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Face Swelling, Fever

Wiler, Jennifer L. MD, MBA

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doi: 10.1097/01.EEM.0000465703.85820.a7

    A 53-year-old woman presented with left face swelling and fever. She denied voice or vision changes, headache, chest pain, and drooling to stridor. What is the likely diagnosis, and how would you evaluate and treat it?

    Find the diagnosis and case discussion on p. 12.

    Diagnosis: Parotitis

    The parotid (“around the ear”) gland is the largest salivary gland. It lays posterior to the mandibular ramus and secretes saliva via the Stensen duct (also known as the parotid duct), which initiates digestion as part of the mastication process.

    Inflammation of the parotid gland, parotitis, has a number of known etiologies, including infection (bacterial, viral including HIV), autoimmune infiltration (Sjögren, Mikulicz syndrome, sarcoidosis), irritation (e.g., from bulimia), fibrosis (e.g., tuberculosis, syphilis), iatrogenic injury, dehydration or decreased salivary outflow, inflammation (e.g., complication from inferior alveolar local anesthesia nerve block), and tumor (most are benign). (Clin Rheumatol 2011;30[8]:1123; Oral Maxillofac Surg Clin North Am 2009;21[3]:331.) Infection can also result from parotid gland salivary stone obstruction, which results in secondary infection and can be chronic. (Emerg Med Clin North Am 2013;31[2]:481.)

    The most common cause of parotitis is mumps. (J Pathol 2015;235[2]:242.) The incidence of mumps has significantly decreased in developed countries since widespread vaccinations started in the 1970s. (Vaccine 2012;30[48]:6918.) Caused by the paramyxovirus, mumps is typically self-limiting when it does occur. It rarely progresses to deafness, orchitis, meningoencephalitis, or pancreatitis. (J R Soc Med 2006;99[11]:573.) Today in developing countries, medication reaction in the elderly (e.g., antihistaminic reaction) is a more typical etiology. (Ann Pharmacother 2012;46[12]:1688.) The mortality rate of bacterial parotitis was as high as 80 percent in the 1800s. Interestingly, this was most commonly described in post-operative patients who were hydrated. This results in severe bacterial parotitis, which developed into fulminant sepsis.

    Parotitis can present with nontender or tender (worse with chewing) swelling, fever, and dry mouth. Symptoms can be bilateral, and patients may have associated systemic symptoms depending on the etiology. The emergency department diagnostic evaluation depends on the concern for an underlying acute condition. Imaging is reserved for differentiation of inflammation versus abscess and concern for an infiltrating tumor. (Emerg Med Clin North Am 2013;31[2]:481.)

    Treatment also depends on the etiology. Sialolithiasis can be treated with hydration, sialogogues, and massage, but surgical resection may be necessary. Parotitis can progress to parotid abscess, which may require surgical resection. Surgical treatment complications include facial paralysis and facial scarring resulting in cosmetic deformity. (J Laryngol Otol 2012;126[3]:322.) The recommended treatment of parotitis of an unknown or unclear etiology can include sialogogues, massage, and antibiotics.

    This patient was admitted to the hospital for intravenous antibiotics for an initial concern of bacterial parotitis. She was ultimately diagnosed with Sjögren's syndrome.

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