Elderly Male With Cheek Swelling

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A 71-year-old man presented to the emergency department with progressive swelling and tenderness of his left cheek. He was taking metformin for diabetes and amitriptyline for fibromyalgia. His initial vital signs revealed a temperature of 39.3°C (103°F), pulse rate of 105 beats/min, and blood pressure of 96/50 mm Hg. Examination demonstrated firm, tender, warm, and erythematous swelling over the left mandibular ramus that extended to the cheek (Figure 1). Massage of the area solidified the diagnosis (Figure 2).

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• Figure 1. 

  Patient at presentation, demonstrating unilateral facial swelling and erythema.

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• Figure 2. 

  Direct external pressure over the swelling resulted in pus emanating from Stensen's duct. Used with permission of Sarah Nelson, MD, Department of Emergency Medicine, Maine Medical Center, Portland, ME.

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Diagnosis 

Acute suppurative parotitis. Acute suppurative parotitis affects primarily the elderly and immunocompromised. Predisposing factors include poor oral hygiene, dehydration, malnutrition, alcoholism, diabetes, autoimmune disease, use of oral secretion-reducing medications, and ductal obstruction by sialolithiasis, tumor, or foreign body.¹, ² The differential diagnosis includes viral infection (mumps), sarcoidosis, sialolithiasis, chronic recurrent parotitis, and neoplasm.¹ The most commonly cultured microorganisms are Staphylococcus aureus (including MRSA³), α-hemolytic streptococci, enteric gram-negative rods, and anaerobic bacteria.

Patients typically present with unilateral facial swelling, erythema, and tenderness. They commonly have fever with leukocytosis and may progress to frank sepsis. Purulent material can frequently be expressed from the orifice of Stensen's duct. Locally advanced disease can spread to adjacent head and neck structures, causing abscess formation, jugular vein septic thrombophlebitis, osteomyelitis, and facial nerve palsies.²

Ultrasonography and computed tomography scanning are appropriate diagnostic methods. Treatment includes rehydration, nutritional support, warm compresses, sialogogues, good oral hygiene, and focused antimicrobial therapy. Surgical intervention is indicated for lack of improvement with antibiotic therapy, facial nerve involvement, local extension beyond the glandular capsule, and frank abscess formation.¹

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References 

1. Fattahi TT, Lyu PE, Van Sickels JE. Management of acute suppurative parotitis. J Oral Maxillofac Surg. 2002;60:446–448
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2. Sheppard DC, Chambers HF. Suppurative parotitis. Western J Med. 1998;169:116–117
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3. Nicolasora NP, Zacharek MA, Malani AN. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging cause of acute bacterial parotitis. South Med Assoc. 2009;102:208–210
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