## 4 Discussion
It is reported that the recurrence of swellings after treatment, if it does occur, tends to be less intense and less painful and the treatment can be performed again in cases of several recurrences of swellings [8; 24; 27]. In this study, two children (12%) needed a second intervention, and one child (6%) needed up to four interventions in order to reach a successful treatment result. A meta-analysis [26] reported bilateral symptoms in 39% of cases. Another study [28] showed bilateral involvement in almost 50% of cases. Yet, bilateral symptoms were also reported to be as low as 14% [49]. In this study, only one child (6%) had bilateral symptomatic glands. All the children in this study were treated within two months of diagnosis, the vast majority of them bilaterally, even though only one gland was symptomatic. Some institutions perform sialoendoscopy bilaterally regardless of whether both glands are involved [46]. Yet lately, it was noted that in cases of a unilaterally affected gland, it is not required to operate bilaterally [53]. In another study, all the children who underwent a repeated sialoendoscopy due to a recurrence were those who first presented and were treated for unilateral parotitis [49]. In this study, 12 children with unilaterally affected glands underwent bilateral sialoendoscopy. In 11 of these, pathological findings were found on the asymptomatic side (\(p\)-value \(<\) 0.001). Only one child out of twelve had no pathological findings in sialoendoscopy in the contralateral asymptomatic gland. Therefore, bilateral treatment is recommended also when only one gland is symptomatic, and such prophylactic treatment may prevent the currently asymptomatic gland from becoming symptomatic later. Potential side effects that might occur as a result of sialoendoscopy are swelling of the gland, perforation which might lead to swelling of the parapharyngeal space, and obstruction of the upper airway or breaching of the duct [22; 44; 54; 55]. Complications of this procedure are rather rare and are not commonly reported in the literature, especially in the context of JRP. Yet, possible complications may be that of perforation of the duct, formation of duct stricture, and post-operative swelling of the operated gland [54]. In this study, no intra- or post-operative complications were seen. Immediate short-term post-operative swelling of the parotid gland was expected and was considered an innocent surgical sequel that resolves spontaneously or with the help of self-massaging and was not considered a complication. Different solutions for gland irrigation are reported in the literature. In this study, the glands were washed with saline, and later with dexamethasone. However, irrigation with saline only, saline with steroids, saline with antibiotics, or saline with both steroids and antibiotics have been reported [8; 26; 33; 50; 53]. As similar effectiveness has been seen irrespective of the solution composition, it is considered that the main effect of irrigation is breaking the cycle of mucous secretion and stasis through the evacuation of intra-ductal mucous plugs and debris [1; 19]. Performing the sialoendoscopy under local rather than general anesthesia is age-dependent, and among children, it is mostly performed under general anesthesia [4; 56; 24; 57]. A recent study [27], which performed sialoendoscopy on patients with JRP, performed it under local anesthesia only with patients older than 16 years, and two additional studies [43; 50] suggested that sialoendoscopy under local anesthesia may be useful for patients older than 8 years of age. Sialoendoscopy under sedation was also reported [49]. In this study, two children, the eldest in the study population, aged 13 and 16, were treated under local anesthesia. Both children had a successful treatment result and did not suffer from any episodes after the endoscopy. Still, the majority of the children, 15 out of 17, were treated under general anesthesia, as is often required in the pediatric population [21; 31; 46; 48; 50; 57].