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Neonatal suppurative parotitis.

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A 2-week-old premature male infant was referred to the pediatric otolaryngology service with a 1-day history of a right periauricular swelling. He was the product of a 32-week pregnancy and was delivered via cesarean section. On examination, he was afebrile and irritable but feeding normally. His weight was 2,200 g. The skin over the right parotid and preauricular region was erythematous and inflamed (figure, A). The parotid gland was firm and tender on palpation. Pressure over the gland resulted in expression of pus from the Stensen duct (figure, B). The pus was sent for culture, which grew Staphylococcus aureus.

Ultrasonography of the gland revealed hypoechoic areas consistent with parotitis. The infant's white blood cell count was 19,000, with neutrophilia.

The patient was started on IV ampicillin/sulbactam, to which he responded rapidly with complete resolution of the inflammatory signs and swelling. After 5 days of IV therapy, he was switched to oral amoxicillin/ clavulanate, for a total of 14 days of antibiotic therapy.

Infections of the salivary glands are rare in neonates, but when they occur, the parotid gland is the most commonly affected. Neonatal suppurative parotitis (NSP) is an uncommon disease defined by the presence of parotid enlargement and purulent fluid expressed from the Stenson duct. Because of its rarity, the literature is limited to case reports and a few case series. A MEDLINE search revealed only 27 cases reported since 1990. The major predisposing factors identified are premature birth (38%) and male gender (71%). (1) Dehydration and nasogastric feeding are also associated with the condition. The involvement is usually unilateral, but bilateral infections have been reported.

S aureus is the most common pathogen identified in NSP, and in one case series was found in 56% of cases. (1) Escherichia coli, Streptococcus viridans, Streptococcus pneumoniae, Streptococcus pyogenes, Pseudomonas, Klebsiella pneumoniae, and anaerobic bacteria also have been isolated. (2)

The parotid produces exclusively serous secretions that lack the bacteriostatic properties of the mucoid component found in other mixed glands. This predisposes the parotid to ascending infection through the Stenson duct in the setting of stasis, such as in the dehydrated patient. Another proposed pathogenic mechanism of parotid infection is via hematogenous seeding. (3)

Clinical presentation of a neonate with NSP typically includes fever, local edema, erythema, and tenderness over the preauricular area 7 to 14 days after birth. (3) Laboratory tests generally show leukocytosis with a left shift, as well as negative blood, CSF, and urine cultures. Amylase levels have been reported to be elevated in 45% of cases.; Imaging can be performed if an abscess is suspected, or if there is no clinical improvement after 48 hours of IV antibiotic therapy. (4) Ultrasonography frequently demonstrates a marked increase in the size of the gland and a coarse echo pattern. (2)

The treatment of NSP is early antibiotic therapy guided by cultures, with 83% of patients achieving complete resolution of symptoms. Failure to improve after 48 hours of appropriate antibiotic therapy should prompt repeat imaging with ultrasonography to identify abscess formation. Incision and drainage is required infrequently as most patients respond to intravenous antibiotic therapy. Recurrence is uncommon.

The increase in the incidence of premature births, prolonged neonatal intensive care unit stays, and growing antibiotic resistance make this a diagnosis with which all otolaryngologists should be familiar.

References

(1.) Spiegel R, Miron D, Sakran W, Horovitz Y. Acute neonatal suppurative parotitis: Case reports and review. Pediatr Infect Dis J 2004; 23(1):76-8.

(2.) Sabatino G, Verrotti A, de Martino M, et al. Neonatal suppurative parotitis: A study of five cases. Eur J Pediatr 1999; 158(4):312-14.

(3.) Leake D, Leake R. Neonatal suppurative parotitis. Pediatrics 1970; 46(2):202-7.

(4.) Schwab J, Baroody F. Neonatal suppurative parotitis: A case report. Clin Pediatr (Phila) 2003;42(6):565-6.

From the Department of Otorhinolaryngology-Head and Neck Surgery, Division of Pediatric Otolaryngology, University of Maryland School of Medicine, Baltimore.

Alba Miranda, MD; Kevin D. Pereira, MD
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Title Annotation:PEDIATRIC OTOLARYNGOLOGY CLINIC
Author:Miranda, Alba; Pereira, Kevin D.
Publication:Ear, Nose and Throat Journal
Article Type:Case study
Geographic Code:1USA
Date:Oct 1, 2010
Words:659
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