J. Paediatr.
Child Health (2002) 38, 92–94
Instructive Case
Recurrent parotitis
D ISAACS
The Children’s Hospital at Westmead, Westmead New South Wales, Australia
CASE REPORT
A 13-year-old boy, the fourth child of non-consanguineous
parents, presented with acute swelling of 48 h duration of his
right parotid gland. Over the previous 4 years he had experi-
enced more than 10 episodes of parotid swelling, all but one of
them unilateral, and with either the right or the left gland
swollen. Typically, these episodes started as a slight swelling
and tenderness of the gland and progressed rapidly over 24 h to
become enlarged and tender, with some overlying redness.
Eating was painful. The swelling would resolve spontaneously
over 2–7 days. The pain was helped by paracetamol–codeine
(Panadeine Forte). There was no family history of parotid
swelling. Eight days earlier, when asymptomatic, the boy’s
general practitioner had ordered plain radiographs and ultra-
sound of the parotids. The X-rays were normal, but the ultra-
sound showed a ‘mildly inhomogeneous appearance bilaterally
with scattered small nodules’. No stones were seen and there
was no evidence of obstruction.
On this occasion, the pain and swelling were no more severe
than usual. The boy was referred to the oral surgeon. He was
febrile, 38.5°C, unable to fully open his mouth, and tender over
his right parotid gland, which was enlarged with overlying
redness. Gentle pressure over the gland did not cause any
discharge from the parotid duct.
The patient was admitted to hospital with a presumptive
diagnosis of purulent parotitis, and started on intravenous
antibiotics.
A blood count was found to be essentially normal (haemo-
globin (Hb) 127 g/L, white blood cell (WBC) count 9.6 ×
109/L, neutrophils 7.4, platelets 215, erythrocyte sedimentation
rate (ESR) 17 mm/h). Mumps serology was positive for IgG,
but neg-ative for IgM. Antinuclear antibody was negative.
Serum immunoglobulin levels were normal. An urgent
computed tomographic (CT) scan with contrast showed the
right parotid to be bulkier than the left, and of increased
density. There was ‘diffuse thickening immediately anterior to
the right parotid, which is a thickened masseter muscle,
and . . . overlying subcutaneous fat thickening’. The appear-
ance was interpreted as an extensive inflammatory process
involving the right parotid gland and extending anteriorly into
the right masseter and overlying subcutaneous tissues.
After 24 h the patient was afebrile, the swelling had
reduced, but he still had markedly limited mouth opening
capacity. A fine needle aspirate biopsy of the parotid gland,
Correspondence: Dr D Isaacs, The Children’s Hospital at Westmead, Locked Bag 4001, Westmead New South Wales 2145, Australia.
Fax: +61 2 9845 3421; email: davidi@chw.edu.au
Accepted for publication 29 March 2001.
performed under local anaesthetic, showed non-specific
inflammatory changes and no growth from cultures. The
patient found this procedure exceedingly painful.
The patient remained afebrile and well, but the gland was
very tender for the next 2–3 days. He was discharged home
after 5 days, continued on oral antibiotics for 10 days and
referred as an outpatient to the Immunology and Infectious
Diseases Department.
It was felt that the patient’s diagnosis was recurrent parotitis
of childhood, an idiopathic condition, distinct from acute suppu-
rative parotitis. In retrospect, the ultrasound scan was consistent
with bilateral punctate sialectasis, which is typical of recurrent
parotitis (Fig. 1). It was advised that future exacerbation should
be managed with analgesia alone, and that the natural history of
this condition was of spontaneous improvement with time. There
is usually complete resolution after puberty.
DISCUSSION
Recurrent parotitis has been defined as recurrent parotid
inflammation, generally associated with non-obstructive sialec-
tasis of the parotid gland.1,2 An alternative name is juvenile
recurrent parotitis.3 The condition should be distinguished from
suppurative parotitis, in which pus can easily be expressed
from the parotid duct.4
The usual age of onset is 3–6 years, but this was found to
vary from 3 months to 16 years in the series of Ericson et al.
comprising 20 patients.5 Recurrent parotitis is most often
described in children and tends to resolve after puberty.1–5
However, Watkin and Hobsley reported a series of 68 patients
of whom only 26 had onset in childhood.6 Childhood onset
disease is usually more common in males by about 3:1, but in
adult-onset disease women predominate by 7.5:1.6
The number of attacks varies from one to five per year,
averaging three or four, but patients have been described with
20 or more attacks per year.1–5 The frequency tends to peak at
school age (5–7 years), and 80–90% resolve by puberty.1,2,5
Pain and swelling lasts about 2–14 days, and resolves spon-
taneously. There is no evidence that antibiotics affect the
duration of episodes.1–5 Fever and redness are common, but at
most, a drop of white mucopus may be expressed from the
parotid duct, and this grows normal mouth flora.5 Symptoms
are more often unilateral than bilateral, but the affected side
may alternate2 (Fig. 2).
Recurrent parotitis 93

Fig. 1 Ultrasound of the superficial lobes of both parotid glands. The right is relatively normal. The left contains a large lymph node and multiple,
hypoechoic, ovoid nodules, 2–3 mm in diameter, suggestive of sialectasis.

The hallmark of recurrent parotitis is sialectasis, which is

usually bilateral, even if one gland is symptom-free. Sialectasis
was originally diagnosed by sialography, but ultrasound has
superseded this technique. Both sialograms and ultrasound
scans can exclude the presence of stones. In recurrent parotitis,
the sialectasis is typically of scattered punctate or globular
swelling of the peripheral ducts.5
The pathogenesis of recurrent parotitis remains unknown.
Hamilton Bailey, in 1945, suggested congenital anomaly of the
ductal system, analogous to congenital bronchiectasis,7 but there
is no evidence to support this theory, which also does not explain
resolution with time. Others have suggested that low salivary
flow rate, either primary or due to infection, might predispose to
inflammation. The histopathological picture includes periductal
lymphocytic infiltration,5 and auto-immune or other immuno-
logical mechanisms have been proposed. Most children with
recurrent parotitis have no demonstrable immune deficit, but
children with immunoglobulin deficiency, such as those with
common variable immunodeficiency, may sometimes present
with recurrent parotitis.8,9 For this reason it is recommended to
measure serum immunoglobulin levels in children with recurrent
parotitis. Persistent parotid swelling is caused by HIV infection
as part of a generalized lymphadenopathy, and should not cause
problems in differential diagnosis.

Treatment

The treatment for recurrent parotitis is controversial. Because

of the frequency and duration of attacks, opiate analgesics
should generally be avoided: we have seen one teenage boy
become addicted to pethidine. However, adequate analgesia is
important. Although antibiotics are often prescribed, it has not
been shown that they shorten attacks, which tend to resolve
Fig. 2 Child with unilateral parotid swelling. whether or not antibiotics are given. Unproven interventions
94
include warmth, massage, duct probing and sialagogic agents
(e.g. lemon juice) to stimulate saliva flow. Radical inter-
ventions are equally unproven, but this has not stopped the
occasional use of radiotherapy, parotid duct ligation and
parotidectomy (curative, but with an associated risk of facial
nerve palsy).2 In general, most children need little intervention
except analgesia and reassurance.
SUMMARY
• Recurrent parotitis presents with intermittent swelling of one or
both parotid glands, pain, fever and redness.
• Recurrent parotitis is different from suppurative parotitis, because
of the recurrence history and the inability to express pus from the
parotid duct.
• Recurrent parotitis can usually be confirmed by finding punctate
sialectasis of one or both glands by ultrasound (or sialogram).
• Serum immunoglobulins should be measured, although they are
usually normal.
• Antibiotics have not been shown to be beneficial.
• Children with recurrent parotitis are at risk of over-investigation
and over-treatment.
D Isaacs
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