Sialolithiasis is the medical term for salivary gland stones. These stones, or calculi, are mostly composed of calcium, but they also contain magnesium, potassium, and ammonium. Your mouth has three salivary glands that can develop stones: parotid , submandibular, sublingual, and minor salivary glands. Due to being large, long, and having slow salivary flow, you are most likely to develop a salivary gland stone in your submandibular salivary gland.
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Sialendoscopic view before A and after B stenosis dilatation of a tertiary division of Stensen duct. The thick arrows show the stenotic area that was dilated. The fine dashed arrows show the departure of the same ductal branch. Sialendoscopic laser fragmentation of a submandibular stone and fragment retrieval with a grasping basket. Marchal F, Dulguerov P. Sialolithiasis Management : The State of the Art. Arch Otolaryngol Head Neck Surg.
The authors have no relevant financial interest in this article. Sialolithiasis is the main cause of unilateral diffuse parotid or submandibular gland swelling. Sialolithiasis results in a mechanical obstruction of the salivary duct, causing repetitive swelling during meals, which can remain transitory or be complicated by bacterial infections.
In the early s, several authors have attempted to cure sialolithiasis conservatively. Radiologists dealing with sialoliths during sialography have attempted retrieval of these stones using a Dormia basket either blindly 8 or under sialographic control. Others, inspired by urologic techniques, developed extracorporal lithotripsy for sialolithiasis.
Thanks to major advances in optical technologies, complete exploration of the salivary ductal system and a precise evaluation of its pathologic state are now possible.
Sialendoscopy, 13 , 14 or sialoendoscopy 15 as it is called by others, is therefore a new procedure, aiming to visualize the lumen of the salivary ducts to diagnose and treat ductal diseases. The objective of this article is to review the existing diagnostic and interventional modalities for sialolithiasis management.
Sialolithiasis is composed of varying ratios of organic and inorganic substances. The organic substances are glycoproteins, mucopolysaccharides, and cellular debris. Often, the organic substances predominate in the center of the stone, while the periphery is essentially inorganic. The exact pathogenesis of sialolithiasis remains unknown, and various hypotheses have been proposed. The annual growth rate of established salivary stones has been estimated to be 1 mm per year.
According to 2 recent studies, 25 , 26 the size ranges from 2 mm to 2 cm, with the mean being 3. The etiologic agents responsible for sialolithiasis remain elusive. Sheman and McGurk 28 attempted to correlate the geographic distribution of water hardness and salivary calculi. This study indicated no link between water hardness and sialolithiasis or sialadenitis, suggesting that high calcium intake might not lead to salivary calculi.
In rats, experimentally induced hypercalcemia failed to result in sialoliths. There is a recent interest in the effects of tobacco on saliva. Tobacco smoking has been shown to result in an increased cytotoxic activity of saliva, a decreased polymorphonuclear phagocytic ability, and a reduction of salivary amylase, including salivary protecting proteins, such as peroxidase. In a recent epidemiological study examining the nutritional habits and other behaviors of patients with sialolithiasis, tobacco smoking was found to be the only positive correlation with the disease M.
Oedman, MD, unpublished data, The classic occlusal film effectively shows ductal stones, while intraglandular and small stones can be missed. Often performed, computed tomographic scan is adequate for diagnosing sialolithiasis only if the stone is large or if radiological slices are performed every millimeter. Among the disadvantages are the lack of precise localization of the stone and the absence of visualization of the ducts and their anomalies.
Ultrasonography US is a noninvasive method of diagnosis, especially popular in Europe. In addition, US has limitations for detection of sialolithiasis. Sialography consists of an opacification of the salivary ducts by a retrograde intracannular injection of water-soluble radiopaque dye. Sialography is considered the gold standard because it provides a clear image not only of the stones but also of the ductal morphologic structure. Nevertheless, the success of therapeutic sialography has never been documented.
Disadvantages include the irradiation doses, pain associated with the procedure, possibility of canal wall perforation, and complications of infection and anaphylactic shock. Magnetic resonance sialography is a new diagnostic procedure, with promising results.
It consists of 3-mm T2-weighted fast spin—echo slides, performed in the sagittal and axial planes. Volumetric reconstruction is then performed, allowing a visualization of the ducts and their condition. The advantages include a rapid, totally noninvasive technique, no dye injection, no irradiation, and no associated pain.
The disadvantages are 1 the 45 minutes required for the reconstruction although the acquisition time is 10 minutes ; 2 MR imaging—associated inconveniences such as equipment costs, ferromagnetic implants, and examination intolerance by claustrophobic patients; and 3 limitations because of artifacts resulting from dental bridges.
Diagnostic sialendoscopy is a recently described 13 , 40 procedure that allows an almost complete exploration of the ductal system, including the main duct and secondary and tertiary branches Figure 1.
The need for a semirigid system has been demonstrated by the difficulty in directing a flexible system without a mobile tip and its fragility and poor image quality. Sialendoscopy can be done as an outpatient procedure in the clinic with the patient sitting in a chair or partially recumbent. Local anesthesia is used. Progressive dilatation of the papilla is performed with salivary sounds of progressively larger diameters.
Endoscopy is performed with progressive endoluminal irrigation using a local anesthetic solution. The diagnostic and interventional sialendoscope that we recommend 1. Sialendoscopy provides direct, reliable information about most ductal pathologic conditions and reduces the need for radiological investigations.
The indications for diagnostic sialendoscopy are all intermittent salivary gland swellings of unclear origin. Even children 42 and senior populations are suitable candidates for this technique. Despite its apparent simplicity, sialendoscopy is technically challenging. Operating the rigid sialendoscope is delicate, requires experience, and may be hazardous because of theoretical risks of perforation and vascular or neural damage.
Progression in the canal should be completely atraumatic and performed only under adequate vision. Significant trauma to the ductal wall could result in subsequent stenosis. Marsupialization of the ductal papillae should be avoided or kept as small as possible to prevent retrograde passage of air and aliments.
Perforations of iatrogenic origin outside the gland can lead to diffuse swelling of the floor of mouth, with potential risk of life-threatening swelling. In conclusion, diagnostic sialendoscopy is an outpatient evaluation procedure, performed under local anesthesia, with proven efficacy.
The classic treatment of sialolithiasis is antibiotics and anti-inflammatory agents, hoping for a spontaneous stone expression through the papilla. In cases of submandibular stones located close to Wharton papillae, a marsupialization sialodochoplasty is performed and the stone removed. It is commonly believed that a gland with sialolithiasis is no longer functional. A conservative approach even in long-standing sialolithiasis appears therefore to be justified.
External lithotripsy, initially reported by Iro and colleagues 12 in the early s, is becoming popular but requires several sessions at intervals of a few weeks. Once fragmented, stones are expected to evacuate spontaneously since no stone extraction is described with this technique. The remaining stone debris can be seen as the ideal nidus for further calcification and sialolithiasis recurrence.
In addition, these techniques could result in significant damage to the gland. Other techniques for sialolithiasis fragmentation have been described, such as those using electrohydraulic 55 and pneumoblastic 56 devices.
Electrohydraulic devices, initially described as promising, 55 have been proven to be of low efficacy at low voltages. Although we have found that at higher voltages destruction of stones was possible, injuries of the canal wall have been described and the technique criticized. Although no clinical trials using this technique for salivary stones have been published, in vitro investigations tend to emphasize the risks of canal wall perforations.
The literature on Stensen duct sialendoscopy is limited, as most series report on parotid as well as submandibular sialolithiasis. Probably, the smaller diameter of the Stensen duct 58 has made its exploration more challenging. Previous authors 8 have performed blind endoscopic stone retrieval with a Dormia basket Figure 2 , corresponding possibly to a "endoscopically-assisted stone retrieval" but not to interventional sialendoscopy.
Although we initially used this method, we no longer recommend this procedure because of the blindness of the technique and the potential risks of perforation and ductal lesions.
Five generations of endoscopes have been developed and evaluated. Satisfactory results were obtained with semirigid endoscopy, which initially consisted of the juxtaposition of 2 tubes. Because of the size of the instrument relative to the ductal lumen, progression within the canal was difficult and resulted in ductal wall tears.
The results of interventional sialendoscopy are directly related to the size of the stones in the submandibular and parotid glands. Sialolithiasis can either be round or exhibit sharp edges. In our hands, round stones are associated with an easy retrieval, while stones with edges are often embedded in the canal wall.
In parotid sialoliths, size is probably the most important factor in predicting the success of interventional sialendoscopy. For these sialoliths, fragmentation before extraction is necessary. In our opinion, the best system is the fragmentation of sialoliths using a fiber-optic laser, as initially described by Gundlach et al. An advantage is the retrieval of sialoliths and their fragments after lithotripsy, which is absent from most previously described methods.
The holmium laser is well known and has proven efficacy for urolithiasis. It should be used only under clear vision, tangential to the duct, and only in cases of sialolithiasis. The dye laser 11 has proven efficacy and low morbidity, as the high energy delivered is not absorbed by the tissues. Unfortunately, the cost of the device and its specificity may render its acquisition difficult. Among submandibular and parotid endoscopies, we have not encountered any significant complications, such as damage to the facial or lingual nerves, gross hemorrhage, or major canal wall perforations.
Nevertheless, minor canal wall perforations have been observed, leading to hospitalization because of swelling of the floor of mouth. Blockages of the grasping basket in 5 cases, requiring firm traction under general anesthesia for retrieval, and ruptures of the basket in 3 cases, none requiring gland resection, also have occurred.
These are traumatic experiences for the patient and the surgeon, potentially resulting in emergency submandibular gland resection, and should advocate for an extreme cautiousness in the use of the grasping basket. The approach toward unilateral salivary gland swelling Figure 4 is the same for the submandibular and parotid glands, although the smaller diameter of the parotid ductal system renders the procedure more challenging. Once a clinical suspicion of a ductal obstruction is present, we tend to favor diagnostic sialendoscopy as the initial procedure of choice, mainly because of its minimally invasive nature and excellent patient acceptance.
In cases of multiple glandular symptoms or unclear clinical presentation, MR sialography should be performed so that the texture of the gland, surrounding tissue, and ductal system of several salivary glands can be assessed. If diagnostic sialendoscopy reveals 1 or more stones or other ductal pathologic conditions, such as stenosis , the interventional procedure can be conducted in the same setting.
Sialendoscopic view before A and after B stenosis dilatation of a tertiary division of Stensen duct. The thick arrows show the stenotic area that was dilated. The fine dashed arrows show the departure of the same ductal branch. Sialendoscopic laser fragmentation of a submandibular stone and fragment retrieval with a grasping basket.
Salivary Duct Stones
Last updated: December 22, Revisions: 7. Sialolithiasis is the presence of calculi in the salivary glands or ducts. Stones will form in the salivary gland or ducts following the stagnation of saliva ; they are typically composed of calcium phosphate and hydroxyapatite, as the saliva is rich in calcium. They have an incidence of approximately cases per million population per year. Figure 1 — The three major salivary glands, the parotid, submandibular, and sublingual glands. Sialolithiasis most commonly occur in the submandibular gland , due to the anatomy of this duct being long and its flow of saliva against gravity. Individuals with sialolithiasis tend to be asymptomatic , however a small proportion can have an intermittent facial swelling associated with eating, which can be painful or painless.