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Submandibular Sialadenitis/Sialadenosis Workup

  • Author: Adi Yoskovitch, MD, MSc; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: May 06, 2016

Laboratory Studies

See the list below:

  • In evaluating the patient with sialadenitis, steps should be taken in the following order: history, physical examination, culture, laboratory investigation, radiography, and if indicated, fine-needle aspiration biopsy (see History and Physical).
  • Laboratory investigations should begin with culture of the offending gland (if possible, prior to the administration of antibiotics).
  • Blood cultures should be obtained in the patient exhibiting bacteremia or sepsis.
  • As a rule, needle aspiration of a suspected abscess is not indicated.
  • Routine electrolytes and complete blood cell count with differential should be obtained to assess for any evidence of dehydration or systemic infection.
  • If a diagnosis of autoimmunity is entertained, serum analysis for antinuclear antibody, SS-A, SS-B, and erythrocyte sedimentation rate should be conducted.

Imaging Studies


Numerous radiologic techniques are available in submandibular imaging. Deciding which study to obtain first is often difficult. Examination selection should be based in part on the suspected cause of the problem. The authors' institution tends to begin with plain radiography, followed by the use of computed tomography scanning with combined sialography.


Of all the radiologic examinations available, one of the simplest is conventional plain radiography.[2] Anteroposterior, lateral, and oblique intraoral occlusal views are used. This technique is particularly valuable in evaluating the presence of calculi, which are radio-opaque in approximately 70% of cases. These radiographs are limited in that they do not provide any information about the ductal system or soft tissues.


Sialography can be used to evaluate sialolithiasis or other obstructive entities, as well as inflammatory and neoplastic disease. In this technique, a water-soluble medium such as meglumine diatrizoate is injected into the Wharton duct and lateral, oblique, and anteroposterior plain radiographs are obtained in order to assess the ductal arborization. Contraindications for this test are iodine allergy and acute sialadenitis.

Any filling defects (eg, calculi), retained secretions (eg, chronic sialadenitis), stricture formation (eg, inflammation), extravasation (eg, Sjögren disease), or irregularly contoured borders (eg, neoplasm) are noted.


Ultrasonography can be used to differentiate between solid versus cystic lesions of the gland. It can also be used to differentiate intrinsic from extrinsic disease and can be helpful in identification of abscess formation. A 2009 study by Bozzato et al determined that application of ascorbic acid (vitamin C) as a contrast agent can aid in the ultrasound assessment of obstructive sialadenitis of the parotid and submandibular glands.[3, 4]

A study by Omotehara et al indicated that ultrasonography is effective in the diagnosis of immunoglobulin G4–related sclerosing sialadenitis (IgG4-SS), with ultrasonography showing the submandibular gland to have a significantly greater longitudinal diameter and thickness in patients with IgG4-SS than in controls. In addition, a rough contour to the gland was found in 62.9% of the patients, versus 8.3% of the controls. Moreover, in an examination of internal echo textures, patients showed multiple hypoechoic nodule patterns or diffuse hypoechoic patterns, in contrast to controls, who were found to have only homogeneous echo textures. Additionally, significantly higher color Doppler signaling was observed in cases of IgG4-SS than in controls.[5, 6]

In an examination of the parotid and submandibular glands, a study by Li et al suggested that ultrasonography may also be helpful in posttreatment follow-up of IgG4 sialadenitis, finding that the treated glands decreased significantly in volume and that their internal echoes showed greater homogeneity.[7]

CT Scanning

Computed tomography (CT) scanning is an excellent modality in differentiating intrinsic versus extrinsic glandular disease. It is also extremely valuable in defining abscess formation versus phlegmon. It is limited in evaluating the ductal system unless combined with simultaneous sialography.


Magnetic resonance imaging (MRI) is of little utility in sialadenitis or sialadenosis. It does not allow evaluation of the ductal system, and it is not helpful in defining calcifications. It is an excellent tool for soft tissue definition and is invaluable in instances of suspected neoplasia.



See the list below:

  • Fine-needle aspiration and biopsy
    • Open biopsy of the lip should be considered when the diagnosis of Sjögren disease is contemplated.
    • If suspicion of a solid neoplasm masquerading as sialadenitis is significant, a fine-needle aspiration with biopsy should be undertaken. The management and differential diagnosis of submandibular neoplasms is beyond the scope of the current discussion.
Contributor Information and Disclosures

Adi Yoskovitch, MD, MSc Chief, Department of Otolaryngology - Head and Neck Surgery, Fleury Hospital, Canada

Adi Yoskovitch, MD, MSc is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Canadian Academy of Facial Plastic and Reconstructive Surgery, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dominique Dorion, MD, MSc, FRCSC, FACS Deputy Dean and Associate Dean of Resources, Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Université de Sherbrooke, Canada

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Richard V Smith, MD Director of Clinical Affairs, Associate Professor, Department of Otolaryngology, Division of Head and Neck Surgery, Einstein College of Medicine, Montefiore Medical Center

Richard V Smith, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, The Triological Society, American Medical Association, American Medical Student Association/Foundation, Medical Society of the District of Columbia, New York Academy of Medicine, Vermont Medical Society

Disclosure: Nothing to disclose.

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Submandibular calculus.
Sialogram with stenosis secondary to chronic sialadenosis.
Submandibular abscess and associated Ludwig angina.
Submandibular neoplasm.
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