What are the causes and treatments for an enlarged salivary gland?

Enlarged Salivary Gland: Causes and Treatment

An enlarged salivary gland requires immediate clinical assessment to distinguish between infectious, obstructive, inflammatory, and neoplastic causes, with treatment ranging from conservative management for benign conditions to surgical excision for tumors.

Diagnostic Evaluation

Initial Clinical Assessment

• Examine for signs of malignancy: facial nerve paralysis, trismus, skin infiltration, rapid growth, pain, and fixation to surrounding structures 1
• Palpate the gland and neck: assess size, consistency, mobility, tenderness, and cervical lymphadenopathy 1
• Perform bimanual palpation for submandibular glands to detect stones 2
• Check for systemic disease: bilateral painless enlargement suggests sialadenosis from metabolic disorders, malnutrition, or chronic illness 3, 4

Imaging Studies

• Order CT scan with contrast or high-resolution ultrasound as the standard imaging for all salivary gland enlargements 1
• Use ultrasound first for suspected stones (sensitivity for submandibular stones >80%) and to differentiate solid from cystic masses 2, 5
• Consider MRI when evaluating for perineural spread, skull base invasion, or better soft tissue characterization 1
• Obtain chest CT if malignancy is suspected to evaluate for distant metastases 1

Tissue Diagnosis

• Perform fine-needle aspiration cytology for preoperative diagnosis of suspected neoplasms 1, 5
• Proceed directly to excisional biopsy with frozen section for major salivary gland tumors rather than incisional biopsy 1
• Use simple biopsy for minor salivary gland lesions 1

Common Causes and Specific Treatments

Acute Bacterial Sialadenitis

• Treat with antibiotics covering Staphylococcus aureus (most common pathogen), salivary massage, aggressive hydration, and sialagogues like lemon drops or vitamin C lozenges 5, 4
• Optimize oral hygiene and address predisposing factors (dehydration, medications causing xerostomia) 4
• Apply warm compresses to affected gland 4

Obstructive Disorders (Sialolithiasis)

• Remove stones surgically through intraoral approach when located in the submandibular duct, with technique determined by stone size and location 2
• Consider sialendoscopy as a gland-sparing technique for both stone removal and duct strictures 4
• Provide post-procedure care: rinse with 0.1% chlorhexidine solution for 1 minute after procedure and daily during healing, avoid spicy/acidic/hot foods 2

Viral Sialadenitis

• Treat the underlying viral infection (mumps, HIV) with supportive care; no specific salivary gland intervention needed 5

Chronic/Recurrent Inflammatory Conditions

• Manage conservatively with hydration, sialagogues, massage, and medication adjustment 4
• Consider sialendoscopy for recurrent parotitis of childhood and chronic sialadenitis 4

Neoplasms (Benign and Malignant)

Stage I Tumors (T1a, T2a, N0, M0)

• Perform complete surgical excision: remove entire gland for major salivary gland tumors; perform wide radical resection for minor salivary gland tumors 1
• Do NOT perform routine neck dissection for low-grade stage I tumors 1
• Avoid adjuvant radiotherapy if resection is macroscopically and microscopically complete, even for high-grade tumors 1
• Add postoperative radiotherapy with photons (±electrons) if excision is incomplete or tumor at margins 1

Advanced Stage Tumors (Stage II-IV)

• Combine surgery with postoperative radiotherapy for all stage II, III, and IV high-grade tumors 1
• Add radiotherapy for low-grade stage III and IV tumors 1
• Perform ipsilateral neck dissection for T2a high-grade tumors (standard) and consider for T1a tumors 1
• Use neutron therapy alone for inoperable tumors regardless of stage and grade 1

Surgical Principles

• Never preserve nerves at the expense of tumor clearance 1
• Excise outside the capsule for encapsulated tumors 1
• Stage using TNM AJC/UICC classification and histological grade (low vs high) 1

Sialadenosis

• Address underlying systemic disease (diabetes, malnutrition, alcoholism, bulimia) as this is a chronic bilateral noninflammatory enlargement 3, 4
• No surgical intervention needed unless cosmetic concerns are severe 3

Post-Treatment Surveillance (for Malignancies)

• Examine quarterly for first 2-3 years, then biannually until 5 years, then yearly 1
• Obtain baseline imaging (contrast CT or MRI) at 3 months post-treatment 1
• Perform surveillance imaging every 6-12 months for first 2 years, then symptom-directed for years 3-5 1
• Continue yearly chest CT for high-grade histology beyond 5 years 1

Critical Pitfalls to Avoid

• Do not perform incisional biopsy on major salivary gland masses; this violates surgical planes and increases recurrence risk 1
• Do not assume bilateral painless enlargement is benign; obtain tissue diagnosis to exclude lymphoma or bilateral Warthin tumors 3
• Do not delay imaging when clinical examination suggests malignancy (facial paralysis, rapid growth, fixation) 1
• Do not use chemotherapy outside clinical trials as its role remains unclear 1