Parotid Swelling with Facial Paralysis: A Complication of Intravenous Urography

Abstract

As newer and more refined methods of treatment increase, iatrogenic diseases also become more numerous and variable. We present an example in the following report of parotid swelling with seventh nerve paralysis, which appeared to be a reaction to intravenous urography. Case Report Eighteen months previously, a 48-year-old man had been admitted with a gunshot wound of the right lower quadrant. Intravenous urography with Hypaque, performed before laparotomy, had caused no reactions. Multiple small bowel perforations were repaired. There was no history of allergic diseases. Of two blood-smear examinations, one showed 5 per cent eosinophils and the other none. Convalescent blood pressure was 140/90 mm Hg. The patient did well and was discharged. Two months later the patient returned with a right retroperitoneal abscess. Intravenous urography with Hypaque was repeated and resulted in a normal roentgenographic appearance. Again, no reactions were noted. The blood smear examination showed eosinophils of 1 per cent. A third admission was required because of epistaxis, which was promptly controlled. At this time the blood pressure averaged 230/130 mm Hg, and an investigation for the cause of the hypertension was instituted. Apresoline 25 mg every four hours was started on the day of admission, and the blood pressure fell slowly to 180/110. Four days later Aldomet was added, 250 mg every six hours. On the fifth day after admission an intravenous urography with 60 ml of 50 per cent Hypaque again resulted in normal findings. Thirty minutes after the injection the patient complained of painful swelling of both parotid glands, more severe on the right. A right facial weakness was noted by the patient at three hours, progressing to maximal at twelve hours. Although the parotid swelling was clearly evident at twelve hours, it did not become maximal until twenty-four hours after the injection. Examination at that time revealed tender swelling of the parotid glands, greater on the right. Change in taste, hyper-acusis, or lacrimation deficit was not experienced, indicating that the nerve was intact to the origin of the chorda tympani. Secretions expressed from Stensen's duct were clear. Prednisone 25 mg per day and Benadryl 25 mg every six hours were instituted. The patient's usual intake of oral fluids was increased by 2 liters per day. Four days later the parotid swelling began to decrease, and by the next day the glands appeared of normal size. The paralysis of the facial nerve was unchanged, and stimulation of the nerve elicited no response on the involved side. Seventeen days after the onset of paralysis, electromyography demonstrated complete denervation of all 3 major divisions of the right facial nerve without signs of reinnervation. At five weeks, on decompression of the facial nerve, hemorrhage and edema were seen just distal to the origin of the chorda tympani and before the exit through the stylomastoid foramen.