Ia parotidomegaly swelling is located above and behind the angle of the jaw, in front of the tragus and lobule of the ear flap. She may be :
– Unilateral or bilateral;
– Sudden or gradual onset;
– Asymptomatic or be part of a more general context: infectious, inflammatory, painful, impaired general condition, weight loss.
It is the combination of these different items that guides rather easily to a particular pathology.
PAROTITIS ACUTE:
Viral parotitis:
They are dominated in children or young adults with mumps, including in the vaccinated population.
Mumps:
In 2000, the network “Sentinel” reported 17 000 cases of which 60% were vaccinated and one third had more than 18 years.
Diagnostic:
The disease begins in an infectious context by a sore throat and ear pain and united, more often bilateral. Very quickly appears the parotid swelling.
We must seek testicular locations and neuromeningeal which are fortunately rare but may provide sterility and inappareillable permanent deafness (no complications observed in the 17 000 cases in 2000).
The diagnosis is clinical. If in doubt in an adult, there is a serology that must be redone after two days to be interpreted correctly.
Treatment:
Treatment is symptomatic with rest, antipyretics and analgesics.
Other viruses:
He is reported to parotitis coxsackie A, Echovirus and parainfluenza virus.
Bacterial parotitis:
They occur in another population: rather old and in poor condition.
In these people, the oral fl ora undergoing changes due to various modifi cations oral.
In these infections, most commonly found Staphylococcus aureus and streptococcus viridans. In recent years we noted the emergence of other bacterial strains such as bacilli gram – and anaerobic.
They appear, with fever, by unilateral, inflammatory swelling, induration, pain, increased by movement of the jaw, sometimes with a lockjaw.
The examination showed tenderness and pus that springs spontaneously or after gentle massage of the gland to the opening of Stenon channel. Thereof is located opposite the second molar.
These parotitis were before the advent of antibiotics a formidable prognosis with a 80% mortality; presently it is still not negligible, of the order of 20%.
It is important to try to identify the germ and so be a bacteriological sampling at the orifice of Steno channel
and optionally blood cultures in case of high fever.
Biology shows a neutrophilia, increased erythrocyte sedimentation rate and C-reactive protein.
It is useful to make a radio and an ultrasound to check if there is a gallstone or an underlying pathology.
Finally it is important to research and correct predisposing factors: xerostomia (especially iatrogenic), oral diseases, malnutrition, dehydration, diabetes, alcoholism.
Treatment:
It is based on broad-spectrum antibiotics primarily oriented Staphylococcus aureus and streptococci.
In elderly and frail, it will be performed in hospital early days, parenterally (dual or triple therapy from the samples taken).
Increasingly rarely, if medical failure, it can be performed a surgery drainage of an abscess or a partial or total parotidectomy.
Salivary calculi:
At least 8 out of 10, they are located in the submandibular glands. But found almost 20% of parotid stones.
In this location they are often smaller.
Clinic:
Conventionally, there is a sharp pain with swelling of the gland which occurs just before (olfactory stimulation) or with meals, preventing food and yields spontaneously or with treatment. This is the “salivary colic.”
In fact, often there is only swelling, slurred gland occurring at mealtime, persistent few hours, then gradually deflating in the following hours. The phenomenon occurs at every meal.
Finally, there may be an incidental finding during radiological examinations.
Treatment:
Medical:
At the time of crises, given in combination a non-steroidal anti-inflammatory antispasmodic with a kind Spasfon®. It may be interesting to salivate the patient to facilitate the evacuation of the stones; for it is asked to chew gum.
If the calculation is stuck in the gland, the risk is that it develops a chronic infection with partial destruction of the gland.
Surgical:
It was the only treatment in case of failure of medical treatment.
It consists in a superficial parotidectomy with conservation of the facial nerve. The operation is delicate and can lead to facial paralysis roughly transient.
Endoscopy:
It has been developed thanks to the miniaturization of endoscopes that are less than one millimeter in diameter.
It is envisaged when the lithiasis is movable in a permeable channel with a functional gland.
The exam is painless and virtually no complications.
Lithotripsy:
It became feasible by the development of specialized devices to this pathology.
It is important not to use the kidney lithotripter.
It is practiced on intra glandular calculations, regardless of their size.
But first, check with Sialography that the channel is at least one millimeter in diameter to pass the fragments of the stones.
These will evacuate spontaneously or by endoscopy.
In the suites commonly found mild pain with a transient swelling (20%), benign ductal bleeding (65%), and secondary infections (10%).
PAROTIDOMEGALY COMMENTS:
Bilateral Parotidomegaly:
Sarcoidosis:
This is the Heefordt syndrome associating fever, enlarged parotid and lacrimal gland, bilateral iridocyclitis and impairment of cranial pairs like facial paralysis (usually bilateral).
Achieving eye and cranial nerves requires steroid treatment.
Syndrome Sjögren:
It is characterized by the combination of a dry syndrome (dry mouth or xerostomia), a dry eye (or xerophthalmia) and systemic disease.
The diagnosis is focused on the combination of two of these three criteria.
We speak of secondary Sjögren syndrome when there is a systemic disease, if not primary Sjögren’s syndrome.
The systemic diseases are found:
– Rheumatoid arthritis in about 50% syndromes secondary Sjögren;
– Lupus erythematosus in 20%;
– Scleroderma and CREST syndrome in 15%;
– More rarely one can find a s yndrome Sharp, dermatomyositis, and autoimmune diseases member (primary biliary cirrhosis, thyroiditis, pernicious anemia).
The sugar test serves as guidance but is not very precise: leave a sugar melt in the mouth, it is positive if it takes longer than three minutes to dissolve completely.
Biopsy of salivary glands is made at the inner face of the lower lip.
The Schirmer test confirms dry eye.
It consists of applying to the inner corner of the eye blotting (35 × 0.5 mm) and note the progress of the humidification 5 minutes (<5 mm).
Keratoconjunctivitis sicca is sought by the Rose Bengal test and the time to tear film break.
Wanted violations:
– Rheumatic arthralgia (especially wrists, hands, fingers), myalgia;
– Respiratory: fibrosis, pneumonitis, interstitial lung disease;
– Kidney: tubulopathy subclinical (hyperchloraemic acidosis, rarely hypokalemia, and occasionally osteomalacia);
– Neurological: central and peripheral (sensorimotor polyneuropathy symmetrical).
quite frequently include inflammatory anemia, that can be associated with leukopenia.
There is a high sedimentation rate with inflammation and protein electrophoresis polyclonal hypergammaglobulinemia often very important.
Rheumatoid factor is present in about 2/3 of cases.
We must seek antinuclear anti-SS-A-type and anti-SS-B specific for Sjögren’s syndrome.
Other immunological abnormalities are less interesting because less specific.
Evolution:
Risk is the occurrence of lymphoma, which means to follow these patients for many years.
We must monitor the lower gamma globulin, the disappearance of antibodies, increased beta 2 microglobulinemia are early signs of transformation Sjögren’s syndrome.
Treatment:
To treat hyposialie: we try to stimulate the salivary glands or by cholinergic drugs such as pilocarpine (Salagen®) eserine (GénéserineR), the ANETHOLTRITHIONE (Sulfarlem S25®) by Jaborandi dye in compounding or by electrical stimulation (saliva + battery), or by reflex stimulation using chewinggums or lozenges.
To treat xerophthalmia: artificial tears are used, gels and conjunctival implants (Lacrisert®)
Background Treatment includes cortisone, Plaquenil®, immunosuppressants, discussed by the teams and the degree of systemic involvement.
To evaluate and initiate with specialists in each case.
Nutritional Parotidomegaly:
Bread eaters in excess:
In these people one can find enlarged parotid glands. To search for questioning.
Alcoholism:
Sometimes there is a breach with parotid hypertrophy. Search for other alcoholism and cirrhosis signs.
Anorexia:
It is possible to find a secluded parotidomegaly if anorexia nervosa, but especially in cases of anorexia-bulimia with vomiting.
The clinical signs should be investigated with this habit also skin lesions at the top of the proximal phalanges of the index and middle fingers, corresponding to repeated contact with the upper incisors.
In this case it evolves in a particular context: it comes to girls with abnormal thinness (which may be less obvious if anorexia bulimia).
This hypertrophy usually appears after several months of evolution.
Sometimes patients consult to this pathology but in fact most often it is hidden, and it is a chance discovery during a consultation.
It pays to look almost constant amenorrhea.
There is no specific treatment is the correction of anorexia that will cure this parotidomegaly.
Syndrome diffuse lymphocytic infiltration:
This is a condition affecting people infected with the virus of human ummunodéficience (HIV). There are frequently cystic lesions in the gland. It may be interesting to do an FNA needle to remove a sarcoma or lymphoma.
The treatment is actually that of HIV, hypertrophy regressing under antiretroviral therapy.
Unilateral Parotidomegaly:
They are the prerogative of tumors. These are benign in the vast majority of cases.
Local pain, facial paralysis, cervical lymphadenopathy satellite, moving towards a cancerous tumor, but in fact only the histological examination allows a definitive diagnosis.
Additional tests have little interest, radiography and Sialography are useless, ultrasound is limited by the fact that evil explores the deep lobe and para pharyngeal spaces. CT and MRI are more effective but are only useful in preoperative, if there is a suspicion of deep lobe damage or signs of malignancy.
Biopsy is against-indicated because it can damage the facial nerve, and in cancer then there is a risk of tumor swarming.
FNA needle is used by some teams, but it does not unanimously by lack of sensitivity and specificity.
We see that all parotid tumor should be surgically explored.
Benign:
They are dominated by the pleomorphic adenoma (old mixed tumor), which represents 2/3 parotid tumors. Adenoma monomorphic (10 to 15%), tumor Whartin (5 to 10%) almost complements other forms.
Surgical treatment consists of a superficial parotidectomy with conservation of the facial nerve, if the tumor seat in the superficial lobe; a total parotidectomy with preservation of nerve if the tumor is very large or located in the deep lobe.
The main risk of this surgery is facial paralysis. Most of the time it is temporary and recovered in a variable delay (up to 1 year and a half). There is a rate of 5 to 15% of permanent damage.
Malignancies:
They represent about 15% of tumors.
Include: mucoepidermoid carcinoma (1/3), adenocarcinoma (1/5), adenoid cystic carcinoma (1/5), carcinoma in pleomorphic adenoma (1/10).
Surgical treatment is by total parotidectomy with conservation of the facial nerve there is no paralysis before, associated with lymph node dissection if metastases.
Some teams are still this preventive cleaning in all cases, others in case of high grade.
adjuvant radiotherapy was performed in cases of high grade.