Swelling in front of the ear: salivary gland or lymph node?

MSD Manuals writes that the parotid glands, the largest pair of salivary glands, lie just behind the jaw, below and in front of the ears. The duct that carries saliva from the gland to the mouth passes through the cheek and opens into the mouth level with the upper molars. Most swellings in front of the ear come from inflammation or blockage of this gland, or from a lump growing inside it. There are also small lymph nodes just over and inside the gland; these too can swell in response to an infection nearby.

Mumps is the well-known swelling of this area. The NHS writes that the main symptom of mumps is painful swelling around the cheeks and neck that builds up over a few days, that the swelling usually starts on one side of the face and then spreads to both sides, and that it sometimes stays on one side only. A headache, a high temperature, aching muscles and tiredness can start a few days before the swelling. The NHS notes that it is very unlikely in someone who has had two doses of the measles, mumps and rubella (MMR) vaccine or has had mumps before; it usually gets better within 2 weeks without treatment.

The second large group is a blocked salivary duct. MSD Manuals writes that the typical symptoms of a blocked duct are swelling and pain over the gland, which get worse after eating, particularly after something that increases saliva such as pickles or lemon juice; the swelling can go down within a few hours, and saliva can suddenly gush out of the duct. The NHS also notes that intense pain at mealtimes can show that a stone has completely blocked the gland, and that this pain usually lasts 1 to 2 hours.

This leads to an observation you can make at home. Take a slice of lemon or a sour sweet and then pay attention to the swelling. If the swelling becomes more pronounced, tight and painful, a blockage in the duct becomes more likely; if nothing changes, the cause may be something else. In front of a mirror, look inside your cheek, level with your upper molars, and press gently on the gland from the outside: if cloudy or pus-like fluid comes out of the duct opening instead of clear saliva, that is a sign of infection. These observations do not make a diagnosis; they make it clearer what to tell the doctor.

How salivary stones are distributed gives a clue as well. A review published in American Family Physician writes that more than 80% of stones form in the salivary gland under the jaw (the submandibular gland). Stones are rarer in the parotid; on the other hand, according to the same review, the parotid is more prone to infections and tumours. So with a swelling in front of the ear, a stone is one possibility, but not the only one.

The picture of a bacterial infection of the gland (sialadenitis) is different. MSD Manuals describes a fever, chills and painful swelling on one side, with the gland firm and tender all over and the skin over it red and swollen. This infection is most common in the parotid and is typically seen in people in their 50s and 60s, in chronically ill patients with a dry mouth and in people with Sjögren's syndrome (an immune disease affecting the salivary and tear glands). Medicines that cause a dry mouth and not drinking enough also set the scene for it.

A painless, slowly growing lump is a different path. MSD Manuals writes that about 85% of salivary gland tumours arise in the parotid, and that 75 to 80% are benign, slow-growing, movable, painless and usually a single lump. The commonest benign tumour is the pleomorphic adenoma; MSD notes that it can become malignant, but that this usually happens after the tumour has been in place for 15 to 20 years. This is why even a lump that looks benign should not be left for years.

The signs that set a malignant one apart have also been described. MSD regards lumps that grow quickly or have a sudden growth spurt, are hard, have irregular edges and are fixed to their surroundings as worrying; when malignant tumours spread to nerves, they can cause numbness, tingling or difficulty moving part of the face. The nerve that moves the face running through the parotid gland explains why facial paralysis together with a lump in front of the ear is taken seriously.

There is also a picture that is pain rather than swelling. The NHS lists pain around the jaw, ear and temple, clicking or popping noises when the jaw moves, being unable to open the mouth fully and locking among the features of jaw joint disorder (TMD). If you feel pain in front of the ear but there is no swelling you can see or feel, and the pain gets worse when you chew, the cause may be the joint rather than the gland.

The conditions in the first list are usually dealt with by simple measures and a planned appointment. If even a single point from the second list applies, do not wait.

The sequence starts with danger. Before thinking about what the swelling is, it is made sure that there is no emergency involving the facial nerve or the airway.

1. 1

   Emergency signs first

   If there is a drooping face, being unable to close the eye, slurred speech, weakness in an arm, or difficulty swallowing or breathing, the assessment is done at A&E. Call 112; the NHS says not to drive yourself to A&E.

2. 2

   History: when it started, and what changes it

   You are asked how long the swelling has been there, how it relates to eating, whether you have a fever, your vaccination status, whether anyone around you has mumps, any medicines that cause a dry mouth, and any recent throat, tooth or ear infection. Say what you noticed with the lemon test.

3. 3

   Examination by hand

   It is checked whether the swelling covers the whole gland or is a separate lump within it, how hard it is, whether it moves and whether it is stuck to the skin. The gland is pressed to see what comes out of the duct opening inside the mouth; MSD writes that if pus comes out, a sample is sent for culture.

4. 4

   Checking the facial nerve

   The two halves of the face are compared by raising the eyebrows, closing the eyes tightly, smiling and puffing out the cheeks. Even a slight asymmetry is noted, because loss of facial movement together with a lump changes the direction of the assessment.

5. 5

   Imaging

   MSD writes that with salivary gland inflammation, ultrasound is the imaging of first choice, and that it is used first in children too. If needed, a CT or MRI scan is added.

6. 6

   A fine-needle biopsy if needed

   If there is a lump, MSD writes that the cell type is determined by fine-needle aspiration biopsy. Monitoring or surgery is planned according to the result.

There is no single treatment for swelling in front of the ear; what is done depends on where the swelling comes from.

The following are wrong decisions often seen with this complaint. We set them out so that you can ask the right questions, whichever doctor you see.

The timings vary with the source of the swelling. The sequence below is a general framework; the plan of the doctor who examines you comes first.

1. The first week

   Swelling of a lymph node due to an infection is expected to start going down. The NHS wants you to see a doctor if a swelling has not gone down within 1 week or is growing.

2. The first 2 weeks

   The NHS writes that both mumps and swelling of a lymph node due to an infection usually clear within 1 to 2 weeks. If the swelling is still there at the end of this time, the picture should be reassessed.

3. Stones and blockage

   The NHS writes that symptoms last until the stone comes out or is removed, and that stones that have been removed do not usually come back.

4. If a lump has been found

   Monitoring or surgery is planned according to the imaging and, if needed, the biopsy result. It is advised not to leave a benign tumour for years, because MSD notes that a pleomorphic adenoma can become malignant after a long time.

We are not giving a single figure here, because behind a swelling in front of the ear there may be a viral infection that clears in a few days, a gland infection that needs antibiotics, or a lump that needs an operation. These are the items that determine the scope:

The source of the swelling

A lymph node, mumps, a stone, a bacterial infection and a tumour follow entirely different paths.

Imaging

Ultrasound is usually enough; in some cases a CT or MRI scan is needed.

Biopsy

If there is a lump, a fine-needle biopsy and the pathology examination are separate items.

Whether a procedure is needed

Removing a stone, draining an abscess or gland surgery widens the scope.