Sialolithiasis

Sialolithiasis refers to the formation of concrements (sialoliths) inside the ducts or parenchyma of salivary glands and most commonly occurs in the submandibular glands and their ducts.

Sialolithiasis is the most common disease of salivary glands, accounting for approximately 50% of all major salivary gland pathology 5. The submandibular salivary gland is most commonly affected (80-90% of cases) with almost all the remaining cases located in the parotid duct 1-2,5,6. This is primarily believed to be due to the increased viscosity of the secretions from the submandibular gland 6.

Sialolithiasis is a disease of adults, typically between 30 and 60 years of age. There is a male predilection 5.

Typically patient presents with a history of recurrent swelling and pain in the involved gland usually associated with eating due to obstructions of the draining duct, e.g. submandibular duct (Wharton's duct) thus slowing down or disabling the flow of saliva. This, in turn, predisposes infection of the gland proximal to the obstruction, resulting in bacterial sialoadenitis.

In chronic cases of obstruction, the gland undergoes fatty atrophy and becomes asymptomatic, unless secondarily infected.

Multimodal imaging can be used to evaluate these stones.

Plain radiograph

Not all stones are radiopaque. Plain radiography is able to visualise only 80-90% of submandibular stones (which are usually located in the duct 6)  and ~60% of parotid duct stones (more frequently found within the gland itself 6) presumably due to differences in the composition of the secretion of the parent glands 2-3. Oblique views are often required to project the stones away from adjacent bone and teeth.

Sialography

Sialography excels at delineating the exact size and location of stones within the salivary gland ducts. The stone will be visualised as a filling defect within the duct. In some cases, contrast will not be able to pass beyond the stone.

However, if active infection is suspected, sialography is contraindicated due to the risk of exacerbating the extent of infection 2.

Ultrasound

Ultrasonography is well-established in cases of clinical suspicion of sialolithiasis, able not only to visualise the stone in many instances but also the gland 2-3. Stones appear as strongly hyperechoic lines or points with distal acoustic shadowing represent stones. Small stones (< 2 mm) may however not shadow 2-3. Ultrasound is able to visualise stones that are radiolucent.

In acute obstructive cases, the gland appears enlarged and excretory ducts proximal to the stone may be visibly dilated.

Examination is best performed with small high-frequency intra-oral probes 5.

CT

CT is excellent at visualising stones both within the duct and within the gland. The spatial resolution is not as high as plain radiography and as such very small stones may not be evident.

Additionally, CT is able to assess the gland, although not as well as MRI (see below). In acute obstructive cases, the gland may appear enlarged, hyperdense and associated with stranding and enhancement following contrast administration.

In chronic cases, fatty atrophy will be evident, with the parenchyma reduced in volume and replaced by fat.

MRI

MRI is able not only to visualise larger stones but able in many instances to map the ductal anatomy and to assess the gland 2,4.

Stones appear as low signal regions (on all sequences) outlined by high signal saliva on T2 weighted images 2.

MRI is able to distinguish acute from chronic obstruction as well as glands with only incomplete obstruction 1.

In the acute setting glands are enlarged and demonstrate inflammatory changes:

  • T1: reduced signal compared to the other side
  • T2: increased signal (best seen on fat suppressed sequences)

In chronic cases, the gland is reduced in size and demonstrates fatty atrophy 1:

  • T1: increased signal compared to the other side
  • T2: reduced signal of gland parenchyma which is itself reduced in amount

In cases where a small non-obstructive sialolith is present, the gland may appear entirely normal.

In many instances, conservative medical management suffices. Hydration, moist heat are helpful and NSAIDS may be beneficial. Sucking on something sour, such as a lemon, may increase salivation and promote spontaneous expulsion of the stone.

If these measures are unsuccessful, surgical removal of the salivary stone from the duct after may be required. In chronic cases or if the stone is positioned within the parenchyma of the submandibular salivary gland, the gland may need to be excised.

Increasingly non-surgical options exist to treat symptomatic stones, including 4:

  • extracorporal sialolithotripsy
  • endoscopic stone removal
  • endoluminal balloon dilatation and stone extraction

The differential diagnosis really depends on the modality. In general, there is little confusion as clinical presentation is relatively specific. For plain radiography and CT, the differential is that of other calcific foci, which include 2:

  • haemangioma/phlebolith
  • atherosclerotic calcification

Filling defects on sialography may be caused by:

  • injected bubble of air
  • tumour
  • blood clot
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Article Information

rID: 2044
System: Head & Neck
Tags: ent, dental
Synonyms or Alternate Spellings:
  • Salivary duct stones
  • Salivary duct stone
  • Salivary duct calculus

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Cases and Figures

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    Case 1: submandibular duct stone
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    Case 1: submandibular duct stone
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    Case 1: submandibular duct stone
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    Case 2: parotid duct stone
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    Case 5: submandibular duct stone
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    Case 6: submandibular duct stone
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    Case 8: submandibular duct stone
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    Case 9: submandibular duct stone
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    Case 10: seen as signal void on MRI
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    Case 11: with submandibular sialadenititis
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    Case 13: submandibular gland stone
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    Case 16: right submandibular gland stone
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