Does a 69-year-old male with an enlarged left submandibular gland, heterogeneous appearance on ultrasound, and multiple subcentimeter lymph nodes require further monitoring?

Management of Enlarged Submandibular Gland with Heterogeneous Appearance

Further evaluation with fine-needle aspiration (FNA) is strongly recommended for this 69-year-old male with an asymmetrically enlarged left submandibular gland showing heterogeneous appearance and increased vascularity on ultrasound.

Clinical Assessment of the Findings

The ultrasound findings in this case reveal several concerning features:

• Significant size discrepancy between the glands (left: 4.6 x 2.7 x 1.7 cm vs. right: 3.5 x 2.5 x 1.3 cm)
• Heterogeneous appearance of the anterior portion of the left gland
• Increased vascularity in the affected area
• Multiple subcentimeter lymph nodes in bilateral neck

Risk Assessment

These findings raise concern for potential neoplastic processes. While the differential diagnosis is broad, the combination of:

• Heterogeneous echotexture
• Increased vascularity
• Presence of multiple neck lymph nodes

Warrants further diagnostic evaluation rather than simple observation.

Diagnostic Algorithm

1. Fine-needle aspiration (FNA) of the left submandibular gland

   • FNA is the next appropriate step to establish a tissue diagnosis
   • This is particularly important given the heterogeneous appearance and increased vascularity 1

2. Evaluation of regional lymph nodes

   • The presence of multiple subcentimeter lymph nodes requires assessment
   • If any lymph nodes are clinically concerning or enlarge during follow-up, ultrasound-guided FNA should be performed 2

3. Consider cross-sectional imaging

   • If FNA results are inconclusive or suggest malignancy, MRI or CT would be appropriate for complete staging and surgical planning 2

Rationale for Recommendation

The American College of Radiology considers concerning features of lymph nodes to include heterogeneous internal architecture, abnormal enhancement patterns, and increased vascularity 1. The patient's submandibular gland demonstrates heterogeneity and increased vascularity, which are concerning features that warrant tissue diagnosis.

While many submandibular swellings are benign, the combination of:

1. Advanced age (69 years)
2. Unilateral enlargement
3. Heterogeneous appearance
4. Increased vascularity

Creates sufficient concern to recommend definitive tissue diagnosis rather than observation alone.

Important Considerations

• Submandibular gland involvement in head and neck carcinomas typically occurs through direct extension from a primary tumor or from locally involved lymph nodes rather than through intraglandular metastasis 3, 4
• Studies have shown that the submandibular gland itself does not contain intraglandular lymph nodes, making primary lymphatic metastasis to the gland unlikely 4
• However, primary salivary gland malignancies can arise within the submandibular gland itself and require prompt diagnosis and treatment

Follow-up Recommendations

If FNA is negative or inconclusive but clinical suspicion remains:

• Repeat ultrasound in 3 months to assess for interval change
• Consider surgical excision for definitive diagnosis if uncertainty persists

If FNA confirms malignancy:

• Prompt referral to head and neck surgery for definitive management
• Complete staging with cross-sectional imaging (MRI or CT) of the neck and chest

Pitfalls to Avoid

1. Mistaking reactive lymphadenopathy for primary gland pathology

   • Careful evaluation of the relationship between lymph nodes and the gland is essential

2. Delaying diagnosis based on normal-appearing lymph nodes

   • Even with subcentimeter lymph nodes, the heterogeneous gland appearance warrants investigation

3. Relying solely on size criteria

   • The heterogeneous appearance and increased vascularity are more concerning than size alone

4. Assuming benign etiology based on duration of symptoms

   • Even slow-growing masses can represent malignancy, particularly in older patients

In conclusion, this patient's findings cannot be dismissed as normal variation or benign pathology without further investigation. The heterogeneous appearance with increased vascularity in an asymmetrically enlarged submandibular gland requires tissue diagnosis to rule out malignancy.