What is the appropriate management for a patient with a swollen submandibular gland?

Management of Swollen Submandibular Gland

Begin with conservative management including warm compresses, aggressive hydration, gland massage, and sialagogues as first-line therapy, while simultaneously performing intraoral inspection and bimanual palpation to identify ductal stones, and obtain ultrasound imaging to differentiate between inflammatory, obstructive, and neoplastic causes. 1, 2

Initial Clinical Assessment

Perform intraoral inspection and bimanual palpation immediately to identify stones in Wharton's duct or within the gland itself, as this is essential for determining the underlying cause 1, 2. The differential diagnosis is broad and includes:

• Obstructive causes: Sialolithiasis (stones), mechanical compression of Wharton's duct 1, 3, 4
• Infectious/inflammatory: Acute bacterial sialadenitis, chronic sialadenitis 1, 5
• Autoimmune: Sjögren's syndrome, sarcoidosis, IgG4-related disease (typically bilateral) 6, 7
• Neoplastic: Pleomorphic adenoma, malignant tumors, lymphoma 3, 7
• Other: Dental infection with tracking sinus, post-surgical complications 1, 8

In patients over 40 years old, metastatic disease is the most common cause of asymmetric submandibular enlargement and must be ruled out first by examining the head, face, mouth, and considering distant primary sites 7.

Imaging Strategy

Ultrasound is the mandatory first-line imaging modality due to its effectiveness in identifying stones, masses, assessing glandular architecture, and differentiating between gland enlargement versus lymphadenopathy 2, 6. Ultrasound can identify ductal obstruction, dilatation, and internal vascularity 3, 8.

For suspected tumors or complex cases requiring superior soft tissue resolution, obtain MRI with contrast to delineate tumor margins and assess perineural spread, which is common in salivary gland malignancies 2.

CT with contrast is indicated when evaluating malignant tumor extent, bone invasion, or metastatic disease 2.

Conservative Management Protocol

Initiate the following measures immediately for inflammatory or obstructive causes 1, 2:

• Warm compresses applied to the affected area to promote salivary flow 1
• Aggressive hydration to dilute saliva and reduce viscosity 1
• Gentle gland massage to encourage drainage (use caution in elderly patients or those with suspected carotid stenosis) 1
• Sialagogues (saliva stimulants such as lemon drops or sugar-free candy) to increase flow and reduce stasis 1
• NSAIDs for pain and inflammation 1
• Avoid opioid combinations due to strong recommendations against their use 1

Antibiotic Therapy

Prescribe oral antistaphylococcal antibiotics if bacterial infection is suspected while awaiting culture results, particularly in acute sialadenitis with fever, tenderness, and purulent discharge from the duct 1, 5.

Critical Monitoring

Monitor closely for signs of airway compromise, which may develop rapidly in acute sialadenitis with excessive salivation and swelling 1, 2. Post-surgical submandibular swelling typically occurs within 4 hours of extubation 1.

Maintain a low threshold for reintubation if acute sialadenitis causes significant airway swelling 1, 2.

Watch for neurologic complications including 2:

• Brachial plexopathy
• Facial nerve palsy
• Horner syndrome

When to Pursue Tissue Diagnosis

Obtain fine-needle aspiration or core biopsy when imaging suggests neoplasm, when conservative management fails, or when clinical features are atypical 6, 3. This is particularly important given that malignancy must be excluded in persistent unilateral swelling, especially in patients over 40 7.

Surgical Referral Indications

Refer for surgical consultation in the following scenarios 1, 2:

• Persistent or recurrent symptoms despite conservative management
• Confirmed sialolithiasis not amenable to conservative measures
• Suspected or confirmed malignancy (requires surgery with potential postoperative radiotherapy) 1, 2
• Airway compromise requiring urgent intervention

Be aware that surgical excision carries risk of injury to the marginal mandibular branch of the facial nerve 1, 2.

Special Consideration for Bilateral Swelling

If bilateral submandibular swelling is present, the diagnostic approach shifts significantly 6:

• Sarcoidosis is the leading differential with characteristic symmetrical enlargement, elevated ACE level (>50% upper limit of normal), hypercalcemia, and non-caseating granulomas on biopsy 6
• Test for Sjögren's syndrome with anti-SSA/SSB antibodies and consider minor salivary gland biopsy 6
• Consider IgG4-related disease with characteristic plasma cell infiltration 6
• Rule out HIV-associated salivary gland disease 6
• Evaluate for lymphoma if lymphadenopathy present, looking for B symptoms (fever, weight loss, night sweats) 6