Bilateral parotid swelling in a young female.

A 17 years female presented with painless progressive swelling of both the parotid regions for last two years. The swelling started first on the left side and within next three months, also appeared on the right side. She also had few episodes of self-limited epistaxis of brief duration during that period. For last few weeks, patient also noticed difficulty in fully opening the mouth and closing the eyes. On examination, both the parotid glands were diffusely enlarged, firm, non-tender with smooth surface, fixed to the surrounding structures, and with out any local signs of inflammation (Fig. 1). Bilateral lower motor neuron type facial palsy was noted; other cranial nerves were normal. Anterior rhinoscopy was inconclusive while posterior rhinoscopy revealed a fleshy, vascular mass in the roof of the nasopharynx with extension to its left lateral wall. Lymph nodes in the cervical region or elsewhere were not palpable. Rest of the examination was normal. Investigations showed anemia (Hb 8.2 gm %) with elevated ESR (86 mm at 1st hour). Renal and hepatic biochemical profile, skull X-ray and CT scan of brain were normal. CT scan of neck showed a large soft tissue mass in the nasopharynx extending downwards and into parapharyngeal spaces, with bilaterally enlarged parotid glands containing multiple heterogeneously enhancing masses inside (Fig. 2). On rhinoscopic biopsy, the mass was diagnosed as nasopharyngeal carcinoma. Ultimately, limited excision biopsy of the parotid gland was undertaken which also revealed poorly-differentiated nasopharyngeal carcinoma metastatic to it (Fig. 3). In metastatic parotid cancer, the primary tumour site is in the mucosal layer of the upper airway or digestive tract in 23%.1 On the other hand, only 1.4% patients of nasopharyngeal carcinoma have parotid involvement.2 Metastatic deposits may directly occur in the parotids, or the gland may be involved by extra capsular spread from enlarged cervical lymph nodes or infiltrated directly by the primary lesion in the nasopharynx.2 In bilateral parotid enlargement, apart from more usual causes, the possibility of metastasis (particularly from upper aero-digestive tract) should also be considered.