What is the treatment for a patient with a salivary stone (sialolithiasis)?

Treatment of Salivary Stones (Sialolithiasis)

The primary treatment for salivary stones is surgical removal, with the specific approach determined by the stone's size and location to preserve glandular function whenever possible.

Diagnosis

Before treatment, proper diagnosis is essential:

• Clinical presentation: Intermittent pain and swelling of the affected salivary gland, typically occurring just before or during meals 1
• Physical examination: Bimanual palpation may allow detection of the stone, particularly if located in the duct 1
• Imaging:
  • Ultrasound is the first-line imaging modality for salivary gland disorders 1
  • Additional imaging may include sialography, CT scan, or MRI in complex cases 2

Treatment Algorithm

1. Conservative Management (for small stones or initial presentation)

• Salivary gland massage
• Sialogogues (substances that stimulate salivary flow)
• Hydration
• Oral analgesics for pain control
• Antibiotics if infection is present 3

2. Minimally Invasive Approaches (for accessible stones)

• Sialendoscopy: Endoscopic removal of stones, particularly effective for smaller stones

  • Success rate of 98% for parotid stones when used alone 4
  • Can remove about 5% of submandibular stones when used alone 4

• Transoral stone removal:

  • Most common approach for submandibular stones (92% of cases)
  • Long-term success rate ≥90% 4

• Combined approaches:

  • Sialendoscopy with incisional technique (89% success rate for parotid stones) 4

3. Advanced Techniques

• Extracorporeal shock wave lithotripsy (ESWL):
  • Used for 52% of parotid stones with 79% long-term success rate
  • More effective for parotid stones (57% success) than submandibular stones (33% success) 5

4. Surgical Gland Removal (last resort)

• Submandibular gland removal: Required in only 4% of submandibular stone cases 4
• Parotidectomy: Required in only 4% of parotid stone cases 4

Stone Location Considerations

• Submandibular gland stones (84% of all salivary stones):

  • 90% located in Wharton's duct 2
  • Transoral removal is most effective 4

• Parotid gland stones (13% of all salivary stones):

  • More often located within the gland itself 2
  • Sialendoscopy and ESWL are more commonly used 4

Complications and Considerations

• If left untreated, salivary stones can lead to chronic sialadenitis and glandular atrophy 3
• Gland-preserving techniques should be prioritized whenever possible 4
• Antimicrobial prophylaxis should be administered prior to invasive procedures based on prior culture results and local antibiogram 1
• If purulent discharge is encountered during any procedure, it should be aborted, appropriate drainage established, and antibiotic therapy continued 1

Follow-up

• Monitor for symptom resolution
• Evaluate for recurrence of stones or development of chronic sialadenitis
• Long-term success rates for gland-preserving techniques range from 79-98% depending on the method and stone location 4

Modern management of sialolithiasis has evolved significantly, with gland-preserving techniques now being the standard of care rather than gland removal, which is reserved only for cases where less invasive approaches have failed.