14. Salivary Gland diseases case 2_integrated

Clinical Case Discussion Of Asymptomatic Mucosal Swelling

Patient Presentation and History¹

A 40-year-old male presented with an asymptomatic mucosal swelling. The patient was unaware of the lesion’s presence; it was discovered coincidentally during a routine dental examination.

• Medical History: Non-contributory.
• Social History:
  • Smoker for 10 years (15 cigarettes per day).
  • Consumes 2 alcoholic drinks per day.

Case Description and Patient History

Clinical Case Activity

1. Identify the pathosis and describe the clinical features.

Identification:

• The lesion is a red abnormality located on the palate.
• It is a solitary, asymptomatic lesion.

Clinical Description:

• Elevation: It is a raised, slightly elevated lesion (a lump).
• Consistency: It is a solid lesion rather than fluid-filled.
• Margins: It is well-defined.
• Symptoms: The patient was unaware of it; it is asymptomatic with no ulceration.
• Location Context: There are many minor salivary glands under the palatal mucosa in this area.

2. What is the differential diagnosis?

• Salivary Gland tumour such as pleomorphic adenoma or mucoepidermal carcinoma
  • Minor salivary gland tumors (e.g., Pleomorphic adenoma).
  • Warthin tumor (though noted as less common in this presentation).
  • Malignant salivary gland tumor (noting that these can be misleadingly well-defined and slow-growing).
• pyogenic granuloma
• Fibroepithelial polyp
  • Note: Though the lesion is not pedunculated.
• Squamous cell carcinoma
• Vascular/Red Lesions:
  • Erythroplakia (less likely because erythroplakia is a red patch, whereas this is a raised lump).
• Reactive/Inflammatory Lesions:
  • Thermal burn (less likely as there is no edema or pain).

Excluded Diagnoses:

• Lichen Planus: Ruled out because lichen planus presents as reticular or “cobblestone” patterns and is not typically a raised lump.
• Mucocele: Ruled out because the lesion is solid, whereas a mucocele is fluid-filled.

3. What are the relevant clinical investigations?

most common locations for salivary gland tumours are upper lip and palate:

• we want to do an incisional biopsy because:
  • a benign salivary gland tumour has a very different excision than a malignant one
  • This is the preferred investigation to determine if the lesion is benign or malignant, as this dictates the surgical approach.
• histology:
  • cellular pleomorphism
  • hyperchromatism , dark staining
  • mucin collections
  • mucoepidermal tumour characteristics
  • Examination for duct-like structures and cystic spaces containing mucin.
  • Special staining to differentiate cell types.
  • low grade:
    • theres more mucin, which means its still well-differentiated
  • Assessment for invasion of bone or other structures.

4. What is the diagnosis?

• Mucoepidermoid Carcinoma:
  • The lesion is identified as a malignant salivary gland tumor.
  • Histological features: Presence of cystic components, epithelial cells, and mucin.
  • Grading: Can range from low-grade (better prognosis, more mucin) to high-grade (poor prognosis, less differentiation).

5. How would you manage this patient?

• Surgery: The primary treatment is surgical excision.
• Surgical Planning: The extent of the excision depends on whether the biopsy shows a benign or malignant process.
• Adjunctive Therapy: Post-operative radiation may be used for more advanced cases, such as those with bone invasion or tumor spread.

Footnotes

1. Original PDF page 1: 14. Salivary gland disease case 2, p.1 ↩