Rev. Bras. Anestesiol. vol.66 número6

RevBrasAnestesiol.2016;66(6):661---663

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Bilateral

parotitis

in

a

patient

under

continuous

positive

airway

pressure

treatment

Ruslan

Abdullayev

,

Filiz

Cosku

Saral

,

Omer

Burak

Kucukebe

,

Hakan

Sezgin

Sayiner

_,

_Cem

_Bayraktar

_,

_Sadik

_Akgun

a_{AdiyamanUniversityResearchHospital,DepartmentofAnesthesiologyandReanimation,Adiyaman,Turkey} b_{IstanbulUniversity,IstanbulMedicalFaculty,DepartmentofClinicalMicrobiology,Istanbul,Turkey}

c_{AdiyamanUniversityResearchHospital,DepartmentofInfectiousDiseasesandBacteriology,Adiyaman,Turkey} d_{AdiyamanUniversityResearchHospital,DepartmentofOtorhinolaryngology,Adiyaman,Turkey}

e_{AdiyamanUniversityResearchHospital,DepartmentofClinicalMicrobiology,Adiyaman,Turkey}

Received20March2014;accepted6May2014

Availableonline3June2014

KEYWORDS

Parotitis;

Bilateralparotitis; Pneumoparotitis; Continuouspositive airwaypressure

Abstract

Backgroundandobjectives: Many conditions such as bacterial andviral infectious diseases, mechanicalobstructionduetoairandcalculianddrugscancauseparotitis.Wepresentacase ofunusualbilateralparotitisinapatientundernon-invasivecontinuouspositiveairwaypressure (CPAP)therapyforchronicobstructivepulmonarydiseaseexacerbationinintensivecareunit.

Casereport: A36-year-oldpatientwasadmittedtointensive careunitwiththediagnosisof chronicobstructive pulmonarydisease exacerbation.Antibiotherapy,bronchodilatortherapy and non-invasivepositive pressure ventilationwere applied astreatment regimen. Painless swellings developed on the 3rdday of admissionon the right anda day after this onthe left parotidglands.Amylaselevelswereincreasedandultrasonographicevaluationrevealed bilateralparotitis.Nointerventionwasmadeandthetherapywascontinued.Thepatientwas dischargedonthe6thdaywithclinicalimprovementandregressionofparotidswellingswithout anycomplications.

Conclusions: ParotitismayhaveoccurredafterretrogradeairflowintheStensenductduring CPAPapplication.Aftertheexclusionofpossibleviralandbacteriologicaletiologiesandpossible drugreactionswecanfocusonthisdiagnosis.

©2014SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗_{Correspondingauthor.}

E-mail:ruslanjnr@hotmail.com(R.Abdullayev). http://dx.doi.org/10.1016/j.bjane.2014.05.008

662 R.Abdullayevetal.

PALAVRAS-CHAVE

Parotidite;

Parotiditebilateral; Pneumoparotidite; Pressãopositiva contínuadasvias aéreas

Parotiditebilateralempacientesobtratamentocompressãopositivacontínua

dasviasaéreas

Resumo

Justificativaeobjetivos: Muitascondic¸õespodemcausarparotidite,incluindodoenc¸as infec-ciosas virais e bacterianas, obstruc¸ão mecânica por causa da presenc¸a de ar, cálculos e medicamentos. Apresentamos um caso de parotidite bilateral incomum em um paciente sob tratamento com pressão positiva contínua não invasiva das vias aéreas (PPCVA) para exacerbac¸ãodadoenc¸apulmonarobstrutivacrônicaemunidadedeterapiaintensiva.

Relatodecaso:Paciente de36 anos, internado em unidade de terapiaintensiva com diag-nóstico de exacerbac¸ão da doenc¸a pulmonar obstrutiva crônica. Antibioterapia, terapia broncodilatadoraeventilac¸ãocompressãopositivanãoinvasivaforamaplicadascomoregime detratamento.Noterceirodiadeinternac¸ão,inchac¸osindoloresdesenvolveram-seàdireita daglândulaparótidae,depois,àesquerda.Osníveisdeamilaseaumentarameoexame ultra-ssonográfico revelouparotiditebilateral. Nenhumaintervenc¸ãofoi feitaeo tratamentofoi continuado.Opacienterecebeualtanosextodia,commelhoriaclínicaeregressãodoinchac¸o daparótida,semcomplicac¸ões.

Conclusões:AparotiditepodeterocorridoapósofluxoretrógradodeardodutodeStensen duranteaaplicac¸ãodePPCVA.Apósaexclusãodepossíveisetiologiasviraisebacteriológicas epossíveisreac¸õesmedicamentosas,podemosfocarnodiagnóstico.

©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Parotitisisoneof themostcommonly encountered condi-tionsamongnon-neoplasticdisordersofthesalivaryglands.1

Mumps, other viral and bacterial infections, duct calculi, Sjögren’sdisease,anddrugreactionscanbelistedas rea-sonsforacuteparotitis.2_{Oneofthemostcommonreasons}

ofdruginducedparotitisistheuseofiodineandiodine con-taining drugs as contrast agents. Parotitis formed due to iodineis named as‘‘iodine mumps’’.3,4 _{Many other drugs}

otherthaniodinecan formparotitisaswell.Amongthese drugsarephenylbutazone,oxyphenbutazone; chlormethia-zole,methimazole; epinephrine; naproxen;phenothiazine antipsychotics as promazine and thioridazine; clozapine; organophosphate insecticides; l-asparaginase, cytarabine; H-2 blockers such as famotidine, cimetidine, ranitidine; interferon alfa; trimipramine; methyldopa; nifedipine, nicardipine;isoproterenol;ritodrine;ACEinhibitorsas cap-topril,ramipril, enalapril; antibiotics suchascefuroxime, doxycycline, minocycline, nitrofurantoin,sulfadiazine,and trimethoprimsulfametoxazole.5,6

We present a case of bilateral parotitis in a patient under non-invasive CPAP therapy for chronic obstructive pulmonary disease (COPD) exacerbation in intensive care unit.

Case

report

A 36-year-old patient with congenital bronchiectasis was admittedtointensivecareunitwiththediagnosisofCOPD. Antibiotherapy, bronchodilator therapy and non-invasive positive pressure ventilation were applied as treatment regimen. Painless swellings developed on the 3rd day of

admission on the right and a day after this on the left parotidglands.Ultrasonographic(USG)evaluationrevealed parotitis. Blood amylase levels were 197 and 3010U/L respectively on the 2nd and 4th days of gland swelling. MumpsELISArevealedIgM(−)andIgG(+).Thepatient’sdrug therapyconsistedofranitidine1×50mgiv,sulbactam ampi-cillin4×1giv,clarithromycin2×500mgiv,acetylcysteine 2×600mgiv,methylprednisolone2×40mgiv,ipratropium bromide 4×0.5mg inh, salbutamol 4×2.5mg inh, and budesonide2×0.25mginh.Thepatientwasdischargedon the 6th day with clinical improvement and regression of parotidswellingswithoutanycomplications.After10days the patient hadpolyclinic control, where the blood amy-lase level wasmeasured as 125U/L and the parotid USG wasreportedasmildparotitisbilaterally.COPDdrug treat-ment was regulated and the patientwas sent home with suggestions.

Discussion

Theetiologicalmechanismsofparotitiscomprise mechani-cal trauma, infection,hypersensitivity reactions, obstruc-tion of parotid ducts with calculi, air and thickened secretions,parasympatheticstimulation,musclerelaxation, and drug reactions (type A and type B).7,8 _{Our patient}

hadsomeof theseriskfactors.Withranitidine,whichthe patientwasusing,therehadbeen reportsofdruginduced parotitis.9,10_{Suchpatientshadresultedinrecoverywith}

BilateralparotitisinpatientunderCPAPtreatment 663

Scalecanbeusedtoestablishthediagnosisofdruginduced parotitis.6

Besides this,increasedoralcavity pressuredueto pos-itive airway pressure application as a treatment regimen mayhave causedretrograde airmovement in theStensen ductandobstruction,andthismayhaveresultedin paroti-tis.Akcaboyetal.andBaykaletal.blamedretrogradeair flowintotheparotidglandandintraoralpressureriseinthe developmentof postoperativeparotitis.11,12 _{The condition}

associated withinflammation of the parotid glanddue to retrogradeairflowintheparotidductsisnamed as pneu-moparotitis. This condition is characterized with painless swellingandcrepitations.13,14 _{Thereasonscanbelistedas}

habitofcheekinflation,coughattacksinasthma exacerba-tion,straining and coughing during anesthesia, conditions withincreasedintraoralpressure,dentalinstrumentations, balloon inflation, and wind instrument use.14 _{Our patient}

had intermittent positive airway pressure application as treatment regimen. This may have been associated with pneumoparotitisduetoincreasedintraoralcavitypressure. Boththeparotidglandsofthepatienthadpainlessswellings, butnocrepitationwasdetermined.Ultrasonographic eval-uationrevealednofindingsofair,butdetailedexamination todeterminethepresenceofairwasnotperformed. Com-puted tomography would have demonstrated more clear results.

Unilateralparotitisisgenerallyduetoductobstruction, whereasbilateralparotitisismorecommonlyattributedto asystemicdisease.15_{WesuggestedStensenductobstruction}

withair,ratherthanasystemicdiseaseastheprobable eti-ologicalfactor inourpatient.Bilateralparotitisformedas aresultofductobstructionisaratheruncommonsituation. Moreover,thereisnoreportofparotitisafter CPAPin the literature.

We have notinvestigatedviralandbacteriological rea-sons for parotitisotherthan mumpsinourpatient.These factorsshouldhavebeenconsideredaswell.

Parotitis can occur after retrograde air flow in the Stensenductduring CPAP application. Afterthe exclusion ofotherpossibleviralandbacteriologicaletiologiesin addi-tiontothemeasurementofmumpsantibodiesandpossible drugreactions,wecanfocusonthisdiagnosis.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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