## 4 Discussion  
JRP mostly presents in the swelling of one, or sometimes, both parotid glands, enduring from several days to a week, with an asymptomatic period between episodes. Episodes tend to stop in early adulthood, for unknown reasons [1; 23]. As mentioned above, the first episode commonly occurs between the ages of 3-6 years old and is more common in males [1; 8; 24; 25; 26; 27]. Equal distribution between genders was also reported [28]. The data in this research shows the mean age of the children was 6.7 years, with a male predominance (70%). Ultrasonography (US) is a common, cost-effective, noninvasive method, broadly used in the pediatric population for many indications. This modality can detect intra- and extra-glandular lesions, lymph nodes, and features that suggest the diagnosis of JRP, such as multiple areas of 2-4 mm hypoechoic lesions that represent ductal ectasia, lymphocytic infiltration, and sialectasis [13; 14]. US is suggested as the first-line imaging method when suspecting JRP [29; 30; 31] and is very efficient in the acute phase. Between episodes, US findings will usually appear normal. In this study, pre-operative US was performed in 21 glands, 14 of which were symptomatic and 7 asymptomatic. The US findings were a heterogenic appearance and strictures of dilation in the ducts, yet no specific US characteristics were observed. Figure 4: Sialoendoscopic appearance of the parotid duct: a duct showing stricture. Figure 5: Sialoendoscopic appearance of the parotid duct: a duct showing a mucous plug. Various treatment options have been suggested for JRP over the years. These options can be classified as invasive or noninvasive and are utilized for either the acute or chronic phases. The management of the acute phase is mostly aimed at relieving the symptoms of pain, swelling, and fever. Conservative measures for the acute phase are stimulating salivary flow by hydration or with the use of sialagogues, massaging the gland, and relieving the pain with anti-inflammatory medications and analgesics [22]. The prescription of antibiotics during the acute phase is considered controversial and is not proven to affect the course of the disease. Yet if signs of infection arise, antibiotic treatment should be given [32]. Sialoendoscopy is contra-indicated during the acute phase and might be more harmful than helpful [22]. Management of the chronic phase, which follows the acute phase, is aimed at reducing the frequency and severity of swellings, if they tend to reoccur. In the past, patients who did not benefit at all from conservative treatment may have proceeded to surgery, which included ablative measures like tympanic neuroctomy, parotid duct ligation, and for severe refractory cases, gland excision or radiation. Parotidectomy, once considered the gold standard treatment for severe JRP, alongside the aforementioned invasive treatments, had numerous risks and potential side effects including facial nerve injury, a bad esthetic outcome, numbness of the earlobe, and Frey's syndrome. These techniques are not routinely in use today for treating JRP, except in strictly selected severe cases [1; 18; 33]. An additional procedure used previously that was considered less invasive was an injection of sclerosing materials into the ductal system [33; 34]. In the last couple of decades, many studies have reported the increased efficacy of different minimally invasive treatments, namely sialography and sialoendoscopy, which have been shown to be effective, safe, clinically helpful, and with lower rates of complications [22]. In sialography, the anatomical structure of the parotid duct is depicted, and anatomical malformations can be detected by injecting a sialographic contrast dye through the ductal system. This produces a therapeutic effect that is attributed to the flushing of the ductal debris, the dilation of the duct, or the antibacterial effect of the iodine-based contrast material [35; 36; 37; 22].