Parotitis Treatment & Management
- Author: Jerry W Templer, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Most episodes of chronic parotitis are treated symptomatically. Sialogogues, local heat, gentle massage of the gland from posterior to anterior, and hydration provide variable symptomatic relief. When pus is expressed from the Stensen duct, culture and sensitivity studies guide antibiotic selection. Treatment of the primary disease (eg, HIV, rheumatoid arthritis) is all that is required. Some authors advocate intermittent irrigation of the ductal system with saline, steroid solution, and/or an antibiotic to treat the infection and mechanically remove inspissated mucous or pus from the ducts. This may retard the disease progression. The rationale is stronger for those with the dilated “sausage-shaped” ducts.
This treatment is advocated for those patients not responding to symptomatic treatment and should be attempted before considering surgery. Baurmash advocates a Decadron (dexamethasone) and penicillin solution in saline to cleanse the ducts and for topical therapy. If successful, this irrigation is repeated as needed.
Acute bacterial parotitis is caused by bacteria that ascends from the mouth and most frequently occurs in chronically ill patients. The patient quickly becomes extremely ill. In the hospital setting, S aureus is apt to be methicillin resistant (MRSA). Gram stains and culture and sensitivity testing is ordered. Intravenous vancomycin at 500 mg every 6 hours is begun empirically. Therapy may be altered based upon cultures or infectious disease consultation.
The treatment of chronic parotitis is based on the symptoms of the patient and decisions are, by definition, subjective. Recurring parotitis, an unpleasant and distressing condition, is managed conservatively in most instances but occasionally requires surgery to end the frequent and severe episodes of infection. The decision for surgery is based on subjective symptoms.
The swollen inflamed gland makes surgery more difficult, and the incidence of injury to the facial nerve may be slightly higher than for removal of benign tumors.
The standard treatment is superficial parotidectomy, but if CT scanning or surgery reveals significant involvement of the deep lobe, that portion of the gland is dissected from beneath the nerve.
Fibrosis makes the tensile strength of the surrounding gland much greater than the nerve itself. Surgery is difficult and expensive. Parotidectomy is still the most acceptable treatment in the United States.
In tympanic neurectomy, the parasympathetic supply to the parotid gland is sectioned within the middle ear so as to cause gland atrophy. Success is not uniform, but the magnitude of the surgery is less. If one believes that decreased salivary flow is the cause of chronic parotitis, the treatment is irrational.
In ligation of the parotid duct, the duct can be ligated so as to cause atrophy of the gland and prevent ascending bacterial infections from entering the mouth. The duct should be dissected for a short distance within the cheek and severed. The duct should be oversewn to ensure that the soft tissue heals. Simple ligation frequently results in recanalization of the duct. The procedure is based on assumptions that may not be true, and the rationale is weak.
Intermittent reports of another treatment technique, instillation of methyl violet into the parotid duct to destroy the gland, have been made for more than 40 years. The procedure is not commonly performed in the United States, however, possibly because of the fear that the chemical may be carcinogenic. The gland is massaged to remove saliva, and the duct is cannulated with a 1-3 mm polyethylene tube. One to 3 mL of 1% methyl violet is instilled until the ducts are full and the patient complains of pressure. The tube is occluded for 30 minutes and then removed. The gland swells for 1-2 weeks, and the duct system should be obliterated in 2-4 weeks. If symptoms persist after this time, a second injection may be performed. This method is much cheaper than parotidectomy and should prevent ascending infections from the mouth. Whether the acini involute and disappear is not certain. Other substances such as tetracycline have been shown to cause necrosis of the gland when instilled into the ductal system.
A literature review by Ramakrishna et al indicated that sialendoscopy can be used to safely and effectively treat juvenile recurring parotitis. The investigators reported that the weighted pooled proportions of success rates as measured by the occurrence of no additional episodes of parotitis were 73% (by patient; n=120) and 81% (by gland; n=165). The weighted pooled proportion of success rates as measured by the need for no additional sialendoscopy was 87% (by patient).
Patients with autoimmune parotitis experience xerostomia and excessive tooth decay. These patients should have dental consultation and frequent dental care.
The diet does not significantly affect cases of parotitis.
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