Salivary Gland Disorders in ENT
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Direct answer
Mealtime swelling of a salivary gland points to obstruction — sialolithiasis, overwhelmingly of the submandibular gland, where a stone in Wharton's duct blocks the flow and produces painful gland enlargement at eating that subsides between meals. Inflammatory disease ranges from mumps parotitis and bacterial sialadenitis in the dehydrated patient to Sjogren's syndrome, while the tumour side obeys one rule: pleomorphic adenoma is the commonest benign tumour, mucoepidermoid carcinoma the commonest malignant, about four in five parotid tumours are benign, and facial nerve preservation defines parotid surgery. Ultrasound first, then fine-needle aspiration cytology, is the standard pathway for any persistent salivary lump.
What you must remember
- Stone facts: 80-90 percent of calculi form in the submandibular gland — mucoid, alkaline, calcium-rich saliva draining upward through a long duct explains it; most submandibular stones are radio-opaque, most parotid stones are not.
- Clinical pattern of obstruction: painful pre- and peri-prandial swelling of the involved gland, easing over an hour or two after meals; a palpable stone in the floor of mouth bimanually; pus at the duct orifice with superimposed infection.
- Sialadenitis causes: mumps (bilateral painful parotitis in an unvaccinated child, rare since universal immunisation), acute bacterial sialadenitis with Staphylococcus aureus in dehydration and post-operative patients, recurrent parotitis of childhood, and radiation or drug-induced xerostomia.
- Sjogren syndrome: dry eyes and dry mouth with parotid enlargement, anti-Ro and anti-La antibodies, and increased lymphoma risk — the systemic entry point examiners love.
- Tumour rules: pleomorphic adenoma — slow, firm, mobile, the middle-aged "parotid lump"; Warthin tumour — older male smokers, sometimes bilateral; mucoepidermoid carcinoma — the commonest malignancy; adenoid cystic carcinoma — perineural spread and late lung metastases; facial weakness or skin fixation suggests malignancy.
- Surgical anatomy: superficial parotidectomy with formal facial nerve dissection is both diagnostic and therapeutic for parotid lumps; submandibular gland excision removes the chronically stone-forming gland; ranula — a sublingual mucous retention cyst — presents as a floor-of-mouth collections, "plunging" when it herniates through mylohyoid into the neck.
- Post-parotidectomy syndromes to quote: Frey's syndrome — gustatory sweating from aberrant regeneration of parasympathetic fibres to overlying skin, positive on iodine-starch test — plus facial nerve palsy, salivary fistula and numb ear syndrome from the great auricular nerve.
- Investigation ladder: ultrasound first, fine-needle aspiration cytology for tissue, sialography or MR sialography for ducts, CT or MRI for deep-lobe and malignant staging.
Two consultations that cover the syllabus
A 38-year-old man reports two years of mealtime swelling under the left jaw; bimanual palpation finds a hard pea-sized stone near the punctum, and ultrasound confirms a 6 mm Wharton's duct calculus. A stone within the duct close to the punctum is retrieved transorally — duct incision, stone delivery, marsupialisation; a stone in the gland's hilum, or a gland destroyed by recurrent sialadenitis, is treated by submandibular excision through a crease incision, protecting the marginal mandibular nerve, hypoglossal and lingual nerves.
Contrast a 45-year-old woman with a two-year painless firm right parotid swelling and no facial weakness: fine-needle aspiration reports pleomorphic adenoma, and superficial parotidectomy with facial nerve identification follows, the nerve preserved unless invaded by malignancy. Had she presented with a rapidly enlarging fixed mass, facial palsy or neck nodes, the plan shifts to wider imaging and total parotidectomy with nerve sacrifice — the benign-malignant fork the whole topic organises around.
Where examiners dig
The favourite viva pair is why submandibular, not parotid, stones dominate — saliva composition plus gravity-dependent drainage through a long duct with a punctum narrower than the hilum. The second probe is the facial nerve: its course between superficial and deep lobes, its five branches, and the rule that no parotid lump is enucleated — shell-out recurrences made superficial parotidectomy the standard. Third, Frey's syndrome: the mechanism is parasympathetic-secretomotor fibres regenerating into sympathetic-sweat pathways, demonstrated by the starch-iodine test — a physiological explanation examiners reward over the eponym alone.
Frequently asked questions
Why do salivary stones form most often in the submandibular gland?
Its saliva is mucoid, alkaline and calcium-rich, and Wharton's duct is long with uphill drainage against gravity and a narrow punctum, favouring stasis and calcification.
What is Frey's syndrome?
Gustatory sweating and flushing over the parotid region after parotidectomy, from parasympathetic secretomotor fibres regenerating into sweat gland pathways; demonstrated by the iodine-starch test.
Which are the commonest benign and malignant salivary tumours?
Pleomorphic adenoma is the commonest benign tumour and mucoepidermoid carcinoma the commonest malignancy; adenoid cystic carcinoma is notorious for perineural spread.
How is a persistent parotid lump evaluated?
Ultrasound as first-line imaging, fine-needle aspiration cytology for histology, and cross-sectional imaging for deep-lobe or suspicious lesions — most parotid lumps prove benign.
What is a plunging ranula?
A mucous retention cyst of the sublingual gland that herniates through the mylohyoid muscle to present as a submandibular neck swelling, treated by excision of the sublingual gland rather than simple drainage.