Kembara Xtra - Medicine - Acute and Chronic Parotitis

Kembara Xtra - Medicine - Acute and Chronic Parotitis 
The inflammation of the parotid gland brought on by an infection, a systemic disease, a physical obstruction, or medicine is known as parotitis.
● The largest salivary gland, the parotid gland, is situated behind the angle of the jaw, lateral and anterior to the masseter muscle. It extends posteriorly over the sternocleidomastoid muscle. The parotid duct, also known as the Stensen duct, enters the buccal mucosa opposite the second maxillary molar. The branches of the facial nerve divide the gland into lobes. It produces serous secretions that lack bacteriostatic properties, making it more susceptible to infection than other salivary glands.

Epidemiology 

The most frequent cause of parotitis in children is viral, though prevalence has declined with the development of the measles vaccination.
Although it is less frequent, acute bacterial parotitis happens more frequently in older individuals, newborns, and postoperative patients.
The second most frequent inflammatory cause of parotitis in children in the United States is juvenile recurrent parotitis (JRP); the first episode often happens between the ages of 3 and 6 years.
Adults are most commonly affected by chronic parotitis, which typically manifests between the ages of 40 and 60. Chronic bilateral parotid enlargement is a typical HIV infection symptom.

Pathophysiology and Etiology 
Acute viral parotitis starts as a systemic infection that concentrates in the parotid gland and causes swelling and inflammation.
- The paramyxovirus known as the mumps prefers to infect the parotid gland and is traditionally associated with parotitis 16 to 18 days after infection. National reporting requirements apply to the measles.
- Other viral infections include influenza A, coxsackievirus, enterovirus, echovirus, parainfluenza, epstein-barr virus (EBV), and human herpesvirus 6 (HHV-6). - Adenovirus and cytomegalovirus (CMV) have been detected in HIV patients.
- Case studies show that parotitis is a possible symptom of SARS-CoV-2 infection.
Acute bacterial parotitis is caused by a standstill in salivary flow, which allows germs to enter the gland retrogradely and cause localized infection.
- Staphylococcus aureus, Streptococcus pneumoniae, and anaerobes are the most prevalent pathogens. Streptococcus viridans, Escherichia coli, and Haemophilus influenzae are less frequent.
- Patients who are chronically unwell or who are in hospitals may have Klebsiella, Enterobacter, or Pseudomonas.
- Think about Bartonella henselae exposure from cats.
- Could be a sign of group B late-onset syndrome.
(Rare) Streptococcus
- Immunocompromised patients have been found to have Mycobacterium tuberculosis.
Candida has been isolated in people who are chronically unwell or hospitalized.
Acute, recurring parotitis - Mechanical: Repeated sialolith production causes ductal wall damage, fibrosis, and stricture formation in patients with a history of trauma or dental caries. Air becomes trapped in the parotid gland ducts, causing pneumoparotitis, which can occasionally develop during dental cleanings, in glassblowers, scuba divers, and those who play wind instruments. "Anesthesia mumps": this condition may be brought on by temporary mechanical compression of the Stensen duct by breathing devices, loss of muscle tone around the Stensen orifice following the use of neuromuscular relaxants, increased salivary production, or increased head flexion or rotation when under general anesthesia. HIV individuals who experience chronic parotitis may have benign lymphoepithelial cysts, follicular hyperplasia of the parotid lymph nodes, or diffuse infiltrative lymphocytosis syndrome, which results in CD8 cell infiltration of the parotid gland. After starting antiretroviral medication, immunological reconstitution may be a secondary cause of parotitis. Acute parotitis has been described in case reports as a Kawasaki illness symptom.
Immunosuppression, HIV, chemotherapy, radiation, malnutrition, and drunkenness are risk factors.
Inability to receive the MMR vaccine causes acute viral parotitis. Dehydration, disability, poor oral hygiene, Sjögren syndrome, cystic fibrosis, bulimia/anorexia, sialolithiasis (stones), ductal stenosis, and trauma cause acute bacterial parotitis. Prematurity, dehydration, low birth weight, ductal blockage, oral trauma, and anatomical anomalies are all associated with neonatal parotitis. JRP includes dental malocclusion, congenital duct malformation, immunologic anomalies, and disrupted enzyme activity. Drug-induced parotitis includes anticholinergics, ACE inhibitors (captopril), antihistamines, tricyclic antidepressants, antipsychotics (phenylbutazone, thioridazine, clozapine), iodine (contrast media), and Lasparaginase. Chronic paro

Basic Prevention 
Completing the MMR vaccine series; vaccination during childhood does not guarantee prevention, probably because immunity deteriorates with time.
- Two doses of the MMR vaccination, spaced by 28 days, should be given to people without proof of prior immunity to the mumps.
- The mumps vaccine shouldn't be given to pregnant women.
After receiving the vaccine, pregnancy should be avoided for four weeks.
Maintain appropriate hydration, proper oral hygiene, stop smoking, refrain from drinking alcohol, and refrain from frequent purging.


Associated Conditions Sialolithiasis, sarcoidosis, sjögren syndrome, HIV, mumps, and syphilis


Acute parotitis is diagnosed by the abrupt development of discomfort and swelling in the cheek.
- Bilateral viral parotitis is frequently associated by fever, malaise, anorexia, headaches, myalgias, and arthralgias.
- Fever is a symptom of bacterial parotitis.
JRP typically affects one side, and the pain and swelling go away after 2 weeks.
Other signs and symptoms include trismus, pain made worse by chewing or by meals that make you salivate more, a dry mouth with an off flavor, trouble drinking or eating, anorexia, or dehydration. Sialolithiasis is characterized by frequent episodes of acute swelling and pain that are made worse by food. Chronic parotitis manifests as recurring or chronic nontender swelling of one or both parotid glands, and may be accompanied by swelling around the Stensen duct.

clinical assessment 
Parotid gland swelling or hypertrophy, which can make the ear protrude upward and outward or hide the mandibular angle.
Palpate the mandibular ramus anteriorly and inferiorly along with one hand while using the other to feel the Stensen duct inside the mouth cavity starting at the attachment of the earlobe. In contrast to unilateral discomfort, erythema, and warmth, bilateral tenderness suggests a viral origin.
- Typically, chronic parotitis is not painful.
Dental decay, halitosis, and trismus could be present.
Drainage from the Stensen duct may be a sign of superinfection or bacterial parotitis. In cases of bacterial and viral infection, the opening of the duct may appear edematous and erythematous.
In JRP, the Stensen duct is frequently enlarged, dilated, erythematous, and swollen; in severe cases, facial nerve palsy may be present.

Multiple Diagnoses 

Cellulitis, Ludwig angina, lymphoma, neoplasm, lymphangitis, cervical adenitis, otitis externa, odontogenic infections, and 

Laboratory Results 
The history and examination are enough to make a diagnosis.
Perform aerobic culture of purulent drainage from Stensen duct or aerobic and anaerobic culture of gland or abscess needle aspiration. Perform anaerobic cultures exclusively from fluid obtained by needle aspiration since those obtained from the Stensen duct are likely to include oropharyngeal contamination.
Leukocytosis and increased amylase levels have been linked to acute bacterial parotitis.
● The CDC advises taking a buccal swab for mumps RT-PCR if symptoms first appear within three days. Get a serum sample for IgM testing together with a buccal swab if the symptoms have been present for more than three days.
- The parotid gland should be massaged for 30 seconds prior to performing a buccal swab to collect the best mumps RT-PCR results. IgM may be mistakenly negative in places with high vaccination rates, necessitating a connection with clinical symptoms.
- Consider repeating serum testing if initial IgM and RT-PCR results obtained within three days of the onset of symptoms are negative and there is a high clinical suspicion of the mumps, as the IgM response could not be visible until five days following the onset of symptoms.
Send CMV titers for patients with immune system weakened.
 To determine the underlying cause of chronic, recurrent, or non-tender parotitis, get tested for HIV, PPD, SS-A/SS-B antibodies, rheumatoid factor, and antinuclear antibodies.
Imaging may be performed to check for abscesses, tumors, ductal stenosis, or sialolithiasis during the initial tests (lab).
Ultrasound has a good sensitivity for detecting abscess and ductal lithiasis and is the first line of diagnostic testing for sialadenitis (1)[B]. You could also use a CT or MRI.
Tests in the Future & Special Considerations
In order to evaluate the morphology and functional integrity of the gland (diagnostic and therapeutic) in chronic parotitis, consider sialography (1)[C].
Other/Diagnostic Procedures
If there is a possibility of sarcoidosis, Sjögren syndrome, or tuberculosis, think about having a biopsy or fine-needle aspiration.
Sarcoidosis may result in noncaseating granulomas.
Infections with B. henselae and TB can both cause caseating granulomas.

Usually a self-contained course, management. Supportive care should be used, including rest, water, analgesia, and antipyretics.
- Consume hard candies to increase salivation.
- Applying localized heat and using light massage.
Patients with mumps should be isolated with conventional and droplet precautions for 5 days following the development of parotid enlargement. - Chronic parotitis: Encourage good dental hygiene and address the underlying etiology.
The CDC advises administering the MMR vaccine during a mumps outbreak, even in those who have received all three doses; this is especially important for those whose second MMR was given more than 13 years earlier.


Medication 

No evidence supports the use of immunoglobulin for postexposure prophylaxis or treatment of viral parotitis; antibiotics may be started if the patient exhibits toxic symptoms. Acute bacterial parotitis: amoxicillin/clavulanate or ciprofloxacin and clindamycin for outpatients; ampicillin/sulbactam or cefuroxime and metronidazole for chronic illness or hospitalization; if MRSA is likely, try vancomycin or linezolid.
Sjögren syndrome recurrent parotitis: Pilocarpine and cevimeline can increase salivation, stop an infection from rising, and relieve symptoms.
An alternative treatment option for these people is the injection of the botulinum toxin, which reduces salivation and sialectasis.


Referral 
Consult an otolaryngologist if you have sialolithiasis, ductal stenosis, chronic blockage from Sjögren syndrome, or more than one recurrence annually because these conditions may necessitate sialendoscopy, duct ligation, ductoplasty, or parotidectomy (4)[B].
If a parotid lump is discovered, cancer is suspected, or if antibiotics don't help, consult an otolaryngologist.

Surgical Techniques 
Consider needle aspiration if you have bacterial parotitis with an abscess or if your condition worsens and your pain, erythema, and swelling don't go away after taking your medicine.
If a patient has severe recurring parotitis with an underlying cause that predisposes them to recurrence, consider superficial parotidectomy.
Sialendoscopy with steroid irrigation is safe and successful for treating JRP, however US is advised first to distinguish JRP from ductal stones.
Sclerotherapy with methyl violet or tetracycline is regarded a conclusive treatment for chronic parotitis and is successful in treating cysts in HIV parotitis.


Admission

Accept patients with concomitant conditions, systemic involvement, an inability to take PO, newborns, or patients for whom it is not practical to maintain close outpatient follow-up.

Take Action 

Improvement from antibiotic treatment for bacterial parotitis should be shown within 48 hours when accompanied with appropriate hydration; otherwise, the patient should undergo another evaluation.

Diet 
Make sure to drink enough water, and use hard or sour candy to encourage salivation.

The prognosis for viral infection in immunocompetent people is typically very good.
Parotid cysts in HIV-positive people are mostly benign lymphoepithelial lesions that sporadically convert into cancer.
Patients with Sjögren syndrome have a higher incidence of malignant lymphoma or lymphoepithelial carcinoma.

Complications 
Orchitis, oophoritis, mastitis, aseptic meningitis, encephalitis, pancreatitis, myocarditis, sensorineural hearing loss, and nephritis are a few possible mumps complications.
Bacterial parotitis can cause facial paralysis and the creation of abscesses if left untreated.
Chronic autoimmune parotitis can lead to neoplasm, while chronic inflammatory parotitis can cause facial nerve paralysis.

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