What are the treatment options for salivary gland swelling?

Treatment of Salivary Gland Swelling

The treatment of salivary gland swelling depends critically on the underlying etiology: acute bacterial sialadenitis requires antibiotics plus conservative measures, obstructive disease (stones/strictures) requires obstruction relief via sialendoscopy or surgery, viral causes need supportive care only, and malignant tumors mandate complete surgical excision with or without radiotherapy based on stage and grade. 1, 2

Initial Diagnostic Differentiation

Before initiating treatment, you must distinguish between infectious, obstructive, inflammatory, and neoplastic causes through:

• Clinical examination focusing on whether swelling is unilateral vs bilateral, acute vs chronic/recurrent, and whether pain is periprandial (suggests obstruction) 3, 2
• Bimanual palpation to detect stones, with ultrasound as the standard imaging to confirm stone location and size 4, 2
• Assessment for red flags including facial paralysis, trismus, cutaneous infiltration, or painless solitary neck mass (all suggest malignancy requiring urgent referral) 5

Treatment by Etiology

Acute Bacterial Sialadenitis

Treat with antibiotics targeting Staphylococcus aureus (the most common pathogen), combined with aggressive conservative measures: 1, 2

• Anti-staphylococcal antibiotics (first-line therapy) 1
• Salivary massage to promote drainage 1
• Aggressive hydration 1, 2
• Sialagogues such as lemon drops or vitamin C lozenges to increase salivary flow 1, 2
• Warm compresses 2
• Optimize oral hygiene 2

Common pitfall: Failing to recognize impending airway obstruction in severe cases—monitor closely for respiratory compromise and consider early ENT consultation if swelling progresses rapidly 5

Obstructive Disease (Sialolithiasis/Strictures)

Management is directed at relieving the obstruction, with sialendoscopy as the preferred gland-sparing technique: 1, 3, 2

• For stones under the tongue (submandibular duct): Surgical removal through intraoral approach, with technique determined by stone size and location 4
• For stones/strictures not amenable to simple removal: Sialendoscopy provides both diagnosis and concurrent therapeutic intervention 3, 6
• Post-procedure care includes oral rinses with 0.1% chlorhexidine solution for 1 minute after procedure and daily during healing, avoiding spicy/acidic/hot foods, and maintaining regular oral hygiene 4

Note: Submandibular glands account for >80% of salivary stones due to their mucinous secretions high in calcium/phosphate salts and upward-flowing duct 2

Viral Sialadenitis

Treatment is directed at the underlying viral disease with supportive care only: 1

• Mumps and HIV are common viral etiologies 1
• No antibiotics indicated 1
• Conservative measures (hydration, sialagogues, warm compresses) for symptom relief 2

Recurrent/Chronic Inflammatory Disease

More likely inflammatory than infectious—treat underlying cause and consider sialendoscopy if conservative measures fail: 1, 3

• Examples include juvenile recurrent parotitis and chronic sialadenitis 1, 6
• Conservative management first: treat predisposing factors (dehydration, malnutrition, medications), increase salivary flow with sialagogues, hydration, massage 2
• Refer to otolaryngology if conservative treatment fails 3
• Sialendoscopy can directly visualize tissues, provide diagnosis, and guide treatment 3, 6
• Sialendoscopic dilatation is possible for juvenile recurrent parotitis 6

Malignant Tumors

Complete surgical excision is the standard treatment, with postoperative radiotherapy added based on clinical stage and histological grade: 5

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

• Major gland tumors: Complete excision of the entire gland 5
• Minor gland tumors: Wide radical resection 5
• If resection is complete (macro- and microscopically): No adjuvant radiotherapy needed, even for high-grade tumors 5
• If resection is incomplete or margins positive: Postoperative radiotherapy with photons (±electrons) using standard fractionation is mandatory 5

For Advanced Stage Disease:

• Stage II, III, IV high-grade tumors: Surgery plus routine postoperative radiotherapy 5
• Stage III, IV low-grade tumors: Surgery plus routine postoperative radiotherapy 5
• Inoperable tumors: Neutron therapy alone is the treatment of choice when available 5
• T2 high-grade tumors: Ipsilateral neck dissection is standard 5

Critical principle: Nerves should not be conserved at the expense of tumor clearance 5

Chemotherapy role remains unclear and should only be given within clinical trials—it has no role as routine treatment 5

Post-Treatment Surveillance for Malignancy

• Clinical follow-up: Quarterly for first 2-3 years, then biannually until 5 years, then yearly 5
• Baseline imaging: Contrast CT or MRI of primary site and/or PET/CT at 3 months post-treatment 5
• Surveillance imaging: Every 6-12 months for first 2 years (primary site and chest CT) 5
• Years 3-5: Imaging directed by symptoms/exam findings; yearly imaging for high-grade histology 5
• Beyond 5 years: Yearly examination with chest CT for high-grade tumors 5

When to Refer

Immediate ENT referral for: 1, 3

• Painless solitary neck mass (possible malignancy) 1
• Signs of malignancy (facial paralysis, trismus, cutaneous infiltration) 5
• Failure of conservative treatment 3
• Rapidly progressive swelling with airway concerns 5