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Case Study 3 - Parotid Duct Abscess

figure-1-cssd.pngA 51-year old male presented to the Emergency Room complaining of painful left-sided facial swelling that had begun approximately 48 hours earlier. The patient had visited the dentist 4 days prior to the onset of his symptoms but he described having experienced episodes of intermittent, bilateral swelling of the parotids for the past 6 months, all of which resolved with parotid massage. His past medical history was significant for essential hypertension, which was well-controlled with Losartan. He denied any recent illness, was HIV–negative and a non-smoker.

Physical examination revealed the patient was febrile (100.9°F) with a firm and tender-to-palpation left parotid gland with fluctuant mid-face edema below the zygomatic arch. The right parotid gland showed mild, non-fluctuant edema on palpation. Prominent, edematous parotid papilla were noted bilaterally, with both right and left papilla revealing some purulence at the punctum. The facial nerve was intact and no trismus was noted. Computed tomography (CT) scans of the face revealed inflammation and collection of cystic fluid in the right and left parotid glands. The left gland also showed greater dilatation of the distal Stensen’s duct as compared to the right gland (Figure 1). A subsequent blood test showed an elevated white blood count of 19 TH/cmm. A diagnosis of bilateral parotitis was made and the patient given Diluadid 2 mg for pain, Unasyn 3 mg IV and 3 courses of Decadron 8 mg every 8 hrs.

Discharge from the right and left Stensen’s ducts was collected for culture. Initially, a 4.0 salivary dilator was introduced into the left and right parotid punctae but could not be passed further than 3 mm on either side. Upon aggressive parotid massage, 2 cc of purulence was expressed from the right parotid gland. Fine needle aspiration (FNA) was utilized to collect a total of 30 cc from three separate sites in the left parotid gland. Subsequent cultures of the right parotid were positive for Streptococcus viridans, coagulase-negative Staphylococcus, and Candida albicans. The left parotid had no growth over a 48 hr. period but Gram staining showed a high number of white blood cells. The patient’s antibiotic regime was changed from Unasyn to Clindamycin 600 mg PO TID and Ciprofloxacin 500 mg PO BID. Pain was managed with Hydrocodone and sialagogues and warm compresses were recommended. The patient was discharged with oral antibiotics 2 days after presenting to the E.D. In a clinic follow-up a week later the decision was made to perform a bilateral sialodochoplasty and sialoendoscopy with dilation. 

The surgery was performed with the patient in a supine position under general oroendotracheal anesthesia. 1 cc of lidocaine 1% with 100,000 epinephrine was injected for local anesthesia at the papillae of the bilateral parotid gland ducts. First the left and then the right parotid ducts were probed with the Cook™ Salivary guide wire, and then the Cook™ Salivary catheters, beginning at 4.0 F and up to 7.0 F, were used to dilate the duct. Approximately 30 cc of brown purulent fluid was expressed from the left side and no purulence was expressed from the right side. Pott’s scissors were then used to filet the mucosa overlying the guidewire for approximately 4 to 5 mm. The sialoendoscope was advanced into the parotid ducts under continuous irrigation with normal saline. Visualization was poor in the left duct due to blood clots; however, the right duct was easily visualized and contained inflamed, thickened mucosa with some debris. Both ducts were irrigated with 5 cc of a 10 cc solution containing 80 mg gentamicin and 40 mg Kenalog. Finally, the endoscope was removed and silastic stents were placed in bilateral ducts and secured to the buccal mucosa with 6-0 Vicryl. The patient tolerated the procedure well and he was discharged later that day.

The left stent was removed at the 1 week follow-up appointment and the right stent extruded on its own shortly thereafter. At the 7 week follow-up appointment, the patient was asymptomatic with no pain and/or facial weakness/numbness. The bilateral parotid ducts were patent with clear saliva flowing. We advised the patient to continue with parotid massage, sialagogues, and increased hydration. At 1 year follow-up the patient was completely asymptomatic.