Understanding Sialolithiasis: Symptoms, Diagnosis, and Treatment

What is sialolithiasis?

Sialoliths, more commonly referred to as salivary gland stones, are calcified structures or stones within any of the major salivary glands, These stones vary in size and can be found anywhere along the salivary duct or within the gland itself. 

Typical presentation

Patients with sialolithiasis often present with swelling of the affected salivary gland, especially noticeable around meal times, when salivary flow increases, leading to pain and tenderness. 

Remind me how to palpate the salivary glands… 

Diagnosing sialolithiasis can be done clinically but involves a physical exam that often isn’t routine in the urgent care setting. Here’s a quick refresher:

1. Inspection: Visually assess the area around the parotid and submandibular glands for signs of swelling or erythema.
2. Palpation: Gently palpate the affected salivary gland. An enlarged, firm and tender gland is often indicative of sialolithiasis. Be sure to examine the parotid glands, including the tail just under the jaw and the submandibular glands, which can sometimes be mistaken for lymph nodes. Inside the mouth, check near the maxillary molars (parotid ducts) and under the tongue (submandibular ducts) for any palpable stones.
3. Salivary Flow Test: After drying the area with a paper towel, massage the glands to stimulate saliva production. Evaluate the drainage: clear fluid suggests normal function, while purulent drainage may indicate infection.

Differential Diagnoses

Differentiating sialolithiasis from similar conditions is essential, as each requires a different treatment approach. 

• Neoplasms: Unlike stones, tumors typically do not cause rapid swelling and pain or fluctuate with eating/drinking.
• Dental Abscesses: Look for fluctuant lesions or other signs of infection. 
• Cellulitis: Involvement of the surrounding tissue can mimic sialolithiasis symptoms.
• Muscle Infections: Conditions affecting the buccinator or masseter muscles can also present similarly.

Complications of Sialolithiasis

If left untreated, sialolithiasis can lead to significant complications, including obstruction caused by stones, which can impede salivary flow, creating a favorable environment for bacterial infections. This backflow can result in sialadenitis, which may lead to chronic inflammation and long-term damage to the salivary glands.

Imaging Considerations

In many cases, physical exam findings and palpation can help identify sialoliths, but imaging may be needed depending on the clinical scenario:

• X-rays: While often available in urgent care, they may miss non-radiopaque stones.
• Ultrasound: Effective for some stones, but user-dependent and may miss smaller ones.
• CT Scan: A non-contrast CT scan is the gold standard for salivary stone visualization. For infection concerns, consider a contrast-enhanced CT.

Management Strategies

Management of sialolithiasis largely depends on the size and location of the stone:

• Conservative Management: Many cases of a small sialolith in an otherwise stable patient can be managed with hydration, warm compresses, non-steroidal anti-inflammatory drugs (NSAIDs), and sialogogues—substances that stimulate saliva production.
• Referral: If the stone is visible or palpable, then it is large enough that an ENT referral is advisable for potential surgical intervention.

Sialogogues: What to Recommend?

Sialogogues help stimulate saliva and may aid in managing sialolithiasis. Think of items that make your mouth water: sour candies, lemon juice, and other citric acid-rich foods are all effective options. Encouraging patients to stay well-hydrated is also crucial in managing this condition.

Antibiotic Considerations

In cases where patients show signs of sialadenitis—such as fever, purulent discharge, or significant inflammation—antibiotics are indicated, as is potential transfer to a higher level of care. If you do determine the patient can be managed as an outpatient, Augmentin is a good choice for treatment based on the predominant bacteria.

Conclusion

Sialolithiasis may not be an everyday complaint in urgent care, but a thorough physical exam can help you diagnose and treat this condition.