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A Middle-aged Woman With Parotid Swelling

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 53-year-old woman presented to the emergency department after awakening with right preauricular and right upper neck swelling. She had a history of coronary artery disease and prior myocardial infarction that was treated with warfarin. She denied any personal or family history of cancer. She was previously briefly a smoker. A physical examination revealed no erythema or tenderness of the parotid. Her cranial nerves were intact, specifically the right facial nerve and its branches. The oral mucosa was intact with no epithelial lesions. Urinalysis results revealed slight hematuria. Her international normalized ratio (INR) was 4.4. Contrast-enhanced computed tomography (CT) revealed an ill-defined infiltrative mass centered in the deep lobe of the right parotid with extension into surrounding soft tissue spaces (Figure, A). A follow-up CT was performed 6 weeks later (Figure, B).

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C. Parotid gland hemorrhage

Swelling of the parotid gland has a broad differential diagnosis, but enlargement from spontaneous bleeding is rare. Etiologies that frequently cause enlargement of the parotid region can be divided into either neoplasms or inflammation. In adult patients, a neoplastic process is generally more likely. Children and young adults have a propensity for infection or other inflammatory pathology.1 Differentiating between benign and malignant parotid gland lesions with imaging can be challenging, as they are often visually indistinguishable. In the early stages of cancer, clinical features, such as pain, fixation, or paralysis, may be absent, especially in low-grade tumors.2 When clinical symptoms do arise, a high-grade infiltrative lesion should be considered.2

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Article Information

Corresponding Author: Barton F. Branstetter, MD, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213 (bfb1@pitt.edu).

Published Online: May 5, 2022. doi:10.1001/jamaoto.2022.0661

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

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