#Introduction
Sialolithiasis is a condition in which stones (calculi) form in the salivary glands or ducts, blocking the flow of saliva. It is the most common disease of the salivary glands, accounting for approximately 50% of all major salivary gland pathology¹. The submandibular gland is the most frequently affected site, followed by the parotid gland². Sialolithiasis can cause pain, swelling, infection, and reduced salivary function³.
Case study:
In this case report, we present a patient with acute onset pain and swelling of the right submandibular region due to a large calculus in the proximal Wharton's duct.
#Case Presentation:
A 45-year-old male presented to the emergency department with a history of sudden onset pain and swelling of the right submandibular region that started 12 hours ago. He reported that the pain was severe, throbbing, and radiating to the ear and neck. He also complained of dry mouth and difficulty swallowing. He denied any fever, chills, trauma, or previous episodes of similar symptoms. He had no history of smoking, alcohol consumption, or systemic diseases. His physical examination revealed a tender, firm, and enlarged right submandibular gland with overlying erythema. There was no palpable mass or lymphadenopathy. His oral cavity was dry and his tongue was coated. His vital signs were normal.
# Ultrasound Findings
An ultrasound examination of the right submandibular region was performed using a high-frequency linear transducer. The ultrasound showed a calculus of 8 mm in diameter in the proximal Wharton's duct with mild dilation of the duct (Figure 1 to 5). The calculus appeared as a hyperechoic structure with posterior acoustic shadowing. The submandibular gland parenchyma was normal in echotexture and vascularity. There was no evidence of abscess formation or sialadenitis.
[Figure 1 to 5]: Ultrasound image showing a calculus (arrow) in the proximal Wharton's duct with mild ductal dilation:
# Etiology
The exact etiology of sialolithiasis is unknown, but several factors have been proposed to contribute to its formation. These include:
- Dehydration: Reduced fluid intake or increased fluid loss can lead to decreased salivary flow and increased concentration of calcium and phosphate in saliva⁵.
- Smoking: Tobacco use can alter the composition and pH of saliva, as well as cause inflammation and fibrosis of the salivary ducts⁶.
- Diet: High intake of calcium or oxalate-rich foods can increase the risk of sialolithiasis by increasing the saturation of these minerals in saliva⁷.
- Medications: Certain drugs, such as antihistamines, diuretics, anticholinergics, and beta-blockers, can reduce salivary secretion and cause xerostomia.
- Infections: Bacterial or viral infections can cause inflammation and obstruction of the salivary ducts, as well as alter the pH and viscosity of saliva.
- Anatomical factors: The submandibular gland is more prone to sialolithiasis than other salivary glands because of its longer and tortuous duct, its alkaline and mucinous saliva, and its dependent position that favors gravity-dependent sedimentation.
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# Management of sialolithiasis
The management of sialolithiasis depends on the size, location, number, and symptoms of the calculi. The main goals are to relieve pain, restore salivary flow, prevent infection, and remove the calculi. The possible treatment options include:
- Conservative measures: These include hydration, massage, heat application, sialogogues (substances that stimulate salivary secretion), antibiotics (if infection is present), and analgesics (for pain relief). These measures can be effective for small or distal calculi that can be spontaneously expelled.
- Sialendoscopy: This is a minimally invasive technique that involves inserting a small endoscope into the salivary duct to visualize and remove the calculi using micro-instruments or laser. This technique has high success rates and low complication rates for calculi located in the proximal or middle part of the duct.
- Extracorporeal shock wave lithotripsy (ESWL): This is a non-invasive technique that uses high-energy sound waves to break up the calculi into smaller fragments that can be flushed out by saliva. This technique can be used for large or multiple calculi that are not amenable to sialendoscopy.
- Surgery: This is the last resort for sialolithiasis that is refractory to other modalities or complicated by recurrent infections or glandular damage. The surgical options include ductal incision, calculus extraction, ductal dilation, or gland excision. Surgery has higher risks of complications, such as nerve injury, bleeding, infection, and salivary fistula.
# Prognosis of sialolithiasis in this case:
The prognosis of sialolithiasis is generally good, especially if the condition is diagnosed and treated early. Most patients achieve complete resolution of symptoms and restoration of salivary function after appropriate treatment. However, some patients may experience recurrence of sialolithiasis, especially if the underlying etiological factors are not addressed. The recurrence rate ranges from 5% to 15%. Recurrence can be prevented by maintaining adequate hydration, avoiding smoking, eating a balanced diet, and practicing good oral hygiene.
# Conclusion
Sialolithiasis is a common and benign condition that can cause pain and swelling of the salivary glands. Ultrasound is a useful imaging modality for diagnosing and evaluating sialolithiasis. The treatment options vary depending on the size, location, number, and symptoms of the calculi. The prognosis is generally good with timely and appropriate management. Recurrence can be prevented by modifying the risk factors and following up regularly.
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(2) Salivary Stones: Causes, Symptoms & Treatment - Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/24344-sialolithiasis.
(3) Submandibular Gland: Anatomy, Function, Conditions - Verywell Health. https://www.verywellhealth.com/submandibular-gland-5101463.
(4) Sialolithiasis - Wikipedia. https://en.wikipedia.org/wiki/Sialolithiasis.
(5) Sialolithiasis Symptoms, Diagnosis, and Treatments - Verywell Health. https://www.verywellhealth.com/everything-you-need-to-know-about-sialolithiasis-1192027.
(6) undefined. https://doi.org/10.53347/rID-2044.
(7) undefined. https://radiopaedia.org/articles/2044.
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