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