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

Submandibular Gland Swelling in HPV Patient: Diagnostic and Management Approach

Obtain urgent contrast-enhanced CT or ultrasound of the neck followed by fine-needle aspiration biopsy to rule out malignancy, as HPV does not cause primary salivary gland disease and persistent submandibular swelling requires exclusion of other pathology. 1

Critical Initial Understanding

• HPV does not cause submandibular gland pathology. The American Academy of Otolaryngology-Head and Neck Surgery clearly states that HPV-associated head and neck cancers typically manifest in the oropharynx, not the submandibular gland itself. 1
• Your patient's HPV history is likely unrelated to the submandibular swelling and should not delay appropriate workup. 1

Immediate Diagnostic Algorithm

Step 1: Imaging

• Obtain contrast-enhanced CT of the neck with specific attention to the submandibular region as the initial imaging modality. 1
• Alternative: Ultrasound followed by fine-needle aspiration if CT is contraindicated. 1

Step 2: Interpret Imaging for High-Risk Features

The American College of Radiology assigns high suspicion (NI-RADS 3) requiring biopsy if any of the following are present: 1

• New or enlarging discrete nodule with intense enhancement
• Necrotic lymph node
• Any morphologically abnormal node

Step 3: Tissue Diagnosis

• Proceed directly to fine-needle aspiration biopsy for any suspicious findings on imaging. 1
• Diagnosis of submandibular lumps is usually straightforward using history, examination, fine-needle aspiration, and radiological examination. 2

Differential Diagnosis to Consider

The most common causes of submandibular swelling include: 2, 3

• Chronic sialoadenitis due to sialolithiasis (stone obstruction)
• Sialoadenosis (non-inflammatory enlargement)
• Benign neoplasm (pleomorphic adenoma most common)
• Malignant neoplasm (either primary salivary gland tumor or metastatic disease)
• Enlarged lymph node (can be difficult to differentiate from gland enlargement)

Key Clinical Examination Points

• Perform intra-oral inspection and bimanual palpation of the submandibular gland to differentiate gland enlargement from lymphadenopathy. 2
• Palpate for stones in Wharton's duct opening at the floor of mouth. 2
• Complete oropharyngeal examination to exclude concurrent HPV-related mucosal lesions, though these would not explain the submandibular swelling. 1

Management Based on Diagnosis

If Inflammatory (Sialoadenitis/Sialolithiasis):

• Acute suppurative sialadenitis: antibiotics, salivary massage, hydration, and sialagogues (lemon drops or vitamin C lozenges). 3
• Chronic/recurrent inflammation: management directed at relieving obstruction. 3

If Neoplastic:

• Most salivary gland tumors are benign and treated with surgical excision. 3
• Malignant tumors require oncologic surgical management. 3

Concurrent HPV Management Considerations

While addressing the submandibular swelling, ensure appropriate HPV-related care:

• For female patients: Ensure cervical cancer screening is current with annual Pap smears, as patients with history of STDs are at increased risk. 4
• Examine for oral HPV lesions during oropharyngeal examination, including verruca vulgaris, condyloma acuminatum, or squamous papilloma, though these are distinct from the submandibular pathology. 4, 5

Critical Pitfalls to Avoid

• Do not assume HPV history explains submandibular swelling – this delays appropriate diagnosis of the actual pathology. 1
• Do not confuse submandibular gland enlargement with lymphadenopathy – careful bimanual palpation is essential. 2
• Do not delay imaging and biopsy in persistent swelling, as malignancy must be excluded. 1