Parotitis

What is Parotitis?

The parotid gland is one of our saliva-producing glands. It’s nestled within its own protective capsule and consists of two parts, a superficial lobe and a deep lobe, with the facial nerve in between. Its key function is to produce saliva when the body signals it to do so. This saliva is then released into the mouth through the Stensen canal, a little tube that runs through certain facial muscles and opens up in the mouth next to our second upper molar. This saliva assists with chewing, swallowing, speaking, and digesting food. Plus, it contains key ingredients like electrolytes, mucin, and digestive enzymes such as amylase.

Parotitis is when these parotid glands get inflamed. It’s the most frequently seen inflammation amongst our major salivary glands. Sometimes, parotitis only affects the local area, but it can also be a sign of a more widespread illness.

Several factors can increase the risk of parotitis. These include dehydration, malnutrition, reduced immunity, blockages due to stones in the gland (sialolithiasis), oral cancers, and medicines that reduce the amount of saliva. Though rare, severe complications from parotitis or procedures on the parotid gland can occur – these can include a bone infection (osteomyelitis), Lemierre syndrome (a rare infectious disease), widespread infection (sepsis), organ failure, and facial paralysis.

What Causes Parotitis?

Parotitis refers to the inflammation or infection of the parotid gland, which is one of the main salivary glands in your mouth. The causes of this condition are many, ranging from infections to various inflammatory conditions.

Acute bacterial parotitis, while rare, can impact people of all ages. It’s especially a concern for older adults and newborns. Senior citizens are more at risk because they often take medications that reduce the amount of saliva produced by their bodies, thus making them more susceptible to infection. In newborns, parotitis can be life-threatening if not treated quickly with the correct antibiotics and proper hydration. The causes of parotitis in newborns are the same as in adults.

Chronic bacterial parotitis is often caused by blockages or injuries in the salivary gland’s ducts. One of the key factors is a decrease in the salivary flow, which can be caused by inflammation. However, it’s important to note that while a bacterial infection might contribute to the problem, most chronic diseases of this kind are due to autoimmune or unknown causes.

Mumps, a virus spread through droplets or through direct contact with mouth secretions that contain the virus, can also cause parotitis. Thanks to widespread vaccination programs, mumps is now a rare disease in developed countries. It’s recommended that children receive their first mumps vaccine at one year old and a second dose between the ages of 4 and 6.

People who have HIV may experience parotitis along with general swelling of their lymph nodes and enlargement of their salivary glands. Tuberculosis can also lead to parotitis, but cases are relatively rare. If a person does have tuberculosis-induced parotitis, there’s a 25% chance they could potentially infect others with pulmonary tuberculosis. Influenza, or the flu, has also been known to cause parotitis with mainly people under the age of 20 being affected.

Other conditions associated with parotitis include chronic punctate parotitis (which can also be known by many different names), cystic fibrosis, dehydration, poor nutrition, recent abdominal surgery, weakened immune systems, and infections in the teeth or gums. Other risk factors for acute bacterial parotitis can include various types of bacteria, such as staph aureus, strep viridans, E. coli, and anaerobic oral flora. In newborns, group B streptococcus infection should also be considered. In Southeast Asia, melioidosis, an infectious disease caused by the bacteria pseudomonas pseudomallei found in contaminated water, is common as well.

Among viral infections, mumps is the classic cause of parotitis. But it can also be caused by other viruses including coxsackie A, cytomegalovirus, echovirus, enterovirus, influenza, and parainfluenza.

Inflammatory conditions like sarcoidosis, Sjögren syndrome, rheumatoid arthritis, and systemic lupus erythematosus can also result in parotitis. Trauma, certain surgical procedures, exposure to specific drugs, and radiation therapy can lead to parotitis as well.

Chronic non-specific parotitis and recurrent parotitis in children have no specific infectious cause. This type of parotitis might occur because of scar tissue in the mouth, blockages, and dilation of the salivary ducts. Though antibiotics are often used in treatment, it’s important to understand that there may not be a direct infectious cause in these cases.

Risk Factors and Frequency for Parotitis

Acute bacterial parotitis is an infection of the saliva gland that is rare and affects both sexes equally. It is seen mostly in older people and is responsible for about 0.01 to 0.02% of hospital admissions. It also occurs in 0.002 to 0.04% of patients after surgery. Acute parotitis in newborns is even more rare, with fewer than 4 in 10,000 hospital admissions being due to this condition.

Chronic parotitis, a long-term inflammation of the saliva glands, affects men and women equally. Interestingly, Sjogren syndrome, a condition that can cause chronic parotitis, is nine times more common in women. On the other hand, repeated episodes of parotitis during childhood are more common in boys. Sarcoidosis, another condition that can cause chronic parotitis, is the most common among African American adults aged 20 to 40 years.

Parotitis, the general term for inflammation of the saliva glands, affects all races equally. However, a past study in a children’s hospital found that repeat episodes of parotitis in children were more common in Black boys aged 2 to 8 years.

Signs and Symptoms of Parotitis

Parotitis, or inflammation of the parotid glands, causes symptoms that can vary based on the underlying cause. These glands, located in front of each ear, can become enlarged and painful. The disease can affect one or both glands. In conditions like mumps or inflammation, you’ll often see both parotid glands affected. However, if a bacterial infection is the cause, usually only one gland will be affected, and there may also be a fever.

Pain with chewing is common in parotitis and can feel like it’s radiating from the gland to the ear. Pain often decreases about 30 to 60 minutes after eating. Depending on the kind of parotitis, symptoms can include swelling, pain, and variable levels of discomfort. Here are some forms of the condition and their unique symptoms:

• Acute bacterial parotitis often causes gradually worsening swelling and pain, especially during chewing.
• Acute viral parotitis (mumps) leads to pain and swelling lasting about 5 to 9 days, along with mild fatigue, loss of appetite, and fever. Both parotid glands are usually involved.
• In HIV parotitis, the gland swelling is usually painless, and the person may not show any symptoms.
• Tuberculous parotitis causes chronic swelling that is typically not painful, often in one gland. There may also be a lump within the gland and symptoms of tuberculosis.
• Sjögren syndrome leads to continuing, unexplained swelling of the parotid glands. It often co-occurs with autoimmune diseases. The discomfort is usually mild and associated with dry mouth and eyes.
• Recurrent parotitis in childhood results in repeated episodes of swelling of one or both parotid glands in young children.
• Sarcoidosis leads to chronic, non-tender swelling of the parotid gland.
• In chronic, nonspecific parotitis, patients experience painful inflammation of the parotid gland lasting from hours to weeks, with periods where they may not experience any symptoms.

During an examination, the parotid gland usually appears larger than normal, swollen, tender, hardened, and sometimes warm. A doctor may see pus when gently massaging the gland if a bacterial infection is the cause. When the swelling is around the duct, or a stone can be seen or felt, it’s usually because of sialolithiasis, a condition that develops because of a stone blocking salivary flow. The gland is normally tender and warm in acute parotitis, while chronic autoimmune parotitis is often not tender.

Testing for Parotitis

Parotitis, or inflammation of the parotid glands (saliva-producing glands located in front of your ears), is usually identified through observable symptoms. If you have drainage from the Stensen duct (the main saliva-carrying pipeline from the parotid gland), then a sample may be taken to test for the presence of bacteria. Your doctor might also check your serum amylase levels which can be increased in cases of Parotitis but this is not a specific result; the levels can be raised due to other conditions too.

Sometimes special blood tests to detect inflammatory markers like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) might be used to support the diagnosis of parotitis. However, these markers could be elevated in many other conditions as well and hence are also nonspecific.

Some studies suggest that a test known as a scintigraphy, which provides detailed images of your body’s interior might be useful for diagnosing chronic obstructive parotitis, a type of persistent blockage of the saliva gland.

Usually, imaging isn’t necessary for diagnosing parotitis. Ultrasound can help confirm the presence of sialolithiasis (saliva stone) or an abscess (a collection of pus), distinguish between solid and fluid-filled lumps in the gland, and mark out areas of diminished echogenicity often present in punctate sialectasis (minuscule dilation of the saliva ducts). In rare cases, X-ray or CT scan might be used to diagnose sialolithiasis or multiple parotid calcifications (hard deposits) in chronic parotitis. MRI scan can also help tell apart chronic parotitis from cancerous changes within the gland. For people with HIV parotitis, MRI could potentially be diagnostic by showing multiple cyst formations.

Sialography, an X-ray examination of the salivary glands and ducts, was once the recognized “gold standard” for visualizing the details of the parotid ductal system (passages that carry saliva). However, this procedure is less common now. These days, the use of sialendoscopy, a minimally invasive procedure that involves inserting a small lighted tube into the salivary duct for visual examination, has been proven useful in chronic parotitis and juvenile recurrent parotitis cases.

In some instances, a small incision or a fine-needle biopsy might be performed on the parotid tail (part of the parotid gland that overlaps the neck area), and the sample may be sent for culture to determine the cause of infection or for histopathology, to study the microscopic structure of tissues. That said, usually, a biopsy is not needed to diagnose parotitis. Different types of parotitis can have their own unique presentations; for example, HIV parotitis often includes lymphoepithelial cysts, noncaseating granulomas are found in sarcoid parotitis, and lymphocytic invasion accompanied by acinar destruction can be seen in cases of cancerous lymphoma.

Treatment Options for Parotitis

Parotitis is a condition that causes inflammation in one or both of the parotid glands, which are the major salivary glands located behind your jaw and in front of your ears. Parotitis treatment primarily focuses on relief from its symptoms. This often involves applying warmth to the affected area, gently massaging the gland, staying adequately hydrated, and frequently stimulating saliva production (for example, by eating sour foods or lemon candies). Over-the-counter pain relievers like acetaminophen or ibuprofen can help manage discomfort.

If there is a visible & ‘purulent drainage’- a thick yellowish or greenish opaque liquid full of inflammatory white blood cells- while massaging the gland, your healthcare provider may need to take culture samples for testing. This will determine the most suitable antibiotic therapy to treat the infection.

Parotitis can also occur due to sialolithiasis, a condition where stones form in the salivary glands. This condition can often be treated using warmth, massage, and increasing saliva production. However, in some cases, it may require removal of the salivary gland stone which is done under local anesthesia and requires minimally invasive procedures. Some persistent cases may also require treatments such as Extracorporeal Shock Wave Lithotripsy (a treatment that breaks down the stone into smaller pieces) or sialendoscopy, a minimally invasive procedure performed by otolaryngology specialists.

In cases where parotitis is thought to be due to human immunodeficiency virus (HIV) or chronic autoimmune conditions (like rheumatoid arthritis or Sjögren syndrome), treatment should be geared to address the underlying issues with therapies that help manage these conditions.

For acute bacterial parotitis, treatment should include staying hydrated, managing pain, and taking antibiotics for 7 to 10 days. The specific type of antibiotic prescribed will depend on the type of bacteria causing the infection. For example, for a dental infection suspected to have caused parotitis, doctors may recommend specific antibiotics that are designed to target and eliminate anaerobic bacteria, which are bacteria that can survive without oxygen.”

For newborns, parotitis can be life-threatening, so treatment usually involves antibiotics. If there’s no improvement within 48 hours, surgery to remove part or all of the salivary gland may be necessary. For rare cases of parotitis due to extrapulmonary tuberculosis, antitubercular medications are usually effective.

If a patient’s parotitis does not respond to conservative treatments like hydration and antibiotics, incision and drainage may be necessary. In some cases, doctors may even recommend rinsing the duct system with a saline solution to remove clogged mucus or pus. In specific cases of parotitis caused by HIV, treatment might consist of antiviral therapy, low-intensity radiation, or surgery to reduce the size of the gland.

Finally, for chronic parotitis, if the swelling does not reduce, or if the inflammation threatens to cause facial nerve paralysis, surgical treatment might be necessary. This often involves removing part of the parotid gland or applying a specific dye to the gland.

What else can Parotitis be?

Parotitis, also known as inflammation of the parotid gland, can be caused by a variety of factors. One of the common causes of parotitis is a condition called sialolithiasis, which is when a stone forms in the gland or its duct. Sometimes, these stones can actually leave the gland and move into the neck, which can cause an inflammatory mass.

Another way parotitis can occur is through a condition called pneumoparotitis, which happens when air gets into the parotid ducts from high pressures in the mouth. This could happen to those who play wind instruments, scuba dive, or blow glass. Though it’s rare, the pressure change can occasionally lead to bacterial parotitis and in extremely rare cases, can cause the parotid gland to rupture.

Sialosis, or sialadenosis, is a different sort of condition that causes the parotid glands to become engorged and soft, but it doesn’t involve inflammation. This disorder often affects people between ages 20 and 60, and it’s just as common in men as in women. At this time, we don’t have a clear understanding of what causes sialosis, though it could be linked to issues with the autonomic nervous system. It’s often found in conjunction with certain endocrine disorders like diabetes, nutritional issues like pellagra or bulimia, and certain medications. A diagnosis of sialosis is usually based on two things: both glands being affected together and a biopsy showing that the glandular cells are enlarged and have granules in them that are more dense than normal.

What to expect with Parotitis

Parotitis, or inflammation of the parotid glands, generally has a positive outcome, and the underlying diseases often determine this. Most parotitis cases resolve on their own or with the help of antibacterial treatment, without recurrence or complications. In some instances, children may have juvenile recurrent parotitis, a condition that can cause symptoms for days to weeks and may need partial removal of the parotid gland, referred to as partial parotidectomy.

Newborns can also experience parotitis, which can be life-threatening. In rare cases, severe bacterial parotitis may lead to osteomyelitis (a bone infection), sepsis (a life-threatening infection that spreads throughout the body), organ failure, and even death.

Possible Complications When Diagnosed with Parotitis

Chronic bacterial parotitis occurs from ongoing autoimmune diseases or untreated bacterial infections, causing inflammation in the glandular ducts, narrowing of these ducts, and reduced saliva flow. In some rare cases, a channel might form between the infected area and the skin’s surface, known as a fistula.

There is also a chance that tumors, such as lymphoma, might reside from chronic autoimmune parotitis.

Facial paralysis is an unusual complication, but it can happen due to chronic inflammation caused by Sjogren syndrome, systemic lupus erythematosus, or the uncommon condition called Heerfordt-Waldenstrom syndrome. Damage to the facial nerve may also happen because of a biopsy or surgery of the parotid gland.

Despite the proximity of the maxillary and external carotid arteries to the parotid gland, vascular complications from parotitis are rare. However, the surgery of the parotid gland should be handled carefully due to the risk of vascular injury.

Dry mouth can not only be uncomfortable but can also interfere with your eating due to changes in taste and difficulties in the process of chewing food from the lack of lubrication necessary for the formation of a food bolus. This can lead to malnutrition.

A viral infection caused by mumps might also lead to parotitis, which can be related to meningitis or inflammation of the brain in around 10% of patients. It may also cause inflammation of the pancreas, swelling of the testicles in up to 30% of males who have reached puberty, or even loss of nerve-related hearing.

In rare circumstances, parotitis can lead to the development of a dangerous blood clot in the jugular vein, a condition known as septic thrombophlebitis. This is typically caused by a bacterial infection in the mouth and throat.

A peculiar complication of parotitis is Frey syndrome, which can result in excessive sweating and numbness on the cheek in front of the ear during salivation. This is caused by damage to the auriculotemporal nerve.

Another unusual consequence of parotitis is the Eagle syndrome, which can cause a feeling of a foreign object in the throat and face or neck pain due to an elongated styloid process. That most commonly results from an injury or a tonsil removal surgery but can rarely follow an acute parotitis.

Complications of Parotitis:

• Narrowing of glandular ducts and reduced saliva flow
• Formation of a fistula
• Potential occurrence of tumors
• Facial paralysis
• Vascular complications from surgery
• Difficulty eating and potential malnutrition due to dry mouth
• Potential relation to mumps, meningitis, or inflammation of the brain
• Development of septic thrombophlebitis
• Eagle syndrome, causing throat or facial pain
• Frey syndrome, causing excessive sweating and numbness during salivation

Preventing Parotitis

The most important thing for patients to do is to stay properly hydrated. Try to avoid medicines that can cause a dry mouth, such as antihistamines (used for allergies), decongestants (used for colds), antidepressants, diuretics (water pills), certain blood pressure medications, muscle relaxers, and antibiotics. Avoid using substances like cocaine, methamphetamine, and alcohol. It’s also recommended to avoid chewing tobacco or smoking anything, including marijuana, as these can decrease the amount of saliva in your mouth.

Getting vaccinated with the MMR (measles, mumps, and rubella) vaccine has greatly reduced the number of mumps cases (by 99% in the United States). But, you can still get this disease if you haven’t been vaccinated or if you haven’t received all three recommended doses of the vaccine.