Parotitis, Acute and Chronic

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Basics

Description

  • Inflammation of the parotid gland caused by infection, systemic illnesses, mechanical obstruction, or medications
  • Can be unilateral or bilateral, acute or chronic
  • The parotid gland is the largest of the salivary glands, located lateral to the masseter muscle anteriorly and extending posteriorly over the sternocleidomastoid muscle behind the angle of the mandible.
  • It produces exclusively serous secretions, which lack the bacteriostatic properties of mucinous secretions, making the parotid gland more susceptible to infection than other salivary glands.
  • The parotid duct, also called the Stensen duct, pierces the buccinator muscle to enter the buccal mucosa just opposite the 2nd maxillary molar.
  • The branches of the 7th cranial nerve or “facial nerve” bisect the gland into lobes.
  • The parotid gland contains 3 to 24 lymph nodes.

Epidemiology

  • Viral parotitis is the most common cause of parotitis in children; has decreased since the advent of the mumps vaccine
  • Acute bacterial parotitis occurs more frequently in elderly, neonates (especially preterm infants), and postoperative patients.
  • Juvenile recurrent parotitis (JRP) is the second most common inflammatory cause of parotitis in children in the United States; first episode usually occurs between 3 and 6 years.
  • Chronic parotitis mainly affects adults, more often females. The average age of presentation is between 40 and 60 years.
  • Chronic bilateral parotid enlargement is a common manifestation of HIV infection; for perinatally HIV-infected children, the average age of onset for parotid enlargement is 5 years.

Etiology and Pathophysiology

  • Acute viral parotitis begins as a systemic infection that localizes to the parotid gland, resulting in inflammation and swelling of the gland. Viral pathogens:
    • Mumps, or paramyxovirus, has a predilection for the parotid gland and classically linked to parotitis.
    • Parainfluenza virus types 1, 2, and 3; influenza A; coxsackievirus; Epstein-Barr virus (EBV); human herpesvirus (HHV6)
    • Cytomegalovirus (CMV) and adenovirus have been seen in patients with HIV.
    • Case reports demonstrate that parotitis can be a clinical manifestation of SARS-CoV 2 infection.
  • Nonviral infections results from stasis of salivary flow that allows retrograde introduction of bacterial pathogens into the gland. Common pathogens:
    • Staphylococcus aureus and anaerobes (oral flora) most commonly
    • Streptococcus pneumoniae, viridans streptococci, Escherichia coli, and Haemophilus influenzae (less common)
    • Other gram-negative rods, such as Klebsiella, Enterobacter, and Pseudomonas, can be seen in chronically ill or hospitalized patients.
    • Bartonella henselae in patients with cat exposure and manifestation of late-onset group B Streptococcus
    • Fungal infections include Candida (chronically ill or hospitalized patients) and Actinomyces in patients with a history of trauma or dental caries.
  • Recurrent parotitis etiologies:
    • JRP may be secondary to chronic inflammation; etiology is unknown, but a genetic predisposition may exist.
    • Mechanical: Repeated sialolith formation leads to ductal wall damage, fibrosis, and stricture formation.
    • Pneumoparotitis may occur when air is trapped in the ducts of the parotid gland; seen in wind instrument players, glass blowers, scuba divers, and with dental cleaning
    • Certain medications and chronic diseases (see “Risk Factors”) predispose to chronic parotitis.
    • Pediatric considerations include case reports of acute parotitis as a symptom of Kawasaki disease.

Risk Factors

  • Lack of mumps, measles, rubella (MMR) vaccination
  • Conditions that predispose to salivary stasis, such as dehydration, debilitation, poor oral hygiene, Sjögren syndrome, cystic fibrosis, bulimia/anorexia, sialolithiasis (stones), ductal stenosis, trauma
  • Immunosuppression, HIV, chemotherapy, radiation, malnutrition, alcoholism
  • Neonatal parotitis: prematurity, dehydration, low birth weight, ductal obstruction, oral trauma, structural abnormalities, immunosuppression
  • JRP: dental malocclusion, congenital duct malformation, genetic factors, immunologic anomalies, disrupted enzyme activity
  • Drug-induced parotitis: medications such as anticholinergics, ACE inhibitors (captopril), antihistamines, tricyclic antidepressants, antipsychotics (phenylbutazone, thioridazine, clozapine), iodine (contrast media), and L-asparaginase
  • Chronic parotitis: ductal stenosis, HIV, tuberculosis, Sjögren syndrome, sarcoidosis, uremia, diabetes, gout, and atopy

General Prevention

  • MMR vaccination
    • Pregnant women should not receive the mumps vaccine, and pregnancy should be avoided for 4 weeks after vaccination.
  • Maintain adequate hydration and good dental hygiene; smoking cessation, abstinence from alcohol, and avoidance of chronic purging

Commonly Associated Conditions

Mumps, HIV, Sjögren syndrome, sarcoidosis, sialolithiasis

-- To view the remaining sections of this topic, please or --

Basics

Description

  • Inflammation of the parotid gland caused by infection, systemic illnesses, mechanical obstruction, or medications
  • Can be unilateral or bilateral, acute or chronic
  • The parotid gland is the largest of the salivary glands, located lateral to the masseter muscle anteriorly and extending posteriorly over the sternocleidomastoid muscle behind the angle of the mandible.
  • It produces exclusively serous secretions, which lack the bacteriostatic properties of mucinous secretions, making the parotid gland more susceptible to infection than other salivary glands.
  • The parotid duct, also called the Stensen duct, pierces the buccinator muscle to enter the buccal mucosa just opposite the 2nd maxillary molar.
  • The branches of the 7th cranial nerve or “facial nerve” bisect the gland into lobes.
  • The parotid gland contains 3 to 24 lymph nodes.

Epidemiology

  • Viral parotitis is the most common cause of parotitis in children; has decreased since the advent of the mumps vaccine
  • Acute bacterial parotitis occurs more frequently in elderly, neonates (especially preterm infants), and postoperative patients.
  • Juvenile recurrent parotitis (JRP) is the second most common inflammatory cause of parotitis in children in the United States; first episode usually occurs between 3 and 6 years.
  • Chronic parotitis mainly affects adults, more often females. The average age of presentation is between 40 and 60 years.
  • Chronic bilateral parotid enlargement is a common manifestation of HIV infection; for perinatally HIV-infected children, the average age of onset for parotid enlargement is 5 years.

Etiology and Pathophysiology

  • Acute viral parotitis begins as a systemic infection that localizes to the parotid gland, resulting in inflammation and swelling of the gland. Viral pathogens:
    • Mumps, or paramyxovirus, has a predilection for the parotid gland and classically linked to parotitis.
    • Parainfluenza virus types 1, 2, and 3; influenza A; coxsackievirus; Epstein-Barr virus (EBV); human herpesvirus (HHV6)
    • Cytomegalovirus (CMV) and adenovirus have been seen in patients with HIV.
    • Case reports demonstrate that parotitis can be a clinical manifestation of SARS-CoV 2 infection.
  • Nonviral infections results from stasis of salivary flow that allows retrograde introduction of bacterial pathogens into the gland. Common pathogens:
    • Staphylococcus aureus and anaerobes (oral flora) most commonly
    • Streptococcus pneumoniae, viridans streptococci, Escherichia coli, and Haemophilus influenzae (less common)
    • Other gram-negative rods, such as Klebsiella, Enterobacter, and Pseudomonas, can be seen in chronically ill or hospitalized patients.
    • Bartonella henselae in patients with cat exposure and manifestation of late-onset group B Streptococcus
    • Fungal infections include Candida (chronically ill or hospitalized patients) and Actinomyces in patients with a history of trauma or dental caries.
  • Recurrent parotitis etiologies:
    • JRP may be secondary to chronic inflammation; etiology is unknown, but a genetic predisposition may exist.
    • Mechanical: Repeated sialolith formation leads to ductal wall damage, fibrosis, and stricture formation.
    • Pneumoparotitis may occur when air is trapped in the ducts of the parotid gland; seen in wind instrument players, glass blowers, scuba divers, and with dental cleaning
    • Certain medications and chronic diseases (see “Risk Factors”) predispose to chronic parotitis.
    • Pediatric considerations include case reports of acute parotitis as a symptom of Kawasaki disease.

Risk Factors

  • Lack of mumps, measles, rubella (MMR) vaccination
  • Conditions that predispose to salivary stasis, such as dehydration, debilitation, poor oral hygiene, Sjögren syndrome, cystic fibrosis, bulimia/anorexia, sialolithiasis (stones), ductal stenosis, trauma
  • Immunosuppression, HIV, chemotherapy, radiation, malnutrition, alcoholism
  • Neonatal parotitis: prematurity, dehydration, low birth weight, ductal obstruction, oral trauma, structural abnormalities, immunosuppression
  • JRP: dental malocclusion, congenital duct malformation, genetic factors, immunologic anomalies, disrupted enzyme activity
  • Drug-induced parotitis: medications such as anticholinergics, ACE inhibitors (captopril), antihistamines, tricyclic antidepressants, antipsychotics (phenylbutazone, thioridazine, clozapine), iodine (contrast media), and L-asparaginase
  • Chronic parotitis: ductal stenosis, HIV, tuberculosis, Sjögren syndrome, sarcoidosis, uremia, diabetes, gout, and atopy

General Prevention

  • MMR vaccination
    • Pregnant women should not receive the mumps vaccine, and pregnancy should be avoided for 4 weeks after vaccination.
  • Maintain adequate hydration and good dental hygiene; smoking cessation, abstinence from alcohol, and avoidance of chronic purging

Commonly Associated Conditions

Mumps, HIV, Sjögren syndrome, sarcoidosis, sialolithiasis

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