The Case of the Disappearing Salivary Gland Swelling

A 40-year-old female came to the clinic complaining of a swelling that appeared over her parotid region, was slightly painful but resolved over half an hour. She could speed up the process by applying pressure over the gland. She said that when she applied the pressure, the taste in her mouth became somewhat salty. There were no constitutional symptoms. The patient had seen a couple of dentists before coming to us, she had been advised a series of tests including a panoramic film, ultrasound, complete blood picture and fine needle aspiration cytology. Their listed differential diagnosis was pleomorphic adenoma?

When I examined the patient there was no identifiable swelling, both extra and intra-orally. Thick, mucinous saliva was expelled from the salivary gland on initial milking. The saliva on persistent milking was watery. The panoramic film was clear of any obvious pathology, the ultrasound report was suggestive of inflammation in the salivary gland, and the blood work was normal. Since there was no identifiable pathology, the pathologist had refused to perform an FNAC. 

So we concluded that there was some blockage in the salivary gland duct that was preventing the salivary gland duct to drain completely resulting in the swelling. Once the duct was able to drain the saliva, the swelling would disappear. The blockage in the duct was obviously not because of a lith, we would have been able to see that on radiograph. The cause was most likely a mucus plug. 

Conservative management required us to push the mucus plug out by increasing the salivary flow. We recommended compression of the gland at least twice daily and use of sugar-free lemon lozenges multiple times a day. The patient called after 4 days saying that she was symptom free, and wanted to discontinue lemon lozenges because she didn't care much for the taste. We asked her to complete 7 days and then let us know how she's feeling. 

She continues to be symptom-free for about 2 weeks now. Whatever was obstructing the duct was expelled out by the salivary gland stimulation. 

Comments:

Swellings that grow and regress in size over a period of time are usually inflammatory in nature. Pleomorphic adenoma is a benign salivary gland tumor and was not reasonable differential here. Neoplastic growths don't regress, instead they continue to increase in size. 

Also pleomorphic adenoma would be palpable. No palpable growth was identified during the oral examination.