Partial facial paralysis induced by sialolithiasis of the parotid gland: a case report

BACKGROUND

Facial paralysis due to parotid sialolithiasis-induced parotitis is a unusual clinical phenomenon that has not been reported in prior literature. This scenario can present a diagnostic challenge due to its rarity and complex symptomatology, particularly if a patient has other potential contributing factors such as facial trauma or bilateral forehead botox injections as in this patient. This case report elucidates such a complex presentation, aiming to increase awareness and promote timely recognition among clinicians.

CASE PRESENTATION

A 56-year-old male, with a medical history significant for hyperlipidemia, recurrent parotitis secondary to parotid sialolithiasis, and recent bilateral forehead cosmetic Botox injections presented to the emergency department with right lower facial drooping. This onset was about an hour after waking up and was of 4 h duration. The patient also had a history of a recent ground level fall four days prior that resulted in facial trauma to his right eyebrow without any evident neurological deficits in the region of the injury. A thorough neurological exam revealed sensory and motor deficits across the entirety of the right face, indicating a potential lesion affecting the buccal and marginal mandibular branches of the facial nerve (CN VII). Several differential diagnoses were considered for the lower motor neuron lesion, including soft tissue trauma or swelling from the recent fall, compression due to the known parotid stone, stroke, and complex migraines. An MRI of the brain was conducted to rule out a stroke, with no significant findings. A subsequent CT scan of the neck revealed an obstructed and dilated right Stensen's duct with a noticeably larger and anteriorly displaced sialolith and evidence of parotid gland inflammation. A final diagnosis of facial palsy due to parotitis secondary to sialolithiasis was made. The patient was discharged and later scheduled for a procedure to remove the sialolith which resolved his facial paralysis.

CONCLUSIONS

This case emphasizes the need for a comprehensive approach to the differential diagnosis in presentations of facial palsy. It underscores the potential involvement of parotid sialolithiasis, particularly in patients with a history of recurrent parotitis or facial trauma. Prompt recognition of such uncommon presentations can prevent undue interventions, aid in timely appropriate management, and significantly contribute to the patient's recovery and prevention of long-term complications.

MR sialographic assessment of the masseter muscle and the ductal kinking in patients with recurrent parotitis

Dysfunction of the masseter muscle may cause pathological kinking of the parotid duct leading to parotitis; MR sialography is a non-invasive radiological examination that allows to evaluate dynamically the ductal system of the parotid glands. In the present study we aimed to assess the relationships between Stensen's duct and masseter muscle and their implications in the aetiopathogenesis of recurrent parotitis secondary to masseter muscle dysfunction. Forty-one patients with recurrent unilateral parotitis and nine with bilateral recurrent parotitis, all with a clinical suspicious of masseter muscle hypertrophy due to bruxism were enrolled. They underwent ultrasonography as a first line examination and then MR sialography and sialendoscopy. Different anatomical features were studied. Involved parotid glands had a wider duct compared to contralateral unaffected parotid glands of patients with recurrent parotitis (p = 0.00134); male subjects with parotitis had a longer duct compared to the salivary glands of healthy patients (p = 0.00943 for affected glands and p = 0.00629 for the contralateral). A concordance between the evidence of an acute duct angle during sialendoscopy and a wider duct in patients with parotitis was observed although not statistically significant. These initial findings suggest that the masticatory muscle dysfunction related to bruxism seems to condition alteration of parotid duct course and anatomy thus favouring the occurrence of recurrent parotitis. A specific diagnostic iter based on clinical evaluation, dynamic ultrasonography and MR sialography, is therefore, mandatory to confirm the relationship between masseter muscle anatomy and parotid duct anomalies; this is the premise for an adequate therapeutic approach to underlying masticatory muscle disorder.

Juvenile idiopathic recurrent parotitis (JIRP) treated with short course steroids, a case series study and one decade follow up for potential autoimmune disorder

BACKGROUND

Juvenile idiopathic recurrent parotitis (JIRP) in children is a condition characterized with recurrent episodes of idiopathic parotid gland inflammation. Since there are no definitive guidelines for diagnosis and management of this condition, we present a consecutive case series of patients with more than one decade follow up and their dramatic response to short course treatment by prednisolone.

METHODS

We conducted this study by retrospectively reviewed medical charts of children who were diagnosed with JIRP, from 1 January 2002 to 29 February 2023. We performed usual serological tests to exclude some possible background. We administered short course prednisolone on first day of episode as divided dosage (0.5 mg /kg).

RESULTS

In this case series of 10 patients (70%) were male, median age of onset was 5 years, duration of episodes 5 days, and the mean course of disease were 3.8 years. The average follows up of patients was near 10 years. In comparison with their natural course of disease all patients showed a dramatic response to treatment on the first day of administration of prednisolone (P Value 0.005). For ten years follow up there was not any additional accompanying autoimmune disorder.

CONCLUSION

Short course prednisolone on first day of each episode and its dramatic and meaningful response in our patients, introduce a new, effective, fast, and inexpensive regimen of therapy in patients with JIRP.

Viral detection from negative mumps cases with respiratory symptoms in Gwangju, South Korea in 2021

Mumps is the second-most reported infectious disease in South Korea; however, due to the low pathogen confirmation rate in laboratory diagnoses, we proposed a method for reevaluating the high incidence rate via the laboratory verification of other viral diseases. In 2021, 63 cases of pharyngeal or cheek mucosal swabs of suspected mumps cases in Gwangju, South Korea, were assessed for causative pathogens using massive simultaneous pathogen testing. More than one respiratory virus was detected in 60 cases (95.2%), 44 (73.3%) of which were co-detected. Human rhinovirus was detected in 47 cases, followed by human herpesvirus (HHV)6 in 30; HHV4 (17), human bocavirus (17), HHV5 (10), and human parainfluenza virus 3 (6) were also detected. Our findings suggest the need for further investigations on the pathogenesis of diseases mimicking mumps, which are considered to aid with appropriate public health responses, treatment, and the prevention of infectious disease outbreaks. This article is protected by copyright. All rights reserved.

Pediatric rheumatologists' perspectives on diagnosis, treatment, and outcomes of Sjögren disease in children and adolescents

BACKGROUND

Sjögren disease in children and adolescents (pedSD) presents differently than adult disease. Diagnosis and classification are controversial, optimal treatment is unknown and outcomes are poorly understood. Here, we describe the current perspectives of pediatric rheumatologists on diagnosis, treatment, and outcomes of pedSD.

METHODS

A voluntary, 17-question survey was distributed to providers in the Childhood Arthritis and Rheumatology Research Alliance and/or the American College of Rheumatology Childhood Sjögren's Study Group at the 2020 Convergence Virtual Conference. Findings are reported using descriptive statistics and chi-square testing.

RESULTS

Of 465 eligible providers, 157 (34%) responded with 135 (29%) completing the survey. The majority (85%) saw five or fewer patients with pedSD in the past year. Parotitis, dry eye and/or dry mouth, and constitutional symptoms were among the most specific and common clinical features. Most providers (77%) used clinical judgment guided by adult criteria for diagnosis. The vast majority (86-99%) of survey participants indicated routine use of serologic testing, while salivary gland ultrasound, minor salivary gland biopsy and other diagnostic tests were less often used. The most commonly prescribed systemic immunomodulators were hydroxychloroquine, corticosteroids, methotrexate, rituximab, and mycophenolate. Seven providers reported malignancy in a patient with pedSD, including one death.

CONCLUSIONS

Pediatric rheumatologists diagnose and treat pedSD; however, most only see a few patients per year and rely on clinical judgment and laboratory testing for diagnosis. Treatment frequently includes systemic immunomodulators and malignancies are reported. More studies are needed to better understand natural history, risk factors, and the impact of interventions on outcomes.

Recurrent or persistent salivary gland enlargement in children: When is it Sjögren's?

OBJECTIVES

To describe characteristic features in children with recurrent or persistent salivary gland enlargement and to propose a diagnostic algorithm with specific consideration for Sjögren's disease (SD).

METHODS

In this single-center, prospective study, 45 patients < 18 years, with recurrent or persistent salivary gland enlargement of unknown etiology were enrolled from 2006 to 2019. We collected detailed clinical information to characterize this group of patients including specific details of their major salivary gland signs and symptoms. We compared clinical, laboratory and radiological parameters between 4 groups based on the results of labial salivary gland biopsy (LSGB) and between patients who met existing SD criteria or not.

RESULTS

44 patients, with a mean age of 6.8 years and female to male ratio 21:23 were observed over a mean of 3.8 years. Characteristics of salivary gland swelling episodes varied considerably between individuals, but the majority experienced ≤5 episodes per year, lasting ≤ 1 week, with swelling affecting either or both glands. Ocular and oral dryness symptoms were observed only in 25% and 59% patients, respectively. The majority were positive for ANA, but negative for SD-specific antibodies. A total of 75% patients fulfilled at least one of the existing SD criteria.

CONCLUSION

SD is a major cause of recurrent salivary gland enlargement in children. For children meeting adult criteria, the diagnosis of SD is clear. However, for the many children without dryness symptoms, objective dryness, or SD-specific antibodies, further workup including a combination of salivary gland imaging and histopathological examination can help establish the diagnosis of SD.

Unique Aspects of Pediatric Sjögren Disease

Sjögren disease increasingly is recognized in pediatric patients. Clinical features, primarily parotitis and sicca symptoms, and results of diagnostic tests may be different from those in adult disease. Adult criteria fail to capture most pediatric patients. Pediatric-specific criteria are urgently needed to define the natural history of the disease, identify risk and prognostic factors, and evaluate the impact of therapeutics and other interventions on disease course in young patients.

Role of ranulas in early diagnosis of Sjögren’s syndrome: A case report

BACKGROUND

Although the presentations of Sjögren’s syndrome (SS) are variable, ranging from mild dryness to wider systemic involvement, ranulas as early clinical signs were scarcely reported. Here, we present an adult patient with SS, who developed a unilateral simple ranula and was diagnosed primary SS 3 years later. We also provide a review of cases of SS and ranulas from 1980 to 2020.

CASE SUMMARY

A 22-year-old girl was found to have a left painless floor-of-mouth lesion 3 years ago, without obvious trauma or inducement. The diagnosis of a unilateral (left) simple ranula was made, and the ranula was surgically treated. Within 3 years after the ranula surgery, she developed acute lymphadenectasis in unilateral parotid twice without inducement, and ultrasonic examination revealed diffuse lesions in bilateral parotids and submandibular glands, which strongly suggested SS. Serologic tests and the unstimulated whole saliva flow rate confirmed the SS diagnosis.

CONCLUSION

Our study underlines that ranulas are early clinical signs of SS. As early diagnosis and early intervention of SS are important to obtain better outcomes, our findings underline the need for histopathological test after sublingual adenectomy and imaging detection of exocrine glands for the patients with ranulas.

COVID-19 associated parotitis

While Coronavirus 2019 (COVID-19) typically presents with respiratory tract symptoms, atypical manifestations have been reported. We present a case of a 46-year-old man who presented with fever but no respiratory tract symptoms, and later develops bilateral parotitis. We review the literature for all other reported cases of parotitis and describe common features of these cases. It is important to consider COVID-19 in cases of parotitis, as this impacts patient management and ensures important infection control measures are undertaken.

Clinical characteristics that predict parotid abscess: An observational cohort study

Background

We analysed clinical factors that are predictive of a diagnosis of parotid abscess among patients with bacterial parotitis.

Material and methods

This retrospective study included 64 hospitalised patients who were diagnosed with parotid abscess, or bacterial parotitis. Data on patient demographics, clinical characteristics, and clinical management were collected. Predictive factors for parotid abscess were evaluated using univariate and multivariate analysis.

Results

There were 25 patients with parotid abscess and 39 with bacterial parotitis. All patients presented with moderate-to-severe disease, required parenteral antibiotics, or had indicators for surgical drainage. Patient profiles and immune status were not significantly associated with parotid abscess. However, parameters that were significantly related to parotid abscess were subacute presentation (approximate 10.4 days) (p value = 0.016), fluctuation (p value < 0.001), and normal (haemoglobin) Hb level >12–13 g/dL (p value = 0.035). Imaging indicated the abscess location, extension and evaluated the complications. Surgical drainage with small skin incision and antibiotic coverage for possible pathogens, in particular Staphylococcus spp. and Streptococcus spp. produced favourable patient outcomes. Complication was identified in 3 cases with included septicaemia and cellulitis of the face and parapharyngeal space.

Conclusions

Among bacterial parotitis patients, parotid abscess should be considered in whom presented with subacute duration of symptoms, enlarged glands with fluctuation, and non-anaemic problem. Instead of standard skin incision of parotidectomy, small vertical skin incision over a well localised abscess pocket or fluctuated area achieved the good results.

•

Parotid abscess should be considered in subacute duration of parotid enlargement.

•

There was no related host immunity with parotid abscess formation.

•

Favourable treatment outcome achieved from adequate drainage and proper antibiotics.

•

Small vertical skin incision provided good results and no re-form an abscess.

Juvenile recurrent parotitis: Review and proposed management algorithm

INTRODUCTION

Despite being the second most common salivary disease in childhood, the aetiology and appropriate management of juvenile recurrent parotitis (JRP) remains uncertain. Consequently patients may be misdiagnosed, or even undergo indeterminate or potentially invasive procedures without benefit. This article reviews the current understanding of the epidemiology and pathophysiology of JRP, and to appraise the management options available.

METHODS AND RESULTS

Medline and Google Scholar databases were searched and peer reviewed journal articles assessed. The epidemiology of JRP remains uncertain, and the clinical presentation of JRP can vary widely in frequency and severity. Diagnosis is still largely based on clinical signs and symptoms including parotid swelling, pain and fever. Investigation typically focuses on the exclusion of other diseases and immunodeficiencies, however there are noted typical radiological findings on both ultrasound and magnetic resonance imaging. The ideal management of this condition still remains unclear, however symptoms typically resolve by puberty. Treatment focuses on minimally invasive procedures such as sialography and sialendoscopy to reduce the frequency and severity of acute episodes.

CONCLUSIONS

Acute episodes of JRP can occur up to 30 times per year and have a significant impact on the quality of life of an affected child. Consequently a management algorithm is proposed based on the exclusion of other pathology. There is increasing evidence for non-ablative, minimally invasive approaches such as sialography and sialendoscopy to reduce the impact of this disease.

Parotitis caused by Mycobacteroides abscessus subspecies abscessus

Rapidly growing mycobacteria rarely causes parotitis. We report a rare case of Mycobacteroides abscessus subspecies abscessus (MAB) parotitis in a previously healthy 26-year-old woman. She presented to the previous hospital with a swelling over the right parotid region, and a computed tomography scan revealed multiple abscesses in the swollen parotid gland. Histopathology showed granulomatous inflammation with acid-fast bacilli; however, a subsequent culture failed to isolate mycobacterium. Despite repeated antibiotic therapy and multiple surgical interventions including partial incision and drainage of the abscesses, the parotitis did not resolved. At six months after presentation, she was referred to our institute. We performed enlarged resection of the necrotic tissue and abscesses, and the sample cultivated after homogenization was positive for mycobacterium. The isolate was finally identified as MAB. She underwent long-term postoperative antibiotic therapy for MAB, with a favorable outcome. To the best of our knowledge, this is the first case of MAB parotitis where the subspecies has been identified. MAB is much more intractable than the other subspecies. We highlight the importance of the correct identification of MAB, which leads to the appropriate treatment.

Botulinum Toxin Injection for Chronic Parotitis: A Multi-Center and Prospective Trial

OBJECTIVE

When conservative therapy fails for chronic parotitis, sialendoscopic treatment or surgical excision can be considered. However, these are financially costly or invasive. Thus, this study aimed to evaluate the clinical efficacy and safety of botulinum toxin (BTX) injection and to further analyze its effect on parotid gland function and volume using salivary single-photon emission computed tomography (SPECT)-computed tomography (CT).

METHODS

This clinical trial has been registered in the Clinical Research Information Service, Republic of Korea. Fourteen patients with chronic parotitis received BTX injections into the parotid glands. Pain, postprandial pain, swelling, aesthetic discomfort, and salivary flow rate were assessed before injection, at 2 weeks, and at 1, 3, and 6 months. Salivary SPECT-CT was performed before injection and again 3 and 6 months after to assess the volume and uptake changes.

RESULTS

All subjective symptoms decreased significantly until 1 month and then increased. However, at 6 months, all subjective symptoms were determined to be better than before injection. The unstimulated and stimulated salivary flow rate did not show a significant difference over time. No significant difference was noted in parotid gland volume or uptake on salivary SPECT-CT over time.

CONCLUSION

BTX injection can be an alternative treatment option for chronic parotitis.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1903-E1909, 2021.

COVID-19 associated parotitis

As the 2019 coronavirus pandemic has unfolded, an increasing number of atypical presentations of COVID-19 have been reported. As patients with COVID-19 often present to emergency departments for initial care, it is important that emergency clinicians are familiar with these atypical presentations in order to prevent disease transmission. We present a case of a 21-year-old woman diagnosed in our ED with COVID-19 associated parotitis and review the epidemiology and management of parotitis. We discuss the importance of considering COVID-19 in the differential of parotitis and other viral-associated syndromes and emphasize the importance of donning personal protective equipment during the initial evaluation.

Sjögren's syndrome in children with recurrent parotitis

OBJECTIVE

Optimize the diagnosis of pediatric Sjögren's syndrome in children who present with parotitis.

METHODS

Twenty children presented to a pediatric otolaryngology or rheumatology clinic with recurrent parotitis. Presenting symptoms, serologies, sialendoscopy findings, and minor salivary gland biopsy pathology results were reviewed.

RESULTS

Twenty patients aged 3-17 years presented with recurrent parotitis. Ten percent of this cohort met the American-European Consensus Group adult diagnostic criteria for Sjögren's syndrome. Forty percent of this cohort met diagnosis of Sjögren's syndrome when utilizing Bartunkova's proposed pediatric criteria for diagnosis of Sjögren's syndrome.

CONCLUSION

Sjögren's syndrome is surprisingly common in pediatric patients who present with recurrent parotitis. Otolaryngologists who treat pediatric parotitis should have a high index of suspicion for Sjögren's syndrome.

LEVEL OF EVIDENCE

4.

Influenza-Related Parotitis during a Large Mumps Outbreak - Arkansas, 2016-2017

During August 2016-July 2017, Arkansas experienced a large mumps (parotitis) outbreak; however, mumps-negative cases of parotitis were also identified in this period. Nineteen of 215 samples (9%) randomly selected for influenza PCR testing were positive for influenza A virus. Practitioners should consider influenza as a cause of nonmumps parotitis.

Retrograde parotidectomy under local anesthesia for benign, malignant, and inflammatory lesions

OBJECTIVE

To report the patient selection, surgical technique, and outcomes of parotidectomy using local anesthesia under monitored anesthesia care (MAC).

METHODS

A retrospective chart review was performed for patients undergoing parotidectomy under local anesthesia at an academic head and neck surgery center.

RESULTS

Six patients deemed high risk for general anesthesia (GA) due to medical comorbidities or with a strong preference to avoid GA underwent parotidectomy using local anesthesia and MAC. Parotidectomy was performed for several indications, including benign tumors, malignant tumors, and chronic sialadenitis. Mean age of patients was 78.0 ± 7.9 years, and all had an American Society of Anesthesia score ≥ 2 and Charlson comorbidity index ≥4. Mean operative time was 102.8 ± 38.3 min, comparable to that of parotidectomy under general anesthesia. No major complications occurred. Minor complications included three cases of temporary postoperative facial nerve weakness limited to 1-2 lower division branches. At most recent follow up (10 to 48 months), all patients were medically stable and disease free.

CONCLUSION

In carefully selected patients, parotidectomy under local anesthesia is a viable treatment alternative that can be offered to patients. Successful outcomes require preoperative counseling, meticulous technique, and close collaboration with anesthesia colleagues.

Mumps outbreak with high complication rates among residents in a university teaching hospital

According to the US Advisory Committee on Immunization Practices recommendations, only health care personnel (HCP) with adequate evidence of immunity should be exposed to patients with a suspected diagnosis of mumps. Here we report a hospital-outbreak scenario among medical residents with no previous vaccination record against mumps who had a high rate of complications. We also describe the importance and impact of full and proper vaccination, as well as isolation, of HCP in stopping the outbreak and, finally, review opportunities for improving the safety of HCP.

Imaging of Inflammatory Disorders of Salivary Glands

Sialadenitis is among the most common conditions that affect the salivary glands. Inflammation of the salivary glands occurs as the end result of a variety of pathologic conditions, including infectious, autoimmune, and idiopathic causes. Clinically, inflammation of the salivary gland causes pain and localized swelling. The presentation may be acute or chronic, and can be recurrent. Because there is significant overlap of underlying disease mechanisms and clinical presentations, radiologic evaluation often plays a significant role in evaluation. This article is a brief review of sialadenitis, including disease mechanisms, causes, and the practical imaging of the salivary glands.

Clinical presentation and treatment of melioidosis in the head and neck region

BACKGROUND

Although melioidosis in the head and neck region is uncommon, it is a potentially life-threatening infection. Thus, early diagnosis and proper management are very important.

OBJECTIVES

To report the clinical presentation and management of melioidosis in the head and neck.

METHOD

A retrospective study was conducted from 1 January 2013 to 31 October 2016 in Mukdahan Hospital, Thailand. Case records of patients who had presented with culture-positive melioidosis were analysed.

RESULTS

Medical records of 49 patients (23 males and 26 females) were analysed. Patients ranged in age from 1 to 75 years. Clinical presentations included 22 parotid abscesses, 16 neck abscesses and 11 suppurative lymphadenitis cases. Only 35 patients (71 per cent) had high indirect haemagglutination assay titres of ≥ 1:160 (95 per cent confidence interval = 45.35-88.28). Almost half of the patients received intravenous ceftazidime and subsequently oral co-trimoxazole. Oral antibiotic regimens were prescribed for mild localised melioidosis. Overall, 95.65 per cent of patients were in remission and no relapses were observed (95 per cent confidence interval = 85.47-98.80).

CONCLUSION

Careful clinical correlation and proper investigation are required to establish an early diagnosis of melioidosis and to initiate appropriate treatment.

Mycobacterium mageritense Parotitis in an Immunocompetent Adult

Mycobacterium mageritense, a rapidly growing mycobacterium, is a rare clinical pathogen. Furthermore, parotitis due to non-tuberculosis mycobacterium is very rare in adults. Herein, we report the first case of M. mageritense parotitis in an immunocompetent adult. A 40-year-old man presented with swelling in a left parotid lesion. He was diagnosed with parotitis. The culture from the parotid abscess grew M. mageritense. He was unsuccessfully treated with levofloxacin monotherapy. Trimethoprim-sulfamethoxazole was added, leading to some clinical response; however, the erythema persisted despite 14 months of antibiotic therapy. Subsequently, the skin lesion was surgically removed. The antibiotic treatment was ceased a week after surgery as the postoperative course was uneventful and the lesion had improved. No recurrence was noted at 7 months after surgery. Although extremely rare, M. mageritense can cause parotitis in immunocompetent adults, and may not be sufficiently treated with antibiotics alone.

Sialendoscopic Approach in Management of Juvenile Recurrent Parotitis

To assess the role of sialendoscopy as a diagnostic and therapeutic modality in juvenile recurrent parotitis. Juvenile recurrent parotitis (JRP) is the second most frequent salivary gland disease in childhood and is characterized by recurrent non suppurative and non obstructive parotid inflammation. These attacks influence the quality of life and can even lead to gland destruction, and there are no definitive treatment to avoid them. Sialendoscopic dilatation is emerging as the new treatment modality in this aspect.

STUDY DESIGN

 retrospective study.

STUDY SETTING

Department of Otorhinolaryngology in tertiary care hospital. 17 cases of juvenile recurrent parotitis (i.e. children of age group 3-11 years presenting with complaints of recurrent parotid region swelling and pain, sometimes associated with fever) were included in the study during October 2012-September 2015. All cases underwent sialendoscopy under general anaesthesia. Diagnostic (classifying the ductal lesion) and interventional sialendoscopic procedure (dilatation with instillation of steroid) were carried out in single sitting. Follow up was done for a minimum of 6 months (range 6-36 months). 17 patients with mean age of 5.6 years and gender distribution of 47:53 (boys:girls) underwent sialendoscopy for JRP. 8 patients presented with unilateral parotitis and 9 with bilateral. The mean number of attacks in previous 1 year were 9.2. Average time for procedure was 20 min. All cases had ductal stenosis and ductal mucosa was pale in 15 cases on endoscopy. 1 patient underwent repeat endoscopy after 2 years. 50% had complete resolution of symptoms and 6 patients had one mild (swelling not associated with fever which subsided on its own) attack after treatment. Follow up period ranged from 6 months to 3 years. No complications were observed. Sialendoscopy has emerged as a viable option for assessment and treatment of JRP. Dilatation of the parotid duct and steroid instillation has significantly reduced the morbidity of this condition.

Emergent lineages of mumps virus suggest the need for a polyvalent vaccine

Mumps outbreaks among vaccinated patients have become increasingly common in recent years. While there are multiple conditions driving this re-emergence, convention has suggested that these outbreaks are associated with waning immunity rather than vaccine escape. Molecular evidence from both the ongoing American and Dutch outbreaks in conjunction with recent structural biology studies challenge this convention, and suggest that emergent lineages of mumps virus exhibit key differences in antigenic epitopes from the vaccine strain employed: Jeryl-Lynn 5. The American and Dutch 2016-2017 outbreak lineages were examined using computational biology through the lens of diversity in immunogenic epitopes. Findings are discussed and the laboratory evidence indicating neutralization of heterologous mumps strains by serum from vaccinated individuals is reviewed. Taken together, it is concluded that the number of heterologous epitopes occurring in mumps virus in conjunction with waning immunity is facilitating small outbreaks in vaccinated patients, and that consideration of a polyvalent mumps vaccine is warranted.

Pediatric primary Sjögren syndrome presenting with bilateral ranulas: A case report and systematic review of the literature

CONTEXT

Primary Sjögren syndrome is uncommon in children, and the standard clinical criteria used in diagnosis of adult Sjögren syndrome will miss many children with the disease. Floor of mouth ranulas have not been described in Sjögren syndrome.

OBJECTIVE

This study aims to describe a novel presentation of juvenile primary Sjögren syndrome, and to present a comprehensive systematic review of the literature regarding the presentation and diagnosis of Sjögren syndrome in children.

DATA SOURCES

Ovid MEDLINE.

STUDY SELECTION

A MEDLINE literature search was performed using the following search terms: primary, Sjögren, disease, and children. Results were limited to human subjects and articles written in English between 1981 and 2014. Applicable articles were reviewed and qualitatively summarized.

DATA EXTRACTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRIMA).

RESULTS

Initial MEDLINE search yielded 146 articles, 80 of which were excluded as not clinically pertaining to Sjögren syndrome. An additional 25 were excluded due to lack of pediatric-specific data. Systematic review of the literature revealed no reports of ranula in association with Sjögren syndrome. 6 papers were manually included from review of reference lists of included articles. Our review indicated that recurrent parotitis is the most commonly reported presenting symptom in children, followed by ocular and oral symptoms, musculoskeletal, and renal symptoms. Compared to adults, children are less likely to present with dry eyes and mouth.

LIMITATIONS

All studies were retrospective chart reviews, case series or case reports.

CONCLUSION

This is the first report of a child presenting with floor of mouth ranulas in association with Sjögren syndrome. While recurrent parotitis is the most common presentation in children, other salivary gland and extra-salivary manifestations may be seen, and the clinician must maintain a high index of suspicion for underlying Sjögren syndrome.

Development of acute parotitis after non-invasive ventilation

A 90-year-old woman underwent laparoscopic exploratory laparotomy for evaluation of suspected mesenteric ischemia. She was promptly extubated postoperatively and transferred to the intensive care unit, where on the first postoperative day she developed hypoxemia necessitating initiation of noninvasive ventilation (NIV) with bilevel positive airway pressure (BiPAP). After 8 hours of BiPAP, she was noted to have swelling, erythema and tenderness in the right preauricular area. Ultrasound evaluation demonstrated an enlarged right parotid gland. With discontinuation of BiPAP and supportive measures, parotitis resolved within 6 days. The mechanism of NIV-induced acute parotitis likely involves transmission of positive pressure to the oral cavity, causing obstruction to salivary flow within the parotid (Stensen) duct. Conditions that increase salivary viscosity and promote salivary stasis, such as advanced age, dehydration, and absence of salivary gland stimulation due to restriction of oral intake, may render patients more susceptible to this complication. As NIV will continue to be a commonly-used modality for the treatment of acute respiratory failure, clinicians should be aware of this phenomenon.

Core curriculum illustration: pediatric viral parotitis

This is the 36th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Melioidosis parotitis in children

A recent paper published in JVATiTD reporting a child in Hainan with parotitis caused by Burkholderia pseudomallei misleadingly described parotitis as a rare manifestation of melioidosis. In fact, it is one of the commonest forms of paediatric melioidosis seen in other parts of Southeast Asia, although interestingly not in Australia.

Pediatric suppurative parotitis caused by Burkholderia pseudomallei

BACKGROUND

Suppurative parotitis caused by Burkholderia pseudomallei has been rarely found outside endemic areas.

CASE PRESENTATION

Herein, we report the recovery of Burkholderia pseudomallei from the pus of a suppurative parotitis observed in a 12-year-old boy who lived in Hainan province, China. Specimens of necrotic tissue were collected and sections were stained with hematoxylin and eosin. Pus sample was also collected for bacteriological examination. The suppurative inflammation was observed in the necrotic tissue section and Burkholderia pseudomallei were detected in the sample.

CONCLUSION

In this adolescent, Burkholderia pseudomallei infection was present in the parotid, which consists of the first report of this bacterium in a parotitis case acquired in China.

Complete genome sequence of mumps viruses isolated from patients with parotitis, pancreatitis and encephalitis in India

Limited information is available regarding epidemiology of mumps in India. Mumps vaccine is not included in the Universal Immunization Program of India. The complete genome sequences of Indian mumps virus (MuV) isolates are not available, hence this study was performed. Five isolates from bilateral parotitis and pancreatitis patients from Maharashtra, a MuV isolate from unilateral parotitis patient from Tamil Nadu, and a MuV isolate from encephalitis patient from Uttar Pradesh were genotyped by the standard protocol of the World Health Organization and subsequently complete genomes were sequenced. Indian MuV genomes were compared with published MuV genomes, including reference genotypes and eight vaccine strains for the genetic differences. The SH gene analysis revealed that five MuV isolates belonged to genotype C and two belonged to genotype G strains. The percent nucleotide divergence (PND) was 1.1% amongst five MuV genotype C strains and 2.2% amongst two MuV genotype G strains. A comparison with widely used mumps Jeryl Lynn vaccine strain revealed that Indian mumps isolates had 54, 54, 53, 49, 49, 38, and 49 amino acid substitutions in Chennai-2012, Kushinagar-2013, Pune-2008, Osmanabad-2012a, Osmanabad-2012b, Pune-1986 and Pune-2012, respectively. This study reports the complete genome sequences of Indian MuV strains obtained in years 1986, 2008, 2012 and 2013 that may be useful for further studies in India and globally.

Decreased salivary matrix metalloproteinase-8 reflecting a defensive potential in juvenile parotitis

OBJECTIVE

Matrix metalloproteinases MMP-2 and MMP-9 have been associated with juvenile parotitis. However, the role of MMP-8 has not been addressed previously. This work focuses on salivary MMP-8 and -9 levels in juvenile parotitis.

METHODS

During a five-year period at Helsinki University Hospital, a tertiary care hospital, 41 patients aged 17 or under, were identified as having parotitis; from 36 of these patients, saliva samples were collected for MMP-8 IFMA (time-resolved immunofluorometric assay) analyses. Control saliva samples were collected from 34 age- and gender-matched children admitted for an elective surgery who had no history of parotitis. For comparison, salivary levels of MMP-9, tissue inhibitor of matrix metalloproteinase (TIMP-1), MMP-8/TIMP-1 ratio, human neutrophil elastase (HNE), and myeloperoxidase (MPO) were analyzed by ELISA. Additionally, salivary MMP-8 levels were compared to historical saliva samples from 18 adult gingivitis patients as well as to 10 healthy adult controls.

RESULTS

The median (25%, 75% percentile) MMP-8 concentration in saliva of parotitis patients was significantly lower than MMP-8 concentration in saliva of their controls [50.4ng/ml (37.5, 72.9) vs. 148.5ng/ml (101.2, 178.5) p<0.0001] and lower than in patients with gingivitis [347.9ng/ml (242.6, 383.2) p<0.0001] or healthy adult controls [257.2ng/ml (164.9, 320.7) p<0.0001]. The MMP-8/TIMP-1 ratio was lower than in controls [0.13 (0.05-0.02) vs. 0.3 (0.17-0.46) p<0.0001]. The median MMP-9 concentration in saliva of parotitis patients was significantly higher than in controls [143.9ng/m (68.8-189.0) vs. 34.9ng/ml (16.3-87.6) p<0.0001]. Neither HNE, MPO, nor TIMP-1 alone separated the patients from the control groups.

CONCLUSIONS

MMP-9 was up-regulated in juvenile parotitis saliva, suggesting that MMP-9 may play a destructive role in juvenile parotitis, as others have suggested. The present novel findings reveal a decreased salivary MMP-8 concentration, suggesting that MMP-8 may reflect in juvenile parotitis down-regulated or anti-inflammatory immune characteristics.

Parotid abscess in children - A tertiary rural hospital experience

Parotid abscess is a rare complication of acute parotitis in children. Acute parotitis occurs due to infection of intra-parotid or para-parotid lymph nodes or glandular parenchyma of the parotid gland which may progress to parotid abscess.

OBJECTIVES

To document the causative organism, clinical behaviour and response to treatment in paediatric parotid abscess.

MATERIALS AND METHODS

A retrospective study was done in our tertiary rural hospital from May 2007 to May 2015 to identify and analyse paediatric parotid abscess in 80 unilateral parotitis cases.

RESULTS

7 cases of parotid abscess were identified. 4 cases were diagnosed clinically and in 3 cases ultrasound was done showing heterogenous, hyperechoic, solid and cystic areas. In 2 patients, abscess was extending to the submandibular space. Incision and drainage was done in all patients. The most common bacteria was Methicillin Sensitive Staphylococcus aureus. Escherichia coli was reported in one patient, and was rare in parotid region. 2 patients had House Brackmann grade 2 marginal mandibular nerve palsy, and they recovered within 4½ months.

CONCLUSION

Parotid abscess is an uncommon but life-threatening condition in paediatric age group. Poor orodental hygiene was most important predisposing factor. Abscess can be diagnosed clinically and ultrasound scan is also an important diagnostic tool. It is commonly caused by Gram positive cocci and responds well to incision and drainage followed by appropriate antibiotics. No fistula may result if treated early.

Acute unilateral anesthesia mumps after hysteroscopic surgery under general anesthesia: a case report

Acute unilateral parotid gland swelling after general anesthesia, anesthesia mumps is rare and when occurred, it is associated with the patient's position and with long-lasting surgery. The exact mechanism or etiology has not been fully established but stasis of gland secretion, blockage of Stensen's duct by direct compression, or retrograde flow of air by increased the oral cavity pressure are suspicious reasons. We experienced a case of soft tissue swelling in the left preauricular and submandibular regions in a 40-year-old female patient after short-lasting, hysteroscopic myomectomy performed in the lithotomy position with no suspicious predisposing factor. It is required to pay attention on the fact that even with the usual face mask ventilation can lead to the development of anesthesia mumps.

Suppurative parotitis in a girl: a case report from ahvaz, iran

INTRODUCTION

Neonatal parotitis is a rare disease. Neonatal suppurative parotitis commonly presents with facial swelling, irritability, tenderness of parotid region, and with or without fever. Acute neonatal suppurative parotitis is one of the differential diagnoses of facial swelling with a prevalence of 3.8/10'000 of neonatal admission.

CASE PRESENTATION

A 32-day-old girl with fever and restlessness was admitted in the hospital. Left facial swelling was found during physical examination. Redness was observed in the face. Prenatal history was normal. Birth weight was 3500 g. Body weight, length, and head circumference were 4300 g (75 th percentile), 52 cm (50 th percentile), and 38 cm (75 th percentile), respectively. She was breastfed. Pulse and respiratory rates were 130/min and 50/min, respectively. Axillary temperature was 37.8°C. Head examination revealed normal sized fontanel (1.5 × 1.5 cm) without bulging. Eye and ear were normal. Abdominal examination revealed no abnormal findings. Results of urine analysis and culture were normal. Blood urea nitrogen, sodium, potassium, and blood sugar were normal. Blood amylase was 10 U/L. Bilateral multiple reactive lymph node (size = 6 × 10 mm) at anterior cervical chain with a left facial swelling was observed in ultrasonography report. Pus was obtained following gentle pressure on Stensen's duct. Staphylococcus aureus was detected in the microscopic and microbiological evaluations.The patient received a seven-day treatment course with vancomycin and amikacin. Neonate was discharged in a good condition.

CONCLUSIONS

Acute suppurative parotitis should be suspected in infants with fever, and irritability in pre-auricular region; and should be treated with appropriate antibiotics.

[Bilateral parotitis in a patient under continuous positive airway pressure treatment]

BACKGROUND AND OBJECTIVES

Many conditions such as bacterial and viral infectious diseases, mechanical obstruction due to air and calculi and drugs can cause parotitis. We present a case of unusual bilateral parotitis in a patient under non-invasive continuous positive airway pressure (CPAP) therapy for chronic obstructive pulmonary disease exacerbation in intensive care unit.

CASE REPORT

A 36-year-old patient was admitted to intensive care unit with the diagnosis of chronic obstructive pulmonary disease exacerbation. Antibiotherapy, bronchodilator therapy and non-invasive positive pressure ventilation were applied as treatment regimen. Painless swellings developed on the 3rd day of admission on the right and a day after this on the left parotid glands. Amylase levels were increased and ultrasonographic evaluation revealed bilateral parotitis. No intervention was made and the therapy was continued. The patient was discharged on the 6th day with clinical improvement and regression of parotid swellings without any complications.

CONCLUSIONS

Parotitis may have occurred after retrograde air flow in the Stensen duct during CPAP application. After the exclusion of possible viral and bacteriological etiologies and possible drug reactions we can focus on this diagnosis.

Mumps resurgence in Denmark

BACKGROUND

The past decade has witnessed a resurgence of parotitisvirus (mumps) in several countries where seemingly good mumps control otherwise had been achieved through vaccination. Recently detection of mumps has increased in Denmark.

OBJECTIVES

To describe the age-specific changes and time trends of parotitisvirus detection in Denmark over a 10 year period.

STUDY DESIGN

Retrospective cohort study based on national laboratory data for parotitisvirus typing surveillance and national epidemiology data for mumps reporting.

RESULTS

The parotitisvirus detection rate has increased almost 10 times during the past 10 years from an incidence <0.1 per 100,000 in 2003 to 0.96 per 100,000 in 2013. The age distribution has shifted from children to young adults, and most cases are unvaccinated (54%) or vaccinated once (41%). The increase is due mainly to the existence of cohorts with low MMR vaccine coverage.

CONCLUSION

Analysis of mumps surveillance data from Denmark documents that the incidence of mumps is increasing, and that the resurgence of parotitisvirus is primarily occurring among young Danish adults. Almost half of the infected clinical mumps cases had received the first dose of MMR.

Bilateral parotitis in a patient under continuous positive airway pressure treatment

BACKGROUND AND OBJECTIVES

Many conditions such as bacterial and viral infectious diseases, mechanical obstruction due to air and calculi and drugs can cause parotitis. We present a case of unusual bilateral parotitis in a patient under non-invasive continuous positive airway pressure (CPAP) therapy for chronic obstructive pulmonary disease exacerbation in intensive care unit.

CASE REPORT

A 36-year-old patient was admitted to intensive care unit with the diagnosis of chronic obstructive pulmonary disease exacerbation. Antibiotherapy, bronchodilator therapy and non-invasive positive pressure ventilation were applied as treatment regimen. Painless swellings developed on the 3rd day of admission on the right and a day after this on the left parotid glands. Amylase levels were increased and ultrasonographic evaluation revealed bilateral parotitis. No intervention was made and the therapy was continued. The patient was discharged on the 6th day with clinical improvement and regression of parotid swellings without any complications.

CONCLUSIONS

Parotitis may have occurred after retrograde air flow in the Stensen duct during CPAP application. After the exclusion of possible viral and bacteriological etiologies and possible drug reactions we can focus on this diagnosis.

[Pneumoparotid: a rare cause of recurrent parotid swelling]

INTRODUCTION

Pneumoparotid is a rare cause of recurrent parotid swelling. It is often fortuitous, caused by an action inducing intraoral pressure, increased or self-induced.

OBSERVATION

An 8-year-old boy presented with recurrent right unilateral parotid swelling for 2 years. A CT-scan was performed, outside of the acute phase, which revealed the presence of intraparotid air bubbles.

DISCUSSION

Pneumoparotitis results from air flowing back into Stensen's duct, due to an anatomical abnormality and a significant increase of intraoral pressure. The diagnosis is made on clinical examination, often completed by a morphological examination (cervicofacial CT-scan or parotid ultrasound investigation). The outcome is most often favorable, with symptomatic treatment, and sometimes antibiotic prophylaxis. Patient education is the best means to prevent recurrence.

Unveiling the hidden eagle: acute parotitis-induced eagle syndrome

Context:

A cervicofacial pain and foreign body sensation in pharynx associated with styloid process elongation is called Eagle syndrome. Typically, this syndrome is provoked by tonsillectomy or trauma. We report the first case of acute parotitis-induced Eagle syndrome.

Case Report:

A 65-year-old woman presented with right facial pain. CT scan of neck revealed asymmetric enhancement of the right parotid gland compatible with acute parotitis. All inflammation was resolved with antibiotics. However, the patient complained of pain in right mandibular region out of proportion to inflammation. Review CT found to have an asymmetrically long right styloid process measures. The diagnosis of acute parotitis-induced Eagle syndrome was established.

Conclusion:

Physicians should have a high index of suspicion for Eagle syndrome in patients with atypical neck pain and elongated styloid process since another significant manifestation of Eagle syndrome is carotid artery compression leading to recurrent syncope or stroke.

Sialendoscopy for the diagnosis and treatment of juvenile recurrent parotitis

PURPOSE

The aim of the current study was to analyze the use of sialendoscopy for the diagnosis and treatment of juvenile recurrent parotitis (JRP), note possible complications, and the rate of disease recurrence. We believe that this cutting edge procedure may be very effective both for the diagnosis and treatment of JRP, with few complications and low rates of recurrence.

PATIENTS AND METHODS

A retrospective descriptive case study was conducted on a sample of patients presenting with JRP. Data was collected from the patient's medical records. Diagnostic sialendoscopy was performed to identify and classify the ductal pathology, treated by interventional therapeutic sialendoscopy. We carefully noted all complications and the disease recurrence rates.

RESULTS

The patient sample included 50 children presenting with JRP (33 M, 17 F; age range: 2 to 16 years). Seven children presented with bilateral parotitis, the remaining 43 with unilateral parotitis. The study was conducted from 2003 to 2012. There was a statistically significant association between sialendoscopic data and the actual outcome. Seven children underwent additional sialendoscopy because of recurrence. They were all in the group of children presenting with unilateral parotitis.

DISCUSSION

Our results validate the expected outcome. Sialendoscopy is an accurate technique for the diagnosis of JPR, and an effective tool for the treatment of JRP, with a low rate of complications and recurrence.

Parotid sialolithiasis in a two-year-old boy

Sialolithiasis is caused by the obstruction of a salivary gland or its excretory duct by the formation of calcareous concretions or sialoliths; this results in salivary ectasia and provokes subsequent dilation of the salivary gland. Sialolithiasis is relatively common, accounting for 30% of salivary diseases; however, it is rarely observed in childhood. This case report describes a 2-year-old male patient who complained of a painful swelling over the right cheek, and presented with palpable stones and pus discharge from the orifice of the right Stensen's duct. Computerized tomography of the neck confirmed the diagnosis, and the patient received intravenous empiric antibiotics combined with intraoral sialolithotomy. We also provide a review of the spectrum of concepts regarding the pathogenesis, diagnosis, and treatment of sialolithiasis.

Reversible facial nerve palsy due to parotid abscess

INTRODUCTION

A facial nerve palsy combined with parotid enlargement usually suggests malignancy. It is highly unusual for facial nerve palsy to result from a benign situation such as inflammation or infection of the gland.

PRESENTATION OF CASE

We present a rare case of facial nerve palsy due to parotid abscess.

DISCUSSION

A literature search retrieved thirty-two cases of facial nerve palsy due to benign parotid lesions since 1969. Only nine reported the presence of a parotid abscess. The etiology of paralysis remains unknown although certain factors such as the virulence of the offending organisms or perineuritis, have been suggested. Best diagnostic evaluation and management are discussed.

CONCLUSION

In clinical practice, exclusion of malignancy is mandatory, as it represents the most common cause of facial palsy in the presence of a parotid lump.

Rare case of paragonimiasis with involvement of the parotid gland alone in a 5-year-old boy

Paragonimiasis is a parasitic disease caused by Paragonimus trematodes, which are typical food-borne zoonoses prevalent in Asia, West Africa, and Latin America. A clinical infection by paragonimiasis usually begins with cough, haemoptysis, and dyspnoea, some of which overlap with symptoms of tuberculosis and other pulmonary disorders. Human paragonimiasis presents as a complex set of symptoms that may result in misdiagnosis and delayed treatment. The parotid is seldom affected. We describe the case of a 5-year-old boy with paragonimiasis who presented with a swelling of the parotid and no pulmonary signs or symptoms.

[Clozapine-induced parotitis: a case study]

INTRODUCTION

Clozapine is the drug of choice for patients with an unsatisfactory response to routine antipsychotic treatment. Side effects such as sedation, weight gain, hypotension and hypersialorrhea are frequently reported whereas clozapine-induced parotitis is a less known complication.

CASE REPORT

We report the case of a 32-year-old woman with a refractory schizoaffective disorder, bipolar type. The failure to respond to at least two well-conducted antipsychotic trials with flupentixol and risperidone, led clinicians to prescribe clozapine, which was started three years earlier. Since its introduction, clozapine induced sialorrhea, which has been managed until now with anticholinergic medication. Recently, Mrs B. was hospitalized for a new relapse. Once treatment compliance checked (good level of plasmatic dosage), we decided to increase the dose of clozapine from 350 mg/d to 500 mg/d. Twenty days later, Mrs B. exhibited improvement of symptoms but complained of acute bilateral auricular pain and odynophagia. The bilateral and comparative clinical exam displayed a bilateral filling of the retromandibular depression, the painful swelling of the parotid gland, along with ptyalism and a slight inflammatory oedema of the Stenon duct orifice. Mrs B. was apyretic, with physiological constants within the limits of normal values. The biological analyses displayed a discrete inflammatory syndrome (mild hyperleucocytosis and anemia), a negative mumps IgM test and positive mumps IgG test, and a 1050 ng/mL clozapine blood level. Once viral parotitis was ruled out, the involvement of clozapine was evoked. Symptomatic medication was prescribed with per os analgesic (paracetamol) and antiseptic mouthwash (Éludril). Clozapine dosage was lowered to 400 mg/d. A week later, clinical examination confirmed improvement of the medical and psychiatric conditions.

DISCUSSION

We report the case of a patient who developed a parotitis following clozapine dose adjustment. Clozapine induced parotitis was retained once the infectious and other organic etiologies had been ruled out. Previous cases of clozapine-induced parotitis have already been reported and we have some arguments to suspect this etiology in our case. First, Mrs B. experienced more hypersialorrhea with the increase in clozapine dosage. Second, the anticholinergic medication was interrupted 3 days before the episode of parotitis. Two main pathophysiological hypotheses, immune and inflammatory, have already been proposed to explain clozapine-induced parotitis. In the former, the immunomodulating properties of clozapine may sensitize the mononuclear blood cells, leading to the sialadenitis. The latter hypothesis is the more documented and proposes that clozapine-induced hypersialorrhea may be responsible for a chronic inflammatory state that can lead to the formation of a parotid lithiasis and consequently parotitis. This case report illustrates clozapine induced-parotitis, a poorly known complication of this compound. Clinicians should be aware of its hypersialorrhea and inflammatory consequences in order to better prevent the occurrence of this complication.

Mycobacterium chelonae infection of the parotid gland

Mycobacterium chelonae can cause numerous infections, including lung disease, local cutaneous disease, osteomyelitis, joint infections and ocular disease. With the exception of lung disease, these syndromes commonly develop after direct inoculation. The most common clinical presentation in immunocompetent individuals is skin and soft tissue infection. We present a case of M. chelonae infection of the parotid gland that was successfully treated with clarithromycin monotherapy. To our knowledge, this is the first case report of M. chelonae parotitis in an adult.