CC
A 69-year-old female presents to the emergency department (ED) complaining of left-sided facial pain and swelling. You are consulted for further management.
HPI
The patient reports that 1 week ago, she experienced left-sided facial swelling after a meal, which gradually self-resolved. Two days before presentation, she experienced another episode of left-sided facial swelling after a meal, which continued to worsen. Because of the progressive nature of the swelling and onset of pain, she presented to the ED for further care. She reports a foul taste in her mouth, limited mouth opening, and decreased appetite. She also endorses the onset of fever and chills with temperatures ranging between 38.3 ° and 38.9 ° C starting 1 day earlier.
A thorough clinical history refines the differential diagnosis and guides the work-up and treatment. In a case in which parotitis is at the top of the differential diagnosis, it is important to assess the following: (1) duration of symptoms; (2) presence of pain; (3) continuous, episodic, or recurrent symptoms; (4) presence of viral prodrome; and (5) associated joint pains or dry eyes.
PMHX/PDHX/medications/allergies/SH/FH
The patient’s medical history includes chronic obstructive pulmonary disease requiring oxygen at home, atrial flutter, prior pulmonary embolus on warfarin, hypertension, hyperlipidemia, congestive heart failure, rheumatoid arthritis, and hypothyroidism. She has previously undergone tonsillectomy. Her medications include gabapentin, omeprazole, torsemide, tramadol, multiple inhalers, metoprolol, levothyroxine, and warfarin. She denies any alcohol, tobacco, or recreational drug use.
The patient’s age and extensive list of medical comorbidities is consistent with the bimodal distribution of patients most commonly affected by acute suppurative parotitis (ASP). A majority of cases occur in older adult patients and infants younger than 1 year of age. Risk factors for ASP demonstrated by this patient include dehydration, hypothyroidism (immunosuppressed state), mechanical obstruction of salivary flow (sialolithiasis), poor oral hygiene, and decreased salivary flow secondary to medications. Other potential comorbidities such as bulimia and autoimmune diseases must be assessed on the review of systems.
Examination
General. The patient is an older adult female who appears older than her stated age. She is shaking and appears to be in substantial pain with subtle facial movements. She has a nasal cannula in place for her baseline oxygen requirement.
Vital signs. Her blood pressure is 160/73 mm Hg, heart rate is 79 bpm, and respiratory rate is 18 breaths per minute. She has an oxygen saturation of 97% with a nasal cannula at 3 L/min. Her temperature is 39.6 ° C, and she is endorsing 8 of 10 on the pain scale.
Maxillofacial. She has obvious facial asymmetry with swelling of the soft tissues overlying the left preauricular area and angle of the mandible ( Fig. 44.1 ). The tissue is indurated and exquisitely tender to palpation. She has palpable, mobile, tender lymph nodes in her left precervical chain. The inferior border of the mandible is easily palpable. Her maximal incisal opening is 18 mm ( Fig. 44.2 ).
Intraoral. Oral hygiene is poor with generalized build-up of plaque and calculus throughout the dentition. The oral mucous membranes are dry (dehydration). Extraoral palpation of the left parotid gland elicits intraoral purulent drainage from Stenson’s duct ( Fig. 44.3 ). The contralateral parotid gland and both submandibular glands express clear saliva. There is no fluctuance or swelling within the buccal vestibules. The floor of mouth is soft and nonelevated. The uvula is midline. The oropharynx and tonsillar pillars are benign.
Imaging
Facial swelling, pain, and fever are the common presenting symptoms for ASP, but other infections, such as those of odontogenic origin, may present in a similar manner and cause swelling of the periparotid region. In patients with a poor dentition and unclear source of infection, a panoramic radiograph is a useful screening study to help rule out possible odontogenic sources of infection. The current patient’s panoramic radiograph shows a heavily restored posterior dentition with periapical radiolucencies associated with the roots of the left mandibular second molar but no obvious identifiable source for her current presentation ( Fig. 44.4 ).
Further imaging may be warranted if there are concerns for abscess with extraglandular extension and deep space involvement or obstructive pathology (sialolith or neoplasm). Of note, a creatinine level or estimated glomerular filtration rate is typically required for all patients before intravenous (IV) contrast-enhanced computed tomography (CT). The patient underwent contrast CT, which showed swelling of the left parotid gland and edema of the surrounding soft tissues ( Fig. 44.5 ). There is no evidence of a drainable fluid collection or abscess formation. A 6-mm-diameter stone is seen at the end of Stensen’s duct with proximal dilatation ( Fig. 44.6 ). If a mass, fluid collection, or lesion had been noted, a fine-needle aspiration (FNA) may be warranted as part of the workup. Also, a sialogram is likely contraindicated in this acute setting because it is extremely painful in the patient with acute parotitis and could lead to glandular damage. Of note, a sialogram is performed to diagnose blockage of the salivary flow caused by stones or strictures. This examination is done by introducing a small tube into Stenson’s duct intraorally and injecting a small amount of radiopaque dye to delineate the duct anatomy.
Labs
A complete blood count with differential is part of the workup for any infectious patient, particularly to assess the white blood cell (WBC) count. A basic metabolic panel (BMP) is also important to evaluate and rule out any metabolic or electrolyte derangements. A ratio of blood urea nitrogen to creatinine greater than 20 to 1 suggests prerenal azotemia and is consistent with dehydration. Blood cultures should be obtained in patients presenting with sepsis or if the patient is immunocompromised. Of note, signs of sepsis include fever, mental status changes, tachycardia, tachypnea, and hypotension. The patient had a leukocytosis with a WBC count of 14,320/μL and a neutrophil predominance (86.7%). The absolute neutrophil count was elevated at 12,430/μL. Her BMP was unremarkable.
Purulent fluid should be sampled when present and sent for Gram stain and culture. Cultures should be sent for aerobes, anaerobes, fungi, and mycobacteria. The patient was swabbed in the ED because she was already draining purulent fluid. It is important to note that cultures obtained from Stensen’s duct may be contaminated with oral flora and unreliable for identifying the causative organism. The Gram stain showed gram-positive cocci in clusters and gram-negative bacilli. The potassium hydroxide (KOH) was unremarkable. The cultures ultimately grew Staphylococcus aureus .
Serum amylase and C-reactive protein (CRP) tests can also be performed and usually show marked elevation. A CRP value obtained weekly postoperatively can be used as a marker for resolution of infection. Of note, CRP is a protein produced by the liver, and elevated levels are a nonspecific indication of systemic inflammation.
Differential diagnosis
The differential diagnosis should include sialadenitis, odontogenic abscess, lymphadenopathy, brachial cleft cyst, temporomandibular joint septic arthritis, otitis externa, masseter hypertrophy, and Lemierre syndrome (septic thrombophlebitis of the internal jugular vein).
Assessment
Acute suppurative parotitis in the setting of dehydration and sialolith.
Treatment:
The initial management of patients with ASP is mostly medical. There should be a low threshold for admission (especially in vulnerable populations) because there is the potential for spread to the deep fascial spaces. Management includes administration of IV antibiotics, aggressive hydration (IV fluids), warm compresses, nutritional support, and sialogogues. If there is a lack of response over a 48-hour period, cultures should be redrawn, antibiotics broadened, and further imaging considered.
The initial antibiotic regimen is selected based on the expected microbiology known to cause ASP because there is no systematic data to inform the selection. S. aureus has been the most commonly isolated pathogen, but infections are usually polymicrobial. Empiric regimens for immunocompetent individuals should be directed against methicillin-susceptible S. aureus , Haemophilus influenzae , viridans streptococci, and oral anaerobes, with strict anaerobes as the causative agent in almost half of the cases of ASP. A large portion of bacteria causing sialadenitis produce beta-lactamase, which should be taken into account when deciding initial empiric therapy. Beta-lactamase–resistant penicillins (e.g., ampicillin–sulbactam) are a first-line choice. In patients with a true penicillin allergy, cefuroxime, ceftriaxone, or levofloxacin combined with metronidazole or clindamycin provides appropriate coverage. Methicillin-resistant S. aureus should only be considered in susceptible populations and should not be covered empirically. When the patient starts to clinically improve, typically within 3 to 5 days, IV antibiotics can be converted to an oral regimen. There are no data to guide the duration of therapy, but for uncomplicated cases, 10 to 14 days of therapy is considered reasonable.
The patient in this case was admitted to the hospital, started on the appropriate IV antibiotics, and aggressively hydrated. She improved, was discharged, and completed a course of oral antibiotics for a total 2-week course. She underwent duct dilation and sialolith extraction several weeks after resolution ( Fig. 44.7 ).
