Step 1 of 14
Presentation, History & Examination
Characterise — acute/chronic, uni/bilateral, diffuse/focal, painful, meal-related, FN, single/multi-gland
Salivary gland enlargement is a presentation, not a diagnosis, and the history and examination sort it before any test. The defining axes are recorded systematically: acute versus chronic; unilateral versus bilateral; diffuse gland enlargement versus a focal mass; painful versus painless; meal-related versus constant; with or without xerostomia, constitutional symptoms, or facial-nerve dysfunction; and single versus multiple glands. Each axis points toward one of the four etiologic buckets.
The pattern is often diagnostic: acute, painful, unilateral suggests infection or acute obstruction; chronic, meal-related suggests a stone or stricture; painless, persistent, focal suggests a neoplasm; and bilateral, diffuse suggests systemic disease. Examination defines the gland (parotid, submandibular, sublingual, minor), the consistency and fixity of any mass, the overlying skin, the facial nerve, the ductal orifice and saliva, and the cervical nodes. A structured history and examination is what turns "a swollen gland" into a working category.
- Axes — acute/chronic, uni/bilateral, diffuse/focal, painful/painless, meal-related, xerostomia, constitutional, FN
- Patterns — acute painful = infection/obstruction; meal-related = stone/stricture; painless focal = neoplasm; bilateral = systemic
- Examine — gland involved, mass consistency/fixity, skin, facial nerve, duct orifice/saliva, cervical nodes
- Single vs multiple glands narrows the differential
★ High-yield pearls (chapter-wide)
- Sort every swollen salivary gland into one of four buckets — infective, obstructive, autoimmune/inflammatory, or neoplastic — because the bucket, set by pattern and a few questions, drives the entire workup.
- Facial-nerve weakness with a parotid mass is malignancy until proven otherwise — salivary duct carcinoma, adenoid cystic, high-grade mucoepidermoid, or metastatic SCC — and demands MRI and tissue, not reassurance.
- Meal-related swelling that builds with eating and settles after is obstructive disease — a stone or a stricture — until imaging says otherwise.
- Ultrasound is the first-line imaging for almost every salivary problem — it finds stones, duct dilatation, and superficial masses, and guides the needle, before any CT or MRI.
- FNAC (reported by the Milan system) is the cornerstone of the salivary mass — open incisional biopsy is avoided because it seeds tumour, risks the facial nerve, and contaminates the surgical field.
- A persistent, painless salivary mass is a neoplasm until proven otherwise — most parotid tumours are benign, but painless and slow does not mean safe.
- A negative CT with persistent obstructive symptoms is the classic indication for diagnostic sialendoscopy, which finds microliths, mucous plugs, and strictures and can treat them in the same sitting.
- Bilateral salivary enlargement points away from a single tumour and toward systemic disease — viral, autoimmune (Sjögren, IgG4, sarcoid), HIV, or metabolic (diabetes, alcohol) — so it triggers a systemic workup.
- Stone size directs obstructive management — small stones pass with conservative measures, intermediate stones suit sialendoscopy, and large or intraparenchymal stones need combined or open approaches — gland preservation first.
- Bilateral cystic parotid enlargement in an at-risk adult is HIV-associated benign lymphoepithelial disease until proven otherwise — test for HIV, and do not just keep aspirating, because the cysts recur almost every time.
Evidence base
2 sources- MOD
Kim MJ & Gluck O · Am Fam Physician · 2024Evidence-based reviewPMID 38905553
Contemporary evidence review of salivary gland disorders — the four-category framework, workup, and management.
- MOD
Bradley PJ · Adv Otorhinolaryngol · 2016ReviewPMID 27092554
Overview of the WHO classification of salivary gland neoplasms — benign and malignant entities and their behaviour.
Decision tree
The triage screen is the first gate. Classification routes the stable patient to one of the aetiology-keyed pathways below. Cross-cut cards capture the chapter's must-not-miss rules.