A swelling near the jaw, in front of the ear, or under the chin that does not resolve on its own is often the first sign that a salivary gland requires attention. Most of these swellings have a benign cause — but they do not disappear without the right diagnosis, and some require surgery. In this article, Dr. Miguel Lopes Oliveira, maxillofacial surgeon at Faces Facial Surgery, explains what causes salivary gland swelling, how it is investigated, and when surgical treatment is the appropriate step.
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- Salivary gland swelling is most commonly caused by benign tumours, stones, mucous plugs, or chronic inflammation.
- Diagnosis follows a structured pathway: clinical examination → ultrasound + fine-needle cytology → CT or MRI → sialendoscopy when indicated.
- Surgery for benign parotid tumours involves parotidectomy with continuous intraoperative facial nerve monitoring.
- Patients typically stay one night after surgery for drainage and airway observation.
- A maxillofacial surgeon manages the entire process — from the first consultation to the operating room.
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Where Does Salivary Gland Swelling Appear — and Why Does It Matter?
There are three pairs of major salivary glands: the parotid glands (located just in front of and below each ear), the submandibular glands (under the jaw on each side), and the sublingual glands (under the tongue). Hundreds of minor glands are also distributed throughout the mouth and throat. When one of these glands swells, the location of the swelling is an important diagnostic clue.
A painless, slowly growing lump in the parotid region is the most common presentation of a benign tumour. Painful swelling under the jaw — particularly one that worsens at mealtimes — is more typical of a salivary stone blocking the submandibular duct. Bilateral or diffuse enlargement of multiple glands may suggest a systemic inflammatory process. The character of the swelling — its onset, consistency, tenderness, and relationship to eating — guides the initial clinical assessment.
The Most Common Benign Causes of Salivary Gland Swelling
The majority of salivary gland swellings encountered in a maxillofacial surgery practice are benign. The four most frequent conditions are:
Pleomorphic adenoma is the most common salivary gland tumour overall, and arises most often in the parotid gland. It presents as a firm, painless, slow-growing mass — typically present for months or years before the patient seeks assessment. Despite being benign, pleomorphic adenoma requires surgical removal: it does not resolve spontaneously, and a small proportion may undergo malignant transformation if left untreated for many years.
Warthin tumour (papillary cystadenoma lymphomatosum) is the second most common benign parotid tumour. It tends to occur in older adults, is more common in men, and has a known association with tobacco use. It is occasionally bilateral. Like pleomorphic adenoma, it is managed surgically, though its behaviour is more predictable.
Sialolithiasis — salivary stones — is the most common cause of obstructive salivary gland swelling, most frequently affecting the submandibular gland. Stones form within the ductal system, obstructing saliva flow. The characteristic pattern is postprandial pain and swelling: the gland enlarges with the mealtime stimulus to produce saliva, which cannot drain freely. In some cases, instead of a calcified stone, a thick mucous plug is the cause — a dense accumulation of secretion that obstructs the duct in the same way, even without calcification.
Chronic inflammation and Sjögren’s syndrome. Not all obstruction involves a stone. Chronic inflammatory conditions — most notably Sjögren’s syndrome, an autoimmune disease affecting exocrine glands — can cause recurrent swelling, reduced salivary flow, and ductal strictures. These patients often present with bilateral parotid or submandibular enlargement, dry mouth, and dry eyes, alongside episodic acute swelling.
How Is a Salivary Gland Swelling Diagnosed?
Diagnosis follows a structured pathway that begins with clinical assessment and proceeds through imaging and, where appropriate, minimally invasive tissue sampling.
Clinical examination is the starting point. Dr. Miguel Lopes Oliveira takes a detailed history — noting the duration and behaviour of the swelling, its relationship to meals, associated pain, and any systemic symptoms — and performs a thorough palpation of the glands and cervical lymph nodes.
Ultrasound and fine-needle aspiration cytology (FNAC) are usually the first investigations requested. Ultrasound defines the size, location, and internal characteristics of the mass (solid, cystic, or mixed), and can identify stones as small as a few millimetres. When a discrete nodule is identified, an ultrasound-guided FNAC can be performed during the same consultation: a fine needle is introduced into the lesion under direct ultrasound control, and the cellular material obtained is sent for cytological analysis. This allows a preliminary characterisation of the lesion — whether it is consistent with a pleomorphic adenoma, a Warthin tumour, or raises concern for malignancy — without any incision or hospitalisation.
CT and MRI are requested before any surgical intervention. CT scanning is the standard pre-operative imaging study: it provides detailed anatomical information about the gland and its relationship to surrounding structures, and is particularly useful for identifying calcified stones and cervical lymphadenopathy. MRI is used in selected cases — particularly when the relationship of a tumour to the facial nerve needs to be better characterised, or when deep parotid lobe extension is suspected.
Sialendoscopy is a specialised technique in which a thin, rigid or semi-rigid endoscope is introduced into the salivary duct under local anaesthesia. It allows direct visual inspection of the ductal system — identifying stones, mucous plugs, strictures, and inflammatory changes — and can be used both as a diagnostic tool and, in selected cases, as a therapeutic one: stones and plugs can be retrieved, and strictures dilated endoscopically. Sialendoscopy is indicated in obstructive cases (stones, chronic sialadenitis, Sjögren’s-related ductal involvement) and is not used in the investigation of tumours.
When Is Surgery the Right Choice?
Surgery is indicated when the diagnosis confirms a benign tumour, when conservative management of obstruction has failed, or when imaging and cytology cannot fully exclude malignancy.
Parotidectomy for benign tumours. When a parotid tumour — such as a pleomorphic adenoma or Warthin tumour — requires removal, the operation is a parotidectomy. The extent of resection (partial or total) is determined by the size and location of the lesion. A defining feature of parotid surgery is its close relationship with the facial nerve, which runs through the substance of the gland and controls the muscles of facial expression. Injury to this nerve is one of the main risks of the procedure. At Faces Facial Surgery, parotidectomies are performed with continuous intraoperative facial nerve monitoring — a system that provides real-time electrical feedback on nerve function throughout the procedure, allowing the surgeon to identify and protect the nerve with greater precision.
Following parotidectomy, patients are admitted for one overnight stay. This is routine practice: a surgical drain is placed to collect fluid and prevent haematoma formation, and the patient is kept under observation to monitor airway and wound status before discharge.
Submandibular gland excision is the standard treatment for submandibular gland tumours. In the context of sialolithiasis, excision of the gland is reserved for cases where conservative or endoscopic approaches have been unsuccessful, or where the gland has been irreversibly damaged by recurrent obstruction. The procedure is performed through a small incision under the jaw and similarly requires an overnight stay.
Sialendoscopy as a conservative surgical alternative. In obstructive cases — whether due to a stone, a mucous plug, or an inflammatory stricture — sialendoscopy may allow resolution without gland excision. Stones can be fragmented and extracted; plugs can be aspirated; strictures can be dilated. This approach preserves gland function and avoids the more extensive recovery associated with open surgery. When sialendoscopy alone is insufficient, a combined approach (endoscopy with a small external incision) may be used.
What If the Swelling Is Not Benign?
The majority of salivary gland tumours are benign, but a minority — particularly those arising in the submandibular or minor salivary glands, or those with rapid growth, facial nerve involvement, or skin fixation — may be malignant. When cytology or intraoperative findings raise concern for malignancy, the surgical approach changes accordingly: a more extensive resection is required, and a cervical lymph node dissection (neck dissection / linfadenectomia cervical) may be performed in the same procedure to assess and treat potential lymphatic spread. Dr. Miguel Lopes Oliveira and his team are trained and equipped to perform this combined approach when oncological criteria require it. Cases confirmed as malignant are subsequently managed in collaboration with an oncology and radiotherapy team.
Why a Maxillofacial Surgeon for Salivary Gland Disease?
The diagnosis and surgical management of salivary gland disease requires specific anatomical knowledge and technical competence that places it squarely within the domain of maxillofacial surgery. The parotid gland’s intimate relationship with the facial nerve, the submandibular triangle’s proximity to the lingual and hypoglossal nerves, and the role of sialendoscopy in ductal pathology are all areas of dedicated training.
Importantly, the process does not need to be fragmented across multiple specialists. At Faces Facial Surgery, a patient with a salivary gland swelling can be assessed, investigated — including ultrasound-guided FNAC — and treated surgically by the same physician. This continuity of care, combined with the availability of intraoperative nerve monitoring and minimally invasive endoscopic techniques, underpins both the safety and quality of the outcomes obtained.