Sialolithiasis

Background

• Development of a calcium carbonate and calcium phosphate stone in a stagnant salivary duct
• >80% occur in the submandibular gland

Clinical Features

• Pain, swelling, and tenderness may resemble parotitis
  • Sialolithiasis is exacerbated by meals and may develop over course of minutes when eating
• Typically unilateral
• A stone may be palpated within the duct and the gland is firm

Differential Diagnosis

Facial Swelling

• Buccal space infections
• Dental problems
• Canine space infection
• Facial cellulitis
• Herpes zoster
• Masticator space infections
• Maxillofacial trauma
• Neoplasm
• Parapharyngeal space infection
• Salivary gland diagnoses
  • Parotitis
    • Bilateral parotitis
    • Suppurative parotitis
    • Viral parotitis (Mumps)
  • Ranula
  • Sialoadenitis
  • Sialolithiasis
• Superior vena cava syndrome

Evaluation

Imaging will likely not change management in the ED setting as treatment involves conservative measures

• 80% of submandibular and 60% of parotid able to been seen on XR
• CT and MRI
• Ultrasound visualizes both the gland and the stone
  • High frequency intra-oral probes
  • Hyperechoic lines with posterior acoustic shadowing
  • Small stones < 2 mm may not shadow
  • Able to assess radiolucent stones
  • In obstruction, gland enlarged and ducts proximal to stone may be dilated

Management

• Antibiotics only indicated if concurrent infection
  • Reasonable to start with Keflex 500 mg q6h x 5 days with close follow up
  • Broaden to Augmentin or Clindamycin prn
• Palpable stones in the distal duct may be 'milked' out
  • From a posterior to anterior direction
• Recommend lemon drops, tart candies, or other sialogogues to promote salivation and stone passage

See Also

Salivary Gland Infections