Parotitis

What the parotid glands do

You have three pairs of major salivary glands. The parotids are the largest, lying over the back of the jaw in front of the ears. Each drains saliva into the mouth through a duct (Stensen's duct) that opens on the inside of the cheek opposite the upper second molar. The facial nerve, which moves the face, runs through the gland, which is why parotid surgery requires care and why facial weakness with a parotid swelling is a warning sign.

Symptoms of parotitis

• Swelling in front of the ear and over the angle of the jaw, which can push the earlobe upward and outward
• Pain and tenderness, worse when chewing or when you smell or taste food, because saliva flow increases
• Redness and warmth of the skin in bacterial infection
• A bad taste, or pus coming out of the duct inside the cheek
• Fever, tiredness and aching
• Dry mouth
• Difficulty opening the mouth fully

Types and causes of parotitis

Viral parotitis

Mumps is the classic cause. After 2 to 3 weeks' incubation, it causes fever, headache and tiredness, followed by swelling of one or both parotids, often giving "hamster cheeks". It usually affects unvaccinated people, but outbreaks still occur among vaccinated young adults in close-contact settings such as colleges. Other viruses, including influenza, Epstein-Barr virus, Coxsackie virus, parainfluenza and HIV, can also cause parotid swelling.

Bacterial (acute suppurative) parotitis

Bacterial parotitis happens when saliva flow drops and bacteria from the mouth travel up the duct. Staphylococcus aureus is the commonest cause. It usually affects one side and is more likely with:

• dehydration and reduced eating or drinking
• recent surgery, particularly in older adults
• poor oral hygiene
• medicines that dry the mouth (antihistamines, diuretics, some antidepressants)
• diabetes and weakened immunity

The gland becomes hard, red, hot and very tender, and pressing it may push pus into the mouth.

Obstructive and chronic parotitis

• Salivary stones: less common in the parotid than in the submandibular gland, they cause swelling and pain during meals that eases over an hour or two.
• Duct narrowing (stricture): after repeated infections.
• Juvenile recurrent parotitis: repeated episodes of swelling in children, usually between ages 3 and 6, that often stop by puberty.

Autoimmune and other causes

• Sjögren's syndrome: recurrent or persistent swelling of both parotids with dry eyes and dry mouth. It carries a raised risk of lymphoma, so a gland that becomes persistently enlarged or hard needs review.
• IgG4-related disease and sarcoidosis: cause firm swelling of several glands.
• Medicines and contrast dye: iodine contrast can rarely cause temporary swelling ("iodide mumps").
• Bulimia and malnutrition: cause painless enlargement of both glands.

Parotitis vs other swellings near the jaw

Diagnosis

A doctor examines the gland, looks inside the mouth at the duct opening, and gently massages the gland to see if pus or cloudy saliva comes out. Tests may include:

• Mumps testing (a swab from the inside of the cheek or blood test) if mumps is suspected. Mumps must be reported to public health authorities
• Swab of pus for culture to guide antibiotics
• Ultrasound to look for abscess, stones or a mass
• CT if an abscess is deep or the swelling is spreading
• Blood tests for Sjögren's syndrome antibodies in recurrent cases
• Sialendoscopy: a tiny camera passed into the duct to find and treat stones or strictures

Treatment

Self-care for all types

• Drink plenty of fluids
• Suck sour candies or lemon drops, or chew sugar-free gum, to stimulate saliva and flush the duct (avoid in the first painful days of mumps if it makes pain worse)
• Massage the gland gently from back to front toward the mouth several times a day
• Apply warm compresses
• Rinse the mouth with warm salt water and keep up good oral hygiene
• Use acetaminophen (paracetamol) or ibuprofen at the label dose for pain and fever. Do not give aspirin to children or teenagers

Bacterial parotitis

Antibiotics that cover Staphylococcus aureus and mouth bacteria are needed, by mouth for mild cases and through a vein in hospital for severe ones. An abscess is drained. Improvement is expected within 48 hours.

Mumps

There is no antiviral treatment. People with mumps should stay away from school, work and others for 5 days after the swelling starts.

Recurrent parotitis

Treatment focuses on the cause: removing stones, widening narrowed ducts with sialendoscopy, managing Sjögren's syndrome, and reviewing medicines that dry the mouth. Removing the gland is rarely needed.

Complications

• Abscess in the gland
• Spread of infection into the neck spaces, which can threaten the airway
• Facial nerve weakness, rare and usually linked to a tumor or severe infection
• Mumps complications: inflammation of the testicles (orchitis) or ovaries, meningitis, pancreatitis and hearing loss

Prevention

Two doses of MMR vaccine protect against mumps for most people. Keeping well hydrated, good oral hygiene, and attention to fluids and mouth care after surgery reduce the risk of bacterial parotitis.

Frequently asked questions

What causes parotitis?

The commonest causes are mumps and other viral infections, and bacterial infection, usually Staphylococcus aureus, in people who are dehydrated, unwell or have a dry mouth. Recurrent parotitis can come from salivary stones, duct narrowing, Sjögren's syndrome or juvenile recurrent parotitis in children.

Is parotitis contagious?

Viral parotitis such as mumps is contagious, spreading through saliva and droplets from a few days before to about 5 days after the swelling starts. Bacterial parotitis and swelling from stones or autoimmune disease are not contagious.

How long does parotitis last?

Mumps swelling usually goes down within 7 to 10 days. Bacterial parotitis improves within 2 to 3 days of starting antibiotics and settles over 1 to 2 weeks. Recurrent forms can flare repeatedly until the underlying cause is treated.

Can parotitis go away on its own?

Viral parotitis usually settles without specific treatment. Bacterial parotitis normally needs antibiotics, and delayed treatment can lead to an abscess. See a doctor for a hot, red, very painful swelling or if pus appears inside the cheek.