Acta Otolaryngol82: 275-278, 1976
NOSOCOMIAL PAROTITIS A. Lundgren, P. Kylen and L. M. Odkvist
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/13 For personal use only.
From the ENT Clinic, Regional and University Hospital, Linkoping, Sweden
Abstract. A total of 22 cases of acute suppurative parotitis are reviewed. The causative factors were severe primary disease with salivary gland hyposecretion related to age (77 years), dehydration, oral inactivity and drugs (19 patients). The oral hygiene was poor and permitted ascending canalicular invasion of resistant staphylococci. The mortality was 27%. The treatment, including preferably cloxacilline and incision, is discussed. To stress the importance of prophylaxis the name “nosocomial parotitis” is suggested.
Acute suppurative parotitis usually occurs in elderly debilitated patients who are seriously ill. Some commonly used synonyms are acute postoperative parotitis, acute necrotic parotitis, acute gangrenous parotitis, acute necrotic parotitis, septic parotitis and parotid abscess (Hemenway & English, 1971). A study of a group of patients suffering from acute suppurative parotitis treated at the ENT Clinic of the Regional and University Hospital, Linkoping, is presented. A review of the symptomatology, pathogenesis and treatment as well as a reason for the name “nosocomial parotitis” are given.
MATERIAL AND METHOD Twenty-two cases of acute suppurative salivary gland inflammation have been treated. The patients were referred for consultation from various departments in the hospital or were treated in the wards of the ENT Clinic. Seventeen of the cases had a unilateral paro-
titis; three cases were bilateral. Two cases of a similar inflammation of the submandibular gland have been included. All of the patients had a serious primary disease. In addition, several of the patients were also debilitated due to advanced age. The average age was 77 years (range 60-92). Nine were men and thirteen women. In seven cases, the inflammation followed an operation. At the time of onset the patients were on p a r e n t e d nutrition (10 cases), diuretic medication (8 cases), psychotrophic drugs of different types given because of agitation, anxiety, insomnia or more serious mental disturbances (10 cases), or atropine and anticholinergic drugs (8 cases). Only three patients were free from drugs (Table I). Twelve of the patients had been treated with antibiotics. Bacterial cultures in 19 of the cases showed Staphylococcus a w e u s which was resistant to most antibiotics, but without exception sensitive to cloxacillin; also mostly to chloramphenicol and erythromycin (Fig. 1). The phage-typing usually showed strain 80/8 1, the nosocomial type. With a few exceptions, all cases were treated with large doses of cloxacilline. A few early cases were operated on under general anaesthesia, with parotidectomy skin incisions and broad incisions of the parotid fascia and extensive drainage of the parotid and paraparotid spaces as suggested by Perzik (1962). In later cases, we used the same principles of drainage, but Acta Otolaryngol82
276
A . Lundgren et al.
Table I. Various drugs presumably contributing to a low salivarypow Diur=diuretics. Antichol=anticholinergics. Psychoti-= psychotropics. Antihist=antihistaminics
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/13 For personal use only.
Case 1 2 3 4 5 6 7 8 9
Diur.
+
+
19 20
+ + + +
c
+
10
I1 12 13 14 15 16 17 18
Antichol. Psychotr. Antihist.
+ +
+ + +
+ +
+++ + + +++++ + +++ + ++ + + ++
+ +
+
21 22
operated earlier under local anaesthesia and were thus able to make more limited incisions and drainage. In some cases, repeated punctures of an abscess were sufficient. This change towards a more conservative attitude was due to the fact that we now have better intensive care and better antibiotics. Six patients (27%) died within 2 weeks and 9 patients (40%) within 2 months after the onset of parotitis. The cause of death in the early cases was a combination of a primary disease and the extra load of the parotitis. The late deaths were due to the primary disease, the parotitis being healed. DISCUSSION A . Symptoms The typical initial symptoms of parotitis are moderate swelling of the parotid region with some tenderness and pain. At this stage, the parotitis may heal spontaneously or within 1-7 days develop into a fully established suppurative parotitis with rapid swelling of the Actu Otolaryngol82
gland, with tense, shining red-blue skin, trismus, pain and intense local tenderness, impeding free head and neck movements. The patients have fever and are seriously affected by the disease. An abscess may occur, as may gangrene of the gland and fistulation through the overlying skin, to the external auditory meatus, the temporo-mandibular joint or to the parapharyngeal regions with further progress to the mediastinum. Secondary glottic oedema with respiratory stridor may occur (Laburthe-Tolra, 1969). Almost exclusively, the parotid gland is affected, rarely the submandibular gland. Of our 22 patients, only 2 had a submandibular inflammation. It is reported that the submandibular glands are so infrequently involved in this infection because of better protection by mucines (Rausch, 1959). In the 7 patients in whom parotitis developed after an operation, the disease began 4 to 8 days postoperatively, which is in accordance with the literature (Perzik, 1962).
B . Pathogenesis 1 . Primary disease Acute, suppurative parotitis occurs in elderly debilitated patients who are seriously ill, often, but not necessarily, postoperatively. 2. Hyposecretory factors In the case history there are always factors contributing to salivary hyposecretion. Age is one of the most important factors. It has been shown that the secretion from the salivary glands decreases with advancing age (Wainwright & Becks, 1943; Korting & KleinSchmidt, 1953). In our series, the average age was 77 years. It is well known that in cases of dehydration the salivary secretion is diminished, sometimes noticeable as xerostomia. The salivary gland activity is stimulated by food intake, by smell and taste and partly by the mechanical effects of chewing, and thus oral inactivity leads to salivary hyposecretion. Xerostomia is often caused by drugs, either by their dehydrating action or by actively
Nosocomial parotitis S I A F . AUREUS - ANTIBIOGRAM NUMEER
CHLORAMFEN
5
OF PATIENTS
10
15
19
ICOL
ERYTHROMYCINE
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/13 For personal use only.
AMPICILLIN
SENSITIVE =
I 11 111
MODERATELY S E N S I T I V E = ALMOST
INSENSITIVE =
RESISTENT =
I'd
Fig. 1 . Antibiogram for the pathogenic staphylococci in 19 of the cases.
decreasing the salivary flow. These drugs are primarily diuretics, parasympatholytics, barbiturates, tricyclic antidepressants and other psychotropic drugs and antihistamines. The majority of our patients were on drugs from the list above, administered either singly or in combinations. Only three of them were drug-free at the onset of parotitis (Table I).
3. Secondary bacterial infection or invasion Normally the saliva flushes the salivary duct system preventing infection. When the salivary flow ceases or is diminished, bacteria from the oral cavity may, in the presence of poor hygiene, invade the parotid gland duct (Amulf, 1951; Faye & Deffez, 1969). Many other theories concerning enzymatic autodigestion, reflexes from the abdominal organs, toxic allergic influence and primary infection have been advanced as regards the cause of acute suppurative parotitis, but they have not been conclusively proved. Treatment The most important measure is to prevent the parotitis. Patients in whom this complication
277
is likely to occur must have a high fluid intake and any administration of salivationdepressant drugs must be avoided. The salivary secretion should be stimulated by lemon juice and by maintaining oral activity, for example, by using chewing gum. The oral hygiene should not be neglected; the oral cavity should be washed and the teeth frequently cleaned. Artificial dentures should not be worn. Oral infections should be treated promptly. The patients must be carefully observed for early symptoms of parotitis as treatment at this stage is highly effective. In case of a manifest septic parotitis, this regimen should be supplemented by the administration of antibiotic drugs, initially preferably cloxacillin. An alternative antibiotic should be given only according to bacterial cultures and antibiograms (see Fig. 1). The diagnosis of a parotid abscess may be difficult as the tense parotid fascia obscures abscess fluctuations by the palpating hand. Needle punctures of the parotid gland may in such cases give the diagnosis, and the aspiration of pus accelerates healing, and provides material for a representative bacterial culture. If the skin overlying the gland is hard, tense and red, incision through the skin should not be postponed, even if needle aspiration is negative. A moderately long incision behind the mandibular angle under local anaesthesia and drainage of the parotid and paraparotid spaces are the procedures of choice. Thorough knowledge of the anatomy prevents damage to the facial nerve. Long incisions and explorations under general anaesthesia in these patients may be fatal if performed in weak patients. Drainage tubes or successive debridements on consecutive days are necessary until healing is achieved. Analgesic drugs are usually necessary.
Prognosis The appearance of acute suppurative parotitis is to be looked upon as an ominous sign. It is obvious that the acute suppurative parotitis in these already severely ill patients may be Acta Otolaryngol82
278
A . Lundgren et al.
the additional complication that the patient cannot tolerate. The cause of death is, however, most often the primary disease. The mortality is approximately 5-35% (Rausch, 1959); in our series 27% within 2 weeks.
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/13 For personal use only.
CONCLUSIONS Acute suppurative parotitis affects seriously ill, elderly patients with an age-related diminished salivary secretion. The secretion is further diminished because of insufficient fluid intake, oral inactivity, and the presence of oral bacteria that may ascend through Stensen’s duct to the parotid gland. The organisms are most frequently resistant staphylococci. We suggest the new provocative name “nosocomial parotitis” to stress that this illness will appear in hospitalized patients if we impair the salivary gland secretion and neglect the patient’s oral and environmental hygiene. ZUSAMMENFASSUNG 22 Falle von akutem, suppurativem Parotit sind bearbeitet worden. Die Ursachen, die zu diesem Zustand gefuhrt
Acta Otolaryngol82
haben, sind: schwere primare Krankheit mit altersbedingter Hyposekretion in den Speicheldriisen (Alter: 77 Jahre), Dehydration, orale Inaktivitat und Pharmaka (19 Patienten). Die orale Hygiene war schlecht und verursachte aufwartssteigende, kanalikulare Invasion von Parotis mit resistenten Staphylokokken. Mortalitat 27%. Die Behandlung, vor allem mit Cloxacillin und Inzision, ist diskutiert worden. Um die Wichtigkeit der Prophylaxe hervorzuheben, ist der Name ,,Nosocomial Parotit“ vorgeschlagen worden.
REFERENCES Arnulf, G. 195 1. Considerations sur les parotidites postoperatoires. Mhrn Acad Chir 77, 544. Faye, C. & Deffez, J. P. 1969. Les parotidites uremiques. L a Vie MPdical50, 2397. Hemenway, W. G. & English, G. M. 1971. Surgical treatment of acute bacterial parotitis. Postgrad Med 50, 114. Korting, G. W. & Kleinschmidt, W. 1953. Derrnat Wochenschr 128, 772. Laburthe-Tolra, Y . 1969. Les parotidites post-operatoires. L a Vie MPdicule 50, 2401. Perzik, S. L. 1962. Surgical management of acute parotitis. Arch Surg 86, 247. Rausch, S. 1959. Die Speicheldriisen des Menschen, p. 344-345. Georg Thieme Verlag, Stuttgart. Wainwright, W. W. & Becks, H. 1943. J Dent Res 22, 403.
NOSOCOMIAL PAROTITIS A. Lundgren, P. Kylen and L. M. Odkvist
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/13 For personal use only.
From the ENT Clinic, Regional and University Hospital, Linkoping, Sweden
Abstract. A total of 22 cases of acute suppurative parotitis are reviewed. The causative factors were severe primary disease with salivary gland hyposecretion related to age (77 years), dehydration, oral inactivity and drugs (19 patients). The oral hygiene was poor and permitted ascending canalicular invasion of resistant staphylococci. The mortality was 27%. The treatment, including preferably cloxacilline and incision, is discussed. To stress the importance of prophylaxis the name “nosocomial parotitis” is suggested.
Acute suppurative parotitis usually occurs in elderly debilitated patients who are seriously ill. Some commonly used synonyms are acute postoperative parotitis, acute necrotic parotitis, acute gangrenous parotitis, acute necrotic parotitis, septic parotitis and parotid abscess (Hemenway & English, 1971). A study of a group of patients suffering from acute suppurative parotitis treated at the ENT Clinic of the Regional and University Hospital, Linkoping, is presented. A review of the symptomatology, pathogenesis and treatment as well as a reason for the name “nosocomial parotitis” are given.
MATERIAL AND METHOD Twenty-two cases of acute suppurative salivary gland inflammation have been treated. The patients were referred for consultation from various departments in the hospital or were treated in the wards of the ENT Clinic. Seventeen of the cases had a unilateral paro-
titis; three cases were bilateral. Two cases of a similar inflammation of the submandibular gland have been included. All of the patients had a serious primary disease. In addition, several of the patients were also debilitated due to advanced age. The average age was 77 years (range 60-92). Nine were men and thirteen women. In seven cases, the inflammation followed an operation. At the time of onset the patients were on p a r e n t e d nutrition (10 cases), diuretic medication (8 cases), psychotrophic drugs of different types given because of agitation, anxiety, insomnia or more serious mental disturbances (10 cases), or atropine and anticholinergic drugs (8 cases). Only three patients were free from drugs (Table I). Twelve of the patients had been treated with antibiotics. Bacterial cultures in 19 of the cases showed Staphylococcus a w e u s which was resistant to most antibiotics, but without exception sensitive to cloxacillin; also mostly to chloramphenicol and erythromycin (Fig. 1). The phage-typing usually showed strain 80/8 1, the nosocomial type. With a few exceptions, all cases were treated with large doses of cloxacilline. A few early cases were operated on under general anaesthesia, with parotidectomy skin incisions and broad incisions of the parotid fascia and extensive drainage of the parotid and paraparotid spaces as suggested by Perzik (1962). In later cases, we used the same principles of drainage, but Acta Otolaryngol82
276
A . Lundgren et al.
Table I. Various drugs presumably contributing to a low salivarypow Diur=diuretics. Antichol=anticholinergics. Psychoti-= psychotropics. Antihist=antihistaminics
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/13 For personal use only.
Case 1 2 3 4 5 6 7 8 9
Diur.
+
+
19 20
+ + + +
c
+
10
I1 12 13 14 15 16 17 18
Antichol. Psychotr. Antihist.
+ +
+ + +
+ +
+++ + + +++++ + +++ + ++ + + ++
+ +
+
21 22
operated earlier under local anaesthesia and were thus able to make more limited incisions and drainage. In some cases, repeated punctures of an abscess were sufficient. This change towards a more conservative attitude was due to the fact that we now have better intensive care and better antibiotics. Six patients (27%) died within 2 weeks and 9 patients (40%) within 2 months after the onset of parotitis. The cause of death in the early cases was a combination of a primary disease and the extra load of the parotitis. The late deaths were due to the primary disease, the parotitis being healed. DISCUSSION A . Symptoms The typical initial symptoms of parotitis are moderate swelling of the parotid region with some tenderness and pain. At this stage, the parotitis may heal spontaneously or within 1-7 days develop into a fully established suppurative parotitis with rapid swelling of the Actu Otolaryngol82
gland, with tense, shining red-blue skin, trismus, pain and intense local tenderness, impeding free head and neck movements. The patients have fever and are seriously affected by the disease. An abscess may occur, as may gangrene of the gland and fistulation through the overlying skin, to the external auditory meatus, the temporo-mandibular joint or to the parapharyngeal regions with further progress to the mediastinum. Secondary glottic oedema with respiratory stridor may occur (Laburthe-Tolra, 1969). Almost exclusively, the parotid gland is affected, rarely the submandibular gland. Of our 22 patients, only 2 had a submandibular inflammation. It is reported that the submandibular glands are so infrequently involved in this infection because of better protection by mucines (Rausch, 1959). In the 7 patients in whom parotitis developed after an operation, the disease began 4 to 8 days postoperatively, which is in accordance with the literature (Perzik, 1962).
B . Pathogenesis 1 . Primary disease Acute, suppurative parotitis occurs in elderly debilitated patients who are seriously ill, often, but not necessarily, postoperatively. 2. Hyposecretory factors In the case history there are always factors contributing to salivary hyposecretion. Age is one of the most important factors. It has been shown that the secretion from the salivary glands decreases with advancing age (Wainwright & Becks, 1943; Korting & KleinSchmidt, 1953). In our series, the average age was 77 years. It is well known that in cases of dehydration the salivary secretion is diminished, sometimes noticeable as xerostomia. The salivary gland activity is stimulated by food intake, by smell and taste and partly by the mechanical effects of chewing, and thus oral inactivity leads to salivary hyposecretion. Xerostomia is often caused by drugs, either by their dehydrating action or by actively
Nosocomial parotitis S I A F . AUREUS - ANTIBIOGRAM NUMEER
CHLORAMFEN
5
OF PATIENTS
10
15
19
ICOL
ERYTHROMYCINE
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/13 For personal use only.
AMPICILLIN
SENSITIVE =
I 11 111
MODERATELY S E N S I T I V E = ALMOST
INSENSITIVE =
RESISTENT =
I'd
Fig. 1 . Antibiogram for the pathogenic staphylococci in 19 of the cases.
decreasing the salivary flow. These drugs are primarily diuretics, parasympatholytics, barbiturates, tricyclic antidepressants and other psychotropic drugs and antihistamines. The majority of our patients were on drugs from the list above, administered either singly or in combinations. Only three of them were drug-free at the onset of parotitis (Table I).
3. Secondary bacterial infection or invasion Normally the saliva flushes the salivary duct system preventing infection. When the salivary flow ceases or is diminished, bacteria from the oral cavity may, in the presence of poor hygiene, invade the parotid gland duct (Amulf, 1951; Faye & Deffez, 1969). Many other theories concerning enzymatic autodigestion, reflexes from the abdominal organs, toxic allergic influence and primary infection have been advanced as regards the cause of acute suppurative parotitis, but they have not been conclusively proved. Treatment The most important measure is to prevent the parotitis. Patients in whom this complication
277
is likely to occur must have a high fluid intake and any administration of salivationdepressant drugs must be avoided. The salivary secretion should be stimulated by lemon juice and by maintaining oral activity, for example, by using chewing gum. The oral hygiene should not be neglected; the oral cavity should be washed and the teeth frequently cleaned. Artificial dentures should not be worn. Oral infections should be treated promptly. The patients must be carefully observed for early symptoms of parotitis as treatment at this stage is highly effective. In case of a manifest septic parotitis, this regimen should be supplemented by the administration of antibiotic drugs, initially preferably cloxacillin. An alternative antibiotic should be given only according to bacterial cultures and antibiograms (see Fig. 1). The diagnosis of a parotid abscess may be difficult as the tense parotid fascia obscures abscess fluctuations by the palpating hand. Needle punctures of the parotid gland may in such cases give the diagnosis, and the aspiration of pus accelerates healing, and provides material for a representative bacterial culture. If the skin overlying the gland is hard, tense and red, incision through the skin should not be postponed, even if needle aspiration is negative. A moderately long incision behind the mandibular angle under local anaesthesia and drainage of the parotid and paraparotid spaces are the procedures of choice. Thorough knowledge of the anatomy prevents damage to the facial nerve. Long incisions and explorations under general anaesthesia in these patients may be fatal if performed in weak patients. Drainage tubes or successive debridements on consecutive days are necessary until healing is achieved. Analgesic drugs are usually necessary.
Prognosis The appearance of acute suppurative parotitis is to be looked upon as an ominous sign. It is obvious that the acute suppurative parotitis in these already severely ill patients may be Acta Otolaryngol82
278
A . Lundgren et al.
the additional complication that the patient cannot tolerate. The cause of death is, however, most often the primary disease. The mortality is approximately 5-35% (Rausch, 1959); in our series 27% within 2 weeks.
Acta Otolaryngol Downloaded from informahealthcare.com by Nyu Medical Center on 05/30/13 For personal use only.
CONCLUSIONS Acute suppurative parotitis affects seriously ill, elderly patients with an age-related diminished salivary secretion. The secretion is further diminished because of insufficient fluid intake, oral inactivity, and the presence of oral bacteria that may ascend through Stensen’s duct to the parotid gland. The organisms are most frequently resistant staphylococci. We suggest the new provocative name “nosocomial parotitis” to stress that this illness will appear in hospitalized patients if we impair the salivary gland secretion and neglect the patient’s oral and environmental hygiene. ZUSAMMENFASSUNG 22 Falle von akutem, suppurativem Parotit sind bearbeitet worden. Die Ursachen, die zu diesem Zustand gefuhrt
Acta Otolaryngol82
haben, sind: schwere primare Krankheit mit altersbedingter Hyposekretion in den Speicheldriisen (Alter: 77 Jahre), Dehydration, orale Inaktivitat und Pharmaka (19 Patienten). Die orale Hygiene war schlecht und verursachte aufwartssteigende, kanalikulare Invasion von Parotis mit resistenten Staphylokokken. Mortalitat 27%. Die Behandlung, vor allem mit Cloxacillin und Inzision, ist diskutiert worden. Um die Wichtigkeit der Prophylaxe hervorzuheben, ist der Name ,,Nosocomial Parotit“ vorgeschlagen worden.
REFERENCES Arnulf, G. 195 1. Considerations sur les parotidites postoperatoires. Mhrn Acad Chir 77, 544. Faye, C. & Deffez, J. P. 1969. Les parotidites uremiques. L a Vie MPdical50, 2397. Hemenway, W. G. & English, G. M. 1971. Surgical treatment of acute bacterial parotitis. Postgrad Med 50, 114. Korting, G. W. & Kleinschmidt, W. 1953. Derrnat Wochenschr 128, 772. Laburthe-Tolra, Y . 1969. Les parotidites post-operatoires. L a Vie MPdicule 50, 2401. Perzik, S. L. 1962. Surgical management of acute parotitis. Arch Surg 86, 247. Rausch, S. 1959. Die Speicheldriisen des Menschen, p. 344-345. Georg Thieme Verlag, Stuttgart. Wainwright, W. W. & Becks, H. 1943. J Dent Res 22, 403.
