Sialolithiasis

Aka: Sialolithiasis, Salivary Gland Calculus, Salivary Duct Obstruction, Sialolith

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II. Definitions

  1. Sialolithiasis
    1. Calculus within Salivary Gland duct and secondary obstruction

III. Epidemiology

  1. Most common in ages 30 to 50 years (rare in children)
  2. Most common cause of Salivary Gland swelling (50% of cases)
  3. Lifetime Prevalence: 0.45%

IV. Pathophysiology: Salivary Gland duct calculus

  1. Submandibular Gland duct or Wharton's Duct obstruction (80-90% of cases)
    1. Located adjacent to frenulum
  2. Parotid Gland duct or Stensen's Duct obstruction (10-20% of cases)
    1. Adjacent to second upper molar

V. Causes

  1. See Xerostomia
  2. Trauma or local inflammation
  3. Chronic disease
    1. Stasis of Saliva and change in composition
    2. Dehydration
    3. Malnutrition
    4. Medications
  4. Infection
    1. Viral Infection (e.g. Mumps)
    2. Bacterial Infection
      1. Staphylococcus aureus
      2. Streptococcus viridans
      3. Streptococcus Pneumoniae
      4. HaemophilusInfluenzae

VI. Symptoms

  1. Localized pain and swelling at affected gland
    1. Usually occurs at Submandibular Gland (angle of jaw)
  2. Pain increases immediately before meals
    1. Persists after the meal

VII. Differential Diagnosis

  1. See Salivary Gland Enlargement
  2. Sialadenitis
  3. Lymphadenitis
  4. Dental abscess

VIII. Imaging

  1. Calculi occur in Submandibular Glands in 90% of cases
  2. Imaging is indicated for obstructive Sialoadenitis without improvement in 48 hours
  3. Ultrasound
    1. Test Sensitivity: 65 to 95%
    2. Test Specificity: 80 to 97%
  4. CT with Contrast and Reconstruction
    1. Test Sensitivity: 96 to 98%
    2. Test Specificity: 88 to 100%
  5. MRI Sialogram
    1. Demonstrates 80% of radiopaque calculi

IX. Labs: Indicators of infectious Sialadenitis

  1. White Blood Cell Count increased
  2. C-Reactive Protein (C-RP) increased
  3. Serum Amylase increased

X. Management

  1. General measures
    1. Maintain hydration with 64 ounces water per day
      1. Avoid Diuretics (Caffeine or Alcohol)
    2. Gentle massage over gland may help expel the stone
    3. Moist heat
    4. NSAIDs
    5. Sialologues induce Salivation (help clear stone)
      1. Lemon drops
      2. Vitamin C lozenges
      3. Citric acid or malic acid (lemons, limes, apples, grapes)
  2. Oral Antibiotics for obstructive Sialoadenitis
    1. See Bacterial Sialoadenitis for complicated infections
    2. Amoxicillin-Clavulanate (Augmentin) 875/125 mg every 12 hours OR
    3. Cefuroxime (Ceftin) 500 mg every 12 hours AND Metronidazole 500 mg every 8 hours OR
    4. Clindamycin 300 to 450 mg orally three to four times daily
  3. Otolaryngology for surgical management
    1. Indicated if Salivary calculus does not pass within 5-7 days
    2. Sialendoscopy (calculus removal with small endoscope)
      1. Effective alternative to surgical excision of calculus
      2. Best efficacy when implemented early in course
      3. Witt (2012) Laryngoscope 122(6): 1306-11 [PubMed]
      4. Luers (2012) Head Neck 34(4): 499-504 [PubMed]
    3. Surgical excision of stone indications
      1. Submandibular stones are accessible to local excision if palpable in the anterior floor of the mouth
      2. Salivary Gland excision indications (if failed sialendoscopy)
        1. Submandibular hilar stones
        2. Parotid duct stones
    4. Other measures
      1. Extracorporeal shockwave lithotripsy
      2. Laser lithotripsy
      3. Transoral robotic surgery

XI. Complications

  1. Obstructive Sialadenitis (Bacterial Sialadenitis)

XII. References

  1. Fedok in Noble (2001) Primary Care Medicine, p. 1770-1
  2. Kim (2024) Am Fam Physician 109(6): 550-9 [PubMed]
  3. Wilson (2014) Am Fam Physician 89(11): 882-8 [PubMed]

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