Case Study of the Week: Sialolithiasis

Patients presenting with significant facial swelling strike fear in me as a medical provider.  With so many essential and complex structures and in considering proximity to the brain, dealing with facial swelling is certainly concerning and necessitates an accurate diagnosis.  Thankfully, at my continuing medical education conference last week we discussed ENT emergencies including one of my favorite diagnoses, sialolithiasis, more commonly known as the salivary stone. 

Case Presentation

A 42 year old female presents to your clinic with right sided facial swelling and discomfort.  She notes the area is slightly tender and pain increases while eating or drinking.  The pain subsides within an hour of eating but increases significantly with each meal.  She denies fever.  She denies and significant medical history and her vital signs are stable.

On exam, you note a large amount of swelling to the lower, right side of the patient's face.  She exhibits exquisite pain with palpation of the submental region.  On examination of the mouth under the patient's tongue, you note swelling to the right sublingual gland.  Based on your exam, you diagnose the patient with sialolithiasis of the sublingual salivary gland. 

Management and Outcome

If a diagnosis of salivary gland stone is unclear, the stone may be seen on X-Ray (about 50% sensitivity) or CT scan.  Typically, this condition is diagnosed based on clinical symptoms.  The provider may even be able to feel the stone.  80% of salivary stones occur in the submandibular region.  

Treatment involves removal of the stone which is usually done conservatively.  The provider may choose to massage the stone out of the duct.  The patient may also massage the gland externally with application of heat.  Typically, consumption of water along with sucking sugar-free lemon drops will stimulate saliva production resulting in expulsion of the stone.  If the stone cannot be removed with conservative measures, an ENT or dentist can remove the stone by making a small incision in the gland.  Shock wave lithotripsy has also been used to reduce the stone to small fragments.

If the stone is not removed in a timely manner, bacterial infection may ensue.  Consider placing patients with salivary stone on antibiotic therapy. 

Discussion

Caused by excess calcium formation and thickened saliva related to factors such as poor nutrition, dehydration, medications or upper respiratory infection, salivary stones are very uncomfortable for patients.  Although they are not dangerous, they should be treated promptly to decrease risk of infection.  Conservative treatment is almost always successful and should be used as first line therapy. 

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