What is the plan of care for a 63-year-old female patient presenting with a swollen left salivary gland located underneath the temporomandibular joint (TMJ)?

Plan of Care for Swollen Left Salivary Gland in a 63-Year-Old Female

The immediate priority is to determine whether this represents an inflammatory/obstructive process versus a neoplasm through clinical assessment and ultrasound imaging, followed by appropriate management based on the underlying etiology. 1, 2

Initial Clinical Assessment

Obtain specific historical details that differentiate the most likely diagnoses:

• Timing of swelling: Pain and swelling occurring just before or during meals strongly suggests sialolithiasis (salivary stone), as salivary flow is stimulated but blocked 2, 3
• Acute versus chronic: Rapid-onset pain and swelling indicates acute suppurative sialadenitis, while chronic or recurrent swelling suggests inflammatory conditions or neoplasm 2, 3
• Associated symptoms: Fever and systemic illness suggest infectious etiology (mumps, bacterial sialadenitis), while painless progressive swelling raises concern for neoplasm 2, 3
• Dry mouth symptoms: Presence of xerostomia with bilateral gland involvement suggests Sjögren's syndrome 2

Physical examination should specifically assess:

• Palpate for stones: Bimanual palpation of the gland and duct to identify calculi 2
• Assess salivary flow: Massage the gland and observe for purulent discharge from the duct opening, which indicates bacterial infection 2, 3
• Facial nerve function: Any facial weakness suggests malignancy with nerve involvement 1
• Skin examination: Check for suspicious cutaneous lesions on the head and neck, as intraparotid lymphadenopathy may represent metastatic disease from skin primaries 1

Diagnostic Imaging

Order high-frequency ultrasound (≥12 MHz) with color Doppler as the first-line imaging modality to distinguish whether the mass is truly within the salivary gland versus extraparotid, identify stones, assess for features suspicious for malignancy, and guide potential fine-needle aspiration if needed 1, 2, 3

Proceed to MRI with and without IV contrast if:

• Deep lobe involvement is suspected on clinical exam or ultrasound 1
• Cranial neuropathy is present (facial nerve palsy, trismus, regional dysesthesia) 1
• Ultrasound shows concerning features requiring better characterization 1
• Perineural spread or skull base invasion needs evaluation 1

Management Based on Etiology

For Obstructive Disease (Sialolithiasis/Stricture)

Conservative management initially:

• Warm compresses, gland massage, and hydration 2, 3
• Sialagogues such as lemon drops or vitamin C lozenges to stimulate salivary flow 2, 3
• Referral to oral/maxillofacial surgery for stone removal or duct management if conservative measures fail 2

For Acute Bacterial Sialadenitis

Treat with antibiotics covering oral flora, salivary massage, hydration, and sialagogues 2, 3

For Suspected Neoplasm

Fine-needle aspiration biopsy (FNAB) is essential to distinguish malignant from benign lesions and avoid unnecessary procedures 1

• Ultrasound-guided FNA is preferred over palpation-guided FNA, as it increases specimen adequacy rates and diagnostic yield 1
• If imaging shows features suspicious for malignancy (T2-hypointensity on MRI, intratumoral cystic components, infiltrative margins, or ill-defined borders), proceed with FNAB before surgical planning 1

For histologically confirmed malignancy:

• Open surgical excision is the standard treatment, with extent depending on tumor grade and stage 1
• Low-grade, early-stage tumors may be managed with partial superficial parotidectomy 1
• High-grade or advanced tumors require at least superficial parotidectomy with consideration of total/subtotal parotidectomy 1
• Adjuvant radiation therapy is indicated for tumors ≥2 cm, high-grade histology, or positive margins 1

For Chronic/Recurrent Cases

Consider autoimmune workup including testing for Sjögren's syndrome if bilateral gland involvement or dry mouth symptoms are present 2

Labial salivary gland biopsy may be indicated for suspected Sjögren's syndrome, looking for focal lymphocytic sialadenitis with dense aggregates of ≥50 mononuclear cells 2

Critical Pitfalls to Avoid

• Do not rely solely on imaging to determine benign versus malignant nature – histologic confirmation through FNAB is required for definitive diagnosis 1
• Do not proceed directly to open biopsy or surgical excision without attempting FNA first for suspected malignancy 1
• Do not underestimate deep lobe involvement when using ultrasound alone – proceed to MRI if deep lobe disease is suspected 1
• Do not make decisions about facial nerve sacrifice based on indeterminate preoperative or intraoperative diagnoses alone 4, 1