Patients with salivary gland disease often present to the emergency department (ED) or urgent care setting with acute onset of pain or swelling of the affected salivary gland. In addition to pain and glandular swelling, patients with sialolithiasis or sialadenitis can also present with fever, trismus, difficulty swallowing, local erythema, change in salivary flow/consistency, or leukocytosis.

The clinical diagnosis of sialolithiasis can be difficult, because a stone may not be evident unless obstruction of a salivary duct and subsequent gland swelling/sialadenitis occurs. An obstructing stone often presents with unilateral salivary gland swelling and worsening pain or swelling that occurs with eating.⁶ The physical exam should include a bimanual palpation of the floor of the mouth, pushing up on the submandibular gland with one hand while intraorally palpating the floor of mouth with the other. An affected gland is firm or tender, and in the case of submandibular gland swelling, the floor of the mouth may be elevated, tender, or inflamed. In sialadenitis, palpation of the gland often leads to expression of pus from the intraoral gland orifice.⁷ For the parotid gland, the path of Stensen duct should be palpated (Figure 12.3). This palpation can sometimes reveal an obvious calcification, although in acute inflammation stones are frequently nonpalpable owing to the overlying soft tissue edema and induration (Figure 12.4). Furthermore, inflamed, firm, irregular glandular tissue can often mimic calcifications.

When the parotid gland is involved, it is important to perform a thorough ipsilateral facial nerve exam. A facial nerve palsy is rarely associated with sialolithiasis or sialadenitis and more often suggests a malignancy, warranting further workup.⁸