A study on the pathogenesis of recurrent parotitis in childhood

[Oral microbiological diversity in patients with salivary adenoid cystic carcinoma]

OBJECTIVE

The aim of this study was to identify the differences in microbial diversity and community in patients with salivary adenoid cystic carcinoma (SACC).

METHODS

Saliva was collected from 13 patients with SACC confirmed by histopathological diagnosis and 10 healthy control subjects. Total metagenomic DNA was extracted. The DNA amplicons of the V3-V4 hypervariable regions of the 16S rRNA gene were generated and subjected to high-throughput sequencing. Microbial diversity and community structure were analyzed with Mothur software.

RESULTS

A total of 16 genera of dominant bacteria in the SACC group were found, including Streptococcus (36.68%), Neisseria (8.55%), Prevotella_7 (7.53%), and Veillonella (6.37%), whereas 15 dominant bacteria in the control group were found, including Streptococcus (18.41%), Neisseria (18.20%), Prevotella_7 (8.89%), Porphyromonas (6.20%), Fusobacterium (5.86%) and Veillonella (5.82%). The statistically different phyla between the two groups were Firmicutes, Proteobacteria and Fusobacterium (P<0.05). The statistically different genera between the two groups were Streptococcus, Neisseria and Porphyromonas (P<0.05), and Capnocytophaga was only detected in patients with SACC.

CONCLUSIONS

Significant differences were observed in the oral microorganisms between the two groups.

Rare Parotid Gland Diseases

The differential diagnosis for "rare" parotid gland diseases is broad and encompasses infectious, neoplastic, autoimmune, metabolic, and iatrogenic etiologies. The body of knowledge of parotid gland diseases has grown owing to advances in imaging and pathologic analysis and molecular technology. This article reviews rare parotid diseases, discussing the respective disease's clinical presentation, diagnosis, imaging, pathogenesis, treatment, and prognosis.

Salivary gland diseases in children

Salivary gland diseases in children are rare, apart from viral-induced diseases. Nevertheless, it is essential for the otolaryngologist to recognize these uncommon findings in children and adolescents and to diagnose and initiate the proper treatment.

The present work provides an overview of the entire spectrum of congenital and acquired diseases of the salivary glands in childhood and adolescence. The current literature was reviewed and the results discussed and summarized.

Besides congenital diseases of the salivary glands in children, the main etiologies of viral and bacterial infections, autoimmune diseases and tumors of the salivary glands were considered. In addition to the known facts, new developments in diagnostics, imaging and therapy, including sialendoscopy in obstructive diseases and chronic recurrent juvenile sialadenitis were taken into account. In addition, systemic causes of salivary gland swelling and the treatment of sialorrhoea were discussed. Although salivary gland diseases in children are usually included in the pathology of the adult, they differ in their incidence and some­times in their symptoms. Clinical diagnostics and especially the surgical treatment are influenced by a stringent indications and a less invasive strategy. Due to the rarity of tumors of the salivary glands in children, it is recommended to treat them in a specialized center with greater surgical experience.

Altogether the knowledge of the differential diagnoses in salivary gland diseases in children is important for otolaryngologists, to indicate the proper therapeutic approach.

Treatment of chronic recurrent juvenile parotitis using sialendoscopy

CONCLUSION

The combination of sialendoscopy and an intraductal application of corticosteroids can be recommended for children with chronic recurrent juvenile parotitis (CRJP) as there is growing evidence for a positive effect in the absence of side effects.

OBJECTIVE

CRJP is a disorder with painful, episodic swelling of the parotid gland in children. The majority of cases have a self-limiting character within 5-10 years, but the disease may also continue into adulthood. CRJP can occur on one or both sides and up to now the etiology has been unclear. The aim of this study was to analyze the therapeutic effect of a sialendoscopic application of corticosteroids on the clinical course of patients with CRJP.

METHODS

We retrospectively analyzed the clinical course of 9 children with 10 parotid glands affected by CRJP, who all underwent sialendoscopy and intraductal application of corticosteroids. In all cases the procedure was conducted under general anesthesia. The average follow-up period was 15 months.

RESULTS

There were no side effects associated with the sialendoscopy. All duct systems showed signs of chronic inflammation with an atrophic or thickened epithelium. At the follow-up visit, CRJP symptoms had completely resolved in eight children. One child still showed slight parotid swellings without the need for antibiotics. None of the parents reported that symptoms had continued at an equal level or worsened after sialendoscopy.

Interventional sialendoscopy for treatment of juvenile recurrent parotitis

OBJECTIVE

To evaluate our preliminary experience with interventional sialendoscopy for the diagnosis and treatment of juvenile recurrent parotitis (JRP).

MATERIALS AND METHODS

Three consecutive pediatric patients with JRP who underwent interventional sialendoscopy were identified. Interventional sialendoscopy consisted of serial dilation of the Stenson's duct, endoscopy of the ductal system and saline irrigation followed by instillation of triamcinolone acetate. Clinical, demographic, procedure-related data and complications were documented. End points of the study were technical success, defined as completion of the procedure, subjective improvement in symptoms as indicated by the patients or their parents and assessment of safety in terms of complications.

RESULTS

Three male patients with a mean age of 9 years (range 6-11 years) underwent interventional sialendoscopy for JRP. Endoscopic findings included a blanched stenotic duct with intraductal debris in those who were symptomatic. Technical success was 100%. The mean number of episodes of JRP in the year prior to presenting to our service among the three patients was 5 (range 4-6 per year). There were no new episodes of JRP reported at the last follow-up. There were no major complications.

CONCLUSION

Our preliminary experience concurs with the current literature and suggests that interventional sialendoscopy is effective for the management of JRP and can be considered for patients who fail conservative medical management.

[Chronic recurrent parotitis]

Chronic recurrent parotitis is a non-obstructive disease with episodes of mostly painful swelling of the gland. It is categorized into a juvenile and an adult form, even without clear information on its actual origin. As to the etiology of the juvenile form, genetic factors and duct malformations as well as bacterial infections are discussed. Very rarely a complete lymphatic transformation of the gland might take place. Juvenile chronic recurrent parotitis is self-limiting in about 90% of all cases, as patients grow up. The diagnosis is based on patient history and clinical findings. Sonography is the imaging method of choice. Sialendoscopy shows a typical whitish pattern of the ducts in juvenile disease. Strictures or stenoses are typical for the adult form. The therapy of choice is gland massage and sialagogues, in addition to the administration of antibiotics. In more severe cases sialendoscopy together with rinsing of the ducts and instillation of cortisone are indicated. Total parotidectomy remains the last choice and is rarely necessary.

Recurrent parotitis of childhood

BACKGROUND

Recurrent parotitis (RP) of childhood is a rare condition of unknown aetiology, probably immunologically mediated.

OBJECTIVE

To review the clinical presentation, diagnosis and management of RP of childhood.

METHODS

Retrospective study from 1983 to 2004 of children diagnosed with RP of childhood at a tertiary children's hospital.

RESULTS

We identified 53 children, 37 (70%) male and 16 (30%) female. The age of onset was biphasic, with peaks at 2-5 years of age and at 10 years. The commonest symptoms were swelling (100%), pain (92.5%) and fever (41.5%). Symptoms usually lasted 2-7 days with a median of 3 days. The mean frequency was 8 episodes per year. The diagnosis was often delayed, >1 year in 70% of patients, maximum 8 years. The most common diagnoses, before the definitive diagnosis of RP, were mumps (21%), 'infection' (15%) and stones (11%). Sialogram (57%) and/or ultrasound (41%) showed sialectasis in 81% of patients. Over half the patients (54%) were given antibiotics at least once to treat the parotitis. Two children had hypogammablobulinaemia, one child had human immunodeficiency virus infection, and one child had Sjogren's syndrome. Two children had high titre antinuclear antibodies.

CONCLUSIONS

Recurrent parotitis had a biphasic age distribution. The major clinical features that distinguish it from other causes of parotid swelling are the lack of pus and recurrent episodes. A clinical diagnosis can often be confirmed by ultrasound. Antibiotics do not have a role in treatment. Affected children should be screened for Sjogren's syndrome and immune deficiency.

New insights into juvenile parotitis

AIM

We inquired about the possibility of a familial trend in juvenile parotitis and evaluated the role of SPINK1 mutations in juvenile parotitis.

METHODS

The clinical records of all children admitted to the Helsinki University Hospital during 1995 to May 2003 because of swelling in the parotid gland were reviewed. A questionnaire on possible recurrences and on familial cases was mailed. As disturbances in trypsin inhibition might be involved in the pathogenesis, we assessed the SPINK1 gene encoding for Kazal-type trypsin inhibitor in voluntary patients. The study group comprised 133 children (boys 82 girls 51) with juvenile parotitis. The median age at presentation of first symptoms was 6.0 y (range 1-19 y).

RESULTS

Recurrent symptoms in the parotid gland were common (57%), and 29% of the children (38/133) had suffered from four or more episodes. A young age at the first episode of symptoms increased the likelihood of recurrences (p<0.0001). Familial cases of parotid swelling were common (22%; response rate 67%). A total of 47 patients (35%) agreed to testing for SPINK1 status. Four children had a major mutation (N34S or P55S), corresponding to an 8.5% (4/47) prevalence, but this was not different from the controls (5%).

CONCLUSION

It is likely that inherited factors are involved in the manifestation of juvenile parotitis in a subset of patients. It is tempting to speculate that disturbed proteolytic balance may play a role in the development of symptoms.

Parotidite recorrente da infância: estudo em longo prazo de cinco casos e revisão da literatura

Parotidite recorrente (PR) é definida como inflamação recorrente em glândula parótida, geralmente associada à sialectasia não-obstrutiva. A PR em crianças é uma condição bem descrita, porém rara e com causa ainda incerta. OBJETIVO: Este estudo tem o propósito de: 1) descrever a evolução de cinco casos de PR com acompanhamento em longo prazo; 2) examinar os achados ultra-sonográficos e sialográficos nestes pacientes; e 3) realizar uma revisão de literatura sobre o tema. FORMA DE ESTUDO: estudo de série. MATERIAL E MÉTODO: Revisaram-se os prontuários, sialografias e ultra-sonografias das crianças atendidas na Divisão de Clínica Otorrinolaringológica do Hospital das Clínicas da F.M.U.S.P. que se apresentaram com achados clínicos típicos de PR, com pelo menos 2 anos de evolução da doença e mais de 1,5 ano de acompanhamento, totalizando cinco casos. Essas crianças foram submetidas à sialografia de glândula parótida dos lados acometidos e ultra-sonografia bilateral no início do acompanhamento, além de ultra-sonografia anual. Os pacientes com parotidite recorrente demonstraram uma preponderância do sexo masculino e uma idade de aparecimento predominantemente entre três e seis anos. A freqüência das crises mostrou uma tendência à diminuição com o tempo. A sialografia mostrou alterações compatíveis com sialectasias em todos os casos e a ultra-sonografia, alterações na textura geralmente com áreas hipoecóicas. A ultra-sonografia do paciente acompanhado por tempo mais prolongado evoluiu para um padrão normal acompanhando o quadro clínico, o que pode sugerir que este exame traz uma vantagem no acompanhamento da atividade da doença.

Virology of infantile chronic recurrent parotitis in Santiago de Chile

Infantile chronic recurrent parotitis (ICRP) has been attributed to multiple causes, including viral infections, and therefore its treatment remains empirical. Our aim was to evaluate the involvement of respiratory and oropharyngeal viruses in acute episodes of ICRP. Seventy children were studied, 50 patients and 20 age-matched controls, in a 2-year follow-up study. Saliva samples were taken from the parotid duct and analyzed by viral isolation and immunofluorescence for adenovirus (Ad), respiratory sincitial virus (RSV), parainfluenza virus (PI), influenza virus (Flu), Cytomegalovirus (CMV), and herpes simplex virus (HSV). Paired sera samples were tested by ELISA for anti-Epstein-Barr virus (EBV) IgG and anti-mumps IgM and IgG. Viral infections were detected in 7/50 (14%) cases of the ICRP group: one CMV; 2 Enteroviruses isolated in human embryonic lung fibroblast cells; 1 Flu A; and 3 mumps virus. No EBV seroconversions were detected. In the control group, 2 out of the 20 children had an asymptomatic mumps positive IgM titer. Our data indicate that the main respiratory and oropharyngeal viruses are not the cause of acute episodes of ICRP in Chilean children.

Possibility of sialographic sonography: a Doppler phantom study

OBJECTIVES

The purpose of this study was to develop a new diagnostic method that has the merits of both sialography and sonography.

STUDY DESIGN

Saline solution and various contrast media (Urografin 76%; 100%, 90%, and 67% Lipiodol Ultra-Fluide; 5% and 1% barium sulfate; and Levovist) were injected into thin tubes at a rate of approximately 0.001 to 0.1 mL/s. The relationship between the Doppler signal intensity and the kind, concentration, and velocity of the fluid was analyzed.

RESULTS

Levovist, 90% and 67% Lipiodol Ultra-Fluide, and the barium sulfate solutions produced Doppler signals. The mixture of Lipiodol Ultra-Fluide and saline solution produced high signals at any concentration, in contrast with the barium sulfate solutions. Signals could be observed at any speed, from the speed of normal sialography down to 0.001 mL/s, and there was a proportional relationship between signal intensity and velocity for all fluids producing signals.

CONCLUSION

The fact that we could obtain high signals with several fluids indicates potential clinical diagnostic usefulness of sialographic sonography.

MRI of chronic recurrent parotitis in childhood

PURPOSE

Chronic recurrent parotitis (CRP) is a rare inflammatory disease characterized by multiple episodes of unilateral or bilateral parotid inflammation over a period of years. The objective of this study was to evaluate the parotid glands using MRI during acute inflammation as well as during symptom-free intervals.

METHOD

Twelve children with a history of CRP were included. Four patients were examined during the acute phase and eight children during symptom-free intervals. MR findings were correlated with the clinical status.

RESULTS

Two different patterns were identified by MRI: acute inflammation versus chronic inflammation. Contrast enhancement of the parotid gland indicated acute inflammation. Cysts due to chronic inflammation were encountered in children who suffered multiple episodes of inflammation.

CONCLUSION

Our findings suggest that CRP is characterized by recurrent, acute exacerbations of inflammation, resulting in a slowly progressive destruction of the parotid gland.

Sonographic analysis of recurrent parotitis in children: a comparative study with sialographic findings

OBJECTIVE

The sonographic features of recurrent parotitis in children were studied to clarify a relationship between sonographic and sialographic findings in this disease.

STUDY DESIGN

Twenty-one glands (7 on follow-up) were examined by 7.5 MHz ultrasonography and sialography. Echo intensity level, distribution of the internal echoes, and size of hypoechoic areas were compared with the size of punctate shadows on the sialograms. Twenty other histopathologic specimens were analyzed to investigate the entity of hypoechoic areas.

RESULTS

Sonography showed hypoechoic, heterogeneous internal echoes, the level of which increased as the punctate shadows enlarged. Hypoechoic areas, all of which were larger than the sialographic punctate shadows, were observed in 62% of the glands. Histopathologic analysis suggests that these hypoechoic areas represent dilated peripheral ducts with lymphocytic infiltration. Sonography was likely to detect changes over time more sensitively than sialography.

CONCLUSIONS

Sonography should be performed as the test of first choice, both in the primary and follow-up stages, in cases of recurrent parotitis in children.

Recurrent parotitis

(1) Recurrent parotitis is probably caused by a congenital abnormality of the salivary gland ducts with recurrent attacks of ascending infection, perhaps aided by dehydration. The parotid gland is predominantly affected probably because of its lower rate of secretion compared with the submandibular gland. (2) The condition mainly affects children between the ages of 3 and 6, with males being more commonly affected. The symptoms peak in the first year of school, and usually, but not invariably, begin to subside at puberty. By the age of 22, most patients are completely symptom-free. When the disease starts after puberty, females are predominantly affected. (3) Ultrasound is the appropriate initial investigation, and is usually supplemented by sialography. The sialography may itself cause a resolution of symptoms. (4) Treatment is conservative in the first instance, and an expectant policy is indicated. More aggressive treatment is justified only for those adults with persistent problems. This may be parotid duct ligation, parotidectomy, or tympanic neurectomy, depending upon the preference and experience of the treating physician.

Microbiology of recurrent parotitis

BACKGROUND

Infantile chronic recurrent parotitis (ICRP) is characterized by episodes of recurrent swelling of the parotid gland with decreased salivary flow and purulent secretion. The etiology of this little unknown clinical condition has been attributed to multiple causes such as canalicular system malformations, ascending bacterial infection, hyposialia, parotitis sequelae, viral infections and immunologic disorders, among others.

METHODS

We studied the types (with counts) of microorganisms involved in ICRP. Saliva samples were obtained from 56 patients and 20 controls, inoculated onto enriched media and incubated under aerobic and anaerobic conditions. Antimicrobial susceptibility and serotyping of the isolated organisms isolated were performed.

RESULTS

Of 57 saliva samples from ICRP patients, 52 (91%) were culture-positive. The most frequently isolated microorganisms were Streptococcus pneumoniae and Haemophilus influenzae. Thirteen of twenty (65%) samples were also culture-positive, mostly for viridans streptococci. However, colony counts were lower than in clinical samples (P < 0.004). Approximately one-third of S. pneumoniae strains resistant or moderately resistant to penicillin, and all H. influenzae strains were susceptible to all of the antimicrobials tested.

CONCLUSIONS

S. pneumoniae or H. influenzae were isolated in high concentrations in IRCP cases but not in controls, suggesting that these microorganisms may have a role in the development of this clinical entity. Quantitative cultures are very important in assessment of the pathogenic role of these microorganisms in patients but not in controls.

Recurrent swelling of parotid glands and Sjögren's syndrome

This study included 125 patients with chronic parotitis, and it presents in particular, a long-term clinical, laboratory, and sialographic study of 22 patients who were diagnosed as having adult recurrent sialadenitis of the parotid glands (ARSPG). Twelve of the 22 patients with ARSPG were shown to have Sjögren's syndrome (SS). These patients had recurrent parotid gland swelling for 1.5-14 years (mean, 5.2 years) before xerostomia and keratoconjunctivitis sicca occurred. Ten of the 22 patients with ARSPG did not develop SS, but did experience recurrent parotitis which extended from childhood into adulthood. The ARSPG underwent remission in seven of these patients. It is suggested that patients with ARSPG, but without a history of parotid gland swellings in childhood, should be diagnosed provisionally as having subclinical SS (SCSS).

Reactive follicular hyperplasia of intraparotid lymphoid tissue presenting as a recurrent parotid enlargement

A patient who had reactive lymphoid hyperplasia of intraparotid lymphoid tissue, clinically presenting as a recurrent parotitis, is described. The case offers a new etiologic mechanism for recurrent parotitis.

Sequential quantitative scintigraphy of parotid glands with chronic inflammatory diseases

A practical, time-saving procedure for sequential quantitative scintigraphy is introduced and 4 parameters chosen from 12 parameters by discriminant analysis are used to evaluate the function of the parotid gland. The examination was performed in 120 cases, including 16 cases with recurrent parotitis in childhood, 33 with chronic obstructive parotitis (COP), 37 with Sjögren's syndrome (SS), 4 with sialadenosis, and 30 normal controls. The scintigraphic findings were analyzed and compared with the histologic findings. The diagnostic value of this method was investigated and scaling for differential diagnosis of COP and SS was established. Scintigraphy is considered to be a useful method for evaluation of parotid function and as a diagnostic aid for SS and COP, especially in patients in whom sialography cannot be performed.

Viruses and salivary gland disease: are there associations?

Viruses can cause sialadenitis and may be associated with other diseases of salivary glands, particularly immunologically mediated and neoplastic lesions. The evidence that such an association with Sjögren's syndrome is causal is reviewed here and shown to be fairly tenuous at present.

Follow-up study of recurrent parotitis in children

Recurrent parotitis in children is a well-described but rare condition of unknown cause. In this follow-up investigation the long-term course of the disease was studied both clinically and radiographically. In 23 of 25 patients investigated, the clinical symptoms disappeared before the patients were 22 years of age, independent of a given therapy. However, sialographic changes, mostly in the form of sialectasis, were seen on follow-up in the majority of cases, in spite of the fact that the patients were clinically symptom free.

The pathogenesis of chronic recurrent parotitis in infants: a study of 93 cases including an analysis of the vascular and glandular changes before and after parasympathectomy

Ninety-three cases of infantile chronic recurrent parotitis are recorded. Fifty-three cases were treated with parasympathectomy which was carried out at 2 levels. Good results were achieved in 79.1% of patients. The paper describes the use of the Doppler examination to study the effects of operation on the physiology of the parotid.

Infantile recurrent sialectatic parotitis: the role of sonography and sialography in diagnosis and follow-up

The results of a clinical, sonographic and sialographic study in 10 children (aged 4-10 years) with recurrent sialectatic parotitis are presented. Alteration in the sonographic pattern of the parotid glands, consisting of multiple hypoechogenic areas in the parenchyma, were found in four cases; milder nonhomogeneity was seen in four cases, and an almost normal pattern in two cases. Sonographic follow-up in two children showed a parallel reduction in non-homogeneity with symptomatic improvement. A probable therapeutic action following sialography using fat-soluble contrast medium was observed in four of the 10 children. The familial nature of the disease, which has not previously been described, is documented.

Salivary gland disease in children: a review. Part 1: Acquired non-neoplastic disease

The early recognition of salivary gland disease depends upon a high index of suspicion by the clinician. A systematic approach to salivary gland disease in children is presented by a group of algorithms, which is supplemented by a discussion of the historical, physical, and diagnostic test findings characteristic of salivary gland pathology. Therapeutic alternatives are discussed for both neoplastic and non-neoplastic disorders.

Juvenile recurrent parotitis: clinicoradiologic follow-up study and the beneficial effect of sialography

In twenty-two children juvenile recurrent parotitis (JRP) was diagnosed on the basis of age at onset, duration of parotid swelling episodes, frequency of attacks, lack of pus formation, and typical sialograms. Age at onset and severity of the disease varied widely. There was a high incidence of upper respiratory tract infection, and in some cases a familial history of JRP was noted. The sialograms revealed acinar and ductal atrophy and severe sialectasis. A dominant feature was impaired glandular function. The follow-up period was notable for a striking decrease in the number of incidents of glandular swelling regardless of the patient's age at the time of his or her first visit to our clinic. Since drug treatment was administered prior to our first examination and no medicaments were prescribed by us, the improvement in the clinical status of the patients is attributed to the sialographic procedures.

Spontaneous regeneration of the parotid salivary gland following juvenile recurrent parotitis

Sialograms of an 18-year-old female patient known to suffer from juvenile recurrent parotitis (JRP) disclosed the destructive glandular changes typical of the disease. During the 10 years subsequent to the sialographic examination, the patient did not experience any further attacks of JRP. Sialograms carried out when the patient was 28 years of age demonstrated a normal gland. This case illustrates that a damaged parotid gland is capable of regeneration following JRP.