Facial nerve palsy in parotid infection- A benign deviance from the malignant norm

Vishwanath M Pattanshetti; Basavaraj Teli; Prashant Sharma; Urbee Gupta; Pravallika Kolli; Adil Anwar Bhagwan

doi:10.4103/jss.jss_63_21

CASE REPORT

Year : 2021 | Volume : 48 | Issue : 3 | Page : 206-209

Facial nerve palsy in parotid infection- A benign deviance from the malignant norm

Vishwanath M Pattanshetti, Basavaraj Teli, Prashant Sharma, Urbee Gupta, Pravallika Kolli, Adil Anwar Bhagwan
Department of General Surgery, JN Medical College, Belagavi, Karnataka, India

Date of Submission	28-May-2021
Date of Acceptance	21-Jul-2021
Date of Web Publication	28-Dec-2021

Correspondence Address:
Dr. Urbee Gupta
Room 511, New PG Ladies' Hostel, JNMC Campus, Nehru Nagar, Belagavi, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jss.jss_63_21

Abstract

Parotid swellings presenting with facial nerve palsy usually imply that the swelling is malignant in nature. In rare cases, it has been reported to have occurred in the setting of benign parotid swellings and parotid abscesses. Our case is one of bilateral parotid abscesses in a reverse transcription polymerase chain reaction negative, CORADS five patients, with left-sided lower motor neuron type of facial nerve palsy with near-total recovery of the facial nerve palsy after resolution of abscess. The likely mechanisms behind the development of facial nerve palsy in case of parotid abscess include perineuritis, ischemia, and direct virulence of the pathogen. Furthermore, coronavirus has a propensity for affecting salivary glands, and parotitis could be an atypical presentation of the COVID 19. In most cases, as in ours, there has been improvement of facial nerve palsy with resolution of the abscess after combined conservative, surgical, and supportive treatment.

Keywords: Facial nerve palsy, benign, parotid abscess

How to cite this article:
Pattanshetti VM, Teli B, Sharma P, Gupta U, Kolli P, Bhagwan AA. Facial nerve palsy in parotid infection- A benign deviance from the malignant norm. J Sci Soc 2021;48:206-9

How to cite this URL:
Pattanshetti VM, Teli B, Sharma P, Gupta U, Kolli P, Bhagwan AA. Facial nerve palsy in parotid infection- A benign deviance from the malignant norm. J Sci Soc [serial online] 2021 [cited 2023 Mar 29];48:206-9. Available from: https://www.jscisociety.com/text.asp?2021/48/3/206/333850

Introduction

Facial nerve palsy in a case of parotid swelling is usually an indicator of malignancy, occurrence of which is unexpected and rare in the setting of benign swellings and infective conditions of the parotid gland such as acute parotitis of bacterial or viral etiology.^[1] There are few case reports about the same in diabetic patients wherein the nerve palsy reversed once the infection was treated by surgical drainage and supportive therapy.^{[2],[3],[4],[5]}

In this report, we present a case of an elderly nondiabetic who had bilateral parotid abscesses with left-sided lower motor neuron facial nerve palsy.

Case Report

A 67-year-old, nondiabetic, nonhypertensive male presented with an 8-day history of bilateral painful parotid swellings and 2 days of spontaneous rupture and purulent discharge from both, asymptomatic for COVID-19 disease but with a CORADS score of 5 (typical for COVID infection) on high-resolution computed tomography (CT) thorax. The patient refused to get admitted and was started on oral antibiotics empirically. Ten days later, he presented with inability to close his left eye and mouth. His vitals were stable and bilateral parotid swellings were nontender and had decreased in size and purulent discharge compared to the initial presentation. An ulcer was seen over the left parotid gland measuring 1 cm × 0.5 cm [Figure 1], with left-sided lower motor neuron facial nerve palsy of House-Brackmann Grade IV [Figure 2], [Figure 3], [Figure 4], [Figure 5] and a healed sinus over the right parotid region. Oral cavity examination revealed normal oral mucosa, edentulous state with normal Stensen's duct. Reverse transcription-polymerase chain reaction (RT-PCR) for coronavirus was negative.

Figure 1: Ulcer

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Figure 2: Loss of wrinkling of forehead (temporal branch and frontalis muscle)

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Figure 3: Inability to close his left eye and keep it closed against resistance (temporal branch and palpebral and orbital fibers of orbicularis oculi) with positive Bell's phenomenon

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Figure 4: Deviation of angle of mouth to the right side while smiling (zygomatic and buccal branches and zygomaticus major muscle)

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Figure 5: Inability to blow out his left cheek and a leak of air through the left side of his mouth

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Contrast-enhanced CT of the neck had revealed bilateral parotid abscess with no extension into parapharyngeal spaces and erosion of mandible with cervical lymph node enlargement [Figure 6]a and [Figure 6]b. No significant collection was detected in ultrasonography neck performed on admission. All routine blood investigations and diabetic workup were within normal limits. Culture sensitivity of pus from the ulcer grew methicillin-resistant Staphylococcus aureus. Fine-needle aspiration cytology (FNAC) and edge biopsy performed to rule out malignancy showed features of acute on chronic sialadenitis and chronic inflammatory lesion and were negative for acid-fast bacillus.

Figure 6: (a) Contrast-enhanced computerized tomography neck (b) Bilateral parotid abscess

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The patient was started on tablet linezolid and intravenous gentamicin injection as per the sensitivity report, along with supportive treatment such as lubricating eye drops for the prevention of exposure keratitis, antiseptic mouth gargles, lozenges as sialogogues, and physiotherapy for the facial nerve palsy. As the abscesses had drained spontaneously, incision and drainage were not warranted. The ulcer over the left parotid area was dressed daily.

After 7-day course of antibiotics and 4 sessions of proprioceptive neuromuscular facilitation exercise (PNF), there was a significant improvement in facial nerve palsy to Grade III House Brackmann and a significant decrease in size of the ulcer and appearance of healthy granulation tissue over ulcer bed [Figure 7]a, [Figure 7]b, [Figure 7]c. The patient was discharged after 11 days of hospital stay. Unfortunately, following discharge, the patient was lost to follow-up.

Figure 7: (a) Healed ulcer, (b) closure of both eyes, (c) symmetrical face

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Discussion

Viral parotitis usually occurs bilaterally, with only 25% cases being unilateral while suppurative parotitis tends to present unilaterally.^[6] Extrapulmonary tuberculosis affecting the parotid glands arises from direct hematogenous spread from pulmonary focus or from lymphatic spread from cervical or intraparotid lymph nodes.^[7] Facial nerve palsy in a parotid swelling is most likely to be due to malignant infiltration of the nerve by the tumor cells.

Acute suppurative parotitis can be attributed to salivary stasis due to block in the Stensen's duct or a decrease in the production of saliva, poor oral hygiene, lack of mastication. The serous nature of secretion and lower concentration of secretory IgA compared to the mucinous secretion of the submandibular glands makes the parotid glands more prone to infection and suppuration. Conditions such as diabetes mellitus, immunocompromised states, autoimmune disorders, congenital sialectasis, preexisting viral infection of the parotid gland predispose to parotitis.^[1]

There are few reports of benign lesions of the parotid gland presenting with facial nerve palsy among which parotid abscess is rare as was demonstrated in the study performed by Makeham et al., where only 1 case among 30 cases of extratemporal facial nerve palsy was due to suppurative parotitis.^[8]

Facial nerve palsy in a parotid abscess case could arise due to impairment of facial nerve function by direct neurotoxic effects of inflammatory mediators, edema, thrombosis of perineural vessels, acute infection, and kinking of nerves as it enters the firm parotid fascia, compression, and stretching of the nerve by enlarging gland.^[9]

CT scan is the recommended imaging modality in this case as it is useful for imaging intraglandular components of mass, extension into deep lobe, parapharyngeal space, erosion of surrounding skeletal structures and relation to the internal jugular vein, cervical lymphadenopathy, and the presence or absence of stone in Stensen's duct. FNAC and biopsy of parotid swellings which present with facial palsy are essential to rule out malignancy.^[1]

Parotitis complicated by facial nerve palsy should be treated with empirical antibiotics and by a conservative approach such as hot compresses, analgesics, sialogogues, and hydration.^[10] Drainage is warranted in cases which present as abscesses, with complications such as septicemia, failure to respond to medical management, extension into parapharyngeal spaces and in case of failure to respond to medical management.^[11]

Physical therapy for facial nerve palsy was started for the patient. PNF works on the principle of initiation of voluntary effort through facilitation of the activity of neuromuscular mechanism through stimulation of proprioceptors, i.e. muscle and tendon spindle which facilitate muscle contraction.^[12]

In the era of COVID-19 pandemic, several atypical presentations of the disease are being reported one of which is acute parotitis. Viral parotitis is caused classically by paramyxovirus and respiratory viruses such as influenza, parainfluenza, coxsackie and Epstein–Barr virus. The COVID-19 virus has been seen to have a high propensity of affecting salivary glands as indicated by the high positive yield (91.7%) of COVID-19 virus-positive sputum samples.^[13]

Our patient had a mixed presentation wherein there was bilaterality as well as suppuration of both the glands. Moreover, the initial CORADS 5 score is suggestive of a respiratory infection but RT-PCR negative report rules out a COVID-19 infection. Therefore, the dilemma persists as to the actual precipitating cause of parotitis in our patient.

Declaration of patient consent

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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