Ultrasound has an established role in the detection of masses in the major salivary glands and potentially malignant adjacent lymph nodes. Because there is overlap in their sonographic features, tissue diagnosis plays an important role in management. This review assesses ultrasound-guided fine needle aspiration biopsy as a diagnostic tool in the characterization of these lesions. The literature, and the authors' experience, suggests that ultrasound-guided fine needle aspiration is a safe and accurate technique, with definable implications for management, when performed in conjunction with cytopathologic expertise.