinatal complications, and no relevant maternal or familial history .
He was found to be in a good general condition and active.Oral cavity examination showed purulent drainage from the left parotid duct. A swab of the pus was collected for culture.Ultrasound examination of the left parotid showing a picture of acute parotits.
intravenous empirical antibiotic therapy with vancomycin plus cefotaxime, culture was
positive for S. aureus .Started to mproved on 4th day and follow up after 9 days of treatment with complete recovery .
Department of Otorhinolaryngology, Porto, Portugal
The Egyptian Journal of Otolaryngology
2016, 32:236–239
Neonatal parotitis:Discussion
Acute bacterial parotitis is rare in the neonatal period. It has a prevalence of 3.8–14/10 000 among neonatal admissions *1.This was the 1st case in Portugal.
Acute parotitis may affect normal healthy neonates, but it seems to be more common in premature infants with low birth weight. May be related to an higher risk for dehydration, which may reduce salivary secretion causing salivary stasis, which promotes bacterial ascent along the salivary duct .
Other risk factors are NG tubing, sepsis, structural abnormalities, facial trauma, and immunodeficiency. This case diagnosed with case, hypogammaglobulinemia A.A follow-up IgA level was within normal , meaning that it was just a transient .
Discussion
*1 Decembrino L, Ruffinazzi G, Russo F, Manzoni P, Stronati M. Monolateral suppurative parotitis in a neonate and review of literature. Int J Pediatr Otorhinolaryngol 2012; 76930–933.
*2 Özdemir H, Karbuz A, Ciftçi E, Fitöz S, Ince E, Dogru U. Acute neonatal
suppurative parotitis: a case report and review of the literature. Int J Infect
Dis 2011; 15e500–e502.
Case 3
Case 3: Submasseteric abscess
A 6.5-year-old male child presented with history of right facial swelling. Initially, it was a small swelling started in the area of the right angle of mandible. Associated with mild pain and low-grade fever. The swelling gradually continued to grow in size and was painful. The patient had history of right lower toothache.
A large diffuse swelling extending from the lower border of the right zygomatic arch down to the submandibular region. It was firm and tender to touch and no fluctuation was elicited on palpation. Oral examination revealed caries in the right upper and lower second molars.
CT scan showed a large irregular, hypodense lesion deep to right masseter muscle, with Right parotid gland was found compressed posteriorly . Intravenous antibiotics were given prior to surgery for 1 week.An incision and drainage was performed,antibiocts contniued for total 3 weeks and Upon review 2 weeks postoperatively, the swelling had totally resolved .
Department of E.N.T. and Head & Neck Surgery, M.L.N. Medical College, Allahabad, Uttar Pradesh, India.
Published in Indian journal of dental research on 25-Apr-2011
Discussion
Submasseteric abscess:Discussion
As the submasseteric space (which is a bare area between the separate attachments of deep and middle portions of the masseter muscle) has no outlet, inadequately treated infections in this area rapidly progress to abscesses.
The differential diagnosis of swelling in this region includes parotid gland pathology, masseteric hypertrophy, temporo-mandibular joint disorders.
In conclusion, submasseteric abscess is a rare abscess (Only a few cases have been reported) which is often misdiagnosed as a parotid abscess or parotitis. The cause is mostly dental in origin. Intravenous antibiotics often fail to alleviate the symptoms and needs prompt drainage .