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SALIVARY GLAND SWELLINGS AND HIV DISEASE
The clinician faced with HIV disease is presented with a multitude of symptoms involving virtually all body systems. Inevitably, the Salivary Gland Center (SGC) has observed painless persistent slow growing soft parotid gland swellings, usually bilateral and associated with cervical lymphadenopathy, in about 5% of HIV positive patients who do not have clinical AIDS. With the passage of time, the usual life-threatening complications can be expected.
The parotid swellings usually represent the presence of multiple lymphoepithelial cysts whose pathogenesis is of interest. During embryologic development, 5 to 10 lymph nodes are trapped within the parotid gland. Enmeshed within these intraparotid nodes is salivary gland tissue. Conversely, submandibular nodes are extraglandular in location and devoid of glandular tissue.
With lymphoidal tissue vulnerable to HIV infection, lymphoproliferative involvement of the intraparotid lymph nodes takes place. Concurrently, intranodal epithelial proliferation with cyst formation ensues. The epithelial proliferation originates from the activity of the embryologically included glandular epithelium. Histologically, the cyst wall contains countless lymphocytes reflecting the remnants of the pre-existing intraparotid lymph node. Parenchymal infiltration by lymphocytes is also seen. It results from normal lymphoproliferative infiltration and spillage of lymphocytes from ruptured nodal walls. Progression of this lymphoidal condition to malignant lymphoma is a distinct possibility requiring constant patient monitoring.
Early clinical recognition of parotid swellings is important because it may represent the first clinical manifestation of HIV disease. Imaging procedures (CT, MRI, ultrasound) play a significant role in prompt diagnosis. The multiple cysts, measuring 0.5 to 5.0 cm, are readily visualized. The SGC recommends ultrasound as the most simple, rapid and cost effective means of diagnosing the presence of these lymphoepithelial cysts.
Treatment has only recently been defined. Initially, observation is an accepted modality. Parotidectomy is performed when the clinical picture and/or periodic fine needle aspirations indicate malignant lymphoma. Occasionally, cosmetic requirements mandate intervention. Cystic fluid aspirations to shrink the parotid swelling, followed by low dosage radiation, have met with some success.
Louis Mandel DDS Director, Salivary Gland Center (212) 305-9982 |