What is the preferred initial treatment for a salivary gland stone?

Preferred Initial Treatment for Salivary Gland Stones

Conservative, gland-preserving minimally invasive techniques—specifically sialendoscopy with or without adjunctive procedures—should be the first-line treatment for salivary stones, achieving stone clearance in 80-90% of cases while avoiding gland excision in over 95% of patients. 1, 2

Treatment Algorithm Based on Stone Characteristics

Initial Diagnostic Approach

• High-resolution ultrasound is the standard imaging modality to localize the stone and assess duct anatomy 3
• Diagnostic sialendoscopy confirms stone presence and duct anatomy while allowing immediate therapeutic intervention 2

Stone Location and Size-Based Treatment Strategy

For Submandibular Stones:

• Transoral stone removal is the primary method for mid-to-distal duct stones, successfully removing 92% of submandibular stones with long-term success rates ≥90% 2
• Sialendoscopy alone removes 5% of submandibular stones when they are small and mobile 2
• Radiologically guided basket retrieval under fluoroscopy achieves complete stone removal in 64% of cases, with symptom relief in 82% of patients where any portion of stone is removed 4
• Only 4% of submandibular cases ultimately require gland excision when minimally invasive techniques fail 2

For Parotid Stones:

• Sialendoscopy alone removes 22% of parotid stones with 98% long-term success 2
• Combined sialendoscopy with incisional technique removes 26% with 89% success 2
• Extracorporeal shock-wave lithotripsy (ESWL) treats 52% of parotid stones with 79% success, particularly for larger stones (average 6.76 mm) 5, 2
• Only 4% of parotid cases require parotidectomy 2

When Initial Techniques Fail

Pneumatic Lithotripsy:

• When conventional sialendoscopic instruments (basket/forceps) fail to retrieve stones, intraductal pneumatic lithotripsy fragments 88% of calculi without major complications 6
• All successfully treated glands return to normal function 6

ESWL as Salvage:

• Complete stone disintegration occurs in 67% of submandibular stones and 100% of parotid stones treated with ESWL 5
• No anesthesia, sedatives, or analgesics required; performed as outpatient procedure 5
• Minor complications include skin petechiae (transient), gland swelling, and self-limiting ductal bleeding in 29% of patients 5

Critical Success Factors

Stone Characteristics Predicting Success

• Mobile stones respond best to basket retrieval 4
• Fixed stones within the duct are the most common reason for basket retrieval failure (22% failure rate) 4
• Stone size averaging 6.76 mm can still be successfully fragmented with ESWL 5

Overall Outcomes with Minimally Invasive Approach

• Complete stone elimination in 80.5% of all cases 1
• Partial stone clearance in 16.7% 1
• Gland excision required in only 2.9% of symptomatic patients with treatment failure 1
• Treatment shifts to outpatient or day-case setting 1

When to Consider Gland Excision

Adenectomy should be reserved for the small minority (2.9-4%) where:

• All minimally invasive techniques have failed 1, 2
• Symptoms persist despite partial stone clearance 1
• Recurrent infections compromise gland function despite stone removal 2

Common Pitfalls to Avoid

• Do not proceed directly to gland excision without attempting minimally invasive techniques first—this outdated approach unnecessarily sacrifices functional glands 1
• Do not abandon treatment after single technique failure—combining methods (sialendoscopy + transoral removal, or sialendoscopy + ESWL, or adding pneumatic lithotripsy) dramatically improves success rates 2, 6
• Do not assume fixed stones require surgery—ESWL or pneumatic lithotripsy can fragment stones that cannot be retrieved intact 6, 5