Review Question - QID 217189

This elderly patient with a history of recent surgery presenting with unilateral painful swelling of the parotid gland, expressible purulence, fever, and leukocytosis most likely has acute bacterial parotitis.

Suppurative parotitis most often occurs in elderly postoperative patients with poor fluid hydration and poor oral hygiene. Salivary stasis in these patients leads to retrograde translocation of oral flora through the parotid duct to the parotid gland. This leads to polymicrobial infection that presents as unilateral erythematous, painful swelling in the preauricular area over the parotid gland, which may extend to the angle of the mandible. Patients usually experience severe facial pain as well as trismus and dysphagia. Purulent material may be expressed from the parotid duct in over 50% of cases. Systemic symptoms may include fevers, chills, and leukocytosis. Prophylaxis includes adequate hydration and maintenance of good oral hygiene, especially in the perioperative period. Management includes adequate fluid intake, parenteral antimicrobial therapy, and surgical drainage of abscesses if present.

Brook reviewed the microbiology and management of bacterial suppurative parotitis. The author found that the most common organisms isolated are Staphylococcus aureus and anaerobes. They recommended that patients with this condition be adequately hydrated and treated with intravenous antibiotics.

Incorrect Answers:
Answer 2: Mucoepidermoid carcinoma is the most common salivary gland tumor. It presents with a focal mass or subacute, unilateral, painless swelling of the parotid gland without purulent drainage from the parotid duct. Imaging with computed tomography (CT) scans or magnetic resonance imaging (MRI) is usually necessary to make the diagnosis.

Answer 3: Mumps virus infection can cause parotitis in children. It can be distinguished from suppurative parotitis by the presence of a prodromal period, leukopenia instead of leukocytosis, and bilateral parotitis. Diagnosis is with nucleic acid or serologic testing. Purulence would be atypical for a viral infection without a superimposed bacterial cause.

Answer 4: Sialolithaisis is a noninfectious cause of parotitis that may mimic suppurative parotitis. It may present with painless or painful swelling, pain that is exacerbated by eating, and fever. The diagnosis is clinical. However, purulent drainage would not be present from the parotid duct.

Answer 5: Anterior temporomandibular joint dislocation can occur during intubation due to extreme jaw opening. This may present with pain in the preauricular area and difficulty moving the jaw. However, this would be expected to present in the immediate postoperative period, and would not be expected to cause fever or leukocytosis.

Bullet Summary:
Bacterial parotitis classically presents in elderly patients who have undergone recent surgery with unilateral painful parotitis, expressible purulence from the parotid duct, fever, and leukocytosis.