Parotitis can occur in any debilitated or dehydrated patient. About one-third of cases occur postoperatively. 20 Suppurative parotitis is believed to occur from the retrograde migration of oral bacteria.19 Predisposing conditions are ductal abnormalities (e.g., stricture), drugs or therapies decreasing the flow of saliva (e.g., phenothiazines, antihistamines, parasympathetic inhibitors, radiation treatment), and poor oral hygiene. 1 2°
Suppurative parotitis presents clinically as a tender, erythematous, and swollen parotid gland. It is bilateral in up to 20 to 25 percent of cases. 19 Pain may extend from the ear to above the mandible. Swelling may progress over the face and neck. The angle of the mandible may be obliterated.18 Fever and trismus may be present, and pus (which should be cultured) may be expressed from the Stenson duct.20 Abscesses can occur, although the fluctuance may be difficult to appreciate on physical exam.
Suppurative sialoadenitis can occur in the other salivary glands, but the expected pathogens and recommended treatment are the same. Usual bacteria are Staph.
aureus mixed with anaerobes.1720 In chronically ill, dehydrated, or hospitalized patients, Pseudomonas, Enterobacter, Klebsiella, enterococci, Proteus, and Candida spp. can be found.
The diagnosis is strictly clinical.17 No specific testing is available. Examination will identify the parotid as the source of discomfort. In patients failing to improve after several days of treatment, CT or ultrasound should be considered to identify a possible abscess. Because it may aggravate the condition, sialography is contraindicated during the acute stage.17
It may be difficult to differentiate viral and suppurative parotitis. The differential is broad and includes sialolithiasis ( T.a.b.!® 2.3.2:.1). Bacterial parotitis is usually associated with higher fever, greater warmth, and more overlying erythema as compared with viral parotitis. Lymphadenitis can present with similar findings but usually involves an identifiable source of infection, is not localized to the parotid, and will not cause purulent discharge from the Stenson duct.
TABLE 232-1 Causes of Salivary Gland Enlargement
Hydration to ensure salivary flow, massage, local heat, and sialogogues (such as lemon drops) are the mainstays of therapy. The patient should receive antibiotics effective against the expected pathogen. Initially recommended antibiotics are amoxicillin/clavulanate or ampicillin/sulbactam. 2 Alternative choices include clindamycin, antistaphylococcal penicillin, cefoxitin, or vancomycin plus metronidazole. 2 Antibiotics should be continued until culture results are known.
Patients who are clinically stable and able to complete their antibiotic regimen may be discharged for outpatient management. Those with hemodynamic instability, vomiting, severe complicating disease, or other factors precluding compliance with their antibiotic therapy should be admitted for intravenous antibiotics. When an abscess is identified, ENT consultation for consideration of surgical drainage is necessary.
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