What is the best course of action for a patient with a history of Human Papillomavirus (HPV) presenting with continuous swelling of the left submandibular gland?

Continuous Swelling of Left Submandibular Gland in HPV Patient

Obtain urgent imaging with contrast-enhanced CT or ultrasound followed by fine-needle aspiration biopsy to rule out malignancy, as persistent submandibular swelling requires tissue diagnosis regardless of HPV status. 1, 2

Initial Diagnostic Approach

The continuous nature of this swelling mandates aggressive workup, as submandibular masses have diverse etiologies ranging from benign inflammatory conditions to malignancy. 2

Key diagnostic steps:

• Perform intra-oral inspection and bimanual palpation to differentiate between submandibular gland enlargement versus lymphadenopathy, and assess for floor-of-mouth masses that may cause gland obstruction 2

• Order contrast-enhanced CT imaging as the initial radiologic study, which can identify discrete nodules, masses, necrotic lymph nodes, or glandular pathology 1

• Arrange fine-needle aspiration (FNA) biopsy for any discrete mass or persistently enlarged gland, as this is essential for definitive diagnosis 1, 2

HPV-Specific Considerations

While HPV primarily affects anogenital and oropharyngeal mucosa, the patient's HPV history raises specific concerns: 3, 4

Critical points regarding HPV and head/neck involvement:

• HPV-associated head and neck cancers typically manifest in the oropharynx (tonsils, base of tongue), not the submandibular gland itself 1, 4

• Submandibular lymph nodes can harbor metastatic HPV-positive oropharyngeal squamous cell carcinoma, which would present as a firm, possibly necrotic node rather than diffuse gland swelling 1

• Direct HPV infection of salivary glands is not a recognized clinical entity - HPV causes mucosal lesions (warts, papillomas, dysplasia, carcinoma) but not primary salivary gland disease 1, 3

Differential Diagnosis to Exclude

Malignant causes requiring urgent diagnosis:

• Metastatic HPV-positive oropharyngeal cancer to submandibular lymph nodes (would show necrotic node on imaging with intense FDG uptake if PET performed) 1

• Primary salivary gland malignancy (mucoepidermoid carcinoma, adenoid cystic carcinoma, acinic cell carcinoma) 2

• Floor-of-mouth squamous cell carcinoma causing submandibular duct obstruction 2

Benign causes (still require confirmation):

• Chronic sialoadenitis from sialolithiasis (stone obstruction) 2

• Sialoadenosis (non-inflammatory gland enlargement from metabolic conditions, eating disorders) 2

• Pleomorphic adenoma (benign salivary tumor) 2

Imaging Interpretation

On contrast-enhanced CT, assign high suspicion (NI-RADS 3) and recommend biopsy if: 1

• New or enlarging discrete nodule with intense enhancement
• Necrotic lymph node (indicates possible metastatic disease)
• Any morphologically abnormal node (loss of fatty hilum, rounded shape, extranodal extension)

Management Algorithm

Step 1: Obtain contrast-enhanced CT of neck with attention to submandibular region 1

Step 2: If discrete mass or abnormal lymph node identified → proceed directly to ultrasound-guided or CT-guided FNA biopsy 1, 2

Step 3: If diffuse gland enlargement without discrete mass → perform intra-oral examination for stone palpation in Wharton's duct, and consider sialography or MR sialography 2

Step 4: Regardless of imaging findings, if swelling persists beyond 2-3 weeks without clear benign etiology → obtain tissue diagnosis via FNA or excisional biopsy 2

Critical Pitfalls to Avoid

• Do not assume HPV history explains submandibular swelling - HPV does not cause primary salivary gland disease 1, 3

• Do not delay biopsy based on patient age or lack of risk factors - malignancy can occur at any age 2

• Do not confuse submandibular gland enlargement with lymphadenopathy - bimanual palpation and imaging are essential to distinguish these 2

• Do not miss floor-of-mouth primary tumors that can cause secondary gland obstruction and swelling 2

Concurrent HPV Management

While evaluating the submandibular swelling: 5

• Ensure cervical cancer screening is current if patient is female (annual Pap smears recommended for those with STD history) 1

• Perform thorough oropharyngeal examination to exclude concurrent HPV-related mucosal lesions 1

• Document any visible genital warts and treat with cryotherapy or patient-applied therapies as appropriate 5