"Chipmunk Cheeks”: Why Does Bulimia Cause Face Swelling?

By Allison Nitsch, MD, FACP, CEDS

“Chipmunk cheeks” – puffiness or swelling of the cheeks – is a common side effect of bulimia nervosa where the salivary glands become inflamed. Caused by frequent episodes of self-induced vomiting, this is temporary and often subsides with treatment.

Bulimia Nervosa & “Chipmunk Cheeks”

“Chipmunk cheeks,” a common term for sialadenosis or enlarged parotid glands, often indicate self-induced vomiting in bulimia nervosa. Even when a patient ceases vomiting, they may notice facial swelling on the sides after a few days. Sialadenosis is often a major source of stress for many patients, causing discomfort, pain and embarrassment.

Sialadenosis causes physical discomfort, but it can also be emotionally distressing. It can trigger appearance anxiety in patients or they might be afraid that everyone will be able to tell they’re struggling with an eating disorder because of the swelling.

Bulimia Nervosa & Compensatory Behaviors

Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors, behaviors used to counteract weight gain from binge eating.1 It is typically associated with an intense fear of weight gain and a distorted body image, despite often maintaining a normal weight.

Purging

Purging behaviors are common in those with bulimia nervosa. Purging involves elimination to compensate for food intake and includes behaviors like:

  • Self-induced vomiting
  • Laxative and/or enema use
  • Diuretic use

Self-induced vomiting

Self-induced vomiting is the most frequently used purging method that patients with eating disorders resort to in order to compensate for binge eating.2,3 Self-induced vomiting can cause multiple medical complications and side effects that affect the mouth, lips, esophagus and teeth. Some complications include:

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

Do other eating disorders lead to face or cheek swelling?

While sialadenosis is commonly linked to bulimia nervosa, this side effect can occur in any patient who purges through self-induced vomiting, including those with anorexia nervosa binge eating/purging subtype (AN-BP) and purging disorder, a term used under 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.1

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.1

What is Sialadenosis?

Sialadenosis occur bilaterally, affecting both sides of the face and jaw. It is commonly described as a relapsing, non-inflammatory, benign swelling of the salivary glands that does not impair gland function.

It is also one of the telltale signs an individual has a history of self-induced vomiting. Once purging stops, the baseline swelling can acutely worsen or appear two to four days later. Sialadenosis is also very common, with up to 50% of those who engage in self-induced vomiting suffering from the phenomenon.2

Salivary gland enlargement

There are three pairs of salivary glands along the sides of the face and 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. While sialadenosis most commonly affects the parotid glands, it can affect any of the salivary glands.4

What Causes Sialadenosis?

When the salivary glands' normal function is disrupted, it causes swelling, saliva buildup, and other changes.

Acinar hypertrophy

In patients with bulimia nervosa, repeated self-induced vomiting causes overstimulation of the salivary glands, especially the acinar cells, which produce and secrete saliva. This leads to the cells enlarging (hypertrophy) in response to the increased demand for saliva.5 These enlarged acinar cells increase the gland's volume, resulting in the swelling characteristic of sialadenosis.

Dysfunction of postganglionic sympathetic neurons

Postganglionic sympathetic neurons play a key role in regulating saliva composition and glandular blood flow. With bulimia nervosa, extended metabolic stress and autonomic imbalance can damage these neurons, impairing their ability to control saliva production precisely. This dysfunction also affects the regulation of saliva's protein content and reduces stimulation of myoepithelial cells, leading to saliva retention and parotid gland enlargement.5,6

Damaged myoepithelial cells

Myoepithelial cells help expel saliva from the acinar cells into the ducts. In patients with bulimia nervosa, autonomic dysregulation and electrolyte imbalances can weaken or damage these cells, decreasing their ability to aid in saliva expulsion.5,6 This hampers saliva flow, causing it to pool within the glandular tissue. The accumulated saliva, along with acinar hypertrophy, may contribute to the swelling observed in sialadenosis.

Other hypotheses

Other hypotheses propose that regurgitation of acidic contents, consumption of carbohydrate dense foods over a short period of time in binge-eating episodes and pancreatic proteolytic enzymes coming back into the mouth during vomiting and stimulating lingual receptors are contributors to sialadenosis.3

Treatment for Sialadenitis

While salivary gland enlargement is typically asymptomatic, painless and benign, inflammation of the gland, called sialadenitis, can occur with interruption of self-induced vomiting, which, if untreated, can result in infection of the gland.

Pain relief

Pain or discomfort can be managed with heating pads or over-the-counter pain relievers, such as ibuprofen or acetaminophen.

Lozenges

Lozenges can also help relieve symptoms by stimulating saliva production. They activate the parasympathetic nervous system, encouraging the salivary glands to produce and release saliva, which can help clear stagnant saliva and reduce pressure.

Pilocarpine

If sialadenitis persist, 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 could affect their recovery, like:7

Parotidectomy

In extremely rare cases, a surgical procedure called a parotidectomy might be necessary to improve the appearance and quality of life when conservative measures haven’t succeeded.8

Are swollen cheeks permanent?

Thankfully, cheek swelling related to eating disorders is temporary. While some cases can last for months or years after recovery, the vast majority of patients will notice that their swelling subsides within a few weeks. Treating the underlying eating disorder, whether it is bulimia nervosa or another eating disorder, is the best approach.

References

  1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: APA.
  2. Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021b). Medical complications of bulimia nervosa. Cleveland Clinic Journal of Medicine, 88(6), 333–343. https://www.acute.org/medical-complications-bulimia-nervosa
  3. Mehler, P. S., & Rylander, M. (2015). Bulimia Nervosa – medical complications. Journal of Eating Disorders, 3(1). https://doi.org/10.1186/s40337-015-0044-4
  4. Scully, C., Bagán, J. V., Eveson, J. W., Barnard, N., & Turner, F. M. (2008). Sialosis: 35 cases of persistent parotid swelling from two countries. British Journal of Oral and Maxillofacial Surgery, 46(6), 468–472. https://doi.org/10.1016/j.bjoms.2008.01.014
  5. Coleman H, Altini M, Nayler S, Richards A. Sialadenosis: A presenting sign in bulimia. Head Neck. 1998;20:758–62.
  6. Donath K, Seifert G. Ultrastructural studies of the parotid glands in sialadenosis. Virchows Arch A Pathol Anat Histol. 1975;365:119–35.
  7. Mehler, P. S., & Wallace, J. A. (1993). Sialadenosis in bulimia: a new treatment. Archives of Otolaryngology-head & Neck Surgery, 119(7), 787–788. https://doi.org/10.1001/archotol.1993.01880190083017
  8. Garcia, B. G., Ferrer, A. D., Jimenez, N. D., & Granados, F. J. A. (2016). Bilateral Parotid Sialadenosis Associated with Long-Standing Bulimia: A Case Report and Literature Review. Journal of Maxillofacial and Oral Surgery, 17(2), 117–121. https://doi.org/10.1007/s12663-016-0913-7
Written by
Allison Nitsch, MD

Allison Nitsch, MD, FACP, CEDS

Allison Nitsch, MD, FACP, CEDS-C, serves as the Physician Team Lead at the ACUTE Center for Eating Disorders and Malnutrition, a role she has held since January 2024 after joining ACUTE in 2020. Dr.…

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