Pneumoparotid: A case report and review of its pathogenesis, diagnosis, and management.Abstract
Pneumoparotid is considered to be a rare entity, but the diagnosis might not be as uncommon as reported. We report a case in which computed tomography incidentally revealed air in the parotid ducts bilaterally. Treatment is aimed at the elimination of predisposing and causative factors, but because our patient denied any symptoms or precipitating factors and had a benign presentation, no immediate intervention was initiated.
Pneumoparotid is the presence of gas in the parotid gland or salivary ducts. It is the result of an increase in intraoral pressure and the subsequent forced entry of air through Stensen's duct. Pneumoparotid can be caused by dental instrumentation, positive-pressure ventilation during anesthesia, chronic cough, and playing a wind instrument and other physical activities that involve forceful exhalation exhalation /ex·ha·la·tion/ (eks?hah-la´shun)
1. the giving off of watery or other vapor.
2. a vapor or other substance exhaled or given off.
3. the act of breathing out. .
The clinical examination can reveal unilateral or bilateral parotid parotid /pa·rot·id/ (pah-rot´id) near the ear.
1. Situated near the ear.
2. Of or relating to a parotid gland.
A parotid gland. swelling, subcutaneous emphysema, or frothy salivary secretions. Computed tomography (CT) and standard sialography confirm the diagnosis. Treatment is aimed at the elimination of precipitating factors. Two treatments have been considered for sialadenitis sialadenitis /si·al·ad·e·ni·tis/ (si?al-ad?e-ni´tis) inflammation of a salivary gland.
si·a·lad·en·i·tis or si·a·lo·ad·e·ni·tis
Inflammation of a salivary gland. secondary to recurrent or chronic episodes of pneumoparotid: transposition of Stensen's duct and parotidectomy Parotidectomy Definition
Parotidectomy is the removal of the parotid gland, a salivary gland near the ear.
The main purpose of parotidectomy is to remove cancerous tumors in the parotid gland. . In this article, we present a case of pneumoparotid, and we review its pathogenesis, diagnosis, and management.
A 50-year-old man came to the otolaryngology clinic with a long history of postnasal postnasal /post·na·sal/ (-na´z'l) posterior to the nose.
1. Located or occurring posterior to the nose or the nasal cavity.
2. drainage and nasal congestion that were refractory to medical management. Screening CT of the paranasal sinuses revealed well-aerated paranasal sinuses and air in Stensen's duct bilaterally (figure).
The patient had not undergone any recent dental manipulation and had never played a wind instrument. Head and neck examination revealed no evidence of parotid swelling. The patient was afebrile afebrile /afe·brile/ (a-feb´ril) without fever.
afebrile adjective Feverless , and the saliva flow from the ducts on manual parotid pressure was normal. In view of these findings, no immediate intervention was initiated. The patient was followed clinically for the potential occurrence of parotitis parotitis /par·oti·tis/ (par?o-ti´tis) inflammation of the parotid gland.
epidemic parotitis mumps.
par·o·ti·tis or pa·rot·i·di·tis
n. or sialadenitis, and he reported no symptoms at 1 month.
Pneumoparotid is the result of an increase in intraoral pressure and the subsequent insufflation insufflation /in·suf·fla·tion/ (-sah-fla´shun)
1. the act of blowing a powder, vapor, or gas into a body cavity.
2. finely powdered or liquid drugs carried into the respiratory passages by such devices as aerosols. of air into Stensen's duct. Other terms for this condition include pneumatocele glandulae parotis,  wind parotitis,  surgical mumps and anesthesia mumps,  and pneumosialadenitis. 
Pathogenesis. The diagnosis is considered rare, but it might not be as uncommon as previously reported. A review of the literature reveals reports of several etiologies. In 1865, Hyrtl first described this condition in musicians who were learning to play wind instruments.  Glassblowers are known to be predisposed to pneumoparotid, as well.  Following anesthesia, patients sometimes strain and cough during extubation while receiving positive pressure, which can cause air to insufflate in·suf·flate
1. To blow into, especially to fill the lungs of an asphyxiated person with air, or to blow a medicated vapor, powder, or anesthetic into the lungs, or into any cavity or orifice of the body.
2. into the parotid gland.  Injury during a dental procedure can occur when the dentist is working near the maxillary molars or when the angulation angulation /an·gu·la·tion/ (ang?gu-la´shun)
1. formation of a sharp obstructive bend, as in the intestine, ureter, or similar tubes.
2. deviation from a straight line, as in a badly set bone. of instruments is improper.  Pneumoparotid has also been induced by nose blowing,  blowing up balloons,  chronic attempts to suppress cough, [8,9] and rapid decompression while scuba diving.  It can also be self-induced, and the literature contains an increasing number of reports involving pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. and adolescent patients who induce parotid insufflation to avoid sc hool or gain attention. [5,1,12] Other episodes have been attributed to anatomic abnormalities, including a patulous patulous /pat·u·lous/ (pat´u-lus) spread widely apart; open; distended.
Freely open or exposed; patent.
spread widely apart; open; distended. Stensen's duct,  masseter muscle In human anatomy, the masseter is one of the muscles of mastication.
It is particularly powerful in herbivores to assist when they are chewing plants. Origin and insertion of the two heads hypertrophy,  and buccinator muscle weakness. 
The anatomy of Stensen's duct normally prevents a retrograde influx of air. Redundant mucosal folds surround the slit-shaped orifice, providing a seal when intraoral pressure increases. In addition, the diameter of the duct orifice is smaller than that of the duct itself.  The buccinator muscle further acts to compress the duct during contraction. However, large increases in intraoral pressure can overwhelm normal protective mechanisms and allow air and saliva to enter the ductal system. Air rupturing through the parotid acini acini Plural of acinus, eg, milk-producing glands of breast can extend to the parapharyngeal space and cause subcutaneous emphysema and airway obstruction. This can progress to involve the retropharyngeal space.
Diagnosis. The history and physical examination are key to the diagnosis. Parotid swelling can be unilateral or bilateral, depending on its cause. Cases involving dental instrumentation are usually unilateral on the side where the work was done. It is necessary to exclude obstructive, inflammatory, metabolic, and neoplastic neoplastic /neo·plas·tic/ (ne?o-plas´tik)
1. pertaining to a neoplasm.
2. pertaining to neoplasia.
pertaining to neoplasia or a neoplasm. causes of parotid enlargement. The clinical examination might reveal subcutaneous emphysema, crepitation crepitation /crep·i·ta·tion/ (krep?i-ta´shun) a dry sound like that of grating the ends of a fractured bone.crep´itant
1. along the course of Stensen's , [1,4,6,10,14] and frothy saliva. [1,4,6,13,14] Patients usually experience pain, tenderness, and erythema. Salivary gland enlargement usually resolves within several days. In contrast, fever and toxicity accompany parotitis as a result of the presence of gas-forming organisms. Recurrent parotid insufflation can predispose the patient to recurrent parotitis and sialectasis.
Radiographic examination confirms the diagnosis. CT and sialography delineate the salivary ducts, salivary gland tissue, and surrounding structures. Ductal dilation is a common finding. Although a normal duct pattern is often seen after repeated episodes of air reflux, the secondary ducts can become dilated and strictured.
Treatment. Treatment is directed toward elimination of the causative or predisposing factors. Depending on the patient's condition, other measures can be taken, including reassurance, massage, hydration, warm compresses, and the prescription of anti-inflammatory medications, prophylactic antibiotics, and sialagogues. Wind instrumentalists and glassblowers can be taught techniques to reduce their chances of insufflation. In cases of self-induction, psychological counseling might be of benefit. Surgical intervention--including salivary gland duct ligation,  the transposition of Stensen's duct to the tonsillar fossa, [4,13] and parotidectomy--can be considered for recurrent infectious episodes.
From the Division of Otolaryngology, Department of Surgery, Duke University Medical Center, Durham, N.C. (Dr. Huang and Dr. Misko), and the Department of Radiology, Asheville (N.C.) VA Medical Hospital (Dr. Schuster).
(1.) Greisen grei·sen
A granitic rock composed chiefly of quartz and mica.
[German, from greissen, to split.]
Noun 1. O. Pneumatocele glandulae parotis. J Laryngol Otol 1968; 82:477-80.
(2.) Saunders HF. Wind parotitis. N Engl J Med 1973;259:698.
(3.) Reilly DJ. Benign transient swelling of the parotid glands following general anesthesia: "Anesthesia mumps." Anesth Analg 1970;49:560-3.
(4.) Brodie HA, Chole RA. Recurrent pneumosialadenitis: A case presentation and new surgical intervention. Otolaryngol Head Neck Surg 1988;98:350-3.
(5.) Markowitz-Spence L, Brodsky L, Siedell G, Stanievich JF. Self-induced pnemoparotitis in an adolescent: Report of a case and review of the literature. Int J Pediatr Otorhinolaryngol 1987;14:113-21.
(6.) Rupp RN. Pneumoparotid: An interesting case of acute parotid swelling. Arch Otolaryngol 1963;77:665.
(7.) Piette E, Walker RT. Poenmoparotid during dental treatment. Oral Surg Oral Med Oral Pathol 1991;72:415-7.
(8.) David ML, Kanga JF. Pneumoparotid: In cystic fibrosis. Clin Pediatr (Plilla) 1988;27:506-8.
(9.) Cook JN, Layton SA. Bilateral parotid swelling associated with chronic obstructive pulmonary disease chronic obstructive pulmonary disease
n. Abbr. COPD
A chronic lung disease, such as asthma or emphysema, in which breathing becomes slowed or forced. : A case of pneumoparotid. Oral Surg Oral Med Oral Pathol 1993;76:157-8.
(10.) Watt J. Benign parotid swellings: A review. Proc R Soc Med 1977;70:483-6.
(11.) Alcalde alcalde (ălkăl`dē, Span. älkäl`dā) [Span., from Arab.,=the judge], Spanish official title, in existence at least from the 11th cent. Since the late 19th cent. RE, Ueyama Y, Lim DJ, Matsumura T. Pneumoparotid: Report of a case. J Oral Maxillofac Surg 1998;56:676-80.
(12.) Goguen LA, April MM, Karmody CS, Carter BL. Self-induced pneumoparotitis. Arch Otolaryngol Head Neck Surg 1995;121:1426-9.
(13.) Telfer MR, Irvine GH. Pneumoparotitis. Br J Surg 1989;76:978.
(14.) Mandel L, Kaynar A, Wazen J. Poenmoparotid: A case report. Oral Surg Oral Med Oral Pathol 199l;72:22-4.