Journal of Oral Rehabilitation 2009 36; 2–8
Review Article
Classification and management of chronic sialadenitis of the
parotid gland
S . W A N G * 1 , F . M A R C H A L †1 , Z . Z O U ‡, J . Z H O U * & S . Q I *
Molecular Laboratory for Gene Therapy, Capital Medical University School of Stomatology, Beijing, China, †Department of Otorhinolaryn-
gology, Head and Neck Surgery, University Hospital of Geneva, Geneva, Switzerland and ‡Department of Oral and Maxillofacial Radiology,
Peking University School of Stomatology, Beijing, China
SUMMARY Saliva has numerous oral functions and
multiple functions in relation to digestion in the
upper gastrointestinal tract. Chronic salivary hypo-
function can lead to severe adverse health out-
comes. Chronic sialadenitis is one of the major
conditions that can cause salivary hypofunction.
A correct diagnosis and management of chronic
sialadenitis is essential for the recovery of salivary
hypofunction. Chronic sialadenitis of the parotid
gland is often seen in the clinic, sometimes also
referred to as recurrent pyogenic parotitis, recurrent
parotitis, non-obstructive parotitis, sialadenitis or
obstructive parotitis, among other terms. The liter-
ature describes several different classifications and
denominations for chronic sialadenitis of the par-
Introduction
Saliva plays a key role in taste, chewing, speech,
digestion and oral health. Saliva is a solvent for the
chemical taste components of foods, a lubricant for all
oral mucosal surfaces as well as the food bolus, and a
supersaturated reservoir of biominerals, such as cal-
cium, phosphate and fluoride, which continually bathes
the teeth, facilitating their remineralization (1–4).
Saliva also buffers against sudden drop in oral pH that
can cause teeth to lose their superficial mineral sub-
stance. Saliva contains antimicrobial agents that directly
kill pathogens, as well as those that prevent their
attachment to cell surfaces in the mouth and allow the
normal fluid motion in the mouth to sweep them away
1
These two authors contributed equally to this article.
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
*Salivary Gland Disease Center and the
otid gland. These various classifications and denom-
inations complicate the definition and diagnostic
criteria, and if chronic sialadenitis of the parotid
gland can develop into Sjogren’s syndrome remains
unclear. Treatment of this condition is also a chal-
lenging problem. Here, we review the presented
classification and denomination of chronic sialade-
nitis of the parotid gland, proposing a classification
based on the disease entities identified in a long-
term follow-up investigation, and discuss the treat-
ment principles for the condition.
KEYWORDS: chronic sialadenitis, classification, man-
agement, parotid gland
Accepted for publication 23 April 2008
(4, 5). As saliva has so many important functions,
chronic salivary hypofunction can lead to severe
adverse health outcomes such as difficulty swallowing,
taste disorders, dental caries, periodontal disease, oral
candidiasis, poor nutrition, etc. (6, 7). Chronic sialade-
nitis is one of the major disorders that can cause salivary
hypofunction. A correct diagnosis and management of
chronic sialadenitis is essential for the recovery of
salivary hypofunction (8). Chronic sialadenitis of the
parotid gland (CSPG) is a common clinical condition,
characterized by intermittent, often painful swelling of
the parotid gland and ⁄ or discharge of pus and inflam-
matory changes in the involved glands (9–11). Chronic
sialadenitis of parotid gland has usually been diagnosed
as recurrent pyogenic parotitis (10, 12), recurrent
parotitis (10), non-obstructive parotitis (13), obstructive
parotitis (10) or benign lymphosialadenopathy (13),
doi: 10.1111/j.1365-2842.2008.01896.x
 CLASSIFICATION AND MANAGEMENT OF CSPG
among other terms. Thus, diagnosis of CSPG has varied
and has lacked well-defined terminology. If CSPG can
develop into Sjogren’s syndrome (SS) is also unknown.
This type of disease can afflict patients in a wide age
range, and its management remains as controversial as
its aetiology of CSPG remains mysterious (11, 14). This
paper presents a review of the classification and man-
agement of this clinical condition.
A review of the classification and
denomination of CSPG
In 1933, Payne (9, 12) proposed ‘recurrent pyogenic
parotitis’ as the diagnosis for patients with recurrent
swelling of the parotid gland and distinguished it from
epidemic parotitis, sialolithiasis and Mikulicz’s disease.
In 1946, Bigler (10) used ‘recurrent parotitis’ as the
term for CSPG and divided it into epidemic parotitis,
suppurative parotitis, obstructive parotitis and recur-
rent parotitis in childhood (RPC). In 1954, Rose (15)
classified recurrent parotitis as parotid swelling with
obstruction, parotid swelling with saliva secretion
reduction or parotid swelling with both characteristics.
In 1964 and 1966, Blatt (13, 16) used the term ‘chronic
suppurative parotitis’ for the condition and classified it
as RPC, suppurative parotitis in adults, or as benign
lymphosialadenopathy. Blatt stated that RPC or suppu-
rative parotitis in adults, also called non-obstructive
parotitis, are autoimmune diseases. In 1971, Heman-
way (17) proposed the term ‘chronic punctuate paro-
titis’ based on sialographic features and classified it as
Mikulicz’s disease and SS. Yoel in 1975 (18), as well
as Finochietto and Yoel in 1952 (19), classified parotitis
as inflammation of ducts, including acute primary
inflammation of the ducts, acute secondary inflamma-
tion of the ducts, or chronic inflammation of the ducts;
and as inflammation of the glands, including acute
parotitis, chronic parotitis, and chronic recurrent par-
otitis. In 1976, Mandel classified parotitis into acute
suppurative parotitis, sialolithiasis, autoimmune disease
including RPC, recurrent parotitis in adulthood (RPA)
or SS (20, 21). In 1977, Work (22) reported that chronic
inflammatory diseases of the parotid gland included
obstructive (stone, stricture, sialadenitis and sialectasis)
or non-obstructive (sialadenitis in adults and child-
hood, non-specific sialadenitis, specific sialadenitis,
benign lymphosialadenopathy, allergy-inducing and
drug-inducing). Rice in 1982 (23), as well as Friedman
et al. in 1986 (24), classified parotitis as acute
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
3
suppurative parotitis, chronic recurrent parotitis, be-
nign lymphosialadenopathy, SS, granuloma or as aris-
ing from viral infection. In 2002, Topazian et al. (14)
classified recurrent swelling of the parotid gland as
bacterial infection, such as chronic recurrent parotitis
and chronic recurrent juvenile parotitis and immuno-
logically mediated diseases such as SS and collagen
sialadenitis. In 2005, Malloy et al. (25) used the term
‘sialadenitis’ to refer to the various inflammatory
conditions affecting the salivary glands, and under the
heading of sialadenitis were included acute suppurative
sialadenitis, chronic sialadenitis, viral sialadenitis, gran-
ulomatous diseases, Wegener’s granulomatosis and SS.
In 2007, Marchal and Bradley (26) classified infections
of the salivary glands as viral diseases, bacterial diseases,
and other diseases including RPC, and granulomatous
sialadenitis, mycobacterium, sarcoidosis, or hydatic
disease.
As the above literature review indicates, the clinical
designation and classification of chronic inflammatory
diseases of the parotid gland lack clear definition and
the diagnostic criteria are easily confused (11, 14, 27),
although the pathological classification for these con-
ditions are relatively clear. An analysis of this confusing
condition leads to the critical questions of what the
entity is and of its association with sialadenitis in adults
and childhood (non-obstructive parotitis), and about its
relationship with SS.
A proposal for the classification and
denomination of CSPG
Since the 1980s, a research team from Capital Medical
University and Peking University, China, has performed
clinical, laboratory, sialographic, scintigraphic and histo-
pathologic studies in 291 patients with chronic parotid
swelling, including a long-term follow-up period of
over 11 years (28–35). Of the group, 102 were paedi-
atric patients ages 15 years or less with recurrent
parotid swelling whose sialograms showed punctate or
globular sialectasis. A long-term (a mean >10 years)
follow-up of 28 paediatric cases with recurrent parotid
swelling showed that patients could undergo remission
(16 cases; 57%) in childhood (before age 15); in these
patients, the punctate sialectasis disappeared or de-
creased on the sialograms 3–5 years after the cessation
of clinical symptoms, and xerostomia and keratocon-
junctivitis were not found in these patients. None of
them developed SS (29, 30, 36). Recurrent swelling of
4 S . W A N G et al.
the parotid gland still presented after the age of 15 years
and extended to adulthood in 12 of these 28 patients
(43%).
A family incidence of RPC was found in five familial
patient groups. A clinical, laboratory and sialographic
study of 35 patients with recurrent parotid swelling
from childhood to adulthood was also performed (29,
30). These 35 patients were previously diagnosed as
having sialadenitis of the parotid gland (nine cases) or
chronic suppurative parotitis (seven cases), or misdiag-
nosed as being in the initial phase of SS (one case).
A long-term follow-up observation (0Æ5–23 years, mean
8 years) revealed that 27 patients were cured clinically
and sialographically. However, marked non-inflamma-
tory enlargement of the parotid gland (sialosis) was also
found in three cases (Fig. 1), which was considered to
arise from chronic inflammation attributable to recur-
rent parotid swelling from childhood to adulthood.
We also investigated the relationship between the
recurrent swelling of the parotid gland and SS (32).
A total of 125 patients with chronic parotitis were
included in this study. Twenty-two patients from this
group (six men) of age ranging from 15 to 45 years
were diagnosed as having sialadenitis of the parotid
gland in adulthood (SPGA; also known as non-obstruc-
tive parotitis or chronic recurrent parotitis). Ten of
these 22 patients had a history of recurrent parotid
swelling during childhood. The sialograms of these 22
patients showed punctate or globular sialectasis, but no
dry mouth symptom was found. The remaining 103 of
these 125 patients had SS based on well-established
criteria (32, 37). A long-term follow-up study of 22
patients with sialadenitis of the parotid gland in
adulthood (SPGA) revealed that 12 of the 22 patients
were shown to have SS, 10 were diagnosed as primary
SS and two were diagnosed as secondary SS. These
patients had recurrent parotid gland swelling for 1Æ5–
14 years (mean, 5Æ2 years) before xerostomia and
Fig. 1. Scheme of the relationship among the different types of recurrent parotid swelling and their diagnoses. RPC, recurrent parotitis in
childhood; RPA, recurrent parotitis in adulthood; SPGA, sialadenitis of the parotid gland in adulthood; SS, Sjogren’s syndrome.
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
keratoconjunctivitis occurred. Ten of the 22 patients
did not develop SS but did experience recurrent
parotitis, which extended from childhood to adulthood.
Seven of these 10 patients experienced remission of the
SPGA. It is suggested that patients with SPGA (recur-
rent parotid swellings, punctuate sialectasis revealed on
sialogram), but without dry mouth and dry eye symp-
toms and a history of parotid gland swelling in child-
hood, should be diagnosed provisionally as having
subclinical SS (Fig. 1).
Another type of recurrent parotid swelling is related
to obstructive factors in the salivary glands. Clinical,
sialographic, scintigraphic and follow-up studies were
performed in 117 parotid glands from 92 cases with
recurrent parotid swelling related to obstructive factors
(33–35). Clinically, this disease is induced by various
local factors that cause retardation or obstruction of
salivary flow, resulting in retrograde infection with
repeated parotid swelling and purulent discharge.
Sialographic features were mainly the irregular dilation
of the main duct extending to the branching ducts.
They may be classified, on the basis of the severity and
pathologic findings of post-operative specimens, into
four types that may be applied as a guide in selecting a
treatment modality. Various causes were identified in
more than half of involved parotid glands (62 ⁄ 117)
including radiolucent stones (35 glands), stricture of the
main duct (17 glands), compression by tumour (four
glands), radiopaque stones (three glands), congenital
dilation of the main duct, foreign body (a kernel of
wheat) and an abscess (one gland).
On the basis of these findings, a practical classifica-
tion system was proposed for the diagnosis of CSPG:
1 Recurrent parotitis in childhood: patients under the
age of 15 years with chronic parotid swelling and
punctate or globular sialectasis as seen in sialograms
and a tendency to spontaneous remission are classified
into this entity (28, 29).
 CLASSIFICATION AND MANAGEMENT OF CSPG
2 Recurrent parotitis in adulthood: this term encom-
passes adult patients (age 15 years or older) who had
RPC lasting into adulthood, also tending to spontaneous
remission (30–32).
3 Chronic obstructive parotitis (COP): this category
includes patients with recurrent parotid swelling attrib-
utable to various obstructive factors, including calculi,
strictures and foreign bodies. The main sialographic and
histopathologic features are dilation and inflammation
of the main and branching ducts (33–35).
Differential diagnosis:
1 Subclinical Sjogren’s syndrome: this syndrome
encompasses patients with recurrent parotid swelling
of unknown aetiology and punctate or globular sialec-
tasis as seen in sialograms, but without a history of RPC
or symptoms of dry mouth and dry eyes (32).
2 Sjogren’s syndrome with retrograde infection of
parotid glands: patients experience recurrent parotid
swelling after being diagnosed with SS (32).
3 Sialosis with secondary infection: patients with
sialosis also have recurrent parotid swelling (28).
Management principles for CSPG
Because RPC and RPA can remit spontaneously, con-
servative therapy should be used mainly to decrease
episodes of parotid swelling. In addition, sialography
not only has diagnostic value but also can aid in
monitoring recovery of RPC and RPA (28–31, 36). The
sialographic findings of COP were divided into four
types reflecting the severity of the disease and could
also be used as a guide in treatment selection (33–35).
Patients with mild changes (sialographic type I) could
enter into remission with conservative methods. The
most severe cases, such as type III or IV, do not respond
to the conservative therapy; however, these patients
should be managed using other methods, such as
sialoendoscopy or parotidectomy or injection of methyl
violet. Subclinical Sjogren’s syndrome is an autoim-
mune disease that should be treated as systemic.
Conservative therapy
It is universally accepted that the initial management of
chronic parotid swelling should be by non-surgical or
conservative methods. The initial management consists
of antibiotics, analgesics, mouth rinses, sialogogues and
self-massage (33). Massaging the parotid gland postero-
anteriorly, use of sialogogues to stimulate secretions and
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
5
good oral hygiene help to reduce the chances of ascend-
ing infection. These methods can control the symptoms
well and may reverse the sialographic changes in mild
forms of chronic sialadenitis (33). Brook (38) suggested
that antibiotics could provide adequate coverage for a
bacterial aetiology of chronic parotid swelling. Few
studies have been published regarding the outcome of
conservative management of patients with chronic
parotid sialadenitis. A retrospective study from a tertiary
referral unit found spontaneous improvement in 56% of
30 adults with recurrent chronic parotitis with punctuate
sialectasis on sialography but no calculi, who were
followed up for > 5 years (11).
Surgical treatment
Only when conservative management has failed does
surgical intervention become necessary. Surgical treat-
ments include minor surgical procedures (e.g. removal
of calculus, duct ligation and ductoplasty) and major
surgical procedures (e.g. superficial parotidectomy,
total parotidectomy and near-total parotidectomy).
Salivary duct ligation Ligation of the parotid duct may
stop the secretion by pressure atrophy of the gland (39).
Nichols (40) argued that there is a lack of functional
and histological data to support this effect of duct
ligation. The causes of failure related to ligature or duct
rupture or the development of a sialocele. Harrison et al.
(41) noted that after ductal ligation of the cat parotid,
atrophic changes of the acinar cells were not conspic-
uous until 4 days post-ligation and extended to
16 days. During this period, ligation and duct rupture
might occur. Some authors have recommended radio-
therapy in conjunction with ligation (42).
Tympanic neurectomy Golding-Wood first described tym-
panic neurectomy for management of parotitis. The
method is aimed at reducing secretion of the parotid
gland by division of the parasympathetic secretomotor
fibres at the tympanic plexus (43, 44). Nichols (40)
argued that tympanic neurectomy was based on a false
assumption: that this branch of the ninth cranial nerve
was the sole parasympathetic secretomotor supply to the
parotid. The VII nerve through the chorda tympani
branch also supplies the parotid, and the possibility of
systemic stimulatory factors could not be discounted.
Motamed et al. (11) analysed the results of tympanic
neurectomy for chronic parotitis by combining the
6 S . W A N G et al.
outcome of all the reported series; the analysis found that
resolution of symptoms occurs in 75% of cases in the
long-term.
Parotidectomy Parotidectomy is the ultimate surgical
option for the treatment of chronic parotitis, but
controversy exists about the exact technique and
timing of the procedure. The following approaches
have been advocated: superficial parotidectomy (45,
46), total parotidectomy (47) and near-total parotidec-
tomy (48).
The goal of any surgical intervention is to achieve
permanent resolution of symptoms with minimal
morbidity. Motamed et al. (11) analysed the results
of all the reported series of chronic parotitis treated
by parotidectomy. The analysis revealed that the
symptoms recurred on average in 8Æ4% of cases
regardless of the type of parotid surgery performed.
The disease recurred in only those patients who had a
superficial parotidectomy, with a mean recurrence
rate of 10%. Moody et al. (46) suggested that a
decision must be made between a superficial parot-
idectomy (with a recurrence rate of 11%, a tempo-
rary palsy rate of 55% and a zero incidence of
permanent palsy) and a total or near-total parotidec-
tomy (with a low incidence of permanent facial nerve
palsy of 2% but no reported recurrence of disease).
They also suggested that a near-total parotidectomy
probably offers the best compromise.
Mini-invasion therapy
Sialoendoscopy has both a diagnostic and therapeutic
role. Nahlieli believed that it is the most effective
method for treating chronic parotid swelling because
removal of the precipitate is facilitated by more
accurate visualization and irrigation and the obstruc-
tive effects of major duct sausaging can be overcome
with its duct-dilating abilities (49–51). In experienced
hands, diagnostic sialoendoscopy can be performed
under local anaesthesia with minimal morbidity and
completed in a reasonable period of time (52, 53).
Some have pointed out the potential problems
encountered in sialography, including the necessity
for contrast injection and pressure injection. It has
been suggested that this technique may improve our
understanding of the aetiology of chronic parotid
swelling (11, 54).
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
Other treatment methods
Methyl violet is a triphenylmethane dye. It has been
used in medicine for almost 100 years as, for example,
an antiseptic for external use or as an anti-helminthic
agent by oral administration. Intra-glandular infusion
of methyl violet, which has been used to treat chronic
parotitis since the 1960s, is considered to be simple and
to have definitive effects (32). However, previous
reports involved limited numbers of patients and did
not characterize the drug’s effect on the gland. We
investigated 16 patients with COP who were treated
with retrograde infusion of methyl violet. The clinical
sequelae of treatment to the gland lasted about
1 month from the presence of acute swelling to the
cessation of any symptoms. Furthermore, no side effects
were reported in the study (55). The pathological
changes induced by retrograde injection of methyl
violet included necrosis or atrophy of acinar cells and
fibrosis of the gland. The ductal system underwent
atrophic changes, and thrombotic obliteration of main
duct (56). Compared with the use of parotidectomy or
ligation of the main duct, this method is a simple,
practical therapy with little risk of side effects (33, 55).
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Correspondence: Dr Songlin Wang, Salivary Gland Disease Center and
the Molecular Laboratory for Gene Therapy, Capital Medical Univer-
sity School of Stomatology, Tian Tan Xi Li no 4, Chongwen District,
Beijing 100050, China.
E-mail: slwang@ccmu.edu.cn