gafacom background

Sialolithiasis causes, symptoms and management

Share this
Advertisement

Sialolithiasis

Sialolithiasis is the presence of calculi in the salivary glands or ducts. Stones will form in the salivary gland or ducts following the stagnation of saliva; they are typically composed of calcium phosphate and hydroxyapatite, as the saliva is rich in calcium

Calculus formation is more common in Wharton duct (draining the submandibular glands) than in Stensen duct (draining the parotid glands). Clinically, a patient may note postprandial pain and local swelling, often with a history of recurrent acute sialadenitis.

Stones in Wharton duct are usually large and radiopaque, whereas those in Stensen duct are usually radiolucent and smaller. Those very close to the orifice of Wharton duct may be palpated manually in the anterior floor of the mouth and removed intraorally by dilating or incising the distal duct. Those more than 1.5–2 cm from the duct are too close to the lingual nerve to be removed safely in this manner.

Similarly, dilation of Stensen duct, located on the buccal surface opposite the second maxillary molar, may relieve distal stricture or allow a small stone to pass. Sialoendoscopy for the management of chronic sialolithiasis is superior to extracorporeal shockwave lithotripsy and fluoroscopically guided basket retrieval.

Repeated episodes of sialadenitis are usually associated with stricture and chronic infection. If the obstruction cannot be safely removed or dilated, excision of the gland may be necessary to relieve recurrent symptoms.

Salivary Gland Anatomy

  • Parotid gland – located superior to the angle of the mandible, the gland is superficial to the masseter muscle and drains (via Stensen’s duct) opposite to the upper second molar
  • Submandibular gland – lying beneath the floor of the mouth in the submandibular triangle, it drains (via Wharton’s duct) into the floor of the mouth, beside the frenulum of the tongue
  • Sublingual gland – located below the mucous membrane of the floor of the mouth, they are drained by multiple small ducts that empty either into Wharton’s duct or directly into the floor of the mouth

Sialolithiasis most commonly occur in the submandibular gland, due to the anatomy of this duct being long and its flow of saliva against gravity. The type of salivary secretions from the submandibular gland are also more mucoid in nature as opposed to the more serous secretions from the parotid gland.

Causes

Conditions such as dehydration which cause thickening, or decreased water content of the saliva can cause the calcium and phosphate in saliva to form a stone. The stones often form in the salivary ducts and can either totally obstruct the salivary duct, or partially occlude it. You may develop sialolithiasis even if you are healthy, and a cause may not always be able to be pinpointed. However, conditions that may cause thick saliva and subsequent sialolithiasis include:

Advertisement
  • Dehydration
  • Use of medications or conditions which cause dry mouth (diuretics and anticholinergics)
  • Sjorgen’s syndrome, lupus, and autoimmune diseases in which the immune system may attack the salivary glands
  • Radiation therapy of the mouth
  • Gout
  • Smoking
  • Trauma

Small stones that do not block the flow of saliva can occur and cause no symptoms. However, when the flow of saliva becomes completely blocked it may cause the associated salivary gland to become infected.

Symptoms of Sialolithiasis

Symptoms usually occur when you try to eat (since that’s when the flow of saliva is stimulated) and may subside within a few hours after eating or attempting to eat. This is important to tell your healthcare providersince it may help differentiate sialolithiasis from other conditions. Symptoms of sialolithiasis may include:

  • Swelling of the affected saliva glands which normally occurs with meals
  • Difficulty opening the mouth
  • Difficulty swallowing
  • A painful lump under the tongue
  • Gritty or strange tasting saliva
  • Dry mouth
  • Pain and swelling usually around the ear or under the jaw

Severe infections of a salivary gland may cause profound symptoms including fever, fatigue, and sometimes noticeable swelling, pain, and redness around the affected gland.

Treatment

Most patients are managed conservatively with oral hydration, analgesia, and sialologues, such as lemon juice, which promote saliva production. Milking / massaging the gland can help as well.

If the gland becomes infected and the patient develops sialedenitis, then antibiotics are typically indicated.

Patients with recurrent or persistent symptoms should be referred for specialist treatment. Interventional radiology procedures are most commonly trialled, which involve fluoroscopic control such that the stones are visualised in the duct and then extracted with a basket.

A surgical approach can be used to remove some more difficult stones; a transoral approach can be used if the stones are distal or a transcervical approach for proximal stones (or where the transoral approach has been unsuccessful). Surgical intervention however comes with risks of damage to the hypoglossal, facial, or lingual nerves.

Other possible interventions include sialoendoscopy (whereby the stones are directly visualised via endoscopic imaging and extracted with a basket) or extracorporeal shockwave lithotripsy (for some stones in the proximal ducts, where transoral retrieval of the stone is not possible).

Gland removal is last resort. Excision of the parotid or submandibular gland are only performed for patients with chronically persisting symptoms.

Advertisement
Share this

Leave a Reply