Self-induced pneumoparotitis

Pneumoparotid: Practical impact of Surgeon performed Ultrasound in an effective Diagnostic Approach

OBJECTIVES

Pneumoparotid is characterized by air inclusions in the parotid duct system. Use of ultrasound has proved valuable for evaluating air inclusions in various parts of the body; the diagnostics of this condition has not been systematically analyzed, however. The aim of this study was to evaluate the value of ultrasound in the detection of air inclusions along the parotid duct system and its closer characterization.

METHODS

Retrospective analysis was carried out of patients diagnosed with pneumoparotid between 2005 and 2020 in a salivary gland center. Ultrasound was performed in all cases, and features of air inclusions were described. Reference standard was the clinical demonstration of foamy saliva after gland massage and/or sialendoscopic evidence of intraductal air inclusions.

RESULTS

Twenty-one patients were identified (48.8 ± 3.8 years). Two were associated with wind instruments; seven were iatrogenic, following treatment for duct stenosis; one after radiotherapy; four with known bruxism and seven were idiopathic and without associated conditions. On ultrasound examination, pneumoparotid was characterized by three phenomena: flattened, mobile hyperechoic reflexes, dirty shadows with reverberation or "sunbeam effect," and shifting shadows during gland massage.

CONCLUSIONS

Ultrasound was useful for characterizing pneumoparotid in a fast and practical way and could serve as imaging tool of first choice.

Etiology of Pneumoparotid: A Systematic Review

Pneumoparotid describes retrogradely insufflated air within the Stensen's duct and/or parotid gland. It is a rare condition with variable causative factors. This study aimed to elucidate the clinical characteristics of pneumoparotid. Reports in all languages were evaluated following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement 2020. A literature search was conducted using electronic medical databases (PubMed, Scopus, Web of Science, EBSCO, Ovid, Google Scholar, SciElo, LILIACS, and others) from 1890 to 30 June 2022. One hundred and seventy patients (mean age; 28.4 years) from 126 studies were reviewed. Common symptoms included swelling (84.7%) and pain (35.9%). Characteristic findings were crepitus in the parotid region (40%) and frothy saliva from the orifice (39.4%). The common etiologies included abnormal habits such as blowing out the cheeks (23.5%), idiopathic (20%), self-induced (15.9%), playing wind instruments such as trumpets or flutes (8.8%), and diseases inducing coughing or sneezing (8.2%). The treatments included antibiotic therapy (30%), behavioral therapy to avoid continuing causative habits (25.9%), psychiatric therapy (8.2%), and surgical procedures (8.2%). Treatment should be individualized and etiology-based. However, the etiology was not identified in 20% of patients. Further detailed data from larger samples are required to clarify and improve the recognition of this entity.

Pneumoparotid related to obstructive sleep apnea syndrome treated by oral appliance with anterior opening to reduce intraoral pressure

Pneumoparotid is associated with retrograde air insufflation in Stensen's duct and the parotid gland. A 57‐year‐old man experienced swelling and pain in the right parotid region after sleeping during a flight. Pneumoparotid and obstructive sleep apnea syndrome were diagnosed. Pneumoparotid was suspected as caused by increased intraoral pressure during sleep; thus, an oral appliance to reduce intraoral pressure was effective. After 9 years, the symptoms recurred on the left side. The appliance was reinserted and helped substantially. This is the first case report of obstructive sleep apnea syndrome accompanying pneumoparotid, treated effectively with an oral appliance, with a 10‐year follow‐up.

Pneumoparotid and Pneumoparotitis: A Literary Review

Pneumoparotid is a rare condition of parotid swelling. The presence of the air in gland parenchyma is caused by an incompetent Stensen’s duct with high pressure may cause the acini’s rupture. We reviewed 49 manuscripts, from 1987 to today, that enrolled a total of 54 patients with pneumoparotid. Our review evaluated the following evaluation parameters: gender, age, etiology, clinical presentation, treatment, days of resolution after diagnosis, relapse and complications. The most frequent etiology is self-induction by swelling the cheeks (53.7%). This cause mainly involves children (74%), for conflicts with parents, excuses for not going to school, nervous tics or adults (16%) with psychiatric disorders. Iatrogenic causes are also frequent (16.6%), for dental treatments (55.5%) or use of continuous positive airway pressure (CPAP) (33.4%). Medical therapy is the most practiced (53.7%), in most cases it is combined with behavioral therapy (25.9%) or psychotherapy (25.9%). Surgery is rarely used (9.2%) as a definitive solution through parotidectomy (50%) or ligation of the duct (50%). The most common complication is subcutaneous emphysema (24.1%), sometimes associated with pneumomediastinum (5.5%). Careful treatment and management are necessary to ensure the resolution of the pathology and counteract the onset of complications.

Pneumoparotitis as a complication of long-term oronasal positive airway pressure for sleep apnea

BACKGROUND

Parotid swelling is rarely caused by pneumoparotitis from retrograde insufflation of air into Stensen's duct. Previous reports have identified occupational exposures, self-induced habits, exercise, spirometry, and short-term positive pressure airway ventilation as causes of salivary duct insufflation.

METHODS

We present 2 cases of pneumoparotitis in patients on long-term oronasal continuous positive airway pressure (CPAP) for obstructive sleep apnea.

RESULTS

A diagnosis of pneumoparotitis was made by CT scan in case 1 and sialography in case 2. Patients were advised to transition from oronasal to nasal-only CPAP. One patient was successfully transferred and had good symptomatic improvement, whereas the second patient did not tolerate nasal CPAP and had persistent symptoms on oronasal CPAP.

CONCLUSION

Long-term use of oronasal CPAP is a potential cause of pneumoparotitis.

Incidental pneumoparotid detected on computed tomography: Should it raise an alarm?

BACKGROUND

Pneumoparotid is often seen in patients as a result of infection or following maneuvers that lead to increase in intraoral pressures. We describe a short series of 5 cases of incidental pneumoparotid, for the first time, detected during neck contrast-enhanced computed tomography (CECT) examination.

METHODS

All neck CECT examinations that had been acquired over a 4-month period for indications other than pertaining to the parotid gland were retrospectively analyzed.

RESULTS

Four hundred cases were reviewed. Five of 80 patients in whom CECT was acquired after the "puffed cheek" maneuver were detected to have incidental pneumoparotid. All remained clinically asymptomatic during the examination.

CONCLUSIONS

Pneumoparotid may be an incidental finding in patients asked to blow air in a closed mouth during CT/magnetic resonance acquisition. An awareness of this benign finding would prevent sudden alarm of interpreting it as an anaerobic infection of the parotid in such patients.

Pneumoparotitis: a case report

BACKGROUND

Pneumoparotid is a rare cause of parotid enlargement. Pneumatic enlargement of the gland is caused by retrograde insufflation via Stensen's duct. Most reported cases have been managed conservatively, thus running a short course.

METHODS AND RESULTS

We report on a case of a 48-year-old man with a chronic painful right facial swelling and symptoms of repeated infection. Clinical examination found a parotid swelling with surgical emphysema and a dilated Stensen's duct. Pneumoparotitis with cystic changes and dilated intraparotid ducts was confirmed by CT. The patient proceeded to undergo excision of the gland, with subsequent resolution of symptoms.

CONCLUSION

Repeated retrograde movement of air and contaminated saliva leads to chronic infection and sialectasis. Management is aimed at preventing these sequelae by identifying and addressing the insult early; however, repeated pneumoparotid leads to chronic pneumoparotitis, the management of which is excision of the gland.

Pneumoparotitis: a diagnostic challenge

Pneumoparotitis is a rare cause of recurrent parotid swelling and its diagnosis can be challenging if the patient does not present with typical symptoms and is not in a risk group for parotitis. Several diagnostic techniques have been described in the literature including plain radiography, sialography and CT scanning. This report suggests that ultrasound is an efficient diagnostic aid and should be routinely used for the diagnosis of this condition.

Pneumoparotid due to spirometry

Pneumoparotid has been described in patients who generate increased intraoral pressures when playing wind instruments, while coughing, and when undergoing dental work. Some patients have intentionally created pneumoparotid to avoid duties at school or in the military, or to gain attention. We describe a patient who developed pneumoparotid during pulmonary function testing. The diagnosis of pneumoparotid depends on a suggestive clinical situation and glandular swelling with or without crepitus. Observation of aerated saliva per Stensen's duct or air in the parotid duct and/or gland by any imaging study is diagnostic if infection with a gas-forming organism can be reasonably excluded. No specific treatment is required, other than the avoidance of predisposing activities.