What are the causes and management of a right-sided swollen gland in an elderly patient?

Right-Sided Swollen Gland in an Elderly Patient: Causes and Management

Immediate Diagnostic Approach

A right-sided swollen gland in an elderly patient requires urgent evaluation to exclude malignancy, particularly lymphoma, which is common in this age group and presents with lymphadenopathy as an initial finding. 1

Critical Initial Assessment

The evaluation must focus on:

• Location specificity: Determine if the swelling is cervical lymphadenopathy, parotid/submandibular gland enlargement, or other neck mass 2
• Texture and mobility: Fixed, hard nodes suggest malignancy; mobile, tender nodes suggest infection or inflammation 2
• Associated symptoms: Fever, night sweats, weight loss (B symptoms) indicate lymphoma; pain with eating suggests salivary pathology 3, 4
• Duration and progression: Rapid growth over weeks suggests aggressive lymphoma or infection; chronic swelling suggests benign or indolent processes 2

Differential Diagnosis by Category

Malignant Causes (Highest Priority in Elderly)

• Lymphoma (follicular lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma): The median age of diagnosis for follicular lymphoma is 61 years, with elderly patients commonly presenting with lymphadenopathy 1
• Metastatic carcinoma: Including Merkel cell carcinoma, which can present with regional lymph node involvement in elderly patients 1
• Salivary gland malignancy: Particularly in parotid or submandibular glands 5, 4

Infectious/Inflammatory Causes

• Bacterial sialadenitis: Acute bacterial infection of parotid or submandibular gland, often with purulent drainage from duct 3, 4
• Sialolithiasis with obstruction: Stones causing gland swelling, more common in submandibular gland 3, 5, 4
• Reactive lymphadenopathy: From local infection (dental, pharyngeal, skin) 2
• Sarcoidosis: Can cause bilateral or unilateral salivary gland swelling with cervical lymphadenopathy 6

Autoimmune/Systemic Causes

• Sjögren's syndrome: Chronic autoimmune disease causing salivary gland enlargement, though typically bilateral; can present with unilateral acute sialadenitis 3
• Sialoadenosis: Non-inflammatory gland enlargement associated with metabolic conditions 5

Mandatory Diagnostic Workup

Physical Examination Specifics

• Intraoral examination: Palpate Stensen's duct (parotid) or Wharton's duct (submandibular) for stones, purulent discharge, or masses 5
• Bimanual palpation: Essential for submandibular masses to differentiate gland from lymph node 5
• Complete lymph node examination: Assess all nodal basins bilaterally for generalized lymphadenopathy suggesting systemic disease 1
• Skin examination: Look for primary cutaneous lesions that could represent Merkel cell carcinoma or other skin malignancies 1

Laboratory Investigations

• Complete blood count with differential: Leukocytosis suggests infection; lymphocytosis may indicate CLL 1, 3
• Inflammatory markers: ESR, CRP for systemic inflammation 6
• LDH and β2-microglobulin: Elevated in lymphoma 1
• Autoimmune serologies: If Sjögren's suspected (anti-SSA, anti-SSB) 3

Imaging Studies

• Ultrasound with elastography: First-line imaging for salivary gland pathology and superficial lymph nodes; can differentiate solid from cystic lesions 3, 6
• CT scan with contrast: For neck, chest, abdomen, and pelvis if lymphoma suspected; essential for staging 1
• PET-CT: Reserved for confirmed lymphoma staging or when malignancy strongly suspected 1

Tissue Diagnosis

Histologic confirmation is mandatory when malignancy is suspected. 1

• Excisional lymph node biopsy: Preferred over fine-needle aspiration for suspected lymphoma, as architecture is essential for diagnosis 1
• Core needle biopsy: Acceptable alternative when excisional biopsy not feasible 1
• Fine-needle aspiration: Insufficient for lymphoma diagnosis but may be used for suspected metastatic carcinoma or salivary tumors 1, 5
• Avoid FNA alone: It is insufficient for appropriate lymphoma diagnosis and should not delay definitive biopsy 1

Management Algorithm Based on Etiology

If Lymphoma Confirmed

• Fitness assessment: Use geriatric assessment tools to stratify as fit, vulnerable, or terminally ill 1
• For follicular lymphoma: Asymptomatic patients may undergo watch-and-wait; symptomatic patients require treatment with rituximab-based regimens (dose-reduced bendamustine-rituximab for elderly) 1
• For CLL: Treatment decisions based on Del(17p)/TP53 mutation status; ibrutinib preferred for elderly patients with high-risk features 1

If Salivary Pathology Confirmed

• Acute bacterial sialadenitis: Intravenous antibiotics, gland massage, hydration; may require incision and drainage if abscess forms 3
• Sialolithiasis: Conservative management with massage and hydration; surgical removal if conservative measures fail 3, 5
• Salivary gland tumor: Surgical excision with appropriate margins; parotidectomy for parotid tumors 1, 5

If Reactive/Infectious Lymphadenopathy

• Treat underlying infection: Antibiotics for bacterial causes; observation for viral causes 2
• Re-evaluate in 2-4 weeks: Persistent lymphadenopathy beyond 4-6 weeks requires biopsy 2

Critical Pitfalls to Avoid

• Do not rely on FNA alone for lymph node diagnosis: This is insufficient for lymphoma classification and can delay appropriate treatment 1
• Do not assume benign etiology based on age alone: Elderly patients have higher rates of malignancy, particularly lymphoma 1
• Do not delay biopsy for persistent lymphadenopathy: Nodes persisting beyond 4-6 weeks without clear infectious cause require tissue diagnosis 2
• Do not overlook systemic symptoms: B symptoms (fever, night sweats, weight loss) mandate urgent evaluation for lymphoma 1
• Do not miss intraoral examination: This provides critical information for differentiating salivary gland from lymph node pathology 5