What is the recommended treatment for a patient with salivary gland stones?

Treatment of Salivary Gland Stones (Sialolithiasis)

For salivary gland stones, treatment should be stratified by stone size and location: stones <5mm accessible in the duct should be removed via intraoral approach with duct preservation; stones 5-10mm require sialendoscopy with laser lithotripsy when feasible; and stones >10mm or those causing recurrent symptoms despite conservative measures warrant surgical gland excision. 1, 2, 3

Initial Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis and stone characteristics:

• Perform bimanual palpation to assess for a palpable stone in the duct, particularly looking for tenderness along Wharton's duct (submandibular) or Stensen's duct (parotid) 1
• Obtain ultrasound imaging as the standard first-line imaging modality to confirm stone location, size, and number—this must be performed by trained personnel 1
• Assess for characteristic symptoms: intermittent pain and swelling that occurs just before or during meals, with potential unpleasant taste if infection is present 1, 2
• Consider CT imaging only if there is concern about involvement of adjacent structures or skull base 4

Treatment Algorithm Based on Stone Characteristics

Small, Accessible Stones (<5mm in the duct)

Conservative management is the first-line approach:

• Salivary gland massage combined with sialogogues (substances that stimulate saliva production) to encourage stone passage 3
• "Milking" of the duct to manually express small stones 5
• Intraoral surgical removal if the stone is easily palpable through the oral mucosa—make an incision over the stone, dissect through mucosa to access the duct, and remove the stone while preserving gland function 1, 2

Medium-Sized Stones (5-10mm)

Sialendoscopy with laser lithotripsy is preferred when available:

• Holmium:YAG laser lithotripsy via sialendoscopy can effectively fragment stones for removal, though this is time-consuming and requires multiple fragmentations for stones >4mm 6
• Wire basket or grasping forceps are used to remove fragmented pieces 6
• This approach preserves gland function and is minimally invasive 6

Important caveat: Multiple large stones in a single gland typically warrant gland excision rather than endoscopic attempts, as the procedure becomes excessively time-consuming with diminishing success rates 6

Large Stones (>10mm) or Intraglandular Stones

Surgical excision is the definitive treatment:

• Stones >10mm are considered "unusual size" and should be reported as such 7
• For submandibular gland stones: Complete surgical removal of the gland with the stone via extraoral approach yields favorable outcomes 5, 7
• For accessible ductal stones: Transoral surgical removal with duct incision can be attempted if the stone is in the anterior duct, with immediate confirmation of salivary secretion return post-operatively 2

Post-Operative Care (Following Intraoral Stone Removal)

Wound care and infection prevention are critical:

• Clean the surgical site with 0.1% chlorhexidine solution immediately post-procedure 1
• Oral rinses with 0.1% chlorhexidine 0.1% solution for 1 minute daily during the healing period 1
• Avoid spicy, acidic, or hot foods that may irritate the surgical site 1
• Maintain meticulous oral hygiene to prevent wound contamination 1
• Confirm return of salivary secretion immediately after surgery to ensure gland function is preserved 2

Management of Infected Salivary Gland (Sialadenitis)

If infection complicates sialolithiasis:

• Cephalosporins are superior to ampicillin-sulbactam due to better salivary penetration 8
• For suspected MRSA: Use vancomycin 30 mg/kg/day IV in 2 divided doses or clindamycin 600-900 mg every 8 hours IV 8
• Surgical intervention is necessary if abscess forms, if no improvement occurs after 48-72 hours of appropriate antibiotics, or if necrotizing infection develops 8

Key Clinical Pitfalls to Avoid

• Do not rely solely on patient symptoms to determine stone size or location—imaging is mandatory as subjective symptoms often do not correlate with objective findings 1
• Do not attempt prolonged endoscopic procedures for multiple large stones—this leads to excessive operative time with poor outcomes; proceed directly to gland excision 6
• Do not use ampicillin-sulbactam alone for sialadenitis due to inadequate salivary penetration 8
• Always confirm gland function preservation immediately after conservative stone removal by observing salivary secretion 2