An 87-year-old man with dementia was brought to the emergency department because of progressive swelling of the right cheek of 3 days' duration. The patient--a nursing home resident--required total care for activities of daily living because of a prior stroke. In addition, he had type 2 diabetes mellitus and hypertension. His current medications included hydrochlorothiazide (12.5 mg/d), 70/30 insulin (30 units bid), and clopidogrel (75 mg/d).
Blood pressure was 138/80 mm Hg; heart rate, 100 beats per minute; temperature, 36.4°C (97.4°F); and respiration rate, 17 breaths per minute. The right parotid region was swollen, warm, and erythematous. Edema and induration extended to the middle of the patient's neck (A).
Laboratory studies revealed a white blood cell count of 24,100/µL with 85% polymorphonuclear cells. Blood urea nitrogen and creatinine levels were acutely elevated (47 and 1.4 mg/dL, respectively), consistent with prerenal azotemia from volume contraction.
A CT scan of the head revealed diffuse swelling and inflammation of the right parotid gland that infiltrated the surrounding muscle and fat planes and extended toward the region of the carotid sheath (B). Acute bacterial parotiditis was diagnosed.
Andrew Koon, MD, Andrew Bagg, MD, Kevin O'Brien, MD, and Carrie Vey, of Tampa, Fla, write that conditions that cause xerostomia and mechanical obstruction in the Stensen duct can result in decreased clearance of colonizing bacteria and predispose patients to acute bacterial parotiditis. This infection commonly occurs in elderly patients who are dehydrated as a result of treatment with diuretics or anticholinergics or recent surgery.1,2
In acute infection, patients often have unilateral swelling of the parotid gland with associated erythema and tenderness. Purulent secretions from the Stensen duct may be noted in more than 50% of the cases. In suppurative parotiditis, the most common isolate is Staphylococcus aureus, followed by Streptococcus viridans. Because Gram-negative and anaerobic organisms may occasionally cause infection, a specimen of gland secretions should be obtained and cultured when possible.3,4
CT or ultrasonography may be necessary when patients are unresponsive to standard treatment within the first 72 hours or when other complications--such as abscess formation within the gland and extension of infection to the deep neck spaces--are suspected. Consider surgical referral for these patients as well as for those with recurrent infection.1,3
In patients with acute bacterial parotiditis, empiric antibiotic coverage of S aureus is essential. Of course, therapy may need to be adjusted based on culture results. When possible, identify and correct factors that may predispose patients to parotiditis.
This patient was initially treated with intravenous nafcillin, parotid gland massage, warm compresses, and lemon drops to promote drainage of purulent material from the Stensen duct (C). The swelling of the parotid gland decreased noticeably within 2 days; however, cultures of secretions were positive for methicillin-resistant S aureus. Vancomycin was substituted for nafcillin, and the infection completely resolved. Hydrochlorothiazide was replaced with another antihypertensive agent. Even though the inflammation extended toward the region of the carotid sheath, additional intervention was not warranted because he had responded quickly to conservative therapy.
1. McQuone SJ. Acute viral and bacterial infections of the salivary glands. Otolaryngol Clin North Am. 1999;32:793-811.
2. Read RC. Orocervical and esophageal infection. In: Cohen J, Powderly W, eds. Infectious Diseases. 2nd ed. St Louis: Elsevier; 2004:464-467.
3. Raad II, Sabbagh MF, Caranasos GJ. Acute bacterial sialadenitis: a study of 29 cases and review. Rev Infect Dis. 1990;12:591-601.
4. Baker AS, Chow AW. Infections of head and neck spaces and salivary glands. In: Gorbach SL, Bartlett JG, Blacklow NR. Infectious Diseases. Philadelphia: Lippincott Williams & Wilkins; 2004:420-427.