Background <p>Preoperative differentiation of benign and malignant salivary gland lesions remains challenging. Contrast-enhanced ultrasound (CEUS) enables real-time assessment of tumor microvascularization and has emerged as a promising adjunct to conventional ultrasound.</p> Purpose <p>To systematically review the evidence on CEUS in focal salivary gland lesions and to evaluate its diagnostic accuracy, including feature-level diagnostic performance.</p> Materials and methods <p>A systematic search of PubMed was conducted for studies published from database inception to December 2025, evaluating contrast-enhanced ultrasound (CEUS) in focal salivary gland lesions, using histopathology as the reference standard. Qualitative and quantitative CEUS features were synthesized. Diagnostic accuracy evidence was assessed at both study and feature levels. Risk of bias was evaluated using the QUADAS-2 tool.</p> Results <p>Ten studies comprising 663 focal salivary gland lesions (470 benign and 193 malignant) were included in the qualitative synthesis. Malignant lesions were consistently associated with heterogeneous enhancement, ill-defined or blurred margins, non-enhancing areas suggestive of necrosis, and altered contrast kinetics. Quantitative CEUS analyses demonstrated shorter time to peak enhancement, higher peak enhancement, steeper wash-in slopes, and larger areas under the time–intensity curve in malignant tumors compared with benign lesions. Only a limited number of studies reported diagnostic accuracy outcomes using predefined criteria, and substantial heterogeneity in diagnostic thresholds and study design precluded reliable pooled meta-analysis. Across the two studies reporting complete diagnostic accuracy data, CEUS sensitivity ranged from 72.1 to 80.0%, whereas specificity ranged from 78.9 to 91.7%. Feature-level analysis indicated that ill-defined enhancement margins were highly specific for malignancy, whereas inhomogeneous enhancement showed higher sensitivity but limited specificity. Wash-in and wash-out kinetics demonstrated variable diagnostic performance across studies.</p> Conclusion <p>CEUS provides valuable functional information for the evaluation of focal salivary gland lesions and complements conventional ultrasound by depicting tumor microvascular characteristics. While several qualitative and quantitative CEUS features are associated with malignancy and may aid preoperative risk stratification, methodological heterogeneity and the limited number of high-quality diagnostic accuracy studies currently restrict definitive conclusions. CEUS should be considered an adjunctive imaging tool rather than a standalone alternative to histopathological diagnosis.</p>