Introduction
Most of the world’s people live in developing countries, and 85% will reside in developing countries by 2030; the world has witnessed a mass migration of refugees from developing countries to Western Europe in recent years; and many surgeons are engaged in surgical outreach programs to developing countries. For all these reasons, a textbook about salivary disease would be incomplete without providing a developing world perspective.
Infectious diseases such as human immunodeficiency virus (HIV) and tuberculosis must always be considered in the differential diagnosis of salivary disease, especially in developing countries. Patients in developing countries also commonly present with advanced tumors due to poor access to medical care ( Fig. 55.1 ). Management algorithms in developing countries must be adapted to the availability of imaging, cytology, histopathology, surgery, and radiation therapy. A survey in 2015 of ear, nose, and throat (ENT) services in 22 sub-Saharan African countries revealed that radiotherapy was rarely or not available in 68% and that parotidectomy was rarely or not available in 29% of the countries surveyed. This is not surprising, as there were only about 15 fellowship-trained head and neck surgeons for 1 billion people in sub-Saharan Africa in 2018. Perhaps the most difficult task for surgeons and oncologists working in an overburdened service with limited resources is to decide who to deny curative treatment, in the face of limited treatment capacity.
Salivary Disease of Developing World Interest
Human Immunodeficiency Virus
Many developing countries, especially in sub-Saharan Africa, have a high prevalence of HIV. Approximately 1–10% of HIV patients have salivary gland enlargement. Because HIV has many salivary gland manifestations, it must be considered in the differential diagnosis of patients presenting with salivary gland pathology ( Box 55.1 ).
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Intraparotid lymphadenopathy
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Lymphoepithelial cysts
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Lymphoid hyperplasia
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Diffuse infiltrative lymphocytosis syndrome
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Benign lymphoepithelial lesions
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Sicca syndrome
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Parotitis secondary to infection
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Cryptococcus infection
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Kaposi sarcoma
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Lymphoma
Benign lymphoepithelial cysts are the most common salivary pathology associated with HIV and are an early indicator of HIV infection ( Fig. 55.2A ). HIV-related lymphoepithelial cysts are of gradual onset, painless and, unlike non-HIV-related parotid cysts, are typically multiple, bilateral, and associated with cervical lymphadenopathy ( Fig. 55.2B ). Two hypotheses for development of lymphoepithelial cysts are: (1) that lymphoid proliferation within the parotid gland causes ductal obstruction and dilatation; or (2) that parotid glandular epithelium becomes entrapped within parotid lymph nodes, resulting in cystic enlargement. When the clinical diagnosis is in doubt, fine needle aspiration cytology (FNAC) may be employed to rule out other causes of parotid lesions. The aspirate typically yields straw colored or turbid fluid. Microscopy findings are nonspecific and reveal a triad of cyst contents (i.e., heterogeneous lymphoid cells and squamous and/or glandular cyst lining); these findings, however, overlap with several other conditions. The cysts are generally responsive to antiretroviral drugs. Only when unresponsive or when a patient cannot be treated with antiretroviral drugs and is concerned about cosmesis is alcohol sclerotherapy indicated. Superficial parotidectomy is only very rarely required.
