A case of "anesthesia mumps" from ICU.

Sir,

Sudden onset unilateral parotid gland swelling is rarely reported from medical intensive care unit (ICU). It is reported predominantly from intraoperative/immediate postoperative setting and is recognized as “anesthesia mumps”.[12] We are presenting a sudden onset left-sided parotid gland swelling in a patient kept in the lateral decubitus position in our ICU.

A 60-year-male patient was admitted in our ICU with idiopathic severe acute pancreatitis (100% necrosis status post necrosectomy) with severe multidrug resistant intraabdominal sepsis, septic shock and acute kidney injury. He was treated with broad spectrum antibiotics, antifungals, vasopressors, mechanical ventilation (tracheostomized), and renal replacement. As per our standard care protocols in ICU, he was also given chlorhexidine mouth care and side-to-side turning 6-8 hourly. In one of such secessions he was kept on left lateral decubitus position. During repositioning he was noted to have sudden onset left-sided neck swelling over the parotid area [Figure 1]. Also, there was no redness on inspection or crepitations on palpation of the swollen area. Ultrasonography revealed no vascular/cystic swelling and confirmed soft tissue swelling. The advice from our otolaryngology fellows was just managing it conservatively. The patient succumbed to his illness within 24 h of onset of this symptom due to ongoing septic shock and multi-organ failure. Post mortem parotid gland biopsy could not be done due to non-availability of consent.

Figure 1

Left-sided parotid swelling in our patient (arrowed)

Like in all other published cases,[123] the exact mechanism of “anesthesia mumps” development in our case is not clear. We suggest that the mechanisms may be: Firstly, ongoing intravascular dehydration with the use of renal replacement may thicken the parotid secretions and may lead to parotid duct occlusion. Secondly, side turning may hamper the arterial supply or venous drainage of same sided parotid resulting in ischemic sialadenitis.[13] Ischemic sialadenitis is a unilateral painful salivary gland swelling. Especially in the setting of very high vasopressor requirement, like in our case this possibility can not be ruled out. Thirdly, in the left lateral position there maybe suction catheter mediated injury of duct opening leading to edema and occlusion. Fourth possibility may be a chlorhexidine mediated damage of Stenon's duct in dependent position.[4] Last but not the least; it may be a manifestation of viral parotitis causing the acute pancreatitis also.[5]

In conclusion, sudden onset dependent side salivary gland swelling may occur in ICU also especially when the patient is kept in the lateral decubitus position. For prevention, frequent head and neck position checking in patient with high need for vasopressor and oral suction using soft suction catheter both are to be highlighted.