Submandibular Gland Swelling After Eating
The most likely cause is sialolithiasis (salivary stone) obstructing Wharton's duct, and first-line treatment consists of aggressive hydration, warm compresses, gland massage, and sialagogues to stimulate salivary flow. 1, 2
Clinical Presentation and Diagnosis
The hallmark presentation of submandibular sialolithiasis is pain and swelling that occurs characteristically just before or during meals, when salivary flow increases and encounters the obstruction. 3 This meal-related timing is pathognomonic and distinguishes it from other causes of submandibular swelling. 4, 5, 6
Essential Physical Examination Findings
- Perform bimanual palpation of the floor of mouth to detect stones in Wharton's duct—you can often directly palpate the calculus. 3, 1, 2
- Inspect intraorally with good lighting to visualize the duct opening and assess for reduced or absent salivary flow from the affected duct. 3, 1, 2
- Palpate the gland itself for tenderness and firmness, which indicates obstruction and inflammation. 3
Imaging Strategy
Ultrasound is the preferred first-line imaging modality for evaluating submandibular pathology due to its effectiveness, safety, and accessibility. 3, 2, 7 CT dental scan may be needed if ultrasound is inconclusive, as it can definitively identify calcifications that may be mistaken for other structures on plain radiographs. 5
First-Line Conservative Management
Begin conservative therapy immediately as it produces satisfactory results for small, accessible stones and even some larger ones. 1, 2, 6
Specific Conservative Measures
- Aggressive intravenous or oral hydration to dilute saliva and reduce viscosity, preventing further obstruction. 1, 2
- Warm compresses applied to the affected submandibular area to promote salivary flow and reduce inflammation. 1, 2
- Gentle massage of the gland from posterior to anterior to encourage stone migration and drainage—exercise caution in elderly patients or those with suspected carotid stenosis. 1, 2
- Sialagogues such as lemon drops, sugar-free sour candies, or xylitol to stimulate salivary flow and help expel the stone. 3, 1, 2
- NSAIDs for pain and inflammation as first-line analgesics; avoid opioid combinations. 1, 2
Role of Antibiotics
Prescribe antibiotics only if bacterial superinfection is clinically suspected (fever, purulent discharge, systemic signs), as most cases are mechanical obstruction without infection. 1, 2 The evidence suggests antibiotics do not have a routine role beyond standard prophylaxis unless superinfection develops. 3, 1
When to Escalate to Surgical Management
Refer to oral and maxillofacial surgery when: 3, 1, 2
- Conservative measures fail after an appropriate trial (typically days to weeks)
- The stone is large (>15 mm) or inaccessible to conservative manipulation 6, 8
- Recurrent episodes occur despite conservative management 5, 6
Surgical options include transoral sialolithotomy for accessible ductal stones or submandibular gland excision for intraglandular stones or chronic sialadenitis. 6, 8, 9
Critical Pitfall: Airway Compromise
Maintain vigilance for airway obstruction, which is the most feared complication of severe submandibular swelling. 3, 1, 2 While rare in simple sialolithiasis, acute severe inflammation can cause life-threatening airway compromise requiring emergent intubation. 3, 2 Watch for progressive bilateral swelling, stridor, or respiratory distress.
Alternative Diagnoses to Consider
If the presentation is bilateral or lacks the characteristic meal-related pattern, consider:
- Sjögren's syndrome (chronic bilateral swelling, dry mouth, positive anti-SSA/SSB antibodies) 3, 7
- Sarcoidosis (bilateral symmetrical enlargement, elevated ACE level, hypercalcemia) 7
- IgG4-related disease (bilateral swelling with characteristic plasma cell infiltration) 7
However, the meal-related unilateral pattern described in your question strongly points to mechanical obstruction from sialolithiasis rather than these systemic conditions. 3, 4, 5