Editing Submandibular lump


== Aetiology ==

* Sialolithiasis
** Can also occasionally occur in parotid
** Associated with chronic sialadenitis
** Composed of mucus, cellular debris and ca/mg/phosphate
** Contributing factors:
*** Salivary stagnation
*** Epithelial injury to duct
*** Precipitation of calcium salts
*** Dehydration, diuretics/anticholinergics, gout, smoking
* Sialadenitis
** Infective
*** Acute
**** Dehydration, radiotherapy, immunosuppression
**** Bacterial - S. aureus, H. influenzae
**** Viral - mumps, coxsackievirus, influenza (also parotid)
*** Chronic (usually associated with conditions that reduce salivary flow)
**** Stone
**** Duct disruption
** Non-infective
*** Sjogren's (also parotid)
* Sialadenosis
** Non-neoplastic, non-inflammatory swelling in association with acinar hypertrophy and ductal atrophy
** Nutritional
** Endocrine (DM, hypothyroidism)
** Metabolic (obesity, cirrhosis)
** Autoimmune
** Drug-induced
* Infiltration
* Tumours

== Presentation ==

* Tumours will be painless swelling
* Stones - pain, swelling induced/exacerbated by eating
* Acute sialadenitis - painful, tender, swollen gland
* Chronic sialadenitis - pain and recurrent enlargement

== Examination ==

* Inspect, palpate bimanually
* Inspect duct orifices
* Check duct for stone

== Investigation ==

* Plain x-ray - usually stones are visible
* USS
* CT will definitely see stones
* MRI best for tumours
* FNA if neoplasm considered

== Management ==

* Acute sialadenitis
** Medial - rehydration, antibiotics (clindamycin), warm compress, massage, sialogogues, improved oral hygiene
** If no improvement after 48 hours, suspect abscess or obstruction/stone
** Can progress to Ludwig's angina
* Stones
** Medical management - generally successful for stones <2mm
*** Hydration
*** Lemon drops
*** Warm compress
*** Massage gland and milk the duct
*** Analgaesia
*** Discontinue anticholinergics
*** Consider antibiotics for secondary infection (cefalexin)
*** Stop smoking
** If medical management fails, step up approach:
*** Distal stones that are palpable within the mouth: duct dilation and removal with fine forceps
**** Risk ranula 
*** Extracorporeal lithotripsy
*** Sialoendoscopy - favourable for smaller stones, more distal, but 86% success rate overall
**** Basket
**** Laser
*** Submandibular gland excision reserved for failed other lines of therapy

[[Category:ENT]]