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Sialolithiasis  or  Salivary Stone

Salivary Stones

return to: Salivary SwellingSalivary Gland Surgery ProtocolsSalivary Ultrasound

see also: Combined Open and Endoscopic Removal of Parotid Stone (sialendoscopy case example) and Salivary Stone Removal with Ductoplasty from Submandibular Gland

video (with spoken audio) of procedures: Sialendoscopy with Stone Removal HOW I DO IT



    1. Definition:  Sialolithiasis = "Salivary stone"      (see also: Salivary Swelling)
      1.  Sialolith (stone) composed of variable amounts of organic cellular debris, glycoproteins, and mucopolysaccharides.
      2. Sialoliths (stone) also composed of variable amounts of inorganic materials calcium, magnesium, manganese, copper, iron and phosphate.
    2. Prevalence / Incidence
      1. Estimated 1% of the population are affected (autopsy studies) (ref Williams1999)
      2. Incidence of 1 per 15,000 to 30,000 based on hospital admission statistics in England (ref Escudier 1999)
      3. Incidence of 1 per 10,000 to 20,000 by personal observation by Dr. Marchal (Marchal 2003)
      4. Calcifications identified by CT imaging of the parotid glands that occur in the parenchyma and are not associated with sialadenitis are not considered 'sialoliths'
        1. Buch et al (2014) identified 4% of patients had incidental parotid calcifications through review of non-contrast head CT scans done on 1,571 patients for reasons other than sialadentitis 
        2. Associated with the presence of calcifications were: HIV, alcoholism, chronic kidney disease, autoimmune disease and elevated alkaline phosphatase
    3. Etiology
      1. Multifactorial causes
        1. Primary pathophysiological process is a decrease in the parotid salivary secretion, both volume and flow rate.(ref Motamed 2003) due to
          1. Obstruction: strictures of the duct or, external pressure on the main duct (tumor), mucus plugging, and congenital abnormalities of the duct.
          2. Other: Radiation damage and immune-mediated diseases.
      2. A decrease in salivary secretion results in stasis; with retrograde bacterial contamination of the ductal system.
        1. Bacterial infection may lead to destruction and fibrosis of gland architecture of acinar elements and ductal ectasia.
          1. Acute suppurative sialadenitis - singular acute event may precipitate others or progress to chronic sialadenitis 
          2. Chronic sialadenitis is more common and often progressive
          3. Sialolithiasis is both a cause and a consequence of chronic recurring sialadenitis (ref Travis 1977)
      3. PCR study found bacterial DNA of Streptococcus genus in all examined sialoliths. (ref Teymoortash 2002)
      4. Epidemiology studies
        1. Tobacco smoking only positive correlation in study of nutritional habits and other behaviors (Marchal 2003)
        2. No link between hypercalcemia or ingestion of hard water (Marchal 2003)
    4. Diagnosis
      1. History of recurrent painful parotid swelling
      2. Physical exam: swollen gland, palpable stone, massage of gland to produce saliva.
      3. Consider blood studies to evaluate auto-immune evaluation: rheumatoid factor, ANA, SS-A, SS-B antibodies.
      4. Radiographic imaging  (see: Sialograms and Sialography )
        1. Ultrasound: advantages - potential for concurrent U/S guided FNA; absence of radiation exposure; inexpensive
        2. MRI: advantages: best study for anatomic definition of salivary glands for tumor, absence of radiation exposure; evolving technology permits 'MRI sialogram"
        3. CT: controversy w or w/o contrast - currently at UIHC: employ contrast; best for defining lymphadenopathy (see Sialolithiasis Radiology)
          1. Phleboliths may be misinterpreted as sialoliths; sialendoscopy or sialogram will resolve (ref Su 2009a)
        4. Sialogram: useful to identify stones - best definition of intraductal architecture; occasionally proves therapeutic as well as diagnostic (duct dilation, 'flushing out gland') (ref Gerry RG 1955)
      5. Sialendoscopy
  2. MANAGEMENT < >Conservative managementAntibiotics / analgesics / mouthwashes / sialogogues / massaging the glandAntibiotic options cover staph aureus: Augmentin, clindamycin (ref Motamed 2003)Mouthwashes? Failing conservative managementDecision to intervene surgically is dependent on the requests of an informed patient and the clinicians successful correlation of symptoms with the pathologic process of sialectasis. Facial pain in the absence of classic swelling associated with meals may be caused by processes other than salivary disorders.Option: Have the patient keep a log book of the swelling episodes and pain intensity.  Counsel re: gland removal as a a definitive invasive but usually (not always) successful approach with an emphasis on alternativesSialendoscopy with laser fragmentation and basket removal -Small stones (< 3 mm) reported 97% success rate with wire basket removal w/o fragmentation (ref Marchal 2001)Larger stones (> 3 mm) reported 35% success with wire basket removal w/o fragmentation; increases to 72% with fragmentation; unusual to approach larger stones without attempted laser fragmentationLithotripsyAvailable in Germany - external lithotripsy may permit spontaneous extrusion of fragmented parotid stones in 40% of casesOften done along with sialendoscopy to assist in removal of stone fragments (ref Luers 2009)Pneumatic LithotripsyOpen Approaches to Parotid Stones and Lab Preparation Missouri Sialendoscopy Course April 17 2015
  3. Salivary Stone Removal with Ductoplasty from Submandibular Gland
  4. Parotidectomy / Submandibular Gland Resection
    1. see also: Case Example 2 Retrograde Sialendoscopy to Prevent Retained Ductal Stone with Submandibular Gland Resection
    2. see also: Case Example Retained Submandibular Stone After Submandibular Gland Resection with neck fistula

Classification of stone location (Goncalves et al 2017)

Sialolithiasis Definition:

from Goncalves et al "Sonography in Diagnosis of Sialolithiasis" J Ultrasound Med 2017;36:2227-2235

 "Hyperechoic reflexes with distal signal loss along the course of the duct"

Submandibular sonographic landmarks

Partoid sonographic landmarks

Intraparenchymal stone

proximally located in parenchyma proximally located in parenchyma

Proximal/hilar stone

1 cm proximal to 1 cm distal to the edge of the mylohyoid muscle 1 cm proximal to the posterior edge of masseter to middle of masseter muscle

Middle third

1 cm distal to the edge of the mylohyoid muscle to the sublingual gland middle of masseter muscle to to anterior edge of masseter

Distal duct including papillary region

from the main mass of the sublingual gland to the papilla anterior edge of masseter muscle to papilla
    1. Williams, M: Sialolithiasis in  pp 819 - 835 The Otolaryngology Clinics of North America  Salivary Gland Disease ed Rice DH and Eisele D Vol 32  number 5  October 1999
    2. Marchal F, Dulgeuerov P, Becker M, Barki G, Disant F, Lehmann W. Specificity of parotid sialendoscopy. Laryngoscope 2001;111:264-71
    3. Iro H, Waitz G, Nitsche N, Benninger J, Schneider T, Ell C.: Extracorporeal piezoelectric shock-wave lithotripsy of salivary gland stones. Laryngoscope 1992;102:492-4
    4. Luers JC, Beutner D: Letter to the editor 'in reference to Lithotripsy for Refractory Pediatric Sialolithiasis (Laryngoscope 2009;119:298-299)  Laryngoscope 2009 August 17 epub
    5. Su Y, Liao G, Wang L, Liang Y, Chu M, and Zheng G: Sialoliths or Phleboliths? Laryngoscope, 119:1344-7, 2009a
    6. Walvekar RR, Carrau R, and Schaitkin B: Endoscopic sialolith removal: orientationand shape as predictors of success. American Journal of Otolaryngology. vol 30, Issue 3 Pages 153-6 (May 2009)
    7. Su, Zu, Liao, Zheng, Cheng, Han and Shan: Salivary gland functional recovery after sialendoscopy. Laryngoscop 2009b Apr:119(4):646-52
    8. Iro H, Zenk J, Escudier MP, Nahlieli O, Capaccio P, Katz P, Brown J, and McGurk M: Outcome of minimally invasive management of salivary calculi in 4,691 patients. Laryngoscope 2009 Feb;119(2):263-8.
    9. Marchal F: A combined endoscopic and external approach for extraction of large stones with preservation of parotid and submandibular glands. Laryngoscope. 2007 Feb;117(2):373-7
    10. Marchal F, Dulguerov P:Sialolithiasis management: the state of the art. Arch Otolaryngol Head Neck Surg. 2003 Sep;129(9):951-6
    11. Escudier MP and McGurk M. Symptomatic sialoadenitis and sialolithiasis in the English population: an estimate of the cost of hospital treatment. Br. Dent J. 1999;186:463-466
    12. Teymoortash A, Wollstein AC, Lippert BM, Peldszus R, Werner JA. Bacteria and pathogenesis of human salivary calculus. Acta Otolaryngol. 2002:122:210-214
    13. Fritsch MH: Algorithms for Treatment of Salivary Gland obstructions Without access to Extracorporeal Lithotripsy. Otolaryngologic Clinics of North America Volume 42, Issue 6, December 2009, pages 1193-1197 mfritsch@iupui.edu
    14. Buch K, Nadgir RN, Fujita A, Tannenbaum AD, Ozonoff A, Sakai O. Clinical associations of incidentally detected parotid gland calcification on CT. Laryngoscope. 2015;125(6):1360-1365. doi:10.1002/lary.25095
    15. Goncalves M, Schapher M, Iro H, Wuest W, Mantsopoulos K, and Koch M: Sonography in the Diagnosis of Sialolithiasis  J Ultrasound Med 2017; 36:2227-2235