A Complication after Percutaneous Nephrolithotomy: Anesthesia Mumps.

Some surgical procedures performed under moderate and sometimes extreme positions expose patients to nonphysiological changes. Especially, the manipulations of a patient in prone and lateral decubitus position might increase complications. Anesthesia mumps has been reported as one of these complications. It has been found to be rare but known entity associated with patients of all age groups and all surgical positions. We herein describe an early noticed acute case of unilateral anesthesia mumps that developed after endotracheal intubation in prone position in a 54-year-old female. Anesthesia mumps may occur in the immediate postoperative period with no suspicious predisposing factor. The reports of such cases would increase the awareness among anesthesiologists and postoperative caregivers regarding this benign complication.

INTRODUCTION

Acute transient swelling of the parotid gland related to anesthesia, defined as “anesthesia mumps,” is a benign and noninfectious complication.[1] It is a rare clinical entity observed immediately following general anesthesia or even after epidural anesthesia.[2] Besides, it is interesting to observe that even the usual face mask ventilation can lead to the development of anesthesia mumps. It can develop intraoperatively or, more often, a few hours later and usually resolves in a few days with no sequelae. Thus, the patients may experience slight pain or distress; however, airway patency is not a problem. Only Kiran et al. reported acute salivary gland swelling during anesthesia induction leading to airway obstruction and tracheotomy.[3] Recently, Cavaliere et al. also described a case of acute postoperative sialadenitis causing complete upper airway obstruction.[4] The exact mechanism of this complication is not yet fully understood, although several theories including increased oral cavity pressure by mask ventilation or by coughing or sneezing of the patient or air passing through Stensen's duct have been put forward.[5]

Percutaneous nephrolithotomy (PNL) is a minimally invasive, effective, and safe surgical procedure for removing large renal stones.[6] Prone position is often preferred for its advantage of providing a larger area for access and manipulation; however, PNL in prone position is separately a challenge for anesthetists.[78]

In this report, we describe a case of acute unilateral anesthesia mumps encountered after PNL to discuss possible pathophysiology and prevention, as well as a review of the available literature.

CASE REPORT

A 54-year-old female patient, with normal history, had PNL under general anesthesia. Following standard monitorization; general anesthesia with propofol, sevoflurane, and remifentanil infusion was performed. Endotracheal intubation was achieved by rocuronium. First, a 5 Fr urethral catheter was inserted in the lithotomy position. At almost 25 min after anesthesia induction, she was placed into prone position with appropriate structural support provided by soft padded bolsters, silicone rolls, and cushions to prevent nerve injuries or pressure ulcers. The surgical procedure lasted 85 min. Afterward, the patient was turned to supine position again and extubated uneventfully, with atropine 0.5 mg and neostigmine 0.05 mg/kg injected intravenously to reverse the muscle relaxation. As soon as, she was transported to postanesthesia care unit a red, painless, firm swelling on the area over the left parotid gland was recognized [Figure 1]. On her physical examination, no temperature rise or crepitation on palpation was detected. Consequently, parotid gland ultrasonography performed 1 h later revealed a few intraglandular lymph nodes with hilar vascularization on superficial region of the left parotid gland. The laboratory findings were normal. The swelling was confirmed to be a unilateral parotid glandular enlargement. She was managed conservatively. The redness spontaneously decreased over the next 24 h and the swelling regressed completely after 4 days [Figure 2].

Figure 1

Photo of patient in postanesthesia care unit

Figure 2

Photo of patient at postoperative 4th day

DISCUSSION

Numerous cases of anesthesia mumps have been reported after various kinds of surgeries including plastic, endoscopic, neurosurgical, abdominal, orthopedic, otolaryngologic, and a few types of gynecological procedures.[5] However, in our case, it was observed in an urological surgery. PNL was begun in the supine position firstly, and then the patient was changed to prone position. The procedure did not last long.

In the literature, not a single factor, but a combination of factors has been postulated in the etiology of this complication. Kwon et al. mentioned about the easy retrograde passage of air into the parotid gland provided by loss of muscle tone caused by muscle relaxants in anesthesia induction.[1] This complicates the mask ventilation by increased positive pressure in the oral cavity during induction. On the other hand, during emergence from general anesthesia, while a patient is still receiving positive pressure ventilation, straining, and coughing may cause retrograde flow of air through Stensen's orifice.[9] Another factor is perioperative use of various drugs such as atropine, succinylcholine, and morphine, as well as preoperative dehydration, causing less, and copious secretions. Mandel and Surattanont explained the vasodilatation and hyperemia in the parotid gland as a result of activation of pharyngeal reflex which in turn stimulation of parasympathetic system.[10] Finally, extreme head positioning during rotation and flexion can occlude Stensen duct or cause temporary ischemia or stasis of the parotid gland. When the head position is changed to normal, the compression is released, and reperfusion injury following ischemia can cause swelling in the surrounding tissues.[911] This is probably the situation that has happened in our case. However, general anesthesia is not the only occasion causing this complication. Pirat et al. reported a case of bilateral submandibular gland swelling even after regional anesthesia for hip replacement.[12] The rebound vasoconstriction caused by sympathetic stimulation in the unblocked area was thought to be the cause in that case. Rosique et al. also described three cases of parotitis in patients undergoing surgery under epidural anesthesia.[2] They supposed dehydration led to transient parotid secretion obstruction and postsurgical parotitis. There are also reports describing rare cases following bronchoscopy or upper gastrointestinal endoscopy under sedation.[131415]

In almost all of these cases, serum amylase almost never increases. In our patient, serum amylase measurement and the blood cell count were normal. Hence, we did not think of any viral and bacterial parotitis or any other allergic conditions.

As far as, we have investigated; this is the first case report of “anesthesia mumps” observed immediately after PNL. In our case, the patient had no comorbidities, thus, anesthesia induction and extubation course were smooth. Moreover, we paid considerable attention during repositioning.

For diagnosis, we used ultrasonography, but sialography, computerized tomography, magnetic resonance are the other alternatives for making a diagnosis.

We had a satisfactory and spontaneous recovery with symptomatic care in this patient. However, extreme edema and copious secretions can compromise airway patency. Thus, it should be considered with careful observation particularly in patients undergoing surgeries with predisposing conditions such as anticholinergic premedication, obesity, a long operation duration, skull-base surgery requiring strong cervical rotation and flexion and prone position. By this report, we wanted to draw the attention of anesthesiologists and surgeons for this rare complication in taking adequate precautions for early diagnosis and proper management.

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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Nil.

Conflicts of interest

There are no conflicts of interest.