A 73-year-old man is seen in the hospital due to severe left facial pain and inability to fully open his mouth. These symptoms began earlier today. Eight days ago, the patient underwent a laparotomy for intestinal obstruction. The procedure went well, and he has had several bowel movements since the operation. Medical history is significant for dementia and colon cancer, which was diagnosed 5 years ago and is currently in remission. The patient resides in a nursing home. Temperature is 38.9 C (102 F), blood pressure is 150/80 mm Hg, pulse is 90/min, and respirations are 16/min. Examination shows swelling, erythema, and severe tenderness in the left preauricular area. Laboratory studies reveal a white blood cell count of 15,600/mm³. Which of the following would most likely have prevented this complication?

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11ec25c8_d8bd_b1da_bc81_f303b42fefa3_MD0003_00 This elderly patient with fever, leukocytosis, and severe tenderness and swelling of the left parotid gland following a recent surgical procedure likely has acute suppurative parotitis. Suppurative parotitis often occurs in elderly postoperative patients, particularly those with dementia who are at risk of inadequate fluid hydration and poor oral hygiene. In these patients, salivary stasis (due to NPO status, poor oral hygiene, and dehydration) leads to retrograde seeding of bacteria from the oral cavity (eg, Staphylococcus aureus, oral flora) through Stensen duct to the parotid gland. Patients then have rapid-onset and excruciatingly painful swelling of the involved parotid gland that is aggravated by chewing. Examination shows an exquisitely tender, swollen, and erythematous gland. Purulent fluid can often be expressed from the parotid duct. Although the diagnosis is typically evident after clinical evaluation, imaging (CT scan or ultrasound) should be obtained to assess for salivary stones or neoplasms obstructing the duct, as well as to differentiate between suppurative parotitis and an abscess. Treatment includes intravenous, broad-spectrum antibiotics (narrowed based on culture results), hydration, sialagogues (increase salivary flow), and massage (expression of purulence from the duct). (Choice B) Polysaccharide vaccine is given to patients age ≥65 to prevent illnesses caused by Streptococcus pneumoniae. However, S aureus and oral flora are much more commonly implicated in suppurative parotitis. (Choice C) Tetanus can present with painful trismus (due to masseter spasm) and sometimes fever. However, unilateral erythema and swelling of the parotid gland would not occur, and other muscle spasms (eg, clenched fists, stiff neck, rigid abdomen) are typically present. (Choice D) Extreme jaw opening (eg, during intubation) can cause anterior temporomandibular joint dislocation, which presents with pain in the preauricular area and difficulty opening or closing the jaw. However, fever with leukocytosis would not be present. (Choice E) Malignant hyperthermia occurs in susceptible patients following administration of volatile anesthetic agents and can present with hyperthermia and masseter muscle spasms. However, it typically presents within an hour of anesthesia induction; is not associated with leukocytosis; and would not have localized symptoms. (Choices F and G) Incentive spirometry and early ambulation can reduce postoperative pulmonary complications (eg, pneumonia), but neither prevent parotitis. Educational objective: Suppurative parotitis presents with exquisitely painful swelling of the parotid gland. This postoperative complication can be prevented with adequate fluid hydration and oral hygiene. References: Cervical lymphadenitis, suppurative parotitis, thyroiditis, and infected cysts. (http://www.ncbi.nlm.nih.gov/pubmed/17561081) Imaging of sialadenitis. (http://www.ncbi.nlm.nih.gov/pubmed/28059621) Acute bacterial suppurative parotitis: microbiology and management. (http://www.ncbi.nlm.nih.gov/pubmed/12544218) Management of acute suppurative parotitis. (http://www.ncbi.nlm.nih.gov/pubmed/11928106)

A 73-Year-Old Man Is Seen in the Hospital Due to Severe