How to remove a salivary stone (sialolith) located under the tongue?

Management of Salivary Stones Under the Tongue

Salivary stones (sialoliths) under the tongue should be surgically removed through an intraoral approach, with the specific technique determined by the stone's size and location.1

Understanding Salivary Stones

• Salivary stones (sialoliths) most frequently occur in the submandibular gland (80-84% of cases), with most located in Wharton's duct (90%)2
• Characteristic symptoms include intermittent pain and swelling that typically occurs just before eating1
• Diagnosis is confirmed through bimanual palpation, with imaging (ultrasound) recommended to confirm location and size1

Diagnostic Approach

• Perform bimanual palpation to locate the stone - if in the duct, salivary flow will be slow or absent1
• Ultrasound is the standard imaging technique for salivary stones and should be performed by trained personnel1
• CT scan may be considered if there's concern about involvement of adjacent structures1

Treatment Options Based on Stone Location and Size

For Small, Easily Accessible Stones:

• Conservative management may be attempted first:
  • Salivary gland massage2
  • Use of sialogogues (substances that stimulate salivary flow)2
  • Milking of ducts to encourage stone movement3

For Stones in Wharton's Duct (Submandibular):

• Intraoral endoscopy-assisted sialolithotomy is recommended for stones in the superficial lobe4
  • This procedure preserves gland function while removing the stone4
  • Success rate is high (89.6% stone-free rate in follow-up)4
  • Performed under general anesthesia with mean operation time of 71 minutes4

For Larger or Less Accessible Stones:

• Surgical removal is required3
• For stones >10mm (considered unusually large), more extensive surgical intervention may be necessary5
• In cases where the stone is deeply embedded or multiple stones are present, removal of the entire gland may be required5

Post-Procedure Care

• Clean wound with 0.1% chlorhexidine solution6
• Oral rinses with 0.1% chlorhexidine solution for 1 minute after the procedure and daily during healing6
• Avoid spicy, acidic, or hot foods that may cause discomfort6
• Maintain regular oral hygiene to keep the wound clean6

Potential Complications

• Recurrent episodes of pain (3.3% of patients)4
• Recurrent episodes of gland swelling (10% of patients)4
• Lingual nerve hypesthesia (rare - reported in only 1 patient in a study of 60 patients)4
• Incomplete stone removal requiring additional procedures4

Follow-up Recommendations

• Clinical examination and sonography should be performed to confirm complete stone removal4
• Monitor for recurrence of symptoms (pain, swelling)4
• Assess salivary flow and gland function4