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Cases presenting as parotid abscesses in children
International Journal of Pediatric Otorhinolaryngology (2007) 71, 897—901
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Cases presenting as parotid abscesses in children Riitta T. Saarinen a,*, Kaija-Leena Kolho b, Anne Pitka ¨ranta a a b
Department of Otorhinolaryngology, Helsinki University Central Hospital, Helsinki, Finland Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland
Received 2 November 2006; received in revised form 5 February 2007; accepted 17 February 2007
KEYWORDS Suppurative parotitis; Mycobacterium Tuberculosis; First brachial cleft fistula
Summary Background: A parotid abscess is a rare complication of acute suppurative parotitis which most often requires hospitalization, intravenous antibiotic therapy, and surgical drainage. Objective: To investigate the clinical picture, treatment, and prognosis of children with a parotid abscess in a search for optional clinical guidelines for treatment. Methods: A retrospective chart review was performed for 10 children (age 17) with a parotid abscess between January 1996 and December 2005. Results: Of the 10 cases of parotid abscess found, 4 children had had parotid-related symptoms before; bacterial culture was positive in 6; 4 had aerobic Gram-positive pathogens, and 1 girl had parotid tuberculosis. All patients received intravenous antibiotic therapy. The initial diagnostic method was ultrasound in nine cases and MRI in one. Four children underwent surgical drainage, and in three cases there was an ultrasound guided needle aspiration of the abscess. Neither surgical drainage nor aspiration led to fistula formation or any other complication. The abscess ruptured spontaneously through the skin of the periauricular area in two cases and into the ear canal in one. During follow-up, all were symptom-free except for two girls diagnosed with first brachial cleft fistulas. One of these also had a reoccurrence of the parotid abscess. Both later underwent superficial parotidectomy due to persistent symptoms. Conclusions: Most parotid abscesses in children are acute multi-bacterial infections not necessarily related to other parotid gland pathologies. Intravenous antibiotic therapy is the cornerstone of treatment, but surgical drainage assists in recovery and should not lead to fistula formation. # 2007 Elsevier Ireland Ltd. All rights reserved.
1. Introduction * Corresponding author at: Department of Otorhinolaryngology, Helsinki University Central Hospital, P.O. Box 220, Haartmaninkatu 4E, 00029 HUS, Finland. Tel.: +358 50 4271 496. E-mail address: [email protected] (R.T. Saarinen).
One rare complication of acute suppurative parotitis — related in adults to poor oral hygiene, long-term debility, and reduction in salivary flow [1] — is a
0165-5876/$ — see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2007.02.011
898
R.T. Saarinen et al.
parotid abscess. However, such an abscess can also appear in relatively young and fit adults with no history of oral pathologies [2]. It has been suggested that acute suppurative parotitis sometimes leads to abscess formation with ‘‘no significant difference in predominating factors in these two entities’’ [3]. In children, few reports of parotid abscesses exist. Various bacteria have been reported to be involved in the parotid inflammation process; the most common being Staphylococcus aureus and anaerobic bacteria in adults [1]. Streptococcus pneumoniae and Haemophilus influenzae have been reported to be among the most common pathogens in recurrent suppurative parotitis [4]. The symptoms of a parotid abscess include marked swelling of the angle of the jaw, and pain while eating. Regional lymphadenitis may occur, as well as purulent secretion from Stensen’s duct. The treatment includes broad-spectrum IV antibiotics, good oral hygiene, and adequate hydration. If an abscess has formed, surgical drainage is advisable [1]. A parotid abscess is a potentially life-threatening disease, since the inflammation can spread to the head and neck causing fasciitis [5] or deeper head and neck abscesses [6]. Most often, parotitis in childhood and adolescence is of non-bacterial origin. Before the era of vaccination, mumps was the most common cause of parotid inflammation [7]. In recurrent juvenile parotitis, painful swellings of the parotid gland and symptom-free periods alternate. Usually, the overall condition of the patient is good, and symptoms can be treated with painkillers alone [8,9]. We have shown, however, that recurrences are common [9]. If pus is detected from Stensen’s duct or the patient’s symptoms are severe, the possibility of acute suppurative parotitis must be considered, and antibiotic treatment is necessary [1,10]. If the clinical symptoms indicate the possibility of abscess
formation, an ultrasound investigation is advisable as the initial diagnostic method [11].
2. Methods The data base of the Helsinki University Central Hospital according to the Classification on Diseases, 10th revision (ICD-10) was searched in otorhinolaryngological patients aged 17 or under who were treated in our institution between January first, 1996, and December 31st, 2005. The diagnostic codes for parotid illnesses and for abscesses in the head and neck region were both included. After review of the patient charts the number of parotid abscesses in children within this time-period totaled 10. The catchment area of Helsinki University Central Hospital covers approximately 1,500,000 inhabitants, and all the children and adolescents suffering from parotid abscess have most likely been admitted to our institution, which is a tertiary centre and the only on-call otorhinolaryngological clinic in the area. Clinical data recorded included age, gender, site of disease, laboratory results, imaging, drainage methods, time of hospitalization, bacteria, antibiotics used, and outcome, as well as other illnesses of importance such as juvenile parotitis, anomalies, and general health. The ethics committee of Helsinki University Central Hospital approved the study protocol.
3. Results A total of 10 children (median age 10, range 2.2—16.8, female 5) suffering from a parotid abscess during the 10-year time-period were retrieved (Table 1). This indicates an annual
Table 1 Characteristics of the 10 children at admission Age (years) 2.2 2.3 5.9 8.2 9.3 10.0 10.8 11.1 11.1 16.8
Gender F M F M M M F F F M
Side Right Right Left Left Left Right Right Right Left Right
Temp. (8C) 37.8 37.8 38.0 NM 37.2 37.0 37.8 38.0 NM 38.1
CRP = C-reactive protein. NM = Not measured. a Reference rage <10 mg/l. b Reference rage 5—14 E9/l. * Elevated value.
CRPa (g/l) 10 38 * 47 * 12 * 12 * 95 * 56 * 92 * NM 79 *
Leucocytesb (xE9/l) *
20.7 18.2 * 20.8 * 7.8 11.1 12.4 12.7 8.0 7.6 8.1
Previous parotitis No No Yes Yes No No Yes No No Yes
Parotid abscesses in children
899
incidence of 0.067 cases per 100,000 inhabitants aged 17. The right side was affected more often (six cases). Four children had suffered from previous parotitis or parotid-related symptoms during the preceding 6—24 months. One girl had a parotid sialadenitis 1.5 months earlier, and one boy had a history of mild swellings of the parotid region several times during the preceding 1.5 years without specific diagnosis. Another girl had had recurrent symptoms of sialadenitis during previous 8 months, and she was later diagnosed to have a first brachial cleft anomaly. Another boy had had eight recurrences of sialadenitis within 2 previous years, and he also had two mild infections afterwards (Table 1). Two girls (aged 2.2 and 5.9) had first brachial cleft fistulas and underwent superficial parotidectomy later; one of these two had a recurrence of a parotid abscess before the operation and the other had had a cleft of lip and palate operation as a toddler. None of the others had any recurrence of an abscess during follow-up. The general health of all patients was good. All children had received per oral antibiotic treatment before hospitalization and bacterial culture; each receiving cefalexine, and one girl at first receiving a combination of amoxicillin and clavulanic acid and thereafter cefalexine. Duration of antibiotic treatment ranged from 7 to 15 days, and eight children developed the abscess during the treatment, two children a few days afterwards. Bacterial cultures were positive for Haemophilus Influenzae (n = 3), and one each Streptococcus pneumoniae,
Proteus mirabilis, and Mycobacterium tuberculosis. In three cases, bacterial culture remained negative, and in one case no culture was performed (Table 2). The girl with Mycobacterium tuberculosis infection was of African origin. Her infection was later shown to have affected her lungs, as well. Her presenting symptoms were right-sided swelling of the parotid gland, trismus, and moderate fever, but no cough. At first she was treated with per oral cephalosporin for suppurative parotitis, but her symptoms persisted, and she developed a large parotid abscess that when needle aspirated twice under ultrasound guidance yielded 20 and 40 ml of pus. Finally, a surgical incision was made, but she did not react as expected to treatment with metronidazole and cefuroxime. Mycobacterium tuberculosis was cultured from both pus samples, and she responded to proper therapy. Additionally, bacterial culture for tuberculosis in three other cases of pediatric parotid abscess showed these cultures to be negative. All patients had similar symptoms prior to admission: mild to moderate fever, swelling of the parotid region, cellulites, and pain. None had bilateral symptoms or symptoms of septic infection nor had any history of oral pathology. No patients were tested for mumps, since MPR vaccination (Mumps, Pertussis, and Rubella) has been part of the Finnish National Vaccination Program since 1982. All 10 children were diagnosed to have a collection of pus within the parotid gland. In nine cases an ultrasound was the initial diagnostic method and in one case MRI (Fig. 1). Five children had MRI later to
Table 2 Microbiological findings and therapy of 10 children with a parotid abscess Bacteria
Intra-venous antibiotics
Drainage
Imaging
Antibiotics prior to hospitalization
Negative
Metronidazole and Penicillin
Spontaneous
MRI
Negative
Metronidazole Cefuroxime Clindamycin Metronidazole Cefuroxime Metronidazole Cefuroxime Cefuroxime Metronidazole Cefuroxime Treatment for tuberculosis Metronidazole Amoxicillin Cefuroxime
US and MRI
and
Needle aspiration and incision Spontaneous Needle aspiration
Amoxicillin and Clavulanic acid po, Cefalexin po Cefalexin po
US and MRI US
Cefalexin po Cefalexin po
and
Needle aspiration
US
Cefalexin po
and
Spontaneous Incision
US and MRI US and MRI
Cefalexin po Cefalexin po
US
and
Needle aspiration and incision Incision
US and MRI
Cefalexin and Metronidazole po Cefalexin po
Incision
US and sialography
Cefalexin po
Haemophilus influenzae Not known Streptococcus pneumoniae Haemophilus influenzae Haemophilus influenzae Mycobacterium tuberculosis Proteus mirabilis Negative Po = per oral.
and
900
Fig. 1 MRI of a 2-year-old girl with a right-sided parotid abscess (arrow).
exclude neoplasms and malformations, and one boy underwent sialography. In seven cases, the abscess was drained, and three experienced spontaneous rupture. Two girls had a fistula formed after spontaneous rupture, with frequent secretion from the fistula; each was diagnosed with a first brachial cleft anomaly, and later needed a superficial parotidectomy (Fig. 1). One suffered from recurrence of the parotid abscess, as well. A needle aspiration guided by ultrasound was used in four cases to drain the abscess. In two cases, a surgical incision was needed later (Table 2). All surgical procedures were performed under general anesthesia, and did not lead to fistula formation. There was no need for more radical surgery in the acute phase. In addition to drainage, all patients received broad-spectrum IV antibiotic therapy, in most cases a combination of metronidazole with penicillin or cefuroxime; one case received clindamycin. Length of hospitalization ranged from 2 to 9 days, median 5.4. No patients had facial nerve palsy due to infection or surgery. The first follow-up visit took place within 1 month. All children were symptom-free after a few months except for the two girls with first brachial cleft fistulas. One boy had a suspicious lymph node in the cauda of the parotid gland which did not resolve within 3 months, whereupon a biopsy was done. The pathological results were consistent with the infection, with no evidence of other kind of pathology.
4. Discussion Our retrospective study provided 10 children having an abscess during a 10-year period; none
R.T. Saarinen et al. had problems in oral hygiene, and their overall health was good. Four had suffered from previous parotitis or parotid-related symptoms during the 2 preceding years, but in six cases the abscesses arose as a complication of the first episode of acute parotis. First brachial cleft fistula is a low-incidence anomaly that can lead to fistula formation and result in frequent suppuration of the parotid gland. Surgical treatment can achieve a permanent cure [12]. In conjunction with their abscess evaluation, two girls were diagnosed with a first brachial cleft fistula; each had an inflammatory opening in the periauricular area with frequent secretion and underwent superficial parotidectomy. One also had a reoccurrence of the parotid abscess before the operation. It is possible that a third child has an undiagnosed brachial cleft, as his abscess ruptured in the ear canal. He has, however, been symptom-free since. Ductal stones are rare in children and none of the children in our study had ductal pathology of any kind, which supports the fact that parotid abscess formation is in most cases of non-obstructive origin. Similar findings have also been reported in adults [2]. Various bacteria cause suppuration of the parotid gland, with Staphylococcus aureus and anaerobic bacteria the commonest pathogens reported and streptococci encountered, as well [1,2,4]. There is even one case report of a candidal parotid abscess [13]. In our study, Haemophilus influenzae was cultured in three samples and streptococci in one (Streptococcus pneumoniae). In three cases, the fact that cultures remained negative may have been due to antibiotic therapy started prior to sampletaking. Tuberculosis of the parotid gland is rare even where the disease is endemic. Patients usually have long-duration swelling of the parotid gland together with systemic symptoms such as cough, fever, and weight loss [14,15]. We had one girl diagnosed with a parotid abscess caused by Mycobacterium tuberculosis. She presented with a large parotid abscess which did not react to conventional antibiotic and surgical treatment in the manner expected. She began to recover only after results of bacterial culture led to correct treatment for tuberculosis. The possibility of tuberculosis should thus be kept in mind even in non-endemic areas, especially if the disease does not react to therapy. If tuberculosis is suspected, and the first culture remains negative, a second culture is advisable. Surgical drainage is considered necessary when an abscess has formed [1]. Methods include quite radical procedures such as multiple drainage incisions or rising of a full posterior-based flap as for parotidectomy. But it seems that in most cases quite
Parotid abscesses in children a small procedure is enough [2], especially when modern imaging techniques can assist in the procedure, and broad-spectrum antibiotic therapy is included. Ultrasound imagining is useful as the initial diagnostic method and for assistance in the surgical incision [11], although with the use of ultrasound alone, one cannot say in all cases, if the abscess were in parotid gland or a suppurative lymph node within the parotid. In our study none of the patients underwent radical drainage procedures. More radical procedures may lead to poor wound healing, fistula formation, and poor cosmetic outcome and therefore should be avoided. Facial nerve dysfunction has been related to parotitis [16] as well as to parotid abscesses [17] in adults. None of our children developed facial nerve dysfunction due to the infection or surgery. Since the parapharyngeal space lies in close connection to the parotid gland, infection may spread, causing dangerous complications [5,6] such as mediastinitis. Early intervention is thus needed. Our series included no mediastinitis nor other spread of infection. Nowadays in developed countries, the most common cause of parotid swelling in childhood is juvenile parotitis [9]. Infections are the second most common, and parotid abscesses represent a small portion of these. However, other causes of parotid symptoms should be kept in mind. Pleomorphic adenoma is the most common benign lesion of the parotid gland in children, and malignancy is also a possibility [18]. All our children were asked for a follow-up visit and either ultrasound investigation or MRI was performed at this point. It should be kept in mind that lymph nodes can be found inside the parotid gland [9]. In our study one boy had a biopsy of an imaged intraglandular lymph node which in pathological investigation showed a normal inflammatory reaction. This study shows that parotid abscesses in children are multi-bacterial infections and not always related to other parotid gland pathologies. Intravenous antibiotic therapy is the cornerstone of treatment, but surgical drainage assists in recovery and does not lead to fistula formation. The antibiotic treatment should be started immediately after diagnosis, and if improvement does not occur within 48 h, or the symptoms are severe, surgical intervention is required. A parotid abscess in childhood is
901 a rare condition, and gaining clinical expertise in this field is not easy.
References [1] I. Brook, Acute bacterial suppurative parotitis: microbiology and management, J. Craniofac. Surg. 14 (2003) 37—40. [2] R. Ganesh, T. Leese, Parotid abscess in Singapore, Singapore Med. J. 46 (2005) 553—556. [3] S. Nusem-Horowitz, M. Wolf, A. Coret, J. Kronenberg, Acute suppurative parotitis and parotid abscess in children, Int. J. Pediatr. Otorhinolaryngol. 32 (1995) 123—127. [4] M.S. Giglio, M. Landaeta, M.E. Pinto, Microbiology of recurrent parotitis, Pediatr. Infect. Dis. J. 16 (1997) 386—390. [5] G. Marioni, R. Bottin, A. Tregnaghi, M. Boninsegna, A. Staffieri, Craniocervical necrotizing fasciitis secondary to parotid gland abscess, Acta Otolaryngol. 123 (2003) 737— 740. [6] R. Kishore, K. Ramachandran, C. Ngoma, N.J. Morgan, Unusual complication of parotid abscess, J. Laryngol. Otol. 118 (2004) 388—390. [7] H. Peltola, I. Davidkin, M. Paunio, M. Valle, P. Leinikki, O.P. Heinonen, Mumps and rubella eliminated from Finland, JAMA 284 (2000) 2643—2647. [8] V.V. Chitre, D.J. Premchandra, Recurrent parotitis, Arch. Dis. Child 77 (1997) 359—363. [9] K.L. Kolho, R. Saarinen, A. Paju, J. Stenman, U.H. Stenman, A. Pitkaranta, New insights into juvenile parotitis, Acta Paediatr. 94 (2005) 1566—1570. [10] R. Laskawi, F. Schaffranietz, C. Arglebe, M. Ellies, Inflammatory diseases of the salivary glands in infants and adolescents, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 129— 136. [11] N. Gritzmann, T. Rettenbacher, A. Hollerweger, P. Macheiner, E. Hubner, Sonography of the salivary glands, Eur. Radiol. 13 (2003) 964—975. [12] J.M. Triglia, R. Nicollas, V. Ducroz, P.J. Koltai, E.N. Garabedian, First branchial cleft anomalies: a study of 39 cases and a review of the literature, Arch. Otolaryngol. Head Neck Surg. 124 (1998) 291—295. [13] E. Even-Tov, A. Niv, M. Kraus, M. Nash, Candida parotitis with abscess formation, Acta Otolaryngol. 126 (2006) 334—336. [14] A.M. Suleiman, Tuberculous parotitis: report of 3 cases, Br. J. Oral. Maxillofac. Surg. 39 (2001) 320—323. [15] A. Chatterjee, M. Varman, T.W. Quinlan, Parotid abscess caused by mycobacterium tuberculosis, Pediatr. Infect. Dis. J. 20 (2001) 912—914. [16] J.C. Andrews, E. Abemayor, D.M. Alessi, R.F. Canalis, Parotitis and facial nerve dysfunction, Arch. Otolaryngol. Head Neck Surg. 115 (1989) 240—242. [17] D.R. Smith, G.K. Hartig, Complete facial paralysis as a result of parotid abscess, Otolaryngol. Head Neck Surg. 117 (1997) S114—S117. [18] L.J. Orvidas, J.L. Kasperbauer, J.E. Lewis, K.D. Olsen, T.G. Lesnick, Pediatric parotid masses, Arch. Otolaryngol. Head Neck Surg. 126 (2000) 177—184.
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Cases presenting as parotid abscesses in children Riitta T. Saarinen a,*, Kaija-Leena Kolho b, Anne Pitka ¨ranta a a b
Department of Otorhinolaryngology, Helsinki University Central Hospital, Helsinki, Finland Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland
Received 2 November 2006; received in revised form 5 February 2007; accepted 17 February 2007
KEYWORDS Suppurative parotitis; Mycobacterium Tuberculosis; First brachial cleft fistula
Summary Background: A parotid abscess is a rare complication of acute suppurative parotitis which most often requires hospitalization, intravenous antibiotic therapy, and surgical drainage. Objective: To investigate the clinical picture, treatment, and prognosis of children with a parotid abscess in a search for optional clinical guidelines for treatment. Methods: A retrospective chart review was performed for 10 children (age 17) with a parotid abscess between January 1996 and December 2005. Results: Of the 10 cases of parotid abscess found, 4 children had had parotid-related symptoms before; bacterial culture was positive in 6; 4 had aerobic Gram-positive pathogens, and 1 girl had parotid tuberculosis. All patients received intravenous antibiotic therapy. The initial diagnostic method was ultrasound in nine cases and MRI in one. Four children underwent surgical drainage, and in three cases there was an ultrasound guided needle aspiration of the abscess. Neither surgical drainage nor aspiration led to fistula formation or any other complication. The abscess ruptured spontaneously through the skin of the periauricular area in two cases and into the ear canal in one. During follow-up, all were symptom-free except for two girls diagnosed with first brachial cleft fistulas. One of these also had a reoccurrence of the parotid abscess. Both later underwent superficial parotidectomy due to persistent symptoms. Conclusions: Most parotid abscesses in children are acute multi-bacterial infections not necessarily related to other parotid gland pathologies. Intravenous antibiotic therapy is the cornerstone of treatment, but surgical drainage assists in recovery and should not lead to fistula formation. # 2007 Elsevier Ireland Ltd. All rights reserved.
1. Introduction * Corresponding author at: Department of Otorhinolaryngology, Helsinki University Central Hospital, P.O. Box 220, Haartmaninkatu 4E, 00029 HUS, Finland. Tel.: +358 50 4271 496. E-mail address: [email protected] (R.T. Saarinen).
One rare complication of acute suppurative parotitis — related in adults to poor oral hygiene, long-term debility, and reduction in salivary flow [1] — is a
0165-5876/$ — see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2007.02.011
898
R.T. Saarinen et al.
parotid abscess. However, such an abscess can also appear in relatively young and fit adults with no history of oral pathologies [2]. It has been suggested that acute suppurative parotitis sometimes leads to abscess formation with ‘‘no significant difference in predominating factors in these two entities’’ [3]. In children, few reports of parotid abscesses exist. Various bacteria have been reported to be involved in the parotid inflammation process; the most common being Staphylococcus aureus and anaerobic bacteria in adults [1]. Streptococcus pneumoniae and Haemophilus influenzae have been reported to be among the most common pathogens in recurrent suppurative parotitis [4]. The symptoms of a parotid abscess include marked swelling of the angle of the jaw, and pain while eating. Regional lymphadenitis may occur, as well as purulent secretion from Stensen’s duct. The treatment includes broad-spectrum IV antibiotics, good oral hygiene, and adequate hydration. If an abscess has formed, surgical drainage is advisable [1]. A parotid abscess is a potentially life-threatening disease, since the inflammation can spread to the head and neck causing fasciitis [5] or deeper head and neck abscesses [6]. Most often, parotitis in childhood and adolescence is of non-bacterial origin. Before the era of vaccination, mumps was the most common cause of parotid inflammation [7]. In recurrent juvenile parotitis, painful swellings of the parotid gland and symptom-free periods alternate. Usually, the overall condition of the patient is good, and symptoms can be treated with painkillers alone [8,9]. We have shown, however, that recurrences are common [9]. If pus is detected from Stensen’s duct or the patient’s symptoms are severe, the possibility of acute suppurative parotitis must be considered, and antibiotic treatment is necessary [1,10]. If the clinical symptoms indicate the possibility of abscess
formation, an ultrasound investigation is advisable as the initial diagnostic method [11].
2. Methods The data base of the Helsinki University Central Hospital according to the Classification on Diseases, 10th revision (ICD-10) was searched in otorhinolaryngological patients aged 17 or under who were treated in our institution between January first, 1996, and December 31st, 2005. The diagnostic codes for parotid illnesses and for abscesses in the head and neck region were both included. After review of the patient charts the number of parotid abscesses in children within this time-period totaled 10. The catchment area of Helsinki University Central Hospital covers approximately 1,500,000 inhabitants, and all the children and adolescents suffering from parotid abscess have most likely been admitted to our institution, which is a tertiary centre and the only on-call otorhinolaryngological clinic in the area. Clinical data recorded included age, gender, site of disease, laboratory results, imaging, drainage methods, time of hospitalization, bacteria, antibiotics used, and outcome, as well as other illnesses of importance such as juvenile parotitis, anomalies, and general health. The ethics committee of Helsinki University Central Hospital approved the study protocol.
3. Results A total of 10 children (median age 10, range 2.2—16.8, female 5) suffering from a parotid abscess during the 10-year time-period were retrieved (Table 1). This indicates an annual
Table 1 Characteristics of the 10 children at admission Age (years) 2.2 2.3 5.9 8.2 9.3 10.0 10.8 11.1 11.1 16.8
Gender F M F M M M F F F M
Side Right Right Left Left Left Right Right Right Left Right
Temp. (8C) 37.8 37.8 38.0 NM 37.2 37.0 37.8 38.0 NM 38.1
CRP = C-reactive protein. NM = Not measured. a Reference rage <10 mg/l. b Reference rage 5—14 E9/l. * Elevated value.
CRPa (g/l) 10 38 * 47 * 12 * 12 * 95 * 56 * 92 * NM 79 *
Leucocytesb (xE9/l) *
20.7 18.2 * 20.8 * 7.8 11.1 12.4 12.7 8.0 7.6 8.1
Previous parotitis No No Yes Yes No No Yes No No Yes
Parotid abscesses in children
899
incidence of 0.067 cases per 100,000 inhabitants aged 17. The right side was affected more often (six cases). Four children had suffered from previous parotitis or parotid-related symptoms during the preceding 6—24 months. One girl had a parotid sialadenitis 1.5 months earlier, and one boy had a history of mild swellings of the parotid region several times during the preceding 1.5 years without specific diagnosis. Another girl had had recurrent symptoms of sialadenitis during previous 8 months, and she was later diagnosed to have a first brachial cleft anomaly. Another boy had had eight recurrences of sialadenitis within 2 previous years, and he also had two mild infections afterwards (Table 1). Two girls (aged 2.2 and 5.9) had first brachial cleft fistulas and underwent superficial parotidectomy later; one of these two had a recurrence of a parotid abscess before the operation and the other had had a cleft of lip and palate operation as a toddler. None of the others had any recurrence of an abscess during follow-up. The general health of all patients was good. All children had received per oral antibiotic treatment before hospitalization and bacterial culture; each receiving cefalexine, and one girl at first receiving a combination of amoxicillin and clavulanic acid and thereafter cefalexine. Duration of antibiotic treatment ranged from 7 to 15 days, and eight children developed the abscess during the treatment, two children a few days afterwards. Bacterial cultures were positive for Haemophilus Influenzae (n = 3), and one each Streptococcus pneumoniae,
Proteus mirabilis, and Mycobacterium tuberculosis. In three cases, bacterial culture remained negative, and in one case no culture was performed (Table 2). The girl with Mycobacterium tuberculosis infection was of African origin. Her infection was later shown to have affected her lungs, as well. Her presenting symptoms were right-sided swelling of the parotid gland, trismus, and moderate fever, but no cough. At first she was treated with per oral cephalosporin for suppurative parotitis, but her symptoms persisted, and she developed a large parotid abscess that when needle aspirated twice under ultrasound guidance yielded 20 and 40 ml of pus. Finally, a surgical incision was made, but she did not react as expected to treatment with metronidazole and cefuroxime. Mycobacterium tuberculosis was cultured from both pus samples, and she responded to proper therapy. Additionally, bacterial culture for tuberculosis in three other cases of pediatric parotid abscess showed these cultures to be negative. All patients had similar symptoms prior to admission: mild to moderate fever, swelling of the parotid region, cellulites, and pain. None had bilateral symptoms or symptoms of septic infection nor had any history of oral pathology. No patients were tested for mumps, since MPR vaccination (Mumps, Pertussis, and Rubella) has been part of the Finnish National Vaccination Program since 1982. All 10 children were diagnosed to have a collection of pus within the parotid gland. In nine cases an ultrasound was the initial diagnostic method and in one case MRI (Fig. 1). Five children had MRI later to
Table 2 Microbiological findings and therapy of 10 children with a parotid abscess Bacteria
Intra-venous antibiotics
Drainage
Imaging
Antibiotics prior to hospitalization
Negative
Metronidazole and Penicillin
Spontaneous
MRI
Negative
Metronidazole Cefuroxime Clindamycin Metronidazole Cefuroxime Metronidazole Cefuroxime Cefuroxime Metronidazole Cefuroxime Treatment for tuberculosis Metronidazole Amoxicillin Cefuroxime
US and MRI
and
Needle aspiration and incision Spontaneous Needle aspiration
Amoxicillin and Clavulanic acid po, Cefalexin po Cefalexin po
US and MRI US
Cefalexin po Cefalexin po
and
Needle aspiration
US
Cefalexin po
and
Spontaneous Incision
US and MRI US and MRI
Cefalexin po Cefalexin po
US
and
Needle aspiration and incision Incision
US and MRI
Cefalexin and Metronidazole po Cefalexin po
Incision
US and sialography
Cefalexin po
Haemophilus influenzae Not known Streptococcus pneumoniae Haemophilus influenzae Haemophilus influenzae Mycobacterium tuberculosis Proteus mirabilis Negative Po = per oral.
and
900
Fig. 1 MRI of a 2-year-old girl with a right-sided parotid abscess (arrow).
exclude neoplasms and malformations, and one boy underwent sialography. In seven cases, the abscess was drained, and three experienced spontaneous rupture. Two girls had a fistula formed after spontaneous rupture, with frequent secretion from the fistula; each was diagnosed with a first brachial cleft anomaly, and later needed a superficial parotidectomy (Fig. 1). One suffered from recurrence of the parotid abscess, as well. A needle aspiration guided by ultrasound was used in four cases to drain the abscess. In two cases, a surgical incision was needed later (Table 2). All surgical procedures were performed under general anesthesia, and did not lead to fistula formation. There was no need for more radical surgery in the acute phase. In addition to drainage, all patients received broad-spectrum IV antibiotic therapy, in most cases a combination of metronidazole with penicillin or cefuroxime; one case received clindamycin. Length of hospitalization ranged from 2 to 9 days, median 5.4. No patients had facial nerve palsy due to infection or surgery. The first follow-up visit took place within 1 month. All children were symptom-free after a few months except for the two girls with first brachial cleft fistulas. One boy had a suspicious lymph node in the cauda of the parotid gland which did not resolve within 3 months, whereupon a biopsy was done. The pathological results were consistent with the infection, with no evidence of other kind of pathology.
4. Discussion Our retrospective study provided 10 children having an abscess during a 10-year period; none
R.T. Saarinen et al. had problems in oral hygiene, and their overall health was good. Four had suffered from previous parotitis or parotid-related symptoms during the 2 preceding years, but in six cases the abscesses arose as a complication of the first episode of acute parotis. First brachial cleft fistula is a low-incidence anomaly that can lead to fistula formation and result in frequent suppuration of the parotid gland. Surgical treatment can achieve a permanent cure [12]. In conjunction with their abscess evaluation, two girls were diagnosed with a first brachial cleft fistula; each had an inflammatory opening in the periauricular area with frequent secretion and underwent superficial parotidectomy. One also had a reoccurrence of the parotid abscess before the operation. It is possible that a third child has an undiagnosed brachial cleft, as his abscess ruptured in the ear canal. He has, however, been symptom-free since. Ductal stones are rare in children and none of the children in our study had ductal pathology of any kind, which supports the fact that parotid abscess formation is in most cases of non-obstructive origin. Similar findings have also been reported in adults [2]. Various bacteria cause suppuration of the parotid gland, with Staphylococcus aureus and anaerobic bacteria the commonest pathogens reported and streptococci encountered, as well [1,2,4]. There is even one case report of a candidal parotid abscess [13]. In our study, Haemophilus influenzae was cultured in three samples and streptococci in one (Streptococcus pneumoniae). In three cases, the fact that cultures remained negative may have been due to antibiotic therapy started prior to sampletaking. Tuberculosis of the parotid gland is rare even where the disease is endemic. Patients usually have long-duration swelling of the parotid gland together with systemic symptoms such as cough, fever, and weight loss [14,15]. We had one girl diagnosed with a parotid abscess caused by Mycobacterium tuberculosis. She presented with a large parotid abscess which did not react to conventional antibiotic and surgical treatment in the manner expected. She began to recover only after results of bacterial culture led to correct treatment for tuberculosis. The possibility of tuberculosis should thus be kept in mind even in non-endemic areas, especially if the disease does not react to therapy. If tuberculosis is suspected, and the first culture remains negative, a second culture is advisable. Surgical drainage is considered necessary when an abscess has formed [1]. Methods include quite radical procedures such as multiple drainage incisions or rising of a full posterior-based flap as for parotidectomy. But it seems that in most cases quite
Parotid abscesses in children a small procedure is enough [2], especially when modern imaging techniques can assist in the procedure, and broad-spectrum antibiotic therapy is included. Ultrasound imagining is useful as the initial diagnostic method and for assistance in the surgical incision [11], although with the use of ultrasound alone, one cannot say in all cases, if the abscess were in parotid gland or a suppurative lymph node within the parotid. In our study none of the patients underwent radical drainage procedures. More radical procedures may lead to poor wound healing, fistula formation, and poor cosmetic outcome and therefore should be avoided. Facial nerve dysfunction has been related to parotitis [16] as well as to parotid abscesses [17] in adults. None of our children developed facial nerve dysfunction due to the infection or surgery. Since the parapharyngeal space lies in close connection to the parotid gland, infection may spread, causing dangerous complications [5,6] such as mediastinitis. Early intervention is thus needed. Our series included no mediastinitis nor other spread of infection. Nowadays in developed countries, the most common cause of parotid swelling in childhood is juvenile parotitis [9]. Infections are the second most common, and parotid abscesses represent a small portion of these. However, other causes of parotid symptoms should be kept in mind. Pleomorphic adenoma is the most common benign lesion of the parotid gland in children, and malignancy is also a possibility [18]. All our children were asked for a follow-up visit and either ultrasound investigation or MRI was performed at this point. It should be kept in mind that lymph nodes can be found inside the parotid gland [9]. In our study one boy had a biopsy of an imaged intraglandular lymph node which in pathological investigation showed a normal inflammatory reaction. This study shows that parotid abscesses in children are multi-bacterial infections and not always related to other parotid gland pathologies. Intravenous antibiotic therapy is the cornerstone of treatment, but surgical drainage assists in recovery and does not lead to fistula formation. The antibiotic treatment should be started immediately after diagnosis, and if improvement does not occur within 48 h, or the symptoms are severe, surgical intervention is required. A parotid abscess in childhood is
901 a rare condition, and gaining clinical expertise in this field is not easy.
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