Page 30 - GP fall 2023

Parotid Gland Swellings: The Most Likely Etiologies
Seen in the Dental Setting

Authors: Cristina Masino, RDH, BS, MBA and Gwen Cohen Brown, DDS, FAAOMP

Introduction: When a patient presents with bilateral parot- gland disease (H-SGD) most commonly
There are various correlations and rela- id swelling, it is imperative to determine the precedes AIDS, these salivary gland lesions
tionships between systemic diseases and etiology of the swelling, which can be done may be the initial clinical manifestation of
the oral cavity, the head, and the neck. In by examination of the parotid glands, order- HIV infection. Clinically, H-SGD most
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order to provide adequate patient care, pro- ing specific blood tests, and consulting with often presents with bilateral salivary gland
viders need to have a strong foundation and other clinicians. The potential diagnoses enlargement and/or xerostomia. Imaging
awareness of oral manifestations and their for this clinical presentation include lesions studies often identify the presence of mul-
relationship to the rest of the body. Many associated with HIV disease, Sjögren’s syn- tiple parotid ‘cysts’.
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of these oral manifestations can help lead to drome, mumps, and alcoholism. It is a wide
a diagnosis of a systemic condition. There- differential diagnosis with vastly differing Parotid swelling in patients with HIV is of-
fore, it is the due diligence of the dental outcomes. ten associated with salivary gland diseases,
team to have the clinical and radiographic such as inflammatory disorders, infections,
knowledge to correctly assess the patient. HIV neoplasms, and benign lymphoepithelial
As dental health care professionals, we are cysts (BLECs). BLEC is characterized by
During the periodic exam and assessment, aware of the widespread global epidemic bilateral parotid gland swelling and cervi-
the head and neck exam is a crucial com- and transmission of the HIV virus. Even de- cal lymphadenopathy, and the presence of
ponent for the possible discovery of any spite worldwide prevention, HIV is still ev- BLECs can serve as an initial clinical mani-
palpable areas that are not within normal ident at high numbers throughout the world. festation of HIV. The pathology of BLECs
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limits. It is estimated that about 3% of the Prevention and a rapid diagnosis will help is unknown, but two hypotheses have been
population suffers from a chronic inflam- decrease the transmission and slow down formulated. The first hypothesis is that
matory rheumatic disease (IRD), and many progression. Rapid initiation of antiretrovi- HIV-related reactive lymphoproliferation
of these patients experience oral manifesta- ral therapy (ART) – as early as the day of occurs in the intraparotid lymph nodes of
tions, which may be the first clinical sign or HIV diagnosis – may be important in glob- the parotid glands. The parotid glandular ep-
symptom of a systemic disease. This exam al HIV management for two main reasons. ithelium becomes trapped within the normal
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carefully assesses the salivary glands and First, as a means to control the HIV epidem- intraparotid lymph nodes, resulting in cystic
any malformations that can be found while enlargement. The second hypothesis is that
palpating areas such as the thyroid, tem- HIV-infected cells migrate into the parotid
poromandibular joint, and occipital lymph glands. This will lead to salivary duct ob-
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nodes. struction, causing a gradual swelling over
time. The clinical presentation of BLEC is
Clinical typically gradual, painless, and comprises
The parotid gland is the largest of the three
paired major salivary glands found in the
oral cavity and is located in the retroman-
dibular fossa. It is bordered superiorly by
the zygomatic arch, anteriorly by the mas-
seter muscle, and posteriorly by the sterno-
cleidomastoid muscle. The parotid glands
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can be palpated anterior and inferior to the
lower half of the ear on the lateral surface
of the cheek. They extend inferiorly to the
lower border of the mandible and superiorly
to the zygomatic arch. Figure 1. HIV parotid gland enlargement.
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Courtesy of Dr. Michael Glick, Professor,
Patients presenting with a swollen parotid University of Pennsylvania Dental School. Figure 2. HIV parotid gland swelling.
gland may be reflecting symptoms of an
underlying systemic condition. Most like- ic, in the absence of a vaccine or cure: an bilateral parotid swelling with diffuse cervi-
ly diagnoses include but are not limited to, undetectable virus means a non-transmissi- cal lymphadenopathy. BLEC is diagnosed
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Sjögren’s syndrome, mumps, HIV, or alco- ble virus. Secondly, to optimize the health based on medical history, physical examina-
holism. All affect the clinical presentation of people living with HIV (PLWH). As- tion, and biopsy. Non-invasive diagnostic
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of the parotid glands; however, the etiology, sessment during a head and neck exam can modalities include ultrasound examination,
treatment, and prognosis for all four condi- expedite the diagnosis of HIV. It is reported CT scanning, and MRI, which are able to
tions are vastly different. Fortunately, sali- that 3%–10% of patients (both adults and detect multiple thin-walled cysts with dif-
vary gland tumors are rare, accounting for children) infected with the human immu- fuse cervical lymphadenopathy. Invasive
just 6% to 8% of head and neck tumors. A nodeficiency virus (HIV) develop lesions diagnostic modalities include fine needle
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salivary gland tumor located in the parotid in the salivary glands. These lesions can aspiration cytology (FNAC) and parotid
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gland can cause a unilateral swelling; how- cause enlargements in the glands that can be gland biopsy, which can exclude malignan-
ever, they are rarely, if ever, bilateral in pre- detected during a visual assessment or pal- cy in the differential diagnosis. However,
sentation. pation. Although the diagnosis of HIV-as- malignancy only occurs in less than 1% of
sociated cystic lymphoepithelial salivary patients with HIV-associated cystic lesions.
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