EENT · PANCE / PANRE

Salivary Gland Disorders (Sialadenitis, Sialolithiasis, Parotitis)

Inflammation or obstruction of salivary glands — postprandial swelling (stone), tender swollen gland with pus (bacterial), bilateral parotitis (mumps).

Also known as: sialadenitis, sialolithiasis, salivary stones, parotitis, mumps, submandibular sialolith

Overview

A group of conditions involving the major salivary glands (parotid, submandibular, sublingual). Sialolithiasis is the formation of calculi within a salivary duct. Sialadenitis is inflammation of a salivary gland, which may be acute bacterial, chronic, viral (parotitis from mumps and other viruses), or autoimmune.

Epidemiology

Sialolithiasis: most common cause of salivary obstruction; 80% involve the submandibular (Wharton) duct because of its long, upward course and viscous mucinous secretion. Acute bacterial sialadenitis: most often parotid; affects dehydrated, postoperative, or elderly patients. Mumps parotitis: now uncommon in vaccinated populations but resurgent in outbreaks.

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Risk factors

Dehydration, fasting, postoperative state
Anticholinergic, antihistamine, diuretic, or psychotropic medications
Poor oral hygiene
Sjogren syndrome and other autoimmune disease (chronic sialadenitis)
Head and neck radiation
Mumps virus exposure in unvaccinated patients
Chronic ductal stricture or prior duct injury

Pathophysiology

Sialolithiasis: stasis of saliva and supersaturation of calcium phosphate within the duct forms a calculus, leading to ductal obstruction, glandular swelling with meals, and secondary infection. Acute bacterial sialadenitis: retrograde ascent of oral flora (Staphylococcus aureus, streptococci, anaerobes) through the duct in a setting of decreased flow. Mumps: lymphotropic paramyxovirus causes acinar inflammation, often bilateral; orchitis, oophoritis, and meningoencephalitis are extraglandular complications.

Clinical presentation

Symptoms

Sialolithiasis: recurrent unilateral gland swelling and pain triggered by meals or the sight of food; symptoms resolve over hours
Acute bacterial sialadenitis: rapidly progressive painful swelling of a single gland, fever, malaise, purulent discharge from the duct on massage
Mumps parotitis: bilateral parotid swelling, low-grade fever, malaise, headache; complications include orchitis (in 20-30% of postpubertal males), meningoencephalitis, deafness
Chronic sialadenitis: recurrent episodes of swelling with reduced salivary flow

Signs / physical exam

Sialolithiasis: bimanual palpation of the floor of the mouth or along the duct may reveal a palpable stone; little or no saliva from the duct orifice on gland massage
Bacterial sialadenitis: tender, erythematous, indurated gland; pus expressible from the duct orifice (Stensen for parotid, Wharton for submandibular)
Mumps: bilateral parotid swelling that obliterates the angle of the mandible; reddened, slightly edematous duct orifice (Stensen) without pus
Facial nerve weakness suggests malignancy or severe deep infection

Classic findings

Postprandial gland swelling that resolves over hours (stone), pus from Stensen duct (bacterial parotitis), bilateral parotid swelling in an unvaccinated patient (mumps).

Differential diagnosis

Lymphadenitis — Tender movable node in the neck, not within glandular tissue; ultrasound clarifies anatomy
Salivary gland neoplasm (pleomorphic adenoma, Warthin, mucoepidermoid carcinoma) — Painless slowly enlarging mass, often parotid; facial nerve involvement suggests malignancy; imaging and FNA
Sjogren syndrome — Chronic bilateral gland enlargement, sicca symptoms, positive anti-Ro/SS-A and anti-La/SS-B
IgG4-related sialadenitis (Mikulicz disease) — Chronic painless gland and lacrimal enlargement, elevated IgG4, responsive to steroids
Cervicofacial abscess from dental source — Tender swelling with associated dental disease; CT delineates abscess
HIV-related parotid lymphoepithelial cysts — Bilateral cystic parotid enlargement in HIV-positive patient
Sarcoidosis (Heerfordt syndrome) — Parotid enlargement, uveitis, facial nerve palsy, fever

Diagnostic workup

Diagnostic criteria

Diagnosis is clinical, supported by imaging. Mumps is confirmed by IgM seroconversion or PCR. Stones are identified on ultrasound or CT. Bacterial sialadenitis is diagnosed by exam plus expression of pus.

Labs

CBC with differential, basic metabolic panel for dehydration
Pus culture from duct orifice if present
Mumps IgM, IgG, and PCR (buccal swab) when mumps suspected
Autoimmune panel (ANA, anti-Ro/SS-A, anti-La/SS-B, IgG4) for chronic disease

Imaging

Ultrasound — first-line for any salivary mass or suspected obstruction; identifies stones, abscess, and gland architecture
Non-contrast CT — excellent sensitivity for calculi; preferred when ultrasound non-diagnostic
Sialography or MR sialography — for ductal strictures or recurrent obstruction without visible stone
FNA biopsy for any persistent mass

Diagnostic algorithm

Feature	Sialolithiasis	Bacterial sialadenitis	Mumps parotitis
Typical onset	Recurrent, meal-triggered	Acute, hours to days	Acute, days; prodrome
Gland involved	Submandibular > parotid	Parotid > submandibular	Parotid (often bilateral)
Fever / systemic	No	Yes	Low-grade; malaise
Pus from duct	No	Yes (key finding)	No (clear saliva)
Lateralization	Unilateral	Unilateral	Bilateral in 70%
First imaging step	Ultrasound or CT	Ultrasound	Clinical; PCR / IgM
Treatment	Hydration, sialagogues, sialendoscopy	Antibiotics, hydration, massage	Supportive only

Differentiating the three common salivary gland presentations.

Treatment

First-line

Hydration, warm compresses, gland massage, sialagogues (sour candies, lemon drops), and good oral hygiene for any obstructive or inflammatory salivary disease
Sialolithiasis: conservative measures plus NSAIDs; small stones near the duct orifice can often be milked out; persistent or proximal stones require sialendoscopy, intraoral stone removal, or gland excision
Acute bacterial sialadenitis: empiric oral antibiotic for outpatient mild disease — amoxicillin-clavulanate or clindamycin; severe cases require IV ampicillin-sulbactam or, if MRSA suspected, vancomycin plus a beta-lactam
Mumps: supportive care only — hydration, analgesia, antipyretics, isolation; report to public health

Second-line / adjunct

Sialendoscopy for ductal stricture or chronic recurrent disease
Surgical excision (submandibulectomy or parotidectomy) for recurrent disease unresponsive to less invasive measures or for chronic gland atrophy
Treatment of underlying autoimmune disease (steroids and disease-modifying therapy for IgG4 disease, Sjogren management)
Vaccination (MMR) for prevention of mumps; postexposure vaccination of contacts during outbreaks

Complications

Abscess formation requiring drainage
Recurrent obstruction with progressive gland atrophy and xerostomia
Spread of infection into the parapharyngeal or masticator space
Mumps orchitis (with possible infertility), oophoritis, meningoencephalitis, sensorineural hearing loss, pancreatitis
Facial nerve injury during surgical procedures

PANCE pearls

Postprandial unilateral gland swelling is sialolithiasis until proven otherwise; ultrasound is the first imaging step.
Submandibular stones predominate because Wharton duct travels uphill against gravity and carries mucin-rich saliva.
Always express the duct orifice — pus confirms bacterial sialadenitis and provides culture material.
Bilateral parotitis in an unvaccinated patient is mumps until proven otherwise; report to public health.
A persistent salivary mass or facial nerve weakness mandates imaging and FNA to exclude malignancy.

References

AAO-HNS — American Academy of Otolaryngology-Head and Neck Surgery clinical resources on salivary gland disorders
CDC — Centers for Disease Control and Prevention: Mumps for Healthcare Providers and ACIP recommendations for MMR
IDSA — IDSA reference on management of skin and soft tissue infections (relevant to bacterial sialadenitis)

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