Salivary Gland Disorders
A high-yield ENT lesson on salivary gland disorders spanning obstruction, infection, autoimmune disease, and neoplasia, framed around board buzzwords and next-best-step decisions. Emphasizes submandibular stones, S. aureus parotitis, mumps, the benign-vs-malignant tumor spread, FNA-first workup, and Sjögren-associated MALT lymphoma.
Overview: four buckets and two rules
Salivary gland disorders cluster into four buckets the boards test: obstruction (stones), infection (bacterial, viral), autoimmune disease, and neoplasia. Three paired major glands matter: the parotid (predominantly serous; the facial nerve, CN VII, runs through it; Stensen duct drains opposite the 2nd upper molar), the submandibular (mixed seromucous; Wharton duct drains to the floor of the mouth), and the sublingual (mucous-predominant).
Two rules anchor everything:
- Stones favor the submandibular / Wharton duct — its duct is long and runs uphill against gravity, and its saliva is more alkaline and mucin-rich (higher calcium/phosphate).
- For tumors, the smaller the gland, the higher the chance of malignancy. Most parotid masses are benign, but a minor-gland mass is more often cancer.
A parotid mass with pain or facial-nerve palsy is malignant until proven otherwise.
- Sialolithiasis: postprandial (mealtime) pain + swelling of the submandibular gland; ~80–90% of stones. Confirm with ultrasound or noncontrast CT.
- First-line for stones: hydration, sialagogues (sour/lemon candy), gland massage, warm compresses, NSAIDs; refractory → sialendoscopy/removal.
- Acute bacterial sialadenitis: usually parotid; S. aureus; dehydrated/elderly/post-op/anticholinergic patients. Tender, red gland with pus expressed from Stensen duct → anti-staph antibiotics + hydration + sialagogues.
- Mumps (paramyxovirus): bilateral parotitis, ↑ serum amylase; complications = orchitis (post-pubertal males), aseptic meningitis, pancreatitis, sensorineural deafness; prevented by MMR.
- Ranula = mucocele (mucus extravasation pseudocyst) of the sublingual gland on the floor of mouth; a plunging ranula dips through mylohyoid into the neck. The common oral mucocele occurs on the lower lip.
Vignette: A 50-year-old man has recurrent pain and swelling under the left jaw that worsens with meals and subsides about an hour later. A hard, tender mass is palpable in the floor of the mouth.
- Diagnosis: submandibular sialolithiasis (Wharton-duct stone).
- Next best step: hydration + sialagogues + gland massage/warm compresses (NSAIDs for pain); ultrasound or noncontrast CT confirms the stone.
- Persistent/large stone or superimposed infection → sialendoscopy or surgical removal.
Trap: swelling that comes and goes with eating points to obstruction, not tumor — neoplasms are persistent, painless masses.
Salivary gland tumors compared
| Tumor | Benign / Malignant | Board buzzwords |
|---|---|---|
| Pleomorphic adenoma | Benign — most common overall | Painless, mobile; epithelial + chondromyxoid stroma; recurs if incompletely excised (pseudopods); may transform to carcinoma ex pleomorphic adenoma |
| Warthin tumor | Benign — 2nd most common | Smokers, older men, may be bilateral/multifocal; parotid only; lymphoid stroma; hot on Tc-99m |
| Mucoepidermoid carcinoma | Malignant — most common | Mucinous + squamous cells; commonest parotid & overall salivary cancer |
| Adenoid cystic carcinoma | Malignant | Painful; perineural invasion; "Swiss-cheese"/cribriform; minor glands & submandibular; late lung mets |
Vignette: A 55-year-old has a painless, slow-growing, mobile mass at the angle of the jaw, with no facial weakness.
- Next best step: fine-needle aspiration (FNA) — the initial tissue diagnostic for a salivary mass (imaging with ultrasound/MRI often accompanies it). Do NOT do incisional biopsy (tumor seeding, CN VII injury).
- FNA → pleomorphic adenoma → superficial parotidectomy with facial-nerve preservation (enucleation causes recurrence).
- Contrast case: a firm, fixed, painful mass with facial droop or cervical nodes → assume malignant (mucoepidermoid or adenoid cystic) → parotidectomy + neck dissection ± radiation.
- Frey syndrome (gustatory sweating) is the classic post-parotidectomy complication (aberrant auriculotemporal nerve regeneration) → treat with botulinum toxin.
- Sjögren syndrome: xerostomia + keratoconjunctivitis sicca (dry mouth + dry eyes), bilateral parotid enlargement; anti-Ro/SSA, anti-La/SSB; diagnose with labial (minor) salivary gland biopsy + Schirmer test; major risk of parotid MALT lymphoma.
- Malignancy red flags in any salivary mass: pain, facial-nerve palsy, rapid growth, fixation to skin/deep tissue, cervical lymphadenopathy.
- Initial tissue test for a salivary mass = FNA, never open/incisional biopsy first.
- Necrotizing sialometaplasia: benign, self-healing palatal ulcer that mimics malignancy histologically and clinically — do not over-treat.
- Facial nerve branches through the parotid — "To Zanzibar By Motor Car": Temporal, Zygomatic, Buccal, Marginal mandibular, Cervical (superior → inferior) — the reason parotid surgery risks CN VII.
- Warthin = the "warm" smoker's tumor: smokers, may be bilateral, and lights up ("hot") on technetium-99m scan.
- Adenoid Cystic loves nerves: Around nerves (perineural), painful, cribriform "Swiss-cheese" pattern, late lung mets.
- "Smaller gland → more malignant" — small but deadly.
Next-best-step decision flow
Board decision flow:
- Mealtime pain + swelling? → obstruction (sialolithiasis) → sialagogues/hydration first, image with ultrasound/noncontrast CT.
- Painful, red gland with purulent Stensen-duct discharge in a dehydrated elder? → bacterial parotitis → anti-staph antibiotics + hydration + sialagogues.
- Bilateral parotitis in an unvaccinated child with ↑ amylase? → mumps → supportive care.
- Persistent painless mass? → neoplasm → FNA first, then superficial parotidectomy for benign disease.
- Any pain, facial palsy, or fixation? → assume malignancy and stage.
- Dry eyes + dry mouth + autoantibodies? → Sjögren → lip biopsy; watch for MALT lymphoma.
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