A Complicated Case of Acute Parotitis Anna Slobodskya DO St. John’s Episcopal Hospital, Far Rockaway, NY Dermatology Suzanne Sirota-Rozenberg DO, Program Director Albert Strojan DO, DME Introduction: Discussion: Conclusion:

Epidemiology: Acute suppurative parotitis can be Acute bacterial suppurative parotitis Acute suppurative parotitis predominantly affects the elderly patients, the majority of whom are debilitated by systemic disease and dehydrated. Diabetes, alcoholism, autoimmune disorders such as Sjogren's is most commonly caused by disease, poor oral hygiene, malnutrition, decrease in salivary flow secondary to medications (such as diuretics, anticholinergics, antihistamines), postsurgical dehydration, and ductal obstruction are some of these seen in various clinical settings. Staphylococcus aureus and is often predisposing risk factors. MRSA parotitis is largely a disease polymicrobial. Many times parotitis Many of the risk factors for acute suppurative parotitis and MRSA overlap, and include old age, multiple co-morbidities, hospital admission and residence in a nursing home. of the elderly with a high occurs in chronically ill elderly patients. The diagnosis is made when Clinical Manifestations: mortality. It is important to the characteristic clinical findings are The most common clinical manifestation of acute suppurative parotitis is the onset of an indurated, warm, erythematous swelling of the pre and postauricular areas that extends to the angle of the mandible. This diagnose these patients early and present including pre and post- is usually a unilateral swelling, although there have been a few cases of bilateral parotitis. The area above the swelling is extremely tender, and patient may have complaint of extreme pain, trismus, and initiate appropriate therapy. A auricular swelling, pain, and dysphagia. Symptoms may be exacerbated by meals. Intraorally, Stensen's duct may appear erythematous or inflamed and purulent material may be expressed from its orifice. Due to the dense fibrous nature of trismus. Purulent drainage may be the parotid fascia, a fluctuant quality is usually not observed. Additionally compression of the facial nerve as it passes through the gland may occur. culture of parotid drainage fluid present at the opening of the duct of (via pus expression or needle Stensen. Acute suppurative parotitis Microbiology: aspiration) and blood cultures is requires prompt aggressive treatment •Staphylococcus aureus is the most common pathogen to prevent respiratory compromise •Microbiology is quite variable and often polymicrobial necessary. Empirical antibiotics and other complications. Treatment •Other pathogens include streptococci, gram-negative bacilli and anaerobes should cover S. aureus (including is generally a 10-14 day course of •Diabetic patients have increased susceptibility to oral yeast carriage. This may be due to decreased salivary flow or increased levels of salivary glucose. A review of the literature revealed only a handful of cases MRSA if risk factors exist) and broad spectrum intravenous where Candida was isolated in a parotid abscess. antibiotics. In recurrent cases of anaerobes, pending susceptibility parotitis, a parotidectomy may be Diagnostic Evaluation and Imaging: results. Drainage is usually only considered •Patient with the above clinical presentation required if an abscess forms. This •An elevated amylase (in the absence of pancreatitis) •Purulent discharge should be collected for a Gram stain and culture. If there is no purulent discharge from Stensen's duct, extra-oral needle aspiration of the swollen gland should be performed case illustrates the importance of •Ultrasonography, CT scan, and MRI are the common radiology imaging used considering Candida Albicans in the •CT scan with IV contrast is often the first radiologic evaluation of choice due to its ability to enhance the different soft tissue densities within the gland differential diagnosis of diabetic Treatment: •Hydration and Antibiotics. patients. • Initial antibiotic therapy should be based on the expected microbiology and host factors. Therapy should be directed against Staphylococcus aureus (including MRSA in nosocomial and nursing Adequate hydration, proper oral home patients), oral aerobes and anaerobes. Therapy should be administered for 10-14 days in uncomplicated cases hygiene, and blood glucose control •Any cause of salivary stasis such as certain medications should be stopped •Attempts should be made to increase salivary flow. are effective measures at Case Report: • applying warm compress to the area preventing reoccurrence. • massaging the gland • maximizing oral hygiene An 83 year old female with a PMH of •irrigating the mouth and giving the patient lemon drops to increase salivation Alzheimer’s dementia, schizoaffective disorder, •Surgical incision and drainage - if the patient does not improve in 48 hours NIDDM and HTN presented to the ED from a •Piliocarpine can be used to stimulate salivary flow nursing home with a two day history of right sided facial swelling. Due to her dementia and Complications: confused mental status, a history was unable Progression of the swelling can lead to many complications. The infections can spread to the deep fascia of the head and neck. Increase in swelling of the neck can cause respiratory obstruction. Additionally, to be obtained from the patient. Per nursing septicemia, osteomyelitis of the adjacent facial bone, and facial nerve palsy are all possible complications. home records, the patient had swelling that had gotten progressively worse over the past two days, with a noted fever of 103F. Her other vitals signs were stable and she was able to follow commands. Images: Clinical presentation was significant for CT Findings: erythema and edema to the right side of the face from the pre-auricular region to the right Marked , and diffuse cutaneous and side of the mouth, with diffuse tenderness to subcutaneous edema diffusely, including palpation and trismus. The facial nerve was determined to be intact. Purulent discharge the temporalis muscle, the overlying scalp. References: was expressed from her right Stensen’s duct. The edematous soft tissues extend laterally The remained of the physical and and caudally, through the peri-auricular 1. AJ, McCaffrey TV. Inflammatory disorders otolaryngologological exam was unremarkable. of the salivary glands. In: Cummings CW, Flint Diagnostic interpretation of a CT of the head soft tissues and tapering towards the PW, Harker LA, Haughey BH, Richardson MA, showed an abnormally enlarged right parotid supraclavicular region. There is thickening Robbins KT et al., eds. Cummings: gland and thickened Stensen’s duct. The of the platysma muscle and right Otolaryngology: Head and Neck Surgery, 4th patient received IV Vancomycin, Clindamycin submandibular gland. Anterior triangle edn. Philadelphia: Elsevier Mosby, and IV fluids. Her treatment also included 2005:1323–9 warm compresses and frequent parotid lymph nodes, are borderline enlarged. The 2. Brook I. Acute bacterial suppurative massage. She was transferred to the ICU to epicenter is the right parotid gland, which is parotitis: microbiology and management. J monitor for respiratory compromise. 48 hours diffusely swollen, including the superficial CraniofacSurg 2003;14: 37–40 into antibiotic treatment, her swelling was not 3. Fattahi TT, Lyu PE, Van Sickels JE. markedly improved. An abscess had formed Lab Values: and deep portion. The gland is abnormally Management of acute suppurative parotitis. J and subsequently was incised and drained. dense. There is diffuse thickening of Oral MaxillofacSurg 2002;60: 446–8 Wound culture results showed MRSA and Stensen’s duct, but without calculi. 4. Smith DR, Hartig GK. Complete facial Candida albicans infection. Fluconazole was CBC: WBC-17.1 Hgb-11.9 Hct-33.4 Plt- 190 Asymmetric thickening of the paralysis as a result of parotid abscess. added to the patient’s treatment regimen. Otolaryngol Head Neck Surg 1997;117: 114– The patient was successfully treated and CMP: Na-134 K-4.3 Cl-95 HCO3-30 BUN-19 Crea-0.77 Gluc- 204 parapharyngeal fat planes, deep portion of 17 discharged after 14 days of treatment with Amylase - 40 the parotid gland, the right lateral 5. Tan, VES. Parotid Abscess: A Five Year instructions to take oral Fluconazole for a total Wound Culture/Gram Stain: Methicillin resistant Staphylococcus pharyngeal wall, from the soft palate to the Review. The Journal of Laryngology& Otology of four weeks of treatment. At follow-up 2007;121: 872-79 examination, the parotitis had resolved. Aureus , Candida Albicans base of the tongue, without airway Blood Culture: No growth obstruction.