Updated: May 23, 2013

Background
The parotid glands are small exocrine glands that rarely call attention to themselves !er"ect "unction
throughout li"e is normal
#ry mouth, drooling, s$elling, and pain are essentially the only symptoms caused %y dys"unction o" the
salivary glands
&n"lammatory s$elling o" the glands may present a serious diagnostic challenge !arotitis presents in
many "orms and the symptoms vary "rom modest to prostrating ' pure viral or %acterial in"ection, an
autoimmune in"lammation, or a com%ination o" these can %e the etiology
Infectious parotitis
This group o" diseases is caused %y kno$n in"ectious agents
Acute bacterial parotitis
'cute %acterial parotitis is no$ in"re(uent, %ut its historical importance and occasional occurrence today
necessitate in)depth kno$ledge o" this entity %y the otolaryngologist Mumps and %acterial parotitis $ere
di""erentiated %y 1*00, %ut neither $as e""ectively treated The mortality rate "or %acterial parotitis $as
*0+ Be"ore anti%iotics and intravenous administration o" "luids $ere availa%le, %acterial parotitis occurred
in postoperative patients or other severely ill patients $ho %ecame dehydrated and contri%uted to their
demise as an incura%le sepsis
,arly in the 20th century, surgeons $ere hesitant to incise and drain parotid a%scesses and "re(uently
used ine""ective conservative measures until the process $as irreversi%le They "eared the conse(uences
o" the unsightly scar and "acial paralysis !arotid a%scess is depicted in the image %elo$
,lderly man $ith parotid a%scess
&n 1-1., /ilienthal descri%ed a surgical treatment that $as very similar to $hat is used today
011
2e called
parotid a%scesses celiac parotitis %ecause they $ere %elieved to %e metastatic "rom a%dominal in"ections
3ther authors used names such as acute surgical parotitis, acute necrotic parotitis, acute gangrenous
parotitis, and other historical designations according to 2emen$ay and ,nglish in 1-.1
021
/ilienthal designed a vertical incision 4ust anterior to the auricle that coursed posteriorly and in"eriorly
%elo$ the ear to 4oin and "ollo$ an upper cervical skin crease that paralleled the lo$er mandi%ular %order
as seen in the image %elo$
011
2e elevated the outlined skin "lap "or$ard to expose the parotid gland and
made multiple incisions into the gland parallel to the "acial nerve %ranches 2e then opened the "ascia
%ehind the angle o" the mandi%le to drain deeper spaces The $ound $as packed and healed %y
secondary intention, resulting in a surprisingly good cosmetic result The num%er o" patients treated %y
this drainage is not kno$n, %ut this treatment $as pro%a%ly almost anecdotal to /ilienthal5s
contemporaries
&ncision outlined "or incision and drainage o" parotid a%scess
&n 1-1-, 6achary 7ope, a British 'rmy surgeon, descri%ed . patients $ith parotitis that he had treated in
Baghdad during the exceptionally hot summer o" 1-1.
031
2e recorded that these soldiers
had heatstroke or $ere severely a""ected %y the extreme heat The patients developed parotid s$elling
accompanied %y "ever and general malaise 7ope made $ide T)shaped incisions in the gland to allo$
drainage 8our o" the . survived a"ter sloughing gangrenous parotid tissue 7ope stated that although the
disease $as a %acterial in"ection, the excessive heat and de%ilitating illness predisposed to its
development
&n 1-23, Blair and !adgett o" 9t /ouis pu%lished an article stating that early surgical drainage o" the
in"ected gland $as sa"e and "re(uently $as li"e saving
0:1
They stated that acute suppurative parotitis $as
an ascending duct in"ection related to decreased salivary "lo$, "ever, and general de%ilitation They
cultured the pus and "ound that Staphylococcus aureus $as the most common organism The treatment
proposed %y Blair and !adgett did not %ecome the standard practice "or several more years 2o$ever,
the high mortality rate decreased early in the 20th century and $as 30);0+ %y 1-30, pro%a%ly %ecause o"
more prompt and e""ective drainage o" the a%scesses
8rom the 1-30s to the 1-<0s, irradiation treatment o" numerous diseases %ecame popular, and several
authors advocated :)< =y delivered over :); days "or %acterial parotitis Most patients $ith severe
in"ections re(uired surgical drainage despite radiation treatment By 1-<0, most pu%lished papers
stressed large doses o" anti%iotics, improved oral hygiene, and increased "luid intake as treatment, $ith
incision and drainage "or "ailures They "ound that the parotid capsule and septations re(uired $ide
exposure and extensive deep incisions parallel to the "acial nerve %ranches to exteriori>e the diseased
gland !hysicians recogni>ed the importance o" hydration and oral hygiene "or de%ilitated patients, and
the incidence o" %acterial parotitis plummeted
!arotitis is no$ more common in elderly patients %ecause many take medications $ith an atropine e""ect
that retards salivary "lo$ and predisposes to ascending in"ection Many psychotropic drugs are relatives
o" antihistamines
Acute parotitis in neonates
This rare "orm o" parotitis is lethal $ithout treatment &n ?anuary 200:, 9piegel et al revie$ed the literature
and stated that only 32 cases had %een reported in 4ournals during the previous 3 decades
0;1
The
characteristic clinical picture $as o" a sick premature in"ant $ith unilateral parotid s$elling and
in"lammation 9eventy)"ive percent o" the cases $ere in male in"ants !us expressed "rom the duct
cultured S aureus in more than hal" o" the cases Most all o" the cultured %acteria $ere "rom organisms
present in the oral cavity, $hich suggests an ascending in"ection "rom the mouth
Treatment is prompt administration o" gentamicin and antistaphylococcal anti%iotics plus ade(uate
hydration, $ith a cure in approximately *0+ o" cases 8ailure to improve a"ter 2:):* hours o" treatment
necessitates surgical drainage @ecurrence is uncommon 'cute %acterial parotitis in children %et$een
one year o" age and adolescence is extremely rare and only a "e$ have %een reported The etiology and
treatment is the same as "or adults
Chronic bacterial parotitis
7hronic %acterial parotitis may exist in the presence o" calculi or stenosis o" the ducts secondary to in4ury
' num%er o" articles and %ook chapters descri%e that chronic in"ection is a se(uela o" acute %acterial
in"ection, %ut the evidence is scant Most authors have suggested that decreased salivary "lo$ $as the
common denominator, %ut reduced "lo$ may %e due to the in"lammation &n most instances, the chronic
disease is either autoimmune or o" unkno$n etiology $ith superimposed %acterial in"ections and should
not %e designated as a chronic %acterial in"ection
Acute viral parotitis (mumps)
Mumps, one o" the classic childhood in"ections, is spread %y droplets or %y direct spread "rom
oropharyngeal secretions that contain the paramyxovirus Universal immuni>ation, $hich %egan in 1-..,
has made the clinical disease unusual in developed countries The child should receive the "irst measles,
mumps and ru%ella AMM@B vaccine at age one year and a second at age :)< years
0<, .1
3ccasional out%reaks o" mumps are seen, mostly in teenagers or patients in their early t$enties $ho did
not receive the second shot Be"ore the vaccines $ere availa%le, exposure $as almost universal, and
clinical disease resulted in <0).0+ o" those $ho $ere exposed The disease $as characteri>ed %y
grossly enlarged and modestly tender parotid glands !arotid stimulation caused pain in the gland and
ear Mumps $as a %enign disease in the vast ma4ority o" cases %ut $as occasionally complicated %y
meningoencephalitis, pancreatitis, orchitis, or dea"ness especially in young adults Treatment $as and is
symptomatic and supportive
HIV parotitis
=enerali>ed lymphadenopathy has long %een associated $ith 2&C, %ut the locali>ed enlargement o" the
parotid gland is less $ell kno$n The course o" the disease is di""erent enough %et$een children and
adults to $arrant a separate description
HIV parotitis in children
9alivary gland involvement in children $ith 2&C is $ell recogni>ed and is much more common than
involvement in adults 7haracteristically, the gland is "irm, nontender, and chronically enlarged Aunilateral
or %ilateralB and usually causes "e$ symptoms /ymphoepithelial cysts are less common than in adults
Derostomia $ith decreased salivary "lo$ rates occurs in adults %ut is in"re(uent in children &n"iltration o"
7#*)positive lymphocytes, possi%ly as a result o" 2&C, ,pstein)Barr virus A,BCB, or an interaction
%et$een the 2, enlarges the gland The diagnosis o" 2&C parotitis is usually clinical $ith the typical
"indings 3ther "orms o" chronic parotitis are rare in children
0*1
The picture is not typical "or acute %acterial in"ection Eo speci"ic treatment exists "or this parotitis, and
none is usually re(uired 9ome evidence indicates that parotid involvement is a good prognostic sign
HIV parotitis in adults
The name lymphoepithelial lesion is "re(uently applied to 2&C parotitis and adds con"usion to the many
names o" parotid in"lammatory diseases ' group at the 9tate University o" Ee$ Fork A9UEFB presented a
series o" ;0 patients $ith 2&C and masses in the tail o" the parotid Most o" the patients $ere prison
inmates and intravenous A&CB drug users !arotidectomy $as per"ormed in 3; patients, $ith patients
earlier in the series undergoing lateral lo%ectomy and later patients undergoing local excision o" involved
tissue
Microscopic examination o" the excised specimen revealed 3 types o" involvement: A1B "ollicular
hyperplasia o" the parotid lymph nodesG A2B di""use in"iltration o" the gland %y lymphocytes A7#* T cellsB
$ith appearance much like 94Hgren diseaseG and A3B %enign lymphoepithelial cysts that are the type o"
involvement most "re(uently descri%ed in the literature The cyst $alls are lined %y strati"ied epithelium
that may %e s(uamous, columnar, cu%oidal, or pseudostrati"ied 'ggregates o" lymphoid tissue are
present $ithin the cyst $alls The salivary parenchyma has a normal appearance M@& sho$s the multiple
cysts $ithin the enlarged glands and is almost diagnostic &" the enlarged gland causes cosmetic
de"ormity or pain, antiviral therapy, lo$)dose radiation therapy, or surgical excision may decrease the si>e
o" the gland
0-1
Most authors suggest enucleation o" large cysts &n some individuals, the parotid gland
symptoms are very similar to and may %e con"used $ith 94Hgren syndrome
Parotitis in tuberculosis
The incidence o" pulmonary tu%erculosis steadily decreased in the United 9tates until 1-*;, %ut the trend
reversed and has %een slo$ly increasing since that time $ith a concurrent rise in
extrapulmonary tu%erculosis
0101
Tu%erculosis is an uncommon cause o" parotitis and is not particularly
important, except that approximately 2;+ o" patients have pulmonary tu%erculosis and may in"ect their
associates 'pproximately 3+ o" patients $ith '&#9 have tu%erculosis, and almost .0+ o" these patients
have pulmonary tu%erculosis
&n the past, extrapulmonary tu%erculosis $as apt to %e due to atypical tu%erculosis, such as the %ovine
variety, %ut today, most cases are due toMycobacterium tuberculosis. !atients have enlarged, nontender,
%ut moderately pain"ul glands &nvolvement is most "re(uently con"ined to the parotid lymph nodes, %ut
the gland may %ecome di""usely involved $ith the disease
The diagnosis is made %y typical chest radiograph "indings, cultures, or histologic diagnosis a"ter the
gland has %een removed The long delay "or cultures prolongs the pu%lic5s exposure to the disease '
positive skin test is not particularly help"ul %ecause o" the high incidence o" positive skin tests in the
general population 8ine)needle aspiration %iopsy occasionally yields /angerhans giant cells, $hich
suggest tu%erculosis Ihen diagnosed and treated $ith antitu%ercular medications, the gland may return
to normal in 1)3 months Untreated cases progress to draining "istulas and "i%rosis
Chronic punctate parotitis (chronic autoimmune parotitis)
'lthough acute %acterial parotitis is "airly $ell understood, chronic enlargement o" the salivary glands $ith
recurring in"ection has caused con"usion "or more than a century Eumerous terms "ound in the literature,
such as Mikulic> disease, 94Hgren syndrome, %enign lymphoepithelial lesion o" =od$in, chronic punctate
sialectasis, and recurrent parotitis o" childhood Aas seen in the image %elo$B, are con"using to the
physician 9ialography $as commonly used in the $orkup o" parotid disease in the past, and this group
demonstrates punctate sialectasis, $hich implies point like dilatations $ithin the gland
9ix)year)old girl $ith recurrent parotitis o" childhood
Mikulicz disease
?ohann Mikulic>)@adecki A1*;0)1-0;B, a pro"essor o" surgery in Breslau, !oland, trained under Theodore
Billroth o" Cienna &n 1***, he encountered a :2)year)old "armer $ho had experienced lachrymal gland
s$ellings "ollo$ed %y enlargement o" the su%maxillary and parotid glands The enlarged lacrimal glands
inter"ered $ith his vision and $ere excised %y Mikulic> The su%maxillary glands $ere also excised, %ut
the parotid glands $ere not removed Mikulic> recorded in his pu%lication that this $as a %enign disease
and $as not related to tu%erculosis, leukemia, or malignant lymphoma 2e %elieved the causative "actor
to %e in"ection Eo other patient $ith an identical disease has %een descri%ed
Un"ortunately, the name Mikulic> has %een associated $ith numerous conditions that involve enlarged
parotid glands ,arly in the 20th century, numerous reports descri%ed conditions associated $ith
enlargement or in"lammation o" the salivary glands &n 1-2., 9cha""er and ?aco%son presented a
simpli"ied grouping $ith only 2 ma4or divisions:
0111
A1B cases in $hich tu%erculosis, leukemia, or some other
disease had enlarged the gland and A2B Mikulic> disease, in $hich these other diseases $ere ruled out
The term JMikulic> diseaseJ pro%a%ly should %e discarded %ecause o" am%iguous de"inition 2o$ever, the
term is so popular that it $ill not soon go a$ay
S!"ren s#ndrome
The next ma4or milestone in the understanding o" chronic parotitis $as the pu%lication o" a paper in 1-33
%y 2enrik 94Hgren, a 9$edish ophthalmologist
0121
&n 1-30, 94Hgren o%served his "irst cases o" keratitis
sicca and %egan a systematic study o" the disease that lasted more than 20 years &n his landmark
pu%lication, he named the disorder keratocon4unctivitis sicca 94Hgren pu%lished so extensively that %y
1-3<, the entity $as re"erred to as 94Hgren syndrome, a name that today is $idely employed throughout
the $orld
94Hgren revie$ed the availa%le literature on the su%4ect and pu%lished histopathologic studies o" the
cornea, con4unctiva, and lachrymal glands 2e reported that this disease a""ected menopausal $omen in
$hom the keratocon4unctivitis sicca $as a local phenomenon 2e stressed that arthritis $as a signi"icant
"eature o" the disease and occurred in most patients !atients had an elevated erythrocyte sedimentation
rate 2ypochromic anemia and "ever $ere occasionally present 94Hgren revived the 9chirmer test "or
measuring tear secretion and populari>ed the use o" the @ose Bengal staining techni(ue "or the
diagnosis
94Hgren syndrome, similar to other connective tissue diseases, is a multisystem disorder $ith diverse
"eatures The entity is classi"ied %y some as a primary condition Aprimary 94Hgren syndromeB or is
associated $ith autoimmune diseases such as lupus erythematosus or rheumatoid arthritis Asecondary
94Hgren syndromeB &n the "ully developed syndrome, most organs seem to %e involved
Most authors classi"y the disease as de"inite 94Hgren syndrome, $hich includes A1B o%4ective evidence o"
keratocon4unctivitis sicca or A2B characteristic pathologic "eatures o" the salivary glands The pro%a%le
94Hgren syndrome re(uires 2 out o" 3 o" the "ollo$ing: A1B recurrent chronic idiopathic salivary gland
s$elling, A2B unexplained xerostomia, and A3B connective tissue disease
The disease most commonly appears in people aged :0)<0 years, %ut it may a""ect small children &n
94Hgren syndrome, the prevalence o" parotitis in $omen versus men is approximately -:1 The involved
parotid gland is enlarged and tender at times Massage o" the gland produces clear saliva $ith "locculated
clumps o" coagulated proteins
The next ma4or development in the evolution o" kno$ledge o" chronic parotitis $as a collective pathologic
study o" JMikulic> #iseaseJ %y Morgan and 7astleman in 1-;3 They reported 1* cases and stated that
the pathologic involvement $as uni"orm in all o" these cases The %asic "eatures are massive lymphoid
in"iltration $ith atrophy o" the acini, proli"eration o" the cells o" the small ducts that leads to narro$ing o"
the lumen, and, "inally, o%literation
The "unctioning parts o" the gland AaciniB are destroyed, leaving the appearance o" large lymph "ollicles
2o$ever, among this distorted architecture, islands o" ductal epithelial cells and myoepithelial cells that
appear "airly healthy can %e o%served These groupings are called epimyoepithelial islands The large
ducts appear to %e normal &n the Morgan and 7astleman series, some o" the surgical procedures $ere
radical parotidectomies, including severing the "acial nerve, %ecause the surgeon %elieved that the
condition $as a malignancy
8or "urther reading on 94Hgren syndrome, please see the Medscape @e"erence articles on the su%4ect in
our !ediatrics, 3phthalmology, ,mergency Medicine,@heumatology, and #ermatology sections
$#mphoepithelial lesion of %od&in
?ohn T =od$in, a Ee$ Fork pathologist, pu%lished a series o" 11 parotidectomy cases in 1-;2 that he
diagnosed as %enign lymphoepithelial lesion o" the parotid gland T$o o" the patients had undergone
radical parotidectomy "ollo$ed %y irradiation %ecause o" the mistaken %elie" that the lesions $ere
malignant Three other patients $ere treated $ith irradiation 9ome had %ilateral enlargement o" the
parotid glands and dry eyes 's a pathologist, he had not intervie$ed the patients, and the recorded
in"ormation $as incomplete
=od$in discussed the $ork o" Mikulic> %ut did not mention 94Hgren, although the history o" the cases
reveals that some undou%tedly $ere 94Hgren syndrome 9everal o" the patients under$ent sialography
that revealed punctate sialectasis 2e suggested that sialography might %e help"ul in the diagnosis %ut
that a needle)aspiration %iopsy $as not ade(uate "or diagnosis 2e suggested incisional %iopsy "or
diagnosis and determined that extensive surgery $as not necessary =od$in noted that several o" the
glands $ere di""usely involved, $hile some had $ell)circumscri%ed areas o" tumor
The =od$in name is most "re(uently associated $ith a circumscri%ed tumor $ith the histologic "eatures o"
94Hgren syndrome Ihy an autoimmune process directed against the salivary gland tissue $ould %e so
locali>ed $ithin the gland is di""icult to understand
Patho"enesis of autoimmune parotitis
The autoimmune diseases listed a%ove appear to %e the same disease process $ith di""erent
mani"estations &nitial insult to the gland may %e a viral in"ection !eptides derived "rom viral antigens and
autoantigens %ecome associated $ith class && histocompati%ility molecules in the cytoplasm o" the
epithelial cell, and the human leukocyte antigen A2/'B complex is su%se(uently expressed on the cell
sur"ace 7#:
K
T cells recogni>e these antigens and release a series o" cytokines, $hich promote "urther
T)cell activation
B cells enter the gland and produce autoanti%odies, including antiL94Hgren syndrome anti%odies Aie, antiL
99)', antiL99)BB and rheumatoid "actor A@8B B cells $ith cell sur"ace @8 can concentrate immune
complexes and present antigens to 7#:
K
T cells The acini are destroyed %y this autoimmune
mechanism 7ontinued cell division o" speci"ic B cells leads to oligoclonal expansion and increased
chance o" karyotypic error associated $ith neoplastic trans"ormation
'iseases of uncertain etiolo"#
9alivary stone AsialolithiasisB
8ormation o" stones $ithin the duct system is one o" the more "re(uent disorders o" the
salivary glands The exact cause is not kno$n, %ut most agree that the stone %egins as a small nidus
and gro$s %y concentric deposition o" inorganic crystals in an organic matrix 7alculi are much less
common in the parotid gland than in the su%mandi%ular gland, possi%ly %ecause the secretions are
more serous than the mucoid saliva o" the su%mandi%ular gland
7alculi do not cause symptoms until they %ecome large enough to impede the "lo$ o"
saliva !artial o%struction causes the gland to in"late itsel" $ith marked stimulation to secrete saliva, as
occurs in eating The gland s$ells $hile eating and soon %ecomes pain"ul The s$elling and pain
su%side in 30)<0 minutes only to recur at the next meal Total o%struction causes pain, s$elling, and
in"ection 7omplications o" the calculi include in"ection $ithin the gland AsialadenitisB, scarring $ith
stenosis, "istula "ormation, and rarely the stone migrates outside the duct to appear as an in"lammatory
mass in the neck
The diagnosis is con"irmed %y imaging studies including plain radiographs $ith or $ithout
in4ection o" contrast media into the duct 7T scans also sho$ single or multiple stones
Treatment is removal o" the stone Massage o" the gland "rom posterior to anterior may
occasionally remove stones, %ut most re(uire surgical removal /idocaine in4ected around the duct
ori"ice and into the duct allo$s serial dilatation $ith graduated dilators The duct is "illeted $ith sharp
scissors and then massage may deliver the stone This is the simplest method o" removal in most
instances %ecause the re(uired instruments are availa%le in the ,ET or dental o""ice ,xtracorporeal
shock $ave lithotripsy is an alternate treatment to "ragment the stone
&nterventional sialoendoscopy is gro$ing in popularity and availa%ility and seems to %e
the %est method o" treatment The duct is anestheti>ed and dilated to insert a telescope "or inspection o"
the large ducts ' $orking channel in the telescope permits irrigation, suction, and insertion o" "orceps,
$ire loop, or even laser energy via a glass "i%er to remove the calculi The clinician has much more
in"ormation as to the condition o" the duct system This instrument is use"ul "or the assessment and
treatment o" several in"lammatory disorders o" the gland
7hronic recurrent parotitis Achronic nonspeci"ic parotitisB
This general term is used "or patients in $hom no de"inite etiology is "ound 2undreds o"
papers on chronic parotitis have discussed the nature and treatment o" the disease or diseases The
theories o" etiology are diverse Many authors are convinced that sialoliths or scarring o" the ducts
cause stasis o" salivary "lo$ and predispose the gland to in"ection is the etiology, %ut this is pro%a%ly
true "or only a minority o" cases
'll authors agree that the spectrum o" symptoms varies "rom mild to incapacitating
,pisodes may last "or several days, paralleling the time course o" a %acterial or viral illness 3thers may
experience episodes that last only a "e$ hours "rom onset to resolution 9ome episodes may last "or
several $eeks Muiescent periods %et$een episodes last "or hours, days, or even years This range
suggests that more than one disease may %e the cause The cases in $hich the pain"ul episodes last
"or hours are pro%a%ly caused %y mediator release rather than in"ection
9ialography generally sho$s marked dilatation AectasiaB o" the ma4or ducts, $ith
narro$ed areas that give the appearance o" a string o" sausage Most authors %elieve that the narro$ed
areas represent strictures o" the ducts The minor ducts are "re(uently not patent and punctuate
sialectasis is not seen This suggests that the disease arises in the ductal system ' num%er o" articles
"rom =reat Britain and ?apan report a condition called Jsialodochitis,J $hich $ould %e included in the
chronic recurrent parotitis group This $ord is not in most 'merican medical dictionaries %ut implies
in"lammation o" the ducts The acini may %e histologically normal, at least in the early stages o" the
disease
Most authors suggest that the treatment o" all "orms o" chronic parotitis should %e
proportional to the symptoms, $hich are su%4ective rather than o%4ective Treatment escalates $ith the
symptoms, "rom massage, sialogogues to anti%iotics, and analgesics !ain seems to %e the driving
symptom !eriodic irrigation o" the 9tensen duct $ith saline, anti%iotics, andNor steroids has %een
advocated $ith good rationale in those patients $ith sialectasia o" the duct This procedure removes
de%ris "rom the duct and deposits the drugs to the needed location 8re(uent irrigation is pro%a%ly
important, %ut the patient cannot per"orm the treatment &" periodic irrigation is success"ul, it should %e
per"ormed rather than removal o" the gland Because the pathophysiology is poorly understood, the
rationale o" several surgical treatments is rather $eak !arotidectomy removes the diseased gland %ut
%egs the (uestion o" speci"ic treatment
@ecurrent parotitis o" childhood
'nother uncommon syndrome that has %een recogni>ed "or the past ;0 years is recurrent
parotitis o" childhood, in $hich recurring episodes clinically resem%le mumps =enerally, episodes %egin
%y age ; years, and virtually all patients %ecome asymptomatic %y age 10)1; years The duration o"
attacks averages 3). days %ut may last 2)3 $eeks in some individuals The spectrum varies "rom mild
and in"re(uent attacks to episodes so "re(uent that they prevent regular school attendance The child,
although not ill, is regularly sent home $ith the diagnosis o" mumps until school o""icials are in"ormed o"
the nature o" the disease
#uring the attacks, the parotid gland is enlarged, moderately red, and tender Massaging
the gland "rom %ack to "ront produces clear saliva $ith lots o" Jsno$"lakesJ or little $hite curds "rom the
9tensen duct The disease is unilateral most commonly and, i" %ilateral, is most apt to %e asymmetric
The child generally is not very sick during the episodes
Bacterial cultures "rom saliva generally produce Streptococcus viridans or another lo$)
virulence %acterium that is considered normal oral "lora ,ven %et$een attacks, %acteria are present in
the saliva Ultrasonography and sialography reveal punctate sialectasis as in 94Hgren syndrome ,ven
$hen symptoms are unilateral, sialectasis is demonstrated %y sialography in the opposite gland in most
instances 9ialographic changes persist even a"ter all other symptoms have ceased 8indings may
eventually disappear, %ut the natural history o" gland "indings is not clear
The histopathology is essentially the same as 94Hgren and Mikulic> disease 9ome
children $ith recurrent parotitis may actually have 94Hgren syndrome and may develop the "ull)%lo$n
clinical picture The cause o" the disease is unkno$n 9ialectases may precede in"ections and may %e a
site o" lo$ered resistance ' num%er o" etiologies have %een suggested The disease is unrelated to
mumps, and $hen viral studies have %een per"ormed, elevated serum titers to numerous other viruses
have %een "ound 3ne theory is that in"ection o" the glands at a young age a""ects the immune system,
and the disease may represent immaturity o" the immunologic response 9earches "or autoanti%odies
have not %een success"ul The %enign sel")limiting nature o" this entity makes autoimmunity dou%t"ul Eo
evidence suggests that allergy is a cause @esolution o" symptoms $ith age may %e due to regeneration
o" glandular elements and return to normal "unction
'pplying local heat applied to the gland, massaging the gland "rom %ack to "ront, and
taking penicillin usually cure individual episodes Treatment o" individual in"ections may prevent in4ury to
the gland parenchyma 9evere disease may %e treated %y parotidectomy !arotidectomy is rarely
indicated
9ialadenosis AsialosisB: &n this disorder, %oth parotid glands may %e di""usely enlarged $ith only
modest symptoms !atients are aged 20)<0 years at onset, and the sexes are e(ually involved The
glands are so"t and nontender Biopsy sho$s the acinar cells to %e enlarged to almost t$ice the normal
diameter and the cytoplasm packed $ith en>yme granules The cause is unkno$n, %ut inappropriate
autonomic nervous system stimuli are "re(uently suggested 'pproximately hal" o" the patients have
endocrine disorders such as dia%etes, nutritional disorders such as pellagra or k$ashiorkor, or have taken
drugs such as guanethidine, thiorida>ine, or isoprenaline &" the symptoms are mild, treatment is not
re(uired &" the glands are dis"iguring, partial parotidectomy should improve the appearance
9arcoidosis
9arcoidosis is a chronic multisystem disorder o" unkno$n cause that is characteri>ed %y
accumulations o" T lymphocytes and mononuclear phagocytes, noncaseating epithelioid granulomas,
and the derangement o" normal tissue architecture 9kin anergy and depressed cellular immune
processes in the %lood are common &n the United 9tates, the incidence is much higher in '"rican
'mericans and generally %egins in people aged 20):0 years
#iagnosis re(uires the typical clinical picture and %iopsy reveals noncaseating
granuloma, plus exclusion o" other diseases associated $ith such granulomas &n most instances, the
process does not attack involved organs, %ut the %ulk o" the accumulated cells may distort the normal
architecture enough to impair "unction The lungs, skin, and lymph nodes are most o"ten a""ected, %ut
the salivary glands are involved in approximately 10+ o" cases Bilateral "irm, smooth, and nontender
parotid enlargement is classic Derostomia occasionally occurs The 2eer"ordt)Ialdenstrom syndrome
consists o" sarcoidosis $ith parotid enlargement, "ever, anterior uveitis, and "acial nerve palsy
9arcoidosis is %enign in most instances, and treatment is generally not advisa%le unless
organ dys"unction occurs The only e""ective treatment is corticosteroids administered "or several
$eeks Treatment o" the parotid glands is not necessary, %ut most $ould treat "acial paralysis %ecause
o" the "ear o" permanent "unction loss
!neumoparotitis: !neumoparotitis is air $ithin the ducts o" the parotid gland $ith or $ithout
in"lammation The duct ori"ice normally "unctions as a valve to prevent air "rom entering the gland "rom a
pressuri>ed oral cavity @arely, an incompetent valve allo$s insu""lation o" air into the duct system
!neumoparotitis most commonly occurs in $ind instrument players, glass %lo$ers, and scu%a divers
3ccasionally, a person learns ho$ to per"orm parotid insu""lation voluntarily The condition is harmless
unless %acteria "rom the mouth cause parotitis @arely, rupture o" the ductal system causes extensive
su%cutaneous emphysema
Miscellaneous causes o" in"lammation and enlargement o" the parotid: 9everal lymph nodes
reside $ithin the parotid gland as a super"icial and deep group o" nodes These nodes may %e involved
$ith any process that a""ects lymph nodes, including %acterial, "ungal, viral, and neoplastic processes
@arely, drugs such as iodides, phenyl%uta>one, thiouracil, isoproterenol, heavy metals, sul"isoxa>ole, and
phenothia>ines cause parotid s$elling The parotid glands may %e incidentally involved in numerous
systemic conditions such as uremia and k$ashiorkor #iseases such as Iegener granuloma or Oimura
disease involve the parotid glands as rare causes o" parotitis
,pidemiology
Mortalit#(Morbidit#
#eath "rom parotitis is extremely unusual !arotitis most "re(uently is a complication o" an underlying
process Mor%idity is generally proportional to the original disease
)ace
!arotitis occurs $ith e(ual "re(uency in people o" all races
Se*
7hronicparotitis occurs $ith e(ual "re(uency in %oth sexes The parotitis o" 94Hgren syndrome has a
male)to)"emale ratio o" 1:- @ecurrent parotitis o" childhood is more common in males
A"e
Ciral parotitis AmumpsB occurs most "re(uently in children !arotitis that accompanies systemic diseases
Aeg, rheumatoid arthritis or 2&CB mirrors the occurrence o" those diseases
History
Symptoms include the following:
Infectious parotitis
o Acute bacterial parotitis: The patient reports progressive painful swelling
of the gland and fever; chewing aggravates the pain.
o Acute viral parotitis (mumps): ain and swelling of the gland last !"#
days. $oderate malaise% anore&ia% and fever occur. 'ilateral involvement
is present in most instances.
o (I) parotitis: *onpainful swelling of the gland occurs; otherwise%
patient is asymptomatic.
o arotitis in tuberculosis: +hronic nontender swelling of one parotid
gland occurs% or a lump is noted within the gland. Symptoms of
tuberculosis are found in some cases.
+hronic punctate parotitis (chronic autoimmune parotitis)
,-./
o $i0ulic1 disease: This is a historical disease only; it should not be
diagnosed today.
o S23gren syndrome: 4ecurrent or chronic swelling of one or both parotid
glands with no apparent cause is noted. It is fre5uently associated with
autoimmune disease. 6iscomfort is modest in most cases and is related
to dry mouth and eyes.
o 7ymphoepithelial lesion of 8odwin: This is a historical category that is
not used today.
6iseases of uncertain etiology
o 4ecurrent parotitis of childhood: 4epetitious episodes of unilateral or
bilateral mumps li0e episodes in a young child are indicative.
o Sarcoidosis: +hronic nontender swelling of parotid gland occurs.
o +hronic nonspecific parotitis: $ost commonly% patients e&perience
episodes of painful parotid inflammation that last for hours to wee0s
with relative asymptomatic periods between. ain varies from mild to
incapacitating.
*e&t
Physical
hysical e&amination of the parotid gland consists of visual e&amination for
swelling and erythema of the overlying s0in.
The acutely inflamed gland is e&5uisitely tender% while the gland is usually
nontender in chronic autoimmune parotitis.
$assaging the gland from posterior to anterior e&presses clear saliva from the
parotid duct in normal glands.
urulent saliva is e&pressed with bacterial parotitis% and clear saliva with small
yellow curds is e&pressed in chronic punctate (autoimmune) parotitis.
revious
*e&t
Causes
In the vast ma2ority of instances% ris0 factors are un0nown.
9ccasionally% drugs such as iodides or guanethidine cause transient swelling of
the gland.
Autoimmune disease causes most cases of chronic parotitis.
4ecurring bacterial parotitis may be caused by stone formation or stenosis of
the duct% but this also occurs in a minority of cases of chronic parotitis.
(I) may cause a type of indolent parotitis that suggests an autoimmune
process.
6ehydration with stasis of salivary flow may cause of acute parotitis. 6rugs
with an atropine effect (eg% antihistamines) may precipitate parotitis on rare
occasions.
WORKUP
7hemical analysis o" saliva
'nti)99)', anti)99)B, and rheumatoid "actor may %e present in autoimmune diseases
9aliva may %e cultured, $hich is help"ul, and it may %e analy>ed chemically, $hich is rarely help"ul
Most la%oratories cannot per"orm use"ul tests on saliva #ental researchers had hopes
"or several decades that analysis o" saliva $ould %e o" diagnostic importance 9aliva has such $ide
variations in composition that analysis has produced little o" diagnostic value
&maging 9tudies
7T scanning and M@& $ith gadolinium enhancement
These studies may %e used to determine the si>e, shape, and some (ualities o"
neoplasms or s$elling $ithin the gland
,ither method relia%ly di""erentiates %et$een solid masses, cystic lesions, and di""use
involvement o" the gland
9ialography
9ialography is used to demonstrate the anatomy o" the drainage system and is a very
use"ul test &n4ury to the ducts or acini is demonstrated $ith this study Many radiologists no longer
per"orm the test, $hich is un"ortunate Most dentists can per"orm sialography in the o""ice The
otolaryngologist can cannulate the duct and in4ect the dye in the radiology suite
' scout radiograph should %e made to rule out radiopa(ue stones or calci"ication $ithin
the gland
' special cannula or P-0 polyethylene tu%ing is inserted into the duct, and iodinated oil
such as Ultravist AiopromideB oily #ionosil is in4ected into the ductal system
The normal ducts can accommodate 0;0)0.; m/ $ithout discom"ort The authors in4ect
until the patient reports discom"ort and then posteroanterior and lateral radiographs are o%tained
The study is repeated ; minutes later Usually, all o" the contrast media has %een
evacuated
The normal ductal system looks like a deciduous tree in $inter &n sialectasis, the
radiographs may have the appearance o" a tree $ith scattered leaves Aas seen in the image %elo$B The
ductal system may %e dilated and demonstrate numerous small strictures giving the appearance o"
JsausagingJ 9ialogram o" patient $ith sialectasis Eotice the appearance o" a tree $ith leaves
Ultrasonography is much easier to per"orm than sialography and seems to %e replacing
sialography in many institutions &t demonstrates solid masses or "luid collections $ithin the gland &t also
can detect hypoechoic areas that correspond to punctate sialectasis %y sialography &t is not as sensitive
as sialography, %ut this is pro%a%ly not clinically signi"icant
!rocedures
Interventional sialoendoscop#
This techni(ue is gro$ing in popularity and availa%ility and seems to %e the %est method o" treatment
01:1
The duct is anestheti>ed and dilated to insert a telescope "or inspection o" the large ducts ' $orking
channel in the telescope permits irrigation, suction, and insertion o" "orceps, $ire loop, or even laser
energy via a glass "i%er to remove the calculi The clinician has much more in"ormation as to the condition
o" the duct system This instrument is use"ul "or the assessment and treatment o" several in"lammatory
disorders o" the gland
'dvances in the management o" chronic sialoadenitis include endoscopic)assisted approaches &nitially,
salivary endoscopy is per"ormed to identi"y any stones &" none is located, ultrasonography or 7T imaging
is recommended The endoscopic)assisted management techni(ue is a sa"e and o"ten e""ective means o"
evaluating the anatomy, administering various irrigations Aeg, saline, anti%iotics, steroidsB, per"orming
sialodochoplasty, removing stones, and placing stents &n ,urope, this techni(ue is mainly per"ormed $ith
the patient under local anesthesia, %ut in the United 9tates, general anesthesia is pre"erred since more
aggressive procedures can %e readily per"ormed at a single setting $ith the patient under anesthesia i"
the endoscopic approach is not success"ul 9tudies suggest a high rate o" symptom control, and "uture
studies are under$ay to "urther address a possi%ly larger role "or this techni(ue
01;, 1<, 1., 1*1
Incisional biops#
Under local anesthesia, a %iopsy o" the tail o" the gland may %e o%tained %y an experienced surgeon
$ithout in4ury to the "acial nerve 8ine)needle aspiration %iopsy "re(uently is diagnostic "or tumors and
may %e help"ul to identi"y cell types and to o%tain material "or cultures $hen the clinical picture suggests
in"ection ,xcisional %iopsy o" a la%ial minor salivary gland may %e diagnostic $hen the clinical picture
suggests 94Hgren syndrome
2istologic 8indings
,xcision o" parotid tissue is in"re(uently used "or diagnosis Ihen removed "or acute in"ection, acute
necrosis o" the glandular elements is o%served 'utoimmune parotitis occasionally progresses to
lymphoma, and %iopsy is per"ormed $hen suspected &nvasion %y lymphocytes and destruction o" the
glandular elements are o%served
TREATMENT N MANAGEMENT
$ost 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. :hen pus is e&pressed from the Stensen
duct% culture and sensitivity studies guide antibiotic selection. Treatment of the primary disease
(eg% (I)% rheumatoid arthritis) is all that is re5uired. 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. 'aurmash advocates a 6ecadron
(de&amethasone) 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
fre5uently occurs in chronically ill patients. The patient 5uic0ly becomes e&tremely ill. In the
hospital setting% S aureus is apt to be methicillin resistant ($4SA). 8ram stains and culture and
sensitivity testing is ordered. Intravenous vancomycin at !?? mg every @ hours is begun
empirically. Therapy may be altered based upon cultures or infectious disease consultation.
9urgical 7are
The treatment of chronic parotitis is based on the symptoms of the patient and decisions are% by
definition% sub2ective.
4ecurring parotitis% an unpleasant and distressing condition% is managed conservatively in
most instances but occasionally re5uires surgery to end the fre5uent and severe episodes of
infection. The decision for surgery is based on sub2ective symptoms.
The swollen inflamed gland ma0es surgery more difficult% and the incidence of in2ury to
the facial nerve may be slightly higher than for removal of benign tumors.
The standard treatment is superficial parotidectomy% but if +T scanning or surgery
reveals significant involvement of the deep lobe% that portion of the gland is dissected from
beneath the nerve.
Aibrosis ma0es the tensile strength of the surrounding gland much greater than the nerve
itself. Surgery is difficult and e&pensive. arotidectomy is still the most acceptable treatment in
the Bnited 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 chee0 and severed. The duct should be oversewn to
ensure that the soft tissue heals. Simple ligation fre5uently results in recanali1ation of the duct.
The procedure is based on assumptions that may not be true% and the rationale is wea0.
Installation of methyl violet into the parotid duct to destroy the gland: Intermittent reports
of this method have been reported for more than C? years% but it is not commonly performed in
the Bnited States% 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 -". mm polyethylene
tube. 9ne to . m7 of -D methyl violet is instilled until the ducts are full and the patient
complains of pressure. The tube is occluded for .? minutes and then removed. The gland swells
for -"E wee0s% and the duct system should be obliterated in E"C wee0s. If symptoms persist
after this time% a second in2ection may be performed. This method is much cheaper than
parotidectomy and should prevent ascending infections from the mouth. :hether the acini
involute and disappear is not certain. 9ther substances such as tetracycline have been shown to
cause necrosis of the gland when instilled into the ductal system.
7onsultations
atients with autoimmune parotitis e&perience &erostomia and e&cessive tooth decay. These
patients should have dental consultation and fre5uent dental care.
#iet
The diet does not signi"icantly a""ect cases o" parotitis
+urther Inpatient Care
2ospitali>ation "or parotitis is extremely unusual !arotitis may arise in hospitali>ed patients $ho are
severely ill, and it is treated as indicated a%ove Asee TreatmentB
Eext
Inpatient , -utpatient Medications
Treatment o" generic parotitis involves no speci"ic medications #iscontinue medicines $ith atropinelike
e""ects and su%stitute other medications $hen "easi%le
!revious
Eext
'eterrence(Prevention
=eneric deterrence is not availa%le
'de(uate hydration, oral hygiene, and minimi>ing medications $ith atropine e""ects are help"ul
&mmuni>ation avoids epidemic parotitis AmumpsB
!revious
Eext
Complications
7hronic parotitis destroys the glandular elements o" the salivary glands and impairs the protective
"unctions o" saliva, leading to dental in"ections and caries
'utoimmune parotitis is associated $ith an increased incidence o" lymphoma
!revious
Eext
Pro"nosis
The prognosis is good "or all "orms o" parotitis 'ssociated or underlying diseases are the actual
determinants o" the prognosis
!revious
Eext
Patient .ducation
!atients $ith chronic parotitis are instructed to maintain scrupulous dental care Minor s$elling and
discom"ort are managed $ith local heat and massage