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Salivary gland stones & sialadenitis

Salivary duct obstruction (stone) ± infection

Overview

Obstruction of a salivary duct by a stone (sialolithiasis — most often the submandibular/Wharton duct) causing painful glandular swelling on eating; if it becomes infected, acute sialadenitis. A persistent salivary lump (especially with facial nerve weakness) needs malignancy excluded instead.

Recognise

Sialolithiasis: recurrent painful swelling of the submandibular gland at MEALTIMES (saliva backs up), settling between meals
A stone may be palpable in the floor of the mouth along the duct
Acute (bacterial) sialadenitis: a hot, tender, swollen gland with pus from the duct, often in dehydrated/elderly patients (Staph aureus)

Red flags

A persistent firm salivary lump, especially with FACIAL NERVE palsy or pain → exclude salivary malignancy (see head & neck cancer)

Differentials & how to tell them apart

Salivary gland tumoura persistent lump (not meal-related swelling); malignancy if facial palsy/pain/fixation

Mumps (viral parotitis)bilateral parotid swelling, systemic viral illness, unimmunised

Sjögren syndromebilateral gland enlargement + dry eyes/mouth + autoimmune features

Investigations

Clinical; ultrasound (or sialography/CT) to locate the stone; bacterial sialadenitis is clinical ± pus swab. Persistent lump → imaging + FNA to exclude tumour.

Management

Hydration + sialagogues/massage; antibiotics if infected; remove persistent stones

1Conservative measures (hydration, gland massage, sialagogues, warm compresses) for stones; treat acute bacterial sialadenitis with antibiotics and rehydration.Gate: Meal-related, intermittent gland swelling = an obstructing stone (benign) — but a PERSISTENT salivary lump (especially with facial nerve weakness) is a tumour until proven otherwise and needs imaging + FNA, not just conservative treatment
2Persistent/symptomatic stones → sialendoscopy or surgical removal (± gland excision); recurrent sialadenitis → ENT/maxillofacial review.

Conservative: hydration, gland massage, sialagogues (lemon/sour sweets), warmth — small stones may pass

Antibiotics (e.g. flucloxacillin/co-amoxiclav) — for acute bacterial sialadenitis

Stone removal / sialendoscopy / gland excision — persistent obstructing stones

Key points

Pain/swelling on eating = ductal stone (usually submandibular). Persistent lump ± facial palsy = think tumour. Bilateral parotid swelling shifts the differential to mumps/Sjögren.

Monitor & prognosis

Symptom recurrence; resolution of infection; exclude tumour if persistent.

Good; stones often manageable conservatively or endoscopically.

Source: NICE CKS; ENT UK