Salivary gland disorders — branching viva

Opening — the child with bilateral parotid swelling

Examiner: A five-year-old boy whose parents declined vaccinations has two days of fever, malaise and progressive bilateral cheek swelling. The parotid glands are enlarged and tender bilaterally, the ear lobes are pushed outward, and the Stensen duct orifice is inflamed but expresses no pus. Talk me through your diagnosis and your immediate assessment. [1]

Candidate should cover: the diagnosis of mumps from the bilateral tender parotid swelling, fever, malaise and under-immunised status, confirmed by the ear-lobe sign and the absence of purulent Stensen duct discharge; and a focused assessment of hydration, testicular tenderness in a post-pubertal boy, neurological signs of meningism, and abdominal tenderness for pancreatitis. [1]

Branch 1 — supportive management and the five-day exclusion

Examiner: How will you manage him, and what is the role of antiviral therapy and school exclusion? [1]

Candidate should cover: supportive care with analgesia, hydration, warm compresses and a soft diet; no role for antiviral therapy; exclusion from school for five days from the onset of parotid swelling; notification of public health; and a safety-net for orchitis, meningitis, pancreatitis and hearing loss. The MMR vaccine is the cornerstone of prevention, with two doses giving approximately 88 per cent protection. [1]

Branch 2 — the child with recurrent unilateral parotid swelling

Examiner: Now a different child: a four-year-old with four episodes of right-sided parotid swelling over eighteen months, each resolving without antibiotics. What has changed, and what will you do? [3]

Candidate should cover: the diagnosis of juvenile recurrent parotitis from the recurrent non-suppurative parotid swelling in a young child; the first-line imaging with ultrasound showing sialectasis and gland heterogeneity; the conservative management with gland massage, warm compresses, sialogogues and analgesia; and the role of sialendoscopy with duct lavage and steroid installation for frequent or severe flares. Most children resolve spontaneously by puberty. [3] [5]

Branch 3 — the neonate with suppurative parotitis

Examiner: Finally, a twelve-day-old premature infant presents with fever, irritability and a unilateral tender parotid mass with overlying erythema. Gentle pressure on the gland expresses purulent discharge from the Stensen duct. What is the diagnosis and the immediate management? [9]

Candidate should cover: the diagnosis of neonatal suppurative parotitis from the unilateral tender parotid swelling, purulent Stensen duct discharge and systemic signs in a premature neonate; the immediate management with intravenous anti-staphylococcal antibiotics covering Staphylococcus aureus, blood and pus cultures, ultrasound to detect abscess, and a low threshold for surgical drainage. Prematurity and dehydration are key risk factors, and the threshold for escalation is low. [9]