Salivary gland disorders — structured clinical encounter

Candidate brief

You are the paediatric registrar in the emergency department. A five-year-old boy whose parents declined vaccinations has two days of fever at 38.8 degrees Celsius, malaise and progressive bilateral cheek swelling. The parotid glands are enlarged and tender bilaterally, the ear lobes are pushed outward and forward, and the Stensen duct orifice is inflamed but expresses no frank pus. He has no testicular pain, neck stiffness or abdominal pain. [1]

Task

Take the focused history, present your differential, justify your diagnosis of mumps, outline your supportive management and your five-day school exclusion advice, and explain the complications you would include in your safety-net. Be prepared to defend the distinction between mumps and suppurative parotitis at the bedside. A second child — a four-year-old with recurrent unilateral parotid swelling — will then be introduced for contrast. [1] [3]

Discussion anchors

• Diagnosis and ear-lobe sign: mumps from the bilateral tender parotid swelling, fever, malaise and under-immunised status, confirmed by the ear-lobe sign (the parotid lifts the ear lobe outward and forward) and the absence of purulent Stensen duct discharge, which distinguishes it from suppurative parotitis. [1]
• Management and exclusion: supportive care with analgesia, hydration, warm compresses and a soft diet, with no role for antiviral therapy; exclusion from school for five days from the onset of parotid swelling; and notification of public health. The MMR vaccine is the cornerstone of prevention, with two doses giving approximately 88 per cent protection. [1]
• Complications: orchitis in up to a third of post-pubertal males, meningitis in 1 to 10 per cent, pancreatitis, and permanent sensorineural hearing loss in approximately 1 in 20,000 cases. The safety-net covers testicular pain, headache, neck stiffness, abdominal pain and hearing change. [1]
• Contrast case: the four-year-old with recurrent unilateral parotid swelling has juvenile recurrent parotitis; ultrasound shows sialectasis and gland heterogeneity; conservative management with gland massage, warm compresses, sialogogues and analgesia is first-line, with sialendoscopy for frequent or severe flares. Most children resolve spontaneously by puberty. [3] [5]
• Neonatal scenario: a premature neonate with unilateral tender parotid swelling, purulent Stensen duct discharge and fever has neonatal suppurative parotitis — intravenous anti-staphylococcal antibiotics, blood and pus cultures, ultrasound, and a low threshold for surgical drainage. [9]