What is the treatment for salivary stones (sialolithiasis)?

Treatment of Salivary Stones (Sialolithiasis)

The primary treatment for salivary stones is surgical removal through an intraoral approach, with the specific technique determined by the stone's size and location. 1

Diagnostic Approach

• Salivary stones (sialoliths) present with characteristic symptoms including intermittent pain and swelling that typically occurs before eating 1
• Diagnosis is confirmed through bimanual palpation of the affected salivary gland 1
• Ultrasound is the standard imaging technique to confirm location and size of salivary stones and should be performed by trained personnel 1
• CT scan may be considered if there's concern about involvement of adjacent structures 1

Treatment Algorithm Based on Stone Size and Location

Small, Easily Accessible Stones

• Conservative management may be attempted first:
  • Salivary gland massage to promote stone expulsion 2
  • Use of sialogogues (substances that stimulate salivary flow) 2
  • Hydration and oral analgesics for symptom management 3
  • Antibiotics if infection is present 3

Larger or Less Accessible Stones

• Minimally invasive techniques:
  • Basket retrieval of stones located in the duct 3
  • Sialendoscopy (endoscopic removal) for stones accessible through the duct 3
  • Salivary lithotripsy (shock wave therapy) to fragment larger stones 3

Very Large Stones (>10mm)

• Surgical intervention is typically required:
  • Complete surgical removal of the affected gland may be necessary for unusually large stones (>10mm) 4
  • Submandibular gland removal is performed via an extraoral approach for large stones embedded in the gland 5

Anatomical Considerations

• Submandibular gland is most commonly affected (84% of cases) 2
  • 90% of submandibular stones are located in Wharton's duct 2
• Parotid gland stones account for approximately 13% of cases 2
  • Parotid stones are more often located in the gland itself rather than the duct 2

Post-Procedure Care

• Oral rinses with 0.1% chlorhexidine solution after the procedure and daily during healing 1
• Avoid spicy, acidic, or hot foods that may cause discomfort 1
• Maintain regular oral hygiene to keep the wound clean 1

Potential Complications

• If left untreated, salivary stones can lead to chronic sialadenitis (inflammation of the salivary gland) 3
• Glandular atrophy may occur with long-standing obstruction 3
• Recurrent infections may necessitate more aggressive treatment 6

Clinical Pearls and Pitfalls

• Stones larger than 5mm in diameter often require surgical intervention rather than conservative management 4
• Submandibular stones are more common due to anatomical factors: the duct is longer, saliva flows against gravity, and the saliva is more alkaline with higher calcium content 4
• Complete removal of the affected gland provides favorable outcomes for very large stones that cannot be managed with minimally invasive techniques 5