Day: April 10, 2023

What Causes Parotitis?

Patient Presentation
A 10-year-old male came to clinic with a 1 day history of left cheek swelling and pain. He denied any trauma and it was described as having an insidious onset with a temperature of 99.8F and some general malaise. He said his “cheek just hurt” in general and a little more with chewing but denied any actual tooth pain, ear pain, or any new sounds with chewing. He had no identified sick contacts. The past medical history showed he was fully vaccinated including for mumps at age 5.5 years. He had regular dental care.

The pertinent physical exam showed a healthy male with normal vital signs and growth parameters. He was afebrile. His left cheek was slightly more prominent and anterior to the ear was slightly swollen and warmer. The angle of the jaw was palpable and there was no specific crepitus or problems with the temporomandibular joint with movement. His ears were normal bilaterally. Intraorally, the cheek potentially was more erythematous and there was some mucopurulent fluid when the parotid glad was milked. No dental pain was elicited when each tooth was tapped and the maxillary sinuses also did not have pain with palpation. The facial nerve did not appear to be affected.

The diagnosis of parotitis was made. As the patient was fully vaccinated, the pediatrician was unsure if testing for mumps would be helpful so he contacted dentistry. They recommended to try to get a culture of the intraoral fluid from the duct if possible, and to start the patient on antibiotics for a probable bacterial cause, along with symptomatic treatment. A dental appointment was made for the following day. The patient’s clinical course showed that he improved over the following week with resolution of all symptoms. The culture grew intraoral flora without a specific predominant organism.

Discussion
The salivary glands are important for creating saliva which helps with taste, digestion, oral health, and speech. Salivary gland problems are not that common but can be painful, annoying or herald potential systemic diseases. The parotid gland is the largest salivary gland lying anterior to the ear within the cheek structures. There are 2 lobes (superficial and deep) and the facial nerve runs between them. The salivary duct opens adjacent to the upper second molar. Infections are the most common cause of parotitis with mumps being the most commonly associated infection especially in unimmunized patients.

Patients with parotitis present with pain or discomfort, swelling, and potentially systemic fever and/or localized temperature elevation. The jaw angle may not be discernable because of the swelling and there may be mucopurulent discharge from the salivary duct. Special attention should be paid to the facial nerve innervation and adjacent structures when examining the patient.

Patients are usually treated supportively for infectious causes with analgesics, sialoguges, parotid gland massage, oral hygiene practices and if appropriate, antibiotics. Consultations with dentists or otorhinolaryngologists may assist primary care providers with outpatient management and is helpful if the diagnosis is not clear.

Learning Point
The differential diagnosis for parotitis and other salivary gland disorders includes:

  • Infections
    • Viral
      • Mumps
      • Adenovirus
      • Coxsackie virus
      • Cytomegalovirus
      • Epstein-Barr virus
      • Influenza
      • Parainfluenza
      • Parvovirus B-19
    • Bacterial
      • Staphylococcus aureus
      • Streptococcus
      • Mycobacterium tuberculosis
      • Mycobacterium avium
    • Other
      • Toxoplasmosis
      • Abscess
  • Inflammatory
    • Sjorgren’s syndrome
    • Sarcoidosis
    • Systemic erythematosus lupus
  • Trauma
    • Hematoma
    • Foreign body
  • Tumor – rare
    • Benign
    • Malignant
    • Other – bony tumors, vascular malformations
  • Other
    • Sialolithiasis – salivary stones
    • Anatomic abnormalities
    • Cystic fibrosis
    • Juvenile recurrent parotitis – a non-obstructive, non-suppurative parotitis
    • Metabolic disorders
  • Problems with adjacent structures may look like parotitis
    • Dental
    • Dermatological
    • Cold panniculitis

Questions for Further Discussion
1. Where are all the salivary glands located?
2. What causes dental caries?
3. What causes facial pain? A review can be found here
4. At what age do teeth exfoliate? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Salivary Gland Disorders and Mumps.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Ellies M, Laskawi R. Diseases of the salivary glands in infants and adolescents. Head Face Med. 2010;6:1. doi:10.1186/1746-160X-6-1

Taji SS, Savage N, Holcombe T, Khan F, Seow WK. Congenital Aplasia of the Major Salivary Glands: Literature Review and Case Report. Pediatr Dent. 2011;33(2):113-118.

Jablenska L, Trinidade A, Meranagri V, Kothari P. Salivary gland pathology in the paediatric population: implications for management and presentation of a rare case. J Laryngol Otol. 2014;128(1):104-106. doi:10.1017/S0022215113003514

Inarejos Clemente EJ, Navallas M, Tolend M, Sunol Capella M, Rubio-Palau J, Albert Cazalla A, Rebollo Polo M. Imaging Evaluation of Pediatric Parotid Gland Abnormalities. RadioGraphics. Accessed January 10, 2023. https://pubs.rsna.org/doi/10.1148/rg.2018170011

Gellrich D, Bichler M, Reichel CA, Schrotzlmair F, Zengel P. Salivary Gland Disorders in Children and Adolescents: A 15-year Experience. Int Arch Otorhinolaryngol. 2020;24(1):e31-e37. doi:10.1055/s-0039-1697993

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa