Pneumoparotid during dental treatment Etienne Piette, MD, BDS,a and Richard T. Walker, BDS, MSc, PhD, FDSRCPS,b Hong Kong PRINCE PHILIP
DENTAL
HOSPITAL,
UNIVERSITY
OF HONG KONG
A rare case of pneumoparotid originating during dental treatment is reported. The condition should be considered in the differential diagnosis of acute parotid swellings. It is transient and does not usually require any treatment. (ORAL SURC ORAL MED ORAL PATHOL 1991;72:415-7)
A cute parotid swellings can usually be traced to infection, obstruction, or both.‘, * More ill-defined causesinclude allergies or an inability of the ductal system to carry the flow of saliva as a result of increased secretions, spasmsof the sphincter of Stensen’s duct, or both. Acute swelling of the parotid gland may rarely occur because of forced reflux of air from the mouth. This should always be kept in mind in the caseof unexplainable enlargement of the salivary glands. We report on one case where the etiologic mechanism originated from dental treatment. CASEREPORT
A 34-year-old woman from southern China was seenfor routine dental care. During the course of preparing a right maxillary third molar for a buccal amalgam without a rubber dam, an air syringe was used and the patient suddenly had a sharp pain on the right side of the face in the region of the parotid gland. A soft elastic swelling about 8 cm in diameter developedrapidly (Fig. 1). On palpation a crunching sensation characteristic of surgical emphysemawas detected. Gingival attachment around maxillary teeth was proved to be intact by probing. The pain soon disappeared, and the cavity was lined and restored. A posteroanterior radiograph showed a round radiolucency in the parotid gland region (Fig. 2). The patient was prescribed oral penicillin (500 mg penicillin four times daily) for 5 days. The swelling completely resolved without complications.
%enior Lecturer,Departmentof Oral and Maxillofacial Surgery. bReaderand Head, Departmentof ConservativeDentistry. 7/12/27983
DISCUSSION
As MandeP states, casereports of displacement of pressured air into the oral soft tissues, resulting in immediate noninfected swellings, rarely relate to the parotid gland. In our case the cause of the swelling seems obvious. During dental treatment, air was forced into the Stensen’sduct in a retrograde way with the use of pressurized air of a cleansing syringe, leading to a sudden painful swelling of the affected gland caused by distention of the area. The thin air stream had been directed toward the cheek when the inner aspectsof a buccal tooth cavity were dried, inadvertently pointing at the orifice of the salivary duct, which is anatomically located on the cheek mucosa in line with the upper molar teeth, usually at the collar of the second molar, allowing air to be insufflated in the branched salivary duct system. Traditional causes of parotid air swellings are found in certain professions; glass blowers4 are well known to have such swellings, as are musicians who play wind instruments such as trumpet, clarinet, or horn.*, 5-8On this matter Reitlinger9 quotes Hyrtl’s 1865 publication on parotid disorders in persons playing wind instruments. Such sporadic cases have also been reported in a child blowing up balloonslo; in children blowing while holding the noseand mouth”, ‘*; in another child with cystic fibrosis who regularly filled the left cheek with air and pressed on it forcefully with the fist, apparently in an attempt to suppressa frequent cough13;in two regimental bugle players14;years ago, in soldiers simulating mumps to escapeduty, by enlarging their parotids with air with bottles as resistance15;or even in a scuba diver after decompression.7 These phe415
416
Piette and Walker
ORAL SCRC ORAL
Fig. 2. Radiograph cent area.
Fig.
1. Clinical swelling in right parotid region
nomena refer to the similar so-called wind parotitis, which has been described in children learning to play a wind instrument and in persons blowing balloons.3,I6 Another interesting cause is known as “anesthesia mumps,” a transient postoperative parotid swelling resulting from a combination of neuromuscular blocking agents, belladonna drugs, and straining or coughing at the time of extubation.“, I8 It is not surprising that, once pressurized air gets into the parotid gland, it can be released into the surrounding tissues.lo In fact, the capsule of the gland seemsto be weak in at least three areas.19Why air can enter the orifice of the Stensen’sduct by increased intraoral pressurealone is still unclear. It seemsthat the static pressure involved would in itself tend to close the papilla, with pressuresworking around the sides, and close the duct with pressure transmitted laterally from the oral cavity. Moreover, slips of buccinator muscle surround the orifice and form a sphincter to guard the opening. The condition seemsto prevail in persons blowing with full cheeks, whereas it is rarer in personswho blow with tension in the cheek musculature,” therefore compressing the Stensen’s duct and preventing passage of air to the gland. If the
MED ORAL PATHOL October 199 1
showing well-demarcated
radiolu-
mechanism remains unclear, its occurrence should be acknowledged. Very rarely, the condition may be complicated by emphysema in the neck. The accumulation of air can be shown by x-ray examination. In one case studied sialographically,iO cystlike air distortions of the arboreal ductal pattern could be seen although there was no overall dilation of the ducts. Definite streaks of air could be visualized in the subcutaneoustissuesoverlying the gland and in the neck. The salivary gland enlargement usually disappears by itself in 1 to 3 days, and no treatment is required. Pain always remains moderate. The danger of this usually accidental condition is the risk of infection. An antibiotic cover for 4 to 5 days seemsappropriate in these cases.In recurrent casestying off the duct has been recommended”; removal of the gland seemsto be an inappropriate and exaggerated treatment. REFERENCES 1. Patey DH. Recurrent swellings of the parotid gland (recurrent parotitis). Mod Trends Surg 1971;3:261-83. 2. Rauch S, Gorlin RJ, Seifert G. Diseasesof the salivary glands. In: Gorlin RJ, Goldman HM, eds. Thoma’s oral pathology. St Louis: CV Mosby, 1970:962-1070. 3. Mandel L. Wind parotitis [Letter]. N Engl J Med 1973; 289:1094. 4. Narath A. LJberoperative Eingriffe bei der Pneumatocoeleder Parotis und des Ductus Stenonianus (Glasblasergeschwulst). Dtsch Z Chir 1912;119:201-20. 5. Rysenaer L, van Deinse JB, Stuyt LB. Pneumo-parotidite recidivante. Pratt Otorhinolaryng (Basel) 1963;25:128-31. 6. Trimble GX. Wind Parotitis [Letter]. N Engl J Med 1973; 289:1094. 7. Watt J. Benign parotid swellings: a review. Proc R Sot Lond [Biol] 1977;70:483-5. 8. Rabinov K, Weber AL. Radiology of the salivary glands. Boston: Hall, 1985:190. 9. Reitlinger A. Parotis Veranderung bei Musikern. Monatsschr Ohrenheilkd 1964;98:101-3.
Volume 72 Number 4 10. Rupp RN. Pneumoparotid: an interesting cause of acute parotid swelling. Arch Otolaryngol 1963;77:665-8. 11. Greisen 0. Pneumatocele glandulae parotis. .I Laryngol 1968; 82:477-80. 12. Pritchett ELC. Wind parotitis [Letter]. N Engl J Med 1973; 289:1094. 13. David ML, Kanga JF. Pneumoparotid in cystic fibrosis. Clin Pediatr 1988;27:506-8. 14. Riley HD Jr. Recurrent parotid swellings. South Med J 1956; 49:523-8. 15. Hemphill RA. Wind parotitis [Letter]. N Engl J Med 1973; 289:1094-S. 16. Saunders H. Wind parotitis [Letter]. N Engl J Med 1973; 289:698. 17. Reilly DJ. Benign transient swelling of the parotid glands fol-
Pneumoparotid during dental treatment
417
lowing general anesthesia:“anesthesia mumps.” Anesth Analg 1970;49:560-3. 18. Sarr MG, Frey H. A unique case of benign postoperative parotid swelling. Johns Hopkins Med J 1980;146:1l-5. 19. Meyers ES. The fibrous capsuleof the parotid gland. Med Aust 1955;42:564-71. Reprint requests:
E. Piette, MD, BDS Deuartment of Oral and Maxillofacial Surnerv The Prince Philip Dental Hospital - . University of Hong Kong 34 Hospital Rd. Hong Kong
DENTAL
HOSPITAL,
UNIVERSITY
OF HONG KONG
A rare case of pneumoparotid originating during dental treatment is reported. The condition should be considered in the differential diagnosis of acute parotid swellings. It is transient and does not usually require any treatment. (ORAL SURC ORAL MED ORAL PATHOL 1991;72:415-7)
A cute parotid swellings can usually be traced to infection, obstruction, or both.‘, * More ill-defined causesinclude allergies or an inability of the ductal system to carry the flow of saliva as a result of increased secretions, spasmsof the sphincter of Stensen’s duct, or both. Acute swelling of the parotid gland may rarely occur because of forced reflux of air from the mouth. This should always be kept in mind in the caseof unexplainable enlargement of the salivary glands. We report on one case where the etiologic mechanism originated from dental treatment. CASEREPORT
A 34-year-old woman from southern China was seenfor routine dental care. During the course of preparing a right maxillary third molar for a buccal amalgam without a rubber dam, an air syringe was used and the patient suddenly had a sharp pain on the right side of the face in the region of the parotid gland. A soft elastic swelling about 8 cm in diameter developedrapidly (Fig. 1). On palpation a crunching sensation characteristic of surgical emphysemawas detected. Gingival attachment around maxillary teeth was proved to be intact by probing. The pain soon disappeared, and the cavity was lined and restored. A posteroanterior radiograph showed a round radiolucency in the parotid gland region (Fig. 2). The patient was prescribed oral penicillin (500 mg penicillin four times daily) for 5 days. The swelling completely resolved without complications.
%enior Lecturer,Departmentof Oral and Maxillofacial Surgery. bReaderand Head, Departmentof ConservativeDentistry. 7/12/27983
DISCUSSION
As MandeP states, casereports of displacement of pressured air into the oral soft tissues, resulting in immediate noninfected swellings, rarely relate to the parotid gland. In our case the cause of the swelling seems obvious. During dental treatment, air was forced into the Stensen’sduct in a retrograde way with the use of pressurized air of a cleansing syringe, leading to a sudden painful swelling of the affected gland caused by distention of the area. The thin air stream had been directed toward the cheek when the inner aspectsof a buccal tooth cavity were dried, inadvertently pointing at the orifice of the salivary duct, which is anatomically located on the cheek mucosa in line with the upper molar teeth, usually at the collar of the second molar, allowing air to be insufflated in the branched salivary duct system. Traditional causes of parotid air swellings are found in certain professions; glass blowers4 are well known to have such swellings, as are musicians who play wind instruments such as trumpet, clarinet, or horn.*, 5-8On this matter Reitlinger9 quotes Hyrtl’s 1865 publication on parotid disorders in persons playing wind instruments. Such sporadic cases have also been reported in a child blowing up balloonslo; in children blowing while holding the noseand mouth”, ‘*; in another child with cystic fibrosis who regularly filled the left cheek with air and pressed on it forcefully with the fist, apparently in an attempt to suppressa frequent cough13;in two regimental bugle players14;years ago, in soldiers simulating mumps to escapeduty, by enlarging their parotids with air with bottles as resistance15;or even in a scuba diver after decompression.7 These phe415
416
Piette and Walker
ORAL SCRC ORAL
Fig. 2. Radiograph cent area.
Fig.
1. Clinical swelling in right parotid region
nomena refer to the similar so-called wind parotitis, which has been described in children learning to play a wind instrument and in persons blowing balloons.3,I6 Another interesting cause is known as “anesthesia mumps,” a transient postoperative parotid swelling resulting from a combination of neuromuscular blocking agents, belladonna drugs, and straining or coughing at the time of extubation.“, I8 It is not surprising that, once pressurized air gets into the parotid gland, it can be released into the surrounding tissues.lo In fact, the capsule of the gland seemsto be weak in at least three areas.19Why air can enter the orifice of the Stensen’sduct by increased intraoral pressurealone is still unclear. It seemsthat the static pressure involved would in itself tend to close the papilla, with pressuresworking around the sides, and close the duct with pressure transmitted laterally from the oral cavity. Moreover, slips of buccinator muscle surround the orifice and form a sphincter to guard the opening. The condition seemsto prevail in persons blowing with full cheeks, whereas it is rarer in personswho blow with tension in the cheek musculature,” therefore compressing the Stensen’s duct and preventing passage of air to the gland. If the
MED ORAL PATHOL October 199 1
showing well-demarcated
radiolu-
mechanism remains unclear, its occurrence should be acknowledged. Very rarely, the condition may be complicated by emphysema in the neck. The accumulation of air can be shown by x-ray examination. In one case studied sialographically,iO cystlike air distortions of the arboreal ductal pattern could be seen although there was no overall dilation of the ducts. Definite streaks of air could be visualized in the subcutaneoustissuesoverlying the gland and in the neck. The salivary gland enlargement usually disappears by itself in 1 to 3 days, and no treatment is required. Pain always remains moderate. The danger of this usually accidental condition is the risk of infection. An antibiotic cover for 4 to 5 days seemsappropriate in these cases.In recurrent casestying off the duct has been recommended”; removal of the gland seemsto be an inappropriate and exaggerated treatment. REFERENCES 1. Patey DH. Recurrent swellings of the parotid gland (recurrent parotitis). Mod Trends Surg 1971;3:261-83. 2. Rauch S, Gorlin RJ, Seifert G. Diseasesof the salivary glands. In: Gorlin RJ, Goldman HM, eds. Thoma’s oral pathology. St Louis: CV Mosby, 1970:962-1070. 3. Mandel L. Wind parotitis [Letter]. N Engl J Med 1973; 289:1094. 4. Narath A. LJberoperative Eingriffe bei der Pneumatocoeleder Parotis und des Ductus Stenonianus (Glasblasergeschwulst). Dtsch Z Chir 1912;119:201-20. 5. Rysenaer L, van Deinse JB, Stuyt LB. Pneumo-parotidite recidivante. Pratt Otorhinolaryng (Basel) 1963;25:128-31. 6. Trimble GX. Wind Parotitis [Letter]. N Engl J Med 1973; 289:1094. 7. Watt J. Benign parotid swellings: a review. Proc R Sot Lond [Biol] 1977;70:483-5. 8. Rabinov K, Weber AL. Radiology of the salivary glands. Boston: Hall, 1985:190. 9. Reitlinger A. Parotis Veranderung bei Musikern. Monatsschr Ohrenheilkd 1964;98:101-3.
Volume 72 Number 4 10. Rupp RN. Pneumoparotid: an interesting cause of acute parotid swelling. Arch Otolaryngol 1963;77:665-8. 11. Greisen 0. Pneumatocele glandulae parotis. .I Laryngol 1968; 82:477-80. 12. Pritchett ELC. Wind parotitis [Letter]. N Engl J Med 1973; 289:1094. 13. David ML, Kanga JF. Pneumoparotid in cystic fibrosis. Clin Pediatr 1988;27:506-8. 14. Riley HD Jr. Recurrent parotid swellings. South Med J 1956; 49:523-8. 15. Hemphill RA. Wind parotitis [Letter]. N Engl J Med 1973; 289:1094-S. 16. Saunders H. Wind parotitis [Letter]. N Engl J Med 1973; 289:698. 17. Reilly DJ. Benign transient swelling of the parotid glands fol-
Pneumoparotid during dental treatment
417
lowing general anesthesia:“anesthesia mumps.” Anesth Analg 1970;49:560-3. 18. Sarr MG, Frey H. A unique case of benign postoperative parotid swelling. Johns Hopkins Med J 1980;146:1l-5. 19. Meyers ES. The fibrous capsuleof the parotid gland. Med Aust 1955;42:564-71. Reprint requests:
E. Piette, MD, BDS Deuartment of Oral and Maxillofacial Surnerv The Prince Philip Dental Hospital - . University of Hong Kong 34 Hospital Rd. Hong Kong
