| Exodontia.Info |
| Release of Salivary Stones |
Useful Website:
European Association of Oral Medicine
Useful Articles:
British Dental Journal 2002. Sialolithiasis. An unusually
large submandibular salivary stone.
Arch Otolaryngol Head Neck Surg 2003. Sialolithiasis
Management - The State of the Art.
Eastman Dental Institute Oral Medicine Clinic (2004).
Obstructive Salivary Disease.
JOMS 2004. Submandibular Salivary Stones - Current
Management Modalities
Acta Otorhinolaryngol Ital 2005. Current Opinions In
Sialolithiasis - diagnosis and treatment.
Dental Update 2006. A Revolution in the Management of
Obstructive Salivary Gland Disease.
JOMS 2007. Sialo-endoscopy & Sialography - Strategies
for Assessment & Treatment of Salivary Gland Obstructions
Acta Oto Rhinolaryngologica Italica 2007. Review.
Modern management of obstructive salivary diseases
Patient UK (2008). Salivary Gland Stones (Salivary Calculi)
ENTNews 2008. Salivary Gland Obstruction, Changing
Patterns of Practice.
BJOMS 2008. Selective management of obstructive
submandibular sialadenitis
BJOMS 2009. Recent advances in the management of
salivary gland disease.
J Oral Maxillofac Surg 2009. Giant Submandibular Sialolith
of remarkable Size in the Comma Area Wharton’s Duct. A
Case Report.
J Oral Maxillofac Surg 2010. Modern Sialography for
Screening of Salivary Gland Obstruction.
Dental Update 2011. Incidental Finding of Sialolithiasis in
the Sublingual Gland - A Diagnostic Dilemma
NEJM 2011. Images in Clinical Medicine. Sialolith of the
Submandibular Salivary Gland
European Association of Oral Medicine
Useful Articles:
British Dental Journal 2002. Sialolithiasis. An unusually
large submandibular salivary stone.
Arch Otolaryngol Head Neck Surg 2003. Sialolithiasis
Management - The State of the Art.
Eastman Dental Institute Oral Medicine Clinic (2004).
Obstructive Salivary Disease.
JOMS 2004. Submandibular Salivary Stones - Current
Management Modalities
Acta Otorhinolaryngol Ital 2005. Current Opinions In
Sialolithiasis - diagnosis and treatment.
Dental Update 2006. A Revolution in the Management of
Obstructive Salivary Gland Disease.
JOMS 2007. Sialo-endoscopy & Sialography - Strategies
for Assessment & Treatment of Salivary Gland Obstructions
Acta Oto Rhinolaryngologica Italica 2007. Review.
Modern management of obstructive salivary diseases
Patient UK (2008). Salivary Gland Stones (Salivary Calculi)
ENTNews 2008. Salivary Gland Obstruction, Changing
Patterns of Practice.
BJOMS 2008. Selective management of obstructive
submandibular sialadenitis
BJOMS 2009. Recent advances in the management of
salivary gland disease.
J Oral Maxillofac Surg 2009. Giant Submandibular Sialolith
of remarkable Size in the Comma Area Wharton’s Duct. A
Case Report.
J Oral Maxillofac Surg 2010. Modern Sialography for
Screening of Salivary Gland Obstruction.
Dental Update 2011. Incidental Finding of Sialolithiasis in
the Sublingual Gland - A Diagnostic Dilemma
NEJM 2011. Images in Clinical Medicine. Sialolith of the
Submandibular Salivary Gland
What are (Submandibular / Sub-lingual) Salivary Gland
Stones?
Sialolithiasis (Salivary Gland Stones) is the most common
disease of the salivary glands. It is affects 12 in 1000 of
the adult population; men are affected twice as much as
women; children are rarely affected.
Sialolithiasis accounts for more than 50% of diseases of
the large salivary glands and is thus the most common
cause of acute and chronic salivary gland infections.
More than 80% occur in the submandibular gland or its
duct, 6% in the parotid gland and 2% in the sublingual
gland or minor salivary glands.
Stones?
Sialolithiasis (Salivary Gland Stones) is the most common
disease of the salivary glands. It is affects 12 in 1000 of
the adult population; men are affected twice as much as
women; children are rarely affected.
Sialolithiasis accounts for more than 50% of diseases of
the large salivary glands and is thus the most common
cause of acute and chronic salivary gland infections.
More than 80% occur in the submandibular gland or its
duct, 6% in the parotid gland and 2% in the sublingual
gland or minor salivary glands.
| Photos of Sialoliths removed from the Submandibular Duct |
Clinical Examination, Investigations & Diagnosis
Careful history and examination are important in the
diagnosis of sialolithiasis (in fact, in all aspects of medicine
& dentistry). Pain and swelling of the concerned gland at
meal-times and in response to other salivary stimuli are
especially important. Complete obstruction of the salivary
duct by a salivary stone causes constant pain and swelling;
pus may be seen draining from the duct and signs of
systemic infection may be present.
Bi-manual palpation of the floor of the mouth, in a
posterior (back) to anterior (front) direction, reveals a
salivary stone in a large number of cases of
submandibular calculi formation. Bi-manual palpation of
the gland itself can be useful, as a uniformly firm and hard
gland suggests a hypo-functional (under-performing) or
non-functional gland.
Imaging studies are very useful for diagnosing
sialolithiasis. Occlusal radiographs (X-rays of the floor of
the mouth) are useful in showing (radio-opaque) stones.
Sialography is useful in patients showing signs of
sialadenitis related to (radio-lucent) stones or deep
submandibular / parotid stones. Sialography is, however,
contra-indicated in acute infection or in marked contrast
allergy (ie an allergy to the contrast media pumped into the
duct and gland).
Careful history and examination are important in the
diagnosis of sialolithiasis (in fact, in all aspects of medicine
& dentistry). Pain and swelling of the concerned gland at
meal-times and in response to other salivary stimuli are
especially important. Complete obstruction of the salivary
duct by a salivary stone causes constant pain and swelling;
pus may be seen draining from the duct and signs of
systemic infection may be present.
Bi-manual palpation of the floor of the mouth, in a
posterior (back) to anterior (front) direction, reveals a
salivary stone in a large number of cases of
submandibular calculi formation. Bi-manual palpation of
the gland itself can be useful, as a uniformly firm and hard
gland suggests a hypo-functional (under-performing) or
non-functional gland.
Imaging studies are very useful for diagnosing
sialolithiasis. Occlusal radiographs (X-rays of the floor of
the mouth) are useful in showing (radio-opaque) stones.
Sialography is useful in patients showing signs of
sialadenitis related to (radio-lucent) stones or deep
submandibular / parotid stones. Sialography is, however,
contra-indicated in acute infection or in marked contrast
allergy (ie an allergy to the contrast media pumped into the
duct and gland).
What does the treatment involve?
There are various methods available for the management
of salivary stones, depending on the gland affected and
stone location.
Patients presenting with sialolithiasis may benefit from a
trial of conservative management especially if the stone is
small.
The patient must be well hydrated (that is, drink frequently)
and must apply moist warm heat and massage the involved
salivary gland, while sialogogues are used to promote
saliva production and flush the stone out of the duct.
With gland swelling and sialolithiasis, infection should be
assumed and antibiotics prescribed. Most stones will
respond to such a regimen, combined with simple
sialolithotomy when required.
If the stone is sufficiently forward in the salivary duct, it
can be ‘milked’ and manipulated through the duct opening;
this can be done with the aid of lacrimal probes and
dilators to open the duct.
Once open, the stone can be identified, ‘milked’ forward,
grasped and removed. The gland is then ‘milked’ to
remove any other debris in the more posterior (back)
portion of the duct.
Almost half of the submandibular calculi lie in the distal
third of the duct and are amenable to simple surgical
release through an incision (cut) directly onto the stone. In
this way more posterior stones, 1 – 2 cm from the salivary
duct punctum, can be removed by cutting directly onto the
stone in the longitudinal axis of the duct. Care is taken as
the lingual nerve lies deep to the duct, but in close
association with the submandibular duct posteriorly.
Subsequently, the stone can be grasped and removed. No
closure is done leaving the duct open for drainage.
If the submandibular gland has been damaged by
recurrent infection and fibrosis or calculi have formed
within the gland, it may require removal.
Alternative methods of treatment have emerged such as
the use of Extracorporeal Shock Wave Lithotripsy (ESWL)
and more recently the use of Endoscopic Intracorporeal
Shockwave Lithotripsy (EISWL), in which shockwaves are
delivered directly to the surface of the stone lodged within
the duct without damaging adjacent tissue (piezoelectric
principle). Both extra and intra-corporeal lithotripsy are
gaining increasing importance in the treatment of salivary
stone disease.
Submandibular gland removal may be indicated following
failure of lithotripsy or if the size of an intra-glandular stone
is > 12 mm as the success of lithotripsy may be < 20% in
such cases.
In the case of small calculi, the treatment of choice should
be medical, instead of surgical. The patient can be
administered natural sialogogues such as small slices of
lemon or sialogogue medication (such as pilocarpine).
Surgical removal of the calculus (or even of the whole
gland) has traditionally been used as an alternative to
medical therapy, whenever the latter was not possible or
when it proved ineffective.
How long will the operation take?
It can be very quick (a few minutes). If the stone is big or
difficult to access, it can take that much longer.
What can I expect after the operation?
It is unlikely to be very sore but regular painkillers will be
arranged for you. There is relatively little swelling following
salivary stone removal.
Do I need any time off work?
Possibly only for the day of the operation.
Will I have a scar?
No.
What are the possible problems?
Bleeding from the wound is unlikely to be a problem. If it
occurs it usually does so within the first 12 hours of surgery
which is why you need to stay in hospital overnight.
Infection is uncommon but if your surgeon thinks it may
happen to you a short course of antibiotics will be arranged.
What are the possible complications?
There are potential complications with any operation.
Fortunately with this type of surgery complications are rare
and may not happen to you.
This list of warnings might seem excessive to some
however the legal ruling in the case of Chester vs Afshar
(2004) would suggest that it is quite prudent / necessary to
list them. Others might say that there isn't enough
information but where do you stop?
The following list of warnings regarding sialolith release is
neither exhaustive nor is it predictive. The most pertinent
warnings have been included here.
Pain. As it is a surgical procedure, there will be soreness
at the operation site. This can last for several days.
Painkillers such as Ibuprofen, Paracetamol, Solpadeine or
Nurofen Plus are very effective. Obviously, the painkiller
you use is dependent on your medical history and the ease
with which the stone was released.
Swelling. There will be swelling afterwards though it will
not be obvious from the outside. Sucking an ice-cube at
the op site will help to decrease the swelling. Avoidance in
the first few hours post-op of alcohol, exercise or hot foods
/ drinks will decrease the degree of swelling that can
develop.
Sutures. The op site will often be closed with stitches.
These dissolve and ‘fall out’ within 10 – 14 days.
Limitation of Mouth Opening. Often the chewing muscles
and the jaw joints are sore after the op so that mouth
opening can be limited for the next few days.
Scarring / Lumpiness at Op Site. Any cut to soft tissues
produces a scar. Initially, after the release of a stone, a
scar may be produced. This softens and disappears (i.e.
improves) with time. The scarring can also be dependent
on the size of the stone, how long it had been present for,
how many infections had been associated with it and the
individuals’ tendency to scarring.
Floor of Mouth Complications. When stitching up the
operation site, sometimes, the stitches can tie off the
Submandibular Duct. If this happens, saliva produced by
the Submandibular Gland can not escape into the mouth
and back pressure into the gland happens. This causes
the Submandibular Gland to swell and become painful.
The floor of the mouth may even rise.
If any of this happens, you will need to contact the OMFS
department or A&E as soon as possible. Because of the
potential of this to happen, stitches are sometimes not
used or if used, are very loose.
Repeat Op. Sometimes not all of the stone is removed or
there were more stones than originally thought (and not
obvious on the X-ray) or the conditions that created the
salivary stone in the first place haven’t changed and a new
stone has formed; hence, the need to repeat the op.
Numbness of the Tongue. The lingual nerve which supplies
feeling to the side of the tongue can become bruised as a
result of surgery. If this occurs you will experience a tingly
or numb feeling in the tongue, similar to the sensation after
having an injection at the dentist. This numbness may take
several months to disappear and in a minority of patients
may last for ever.
Damage to the Submandibular Duct. The submandibular
duct is the name of the tube which carries saliva from the
submandibular gland into the mouth. The duct runs close
to the sublingual gland before opening on the inside of the
mouth under the tongue immediately behind the lower front
teeth. If this duct is damaged, saliva may not drain
properly from the submandibular gland and the gland may
therefore swell in the upper part of the neck. The majority
of these swellings settle down on their own.
Need for Gland Excision. If the stone has caused multiple
infections in the Submandibular Gland, this may have
damaged the gland so much that removal of the stone will
have no beneficial effects. If this is the case, the
Submandibular Gland may need to be removed.
Are there are any long-term effects of having my
(submandibular / sub-lingual) salivary stones removed?
No.
Will I need further appointments?
Not necessarily. If the stone has been removed and it is
thought that all the stone has been removed and that the
procedure was straightforward, then there is no need for
review. If there are any queries, then a review is most
likely.
There are various methods available for the management
of salivary stones, depending on the gland affected and
stone location.
Patients presenting with sialolithiasis may benefit from a
trial of conservative management especially if the stone is
small.
The patient must be well hydrated (that is, drink frequently)
and must apply moist warm heat and massage the involved
salivary gland, while sialogogues are used to promote
saliva production and flush the stone out of the duct.
With gland swelling and sialolithiasis, infection should be
assumed and antibiotics prescribed. Most stones will
respond to such a regimen, combined with simple
sialolithotomy when required.
If the stone is sufficiently forward in the salivary duct, it
can be ‘milked’ and manipulated through the duct opening;
this can be done with the aid of lacrimal probes and
dilators to open the duct.
Once open, the stone can be identified, ‘milked’ forward,
grasped and removed. The gland is then ‘milked’ to
remove any other debris in the more posterior (back)
portion of the duct.
Almost half of the submandibular calculi lie in the distal
third of the duct and are amenable to simple surgical
release through an incision (cut) directly onto the stone. In
this way more posterior stones, 1 – 2 cm from the salivary
duct punctum, can be removed by cutting directly onto the
stone in the longitudinal axis of the duct. Care is taken as
the lingual nerve lies deep to the duct, but in close
association with the submandibular duct posteriorly.
Subsequently, the stone can be grasped and removed. No
closure is done leaving the duct open for drainage.
If the submandibular gland has been damaged by
recurrent infection and fibrosis or calculi have formed
within the gland, it may require removal.
Alternative methods of treatment have emerged such as
the use of Extracorporeal Shock Wave Lithotripsy (ESWL)
and more recently the use of Endoscopic Intracorporeal
Shockwave Lithotripsy (EISWL), in which shockwaves are
delivered directly to the surface of the stone lodged within
the duct without damaging adjacent tissue (piezoelectric
principle). Both extra and intra-corporeal lithotripsy are
gaining increasing importance in the treatment of salivary
stone disease.
Submandibular gland removal may be indicated following
failure of lithotripsy or if the size of an intra-glandular stone
is > 12 mm as the success of lithotripsy may be < 20% in
such cases.
In the case of small calculi, the treatment of choice should
be medical, instead of surgical. The patient can be
administered natural sialogogues such as small slices of
lemon or sialogogue medication (such as pilocarpine).
Surgical removal of the calculus (or even of the whole
gland) has traditionally been used as an alternative to
medical therapy, whenever the latter was not possible or
when it proved ineffective.
How long will the operation take?
It can be very quick (a few minutes). If the stone is big or
difficult to access, it can take that much longer.
What can I expect after the operation?
It is unlikely to be very sore but regular painkillers will be
arranged for you. There is relatively little swelling following
salivary stone removal.
Do I need any time off work?
Possibly only for the day of the operation.
Will I have a scar?
No.
What are the possible problems?
Bleeding from the wound is unlikely to be a problem. If it
occurs it usually does so within the first 12 hours of surgery
which is why you need to stay in hospital overnight.
Infection is uncommon but if your surgeon thinks it may
happen to you a short course of antibiotics will be arranged.
What are the possible complications?
There are potential complications with any operation.
Fortunately with this type of surgery complications are rare
and may not happen to you.
This list of warnings might seem excessive to some
however the legal ruling in the case of Chester vs Afshar
(2004) would suggest that it is quite prudent / necessary to
list them. Others might say that there isn't enough
information but where do you stop?
The following list of warnings regarding sialolith release is
neither exhaustive nor is it predictive. The most pertinent
warnings have been included here.
Pain. As it is a surgical procedure, there will be soreness
at the operation site. This can last for several days.
Painkillers such as Ibuprofen, Paracetamol, Solpadeine or
Nurofen Plus are very effective. Obviously, the painkiller
you use is dependent on your medical history and the ease
with which the stone was released.
Swelling. There will be swelling afterwards though it will
not be obvious from the outside. Sucking an ice-cube at
the op site will help to decrease the swelling. Avoidance in
the first few hours post-op of alcohol, exercise or hot foods
/ drinks will decrease the degree of swelling that can
develop.
Sutures. The op site will often be closed with stitches.
These dissolve and ‘fall out’ within 10 – 14 days.
Limitation of Mouth Opening. Often the chewing muscles
and the jaw joints are sore after the op so that mouth
opening can be limited for the next few days.
Scarring / Lumpiness at Op Site. Any cut to soft tissues
produces a scar. Initially, after the release of a stone, a
scar may be produced. This softens and disappears (i.e.
improves) with time. The scarring can also be dependent
on the size of the stone, how long it had been present for,
how many infections had been associated with it and the
individuals’ tendency to scarring.
Floor of Mouth Complications. When stitching up the
operation site, sometimes, the stitches can tie off the
Submandibular Duct. If this happens, saliva produced by
the Submandibular Gland can not escape into the mouth
and back pressure into the gland happens. This causes
the Submandibular Gland to swell and become painful.
The floor of the mouth may even rise.
If any of this happens, you will need to contact the OMFS
department or A&E as soon as possible. Because of the
potential of this to happen, stitches are sometimes not
used or if used, are very loose.
Repeat Op. Sometimes not all of the stone is removed or
there were more stones than originally thought (and not
obvious on the X-ray) or the conditions that created the
salivary stone in the first place haven’t changed and a new
stone has formed; hence, the need to repeat the op.
Numbness of the Tongue. The lingual nerve which supplies
feeling to the side of the tongue can become bruised as a
result of surgery. If this occurs you will experience a tingly
or numb feeling in the tongue, similar to the sensation after
having an injection at the dentist. This numbness may take
several months to disappear and in a minority of patients
may last for ever.
Damage to the Submandibular Duct. The submandibular
duct is the name of the tube which carries saliva from the
submandibular gland into the mouth. The duct runs close
to the sublingual gland before opening on the inside of the
mouth under the tongue immediately behind the lower front
teeth. If this duct is damaged, saliva may not drain
properly from the submandibular gland and the gland may
therefore swell in the upper part of the neck. The majority
of these swellings settle down on their own.
Need for Gland Excision. If the stone has caused multiple
infections in the Submandibular Gland, this may have
damaged the gland so much that removal of the stone will
have no beneficial effects. If this is the case, the
Submandibular Gland may need to be removed.
Are there are any long-term effects of having my
(submandibular / sub-lingual) salivary stones removed?
No.
Will I need further appointments?
Not necessarily. If the stone has been removed and it is
thought that all the stone has been removed and that the
procedure was straightforward, then there is no need for
review. If there are any queries, then a review is most
likely.
| Last Updated 10th February 2012 |
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