Sudden-Onset Right-Cheek Swelling in a 69-Year-Old Woman

Liza Cholin, BS; Jordan Burlen, BS; Umar Darr, MD

Disclosures

April 27, 2016

Discussion

On the basis of the history and physical examination findings, the most probable diagnosis was determined to be acute suppurative parotitis. The patient had a unilateral, swollen, and tender gland that was draining purulent fluid, which makes an acute bacterial etiology most likely. The patient also had several risk factors for developing infectious parotitis; these include multiple comorbidities and a recent nursing home stay.

A salivary gland neoplasm has a more indolent course and is generally painless. Viral parotitis is found more commonly in young children and is now rare, owing to the widespread use of the measles, mumps, and rubella vaccine. Viral parotitis is also more likely to produce a clear discharge.

Sialoduct stones, or sialolithiasis, is associated with more intermittent pain around the time that the gland is releasing salivary fluids (during eating). A patient with salivary stones generally appears well otherwise and will not have purulent drainage.

Swollen lymph nodes surrounding the parotid gland is another possibility. However, drainage from the gland is not expected, and tenderness is mild if present.

Referring pain from adjacent structures should also be taken into account. Owing to the patient's denial of ear pain and normal findings in the ear and oral cavity, external otitis and dental abscess are less likely.

Finally, some autoimmune cases of parotitis have been noted. Sarcoidosis and Sjögren syndrome are both associated with parotitis. However, they are associated with a more chronic course, and often the swelling is bilateral, with only mild tenderness. Also, other organ systems would be affected with these diseases. The patient in this case report had a fairly unremarkable physical examination and no history of autoimmune disorders, making these unlikely causes.

In this case, on the second day of the parotid swelling, the surgery team was consulted. The team was able to express purulent discharge with gentle massage. They sent the fluid for culture and began treating the patient empirically for acute bacterial parotitis. Intravenous ceftriaxone and doxycycline were continued, and metronidazole was added to that regimen.

The parotid gland is one of three major salivary glands; it has a Stensen duct, which drains saliva during mastication, above the angle of the mandible and anterior to the auricle. Infection of this gland is rare, but when it occurs, it can pose significant problems.

In the past, acute bacterial parotitis was most commonly found in hospitalized patients after a major procedure. With advances in fluid management and prophylactic antibiotics, this clinical picture has dramatically decreased. Presently, it is more common to see acute bacterial parotitis as a nosocomial infection. Risk factors for acute bacterial parotitis include dehydration, poor oral hygiene, medications that reduce the salivary flow, and an obstruction within the parotid gland (ie, calculi, stricture, mass).[1]

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