Family Medicine Residency, Offutt Air Force Base, Neb (Dr. Bryce); Family Medicine Residency, Naval Medical Center Camp Lejeune, NC, and Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (Dr. Ewing); Family Medicine Residency, The University of North Carolina, Chapel Hill (Drs. Waldemann and Mounsey); Department of Otolaryngology/Head and Neck Surgery, The University of North Carolina, Chapel Hill (Dr. Thorp) Anne_mounsey@med.unc.edu
The authors reported no potential conflict of interest relevant to this article.
What is the diagnostic strategy? Three-quarters of patients present with a neck mass from lymph-node metastases. Patients with the risk factors for nasopharyngeal cancer noted above who present with concerning symptoms should have nasoendoscopy with biopsy.
How is it treated? Radiation is the primary treatment, which is combined with chemotherapy for more advanced disease.23 Screening high-risk populations for antibodies to Epstein-Barr virus and performing nasopharyngeal endoscopy on patients who screen positive increases the detection rate of nasopharyngeal cancer; however, this strategy has not been shown to improve survival.9
Salivary gland tumors
What you need to know. Salivary gland neoplasms are a rare and heterogeneous entity, comprising 6% to 8% of head and neck cancers.24 More than 70% of these tumors are located in the parotid gland; 8%, in the submandibular glands; 1%, in the sublingual glands; and the rest, in the minor salivary glands. Most salivary gland tumors are benign; the most prevalent malignant tumors are mucoepidermoid carcinoma (30%) and adenoid cystic carcinoma (10%).25 Additional identified risk factors for a salivary gland tumor include irradiation, prior head and neck cancer, and environmental exposures, including hairdressing, rubber manufacturing, and exposure to nickel compounds.26
What is the diagnostic strategy? The history and physical exam are essential to distinguish a salivary gland tumor from an infectious cause and sialolithiasis. Parotid tumors most commonly present as asymptomatic parotid swelling, although pain can be present in as many as 40% of malignant parotid tumors.25 Facial nerve weakness is found in 25% of parotid tumors; although the differential diagnosis of facial nerve palsy is broad, suspicion of malignancy should be raised in the presence of a parotid mass, progressive unilateral symptoms, hemifacial spasm progressing to weakness, and a history of skin cancer on the face or scalp. Additional characteristics that favor a neoplastic cause are trismus and nontender lymphadenopathy.25
In a series of 100 patients with head and neck cancer, a delay in diagnosis occurred in nearly 25%—most often because of time spent providing inappropriate antibiotic treatment.
In contrast, sialolithiasis is associated with intermittent pain caused by eating and is more common in the settings of dehydration and poor dental hygiene. Sialadenitis should be suspected when the presentation is fever, increased pain and swelling, erythema, and expression of pus from the salivary gland.
