Salivary Gland Disorders

Diagnosis

• The American College of Rheumatology suggests that Sjögren's syndrome can be diagnosed using labial salivary gland biopsy, which may also show non-specific chronic sialadenitis 1
• Focal lymphocytic sialadenitis (FLS) is a feature of Sjögren's syndrome, and pathologists should assess for this and other specific features such as germinal centers (GCs) and lymphoepithelial lesions (LESA) 1
• Tissue biopsy, either fine needle aspiration biopsy (FNAB) or core needle biopsy (CNB), is strongly recommended to distinguish salivary gland cancers from non-malignant salivary lesions, and helps identify specific histological types of tumors and subtypes of malignancies, according to the American Society of Clinical Oncology 2
• The following table summarizes the recommended imaging modalities for salivary gland disorders:

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• MRI with and without IV contrast is preferred for comprehensive evaluation, as it provides information about deep lobe involvement, detects perineural tumor spread, and better characterizes cystic components, as recommended by the American College of Radiology 3, 4
• Determining the duration of swelling is crucial, as a duration of ≥2 weeks raises suspicion for malignancy, and assessing mobility, texture, and size (>1.5 cm is suspicious) can help identify potential malignancies 5
• Checking for associated symptoms such as pain/tenderness, facial nerve function, ulceration of overlying skin, and systemic symptoms (fever, night sweats, weight loss) is essential in evaluating parotid swelling 5

Risk Factors and Red Flags

• Patient age >40 years, tobacco use, alcohol abuse, or immunocompromised status, and associated symptoms such as hoarseness, otalgia, hearing loss, intraoral swelling/ulceration are risk factors for parotid malignancy 5
• Physical findings such as firm, fixed mass, facial nerve weakness, and ulceration are red flags for potential malignancy 5

Treatment and Management

• The American College of Rheumatology recommends treatment of acute bacterial sialadenitis with antibiotics, hydration, warm compresses, sialagogues, and pain management with NSAIDs for no longer than 7-10 days 6
• The American College of Rheumatology recommends treatment of Sjögren's syndrome with hydroxychloroquine 200 mg/day for glandular symptoms, and considers rituximab for refractory cases with severe systemic disease, and glucocorticoids for short-term management of acute flares 6
• The biopsy results determine the extent of surgery required, with partial superficial parotidectomy for low-grade tumors and more extensive surgery for high-grade tumors, according to the American Society of Clinical Oncology 2
• Facial nerve management involves preservation when possible, but resection of involved branches when encased by confirmed malignancy, as stated by the American Society of Clinical Oncology 2
• The management of parotid gland lesions requires a multidisciplinary approach involving otolaryngology, radiology, pathology, and dental specialists to ensure comprehensive care and appropriate treatment of both the parotid cystic lesion and any associated conditions 2

Imaging and Biopsy

• Ultrasound is recommended as the first-line imaging modality for parotid swelling, followed by appropriate cross-sectional imaging based on clinical suspicion, with MRI with contrast being preferred for suspected neoplasms and non-contrast CT for suspected sialoliths, according to the American College of Radiology 3
• Core Needle Biopsy (CNB) is recommended when FNAB is inadequate or inconclusive, with a sensitivity for malignancy of 83-91.7% and a positive predictive value of 98.2-100%, as reported by the American Society of Clinical Oncology 2
• Ancillary testing, such as immunohistochemical or molecular studies on biopsy specimens, can support diagnosis and risk assessment, according to the American Society of Clinical Oncology 2
• Pathologists should report risk of malignancy using a standardized scheme, such as the Milan System for Reporting Salivary Gland Cytopathology, as recommended by the American Society of Clinical Oncology 2