A 56-year-old man comes to the office for evaluation of a gradually enlarging, painless mass above the right angle of the jaw. He has also recently experienced right-sided facial weakness. When he was in his 20s, the patient had Hodgkin disease that was treated with radiation to the neck. Family history is significant for thyroid cancer in his mother. The patient does not use tobacco, alcohol, or illicit drugs. He had several male and female sexual partners in his 30s but has been sexually active with only one partner for the past 15 years. Vital signs are within normal limits. Physical examination shows a firm, nontender mass in the right parotid gland and weakness of all right-sided facial muscles. Which of the following is most concerning for malignancy in this patient?

Question

A 56-year-old man comes to the office for evaluation of a gradually enlarging, painless mass above the right angle of the jaw.  He has also recently experienced right-sided facial weakness.  When he was in his 20s, the patient had Hodgkin disease that was treated with radiation to the neck.  Family history is significant for thyroid cancer in his mother.  The patient does not use tobacco, alcohol, or illicit drugs.  He had several male and female sexual partners in his 30s but has been sexually active with only one partner for the past 15 years.  Vital signs are within normal limits.  Physical examination shows a firm, nontender mass in the right parotid gland and weakness of all right-sided facial muscles.  Which of the following is most concerning for malignancy in this patient?

Quizplus · Accepted Answer

11ec25c8_d816_9c72_bc81_a5044bb34a87_MD0003_00 This patient has an enlarging parotid gland neoplasm. Most parotid neoplasms are benign, but exposure to radiation, as in this patient, is a significant risk factor for malignant disease. Both the facial nerve (CN VII) and the trigeminal nerve (CN V) are closely associated with the parotid gland. The presence of facial droop (CN VII dysfunction) or facial numbness (CN V dysfunction) is very concerning for neural invasion due to malignant disease. As a result, all patients with parotid masses undergo detailed cranial nerve examination. Imaging (CT or MRI) is typically performed. Ultrasound is often used to enable fine-needle aspiration biopsy. Parotid tumors represent a diverse range of pathologies, including primary parotid neoplasms, lymphomas, or metastases (eg, squamous cell carcinoma, melanoma). Surgical resection with sparing of the facial nerve is typically recommended, with possible additional surgery or adjuvant treatment depending on the final histopathologic diagnosis. (Choice A) Having multiple sexual partners is associated with a risk of infection with human papillomavirus, which is an oncogenic virus implicated in head and neck mucosal squamous cell carcinoma. It is not associated with salivary gland malignancies. (Choice B) Several familial cancer syndromes are associated with thyroid malignancy (eg, multiple endocrine neoplasia), but salivary gland malignancies are not seen in any of them. (Choice C) Pain and firmness (or lack thereof) are not reliable indicators of malignancy in parotid tumors. Pain in benign neoplasms can occur with associated infection, hemorrhage, or cystic enlargement. In malignant tumors, pain usually indicates neural invasion. (Choice D) Most tumors that originate in the parotid gland are benign (>80%) rather than malignant. Neoplasms that originate in the submandibular gland or minor salivary glands have a higher likelihood of malignancy. Educational objective: Parotid masses are typically benign. Cranial nerve dysfunction (facial droop, facial numbness) increases concern for malignancy. References: Salivary gland malignancies. (http://www.ncbi.nlm.nih.gov/pubmed/30449524) Utility of preoperative fine needle aspiration in parotid lesions. (http://www.ncbi.nlm.nih.gov/pubmed/28782105) Parotid gland tumors and the facial nerve. (http://www.ncbi.nlm.nih.gov/pubmed/27040587)

A 56-Year-Old Man Comes to the Office for Evaluation of a Gradually