Parotitis

Etiology and predisposing factors

Purulent parotitis is most commonly caused by staphylococci, frequently found as part of microbial associations. Infection invades the parotid gland tissue via three pathways:

1. Ascending (main): bacteria migrate from the oral cavity directly along the excretory duct of the gland — Stensen's duct.
2. Lymphogenic: via the lymphatic system.
3. Hematogenous: via the bloodstream in generalized infections.

There are several factors that significantly increase the risk of ascending infection. The primary trigger is a decrease or complete cessation of saliva secretion. This condition is often observed in severe dehydration, acute general infectious diseases, and in the postoperative period following extensive surgical interventions against the background of weakened host defenses.

Pathogenesis: how inflammation develops

The disease develops sequentially, forming a vicious circle. Initially, inflammation of the excretory duct wall occurs, leading to mucosal edema. The lumen narrows, causing impaired saliva outflow. Secretory stasis exacerbates the inflammatory process, which inevitably spreads to the glandular tissue itself.

There are three main stages of inflammation:

• Serous stage.
• Purulent infiltration of the parotid gland lobules.
• Abscess formation (small purulent foci coalesce into a single cavity).

If the process is not arrested, severe complications develop. Vascular thrombosis of the gland is possible, leading to necrosis of its areas. Melting of the dense gland capsule with the formation of purulent collections spreading to the neck, temple, or rupture of pus into the external auditory meatus is also probable.

Clinical presentation

The symptoms of parotitis consist of pronounced local and general manifestations. The patient's general condition progressively deteriorates, and body temperature rises to 39–40 °C.

Key local symptoms:

• In the early stages, a painful, steadily growing swelling appears in the parotid region.
• Pain increases sharply upon palpation.
• The tissues become increasingly tense day by day.
• The skin over the gland becomes thinned and acquires a red hue.
• When an abscess forms deep within the tissues, indistinct fluctuation begins to be detected.

In a severe, aggressive course, the edema is not limited to a single zone, but rapidly spreads to the neck, cheek, and submandibular region. Serious functional disorders also occur: due to severe pain, the patient finds it difficult to chew and swallow.

Treatment Management

The approach to treatment directly depends on the stage of the disease.

Conservative treatment is used exclusively in the early stages, before purulent tissue breakdown occurs. Its basis is potent antibiotic therapy. In most cases, this allows for the regression of the process. A critical condition is ensuring functional rest for the gland: the patient's lower jaw movements are restricted (talking is discouraged) and only strained or pureed foods are prescribed.

Surgical treatment is indicated when conservative therapy fails and purulent parotitis develops. The goal of the surgery is to open the abscess and ensure reliable outflow of pus (drainage).

Surgical technique:

• The access route is chosen at the site of greatest softening (fluctuation).
• Absolute rule: the incision must run strictly parallel to the branches of the facial nerve. Making incisions perpendicular to their course is strictly prohibited.
• After dissecting the skin and subcutaneous tissue, the surgeon exposes and incises the capsule of the parotid gland.
• Penetration directly into the abscess cavity is performed exclusively by blunt dissection (using a finger, forceps, or surgical clamp). This is critically important to prevent accidental damage to the glandular parenchyma and facial nerve branches.
• The intervention concludes with the evacuation of pus and the placement of a drain (a tube or rubber strip).

Class and exam questions

What else to study on this topic

• Topographic anatomy and the course of facial nerve branches within the parotid gland
• Differential diagnosis of non-epidemic parotitis with other sialadenites
• Technique and options for drainage (using one or two incisions) in deep facial abscesses
• Pathways of purulent spread during purulent melting of the parotid gland capsule

Other topics from the section "CHAPTER 11. SURGICAL INFECTION (PURULENT-INFLAMMATORY DISEASES)"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.