A patient reports swelling in the submandibular region that worsens at mealtimes and is painful when eating. What is the MOST likely diagnosis?

Correct answer: D. Obstructive submandibular sialadenitis (salivary stone)

• A. Ludwig's angina is a rapidly spreading bilateral cellulitis of the submandibular, sublingual and submental spaces with a raised tongue and airway compromise — a surgical emergency with a very different presentation.
• B. Reactive lymphadenopathy produces a discrete node that does not vary with meals.
• C. A thyroglossal duct cyst sits in the MIDLINE of the neck and characteristically MOVES ON SWALLOWING or tongue protrusion. It does not fluctuate with meals.
• D. Correct. Swelling and pain that are PROVOKED BY EATING is the defining history of OBSTRUCTIVE salivary gland disease. Salivary flow is stimulated at mealtimes; if a sialolith obstructs the duct, saliva backs up and the gland swells painfully, then gradually settles between meals. The SUBMANDIBULAR gland accounts for around 80–90% of salivary calculi because its secretion is mucous and alkaline, and Wharton's duct runs uphill against gravity.