Download Acute parotid gland swelling after endoscopy: An unusual

Letter t o E d i t o r
Acute parotid gland swelling after endoscopy:
An unusual complication
Sir,
The scope of diagnosing and treating many gastrointestinal (GI)
diseases has widened significantly due advances in endoscopic
procedures. Upper GI endoscopy is a safe procedure in the
present gastroenterology practice. In most of the countries it is
performed under topical anesthesia. In the past, the procedure was
normally done under parenteral use of sedation and antispasmodic
in addition to local lignocaine. There were a few complications
related to the procedure and medications, which need to be
observed carefully even in the present era of practice of endoscopy.
Swelling of the salivary glands is a rare complication reported in
the literature. The sudden appearance of swelling will cause anxiety
for both the patient and doctor; however, it is generally benign
condition which is transient and painless, and requires no specific
treatment.[1] We report here a case of acute parotid gland swelling
developed immediately after upper GI endoscopy.
CASE REPORT
A 56‑year‑old female was referred for upper GI endoscopy
to evaluate esophageal varices. She was suffering from portal
hypertension with hypersplenism for last 1 year. One year ago she
had variceal band ligation for acute bleeding from varices. She lost
to follow up subsequently and reported after a few months and
found to be severely anemic (Hb 4.8 g/L). The other hematology
work ups suggested hypersplenism without any coagulation defect.
Upper GI endoscopy was performed in left lateral position using
topical pharyngeal anesthesia with 10% lidocaine spray before the
procedure. Esophageal varices (grade 4) were seen with four columns
extending from mid esophagus to lower esophageal sphincter. There
was no evidence of active or recent bleeding in the esophagus or
stomach on endoscopic examination. The grade 2 gastro‑esophageal
varices were detected at the cardia. The stomach mucosa resembled
“water melon” appearance suggestive of portal gastropathy. The
patient had frequent bouts of coughing and retching during the
procedure. After the completion of diagnostic procedure, scope was
withdrawn. Band ligation and sclerotherapy was advised. However,
the patient complained of a painful swelling [Figure 1] on the right
jaw in front of the ear. The swelling had developed immediately after
the procedure. It was 2 cm in size, globular shape, and tender with
firm feel. There was no redness of the skin over the swelling or any
exudate. Opening of mouth was limited due to mild stiffness of the
right temporomandibular (TM) joint and pain. The possible injury
to any of structures involving TM joint, buccal mucosa, or salivary
duct with subsequent parotid swelling was under consideration.
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The patient did not have chest pain, dyspnea, fever, or cyanosis.
Examination of oral cavity including teeth was normal. X ray of
TM joint was normal and ultrasound of the swelling showed mild
parotid enlargement. The swelling gradually decreased over next 1
hour and had completely subsided by evening, though mild pain
still remained. The patient was treated with paracetamol for pain
relief in addition to medication for portal hypertension and anemia.
DISCUSSION
This is a rare complication of flexible upper GI endoscopy,[1]
bronchoscopy[2] and endotracheal intubation for anesthesia. The
case reports are published in the past[3,4] and almost all of them
except one from Turkey and Saudi Arabia[5,6] have been reported
before 1990. Parotid and or submandibular glands are generally
affected (unilateral or bilateral.) Several possible mechanisms have
been proposed in the etiopathogenesis, since the exact mechanism
is unknown. Some authors have concluded that it may be due
to an adverse drug reaction such as to atropine, morphine, or
suxamethonium;[3,7] however, there was no drug in common in all
of the reported cases. Matsuki et al.[4] and Attas et al.[7] proposed
that coughing and straining may lead to venous congestion of
the salivary glands and mild swelling of salivary glands. Couper[8]
reported that manipulation of the head during endoscopy may
lead to obstruction of the thoracic inlet venous drainage with
subsequent congestion of the parotid glands. Finally, Bonchek[3]
and Strowbridge[9] considered the most likely explanation to be that
instrumentation of the upper airway or esophagus stimulates a reflex
arc, with the afferent stimulus coming from the tongue, mouth,
Figure 1: Right-sided parotid swelling
Oncology, Gastroenterology and Hepatology Reports| Jan-Jun 2014 | Vol 3 | Issue 1
Letter to Editor
or pharynx, and intense parasympathetic stimulation resulting
in vasodilatation and transient enlargement of the glands. The
retrograde flow of air through the Stenon’s orifice during straining
and coughing under anesthesia, retention of secretions causing
occlusion of the salivary ducts, in addition to use of pre‑procedure
drugs and systemic dehydration are the most commonly accused
factors.[10]
SUMMARY
This rare complication of upper GI endoscopy should be kept in
mind during and after the procedure. It is imperative that both
endoscopist and physician should be aware of this benign and
transient complication of the procedure. A patient needs to be
reassured after ruling out serious complications of procedure.
No specific intervention is required, since it is a self‑limiting
condition
Arvind Bamanikar, Arjun Lal Kakrani, Rajdeep More
Department of Medicine,
Padmshree Dr. D. Y. Patil Medical College,
Hospital and Centre, Pimpri, Pune,
Maharashtra, India
REFERENCES
1.
Ziccardi V, Molloy PJ. Parotid swelling after endoscopy. Gastrointest
Endosc 1992;38:520.
2. Blackford RW. Recurrent swelling of parotid and submaxillary gland
following bronchoscopy. Ann Otol Rhinol Laryngol 1974;53:54‑64.
3. Bonchek LI. Salivary gland enlargement during induction of anaesthesia.
JAMA 1969;209:1716‑8.
4.
Matsuki A, Wakayama S, Oyama T. Acute transient swelling of the salivary
glands during and following endotracheal anaesthesia. Anaesthesist
1975;24:125‑8.
5. Işler M, Akin M, Senol A, Yariktaş M. Acute bilateral parotid gland swelling
after endoscopy. Turk J Gastroenterol 2011;22:351‑62.
6. Postaci A, Aytac I, Oztekin CV, Dikmen B. Acute unilateral parotid gland
swelling after lateral decubitus position under general anesthesia. Saudi
J Anaesth 2012;6:295‑7.
7. Attas M, Sabawala PB, Keats AS. Acute transient sialadenopathy during
induction of anaesthesia. Anaesthesiology 1968;29:1050‑2.
8.
Couper JL. Benign transient enlargement of the parotid glands associated
with anaesthesia. S Afr Med J 1973;47:316‑8.
9.
Strowbridge NF. Acute salivary gland enlargement following instrumentation
of the upper airway. J R Army Med Corps 1987; 133:163‑5.
10. Narang D, Trikha A, Chandralekha C. Anethesia mumps and Morbit
obesity. Acta Anaesthesiol Belg 2010; 6:83‑5.
Access this article online
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Website: www.oghr.org
Address for the Correspondence:
Dr. A. A. Bamanikar,
Padmshree Dr. D. Y. Patil Medical College,
Hospital and Centre, Sant Tukaram Nagar,
Pimpri, Pune - 411 018, India.
E‑mail: [email protected]
DOI:
10.4103/2348-3113.126646
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Oncology, Gastroenterology and Hepatology Reports| Jan-Jun 2014 | Vol 3 | Issue 1
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