Ultrasonographic features of recurrent parotitis in childhood

Juvenile idiopathic recurrent parotitis (JIRP) treated with short course steroids, a case series study and one decade follow up for potential autoimmune disorder

BACKGROUND

Juvenile idiopathic recurrent parotitis (JIRP) in children is a condition characterized with recurrent episodes of idiopathic parotid gland inflammation. Since there are no definitive guidelines for diagnosis and management of this condition, we present a consecutive case series of patients with more than one decade follow up and their dramatic response to short course treatment by prednisolone.

METHODS

We conducted this study by retrospectively reviewed medical charts of children who were diagnosed with JIRP, from 1 January 2002 to 29 February 2023. We performed usual serological tests to exclude some possible background. We administered short course prednisolone on first day of episode as divided dosage (0.5 mg /kg).

RESULTS

In this case series of 10 patients (70%) were male, median age of onset was 5 years, duration of episodes 5 days, and the mean course of disease were 3.8 years. The average follows up of patients was near 10 years. In comparison with their natural course of disease all patients showed a dramatic response to treatment on the first day of administration of prednisolone (P Value 0.005). For ten years follow up there was not any additional accompanying autoimmune disorder.

CONCLUSION

Short course prednisolone on first day of each episode and its dramatic and meaningful response in our patients, introduce a new, effective, fast, and inexpensive regimen of therapy in patients with JIRP.

Sialendoscopy approach in treating juvenile recurrent parotitis: a systematic review

BACKGROUND

Juvenile recurrent parotitis (JRP) is characterized by recurrent episodes of painful parotid swelling in children. The purpose of this systematic review was to determine the diagnostic and therapeutic effectiveness of sialendoscopy in children affected by JRP.

METHODS

A systematic literature search was performed in PubMed, EMBASE, Scopus and the Cochrane Library until April 2022, without language restrictions or specified start date. Quality assessment was performed using the Newcastle-Ottawa Scale (NOS).

RESULTS

Our review included 524 patients and 646 sialendoscopies. The sample sizes of the different studies ranged from 3 to 77 subjects. Most authors performed sialendoscopy under general anesthesia. The mean percentage of recurrences observed was 25.1% (95% confidence intervals) (CI 23.6-26.6). There was a statistically significant relationship between the number of attacks/year and recurrences (p < 0.05). The percentage of recurrences according to the type of irrigation/flushing used ranged from 22.2% to 25.2%, with no significant differences between the use of corticosteroids alone (25.2% of recurrences), corticosteroids plus antibiotics (25% of recurrences) or saline alone (22.2% of recurrences). Sialoendoscopy has proved in all cases to be a valid method for the diagnosis of JRP, but it does not allow a reliable differential diagnosis with other autoimmune parotitis such as Sjögren's syndrome.

CONCLUSION

According to our results, parotid sialoendoscopy was 74.9% effective as a primary treatment in the prevention of recurrent symptoms in JRP. The type of ductal irrigation used did not significantly influence the prognostic outcome.

The applicability of ultrasound in the diagnosis of inflammatory and obstructive diseases of the major salivary glands: a scoping review

OBJECTIVES

The purpose of the present scoping review was to determine the contribution of ultrasound images in the diagnosis of inflammatory and obstructive diseases of the major salivary glands (MSGs).

METHODS

A search of studies of ultrasonographic assessments of human samples was performed in several electronic databases and grey literature up to July 2021. The extracted data were the examined MSG; the diagnostic value of ultrasound (sensibility, specificity, positive- and negative predictive value, accuracy); features of lesions, including number, echogenicity, echotexture, form, margins, size, posterior acoustic aspect, and location; and related clinical information, such as swelling, palpation, sensible to pain, salivation, lymph nodes, recurrence, duration, and causes.

RESULTS

After verifying the eligibility criteria, 90 articles focused on detecting inflammatory, and obstructive diseases of the MSG were gathered, with variable study designs and size samples. A wide variety of pathologies were assessed, including sialolitiasis (n = 45), acute sialadenitis (n = 30), chronic sialadenitis (n = 25), granulamatous diseases (n = 15), Kuttner's tumor (n = 11), juvenile recurrent parotitis (n = 9), abscess (n = 7), post-radiotherapy sialadenitis (n = 6), sialadenosis (n = 9), abscess (n = 7), IgG4-related disease sialadenitis (n = 5), HIV-sialadenitis (n = 4), obstructive sialadenitis (n = 3), iodinated contrast-induced sialadenitis (n = 2), and pneumoparotitis (n = 1). Most studies were case reports or series of cases. Few studies exhibited data about the accuracy of ultrasound in detecting MSG diseases.

CONCLUSIONS

The present scoping review concluded that ultrasound aspects of different MSG pathologies are similar but contribute to their differential diagnosis and can be considered as a valuable initial method for assessing the MSG of adults and children.

Sialoendoscopy for treatment of juvenile recurrent parotitis: The Brescia experience

OBJECTIVE

To evaluate the role of sialoendoscopy associated with steroid irrigation for juvenile recurrent parotitis (JRP) at a tertiary referral hospital.

METHODS

Clinical records of patients affected by JRP and treated with operative sialoendoscopy between June 2011 and April 2017 were retrospectively reviewed. Data on demographics, number of acute episodes per year before and after surgery, characteristics of the surgical procedure, hospitalization time, and rate of complications were collected. The outcome of the procedure was measured by comparing the number of episodes of parotid swelling before and after salivary endoscopic treatment.

RESULTS

Twenty-three patients for a total of 34 operative sialoendoscopies were included in the study. Before the surgical endoscopic procedure, the mean number of parotid swelling was 10 episodes per year. At sialoendoscopy, typical endoscopic findings such as mucous plugs, stenosis of the duct, intraductal debris, and pale ductal appearance were evident. All patients were discharged on the first postoperative day. A significant decrease in the number of swelling episodes per year was observed compared to the preoperative rate (p = .0004). Complete resolution of the disorder was obtained in 35% of patients.

CONCLUSIONS

Operative sialoendoscopy with steroid irrigation can be considered a valid therapeutic treatment for JRP. The technique is conservative, effective, safe, and, potentially repeatable. Short hospitalization time, rapid recovery, absence of peri-operative complications, and a high rate of good outcomes are the main advantages of this treatment.

Sialendoscopic Approach in Management of Juvenile Recurrent Parotitis

To assess the role of sialendoscopy as a diagnostic and therapeutic modality in juvenile recurrent parotitis. Juvenile recurrent parotitis (JRP) is the second most frequent salivary gland disease in childhood and is characterized by recurrent non suppurative and non obstructive parotid inflammation. These attacks influence the quality of life and can even lead to gland destruction, and there are no definitive treatment to avoid them. Sialendoscopic dilatation is emerging as the new treatment modality in this aspect.

STUDY DESIGN

 retrospective study.

STUDY SETTING

Department of Otorhinolaryngology in tertiary care hospital. 17 cases of juvenile recurrent parotitis (i.e. children of age group 3-11 years presenting with complaints of recurrent parotid region swelling and pain, sometimes associated with fever) were included in the study during October 2012-September 2015. All cases underwent sialendoscopy under general anaesthesia. Diagnostic (classifying the ductal lesion) and interventional sialendoscopic procedure (dilatation with instillation of steroid) were carried out in single sitting. Follow up was done for a minimum of 6 months (range 6-36 months). 17 patients with mean age of 5.6 years and gender distribution of 47:53 (boys:girls) underwent sialendoscopy for JRP. 8 patients presented with unilateral parotitis and 9 with bilateral. The mean number of attacks in previous 1 year were 9.2. Average time for procedure was 20 min. All cases had ductal stenosis and ductal mucosa was pale in 15 cases on endoscopy. 1 patient underwent repeat endoscopy after 2 years. 50% had complete resolution of symptoms and 6 patients had one mild (swelling not associated with fever which subsided on its own) attack after treatment. Follow up period ranged from 6 months to 3 years. No complications were observed. Sialendoscopy has emerged as a viable option for assessment and treatment of JRP. Dilatation of the parotid duct and steroid instillation has significantly reduced the morbidity of this condition.

Paediatric Neck Lumps I – Inflammatory and Neoplastic Lesions Including Salivary Gland Abnormalities

This article will concentrate on solid neck masses in children, giving an overview of 3 main areas: cervical lymphadenopathy, neoplasms presenting as neck masses and salivary gland abnormalities in children. Most neck lumps in children are benign, even solid masses and the child's age is an important factor in narrowing the differential diagnosis. Inflammatory lesions are very common, especially in young children and usually involve lymph nodes, but infected congenital cystic lesions can mimic inflammatory processes. The most common inflammatory masses are reactive or suppurative lymphadenitis, which classically present following an upper respiratory tract or pharyngeal infection. Malignant lesions are seen occasionally and it is important to know when to be concerned about a child's neck mass. Malignant lesions tend to be painless, solid and associated with systemic manifestations. Ultrasound is the primary imaging modality of choice for children, but does have limitations. It is vital that all imaging is interpreted in conjunction with clinical information, especially as imaging findings can be non-specific. Any lesion that does not have typical benign appearances or behaviour requires biopsy. Salivary gland disorders are uncommon in children compared with adults; salivary calculi, autoimmune disorders and tumours are rare. The most frequent cause of parotid swelling in a child is infection, usually viral, although intra-parotid lymph nodes can suppurate resulting in abscess formation. As with neck masses in other locations, certain factors in the clinical history should raise the possibility of malignancy and prompt further investigation, including biopsy. These include rapid growth, facial nerve palsy and associated lymphadenopathy.

Standards for the assessment of salivary glands - an update

The paper is an update of 2011 Standards for Ultrasound Assessment of Salivary Glands, which were developed by the Polish Ultrasound Society. We have described current ultrasound technical requirements, assessment and measurement techniques as well as guidelines for ultrasound description. We have also discussed an ultrasound image of normal salivary glands as well as the most important pathologies, such as inflammation, sialosis, collagenosis, injuries and proliferative processes, with particular emphasis on lesions indicating high risk of malignancy. In acute bacterial inflammation, the salivary glands appear as hypoechoic, enlarged or normal-sized, with increased parenchymal flow. The echogenicity is significantly increased in viral infections. Degenerative lesions may be seen in chronic inflammations. Hyperechoic deposits with acoustic shadowing can be visualized in lithiasis. Parenchymal fibrosis is a dominant feature of sialosis. Sjögren syndrome produces different pictures of salivary gland parenchymal lesions at different stages of the disease. Pleomorphic adenomas are usually hypoechoic, well-defined and polycyclic in most cases. Warthin tumor usually presents as a hypoechoic, oval-shaped lesion with anechoic cystic spaces. Malignancies are characterized by blurred outlines, irregular shape, usually heterogeneous echogenicity and pathological neovascularization. The accompanying metastatic lesions are another indicator of malignancy, however, final diagnosis should be based on biopsy findings.

Recurrent parotitis of childhood or juvenile recurrent parotitis--a review and report of two cases

Recurrent parotitis of childhood is an uncommon condition which affects children of variable age. The condition may be misdiagnosed so delaying treatment. These two case reports highlight the variable signs and symptoms of this unusual condition and the value of ultrasound as an aid to diagnosis.

CLINICAL RELEVANCE

This is to improve awareness of recurrent parotitis of childhood and aid early diagnosis.

Sonography: the leading diagnostic tool for diseases of the salivary glands

Ultrasound examination is the imaging procedure with the best predictive diagnostic capability for the salivary glands. Due to the salivary glands' relatively superficial anatomical location, clear boundary from surrounding tissue and comparatively typical echogenicity, therefore sonography is ideal for diagnosis. In addition, the technical advances in recent years, including higher resolution, color Doppler sonography, contrast-enhanced ultrasound, elastography, and tissue harmonic have lead to an improvement in diagnostic accuracy of sonography further resulting in an expansion of the range of indications. Sonography allows detection of obstructive salivary gland diseases such as stenosis or sialolithiasis, as well as sialadenosis such as Sjögren syndrome. Ultrasound examination alone is sufficient to diagnose benign tumors. However, in the case of malignant tumors, computer tomography or MRI may be also required, especially to determine the question of infiltration of the skull base.

Ultrasound in sialadenitis

The salivary glands are located superficially and are therefore easily accessible to ultrasound (US) examination, particularly if a high-frequency probe designed for small parts is used. Hence, US examination of these organs is widely applied particularly in non-neoplastic pathologies. In this way, it is possible to obtain adequate images without the use of ionizing radiation or complex instrumentation such as magnetic resonance imaging. However, US examination requires an expert clinical knowledge and familiarity with the normal and pathological US anatomy of the area. Limitations and pitfalls linked to US examination of this area should also be kept in mind.

Modern management of juvenile recurrent parotitis

Aims:

To evaluate modern diagnostic and therapeutic management of juvenile recurrent parotitis, and to show the benefits of operative sialoendoscopy on the basis of our experience in 14 patients and the results of others.

Results:

Ultrasonography is sensitive in detecting the pathological features of juvenile recurrent parotitis. Interventional sialoendoscopy is a safe and effective method of treating the disease. In our case series, after a mean follow-up time of 30 months only 5 patients experienced recurrence of symptoms, with a mean symptom-free period of 20 months.

Conclusion:

The use of modern, minimally invasive diagnostic tools such as colour Doppler ultrasonography, magnetic resonance sialography and sialoendoscopy represents a new frontier in the management of juvenile recurrent parotitis. Operative sialoendoscopy also has the important therapeutic benefit of reducing the number of recurrences of acute episodes of parotitis, thus giving patients a better quality of life until puberty.

Bilateral parotid swelling: a radiological review

Bilateral parotid swelling is not an uncommon occurrence and may pose a challenge for clinicians and radiologists. Numerous causes of bilateral parotid swellings have been identified. The purpose of this pictorial review is to display this wide array with a focus on multimodality approach.

MRI and MR sialography of juvenile recurrent parotitis

BACKGROUND

Juvenile recurrent parotitis (JRP) is the second most common inflammatory salivary gland disease of childhood, after mumps. Diagnosis of JRP is usually based on clinical history of recurrent unilateral or bilateral parotid swelling and demonstration of sialectasis. Conventional sialography, digital sialography, US, MRI and sialoendoscopy have been used as investigative tools for the diagnosis of JRP. MR sialography is increasingly recognized as a useful supplement to sialography in salivary duct disorders.

OBJECTIVE

To describe the MRI and MR sialographic findings in children with JRP.

MATERIALS AND METHODS

MR Sialography was performed using T2-weighted three-dimensional constructive interference in steady-state (CISS) and half fourier acquisition single-shot turbo spin-echo (HASTE) sequences in 62 children with inflammatory salivary gland disease. Out of these 62 children, 6 had JRP. Axial T1- and T2-W images were also performed.

RESULTS

The main parotid duct was normal in all six children with JRP. High signal intensity focal lesions suggestive of sialectasis were seen involving both parotid glands in all six children. CISS sequence demonstrated the intraglandular ducts and sialectasis better than HASTE images.

CONCLUSION

MRI and MR sialography can non-invasively delineate the parenchymal and ductal system abnormalities of the parotid glands in children with JRP. Although MR and MR sialography cannot substitute US, they can accurately depict findings such as sialectasis and signal intensity changes in the parotid gland depending upon the phase of the disease (acute vs. chronic inflammation). The radiologist should be familiar with MR findings of JRP.

Clinical ultrasound of the salivary glands

Ultrasound investigation of the major salivary glands has been routinely used for the past 25 years. Ultrasound provides an immediate diagnosis in acute or chronic inflammatory salivary diseases and can visualize sialolithiasis as small as 0.4 mm. Ultrasound is also an important imaging modality for salivary gland tumors, guiding fine needle aspiration (FNA) for cytological diagnosis. It is particularly sensitive in detecting suspicious lymph nodes in the neck and helps to guide FNA. Ultrasound is a first-line tool for diagnosis of salivary pathology. It is simple to use, noninvasive, and well tolerated, even in children.

US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls

Ultrasonography (US) is useful for differential diagnosis of diseases of the salivary glands. In acute inflammation, salivary glands are enlarged and hypoechoic with increased blood flow; they may contain multiple small, oval, hypoechoic areas. In chronic inflammation, salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. Sialosis appears as enlarged hyperechoic glands without focal lesions or increased blood flow. The US features of advanced Sjögren syndrome include inhomogeneous salivary glands with scattered small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow. Pleomorphic adenomas are usually hypoechoic, well-defined, lobulated lesions with posterior acoustic enhancement that may contain calcifications; Warthin tumors are usually oval, hypoechoic, well-defined lesions that often contain anechoic areas and are often hypervascularized. Malignant neoplasms of the salivary glands may have irregular shapes, irregular borders, blurred margins, and a hypoechoic inhomogeneous structure or may have a benign appearance. Salivary gland cysts have well-defined margins, anechoic contents, posterior acoustic enhancement, and no internal blood flow. However, US appearances of some diseases may overlap, thus producing diagnostic pitfalls.

Recurrent parotitis of childhood

BACKGROUND

Recurrent parotitis (RP) of childhood is a rare condition of unknown aetiology, probably immunologically mediated.

OBJECTIVE

To review the clinical presentation, diagnosis and management of RP of childhood.

METHODS

Retrospective study from 1983 to 2004 of children diagnosed with RP of childhood at a tertiary children's hospital.

RESULTS

We identified 53 children, 37 (70%) male and 16 (30%) female. The age of onset was biphasic, with peaks at 2-5 years of age and at 10 years. The commonest symptoms were swelling (100%), pain (92.5%) and fever (41.5%). Symptoms usually lasted 2-7 days with a median of 3 days. The mean frequency was 8 episodes per year. The diagnosis was often delayed, >1 year in 70% of patients, maximum 8 years. The most common diagnoses, before the definitive diagnosis of RP, were mumps (21%), 'infection' (15%) and stones (11%). Sialogram (57%) and/or ultrasound (41%) showed sialectasis in 81% of patients. Over half the patients (54%) were given antibiotics at least once to treat the parotitis. Two children had hypogammablobulinaemia, one child had human immunodeficiency virus infection, and one child had Sjogren's syndrome. Two children had high titre antinuclear antibodies.

CONCLUSIONS

Recurrent parotitis had a biphasic age distribution. The major clinical features that distinguish it from other causes of parotid swelling are the lack of pus and recurrent episodes. A clinical diagnosis can often be confirmed by ultrasound. Antibiotics do not have a role in treatment. Affected children should be screened for Sjogren's syndrome and immune deficiency.

Possibility of sialographic sonography: a Doppler phantom study

OBJECTIVES

The purpose of this study was to develop a new diagnostic method that has the merits of both sialography and sonography.

STUDY DESIGN

Saline solution and various contrast media (Urografin 76%; 100%, 90%, and 67% Lipiodol Ultra-Fluide; 5% and 1% barium sulfate; and Levovist) were injected into thin tubes at a rate of approximately 0.001 to 0.1 mL/s. The relationship between the Doppler signal intensity and the kind, concentration, and velocity of the fluid was analyzed.

RESULTS

Levovist, 90% and 67% Lipiodol Ultra-Fluide, and the barium sulfate solutions produced Doppler signals. The mixture of Lipiodol Ultra-Fluide and saline solution produced high signals at any concentration, in contrast with the barium sulfate solutions. Signals could be observed at any speed, from the speed of normal sialography down to 0.001 mL/s, and there was a proportional relationship between signal intensity and velocity for all fluids producing signals.

CONCLUSION

The fact that we could obtain high signals with several fluids indicates potential clinical diagnostic usefulness of sialographic sonography.

Sonographic analysis of recurrent parotitis in children: a comparative study with sialographic findings

OBJECTIVE

The sonographic features of recurrent parotitis in children were studied to clarify a relationship between sonographic and sialographic findings in this disease.

STUDY DESIGN

Twenty-one glands (7 on follow-up) were examined by 7.5 MHz ultrasonography and sialography. Echo intensity level, distribution of the internal echoes, and size of hypoechoic areas were compared with the size of punctate shadows on the sialograms. Twenty other histopathologic specimens were analyzed to investigate the entity of hypoechoic areas.

RESULTS

Sonography showed hypoechoic, heterogeneous internal echoes, the level of which increased as the punctate shadows enlarged. Hypoechoic areas, all of which were larger than the sialographic punctate shadows, were observed in 62% of the glands. Histopathologic analysis suggests that these hypoechoic areas represent dilated peripheral ducts with lymphocytic infiltration. Sonography was likely to detect changes over time more sensitively than sialography.

CONCLUSIONS

Sonography should be performed as the test of first choice, both in the primary and follow-up stages, in cases of recurrent parotitis in children.

Autosomal dominant juvenile recurrent parotitis

Juvenile recurrent parotitis is a common cause of inflammatory salivary gland swelling in children. A variety of aetiological factors has been proposed for the condition. Here we present a family where four members had juvenile recurrent parotitis and where two other family members may have had an atypical form of the condition. The segregation pattern in the family is consistent with autosomal dominant inheritance with incomplete penetrance and this suggests that, at least in some cases, genetic factors may be implicated in juvenile recurrent parotitis.

Recurrent parotitis

(1) Recurrent parotitis is probably caused by a congenital abnormality of the salivary gland ducts with recurrent attacks of ascending infection, perhaps aided by dehydration. The parotid gland is predominantly affected probably because of its lower rate of secretion compared with the submandibular gland. (2) The condition mainly affects children between the ages of 3 and 6, with males being more commonly affected. The symptoms peak in the first year of school, and usually, but not invariably, begin to subside at puberty. By the age of 22, most patients are completely symptom-free. When the disease starts after puberty, females are predominantly affected. (3) Ultrasound is the appropriate initial investigation, and is usually supplemented by sialography. The sialography may itself cause a resolution of symptoms. (4) Treatment is conservative in the first instance, and an expectant policy is indicated. More aggressive treatment is justified only for those adults with persistent problems. This may be parotid duct ligation, parotidectomy, or tympanic neurectomy, depending upon the preference and experience of the treating physician.