HK J Paediatr (new series) 2011;16:36-40

Recurrent Parotitis in Children

NW LI, WM CHAN, YW KWAN, CW LEUNG

Abstract Recurrent parotitis of childhood is the second most common disease of salivary glands in children next to
mumps. It is defined as recurrent parotid inflammation that is non-obstructive and non-suppurative.
However, the aetiology and management of this disease remains controversial. We report a series of 5
children presenting with this condition who were investigated by ultrasonography and sialography. All of
them were managed conservatively. The aetiology, diagnosis and treatment of this condition is reviewed.
A management plan for this disease is formulated to prevent over-investigated and over-treated situations.

Key words Children; Parotitis; Recurrent

Introduction ultrasonography of the parotid glands. Management of

recurrent parotitis is also controversial. While most tend to
Recurrent parotitis of childhood, or juvenile recurrent treat conservatively with antibiotics and analgesics, 2,4
parotitis, is referred as repeated episodes of parotid gland aggressive therapies have been suggested for the more
inflammation that is non-obstructive and non-suppurative. persistent symptoms, but results vary.2
It is the second most common disease of the salivary gland
in children following mumps.1
The aetiology and pathogenesis of this disease however Case Series
remains uncertain. It is most believed to have a multifactorial
cause such as congenital malformation of the parotid glands In this case study, five children presenting with this
leading to retrograde infection, allergy and the association condition were identified in the hospital discharge database
with auto-immune diseases.2,3 The diagnosis is mainly based of Princess Margaret Hospital from 2006 to 2009. Their
on history taking and physical examination which characteristics, investigation results and imaging findings
is confirmed by imagings such as sialography and were summarised in Tables 1, 2 and 3. The typical
presentation and imaging findings of recurrent parotitis in
one of the patients will be further described. Literature
review of the etiology, diagnosis and treatment of this
condition will also be discussed. Based on this case study
Department of Paediatrics and Adolescent Medicine, Hospital
Authority Infectious Disease Centre, Princess Margaret
and the literature review, we hope to formulate a
Hospital, Lai King Hill Road, Kwai Chung, Kowloon, Hong management plan for this disease to prevent children from
Kong, China being over-investigated and over-treated.
Four of the 5 patients were admitted through the Accident
NW LI MBChB
WM CHAN FHKAM(Paed), FHKCPaed, MRCPCH and Emergency Department and 1 was referred from
YW KWAN FHKAM(Paed), FHKCPaed, MRCPCH another hospital for further investigation of the recurrent
CW LEUNG FHKAM(Paed), FHKCPaed, FRCPCH parotid swelling. The age distribution is between 3 to 5
years old, and the number of recurrence ranges from 2 to 6
Correspondence to: Dr NW LI
times (Table 1). Blood investigation showed a normal or
Received July 29, 2010 elevated white cell count, and 2 out of the 5 patients had an
Li et al 37

elevated amylase level. Screening for auto-immune markers Case Report

including IgA, IgG, IgM and rheumatoid factor, and saliva
for mumps virus culture and serology were all negative A 5-year-old girl complained of acute onset of painful
(Table 2). Parotid sialography was performed in all of them swelling at the right angle of her jaw for 1 day. Mastication
and all showed evidence of dilated branches suggestive of was painful. She did not have fever, respiratory symptoms,
sialectasis. These findings corresponded to the multiple history of local trauma to her face or recent contact with
hypoechoic areas in the parotid gland seen in the persons suspected of having had mumps parotitis. She was
ultrasonography which was performed in 2 of the patients born in Hong Kong and had completed her primary
(Table 3). All 5 children were treated conservatively with immunisation including a dose of MMR vaccine. She had
analgesics and empirical antibiotics before exclusion of a history of right parotitis in 2005, which was confirmed
suppurative parotitis. They were followed up in our not to be mumps by a negative mumps saliva serology and
paediatric infectious disease clinic. was treated with a course of amoxicillin. No cause of the

Table 1 Characteristics of children with recurrent parotitis hospitalised at Princess Margaret Hospital from 2006 to 2009
Sex Date of Age at onset Number of Imaging study Management
1st presentation (year) recurrence
1) Female 2005 5 2 Sialography ultrasonography Antibiotics + analgesics
2) Male 2006 4 5 Sialography Antibiotics + analgesics
3) Female 2008 5 3 Sialography Antibiotics + analgesics
4) Male 2008 5 6 Sialography ultrasonography Antibiotics + analgesics
5) Female 2009 3 4 Sialography Antibiotics + analgesics

Table 2 Investigation results of blood (white cell count, amylase and autoimmune markers) and saliva for the five children
White cell count/ Amylase Autoimmune markers Saliva for mumps culture
neutrophils (IgA, IgG, IgM and rheumatoid factor) and serology
1) 25/22.8 468 Normal Negative
2) 7.8/3.9 1005 Not done Negative
3) 9.6/2.4 266 Not done Negative
4) 10.2/6.7 113 Not done Negative
5) 18.9/15.9 274 Normal Negative

Table 3 Sialography and ultrasonography findings for the five children

Sialography Ultrasonography
1) Puntate sialectasis + poor emptying of contrast in delay film Small hypoechoic areas in parotid gland
2) Dilated terminal side branches + poor emptying of contrast in delay film Not done
3) Dilated terminal side branches + poor emptying of contrast in delay film Not done
4) Globular sialectasis with parenchymal cystic changes + upholding of Multiple hypoechoic areas in parotid gland
contrast in cystic areas in delay film
5) Dilated terminal side branches + poor emptying of contrast in delay film Not done
38 Recurrent Parotitis in Children

disease was identified at that time. Physical examination

showed a 2-3 cm soft tender swelling over the right angle
of jaw with ill-defined border, corresponding to the
anatomical region of the right parotid gland. There were
no dental caries and the right Stenson's duct opening was
not inflammed. No stone or pus could be expressed through
the opening on bimanual palpation and local massage of
the enlarged right parotid gland. Blood tests showed a high
amylase level of 468 U/L (normal range: 38-135 U/L) and
elevated white cell count of 25.13 x 109/L (neutrophil count
22.8 x 109/L). Autoimmune markers including anti-nuclear
antibody and rheumatoid factor, and immunoglobulin
pattern were all normal. Saliva for virus culture and mumps
serology were also negative. The patient was treated with
analgesics and empirical antibiotic (Augmentin). The
swelling resolved spontaneously within a week.

Right parotid sialogram was performed which showed

multiple puntate glandular collections suggestive of puntate
sialectasis and delayed images showed mild uphold of
contrast medium in small ducts (Figures 1 and 2).
Ultrasonography of right parotid gland showed multiple
hypoechoic nodules corresponding to the puntate sialectasis
in sialogram, and enlarged local lymph nodes (Figure 3).

Figure 2 Delayed sialogram image of the right parotid gland

showing mild uphold of contrast medium in the eccentric small
ducts.

Figure 1 Sialogram of the right parotid gland showing multiple Figure 3 Ultrasound image of right parotid gland showing
puntate glandular collections, 1 mm in diameter, suggestive of multiple hypoechoic nodules suggestive of sialectasis.
puntate sialectasis.
Li et al 39

The girl had a few more recurrence during the next 2 years adequate physical examination. It is distinguished from
and were all managed conservatively by antibiotics and suppurative parotitis by the inability to express pus from
analgesics. She is now followed up as an outpatient in our the parotid duct. Parotid sialogram was the conventional
paediatric infectious disease clinic and is managed tool for confirming sialectasis, which is a characteristic
conservatively with advice of maintaining good oral feature of recurrent parotitis. And in our case study, all of
hygiene and adequate hydration. The number of her disease the patients had sialogram performed, which showed
recurrences has markedly decreased with no recurrence this evidence of sialectasis, and only 2 had ultrasonography of
year. parotid glands done as well. However, sialogram has been
superseded by ultrasonography, which is non-invasive and
has been shown to be equally sensitive as conventional
Discussion sialography. 5 Ultrasonography also provides extra
information such as the presence of stones (sialoliths),
Recurrent parotitis is characterised by intermittent abscesses or mass lesions. As a result, many authors
swelling of unilateral or bilateral parotid glands, often recommend using ultrasound as the investigation of
associated with fever, malaise and pain with mastication choice.2,5 The typical features of recurrent parotitis are the
and swallowing. It is commoner in boys with peak age of formation of puntate or globular sialectasis scattered
onset between 3 to 6 years old. Leerdam et al have found a throughout the gland without any stones or destructive
biphasic age distribution of 2 to 5 years old and 10 years changes (Figure 1).4 Sialogram will show multiple round
old.5 The exacerbation usually lasts for few days, and occurs pools of contrast medium about 2-3 mm in size which
every 3 to 4 months. There is, however, a wide variation in persist in delayed films (Figure 2). These correspond to the
the frequency and severity of attacks. It is usually self- multiple hypoechoic areas seen in ultrasound images
limiting and symptoms generally subside after puberty.1, 2, 5 (Figure 3). Computed tomography, magnetic resonance
Differential diagnoses and associated conditions which need imaging and sialendoscopy are also used to assess the
to be considered include Sjogren's syndrome in older parotid gland but they are not widely used due to the
children, which usually has elevated immunoglobulins; relatively high irradiation risk in the former, and the lack
hypogammaglobulinaemia, and immunodeficiency such as of ready availability for the latter.1,6
common variable immunodeficiency or HIV/AIDS. In our The management of recurrent parotitis in children is
case study, the number of patients is too small to show any controversial. Most authors tend to treat conservatively with
significant pattern in gender and age, but they are all treated analgesics and antibiotics. Although the disease is self-
conservatively with gradual subsiding of symptoms, as they limiting and the use of antibiotics does not shorten the
grow older. However, the time needed for the attacks to length of the disease, it is believed that antibiotics may
subside varies. prevent additional damage to glandular parenchyma.2,4
The aetiology and pathogenesis of recurrent parotitis Chitre et al. propose the use of prophylactic antibiotics for
of childhood remain uncertain. The possibility of preventing recurrence. 2 The evidence for bacterial
congenital malformation of the parotid glands resulting involvement in the pathogenesis is poor, and no studies
in low salivation rate leading to dehydration and thus compare outcome with and without antibiotics. In our case
recurrent retrograde infection has been suggested. 2 study, 2 patients were treated with analgesics only in their
Alternatively, the production of puntate sialectasis is subsequent attacks after having their diagnoses confirmed
proposed to be due to the damage of the duct reticulum by sialogram. Their symptoms resolved in 3 to 4 days which
by lymphocytes, as suggested by the typical histological are of the same length of time compared with antibiotics
picture of lymphocytic infiltration of the intralobular treatment. Unproven interventions such as sialogogic agents
d u c t s . H ow eve r, m o s t o f t h e a u t h o r s favo u r a (e.g. lemon juice), warmth, massage and duct probing to
multifactorial cause. Several have associated the stimulate saliva flow have also been mentioned.7 More
disease with viral or bacterial infection, allergy and auto- aggressive therapy such as radiotherapy, parotid duct
immune diseases. Fazekas et al have reported a ligation and parotidectomy have been suggested for disease
correlation between selective IgA deficiency and persisting to adulthood, but results vary and potential
recurrent parotitis.3 permanent damage to the facial nerve is a serious
The diagnosis of recurrent parotitis is usually made on a concern.2 In general, most children need little intervention
clinical basis as suggested by detailed history taking and except reassurance and analgesia, but they are at risk of
40 Recurrent Parotitis in Children

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