Sialolithiasis

Salivary calculi can be seen at any age, peak in the third to sixth decades, and have a male predominance. More than 80 percent of stones occur in the submandibular gland; most of the remainder are found in the parotid.1 19 The sublingual glands are rarely involved. Submandibular sialoliths are more common because of more viscous and alkaline secretions as well as the anatomically "uphill" path of the Wharton (submandibular) duct. 20 Sialoliths are composed mostly of calcium phosphate and organic matrix.19 Multiple stones are seen in approximately 25 percent of patients who present with an initial stone. 20

The symptoms of pain, swelling, and tenderness are similar to those of parotitis and the two conditions may be difficult to differentiate. However, ductal obstructive symptoms (pain and swelling) are exacerbated by meals, when salivary secretion is stimulated.1720 Sialolithiasis usually presents with unilateral swelling and pain in the affected gland. The stone may be palpated within the duct. If there is superimposed infection, the diagnosis may be difficult.

Diagnosis is usually clinical. Although intraoral radiographs visualize more than 90 percent of calculi, extraoral radiographs demonstrate only about 50 percent. This is despite the fact that 80 percent of submandibular calculi are radiopaque. 19 Only 20 percent of parotid calculi are visualized by plain radiography. 17

Sialography, diagnostically limited in the detection of small stones and extrinsic masses, is being replaced by ultrasound, CT, and MRI. These diagnostic procedures are rarely indicated emergently.

Diagnosis and therapy may be initiated on the basis of clinical findings. Conservative treatment is usually effective. Initial management consists of analgesics, antibiotics if there is concurrent infection, massage, and sialogogues (e.g., lemon drops). 1 19 Easily located distal calculi may be digitally "milked" from the duct.19 Alternatively, they may be removed by the specialist by either dilation or incision of the ductal orifice. Most patients with sialolithiasis may be discharged for outpatient management. If there is a concurrent abscess, disposition should be guided by the recommendations for abscess management, as outlined above. Proximal or intraglandular sialoliths should be referred for outpatient ENT evaluation.

Complications of salivary duct obstruction include recurrent or persistent obstruction, sialectasia (irregular dilations of the ductal system resulting in stasis and further stone formation), and superimposed infection.19

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