A 43-year old man presented with a parotid swelling caused by an intraparotid abscess, with the infection extending into the retropharyngeal space, partially obstructing the patient’s airway and leading to life-threatening complications. This is a reminder of the potentially fatal complication of airway compromise which can be overlooked when assessing parotid gland swellings.
As the patient’s primary care provider, the dentist can play a crucial role in such cases, but these patients could present in a range of environments and it is therefore also of relevance to general medical practitioners, accident and emergency staff, ENT and oral and maxillofacial surgeons. Often parotid swellings are managed conservatively using parenteral means with fluids and antibiotic therapy, but in severe cases such as this, more aggressive surgical treatment is required. Early identification and intervention are crucial in this situation.
Mark Gormley1, Julia Winterburn2, Adesh Savla3, Marcus Sinanan4
1Specialty Registrar in Oral Surgery. University of Bristol Dental Hospital, Lower Maudlin Street, Bristol, BS1 2LY.
2Specialty Doctor in Oral and Maxillofacial Surgery. Great Western Hospital, Marlborough Road, Swindon, SN3 6BB.
3Dental Core Trainee in Oral and Maxillofacial Surgery. Great Western Hospital, Marlborough Road, Swindon, SN3 6BB.
4Consultant in Oral and Maxillofacial Surgery. Victoria Hospital, Hayfield Road, Kirkcaldy, Fife KY2 5AH.
*Corresponding Author: Mark Gormley, University of Bristol Dental Hospital, Lower Maudlin Street, Bristol, BS1 2LY.Tel: 07761549923; Email: mark.gormley@bristol.ac.uk
ABSTRACT
A 43-year old man presented with a parotid swelling caused by an intra parotid abscess, with the infection extending into the retropharyngeal space, partially obstructing the patient’s airway and leading to life-threatening complications. This is a reminder of the potentially fatal complication of airway compromise which can be overlooked when assessing parotid gland swellings.
As the patient’s primary care provider, the dentist can play a crucial role in such cases, but these patients could present in a range of environments and it is therefore also of relevance to general medical practitioners, accident and emergency staff, ENT and oral and maxillofacial surgeons. Often parotid swellings are managed conservatively using parenteral means with fluids and antibiotic therapy, but in severe cases such as this, more aggressive surgical treatment is required. Early identification and intervention is crucial in this situation.
Keywords: Abscess; airway; life-threatening parotid; swelling
INTRODUCTION
We present a rare example of parotid abscess resulting in airway compromise with the aim of reminding clinicians of this potentially fatal complication which can be overlooked when assessing parotid gland swellings. Chi et al. published a retrospective study of 14 parotid abscess cases and reported that acute parotitis with abscess formation is uncommon but possibly complicated by deep neck space infection and sepsis. Parenteral antibiotics plus incision and drainage is the treatment of choice [1].
Case presentation
A 43-year-old male presented with a ten-day history of right sided facial swelling, which had increased rapidly in size over the preceding twenty-four hours. He complained of difficulty swallowing, was dehydrated, and spoke with a “hot potato voice”. The patient had a known history of salivary calculi and had experienced repeated pre-prandial swelling with an occasional salty taste but had declined treatment. Medically he suffered from relapsing-remitting multiple sclerosis and was a smoker, with twenty-five pack years. A large, firm swelling was present over the right parotid gland and spreading to the submandibular region, with an overlying erythematous rash and severe trismus. Intra-orally the right buccal sulcus was swollen and tender to palpation. No saliva could be expressed from the right parotid duct. Odontogenic infection was excluded clinically and with an orthopantomogram (OPG) radiograph and acute parotitis was suspected.
Investigations
On examination, the patient was apyrexic, normotensive, with a heart rate of85 beats per minute. He did have a leukocytosis of 36.9× 109/l (upper limit of normal 11.0 × 109/l), with a C-reactive protein (CRP) of 154mg/l (normal range 0-10mg/l).
A computed tomogram (CT) demonstrated a dilated parotid duct with two calculi around 5mm present (Figure 1). A deep parotid abscess was evident around the angle of the mandible, measuring 32 mm x 28mm x 27 mm, possibly involving the right masseter muscle (Figure 2). The right side parapharyngeal tissues were oedematous and the pharynx was significantly narrowed. Worryingly, the upper aerodigestive tract tissues, including the epiglottis were also swollen.
Figure 1: CT head revealing calculi in the dilated right parotid duct and an enlarged gland.
Figure 2: CT head showing a parotid abscess at the angle of the mandible and partially obstructed the airway.
Treatment
The patient was admitted to the intensive care unit following extra-oral incision and drainage of the parotid abscess under general anaesthetic. Access was gained using a modified Blair incision with copious pus exudate expressed, and a drain placed. Simultaneously an attempt was made to retrieve the salivary calculi via a papillotomy, but they were too deep to deliver intra-orally. He was catheterized, given fluids along with dexamethasone, analgesia and intravenous antibiotic therapy. Microbiology advised a Clindamycin and Tazocin regime as gram-positive Streptococci sanguinis and milleri were isolated from the blood and pus cultures respectively. Benzylpenicillin was later added, then stopped following a hypersensitivity reaction, manifesting as a forearm skin rash. The patient remained intubated for six days due to persistent inflammation, residual retropharyngeal collections and thus the impending risk of mediastinitis.
During this time, the drain became blocked and a return to theatre for further drainage was required to manage the residual collections. A second CT scan demonstrated a significant improvement. Following supportive therapy, the patient made a full recovery. While on the ward further calculi were discharged by the patient during gland massage, possibly aided by the papillotomy procedure. After a two-week review, a total parotidectomy was planned to prevent future recurrence in this case.
DISCUSSION
In adults, parotid gland infection with abscess formation is uncommon, but any delay in identification or treatment could lead to sepsis and potential airway compromise, as occurred in this case [1].
As the patient’s primary care provider, the dentist can play a crucial role in such cases. The dentist must first understand the difference in clinical features between chronic sialadenitis and acute suppurative sialadenitis. Chronic sialadenitis, most commonly affecting the parotid gland, presents as repeated episodes of intermittent swelling, pain and inflammation of the gland, especially at mealtimes [2]. This is normally caused by the presence of salivary calculi, strictures or scarring, and immediate treatment in such cases involves massaging the gland towards the orifice opening to stimulate expulsion of the sialolith if present along the duct [3]. Hydration and the use of non-steroidal anti-inflammatory drugs are also important in early management. Later management may include surgical removal of the salivary stone if surgically accessible and early referral for an oral and maxillofacial opinion is advised. In severe cases, excision of the affected salivary gland may help resolve symptoms in the long term [3].
In contrast, acute suppurative parotitis normally occurs in the in the elderly, who are often hospitalised, dehydrated and/ or malnourished. It is thought to be caused by retrograde contamination of the salivary gland from the oral cavity [3,4]. Other predisposing factors include poor oral hygiene, ductal obstruction, anticholinergic drugs, SjÖgren syndrome and immunosuppression amongst others [5-7].
Clinically patients with acute parotitis present with a continuous, firm swelling, extreme localised tenderness, oedema, and possibly trismus. Bacteraemia (or less commonly viraemia) can act as contaminants, resulting in suppurative changes leading to abscess formation in the parotid. Pus may be expressed from the parotid duct opening [3]. The presence of sialoliths can also impair salivary flow and predispose the patient to an acute infection, as in this case [3].
Early identification with correct diagnosis and intervention by means of systemic antimicrobial therapy for acute suppurative sialadenitis, may have prevented exacerbation of the condition. If a dentist makes a provisional diagnosis of acute suppurative parotitis, the patient should be started on systemic antimicrobial therapy and reviewed within 72 hours. Acute bacterial sialadenitis is often caused by Staphylococci and Streptococci, most commonly S. aureus; cultured in 50% to 90% of cases [8,9]. The first-choice treatment for this is systemic Co-amoxiclav [7]. If there is no improvement on review we would advise urgent referral to the local oral and maxillofacial team [10].
Furthermore, patients presenting with suspected neck space infections should have airway, breathing and circulation immediately assessed [10]. The patient should also be advised that if they feel any of these become compromised, they urgently attend their local accident and emergency due to the threat to life. Simple observations such as measuring the patient’s blood pressure, temperature, heart rate, breathing rate can help the dentist to gauge the urgency and need for the patient to be urgently referred into a hospital setting.
If there is extra-capsular spread of infection into the deep fascial planes in the neck it may lead to severe and potentially life-threatening complications [5], such as airway obstruction, and more rarely mediastinitis [11], necrotising fasciitis, septic embolization, dural sinus thrombosis, and intracranial abscess. [12] Although also rare, facial nerve palsy has been reported as a complication of parotid abscess [6]. Often early symptoms do not reflect the disease severity [13,14].
In this case, despite initial vital observations being normal, there was a marked underlying leukocytosis and clinical signs indicating an infectious aetiology [14,15].
If not promptly treated this could lead to mortality as reported by Lampropoulos et al. [4] Imaging is imperative in identifying the source of the infection, assessing its extent and for surgical planning. Ultrasonography is the gold standard in differentiating abscess from cellulitis in superficial cases, however it delivers poor anatomical information. CT is more useful in cases of deep multi-compartment infection, offering quick, detailed images without field-of-view limitations [13].
Although in this case the causative organisms were found to be Streptococci sanguinis and milleri, other organisms should be considered. Day and Shah [16] report a case of acute parotid abscess secondary to tuberculous infection. Fine Needle Aspiration Cytology (FNAC) may therefore be required to ensure the appropriate treatment modality and targeted antimicrobials.
A prompt, accurate diagnosis of parotid swelling determines our management, as surgical intervention is usually not necessary for the smaller swellings, commonly associated with acute suppurative parotitis. Fistula formation can also be avoided if treated early. This case is a rare example of a severe swelling caused by a parotid abscess [17,18].
CONCLUSION
Clinical learning points from this case are reinforced below:
REFERENCES
3. Wilson K.F., Meier J.D., Daniel Ward P. Salivary gland disorders. Am Family Physician, 2014. 89: p. 882-888.
4. Lampropoulos, P., Rizos, S., Marinis, A. Acute suppurative parotitis: adreadful complication in elderly patients. Surgical infection(Larchmt), 2012. 13(4): p. 266-269.
16. Day A, Shah I. Tuberculous Parotid Abscess. Indian Journal of Medical Specialties, 2016. 7(2): p. 88-89.
17. Sanders, P.R., Macpherson, D.W. Acute suppurative parotitis: A forgotten cause of upper airway obstruction. Oral Surg Oral Med OralPathol, 1991. 72: p.412-414.
3. Wilson K.F., Meier J.D., Daniel Ward P. Salivary gland disorders. Am Family Physician, 2014. 89: p. 882-888.
4. Lampropoulos, P., Rizos, S., Marinis, A. Acute suppurative parotitis: adreadful complication in elderly patients. Surgical infection(Larchmt), 2012. 13(4): p. 266-269.
16. Day A, Shah I. Tuberculous Parotid Abscess. Indian Journal of Medical Specialties, 2016. 7(2): p. 88-89.
17. Sanders, P.R., Macpherson, D.W. Acute suppurative parotitis: A forgotten cause of upper airway obstruction. Oral Surg Oral Med OralPathol, 1991. 72: p.412-414.
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