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—conservative management with hydration, sialagogues, massage, and warm compresses is first-line for acute inflammatory and obstructive causes, while malignant tumors require complete surgical excision with or without radiotherapy based on stage and grade. 1, 2

Initial Diagnostic Approach

Before initiating treatment, determine the cause through:

• Clinical examination to assess for rapid-onset pain (suggesting infection), painless mass (suggesting neoplasm), or meal-related symptoms (suggesting obstruction) 1, 2
• Bimanual palpation to identify stones or masses 3
• Imaging with ultrasound as the standard first-line modality, performed by trained personnel 3, 2
• CT or MRI if concern exists for malignancy, deep extension, or adjacent structure involvement 4, 2
• Fine-needle aspiration for cytological diagnosis when neoplasm is suspected 4

Treatment Algorithm by Etiology

Acute Suppurative Sialadenitis (Bacterial)

Treat with antibiotics targeting Staphylococcus aureus, combined with conservative measures to promote salivary flow: 1, 2

• Antibiotics (empiric coverage for S. aureus)
• Salivary massage
• Aggressive hydration
• Sialagogues such as lemon drops or vitamin C lozenges 1
• Warm compresses 2
• Oral hygiene optimization 2

Viral Sialadenitis

Direct treatment at the underlying viral disease (mumps, HIV, juvenile recurrent parotitis in vaccinated populations) 1, 2

• Supportive care with hydration and pain control
• Consider sialendoscopic dilatation for juvenile recurrent parotitis 5

Obstructive Sialadenitis (Sialolithiasis)

Management focuses on relieving the obstruction through conservative measures first, escalating to interventional approaches: 1, 2

Conservative management:

• Hydration
• Sialagogues
• Salivary massage
• Warm compresses
• Medication adjustment if drugs are contributing to salivary stasis 2

Interventional management:

• Sialendoscopy as a gland-sparing technique for both diagnostic and therapeutic purposes 2, 5
• Intraoral surgical removal for stones under the tongue, with technique determined by size and location 3
• Duct cannulation with irrigation, steroid injection, and/or dilatation 6

Post-procedure care for stone removal:

• Clean wound with 0.1% chlorhexidine solution 3
• Oral rinses with 0.1% chlorhexidine for 1 minute after procedure and daily during healing 3
• Avoid spicy, acidic, or hot foods 3
• Maintain regular oral hygiene 3

Eosinophilic Sialodochitis (Allergic Etiology)

For patients with recurrent swelling, atopic disease, and eosinophil-rich mucus plugs: 6

• Anti-allergic medications (used in 58% of cases) 6
• Systemic glucocorticoids (used in 25% of cases) 6
• Duct cannulation with irrigation and/or dilatation (used in 36% of cases) 6
• Consider biologic therapies for refractory cases 6

Malignant Salivary Gland Tumors

Complete surgical excision is the standard treatment, with adjuvant radiotherapy determined by stage and histological grade: 4

Stage I tumors (T1a, T2a, N0, M0):

• Major gland tumors: Complete excision of the gland 4
• Minor gland tumors: Wide radical resection 4
• No adjuvant radiotherapy if resection is macroscopically and microscopically complete, even for high-grade tumors 4
• Postoperative radiotherapy with photons (±electrons) if excision is incomplete or tumor at margins 4

Stage II-IV tumors:

• Routine postoperative radiotherapy for stage II, III, and IV high-grade tumors and for low-grade stage III and IV tumors 4
• Surgery plus radiotherapy is the treatment of choice for high-grade disease 4
• Neutron therapy alone for inoperable tumors or when surgery would cause significant functional sequelae 4

Neck management:

• Ipsilateral neck dissection is standard for T2 high-grade tumors 4
• No routine neck dissection for stage I low-grade tumors 4

Post-Neurosurgical Sialadenitis

For acute swelling following skull base surgery (rare, <1% incidence): 4

• Recognize stereotyped presentation: submandibular swelling contralateral to craniotomy within 4 hours of closure 4
• Aggressive management to prevent airway obstruction 4
• Corticosteroids for airway swelling (used in 47.4% of cases) 4
• Prolonged antibiotics (used in 68.4% of cases, though no bacterial superinfection reported) 4
• Warm compresses, massage, and sialagogues 4
• Aggressive intravenous hydration 4

Key Pitfalls to Avoid

• Do not dismiss painless salivary masses as benign without imaging and tissue diagnosis, as most salivary neoplasms present without pain 1, 2
• Do not perform routine neck dissection for stage I low-grade tumors 4
• Do not sacrifice tumor clearance to preserve nerves during malignancy resection 4
• Do not use chemotherapy outside of clinical trials for salivary malignancies, as its role remains unclear 4
• Recognize that submandibular glands account for >80% of salivary stones despite being smaller than parotid glands 2
• Be aware that post-neurosurgical sialadenitis can cause airway crisis and requires immediate recognition 4

Follow-Up for Malignant Disease

Clinical surveillance should be intensive initially, decreasing over time: 4

• Quarterly history and physical examination for first 2-3 years 4
• Biannual visits until 5 years 4
• Yearly visits thereafter, especially for high-grade histology 4
• Baseline imaging (contrast CT or MRI) at 3 months post-treatment 4
• Surveillance imaging every 6-12 months for first 2 years 4
• Chest CT yearly for high-grade tumors or poor prognostic features 4