PANCE Blueprint EENT (7%)

Salivary disorders (PEARLS)

NCCPA™ PANCE EENT Content Blueprint  Oropharyngeal disorders  salivary disorders

Patient will present as → a 39-year-old female complaining of episodic left-sided jaw pain and swelling. The symptoms are typically aggravated by eating or by the anticipation of eating. Over the last 2-days, the patient has been experiencing worsening pain, redness, and fever. On physical exam, the left salivary gland is exquisitely tender. High-resolution noncontrast computed tomography (CT) scanning reveals a left-sided salivary gland stone.  

Sialadenitis is a bacterial infection of a salivary gland usually caused by sialolithiasis, which is an obstructing stone in the salivary gland

  • Acute swelling of the cheek, which worsens with meals
  • etiology: S. aureus
  • It affects the parotid or submandibular gland, occurs with dehydration or chronic illness (Sjogren syndrome), ductal obstruction



  • CT, ultrasonography, or MRI can confirm sialadenitis or abscess that is not obvious clinically, although MRI may miss an obstructing stone
  • If pus can be expressed from the duct of the affected gland, it is sent for gram stain and culture


  • Clinical diagnosis is usually adequate, but sometimes CT, ultrasonography, or sialography are needed



Antibiotics: Initial treatment is with IV antibiotics active against S. aureus

  • With the increasing prevalence of methicillin-resistant S. aureus, especially among the elderly living in extended-care nursing facilities, vancomycin is often required.
  • Local measures (e.g., sialagogues, warm compresses): Hydration, sialagogues (e.g., lemon juice, hard candy, or some other substance that triggers saliva flow), warm compresses, gland massage, and good oral hygiene are also important. Abscesses require drainage.


  • Many stones pass spontaneously or with the use of sialagogues (e.g., tart, hard candies, lemon drops, Xylitol-containing gum, or candy to increase salivary flow) and manual expression
  • Some require endoscopic surgical removal or lithotripsy

Parotitis (ReelDx)
ReelDx Virtual Rounds (Parotitis)
Patient will present as → an 11-year-old boy with malaise and swelling of his face.  He has no significant past medical history, but it is documented in his chart that his mother declined the recommended standard immunizations for children because of personal beliefs. Vital signs are stable, with the exception of a mild fever. In addition to the facial swelling, physical exam is also notable for swelling around the testes. There are no rashes.

Parotitis is an inflammation of one or both parotid glands, the major salivary glands located on either side of the face, in humans

  • Patients present with fever and chills, periauricular, mandibular pain, and swelling; trismus, dysphagia; purulent drainage
  • Viral ⇒ No discharge, prodrome followed by swelling lasting 5–10 days


  • Bacterial: S. aureus, most common
  • Viral: mumps (paramyxovirus), influenza A virus, parainfluenza, adenovirus, coxsackievirus, Epstein-Barr virus (EBV), cytomegalovirus, herpes simplex virus, human immunodeficiency virus (HIV), and lymphocytic choriomeningitis virus
  • Autoinflammatory: sarcoidosis as part of Mikulicz syndrome

Mumps parotitis

  • Mumps is caused by a paramyxovirus. Likely in a child without a complete vaccination series. Transmitted via airborne droplets
  • Typically, it begins with a few days of fever, headache, myalgia, fatigue, and anorexia, followed by parotitis
  • In adult males, look for an associated orchitis

DX: often clinical

  • Sample purulent exudate, ultrasound-guided needle aspiration; culture, Gram stain
  • Ultrasound ⇒ increased blood flow through the gland, enlargement, nodules
  • CT scan ⇒ extension of inflammation to surrounding tissue
  • Complete blood count (CBC)
  • Serum and urinary amylase rise during the first week of parotitis without underlying pancreatitis
  • Viral shows leukocytosis, increased IgM against mumps

TX: Self-limiting - treat with hydration and rest

  • Vaccination is effective for prevention
  • Contagious for 9 days after onset of parotid swelling

Acute pharyngitis (ReelDx + Lecture) (Prev Lesson)
(Next Lesson) Sialadenitis (Lecture)
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