Medical Care
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. [10] 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.
Surgical Care
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). [32]
A retrospective study by Mikolajczak et al indicated that juvenile recurrent chronic parotitis can be safely and effectively treated with a combination of sialendoscopy and intraductal corticosteroid application. The study involved nine children with recurrent parotitis (10 affected parotid glands total) who underwent the treatment, with no sialendoscopy-associated side effects occurring. After an average follow-up period of 15 months, the investigators found that eight of the children were symptom free. Although the ninth patient still had slight parotid gland swelling at follow-up, antibiotic therapy was not required. [29]
In the aforementioned study by Benaim et al, the investigators stated that sialendoscopy with steroid irrigation may benefit patients with two or more recurrences of juvenile recurrent sialendoscopy. They found that 47% of the study’s patients had no recurrence after their first sialendscopy, with that rate rising to 76% after three sialendoscopies. [22]
However, a 12-patient retrospective study by Roby et al indicated that ductal corticosteroid infusion alone produces a similar outcome to the sialendoscopy/intraductal corticosteroid combination in the treatment of juvenile recurrent parotitis. [30]
A prospective study by Jokela et al indicated that sialendoscopy can also reduce symptoms in adults with chronic recurrent parotitis. The study, which included 49 adult patients with the condition but without sialolithiasis, found a significantly reduced visual analogue scale score and decreased symptom frequency at 3-, 6-, and 12-month follow-up. However, the incidence of complete, permanent symptom resolution was small. [31]
A retrospective study by Guo et al indicated that in patients with Sjögren syndrome–associated chronic obstructive parotitis, interventional sialendoscopy is again an effective treatment. The investigators found that in 17 patients (27 parotid glands) who underwent the procedure, the mean preoperative visual analog scale (VAS) score was significantly improved at 6-month postprocedure follow-up (6 vs 4.5, respectively). [33]
Consultations
Patients with autoimmune parotitis experience xerostomia and excessive tooth decay. These patients should have dental consultation and frequent dental care.
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Elderly man with parotid abscess.
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Six-year-old girl with recurrent parotitis of childhood.
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Sialogram of patient with sialectasis. Notice the appearance of a tree with leaves.
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Incision outlined for incision and drainage of parotid abscess.
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Parotid gland anatomy.
