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Swelling in cheek,maxillofacial surgeon,biopsy,fibrous dysplasia,parotitis

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My daughter is 13 years old. She has been having cheek swelling and associated intense pain that comes about 2 to 3 times a year and lasts about 3 weeks on her right cheek. She is getting this since she was 6 years old. We have been to ENT doctors, Maxillofacial surgeons....etc., Maxillofacial surgeon took a biopsy of the jaw and said it is Fibrous dysplasia. But, when he could not find a significant change in the bone structure during her swelling episodes that occurred after biopsy, he concluded it must be Parotitis and sent us to an ENT doctor. The ENT doctor gave my daughter pain killers and anti-biotic (Clindamycin 150 mg – 3 per day for 10 days = 30 tablets) said she has to manage the pain. The Clindyamycin has no use and her pain and swelling goes out only after it has run its 3 weeks course. When she gets her swelling and pain we have actually experimented by not giving Clindamycin and testing the duration of swelling and pain which is about 3 weeks same as the episodes where we have given Cliindamycin. She is suffering since past 7 years with no resolution. She gets her swelling and associated intense pain about 2 to 3 times a year. Also she gets a type of white paste (a very small quantity) in the inner wall of her right cheek only during the days when her pain is intense (which is usually after a week from the beginning of initial pain and swelling). We have been to several doctors and still with no answers. Please help us to get a resolution and for her to get back to a normal life without pain killers and potentially damaging her liver due to these regular dose of pain killers.

Thanks in advance for your help and assistance in this matter.
Posted Fri, 13 Apr 2012 in Child Health
Answered by Dr. Sumit Bhatti 3 hours later

Thank you for your query.

1. Since her right cheek swelling is recurrent, painful and has been present since 7 years, most causes of cheek swelling are ruled out. Fibrous dysplasia can be picked up on x-rays (ground glass appearance) and contrast CT/ MRI Scans (hypointense expansile bone).

2. The parotid salivary gland is covered by a thick parotid fascia and hence swelling of the parotid gland causes intense pain. The parotid region will also be tense and taut. During an attack, the parotitis or parotid duct obstruction should be picked up on USG Neck, contrast CT / MRI Scans.

3. Clindamycin is the antibiotic of choice as it is excreted in saliva. Lack of effect may point towards an obstruction rather than an infection. I assume that she does not have any dental problems.

4. Parotid salivary secretion is mostly 'serous' and not 'mucoid' like the Sub-mandibular salivary glands. Therefore parotid ducts mostly do not develop large stones (as in Sub-mandibular glands) and instead may develop a sand like sludge of debris. This may explain the white paste like secretion on the inner wall of her right cheek. This is where the Parotid (Stensen's) Duct opens, usually near the second upper molar tooth.

5. A Sialogram should be done when there is no infection. This will reveal any chronic parotitis, stenosis of the duct/s or 'ectasia' (ballooning) of the duct/s and 'acini' (gland structure). There are stents available for salivary ducts now.

6. Sialendoscopy is a new form of endoscopy for the salivary glands. You may arrange for this to confirm any parotid disease. This is an option verses open surgery which has a very high risk of facial nerve damage.

7. Certain rare conditions have to be kept in mind while investigating her conditions:
i) Recurrent parotitis of childhood. (self limiting).
ii) A lymph node compressing the parotid duct.
iii) A benigh lyphangioma.
iv) A Type I First Branchial Cleft Cyst.
v) A mild Sjogren's Syndrome. Does she have any lacrimal / eye swelling? Does she have any xerostomia?

Kindly let me know if she has had any imaging studies done in the past. Are there any detailed clinical examination notes? Any photographs of the swelling and the inner cheek with the location of the paste like discharge?

Hope I have answered your query. You may need to fill in the latest information. If you have any follow up queries I will be available to answer them.


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