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Clinical Challenge
August 2017

Diffuse Parotid Swelling From an Underlying Parotid Mass in a Pediatric Patient

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Rady Children’s Hospital San Diego, University of California–San Diego
JAMA Otolaryngol Head Neck Surg. 2017;143(8):835-836. doi:10.1001/jamaoto.2016.4502

A 4-year-old white girl presented with left jaw pain and signs and symptoms of an upper respiratory tract infection. Her medical history included recurrent acute otitis media requiring tympanostomy tube placement. On physical examination, the left parotid gland was diffusely full and firm, which was consistent with viral parotitis. Gland massage, warm compress, sialagogues, and increased hydration were recommended. At the 2-week follow-up, the swelling had largely resolved with a now-firm, slightly mobile, subcentimeter mass palpable in the anterior parotid gland. Four days later the mass enlarged and became painful. A magnetic resonance imaging (MRI) study identified a 1.2 × 1.7 × 1.6-cm solid mass in the anterior parotid gland with well-defined borders and indention into the masseter muscle. The mass was isointense to muscle on T1, hyperintense on T2, with strong contrast enhancement, heterogeneous internal enhancement and a central focal area of hypointensity (Figure, A). The patient underwent a left superficial parotidectomy. Grossly the lesion was nonencapsulated, firm, dark colored, and was located within the anterior superficial lobe of the parotid gland. Microscopically, the tumor was composed of spindle cells with elongated nuclei in a storiform pattern embedded in moderately dense admixed lymphohistiocytic infiltrate with no atypia (Figure, B). Immunohistochemical analysis (IHC) was positive for activin-like kinase-1 (Alk-1) (Figure, C), vimentin, CD68, and factor XIIIa, and negative for smooth muscle actin (SMA), desmin, cytokeratin, and CD34.