Diagnosis of pneumoparotid associated with playing the tuba

[enewberger]

Dear Friends,
There's a short article entitled "A Tuba Player with Air in the Parotid Gland" in the Feb. 12 number of the New England Journal of Medicine. Although the outcome was thankfully favorable, the author unfortunately declined to give a specific warning to tuba students and their teachers about this risk of uncontrolled breathing and blasting. You don't have to be a radiologist to observe on the 2 imaging studies that accompany the text all the air that dissected from the parotid duct in the child's mouth into his parotid gland.
Here's the link:
http://content.nejm.org/cgi/content/ful ... ?query=TOC" target="_blank" target="_blank" target="_blank" target="_blank" target="_blank
Here's the text:
A 13-year-old boy who had recently begun playing the tuba presented with a 2-day history of facial swelling on the left side and pain without fever or ear or nasal discharge. On physical examination, he had swelling of the left cheek with tenderness on palpation. There was no erythema or crepitance. Massage of the parotid gland resulted in expression of foamy secretions from the parotid duct. Computed tomography of the head, neck, and sinuses (Panel A) revealed air in the left parotid gland (arrow) and in the parotid duct (arrowhead). A reconstructed image (Panel B) also revealed air in the parotid gland (arrow) and lateral to the carotid sheath (arrowhead). There was no radiographic evidence of parotitis or involvement of the retropharyngeal space. The serum amylase level was three times the upper limit of the normal range, probably because of parotid injury; all other laboratory measures were normal. The boy received the diagnosis of pneumoparotid associated with playing the tuba; there was no evidence of parotid infection. Conservative management led to resolution of the symptoms within days. Pneumoparotid can arise in wind-instrument players, glassblowers, and persons in whom air under positive pressure in the oral cavity is forced into the parotid ductal system.
With warm greetings and wishes for good health to all,
Eli Newberger

[joh_tuba]

http://en.wikipedia.org/wiki/Parotid_gland

[Todd S. Malicoate]

Interesting article, but I'm reasonably sure this was an extremely rare case...has anyone on the forum ever heard of this happening to a tuba player before?

If you experience extreme swelling an a "popping and crackling" sensation in the cheeks as the symptoms of this condition describe, you would naturally seek medical attention. The same would follow if you observed the symptoms in a student. I'm not sure why we, as tuba players, would need to have an intimate knowledge of otolaryngology or even be concerned with such a rare phenomenon.

[eupher61]

. I'm not sure why we, as tuba players, would need to have an intimate knowledge of otolaryngology or even be concerned with such a rare phenomenon.

Eli mentions the dangers of

uncontrolled breathing and blasting

Good enough for me. Rare, maybe, but if nothing else, it's a good way to get kids to stop that behavior in the band room.

I doubt Eli would present such information in such detail if it weren't a true possible health hazard.

[Todd S. Malicoate]

Except that there's nothing presented that states that the 13-year-old in question was "uncontrollably breathing" or "blasting." It seems more likely that the child simply has a rare defect in a duct near the bottom teeth which allowed air to enter the gland.

Again, I'm not berating the original poster for bringing this to our attention, but I disagree that it's a potential problem worth worrying about. Certainly, it shouldn't be used to scare kids or other beginning tuba players. Just my opinion, however.

[sloan]

Dear Friends,
There's a short article entitled "A Tuba Player with Air in the Parotid Gland" in the Feb. 12 number of the New England Journal of Medicine. Although the outcome was thankfully favorable, the author unfortunately declined to give a specific warning to tuba students and their teachers about this risk of uncontrolled breathing and blasting. You don't have to be a radiologist to observe on the 2 imaging studies that accompany the text all the air that dissected from the parotid duct in the child's mouth into his parotid gland.
Here's the link:
http://content.nejm.org/cgi/content/ful ... ?query=TOC" target="_blank" target="_blank" target="_blank" target="_blank" target="_blank" target="_blank" target="_blank" target="_blank
Here's the text:
A 13-year-old boy who had recently begun playing the tuba presented with a 2-day history of facial swelling on the left side and pain without fever or ear or nasal discharge. On physical examination, he had swelling of the left cheek with tenderness on palpation. There was no erythema or crepitance. Massage of the parotid gland resulted in expression of foamy secretions from the parotid duct. Computed tomography of the head, neck, and sinuses (Panel A) revealed air in the left parotid gland (arrow) and in the parotid duct (arrowhead). A reconstructed image (Panel B) also revealed air in the parotid gland (arrow) and lateral to the carotid sheath (arrowhead). There was no radiographic evidence of parotitis or involvement of the retropharyngeal space. The serum amylase level was three times the upper limit of the normal range, probably because of parotid injury; all other laboratory measures were normal. The boy received the diagnosis of pneumoparotid associated with playing the tuba; there was no evidence of parotid infection. Conservative management led to resolution of the symptoms within days. Pneumoparotid can arise in wind-instrument players, glassblowers, and persons in whom air under positive pressure in the oral cavity is forced into the parotid ductal system.
With warm greetings and wishes for good health to all,
Eli Newberger

As I read the abstract, this is not a unique case. I also don't see any mention of "uncontrolled breathing and blasting". The abstract states that this is a known occurence in wind players and others who blow "under positive pressure".

I see no reason for a specific warning to tuba players (I'd be more worried about trumpet players!).

My impression is that there may well have been an underlying predisposition to this problem which was exposed by a relatively short period of playing the tuba. I don't see a pressing need to send out a warning to young tuba players or their teachers (although it IS good for the physicians they consult to be aware of the connection...in the rare cases that pop up).

I wonder where the idea comes from that this was caused by "uncontrolled breathing and blasting"? I suppose this might be a reasonable assumption if the player performed on the football field with a band that features blastissimo playing - but this is a 13yo player with who has only "recently begun playing the tuba". I hope his teacher already discourages "uncontrolled breathing and blasting".

Do you have any information on recurrence of this condition? Having occured once, is this player at risk for a recurrence? Should he switch to timpani?

"Conservative treatment" = "take 2 Tylenol, don't touch the tuba, and call me in the morning"?

[sloan]

Eli mentions the dangers of

uncontrolled breathing and blasting

Yes, but where in the abstract can you find any evidence of this?

Perhaps the authors thought that this was implied by "recently began playing the tuba"? I don't think that's a given.

[bilmac]

Got this tee-shirt! There's definitely a correlation between heavy blowing ( I play a lot of contra -bass tuba) and problems with the parotid glands.They can back up and if you don't get them going fairly quickly you can find them infected. You look as if you have the mumps and the pain is excruciating ---you can become so toxic all you can do is lie in bed. Broadly based anti-biotics and staying away from the tuba are the cure but it takes time.
The other big problem is that during winter months we all get colds, especially as we get older.Heavy blowing with a cold is a sure fire way of ending up with sinusitis . It seems that the snot gets blown up in around the sinus cavities and towards the eyes and you end up looking like you've been on the beer.My medically qualified wife lectures me every time it happens since 3 or 4 weeks of grouchiness follow as well as not looking so good.I wonder why I bother playing the wretched thing---------until I get warmed up and the Hirsbrunner gets warmed up and then I remember! Worth it?? Yes!

[tbn.al]

I do not doubt that this can be a serious medical issue as reported by Eli. There must be some sort of predisposition, however, for only one of our many members to report suffering these symptoms himself. Even Eli doesn't mention having suffered these symptoms and obviously he has had years of opportunity to do so. i've been playing a brass instrument for more than 50 years and have never had a problem or heard of anyone else with this problem until today. I would be interested to know what percentage of the wind instrument population might be affected, if anyone has numbers or would hazard a guess. As an aside, I regularly injest medications, both prescription and OTC, that warn of potential side effects, even reported deaths. I still take them because the upside outweighs the risk. I just wonder what the risk factor is before I encourage my grandaughter towards a wind instrument?

[HGillespie]

I'm fairly sure this happened to me a few years back during one of my "return to the tuba" sessions -and I'm way past childhood...physically anyway.

I visited a doc in the box and he had no idea what was going on. He said since I had only mild tenderness and no fever, I shouldn't worry about it. However, if it worsened, return to him or my regular doc. In less than a day it subsided. Good thing, because I had shopping to do.

OK, oh experienced ones....Do you think a gentle and proper warm-up could help prevent this? I think pretty much that's what has been alluded to earlier in this post.

[enewberger]

Hi again. I'm glad to see this productive discussion. Have a look at this thoughtful February 11 press report that contains an interview with the boy's doctor and more.

Here's the link:
http://www.healthcentral.com/PrinterFri ... 24042.html" target="_blank" target="_blank" target="_blank

The text follows below.
Eli


Tuba Spells Trouble for Young Musician
Too much air pressure caused rare problem with salivary gland.

By Randy Dotinga
HealthDay Reporter

WEDNESDAY, Feb. 11 (HealthDay News) -- A wind instrument turned into the wrong instrument for a 13-year-old boy who blew his tuba so hard that he sent air into his salivary gland, where it didn't belong.

Doctors diagnosed the condition after the boy developed swelling and pain around his jaw.

"We didn't suspect such a rare problem," said Dr. Deepa Mukundan, who wrote about the case in the Feb. 12 issue of the New England Journal of Medicine. "The cure in this boy's case was to stop playing the tuba for some time."

Glassblowers and people who play brass instruments are prone to the unusual condition, known as pneumoparotid. Even kids who hold their breath can get it, said Mukundan, an assistant professor of pediatrics at the University of Toledo College of Medicine in Ohio.

Mukundan was called in to see the boy, who was suffering from pain and mild swelling on the left side of his face around the jaw. A CT scan found air in tissues below the skin, a potentially dangerous problem that could lead to infection, she said.

But the boy didn't have a fever and "looked pretty normal," Mukundan said. "That raised a flag to me that this is probably not an infection, that we have to explore other causes of air under the skin."

Doctors talked to the boy and discovered that he'd just started playing the tuba a week or two earlier. This revelation led to the diagnosis -- air in one of his salivary glands.

"Normally, the gland produces saliva and sends it to the mouth through a duct. It's like a valve and doesn't allow anything to go backwards, only forwards," Mukundan said.

But the pressure of blowing on the tuba forced air in the wrong direction, filling the gland, she said.

In this case, the cure was to tell the boy to stop playing the tuba so the air could seep out of the gland into surrounding tissue and disappear, Mukundan said. That worked, although the boy later developed an infection and had to have a salivary gland removed.

While it's very rare, pneumoparotid can strike tuba, trombone, trumpet and even harmonica players because they blow so hard, said Dr. David Myssiorek, a professor of otolaryngology and head and neck surgery at New York University Langone Medical Center.

Imagine the photos of the late, great trumpeter Dizzy Gillespie with his cheeks puffed out, Myssiorek said. "I would be surprised if he never got that [condition]."

By contrast, "instruments like the clarinet and flute require less pressure," Myssiorek said.

It's not clear how to prevent the condition, although music teachers can train musicians to blow their instruments in a different way, if necessary.

The good news: Air in the salivary gland usually isn't a serious condition. "The pain would just resolve with time, and the air finds its way out, the way it came in," Myssiorek said.

More information

Learn more about salivary gland problems from the U.S. National Library of Medicine.
http://www.nlm.nih.gov/medlineplus/sali ... rders.html" target="_blank" target="_blank" target="_blank

Copyright © 2009 ScoutNews, LLC. All rights reserved.

[HGillespie]

US News and World Report has carried this story:

http://health.usnews.com/articles/healt ... ician.html" target="_blank

Is this news a "low blow" to our hobby/profession/passion/obscession?
--sorry had to do that pun...not busy at work today.

[Todd S. Malicoate]

Since I neglected to say so before...Thank you, Dr. Newberger, for bringing this condition to the forum's attention. It is an interesting phenomenon and certainly, as LJV pointed out, good information for us to have in case a problem does come up.

Is there evidence that this is a usually one-time problem, or is it more likely that some people are predisposed to have an ongoing problem with this condition as long as they attempt to play the tuba?

[tbn.al]

We are fortunate to have Dr. Newberger among us. His combination of medical and musical experience places him in a unique position to shed some light on a new to me potential problem. I do not notice any undue pressure in my mouth when I play, even at high volumes, and the chainsaw can produce some serious decibels. I am wondering if there is a physical predisposition that could explain the relative rarity of the condition or could it be just improper technique? Do we have incidences of well trained wind players with this condition? Could the reason Gillespie was not stricken be because his glands were genetically heavy duty jobs able to resist even his massive onslaught? Inquiring minds want to know!
I asked my Dr. Daughter, also a wind player, that is if flute counts, and she just looked at me quizzically. I’ll need to make her look it up. After all it's her daughter's future horn experience that is in jeopardy.
It would seem to me that knowledge of the problem by teachers would enable early intervention. That might keep some other kid from having sugery.

[imperialbari]

One caring poster obviously warns your president off from the dangers of said symptoms: open your mouth well when exhaling.

[tbn.al]

I do not notice any undue pressure in my mouth when I play, even at high volumes, and the chainsaw can produce some serious decibels.

As an aside, I posted this on 2/12/09. On 2/13/09 I went to a family gathering and picked up a slight head cold. By 2/16/09 it had progressed into a full blown sinus infection with 102 fever. I felt better by the next Wednesday and went ahead to a rehearsal. I did not play particularly loud. I noticed no unusual pressure in my head while playing. By Thursday I was quite deaf. My hearing returned by the weekend in my left ear but I am just now five weeks later able to hear anywhere close to normal in my right ear. I have missed 3 performances and had to get subs for numerous rehearsals. I ran 100 to 102 fever for a solid week. High powered antibiotics and steroids seemed to have no effect. I pray my hearing comes back completely on its own. The alternative seems to be surgery to remove the hardened gunk in my middle ear. I certainly didn't take this post seriously because nothing like that ever happened to me. However my trumpet playing doctor friend says I most likely blew the infection into my middle ear through the eustachian tubes. Evidently they become more susceptible to this while infected. Please be careful if you try to play with a head cold. It might be better to just take a few days off.