Juvenile Recurrent Parotitis

Parotitis is the swelling of one or both parotid glands, the salivary glands that are located in the cheek between the ear and jaw on each side of the head.

Juvenile recurrent parotitis is characterized by recurrent episodes of parotid gland swelling.

A child with juvenile recurrent parotitis may have multiple episodes of swelling over a period of years, often accompanied by fever and pain or discomfort. The condition most commonly begins between the ages of 3 to 6, but can start earlier or later. In most cases, the episodes end between the ages of 10 to 15, with no further symptoms.

Some children have mild and infrequent episodes. Others have episodes that are so frequent and intense that they frequently miss school.

The causes of juvenile recurrent parotitis are not fully understood. Possibilities explored by researchers include an underproduction of saliva, congenital malformation of the salivary ducts, history of bacterial or viral infections, genetic predisposition, or underlying autoimmune disorder. The mechanism causing the swelling of the parotic glands appears to involve disruption of the normal flow of saliva, leading to infection of the parotid glands.

The fact that the condition usually disappears at around the age of puberty suggests that narrowing of the salivary ducts may play a role in causing the condition. As the child grows, so do the ducts, and the flow of saliva returns to normal.

Symptoms of juvenile recurrent parotitis include:

• inflammation of the parotid gland, observable as swelling of the jaw near the ear
• pain
• redness in the affected area of the jaw
• fever
• recurrence of inflammation and swelling in repeated episodes, with frequency ranging from once a year to 20 times a year

Each episode usually lasts two to seven days, but may last as long as two or three weeks.

The swelling usually appears on just one side of the head, but it can occur on both sides.

When a child has multiple episodes of swelling and pain in one or both jaws, the child should be seen by an ear, nose and throat specialist (otolaryngologist). At Children’s Hospital of Philadelphia, children are seen in the Head and Neck Disorders Program.

If, based on the child’s symptoms and medical history, juvenile recurrent parotitis is suspected, imaging studies and tests may be ordered to support the diagnosis. Care is taken to distinguish between conditions that can have similar symptoms, such as salivary duct stones (sialoliths), salivary gland tumors, autoimmune disease or lymphoma. Often times, a consultation with a Rheumatologist is requested to evaluate for autoimmune disease that may present similarly.

Imaging studies may include:

• an ultrasound of the jaw and neck, which uses sound waves to create images of the inside of the body
• a CT scan, which uses a combination of X-rays to take detailed pictures of the inside of the body
• an MRI, which uses strong magnets and radiofrequency waves to produce images of the body

Other tests may include:

• gently pressing on the skin above the parotid gland to determine tenderness of the area
• massaging the gland to express saliva for examination
• bacterial culture of the child’s saliva
• Sialoendoscopy (looking in the saliva duct with a tiny camera) to visually assess the saliva duct for evidence of the condition
• extraction of tissue samples for examination under a microscope

In most children — roughly 90% — the symptoms of juvenile recurrent parotitis disappear in puberty without the need for invasive treatment. Because of this, doctors are conservative in their approach to treatment. It is only in severe cases that invasive treatments are considered.

The Head and Neck Disorders Program offers expert diagnosis and treatment for children with juvenile recurrent parotitis. The program’s surgeons have the knowledge and experience to recognize that most patients do well with noninvasive treatments, and the skill to perform delicate procedures when surgical intervention is needed.

Noninvasive treatments used to relieve discomfort and reduce infection include:

• over-the-counter pain medication (especially Tylenol)
• careful oral hygiene
• massage of the parotid gland
• application of heat to the affected area
• chewing gum or sucking on sour candy to stimulate the flow of saliva
• maintaining good hydration by drinking plenty of liquids
• drugs that stimulate the flow of saliva (sialagogues)
• antibiotics

When the intensity and frequency of the swelling episodes are severe, disrupting a child’s school and social life and raising the risk of significant health problems, more aggressive treatment may be considered. These might include:

• sialoendoscopy
• surgical removal of the parotid gland (parotidectomy)

Sialoendoscopy is a procedure performed in the operating room where a tiny fiberoptic camera is used to look inside the saliva duct. For juvenile recurrent parotitis, the appearance of the inside of the ducts can confirm the diagnosis. Irrigating or rinsing out the ducts with saline solution during sialoendoscopy or using a small inflatable balloon to widen the duct is one of the treatments used for severe cases of juvenile recurrent parotitis. These interventions help to return saliva flow to normal and prevent recurrent episodes of parotitis. Sometimes, steroids can also be administered using the endoscope.

Surgery to remove the parotid gland is only considered when a child experiences severe symptoms that do not respond to sialoendoscopy. The surgery must be performed with extreme care, as the facial nerve passes through the parotid gland and must be preserved while the gland around it is removed. The facial nerve controls the ability to close the eyes, raise the eyebrows and smile. A swollen or inflamed parotid gland makes this surgery more difficult. To protect the facial nerve, the surgery may involve removing only the upper portion of the parotid gland (superficial parotidectomy).

Children with juvenile recurrent parotitis almost always face a positive long-term outlook. The condition can usually be managed during childhood with noninvasive treatments that address the symptoms and hygiene practices that reduce the risk of infection and protect the teeth. In the great majority of cases, the condition resolves spontaneously in the years around puberty.

Even in more severe cases, where more invasive treatment is needed, long-term outcomes are generally positive.