Evaluation and Management of Submandibular Swelling
Initial Assessment
The evaluation of submandibular swelling should begin with a focused examination of the neck and oral cavity to distinguish between enlargement of the submandibular gland itself versus other causes such as lymphadenopathy, infection, or neoplasm. 1
Key History Elements to Obtain:
- Duration and progression of swelling
- Pain characteristics (meal-related pain suggests salivary gland pathology)
- Associated symptoms: fever, dysphagia, odynophagia
- History of recurrent episodes
- Recent dental procedures or infections
- Systemic symptoms (weight loss, night sweats)
- Smoking and alcohol history
Physical Examination:
- Bimanual palpation of the floor of mouth and submandibular region
- Inspection for salivary flow from Wharton's duct
- Assessment of tongue mobility
- Examination of dentition and oral mucosa
- Palpation of all cervical lymph node chains
- Inspection of skin overlying the swelling (erythema, warmth)
Differential Diagnosis
Salivary Gland Causes:
- Sialolithiasis (salivary stones)
- Sialadenitis (acute or chronic)
- Salivary gland tumors (benign or malignant)
- Sialoadenosis (non-inflammatory enlargement)
- Sjögren's syndrome
Non-Salivary Gland Causes:
- Lymphadenopathy (reactive, infectious, malignant)
- Dental infections
- Soft tissue infections (abscess, cellulitis)
- Metastatic disease
- Lymphoma
- Congenital lesions (cysts, vascular malformations)
- Fibrodysplasia ossificans progressiva (rare)
Diagnostic Workup
First-line Imaging:
- Ultrasound is the recommended initial imaging modality for evaluating submandibular swelling due to its high sensitivity, non-invasive nature, and ability to distinguish glandular from extraglandular pathology. 1, 2
Additional Imaging Based on Clinical Suspicion:
- CT scan: For suspected malignancy, deep space infections, or when ultrasound is inconclusive
- MRI: For evaluation of suspected malignancy with perineural spread or deep tissue involvement
- Sialography: For evaluation of ductal anatomy (less commonly used now)
Laboratory Tests:
- Complete blood count: To evaluate for infection or malignancy
- Basic metabolic panel: To assess renal function
- Inflammatory markers (ESR, CRP): If infection or inflammatory condition suspected
Tissue Sampling:
- Fine-needle aspiration (FNA): For evaluation of masses or persistent swelling
- Core biopsy: When FNA is non-diagnostic but malignancy is suspected
Management Algorithm
1. Inflammatory/Infectious Causes:
- For acute sialadenitis: Antibiotics (covering oral flora), hydration, sialagogues (lemon drops), warm compresses, and analgesics 1
- For sialolithiasis:
- Small stones (<5mm): Conservative management with hydration, sialagogues, massage
- Larger stones: Referral for sialendoscopy, lithotripsy, or surgical removal
2. Salivary Gland Tumors:
- For suspected neoplasms: Prompt referral to otolaryngology or oral-maxillofacial surgery for definitive management 1
- Benign tumors: Typically require surgical excision
- Malignant tumors: Multidisciplinary approach with surgery, radiation therapy, and/or systemic therapy based on histology and stage
3. Lymphadenopathy:
- Reactive: Treat underlying cause, observe for resolution
- Infectious: Appropriate antimicrobial therapy
- Suspected malignancy: Referral for biopsy and oncologic evaluation
4. Dental Causes:
- Referral to dentistry for management of dental infections
- Antibiotics if significant infection present
Special Considerations
Red Flags Requiring Urgent Attention:
- Rapidly enlarging mass
- Facial nerve weakness
- Trismus (limited mouth opening)
- Dysphagia or airway compromise
- Constitutional symptoms suggesting malignancy
Follow-up Recommendations:
- Inflammatory conditions: Follow until complete resolution
- After treatment of sialolithiasis: Monitor for recurrence
- Benign tumors: Periodic surveillance after removal
- Malignant tumors: Close follow-up according to oncologic protocols
Common Pitfalls to Avoid
- Mistaking lymphadenopathy for submandibular gland enlargement
- Failing to perform intraoral examination, which may miss stones or ductal pathology
- Attributing chronic or recurrent swelling to infection without investigating for underlying stones or tumors
- Delaying imaging in cases of persistent swelling
- Missing malignancy in patients over 40 years with asymmetric submandibular enlargement 3
By following this systematic approach to evaluation and management, clinicians can effectively diagnose and treat the various causes of submandibular swelling while ensuring timely referral for conditions requiring specialist intervention.