Chipmunk Cheeks: Why Does Bulimia Cause Face Swelling?

Bulimia Nervosa & Chipmunk Cheeks

Chipmunk cheeks, bulimia cheeks, bulimia face – these are all terms used to describe the facial swelling characteristic of bulimia nervosa and other purging eating disorders.

What are chipmunk cheeks?

Chipmunk cheeks, a colloquial term for sialadenosis, is a common sign of repeated vomiting in individuals with bulimia nervosa (BN). BN is an eating disorder characterized by cyclical episodes of binge eating and compensatory behavior. Chipmunk cheeks can be a major source of stress for many patients, causing discomfort and embarrassment. Individuals with this side effect may be reluctant to seek out treatment because of concerns about their appearance or fear that everyone will be able to tell they’re struggling with an eating disorder.

Bulimia side effects: face and mouth

People with eating disorders often use compensatory behaviors. This includes purging or non-purging behaviors with the intent to compensate for food intake and prevent weight gain. Non-purging behaviors include any type of compensatory behavior that does not involve purging.

Purging behaviors are common with bulimia. They involve elimination to compensate for food intake and include behaviors like:

• Self-induced vomiting
• Laxative use
• Diuretic use
• Enemas

Self-induced vomiting can cause multiple medical complications and side effects that affect the mouth, lips, esophagus and teeth. Some other complications include:

• Gingivitis
• Periodontal disease
• Enamel erosion
• Tooth damage
• Chronic dry mouth
• Bad breath

What causes chipmunk cheeks?

Chipmunk cheeks (sialadenosis) are one of the telltale signs an individual has been purging through self-induced vomiting. The cause of sialadenosis is the enlargement of the salivary glands. Puffy, swollen or otherwise enlarged salivary glands in the face give a bloated appearance to the sides of the face and the jaw. Around 10-50% of those who engage in self-induced vomiting suffer from the phenomenon.

Salivary gland enlargement

To understand sialadenosis better, picture the three major salivary glands, paired in twos and located under the ear, under the tongue and along the jaw:

• The parotid glands
• The submandibular glands
• The sublingual glands

The salivary glands are responsible for producing saliva, which aids in digestion and other bodily functions. Sometimes, like in the case of those with eating disorders, one or more of these salivary glands can become swollen.

Sialadenosis most commonly affects the parotid glands but can affect any of the salivary glands in the cheeks. Chipmunk cheeks are commonly described as a relapsing, bilateral, non-inflammatory, benign salivary gland enlargement that does not affect the gland functioning.

Peripheral autonomic neuropathy

The exact mechanism for salivary gland enlargement is unknown, but some evidence suggests peripheral autonomic neuropathy as a main factor.

• Peripheral autonomic neuropathy increases acinar protein production and/or an interrupted granular release of the different components of the saliva.
• The accumulation of zymogen granules in the acinar cells causes parotid gland enlargement and impaired salivary secretion.
• The degenerative alteration in myoepithelial cells and postganglionic sympathetic neurons may be the cause of sialadenosis, as they control salivary synthesis and secretion.

Other hypotheses

Another hypothesis is that sialadenosis is the result of either regurgitation of acidic contents, consumption of carbohydrate dense foods over a short period of time in binge-eating episodes or the result of pancreatic proteolytic enzymes coming back into the mouth during vomiting and stimulating lingual receptors.

The enlargement of salivary glands may be associated with elevations in serum amylase levels. There are several studies of patients with BN evaluating salivary content. Some studies have found elevated levels of amylase in both unstimulated and stimulated salivary samples of the patients with BN, but other studies have reported an insignificant difference compared to controls. One study suggests that the oral changes in eating disorders result primarily due to cariogenic dietary patterns and binge eating and purging habits and not due to physiologic salivary alterations.

Treatment for chipmunk cheeks

While salivary gland enlargement is typically asymptomatic, painless and benign, the appearance of chipmunk cheeks can compound already existing body image disturbances in eating disorder patients. Therefore, it remains important to offer options for relief and guide patients through this phase of recovery.

• If patients are experiencing pain or discomfort over the counter pain relievers, such as ibuprofen or acetaminophen, can help.
• Applying heating pads to the area can provide some relief.
• Sialagogues (lemon drops or other tart candies) can also be used to alleviate symptoms by stimulating saliva production.

In persistent cases, a medication called pilocarpine may be used to reduce the size of the salivary glands, but patients should be monitored for serious side effects that may affect their recovery, like diarrhea, vomiting, tachycardia (elevated heart rate), bradycardia (low heart rate) or irregular heartbeat.

In extremely rare occasions, a surgical procedure called a parotidectomy (partial or complete removal of the parotid gland) may be necessary to slim the face.

Sialadenosis is temporary

Thankfully, sialadenosis is temporary. While select cases can persist for months or years following recovery, most patients will notice that their swelling subsides within a couple weeks after purging stops. Treating the underlying eating disorder, whether it is bulimia nervosa or another eating disorder, is the best treatment. Unfortunately, they do not shrink immediately, so it’s important to be patience.

Purging in other eating disorders

While chipmunk cheeks are closely associated with bulimia nervosa, this side effect can occur in any patient that has a purging eating disorder, including anorexia nervosa binge eating/purging subtype (AN-BP) or other specified feeding or eating disorder (OSFED).

Anorexia Nervosa Binge Eating/Purging Subtype

Anorexia nervosa is divided into two subtypes: restricting type (AN-R) and binge eating/purging type. AN-BP shares the same diagnostic criteria as AN-R, but also includes regular engagement in binge-eating or purging alongside restricting behaviors.

Purging Disorder

Unlike bulimia nervosa and AN-BP, purging disorder is not an independent diagnosis, but instead a descriptor of those with OSFED who engage in purging behaviors like self-induced vomiting or laxative and diuretic misuse, without experiencing eating binges or being underweight.

References

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