A 70 y.o. man presents with a one day history of bilateral parotid swelling

What is the differential

Our patient has bilateral parotid enlargement from Sjogren’s syndrome . He had painless bilateral enlargement of the parotids over one day.  He had a similar unilateral event several years pta which resolved spontaneously.   On arrival he spiked a temp to 39 and was treated as bacterial parotitis although cultures from Stensen’s duct were negative. He had ANA + 1:2500, RF 250, sed rate 99, ENA +, ENA SSA+ and anti Jo -.  

The differential of bilateral parotid swelling is extensive although it can be divided into obstructive(related to stones), infectious , malabsorption related (pancreatitis) and immune. Bacterial causes that are  related to a stone in the ductare painful and most commonly in females.  Viral infections are often caused by mumps , cocksackie, or HIV.   There is a chronic parotitis which occurs in children age 2-7 which is painless.

sarcoid is also a cause of bilateral parotid swelling

 Wegeners and Sjogrens are the immune diseases most commonly causing parotid enlargement. Kimura’s disease is bilateral parotid enlargement with elevated IgE and eosinophilia. Tumors can also cause bilateral parotid enlargement specifically Warthin’s tumor,  as well as benign masseteric enlagement .

Radiation, specifically radioactive iodine and pneumoparotid caused by blowing a wind instrument can also cause parotid swelling.

air in parotids

 Sjogrens syndrome  as in our patient, usually results from parotid and salivary gland involvement with dry eyes and dry mouth. Extraglandular manifestions of Sjogrens can includebiliary cirrhosis, pulmonary interstitial disease, renal disease and peripheral neuropathy. 5% of these patients develop B cell lymphoma.

Treatment of the disease is symptomatic , with artificial tears and throat lozenges for dry mouth.  Immunosuppression is not recommended.  Our patient was treated symptomatically after a short course of antibiotics and has remained asymptomatic.

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Gadodia A, Bhalla A, Sharma R, Thakar A, Parshad R.  Bilateral parotid swelling: a radiologic review. Dentomaxillofac rad 2011Oct 40(7) 403-414.

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