Salivary Gland Swelling

• Clinical Definition: A pathological enlargement of either major or minor salivary gland(s) caused by obstruction, infection, or disease.

• Indicators Requiring Urgent Medical Treatment: High fever and/or sudden development of swelling in the submandibular area that may cause dysphagia (difficulty swallowing), dyspnea (breathing problems) and/or purulent drainage into the mouth.

• Immediate Interventions: Hydration, sialagogues, removal of stones through sialendoscopy, antibiotics (for confirmed bacterial infections) and surgical excision.

• Recovery Pathway: Acute infections typically resolve in 7-10 days if treated promptly. However, obstructive conditions often require mechanical deobstruction to clear the obstruction.

• Asymmetrical Facial and Submandibular Swelling: Visible swelling can be seen anteriorly to the earlobe, under the angle of the jaw (angle of the mandible), or under the floor of the mouth.

• Pain While Consuming Meals: Sharp and aching pain associated with eating or smelling food – particularly foods/liquids that stimulate rapid saliva production and are acidic/sour in nature such as kudampuli (Malabar tamarind) which occurs because the rapid saliva production hits a blocked duct and causes pressure against the ductal walls.

• Xerostomia (Dry Mouth): Persistent sensation of having a dry mouth along with tacky/mucoid surfaces in the oral cavity and inability to swallow dry foods such as banana chips (upperi).

• Bad Taste and Halitosis: Presence of purulent fluid (pus) draining from Stensen’s or Wharton’s duct papilla creates bad metallic/salty taste.

• Tenderness: Palpation shows firmness and heat on the surface of the overlying skin

Emergency medical care is needed if you see one of the following symptoms are seen:  

• Airway compromise: A very swollen submandibular region that is moving upward through the neck and threatening upper airway clearance (Ludwig's angina).

• Severe trismus: Inability to open the mouth normally, restricted to less than two fingers wide (or an interincisal clearance of less than 20 mm).

• Neurologic deficits: Drooping at corner of the mouth or unable to close eye, indicating malignant parenchymal infiltration into the parotid gland.

• Systemic high-grade fever: Body temperatures greater than 38.5 °C (101.3 °F) accompanied with rigors, confusion, and spread of cellulitis in the face.

• Sialolithiasis (salivary calculi): Calcium phosphate stones formed inside saliva ducts that block the lumen. This occurs most often in Wharton's duct due to its thick, alkaline mucin content and anti-gravity path of flow.

• Acute bacterial sialadenitis: Bacteria traveling retrograde into the salivary glands (most commonly Staphylococcus aureus), often caused by poor oral hygiene and/or dehydration.

• Viral parotitis: Contagious systemic viral infections that affect the parotid glands, such as influenza, mumps (paramyxovirus), Epstein-Barr virus, and SARS-CoV-2.

• Mucus extravasation phenomena (mucoceles) and ranulas: Mucus leaking out into surrounding tissues from minor salivary ducts or the floor of the sublingual gland due to micro-trauma.

• Autoimmune sialadenopathy: Chronic lymphocytic destruction of salivary acini resulting from autoimmune disorders such as Sjögren's disease and IgG4-related disease.

Risk factors include:

• Chronic dehydration due to low fluid intake coupled with extreme heat from tropical climates cause the saliva to become extremely concentrated and therefore prone to stagnation.

• The diet and lifestyle traumas caused by frequent eating of hard abrasives found in local snack foods such as hard tapioca chips. The abrasives are known to cause micro trauma to the mucosa adjacent to where the ducts open up and allow saliva to pass through.

• Xerostomia caused by medication including routine use of anti-hypertensive medications, anti-histamines, diuretics and/or anti-cholinergic drugs which will decrease resting salivary flow rates.

• Poorly controlled diabetes mellitus, chronic renal disease or thyroid dysfunction.

• Tobacco smoking and betel nut (paan) chewing cause mucosal hyperkeratosis and fibrosis around the salivary duct orifices, leading to ductal stenosis.

You can perform a relatively safe initial assessment before an appointment using a mirror but you should avoid too much pressure:

• Visual Assessment: Look straight at yourself in a well lit mirror. Check both sides of your facial features and jaw line as well as your neck just below your ear lobes for noticeable asymmetry.

• Inspection of Floor of the Mouth: Lift your tongue against the top of your mouth and look for blue/white, shiny swellings located on either side of the base of your tongue or redness surrounding the papillae under the tongue.

• Light Palpation of External Surfaces: Using your clean fingers, touch your jaw line and the areas underneath your ears. Be aware of any localized swelling, sensitivity, lumpiness or radiating pain.

• Assessing Salivary Output: Dry the interior surface of one of your cheeks with a clean tissue. Biting down lightly on a piece of lemon or thinking about something acidic, observe whether clear saliva droplets fall easily into the cheek pouch.

Important: Do not attempt to remove a suspected salivary gland stone using sharp objects at home.

• Bimanual Palpation: A clinical assessment using bimanual palpation; the clinician has a finger placed both in and around the opening of the mouth that will assess:

  • How large or how small the gland is.

  • If there are any stones.

  • What type of stones (how mobile) they may be.

• Radiographic Diagnosis:

  • High Resolution Ultrasound (HR-Ultrasound)

  • Sialography: X-Ray imaging using water-soluble or oil-based iodinated contrast media as a contrast agent.

  • CT Scan

  • MRI: Preferred modality for differentiating soft tissue from each other, including distinguishing between lesions in the parenchyma, and identifying potential masses located in the deeper portion of the parotid gland.

• Sialendoscopy: Micro-endoscopic procedure to visualize through a submillimeter flexible camera directly into the intra-ductal space.

• Conservative management using a combination of an aggressive oral hydration protocol (2.5-3 liters per day), along with other natural sialagogues (such as sour candies or lemon wedges), can help increase salivary flow and remove any minor obstructions in the ductal system.

• Medications used for treatment include targeted antibiotic use (either orally, such as amoxicillin-clavulanate, or IV), NSAIDs to decrease parenchymal edema, and others as needed based upon patient response and severity of symptoms.

• Endoscopic intervention by way of advanced sialendoscopy is possible through the use of microforceps, wire baskets, or holmium laser lithotripsy to break up and retrieve stones within the ductal system while maintaining the functionality of the gland itself.

• There are several different options available for surgically removing salivary glands. The two most common procedures include simple intra-oral incisions directly over a palpable stone or ranula wall to establish a permanent drainage pathway and complete excision of either the superficial parotid or submandibular glands depending upon the location of the involved gland(s).

The cost for health care services related to the diagnosis and treatment of salivary gland disorders may vary widely due to the large geographic area covered and differences in hospital quality and complexity of procedure. For example:

• Ultrasound/Digital X-rays: ₹1200 - ₹3500.

• Non-contrast head/neck CT scans: ₹4000 - ₹8500.

• In-office sialolith removal: ₹8000 - ₹22000.

• Advanced diagnostic/interventional sialendoscopy: ₹45000 - ₹95000.

• Resection of a major salivary gland (parotidectomy/submandibular gland resection): ₹75,000 - ₹1,80,000.

• Dental Practitioner: The role of a General Dental Practitioner is to be responsible for the initial assessment/screening; basic conservatory treatments; improving oral health through the patient's compliance with oral hygiene instruction and referral mapping.

• Oral and Maxillo-Facial Surgeon (OMFS): OMFS are specialists that perform intra-oral ductal lithotomies, sialendoscopies, ranula marsupializations and resections of the head/neck region.

• Ear, Nose & Throat (ENT) Surgeons (Otorhinolaryngologists): Otorhinolaryngologists specialize in performing endoscopic salivary procedures, complex deep lobe parotid surgery and neck dissections.

• Oral Medicine/Radiology: Oral Medicine/Radiologists provide expert radiographic interpretation, biopsy diagnosis of salivary disease pathology and pharmacologic treatment options for patients suffering from autoimmune conditions affecting their salivary glands.

• Emergency (<2–4 hours): An emergency visit to either the ED or to a maxillo-facial surgeon is required when the swelling compromises airway function (e.g. causing difficulty breathing); impairs ability to swallow liquids; results in high fever; or facial paralysis.

• Urgent (within 24–48 hours): If there is discharge from the duct; significant increasing pain; or rapid increase in size of the painful mass; consultation should occur with either an OMFS or ENT specialist.

• Routine/Elective (within 1–2 weeks): Routine appointments can be scheduled with specialists for the management of intermittent swallowing difficulties during meals; non-symptomatic slowly growing masses/nodules; or recurrent episodes of xerostomia.

1. What causes salivary gland swelling when I am eating something spicy or sour?

Spicy or sour foods cause a massive increase in salivary production. The ducts which lead from the salivary glands may be blocked by a small stone (calculus) or a narrowing of the duct. When this happens, the saliva is unable to drain back into the mouth where it normally would go and instead builds up behind the obstruction, causing an immediate and extremely painful swelling.

2. Do salivary stones dissolve naturally? Do they need to be surgically removed?

Small micro-calculi (< 2 mm) cannot dissolve, but increased saliva flow from hydration, warm compresses, and sour sialagogues generates hydrostatic pressure to flush them out mechanically. Larger calcified stones rarely pass on their own, but they are typically retrieved or broken up using minimally invasive sialendoscopy or extracorporeal shockwave lithotripsy (ESWL) rather than traditional open surgery. 

3. Does all swelling of salivary glands indicate cancer? What other causes could there be for swollen salivary glands?

Over 80% of salivary gland swellings are benign. Most commonly, these swellings are due to a simple blockage of a duct or a localized infection of a bacterium (bacterial infection) or virus (viral illness such as mumps). While less than 20% of salivary gland swellings are malignant, most malignancies appear as slowly growing, firm masses that do not hurt.

• Sjögren’s Syndrome: This is an autoimmune disease that primarily affects exocrine glands. It leads to extreme xerostomia (dryness of the mouth) and keratoconjunctivitis sicca (dryness of the eye).

• Ludwig's Angina: Rapidly developing cellulitis of the floor of the mouth that has been known to occur as a result of untreated dental infections or submandibular infections. In many cases Ludwig's Angina creates a serious risk to the patient's airway.

• Mucoceles and Plunging Ranulas: These are fluid filled cysts resulting from damage to either minor or sublingual salivary ducts. Mucoceles and plunging ranulas have been known to grow into surrounding tissue within the neck.

• Routine Professional Scaling and Optimization of Oral Hygiene: Prevents retrograde infection caused by bacterial growth in the area around the ductal openings.

• Custom Salivary Reservoir Prosthetics: Designed to aid those with permanent xerostomia (severe dry mouth) due to disease.

• Reconstruction of the Salivary Gland Intra-oral Duct With Micro-Stents For Support: Temporary stents are placed into the salivary gland duct opening to maintain its diameter after either a stone has been removed from it or if there was damage during repair.

Salivary gland pathology requires prompt clinical distinction to be made between obstructive, mechanical problems and structural parenchymal disorders. To this end, many of the non-invasive treatments that can be performed on patients with salivary gland pathology help preserve healthy salivary gland tissue, which is important because they will prevent long-term atrophy of their salivary glands. If you have experienced repeated swelling in your jaw or experience discomfort while eating, do not perform heavy massage of your jaw area. Seek out a professional opinion from an Oral and Maxillofacial Surgeon or Ear, Nose & Throat Specialist as soon as possible to obtain diagnostic testing and treatment tailored to your needs.