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Parotitis is an
inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...
of one or both
parotid gland The parotid gland is a major salivary gland in many animals. In humans, the two parotid glands are present on either side of the mouth and in front of both ears. They are the largest of the salivary glands. Each parotid is wrapped around the ma ...
s, the major
salivary gland The salivary glands in mammals are exocrine glands that produce saliva through a system of ducts. Humans have three paired major salivary glands ( parotid, submandibular, and sublingual), as well as hundreds of minor salivary glands. Salivary ...
s located on either side of the face, in humans. The parotid gland is the salivary gland most commonly affected by inflammation.


Etymology

From Greek παρωτῖτις (νόσος), parōtĩtis (nósos) : (disease of the) parotid gland < παρωτίς (stem παρωτιδ-) : (gland) behind the ear < παρά - pará : behind, and οὖς - ous (stem ὠτ-, ōt-) : ear.


Causes


Dehydration

''Dehydration:'' This is a common, non-infectious cause of parotitis. It may occur in elderly or after surgery.


Infectious parotitis

''Acute bacterial parotitis:'' is most often caused by a bacterial infection of Staphylococcus aureus but may be caused by any
commensal Commensalism is a long-term biological interaction (symbiosis) in which members of one species gain benefits while those of the other species neither benefit nor are harmed. This is in contrast with mutualism, in which both organisms benefit fro ...
bacteria.
Templer JW, MD, Professor of Otolaryngology, University of Missouri Medical Center at Columbia. Parotitis: Overview, Accessed 03/04/2009
Parotitis presents as swelling at the angle of the jaw. Bacterial parotitis presents as a unilateral swelling, where the gland is swollen and tender and usually produces pus at the Stensen's duct. This pus is usually sampled and the bacteria within are identified. Common causative bacteria are Staphylococcus aureus, Streptococcus pyogenes and Escherichia coli, E coli. It is associated with poor oral hygiene; oral infections and decreased saliva production. Symptoms include fever, dehydration, chills, fast heartbeat and breathing if the infection is causing
sepsis Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
. Medications such as
antihistamine Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provid ...
s and
diuretic A diuretic () is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics i ...
s can be predisposing factors. Treatment is usually antibiotics. ''Parotitis as extrapulmonary tuberculosis:'' The mycobacterium that cause
tuberculosis Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, i ...
can also cause parotid infection. Parotid swelling can be an uncommon symptom of extrapulmonary tuberculosis (TB outside of the lungs). The usual symptoms are a cough, fever, weight loss, shortness of breath, chest pain, tiredness and chills. This is caused by the bacteria Mycobacterium tuberculosis. TB can also affect the heart, thyroid and adrenal glands but the main site of infection is the lungs. Risk factors are chronic alcohol consumption,
diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
, long term steroid use, HIV infection and kidney failure. Those infected tend to have enlarged, nontender, but moderately painful glands. The diagnosis is made by typical chest radiograph findings, cultures, or histologic diagnosis after the gland has been removed. When diagnosed and treated with antitubercular medications, the gland may return to normal in 1–3 months. ''Acute viral parotitis (mumps):'' The most common viral cause of parotitis is mumps. Routine
vaccinations Vaccination is the administration of a vaccine to help the immune system develop immunity from a disease. Vaccines contain a microorganism or virus in a weakened, live or killed state, or proteins or toxins from the organism. In stimulating ...
have dropped the incidence of mumps to a very low level. Mumps resolves on its own in about ten days. A viral infection caused by Paramyxovirus, a single-stranded RNA virus. Common symptoms include fever, headache and bilateral or unilateral parotitis (swelling of the parotid gland on one or both sides of the face). The parotid gland is usually swollen and tender. Parotid swelling usually occurs 16–18 days after exposure to the virus. Treatment includes isolation and therefore prevention of spread of the disease and supportive measures such as hot or cold packs. Mumps usually resolves itself and can be prevented by vaccination. ''HIV parotitis:'' Generalized lymphadenopathy has long been associated with
HIV The human immunodeficiency viruses (HIV) are two species of ''Lentivirus'' (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the immune ...
, but the localized enlargement of the parotid gland is less well known. HIV-associated salivary gland disease can involve many diseases but often presents as enlargement of the parotid gland and a
dry mouth Xerostomia, also known as dry mouth, is dryness in the mouth, which may be associated with a change in the composition of saliva, or reduced salivary flow, or have no identifiable cause. This symptom is very common and is often seen as a side eff ...
. Causes have not been specifically identified but the most likely are viral opportunists and autoimmune responses. Viruses linked to this can include; hepatitis C, cytomegalovirus, paramyxovirus,
influenza A '' A virus'' (''IAV'') causes influenza in birds and some mammals, and is the only species of the genus ''Alphainfluenzavirus'' of the virus family ''Orthomyxoviridae''. Strains of all subtypes of influenza A virus have been isolated from wild ...
, and adenovirus. Treatment is
anti-retroviral therapy The management of HIV/AIDS normally includes the use of multiple antiretroviral drugs as a strategy to control HIV infection. There are several classes of antiretroviral agents that act on different stages of the HIV life-cycle. The use of multiple ...
. ''Disseminated histoplasmosis:'' During a large urban disseminated
histoplasmosis Histoplasmosis is a fungal infection caused by '' Histoplasma capsulatum''. Symptoms of this infection vary greatly, but the disease affects primarily the lungs. Occasionally, other organs are affected; called disseminated histoplasmosis, it can ...
outbreak (est. 100,000 victims) in Indianapolis from 1978 to 1979, manifestations included parotitis.


Autoimmune causes

These are also collectively known as chronic punctate parotitis or chronic autoimmune parotitis. ''Sjögren's syndrome:'' Chronic inflammation of the salivary glands may also be an autoimmune disease known as Sjögren's syndrome. The disease most commonly appears in people aged 40–60 years, but it may affect small children. In Sjögren syndrome, the prevalence of parotitis in women versus men is approximately 9:1. The involved parotid gland is enlarged and tender at times. The cause is unknown. The syndrome is often characterized by excessive dryness in the eyes, mouth, nose, vagina, and skin. ''Lymphoepithelial lesion of Godwin:'' Most frequently associated with a circumscribed tumor with the histologic features of Sjögren syndrome. This designation has also fallen out of favour.


Blockage

Blockage of the main parotid duct, or one of its branches, is often a primary cause of acute parotitis, with further inflammation secondary to
bacteria Bacteria (; singular: bacterium) are ubiquitous, mostly free-living organisms often consisting of one Cell (biology), biological cell. They constitute a large domain (biology), domain of prokaryotic microorganisms. Typically a few micrometr ...
l
superinfection A superinfection is a second infection superimposed on an earlier one, especially by a different microbial agent of exogenous or endogenous origin, that is resistant to the treatment being used against the first infection. Examples of this in bact ...
. The blockage may be from a salivary stone, a
mucous Mucus ( ) is a slippery aqueous secretion produced by, and covering, mucous membranes. It is typically produced from cells found in mucous glands, although it may also originate from mixed glands, which contain both serous and mucous cells. It is ...
plug, or, more rarely, by a tumor, usually benign. Salivary stones (also called
sialolithiasis Sialolithiasis (also termed salivary calculi, or salivary stones) is a crystallopathy where a calcified mass or ''sialolith'' forms within a salivary gland, usually in the duct of the submandibular gland (also termed "Wharton's duct"). Less common ...
, or salivary duct calculus) are mainly made of
calcium Calcium is a chemical element with the symbol Ca and atomic number 20. As an alkaline earth metal, calcium is a reactive metal that forms a dark oxide-nitride layer when exposed to air. Its physical and chemical properties are most similar t ...
, but do not indicate any kind of calcium disorder.Salivary Gland Stones (Salivary Calculi)
Accessed March 20, 2008.
Other causes can be duct stricture (narrowing of the duct), infection or injury. Symptoms may include recurrent swelling, pain and aggravation during eating as this is when saliva production is stimulated. Ductal obstruction may cause less saliva flow, which can result in recurrent gland infections. Stones may be diagnosed via
X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10  picometers to 10  nanometers, corresponding to frequencies in the range 30&nb ...
(with a success rate of about 80%), a computed tomography (CT) scan or medical ultrasonography. Stones may be removed by manipulation in the doctor's office, or, in the worst cases, by surgery.
Lithotripsy Lithotripsy is a non-invasive procedure involving the physical destruction of hardened masses like kidney stones, bezoars or gallstones. The term is derived from the Greek words meaning "breaking (or pulverizing) stones" ( litho- + τρίψω r ...
, also known as "shock wave" treatment, is best known for its use breaking up
kidney stone Kidney stone disease, also known as nephrolithiasis or urolithiasis, is a crystallopathy where a solid piece of material (kidney stone) develops in the urinary tract. Kidney stones typically form in the kidney and leave the body in the urine s ...
s. Lithotripsy can now be used on salivary stones as well. Ultrasound waves break up the stones, and the fragments flush out of the salivary duct.


Diseases of uncertain cause

''Chronic nonspecific parotitis:'' This term is generally used for patients in whom no definite cause is found. Episodes may last for several days, paralleling the time course of a bacterial or viral illness. Others may experience episodes that last only a few hours from onset to resolution. Some episodes may last for several weeks. Quiescent periods between episodes last for hours, days, or even years. ''Recurrent parotitis of childhood:'' The disease is also knows as juvenile recurrent parotitis (JRP). An uncommon syndrome in which recurring episodes clinically resembling mumps. Generally, episodes begin by age 5 years, and the frequency of the episodes generally ceases after the puberty. The duration of attacks averages 3–7 days but may last 2–3 weeks in some individuals. The spectrum varies from mild and infrequent attacks to episodes so frequent that they prevent regular school attendance. Treatment of individual infections may prevent injury to the gland parenchyma. In the past, the disease was treated with aggressive surgical interventions such as Stensen’s duct ligation, superficial or total parotidectomy, and tympanic neurectomy. Nowadays, the disease is managed with sialendoscopic procedure. The sialendoscopy as a relatively safe and minimally invasive technique with a significant impact on the reduction of acute relapse episodes, has immense diagnostic and therapeutic potential in management of juvenile recurrent parotitis. ''Sialadenosis (sialosis):'' In this disorder, both parotid glands may be diffusely enlarged with only modest symptoms. Patients are aged 20–60 years at onset, and the sexes are equally involved. The glands are soft and non-tender. Approximately half of the patients have endocrine disorders such as diabetes, nutritional disorders such as pellagra or kwashiorkor, or have taken drugs such as guanethidine, thioridazine, or isoprenaline. ''
Sarcoidosis Sarcoidosis (also known as ''Besnier-Boeck-Schaumann disease'') is a disease involving abnormal collections of inflammatory cells that form lumps known as granulomata. The disease usually begins in the lungs, skin, or lymph nodes. Less commonly a ...
:'' The lungs, skin, and lymph nodes are most often affected, but the salivary glands are involved in approximately 10% of cases. Bilateral firm, smooth, and non-tender parotid enlargement is classic.
Xerostomia Xerostomia, also known as dry mouth, is dryness in the mouth, which may be associated with a change in the composition of saliva, or reduced salivary flow, or have no identifiable cause. This symptom is very common and is often seen as a side eff ...
occasionally occurs. The Heerfordt-Waldenstrom syndrome consists of
sarcoidosis Sarcoidosis (also known as ''Besnier-Boeck-Schaumann disease'') is a disease involving abnormal collections of inflammatory cells that form lumps known as granulomata. The disease usually begins in the lungs, skin, or lymph nodes. Less commonly a ...
with parotid enlargement, fever, anterior uveitis, and facial nerve palsy. ''IgG4-related sialadenitis'': This term refers to
IgG4-related disease IgG4-related disease (IgG4-RD), formerly known as IgG4-related systemic disease, is a chronic inflammatory condition characterized by tissue infiltration with lymphocytes and IgG4-secreting plasma cells, various degrees of fibrosis (scarring) and ...
(IgG4-RD) involving any of the major salivary glands, i.e. parotid or submandibular glands. This is often symmetrical and is usually associated with manifestations of IgG4-RD elsewhere in the body. IgG4-related sialadenitis is particularly associated with involvement of one or both of the lacrimal glands (referred to as IgG4-related dacryo-sialadenitis). '' Mikulicz's disease'', now considered to be a subtype of IgG4-related disease, was a term used when (i) any two of the parotid, submandibular and lacrimal glands were persistently and symmetrically enlarged and (ii) other diseases that may mimic this presentation were excluded. '' Pneumoparotitis:'' Air within the ducts of the parotid gland with or without inflammation. The duct orifice normally functions as a valve to prevent air from entering the gland from a pressurized oral cavity. Rarely, an incompetent valve allows insufflation of air into the duct system. Pneumoparotitis most commonly occurs in wind instrument players, glass blowers, and scuba divers. Several lymph nodes reside within the parotid gland as a superficial and deep group of nodes. These nodes may be involved with any process that affects lymph nodes, including bacterial, fungal, viral, and neoplastic processes. Rarely, drugs such as
iodide An iodide ion is the ion I−. Compounds with iodine in formal oxidation state −1 are called iodides. In everyday life, iodide is most commonly encountered as a component of iodized salt, which many governments mandate. Worldwide, iodine de ...
s,
phenylbutazone Phenylbutazone, often referred to as "bute", is a nonsteroidal anti-inflammatory drug (NSAID) for the short-term treatment of pain and fever in animals. In the United States and United Kingdom, it is no longer approved for human use (except in th ...
, thiouracil, isoproterenol, heavy metals, sulfisoxazole, and phenothiazines cause parotid swelling. ''Associated with
Bulimia Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eaten ...
:'' Parotid gland swelling is a common feature of self-induced vomiting. This swelling usually develops 3–4 days after the stopping of chronic excessive self-induced vomiting. The swelling is bilateral, with little tenderness. Causes are not well understood. Ideal treatment should be preventative and can involve medication that increases saliva production (sialagogues), anti-inflammatory medication and the application of hot packs. Occasionally
pilocarpine Pilocarpine is a medication used to reduce pressure inside the eye and treat dry mouth. As eye drops it is used to manage angle closure glaucoma until surgery can be performed, ocular hypertension, primary open angle glaucoma, and to bring abo ...
can be used to help resolve the swelling.


Masseteric hypertrophy

Masseteric
hypertrophy Hypertrophy is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It is distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number.Updated by Linda J. ...
(enlargement of the
masseter muscle In human anatomy, the masseter is one of the muscles of mastication. Found only in mammals, it is particularly powerful in herbivores to facilitate chewing of plant matter. The most obvious muscle of mastication is the masseter muscle, since it ...
's volume) can present as facial swelling in the parotid gland area and may be confused with 'true' parotid gland swelling. The specific cause of masseteric hypertrophy is still unclear, but it may be related to tooth grinding or malocclusion. Treatment options can include surgical removal of some of the muscle and botulinum toxin type A injections.


Diagnosis

Serum and urinary amylase rise during the first week of parotitis.


Treatment

Treatment is based on lab investigation report.


Notes


References

* Brook I. Acute bacterial suppurative parotitis: microbiology and management. ournal ArticleJournal of Craniofacial Surgery. 14(1):37–40, 2003. * Mandel L. Surattanont F. Bilateral parotid swelling: a review. eview 60 refs ournal Article. ReviewOral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics. 93(3):221–37, 2002.


External links


eMedicine
{{Oral pathology Salivary gland pathology IgG4-related disease Inflammations Gross pathology