Recurrent Bilateral Anesthesia Mumps after Cesarean Section Under Spinal Anesthesia, Rare Case Report and Literature Review

Abstract

Anesthesia mumps, also known as acute postoperative sialadenitis, is a rare complication that can occur following general or regional anesthesia. The prevalence of this condition ranges from 0.16% to 0.2%. This case report presents a patient with recurrent bilateral parotid swelling after cesarean section (CS) under spinal anesthesia and its management. A 42-year-old G5P4 woman with gestational diabetes mellitus and antiphospholipid syndrome presented for elective cesarean delivery at 39 weeks and two days of gestation under spinal anesthesia. The patient developed bilateral facial swelling after five hours, which was more evident on the right parotid site. A review by an otolaryngologist confirmed the diagnosis of anesthesia mumps. Anesthesia mumps typically presents as painless swelling of the salivary glands. Salivary duct obstruction and hyperemia are believed to be common causes. This case highlights that anesthesia-induced mumps is a reversible and transient complication that may occur after short surgical procedures, such as cesarean sections. Early recovery was achieved following supportive conservative management, with hydration and analgesia.

Introduction

Anesthesia mumps, commonly known as acute postoperative sialadenitis, is a rare complication that can occur following general or, less commonly, regional anesthesia. ¹ This condition involves acute transient swelling of the salivary glands, most commonly affecting the parotid glands, although the submandibular glands can also be involved.^2,3 The condition was first described as “surgical mumps” by Schwarz et al in the 1960s and later defined as “ anesthesia mumps” by Reilly et al a decade later, when they reported three cases among approximately 1,500 patients who underwent general anesthesia.^4,5 Swelling can present as unilateral or bilateral enlargement that develops during surgery or, more commonly, within a few hours after the procedure.^2,6 Anesthesia mumps is generally considered a mild and transitory complication that is usually painless and self-limiting in nature.^1,2 This condition typically resolves spontaneously within hours to a few days, without long-term sequelae. ⁴ However, while most cases are benign, rare instances can lead to serious complications, such as massive facial edema and upper airway obstruction, requiring immediate intervention.^1,2 Despite numerous case reports and small reviews, the incidence, definitive pathophysiology, and standard prevention/management protocols remain undefined and are particularly relevant in obstetric anesthesia, where data are limited, ¹ anesthesia mumps is usually reported after general anesthesia, and this is one of the few cases that occurred following spinal anesthesia. ⁷ Here, we report a post spinal anesthesia onset, bilateral parotid swelling, and its novelty lies in its recurrent nature across sequential pregnancies under spinal anesthesia in the same patient, which has not been thoroughly evaluated in published obstetric literature. This case report has been prepared in accordance with the CARE checklist guidelines. ⁸

Report

A 42-year-old woman, G5P4, height 162 cm, weight 84 kg, BMI 32 kg/m², with gestational diabetes mellitus (GDM) and antiphospholipid syndrome (APS), was prescribed low-dose aspirin (75 mg, presumed for APS prophylaxis) and glucophage (500 mg). The patient reported a history of mumps following her previous cesarean section under spinal anesthesia, which resolved spontaneously after three days. She had received a mumps vaccine in childhood. Preoperative hematological tests, such as white blood cell count and C-reactive protein levels, were within normal limits. Ultrasound studies of the current gestation period were normal throughout pregnancy, with a blood pressure of 122/62 mmHg and SpO₂ of 98%. The patient underwent a repeat elective cesarean section under spinal anesthesia between the L3-L4 intervertebral spaces with a 27-gauge atraumatic spinal needle in the sitting position at a gestational age of 39 weeks and 2 days. After 100% oxygen was supplied before induction, 3 mL of Marcaine 0.5% was used to induce anesthesia. The patient was also intraoperatively administered oxytocin 20/IU and atropine (1 mg) intravenously due to a pulse rate of 48 bpm and 25 mg ephedrine was administered for hypotension. The surgery lasted approximately 45 min. After delivery, the patient was stable and without any complaints. The patient was monitored in the postoperative care unit for 30 min and then transferred to the general ward without any particular issues. Five hours later in the hospital ward, the patient complained of bilateral parotid swelling, which was more pronounced on the right than on the left side and extended to the mandibular angle (Figure 1A and B). Serum amylase levels and white blood cell counts were normal. Physical examination revealed bilateral enlargement of the parotid regions, which was absent in the presophageal and posterior pharyngeal walls, and the orifice of Stensen’s duct was open. There was no pain, redness, respiratory distress, or any other signs or symptoms of inflammation. The patient was intravenously hydrated with 500 mL of normal saline, 1g/IV paracetamol for CS pain control; in addition, considering the risk of infection, 1g/IV amoxicillin-clavulanate was administered empirically before the non-infectious nature of the swelling was fully confirmed by consultation with an ear, nose, and throat (ENT) specialist, acute postoperative sialadenitis or anesthesia mumps was diagnosed, furthermore patient received 50 mg/mL intramuscular (IM) Pethidine hydrochloride as a single dose then the newborn was observed for sedation, poor feeding, or respiratory depression, none of which occurred. The swelling gradually improved over three days and achieved complete clinical resolution by postoperative day four and the patient was discharged without complications.

Figure 1.

Left-side face view of the patient’s parotid swelling 5 hours after surgery. (B) Right-side face of the patient’s parotid swelling

Initially, the patient was anxious as the swelling of the face occurred after the surgery. However, the reassurance by the ENT specialist that there was no danger from the illness and that it would pass gave her relief. Her swelling improved steadily every day, and she was happy with the outcome without undergoing any invasive procedures.

Discussion

The condition typically presents as a painless enlargement that may extend from the preauricular region to the mandibular angle.^2,9 Although most cases are mild with few subjective symptoms, patients may experience mild pain and distress without impairment of airway patency or reflexes, such as swallowing or coughing.^2,9,10 Anesthesia mumps has been reported across various surgical subspecialties, including plastic, endoscopic, neurosurgical, abdominal, orthopaedic, otolaryngologic, gynecological, and urological procedures.^5,11 Most cases were diagnosed after the patient had been anesthetized for a long time under general anesthesia, and the estimates ranged from 0.16%to 0.2%.^1,9

Three articles were retrieved from PubMed related to the anesthetic mumps post spinal anesthesia in CS.^1,7,12 (Table 1). This condition can affect patients of all age groups.^3,13,14 The duration of symptoms is typically brief, with most cases resolving spontaneously within hours to several days.^1,7,12 The present case resolved after four days. However, in rare instances, severe complications can develop, including massive facial edema and complete upper airway obstruction, especially in patients under general anesthesia with predisposing factors, such as obesity, prolonged surgeries, or certain positions leading to vascular compromise and gland ischemia that may require emergency tracheal intubation.^2,5,15 Another study reported that the increased soft-tissue mass in the short, thick neck of morbidly obese patients (BMI> 50 kg/m2) can lead to external compression of regional head-and-neck vasculature and salivary ducts during positioning. ¹⁶ In contrast, our patient had Class I obesity (BMI 32 kg/m²), which may have acted as a minor predisposing factor by contributing to the modest soft-tissue volume around the parotid region. Fortunately, the patient in the present case did not develop airway compromise, highlighting the generally benign nature of this condition when promptly recognized and treated. Although the precise pathophysiology of anesthesia-induced mumps has not yet been fully elucidated, multiple factors have been proposed. When positive pressure is applied to the oral cavity during mask or mechanical ventilation, air can be forced retrogradely into the parotid gland. ⁴ The loss of muscle tone induced by muscle relaxants during general anesthesia facilitates this process by reducing the resistance around the ductal orifice. ¹¹ Additionally, excessive straining, coughing, or sneezing during emergence from anesthesia can cause retrograde airflow through Stensen’s duct, resulting in pneumoparotitis. ¹¹ Another proposed mechanism involves obstruction of the salivary ducts. ¹⁷ Perioperative medications, including anticholinergics (atropine and glycopyrrolate), muscle relaxants (succinylcholine), and sympathomimetics (ephedrine), alter salivary secretion or increase ductal viscosity, potentially occluding salivary ducts.^1,11 Preoperative dehydration or fasting increases the viscosity of saliva and the risk of ductal obstruction.^11,18 Mechanical blockage of the parotid duct can also occur due to endotracheal tube placement and fixation or extreme head positioning during prolonged procedures.^13,19 Additional proposed mechanisms include vascular congestion and venous engorgement of the head and neck region, particularly in patients positioned prone or in the lateral decubitus. ²⁰ Intratracheal manipulation during intubation may stimulate the parasympathetic nerves that mediate the pharyngeal reflex, inducing salivation, vasodilation, and hyperemia in the salivary glands. ¹ In the present case, these predisposing factors were not present; however, proposed hypotheses such as possible compression of the parotid gland in the supine position during surgery, dehydration, class 1 obesity and the use of atropine might theoretically have played a significant role in the recurrence of this case. While changes in microvascular or metabolic function that occur in GDM and APS may affect glandular perfusion or salivary rheology, these mechanisms remain purely theoretical. Currently, there is no strong epidemiological or clinical evidence to suggest that GDM and/or APS are associated with salivary stasis, and these considerations remain entirely theoretical.

Table 1.

Published Cases of Anaesthesia Mumps After Cesarean Section Under Spinal Anaesthesia

References	Age	Spine anaesthesia drug	Additional medications intraoperative	Treatment postoperative	Follow_up	Onset_time	Site
(1)Jarrar et al 2023	31	Marcaine 0.5% (L3-L4)	Ephedrine 30mg, Dexamethasone 8mg, Ceftriaxone 1gm, Esomeprazole 40mg, Syntocinon 30/IU	Dexamethasone 8mg/IV every 8 hours for 24 hours, IV fluids, Paracetamol, Warm compressors	Swelling resolved completely after 48 hours	5 hours postoperatively	Bilateral
(13)Günaydın et al 2021	31	Hyperbaric bupivacaine12mg, morphine 100mcg, fentanyl 10mcg/(L3-L4)	Ephedrine 5mg/IV(4 times), Oxytocin, Dexamethasone 4mg/IV	Pheniramine maleate 45.5mg/IV, Tenoxicam 20mg/IV, isotonic fluid IV/5mL/kg/h	Bilateral reduction in swelling observed at 9th hours postoperative	5 hours postoperatively	Bilateral
(12)Montazeri et al 2022	30	Marcaine 8Ml(0.5%), fentanyl10/mcg (L3-L4)	Sodium valproate 1600mg, Ondansetron 4mg/IV	Hydration with 1000cc normal saline, Hydrocortisone 100mg/IV (single dose)	Left side swelling resolved in 10 hours, right side resolved in 24 hours	7 hours postoperatively	Bilateral
Current case	42	Marcaine 0.5% (L3-L4),	oxytocin 20/IU. Paracetamol/1g/IV, Atropine 1mg/IV	Hydration with 500cc normal saline and Pethidine Hydrochloride 50 mg/ml/M/. paracetamol1g/IV, amoxicillin-clavulanate 1g/IV	Swelling resolved completely after 4 days	5 hours postoperatively	Bilateral

The management of anesthetic mumps is predominantly conservative because the condition is typically self-limiting and resolves spontaneously without specific treatment.^15,20 Most patients improve with symptomatic therapy over hours to several days, without any known sequelae.^1,13 The management strategy typically involves reassurance to the patient and family about the benign nature of the condition, along with symptomatic treatment, including rehydration therapy. ²⁰ Most patients recover fully within a few days, with or without treatment, making aggressive intervention unnecessary in most cases. ⁹ In the present case, the administration of 500 mL normal saline, 50 mg/mL pethidine hydrochloride, 1 g/IV paracetamol, and 1 g/IV amoxicillin-clavulanate facilitated symptom resolution within four days of follow-up. The absence of elevated serum amylase and white blood cells supports the diagnosis of non-infectious sialadenitis, helping differentiate anesthetic mumps from infectious parotitis. Empirical intravenous amoxicillin-clavulanate was administered solely as a clinical precaution upon initial presentation to cover potential acute infectious parotitis before non-infectious anesthetic mumps was formally confirmed by the ENT specialist.

Most published obstetric cases under spinal anesthesia mainly describe isolated episodes, and recurrence in the same patient was not documented among the cases included in our review.^1,7,9,12 Preventive strategies advocated in the literature emphasize the avoidance of excessive head and neck rotation, optimal patient positioning to reduce external gland compression, maintenance of hydration, and careful use of anticholinergic medications that may increase salivary viscosity. Awareness of anesthesia-related mumps as a differential diagnosis for postoperative facial swelling is crucial to avoid unnecessary investigations and interventions.^11,15,17

Infectious parotitis was considered unlikely because the patient had no fever, erythema, purulent discharge, tenderness, leukocytosis, or elevated inflammatory markers. ¹² Sialolithiasis was excluded based on acute swelling, bilateral swelling, postoperative status, and patent Stensen’s orifice, with no colicky meal-related pain. ²¹ Allergic reactions and angioedema were ruled out because of the complete absence of pruritus, urticaria, lip or tongue swelling, or systemic respiratory compromise.^22,23 Physical examination revealed non-fluctuant, non-ecchymotic, diffuse glandular swelling rather than a localized collection. Pneumoparotitis was considered unlikely because there was no crepitus and no history of mask ventilation, coughing, straining, or positive airway pressure. ²⁴ In the present case, ultrasonography was not performed at the time of presentation due to logistical unavailability in the ward setting and to avoid unnecessary investigation delays in reassuring the patient.

This case report has some limitations, such as the fact that it is a single-patient report; no causal relationship can be established between recurrence and potential contributing factors such as atropine use, dehydration, positioning, gestational diabetes mellitus, or antiphospholipid syndrome, and the findings cannot be generalized to other obstetric patients. Diagnosis of anesthesia mumps was based primarily on clinical findings and specialist assessment, without ultrasonography or computed tomography to objectively confirm parotid enlargement or exclude structural causes such as sialolithiasis, abscess, or pneumoparotitis.

Conclusions

This case highlights a novel presentation of recurrent anesthesia-related mumps across sequential obstetric procedures under spinal anesthesia. The self-limiting nature of this entity should not be forgotten by anesthesiologists and surgical teams if they encounter facial swelling after surgery. Early recovery was achieved following conservative supportive management, including hydration and analgesia. If serious complications (e.g., airway obstruction, acute infection, mechanical obstruction) are ruled out, then being able to recognize anesthesia mumps can help provide reassurance and avoid unnecessary diagnostic testing and invasive procedures.

ORCID iD

Parshal Bhandari https://orcid.org/0000-0001-8311-8466

Ethical Considerations

Ethical approval was obtained by Baxshin research center(BRC)

Consent for Publication

Written informed consent was obtained from the patient for the publication of this case report and accompanying images.