Although parotid abscesses can occur without any obvious cause, you will see them most often in debilitated patients, or after major surgery when mouth care has been neglected. The patient's parotid is painful and is usually much swollen; the skin over it is tight and shiny. You may see pus coming from his parotid duct (inside his cheek level with his first molar tooth). Pus forms in several lobules of the gland between its septa, and does not form a single abscess. This, and the division of his facial nerve into its five branches within his parotid gland, make drainage difficult; it is however essential. Don't wait for fluctuation.
PAROTID ABSCESS For the general method, see Section 5.2.
THE MAIN DIFFERENTIAL DIAGNOSIS is mumps. There is no pus at the orifice of the parotid duct, mumps is usually bilateral, and the skin over the swelling is less shiny. Mumps parotitis does NOT require surgical drainage, it resolves spontaneously.
INCISION. Start incising anterior to the patient's pinna. Keeping close to it, proceed towards his mastoid and then continue in the angle between his pinna and his neck until you reach a skin crease, then cut along this for up to 10 cm. Raise a flap of skin and subcutaneous tissue, so as to expose his parotid gland. Make multiple incisions into this in line with the branches of his facial nerve. Explore each incision by Hilton's method and clean out each abscess cavity with gauze. Close the wound with continuous or interrupted sutures of 3/0 monofilament, leaving a dependent corrugated drain emerging from the inferior part of the incision.