Parotitis and Sialadenitis

sialadenitisCaring for children in the ED can be challenging for certain.  Managing the critically ill child requires a lot of skill and action (ex, Can’t Intubate, Can’t Ventilate and Hypercyanotic Spell).  Remaining vigilant for the subtly sick takes a lot of energy and contemplation (ex, Subtle Signs of Heart Failure, Osteosarcoma, and Inborn Errors in the ED).  While these two groups make our job challenging, often I find the relatively “simple” conditions to be surprisingly challenging;  they can generate a number of questions that perhaps I wasn’t ready to answer.  As many of us (in the USA anyway) salivate over our Thanksgiving meals, let us consider the “seemingly simple” condition of Sialadenitis and Parotitis.

 

Sialadenitis: Basics

  • Sialadenitis = inflammation of the salivary glands.
  • Saliva is important! It plays a role in:
    • Digestion, lubrication, and taste
    • Tooth intergrity
    • Defense against bacterial (secretion of IgA)
  • There are Numerous Salivary Glands
    • Parotid Gland
      • Largest of the glands
      • Stensen duct travels parallel to the zygoma, ~1cm inferior to it, and exist opposite the 2nd mandibular molar. [Francis, 2014]
      • Produces two-thirds of stimulated salivation.
      • Lower rate of secretion.
      • Produces primarily serous, watery saliva
      • More likely to become inflamed due to infectious and autoimmune reasons.
    • Submandibular Gland
      • 2nd largest of the glands
      • Wharton duct exists the floor of the mouth near the frenulum of the tongue. [Francis, 2014]
      • Produces two-thirds of the constant salivation.
      • Produced mixture of mucinous and watery saliva.
        • Mucinous saliva aids in lubrication, mastication, and swallowing.
      • More likely to become inflamed by obstructive processes, like stones.
    • Sublingular Glands
      • Multiple smaller glands.
      • Have very small ducts without a dominant duct. [Francis, 2014]
    • Minor Salivary Glands
      • Scattered in the oral cavity and oral pharynx.

 

Sialadenitis: Causes

  • Variety of factors can lead to sialadenitis and often due to multi-factorial processes leading to a “salivary gland inflammatory cycle”.  [Francis, 2014]
    • Sequence of events that decrease saliva flow, increase inflammation, generate ductal dysfunction, and increase mucinous saliva.
    • Predisposing factors = infection, structural abnormality, immune factors, dehydration.
  • Infectious
    • Viral
      • Mumps
        • Vaccination has made this much less common, but outbreaks do occur.
        • Systemic illness… so look for other systems that may be involved.
      • EBV
      • HIV
      • Parainfluenza
    • Bacterial
      • Staph, Strep, H. flu, E. coli, Bacteroides
      • Most commonly occurs in the Parotid Gland. [Francis, 2014]
  • Immunologic
    • Sjogren Syndrome [Baszis, 2012]
      • Chronic inflammatory disease of the exocrine glands.
      • Dry mouth and dry eyes are common.
    • HIV
      • Can cause bilateral involvement (think of this with bilateral parotitis)
      • Often glands are NOT tender.
    • IgA deficiency
    • Juvenile rheumatoid arthritis
    • Ankylosing spondylitis
    • Sarcoidosis [Banks, 2013]
    • Ulcerative colitis
    • Bulimia Nervosa Sialadenosis (unclear etiology, but may be first presentation)
  • Trauma
    • Local obstruction from stones
      • Relatively uncommon in children.
      • Submandibular gland involved in majority of cases (higher amount of mucoid saliva production).
    • Penetrating injuries
    • Blunt injuries
    • Radiation injury

 

Sialadenitis: Presentation

  • Swelling, pain, fever, and erythema of the affected gland.
  • Trimus and Pain with mastication
  • Purulence may be expressed from the associated duct.  [Francis, 2014]
  • Inspissated mucus may also mimic purulence.

 

Sialadenitis: Recurrent?

  • Recurrent or chronic sialadenitis has been associated with several autoimmune disorders.   [Francis, 2014; Baszis, 2012]
  • Causes are, again, likely must-factorial (structural, infectious, obstruction, inflammatory, etc).
  • Juvenile Recurrent Parotitis is a common cause.
    • True incidence is unknown, but thought to be the second most common cause of salivary disease in children worldwide (after Mumps).  [Francis, 2014; Patel, 2009]
    • Has two peaks in age of presentation: ages 2-6 years and at age of puberty.
    • Self-limited and resolves spontaneous after puberty.  [Francis, 2014]
  • Diagnostic sialendoscopy can be useful to help diagnose and manage. [Ramakrishna, 2015]

 

Sialadenitis: Management

  • Diagnosis is primarily a clinical one!  (It’s awesome when you don’t need to order tests!)
  • Treatment is typically conservative:  [Francis, 2014]
    • Pain management 
    • Adequate hydration
      • Dehydration exacerbates inflammatory process.
      • Dehydration makes mucoid saliva more prominent.
    • Warm massage
    • Sialogogues
    • Treat underlying autoimmune / inflammatory disorder.
    • Appropriate antibiotics
      • While bacterial infection may not have initiated the condition, it is difficult to deny the possibility of its involvement.
      • If able to express material from duct, send purulence / inspissated mucus for Gram Stain and Culture.  [Francis, 2014]
      • Antistaphylococcal penicillinases-resistant antibiotics should be started while awaiting culture results.
    • Patients with co-morbidities, fever, or leukocytosis may benefit from inpatient, IV antibiotics. [Stong, 2005]
  • If medical therapies fail, or there is concern for localized complication: [Stong, 2005]
    • May need to image:
      • Ultrasound
        • Considered 1st line option by many.
        • Can help evaluate the gland and abscess formation.
        • May illustrate a stone, but may still miss smaller stones. [Francis, 2014]
      • CT
        • Likely needed if surgical options need to be considered.
    • Surgical options:
      • Stone retrieval and ballon dilation
      • Lithotripsy
      • Gland excision – has become less common
      • Sialendoscopy – has become preferred option

 

Moral of the Morsel

  • The “seemingly simple” conditions occurring in a complex organism (like us Humans) can be less than straight forward.
  • Don’t dismiss sialadenitis as a simple infection and throw antibiotics at it. It is multifactorial and may not merely be an antibiotic deficiency. Keep other etiologies in mind, especially when educating families about it.
  • Recurrent parotitis / sialadenitis warrants additional consideration and referral.

 

References

Ramakrishna J1, Strychowsky J1, Gupta M1, Sommer DD1. Sialendoscopy for the management of juvenile recurrent parotitis: a systematic review and meta-analysis. Laryngoscope. 2015 Jun;125(6):1472-9. PMID: 25393103. [PubMed] [Read by QxMD]

Francis CL1, Larsen CG2. Pediatric sialadenitis. Otolaryngol Clin North Am. 2014 Oct;47(5):763-78. PMID: 25128215. [PubMed] [Read by QxMD]

Banks GC1, Kirse DJ, Anthony E, Bergman S, Shetty AK. Bilateral parotitis as the initial presentation of childhood sarcoidosis. Am J Otolaryngol. 2013 Mar-Apr;34(2):142-4. PMID: 23102965. [PubMed] [Read by QxMD]

Baszis K1, Toib D, Cooper M, French A, White A. Recurrent parotitis as a presentation of primary pediatric Sjögren syndrome. Pediatrics. 2012 Jan;129(1):e179-82. PMID: 22184654. [PubMed] [Read by QxMD]

Saarinen RT1, Kolho KL, Kontio R, Saat R, Salo E, Pitkäranta A. Mandibular osteomyelitis in children mimicking juvenile recurrent parotitis. Int J Pediatr Otorhinolaryngol. 2011 Jun;75(6):811-4. PMID: 21489642. [PubMed] [Read by QxMD]

Patel A1, Karlis V. Diagnosis and management of pediatric salivary gland infections. Oral Maxillofac Surg Clin North Am. 2009 Aug;21(3):345-52. PMID: 19608051. [PubMed] [Read by QxMD]

Stong BC1, Sipp JA, Sobol SE. Pediatric parotitis: a 5-year review at a tertiary care pediatric institution. Int J Pediatr Otorhinolaryngol. 2006 Mar;70(3):541-4. PMID: 16154645. [PubMed] [Read by QxMD]

Orvidas LJ1, Kasperbauer JL, Lewis JE, Olsen KD, Lesnick TG. Pediatric parotid masses. Arch Otolaryngol Head Neck Surg. 2000 Feb;126(2):177-84. PMID: 10680869. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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