What are the diagnostic and intervention methods for salivary stones in a primary care setting?

Management of Salivary Stones in Primary Care

In primary care, diagnose salivary stones through bimanual palpation and ultrasound imaging, then manage small accessible stones conservatively with duct massage, hydration, and sialogogues, while referring larger or inaccessible stones to ENT for surgical removal. 1

Diagnosis

Clinical Presentation

• Look for intermittent pain and swelling that occurs just before or during eating - this is the hallmark symptom pattern 1
• Pain typically worsens with meals due to increased salivary flow against the obstruction 2
• Palpable mass or firmness along the duct may be present 1

Physical Examination

• Perform bimanual palpation of the floor of mouth and submandibular area to feel for stones 1
• Examine for gland swelling and tenderness 2
• Check for purulent discharge from the duct opening, which suggests secondary infection 2

Imaging

• Ultrasound is the first-line imaging modality and should be performed by trained personnel 1, 3
• Ultrasound detects stones in over 90% of cases 4
• Order ultrasound to confirm stone location and size before determining treatment approach 1
• CT scan without contrast can be considered if multiple tiny stones are suspected or ultrasound is inconclusive 3

Primary Care Interventions

Conservative Management (For Small, Accessible Stones)

The primary axiom is "treat the gland, not the stone" 2

• Prescribe antibiotics if signs of infection are present (purulent discharge, fever, significant gland swelling) 2
• Recommend sialogogues (lemon drops, sour candies) to stimulate saliva flow and potentially flush small stones 2
• Instruct patients to apply warm compresses to the affected gland 2
• Teach mechanical stimulation through gentle duct massage ("milking" the duct from posterior to anterior) 5, 2
• Ensure adequate hydration 2

When to Refer to ENT

Refer to otolaryngology for:

• Stones larger than 5mm 6
• Stones not accessible through the oral cavity 1
• Failure of conservative management after 48-72 hours 2
• Recurrent episodes 5
• Stones located posteriorly in the gland parenchyma rather than the duct 5, 6

Surgical Options (Specialist Management)

Intraoral Approach

• Small stones under the tongue should be surgically removed through an intraoral approach 1
• The specific technique depends on stone size and location 1
• This preserves gland function 4

Advanced Techniques (Specialist-Performed)

• Interventional sialendoscopy has 85-95% success rates, especially when combined with other modalities 4
• Extracorporeal shock wave lithotripsy (ESWL) is available for appropriate cases 4
• Gland excision is reserved for large stones (>10mm) within the gland parenchyma or cases with irreversible gland damage 5, 6

Post-Procedure Care (If Performed in Primary Care Setting)

• Rinse with 0.1% chlorhexidine solution for 1 minute after the procedure and daily during healing 1
• Advise avoiding spicy, acidic, or hot foods 1
• Maintain regular oral hygiene 1

Common Pitfalls

• Don't attempt to remove stones that are not clearly visible and accessible at the duct opening - this risks duct injury and should be left to specialists 1
• Don't delay antibiotics if infection is present - submandibular gland infections can progress rapidly 2
• Don't rely solely on plain radiography - many stones are radiolucent and ultrasound is far superior 3