I have a tender area beneath my jaw (submandibular region); what are the possible causes and how should it be evaluated and managed?

Submandibular Tender Area: Evaluation and Management

Most Likely Diagnosis

The most common cause of a tender submandibular area is sialolithiasis (salivary stone), which accounts for 80-90% of salivary stone cases and characteristically presents with intermittent pain and swelling just before or during eating. 1

Initial Diagnostic Approach

Begin with ultrasound imaging and intraoral examination with bimanual palpation to identify the underlying cause. 1 This combination is highly effective and should be your first-line diagnostic strategy.

Key Clinical Features to Assess

• Timing of symptoms: Meal-related pain or swelling strongly suggests sialolithiasis, as obstruction causes gland distention during salivary stimulation. 1, 2
• Pattern of swelling: Intermittent swelling indicates ductal obstruction (stone or stenosis), while persistent swelling suggests infection, chronic inflammation, or neoplasm. 3, 1
• Unilateral vs bilateral: Unilateral involvement points to local pathology (stone, infection, tumor), while bilateral suggests systemic causes. 3
• Palpable findings: Check for tender gland on bimanual palpation and assess salivary flow from the duct—slow or absent flow suggests obstruction. 2, 4

Physical Examination Specifics

• Intraoral examination: Palpate the floor of mouth bimanually to identify stones, assess for purulent discharge from Wharton's duct, and examine for masses or ulcers. 1, 3
• Neck palpation: A nontender neck mass is more suspicious for malignancy than a tender one. 3
• Distinguish from lymph nodes: The submandibular gland itself can be mistaken for an enlarged lymph node—intraoral palpation helps differentiate. 5

Primary Differential Diagnosis

Most Common Causes

1. Sialolithiasis (salivary stone): Intermittent dull, aching pain just before eating with tender gland on palpation. 3, 1, 2

2. Bacterial sialadenitis: Tender swelling with purulent discharge from the duct, fever, more common in dehydrated patients or those with poor oral hygiene. 1

3. Chronic sialadenitis: May be secondary to repeated stone formation or ductal stenosis. 1

4. Temporomandibular disorder (TMD): If pain is at the angle of the jaw, TMD affects 5-12% of the population and is the most common non-dental cause of mandible pain. 2, 4

Less Common but Critical Causes

• Neoplasm: Persistent or progressive unilateral mass, especially in smokers over 40, requires tissue diagnosis to exclude malignancy. 1, 3
• Giant cell arteritis: In patients over 50 with jaw claudication (pain with chewing), temporal tenderness, visual symptoms—this is a medical emergency requiring immediate high-dose corticosteroids to prevent irreversible vision loss. 2, 4

Diagnostic Algorithm

Step 1: Ultrasound imaging as first-line modality—safe, accessible, and highly effective for salivary gland pathology. 1

Step 2: If ultrasound is inconclusive or suggests neoplasm, proceed to CT scan for better characterization. 6

Step 3: Consider fine-needle aspiration for persistent masses to exclude malignancy. 5

Step 4: MRI if neurological cause (trigeminal neuralgia) is suspected. 2

Treatment Approach

For Inflammatory Causes (Sialolithiasis/Sialadenitis)

Conservative management is first-line and includes: 1

• Warm compresses
• Aggressive hydration
• Gentle gland massage
• Sialagogues (lemon drops, sour candies to stimulate saliva)
• NSAIDs for pain
• Antibiotics if infection is present

Surgical management (stone removal or gland excision) is reserved for stones not responding to conservative measures or confirmed malignancy. 1

For TMD (if pain at angle of jaw)

• Early reassurance and simple physiotherapy are often effective. 4
• Night splints fabricated by dentists can reduce masticatory muscle overactivity. 4
• Address psychological factors (depression, catastrophizing) as these significantly increase chronicity risk. 2, 4

Critical Red Flags Requiring Urgent Action

Immediate Evaluation (Within Hours)

Age >50 years with jaw claudication, temporal tenderness, or visual symptoms: Evaluate immediately for giant cell arteritis with ESR/CRP testing and start high-dose corticosteroids (minimum 40 mg prednisone daily) without delay—do not wait for temporal artery biopsy. 2, 4

Urgent Referral (Within 1-2 Weeks)

• Progressive unilateral mass: Requires urgent imaging and referral for malignancy evaluation, especially in smokers over 40. 1, 4
• Airway compromise: Acute sialadenitis can cause airway obstruction requiring close monitoring. 1

Special Considerations

For Smokers

Any persistent or progressive submandibular mass in a smoker over 40 requires tissue diagnosis to exclude metastatic disease from head and neck malignancy. 1 Smoking significantly increases this risk and cessation should be strongly encouraged. 1

Common Pitfall to Avoid

Do not confuse normal anatomic structures (submandibular gland, hyoid bone, transverse process of C2, carotid bulb) for pathologic masses. 3 Bimanual palpation helps distinguish the submandibular gland from lymph nodes. 5