Swollen Necks, Dry Mouths: Diagnosing Salivary Gland Diseases

Gordon H. Sun, MD, MS

Disclosures

June 06, 2019

Could This Be Sialolithiasis?

Given the localized prandial and postprandial oral pain present in this patient, sialolithiasis of the submandibular gland is high on the differential diagnosis list for this case. However, the diagnosis of sialolithiasis cannot be confirmed without performing imaging studies to visualize the obstruction and rule out other etiologies.

The submandibular glands are affected in approximately 80%-90% of sialolithiasis cases.[5] The predisposition for stone formation in the submandibular gland probably stems from both the tortuous inferior route that saliva must take from within the gland to the more superior exit in the floor of the mouth, and the thicker consistency of submandibular secretions.[6,7]

Ultrasonography is quickly supplanting plain-film radiography as the first-line option due to its speed (which is operator-dependent), lower cost, increasing bedside availability, lack of ionizing radiation, and sensitivity in identifying stones as small as 2 mm.[3,6,8,9]

Noncontrast CT also is highly sensitive in the diagnosis of sialolithiasis but has the key disadvantage of exposing patients to ionizing radiation. With the wide variety and availability of faster, less expensive, and more effective tools for identifying salivary gland stones, standalone MRI is rarely used specifically to diagnose sialolithiasis. MRI, however, is an option for evaluating other potential causes of salivary gland obstruction (eg, neoplastic disease), and MR sialography can assist in identifying ductal dilatation associated with an obstructing stone.[7] In this case, ultrasonography confirmed the diagnosis of sialolithiasis.

A Smoker With Facial Swelling

A 55-year-old man presents to the emergency department with right-sided facial swelling which began 2 years earlier. He had previously ignored it because he did not have health insurance and could not afford to see a physician. However, it has now become too big to ignore.

He denies fevers, malaise, facial pain or weakness, sore throat, dysphagia, dyspnea, or dysphonia. His history is notable for type 2 diabetes and hypertension, both of which are well controlled with medications. There is no pertinent family or surgical history. He has a 20-pack/year history of smoking but denies alcohol or recreational drug use. He has no known drug, food, or environmental allergies.

Physical examination reveals a well-appearing and well-nourished man with unlabored breathing and normal vital signs. The only notable finding on exam is a mobile, rounded, preauricular left-sided mass measuring about 4 cm in greatest diameter. There are no overlying skin changes surrounding the mass.

A contrast-enhanced CT of the face and neck demonstrate a well-defined, enhancing 4-cm mass within the superficial lobe of the left parotid gland. There is no pathologic enlargement of the cervical lymph nodes. He is referred to an otolaryngologist for fine-needle aspiration (FNA) and surgical management.

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