Sialolithiasis

Definitions

Sialolithiasis: presence of stones in a salivary gland and/or salivary duct.
Sialadenitis: inflammation of a salivary gland which may result from obstruction or infection.

Epidemiology and Risk Factors

Most cases occur between the ages of 30 and 60. Sialolithiasis is more common in men than women and rare in children, whereas sialadenitis affects both genders equally and can occur in newborns.
Risk factors for sialolithiasis include dehydration, smoking, anticholinergic medications, diuretics, history of kidney stones, hypovolemia.
Risk factors for sialadenitis include the above as well as immunocompromised status and malnutrition.

Pathogenesis

Not clearly known, but currently thought that reduced salivary flow and salivary concentration of calcium are contributing factors.
Almost all (80-90%) stones occur in the submandibular glands, while 10-20% occur in the parotid glands. Sublingual stones can also occur, but are rare.

Clinical Findings

Classically presents as both pain and swelling in affected area worsened by eating.
May also present as painless swelling or as pain without swelling.
Decreased saliva production.
Xerostomia (dry mouth).
If there is worsening pain, erythema, +/- fever, consider an infection.

Physical Exam

Examine the symptomatic area for erythema, crepitus, induration, fluctuance, or swelling.
Palpate the course of the symptomatic gland and associated duct from the posterior part and move anteriorly, feeling for a mass or tenderness.
Ask the patient to elevate their tongue and massage the symptomatic gland; observe for expression of pus from the duct.
Perform a thorough exam of all oral structures to ensure patent airway.

Differential Diagnosis

Viral sialadenitis: glandular swelling and pain commonly preceded by viral prodrome (myalgias, headache, malaise, low-grade fever). May sometimes be bilateral. Mumps is most classically associated with sialadenitis, but other pathogens include parainfluenza, EBV, adenovirus, enterovirus, parvovirus, and HHV-6.
Bacterial sialadenitis: most often involves parotid gland. Is often unilateral, and purulent drainage may be expressed. Pathogens include S. aureus (most common), S. pneumoniae, S. viridans, H. influenzae, Bacteroides.
HIV: Pt’s can develop lymphoepithelial cysts in parotid gland—usually diffuse and symmetric.
Ludwig’s Angina: bilateral diffuse cellulitis of the submandibular space that can lead to severe airway complications. Always examine underneath the tongue.
Sjogren’s Syndrome: typically bilateral swelling and associated symptoms of dry eyes and mouth.
Salivary gland tumor: often presents subacutely and unilaterally, as a firm, nontender mass.

Imaging

If diagnosis is unclear from history and physical exam, imaging may be pursued.

Ultrasound: requires an experienced user, but is cheaper, faster, and effective in diagnosing stones. Recent data suggests that a transoral approach is superior to transcutaneous.
CT: standard of care as it allows for better assessment of other findings such as abscesses, tumors, or strictures. Request fine cuts to make sure not to miss small stones.

Management

Stone without infection—conservative management:

Adequate hydration, topical heat packs, massaging of gland, and sialagogues (sour candy/lemonade) to stimulate the gland.
Treat underlying risk factors if possible (i.e. discontinue anticholinergic meds, smoking cessation, etc.).

If infection present, treat with antistaphylococcal antibiotics:

Cephalexin or dicloxacillin 500mg QID for 7-10 days.
If no improvement in pain, purulent drainage, or fever in 5 days, obtain culture and broaden coverage (Augmentin or clindamycin) until results obtained.
Consider imaging (ultrasound and/or CT with contrast) and ENT consultation if concern for abscess.

Referral to ENT for:

Editor’s submandibular gland stones s/p manual removal (penny for scale):

References

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