Clinical Presentation

Disease affecting the salivary glands will present with enlargement (that may or may not be painful) or as a consequence of dysfunction, usually hypofunction.

Enlargement can affect both major and minor glands and may be episodic or persistent. In the major glands, episodic swellings, worse at meal times and accompanied by pain, are due to obstruction of outflow by intraluminal sialoliths or mucous plugs. Symptoms and signs of ascending infection by pyogenic bacteria may also be present. Extrinsic pressure on the duct system, e.g., by tumours, can present with obstruction. The submandibular gland is most often affected by obstruction, the parotid gland less so.

Persistent localised swellings in the major glands are likely to represent a primary salivary gland neoplasm or lymph node disease. Most major gland tumours arise in the parotid gland and over 80% are benign lesions. From a surgical standpoint, the parotid gland is divided into superficial and deep lobes by the plane of the facial nerve as it traverses the gland. Most tumours arise in the superficial lobe and will present as facial swellings while deep-lobe lesions may present medially as parapharyngeal swellings or as a diffuse enlargement of the parotid region. Around 10% of salivary gland neoplasms arise in the submandibular gland around half of which will be malignant; sublingual gland tumours are very rare and almost always malignant. Motor or sensory nerve dysfunction or pain are sinister findings with a localised swelling in a major salivary gland and often signify malignancy.

Bilateral or multi-gland diffuse swellings point to a systemic process such as sarcoidosis, sialosis or autoimmune phenomena (myoepithelial sialadenitis or HIV).

Minor salivary gland swellings present as submucosal masses. Cystic lesions in young patients located towards the front of the mouth, particularly in the lower lip, will be mucous extravasation cysts; those cystic lesions towards the back of the mouth in older patients are likely to represent retention cysts although some will turn out to be cystic tumours. Neoplasms of the minor salivary glands have an overall benign-to-malignant ratio of 1:1 but tumours of the palate and upper lip are much more likely to be benign than malignant while the converse is true of tumours in the tongue, floor of the mouth and retromolar pad.

Hypofunction usually manifests as xerostomia although some of those who complain of a dry mouth will have perceived rather than real salivary dysfunction. Common causes of xerostomia include drug effects, post-radiotherapy changes and autoimmune disease and, less often, endocrine disturbances.

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