Parotid gland abscess in an underweight infant: A comprehensive analysis

INTRODUCTION

An acute parotid abscess is an uncommon occurrence in paediatric patients and it usually occurs in neonates and premature infants with risk factors such as prematurity, low birth weight, dehydration, prolonged orogastric feeding, immunosuppression, and parotid duct anomalies. Common cause includes infections such as viral, bacterial, and rarely fungal, autoimmune conditions, ductal calculi, or stenosis.^[1,2] Acute parotitis, which is the most common inflammatory condition of the parotid gland, seldom sporadically turns into a parotid abscess. Unilateral disease is more commonly reported. Common organisms isolated are Staphylococcus aureus, Streptococcus pyogenes, and anaerobes.^[3,4] The role of ultrasound is crucial in distinguishing inflammatory changes from the collection of pus thus directing the management plan. Here, we report a case of a 7-month-old underweight male infant who developed a unilateral parotid abscess due to S. aureus infection and was managed with surgical intervention.

CASE REPORT

A 7-month-old male infant, developmentally normal for his age, immunised till date, underweight [Table 1], presented to paediatric emergency with chief complaints of swelling in the right cheek for the past 7 days and fever for 3 days subsided with paracetamol, not associated with chills and rigors.

The swelling was diffuse, insidious in onset, and gradually progressed over 7 days to a size of ~4 × 4 cm at the time of presentation with warmth and tenderness over the swelling. There was no history of recent fever/upper respiratory tract infection, poor feeding or poor activity. There was no history of contact with tuberculosis. The child had papular lesions all over the body and was diagnosed with a case of scabies after a dermatology consultation which was managed with 5% permethrin ointment. General and systemic examination was normal and blood investigations were done for the infant [Table 2].

Ultrasonography of the right parotid appeared heterogeneous with a 2.3 × 2.1 cm heterogenous hypoechoic area with minimal internal echoes. The blood culture taken at the time of presentation was sterile. The patient was started on intravenous antibiotics (cloxacillin and clindamycin) and intravenous fluids. Incision and drainage were done [Figure 1] and ~15 mL pus was drained and sent for exudate culture, Genexpert, and acid-fast bacilli smear. S. aureus was isolated in pus culture which was sensitive to clindamycin, oxacillin, a combination of trimethoprim and sulfamethoxazole, tetracycline and erythromycin, and cloxacillin and clindamycin which were continued as per sensitivity report. In Genexpert, no mycobacteria were detected. Daily cleaning and dressing were done and the patient was discharged.

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Figure 1:

7-month-old male infant with the right parotid swelling with incision given for abscess drainage.

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DISCUSSION

Acute parotitis is the most common inflammatory condition of the parotid gland and usually responds well to medical management but seldom sporadically evolves into a parotid abscess.^[5] Parotid abscess is more common among elderly or immune-compromised patients, but their presentation in immune-competent healthy children and adults is well documented in clinical practice.^[3]

Parotitis should be conservatively managed with adequate hydration, good oral hygiene, and antibiotics if indicated.^[6] However, if treatment is inadequate and/ or the disease progresses, suppurative parotitis or parotid abscess can develop with serious complications.^[7] Various bacteria cause suppuration of the parotid gland, with S. aureus and anaerobic bacteria being the most common pathogens reported and streptococci encountered, as well.^[3,4] Furthermore, there is a case report of candida as a causative organism.^[8] Although tuberculosis is endemic in India but is rarely the causative organism. A recent study showed a possibility of 13-valent pneumococcal conjugate vaccine-derived parotitis in an infant.^[2]

Ductal stones are rare in children and parotid abscess formation is in most cases of non-obstructive origin.^[1]

Furthermore, a differential diagnosis which includes, trauma, lymphadenitis, hemangioma, adenoma, lipoma, parotid gland duct anomalies, intraglandular abscess, and neoplasia should be kept in mind.^[8]

Ultrasonography is the basic radiological investigation of salivary gland swellings and should be the initial imaging modality. Computed tomography scans were preferred over ultrasonography where complications or a neoplastic lesion in a deep location or bone infiltration are suspected.^[6,9]

Management of parotid abscess includes pus drainage and appropriate antibiotic therapy.^[6] Drainage of the pus within the gland can be done either by needle aspiration or incision and drainage of pus. Most paediatric incisions and drainage do not have a complication and show good outcomes while rarer complications, of which most frequently being facial nerve damage can occur in paediatric patients hence making aspiration or exclusive medical therapy generally preferable to incision and drainage.^[5]

CONCLUSION

Although uncommon in children, parotid abscess should be considered as a differential for parotid swellings. Early diagnosis, appropriate antibiotics, and surgical drainage are key for good outcomes. This report adds to the limited literature on parotid abscesses in infants.