Salivary gland disease | Prof. Dr. Alper Tunga Derin

General education only; not a substitute for examination or diagnosis.

What salivary gland disease covers

There are three pairs of major salivary glands: the parotid in front of the ear, the submandibular below the jawbone and the sublingual under the tongue. In addition, hundreds of small (minor) salivary glands line the mouth, palate and throat. The facial nerve, which moves the muscles of the face, runs through the parotid gland, so protecting it is a central goal of parotid surgery.

Salivary stones (sialolithiasis): about 80–90% of stones occur in the submandibular gland; they block the duct and cause meal-related swelling and pain.
Salivary gland inflammation (sialadenitis): may be a bacterial infection linked to dehydration, a stone or duct narrowing, or a viral infection; mumps is the best-known viral cause.
Sjögren syndrome: an autoimmune disease causing dry mouth and eyes and swelling of the salivary glands.
Tumours: most salivary gland tumours arise in the parotid, and most parotid tumours are benign (most often pleomorphic adenoma and Warthin tumour). The proportion of malignant tumours is higher in the submandibular and minor salivary glands.

Symptoms

A swelling in front of the ear, at the angle of the jaw or under the jaw, usually painless and slow-growing.
Swelling and pain that appear during meals and then slowly settle, suggesting a stone or duct blockage.
A painful, red swelling of the gland, a bad taste or pus in the mouth, and fever, suggesting bacterial infection.
Persistent dry mouth and dry eyes.
A lump on the palate or inside the mouth, which may arise from a minor salivary gland.
Weakness or numbness of one side of the face, or limited mouth opening.

When to see a doctor

Situations that need emergency care

A rapidly growing painful swelling with fever, swelling of the floor of the mouth, the tongue being pushed up, or difficulty swallowing or breathing may signal an abscess or deep neck infection and need emergency care.
Sudden weakness of one side of the face needs urgent assessment to rule out other causes, including stroke.
Rapidly increasing swelling of the neck or face, bleeding or breathlessness after surgery.

Situations that need a planned appointment

Any parotid or under-jaw swelling that does not go away within a few weeks.
Rapid growth, pain, hardness, fixation to surrounding tissues, overlying skin changes or facial weakness; these signs should be assessed for malignancy without delay.
Recurrent meal-related swelling or repeated gland infections.
Persistent dry mouth and dry eyes.

Many salivary gland swellings have benign causes, but they can only be told apart by examination and tests. A definite diagnosis and treatment decision are made after examination.

How it is diagnosed

At examination the glands are felt from inside and outside the mouth, the saliva coming from the duct opening is inspected, and each branch of the facial nerve is tested.

Ultrasound: usually the first imaging test; it helps distinguish stones, cysts and masses.
Ultrasound-guided fine-needle aspiration (FNA): results are reported using the international Milan reporting system, which links each diagnostic category to a defined risk of malignancy and a recommended management approach.
If FNA is inadequate, a core-needle biopsy can be done; open (incisional) biopsy of the major glands is generally avoided because of the risk of spilling tumour cells.
MRI and/or CT: show tumour extent, deep-lobe involvement and suspected spread along nerves; CT also helps assess stones and bone. PET-CT may be considered in advanced, high-grade malignant tumours.
If Sjögren syndrome is suspected, blood tests, eye tests and, when needed, a biopsy of the minor salivary glands of the lip are performed.

Clinical exam of the parotid region (stock).

Treatment options

Conservative treatment and medicines

For stones and inflammation, plenty of fluids, warm compresses, gland massage, sour sweets or lemon to stimulate saliva, and painkillers are advised; antibiotics are given for bacterial infection.
Mumps is managed with supportive care; Sjögren syndrome is followed together with rheumatology, with saliva substitutes and careful dental care for dry mouth.

Minimally invasive procedures

Sialendoscopy: a thin endoscope is passed into the duct to remove small stones and widen narrowed ducts; it is usually not done during acute inflammation. Larger stones may be treated with combined approaches such as opening the duct through the mouth or stone fragmentation.
Submandibular gland excision: used when stones or recurrent infection cannot be resolved by other methods, or for tumours of this gland.

Tumour surgery

For benign parotid tumours, complete removal is recommended; depending on site and size, partial, superficial or total parotidectomy is performed. Simply shelling out the lump is not recommended because of the risk of recurrence.
The facial nerve is identified and preserved throughout the operation; intraoperative nerve monitoring may be used to track it.
Surgery is the main treatment for malignant tumours. According to the 2021 ASCO guideline, the facial nerve is preserved if it works before surgery and can be separated from the tumour; involved branches are removed if the nerve is encased by tumour or already weak. For T3–T4 or high-grade tumours, elective treatment of the neck (usually neck dissection) is recommended even if the neck appears normal.
Postoperative radiotherapy is recommended for high-grade tumours, positive margins, perineural invasion, lymph node involvement, lymphovascular invasion, T3–T4 tumours and adenoid cystic carcinoma. In recurrent or metastatic disease, targeted drugs may be considered based on the tumour's molecular features.

Before and after surgery

An anaesthetic assessment is carried out before surgery, and blood thinners are adjusted only on the advice of the treating physician. Possible risks are discussed in detail beforehand.

There is usually a small drain in the wound, which is mostly removed within one or two days; many people return to their usual activities in about two weeks.
Temporary facial weakness can occur and may take a few months, sometimes up to a year, to recover; permanent weakness is less common, and the risk depends on tumour site and size and is higher for deep-lobe tumours.
Numbness of the earlobe and surrounding skin is common and often lessens over time.
Frey syndrome (sweating and flushing of the cheek skin while eating) can appear months after surgery; pain with the first bite of a meal can also occur.
A collection of saliva or blood under the wound, or a salivary leak (fistula), can develop; most settle with simple measures.
Rapidly increasing swelling, bleeding, fever, or redness and discharge from the wound should be reported at once.

Follow-up

Follow-up depends on the type of disease. After treatment of stones or infection, recurrence of symptoms is reassessed. For benign tumours, the pathology result and wound healing are checked; because pleomorphic adenoma can recur years later, long-term follow-up may be advised.

For malignant tumours, regular oncological follow-up including examination and imaging is carried out, and facial nerve function, dry mouth and late effects of radiotherapy are also monitored.

Frequently asked questions

No. Most parotid tumours are benign, the most common being pleomorphic adenoma and Warthin tumour. Still, every lump needs assessment, because they can only be told apart by examination, ultrasound and needle biopsy.

Fine-needle aspiration is the first-line diagnostic test recommended by guidelines for salivary gland lumps. Open (incisional) biopsy of the major glands, by contrast, is generally avoided because of the risk of spilling tumour cells.

Temporary facial weakness can occur after surgery and often recovers within months. Permanent weakness is less common, and the risk depends on the tumour's site, size and type. Every effort is made to preserve the nerve during the operation.

Although pleomorphic adenoma is benign, it can keep growing and, rarely, undergo malignant change over many years. Complete surgical removal is therefore usually recommended; the decision takes age, general health and personal preference into account.

Small stones may pass with plenty of fluids, massage and measures that increase saliva flow. Stones that do not pass or keep recurring may need sialendoscopy or combined procedures; gland removal is mainly considered when these approaches are not enough.

Sources

The general information on this page is based on the guideline and institutional sources below. Individual diagnosis and treatment decisions require an examination.

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