A 52-year-old woman presented to the outpatient department with complaints of bilateral swelling in both her cheeks for the past 8 years. What is the differential diagnosis?
The patient had no pain, fever, dry mouth, chewing difficulty or any other systemic symptoms. Her main concern was the aesthetic appearance of the swelling. She had no history of parotid sialadenitis, allergies, rheumatologic disease, or facial trauma or surgery. The only positive history pointer was multiple caries for which she had gotten dental work done quite a few times.
On examination, non-tender swelling was noticed on the face along the course of the parotid (also called Stensen’s) ducts (Panel A). The swelling was neither erythematous nor warm on palpation. On compressing the swelling, the profuse salivary discharge was noticed firing out from the duct orifices bilaterally, which are present adjacent to the maxillary second molar in the buccal (cheek) mucosa.
Computed tomography of the neck was performed, which revealed bilateral dilatation along the course of the parotid ducts. No cause of obstruction could be identified in the imaging (Panel B).
The patient was hydrated, and a sialagogue agent (pilocarpine) was given along with the salivary massage. The conservative management didn’t produce any results, and the swelling of the parotid gland persisted.
The patient was then advised to opt for a parotidectomy ( surgical excision of the parotid gland); however, the patient refused any surgical procedure.
Therefore, the patient was kept on serial follow-ups. No complications were seen in any of the follow-up visits, neither the patient developed any new symptom.
Painless, non-inflammatory swelling of the parotid glands is called sialadenosis. It mostly affects the parotid gland, and the cause remains unknown in many cases.
The differential diagnosis of a patient presenting with bilateral parotid swelling includes Infection (bacterial, viral), autoimmune diseases, Granulomatous diseases, sarcoidosis, sialadenosis, chronic sialadenitis, Sjogren disease, etc.
Imaging studies like MRI, CT, ultrasonography, scintigraphy, and sialography can be performed to evaluate the etiology of parotid swelling. Not all cases require imaging studies. The majority of the patients with parotid swelling get a diagnosis with a thorough history and clinical examination.
Treatment depends upon the underlying cause of the parotid swelling. If the patient is suffering from sialadenosis, the underlying medical condition should be treated as sialadenosis can persist as long as the medical condition would persist. If no underlying cause is known, the patient can be managed with follow-ups, or if there is a cosmetic concern, then parotidectomy can be performed.
References:
Dong Hoon Lee, M.P. (2020, October 22). Saliva Firing from Parotid Ducts. Retrieved from The New England Journal of Medine: https://www.nejm.org/doi/full/10.1056/NEJMicm1911829
Gadodia A, Bhalla AS, Sharma R, Thakar A, Parshad R. Bilateral parotid swelling: a radiological review. Dentomaxillofac Radiol. 2011;40(7):403-414. DOI:10.1259/dmfr/17889378
