Acute Transient Sialadenitis - "Anesthesia Mumps:" Case Report and Review of Literature.

Acute postoperative sialadenitis, called "anesthesia mumps," has been reported in different surgical procedures. It is usually benign in nature, and the swelling resolves spontaneously without any treatment in the majority of cases. The attending physician should be aware of this transient condition. Very rarely, serious complications can occur such as respiratory distress warranting urgent intervention. We report a case of acute transient sialadenitis in a 6-year-old child who underwent general anesthesia for upper gastrointestinal endoscopy, which resolved spontaneously without any treatment. Copyright:

INTRODUCTION

Transient inflammation and enlargement of salivary glands after general anesthesia, known as anesthesia mumps, is a rare complication encountered in anesthesia.[12] It is usually benign and subsides within few hours. Very rarely, it has caused serious symptoms warranting urgent intervention.[34] The etiology of this condition remains elusive, but possible causes include trauma, infection, hypersensitivity reactions, dehydration, and obstruction of the glandular excretory ducts by position, calculi, or thickened secretions.[5] We report the case of a 6-year-old child who developed acute sialadenitis of the left parotid gland after upper gastrointestinal (GI) endoscopy.

CASE REPORT

A 6-year-old male, weighing 20 kg, was scheduled for upper GI endoscopy and esophageal dilatation. He had postcorrosive ingestion esophageal stenosis. Preoperative anesthesia assessment was unremarkable. He had undergone similar procedures three times in the past 2 years uneventfully. Induction of anesthesia was done with fentanyl 1.5 μg.kg−1 intravenous (i.v.) and propofol 2 mg.kg−1i.v., and tracheal intubation with size 5 cuffed endotracheal tube was facilitated with rocuronium 0.6 mg.kg−1i.v. Anesthesia was maintained with oxygen in air and sevoflurane. The patient was positioned left lateral for endoscopy. The procedure lasted around 2 h and was uneventful. At the end of the procedure, residual muscle relaxant effect was reversed with neostigmine 50 μg.kg− 1i.v. and glycopyrrolate 0.2 mg i.v. At the time of extubation, the patient coughed on the endotracheal tube, however there were no signs of any respiratory distress. The trachea was extubated when he was fully awake, and then he was transferred to the postanesthesia care unit connected to a multiparameter monitor. Soon, a small swelling appeared which was noticed over the left parotid area. It was firm, was irreducible, with no erythema, and was mildly tender, but there was no crepitus. Immediately, it started to increase in size, occupying the left side of the whole neck and face. The patient was fully awake, was afebrile, and did not complain of any pain or difficulty in breathing.

A rapid response team, including an otolaryngologist, was called for assessment. X-ray neck and chest with ultrasound of the swelling was done, which showed a large parotid gland with ductal enlargement without any calculus. The child and his parents were reassured, and he was observed closely in the pediatric intensive care unit (ICU). The swelling started to decrease in size after 6 h and completely disappeared in 48 h. During this whole period, the patient remained hemodynamically stable, with no signs of any respiratory distress. He was discharged home on the 3rd postprocedure day. He again underwent endoscopy 6 months later, uneventfully.

DISCUSSION WITH LITERATURE REVIEW

Transient swelling of the salivary glands after anesthesia has been called anesthesia mumps in the anesthesiology literature. Reports of benign transient enlargement of the parotid gland after general anesthesia date back from the 1960s, when Schwartz named it as surgical mump.[6] However, the term “anesthesia mumps” was coined by Reilly in 1970. He described it as benign self-limiting enlargement of the parotid glands appearing after general anesthesia, relatively unknown and an underdocumented condition.[7] He described three patients with acute transient salivary gland swellings, which have been seen approximately in 1500 patients undergoing general anesthesia over a 10-month period. Since then, many case reports have been described in literature, associated with a wide range of surgeries including neurosurgical, abdominal, plastic, endoscopic, orthopedic, otolaryngologic, and gynecological procedures. Some cases of bilateral swelling of parotid glands have also been reported.[8] This condition does not show predilection to any age and many cases have been reported in pediatric age groups also. Rowel et al. reported acute unilateral enlargement of the parotid gland immediately post craniotomy in a 5-year-old child.[9] Similarly, acute postoperative sialadenitis has been reported in a 3-year-old child who presented for hypospadias repair.[10] There are several other case reports of parotid gland swelling, especially after long-lasting procedures.[11] It is usually transitory and resolves spontaneously without any treatment.[12] However, there are few case reports where it has led to airway obstruction that required reintubation or tracheostomy.[3413]

The factors implicated in its etiology are varied and many presumptions have been reported in literature. Some etiological factors include trauma to the soft tissues of the neck, vascular congestion and venous engorgement of the head and neck, coughing against the endotracheal tube, overactive pharyngeal reflex stimulation of the salivary gland through the parasympathetic nerves, and succinylcholine-stimulated copious secretions.[14] Some authors also claim that presence of underlying disease such as obesity may be a contributing factor too.[15] Sometimes, increased airway pressure (during ventilation with a facial mask) combined with muscle relaxation causes air to enter the parotid gland orifice and obstruction of the excretory ducts.[5] Another possible explanation relates to the extremely rotated position of the patient's head during a prolonged surgical procedure, which may cause obstruction of the Stensen's duct by compression pressure.[16] A rare case of acute parotitis has been reported from the ICU, wherein possibly prolonged obstruction by endotracheal tube and decreased salivary flow by medications could have contributed for its occurrence.[17] Similarly, anesthesia mumps has been reported after prolonged surgery for sacral laminectomy.[18]

This condition is not limited to general anesthesia only and has also been reported after regional anesthesia, probably resulting from dehydration or due to the sympathetic stimulation caused by perioperative use of vasopressors.[19] Adverse drug reactions (usually causing bilateral sialadenitis) have been described during morphine infusion and administration of captopril, nifedipine, and other drugs.[20]

Most of the cases reported in literature were noticed immediately following extubation, however Kati et al. have reported a case of anesthesia mumps after cesarean section in a pregnant woman 24 h after surgery and similarly, some cases reported that swelling appeared 20 h after surgery.[2122]

Although several different mechanisms are suggested, clinical management is much the same. Most of the cases resolve spontaneously within 48 h and no specific treatment is required, however some authors have applied many management strategies ranging from conservative care to surgical approaches, depending on the severity of the condition. Adequate hydration, mouthwash, pain control, and warm compresses on the affected side are helpful in most of the cases.[23]

Many authors have suggested different ways to prevent the development of anesthesia mumps. Some suggest using adaptive-shaped soft pads, whereas others believe that changing the head-and-neck position to avoid mechanical occlusion of the parotid gland and duct may be helpful.[23] This strategy may be desirable during long surgical procedures, but in some cases, anesthesia mumps has developed even after a short surgical procedure.[24] Therefore, other factors need to be considered and taken care of. Mask Ventilation with pressure over the soft tissues for providing positive pressure ventilation could also play a part in parotid gland duct occlusion and gland swelling. Hence, careful consideration should be given to patients with predisposing conditions such as long operation time, premedication involving anticholinergics, prone and lateral decubitus position, extremes of neck extension, obesity, and a history of parotid disease or trauma or past history of anesthesia mumps. In addition, anesthesiologists should be aware that anesthesia mumps can develop with usual face mask ventilation, and a gentle face mask ventilation is desirable.

In our case, the cause for the swelling was probably compression of the parotid gland in the lateral decubitus position. In addition, parasympathetic activation during the insertion of endoscope into the esophagus might have played a role by increasing the secretions. Furthermore, our patient coughed on the endotracheal tube before extubation that could have led to an increase in oropharyngeal pressure and retrograde movement of air in the parotid duct, as hypothesized by Mandel et al. Therefore, anesthesia mumps in our patient was probably multifactorial. In conclusion, acute unilateral or bilateral swelling of the parotid gland after anesthesia can occur rarely. The attending physician should be aware of the transient and benign nature of this condition.

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