Sialolithiasis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]  ; Mehrian Jafarizade, M.D [3]

Sialolithiasis was first discovered by Küttner, a German physician, in 1896 during investigation of chronically swollen submandibular gland. Sialadenoscope were used for the first time in 1991. Sialolithiasis is the presence of stones within the salivary glands or the salivary gland ducts.The exact pathogenesis of sialolithiasis is not fully understood, but the relative stagnation of salivary flow and calcium concentration may be important. Almost 75 percent of sialolithiasis cases are single. 3 percent of stones are bilateral and most of them are located in parotid glands. Stone formation is 80 to 90 percent in the submandibular gland, 6 to 20 percent in the parotid glands and 1 to 2 percent in the sublingual or minor salivary glands. The exact etiology of sialolithiasis is not well understood, but the relative stagnation of salivary flow, and calcium concentration may be important. Sialolithiasis should be differentiated from other diseases that cause swelling in salivary glands, such as acute bacterial sialadenitis, chronic bacterial sialadenitis, viral sialadenitis, human immunodeficiency virus, radiation, and systemic diseases such as, sarcoidosis, and sjögren’s syndrome. Common risk factors in the development of sialolithiasis include dehydration, duiretics, local trauma, sjögrens. Sialolithiasis is mainly diagnosed by history and physical examination. Diagnosis can be confirmed by computed tomography, ultrasound, magnetic resonance sialography, conventional sialography. High resolution noncontrast computed tomography (CT) scanning is the study of choice for the diagnosis of sialolithiasis. Conservative treatment is the first line of therapy in the most patients. The most commonly used treatment options are hydration, moist heat, gland massage, and pain control. Antibiotics can be used in the case of superimposed infection. Many cases of sialolithiasis may not be cured by using medical therapy alone; invasive, or open surgery methods can be used for the salivary gland stones. Most commonly used methods are sialoendoscopy, laser lithotripsy, and stone removal with wire basket. If all of above methods fail, open surgical intervention should be used.

Sialolithiasis was first discovered by Küttner, a German physician, in 1896 during investigation of chronically swollen submandibular gland. Sialadenoscope were used for the first time in 1991.

There is no established system for the classification of sialolithiasis, but it may be classified according to the location of the stone, submandibular glands, parotid glands, and sublinguals or minor salivary glands ; or radiographic charachteristics: radiopaque, or radiolucent.

Sialolithiasis is the presence of stones within the salivary glands or the salivary gland ducts.The exact pathogenesis of sialolithiasis not fully understood but the relative stagnation of salivary flow and calcium concentration may be important. Almost 75 percent of sialolithiasis cases are single. 3 percent of stones are bilateral and most of them are located in parotid glands. Stone formation is 80 to 90 percent in the submandibular gland, 6 to 20 percent in the parotid glands and 1 to 2 percent in the sublingual or minor salivary glands. Sialoadenitis is inflammation of a salivary gland. Acute sialoadenitis may be caused by viral or bacterial infection. Chronic sialoadenitis is caused by repeated episodes of inflammation. On gross pathology, hard yellow -white spherical depositions usually less than 1 cm are seen. On microscopic pathology, dilated ducts with squamous metaplasia or calculi are usually present.

The exact etiology of sialolithiasis is not well understood, but the relative stagnation of salivary flow and calcium concentration may be important.

Sialolithiasis should be differentiated from other diseases that cause swelling in salivary glands, such as acute bacterial sialadenitis, chronic bacterial sialadenitis, viral sialadenitis, human immunodeficiency virus, radiation, and systemic diseases such as, sarcoidosis, and sjögren’s syndrome.

The incidence of sialolithiasis is approximately 100 per 100,000 individuals in autopsy studies worldwide. The prevalence of sialolithiasis is approximately 450 per 100,000 individuals worldwide. Sialolithiasis commonly affects individuals between the ages of 30 and 60 years. There is no racial predilection to sialolithiasis. Men are more commonly affected by sialolithiasis than women.

Common risk factors in the development of sialolithiasis include dehydration, duiretics, local trauma, sjögrens.

There is insufficient evidence to recommend routine screening for sialolithiasis.

If left untreated, patients with sialolithiasis may progress to develop secondary infection and chronic sialadenitis. Common complications of sialolithiasis include infection and recurrence. Prognosis is generally good.

Sialolithiasis is mainly diagnosed by history and physical examination. Diagnosis can be confirmed by computed tomography, ultrasound, magnetic resonance sialography, conventional sialography. High resolution noncontrast computed tomography (CT) scanning is the study of choice for the diagnosis of sialolithiasis.

A positive history of intermittent pain and hard lumps is suggestive of sialolithiasis. The most common symptoms of sialolithiasis include pain and swelling. Less common symptoms of sialolithiasis include painless swelling, pain without swelling and bad breath.

Patients with sialolithiasis usually appear normal. Physical examination of patients with sialolithiasis is usually remarkable for tenderness of the involved gland, palpable hard lump and pus discharging from the duct in cases of acute bacterial sialadenitis.

There are no diagnostic laboratory findings associated with sialolithiasis. In the case of superimposed inflammation and infection, high ESR or leukocytosis may be seen.

There are no ECG findings associated with sialolithiasis.

An x-ray may be helpful in the diagnosis of sialolithiasis. Radiopaque stones can be seen in x-rays.

Ultrasound may be helpful in the diagnosis of sialolithiasis. Findings on ultrasound suggestive of sialolithiasis, include hyperechoic points or lines with distal acoustic shadowing and dilation of the excretory duct.

Head and neck CT scan is the study of choice for the diagnosis of sialolithiasis. Findings on CT scan suggestive of sialolithiasis include hyperdensity of gland with stranding and enlargement of the gland in acute obstruction. In chronic sialolithiasis, fatty atrophy and reduction in salivary gland parenchymal volume may be seen.

Magnetic resonance sialography may be helpful in the diagnosis of sialolithiasis Findings on Magnetic resonance sialography suggestive of sialolithiasis include low signal regions outlined by saliva (high signal regions) on T2 weighted images. MRI can distinguished acute from chronic obstruction.

Sialography may be helpful in the diagnosis of sialolithiasis. Findings on sialography suggestive of sialolithiasis include filling defect and the contrast agent not passing through the duct due to complete obstruction.

There are no other diagnostic studies associated with sialolithiasis.

Conservative treatment is the first line of therapy in the most patients. The most commonly used treatment options are hydration, moist heat, gland massage, and pain control. Antibiotics can be used in the case of superimposed infection. Many cases of sialolithiasis may not be cured by using medical therapy alone; invasive, or open surgery methods can be used for the salivary gland stones.

Many cases of sialolithiasis may not be cured by using medical therapy alone; invasive, or open surgery methods can be used for the salivary gland stones. Most commonly used methods are sialoendoscopy, laser lithotripsy, and stone removal with wire basket. If all of above methods fail, open surgical intervention should be used.

Effective measures for the primary prevention of sialolithiasis include healthy oral care regimen and increased water intake.

Effective measures for the secondary prevention of sialolithiasis include healthy oral care regimen, treatment of underlying disease and avoiding anticholinergic and diuretic medications.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

Sialolithiasis was first discovered by Küttner, a German physician, in 1896 during investigation of chronically swollen submandibular gland. Sialadenoscope were used for the first time in 1991.

Following are a few important aspects about the history of sialolithiasis.

• In 1543, Andreas Vesalius, was the first person who used the name salivary gland.
• Sialolithiasis was first discovered by Küttner, a German physician, in 1896 during investigation of chronically swollen submandibular gland.

• In 1991 for the first time sialoendoscopes were used.^[1]
• In 1765, Lorenz Heister described the first parotidectomy for salivary stones. ^[2]
• In1996, Lomas et al. decribed magnetic resonance sialography for diagnosis of sialolithiasis.^[3]
• George Mc Clellan performed the first parotidectomy due to cancer in the USA in 1805.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

There is no established system for the classification of sialolithiasis, but it may be classified according to the location of the stone, submandibular glands, parotid glands, and sublinguals or minor salivary glands ; or radiographic charachteristics: radiopaque, or radiolucent.

• There is no established system for the classification of sialolithiasis, but sialolithiasis may be classified according to location of the stone.^[1]

Gland	Percent of stones
Submandibular glands	80 to 90
Parotid glands	6 to 20
Sublinguals or minor salivary glands	1 to 2

• Submandibular stones can be classified further as anterior or posterior in relation to the mandibular first molar teeth.
• Stones may be radiopaque, where they be visible on radiographs or radiolucent where they will not show up on radiography
• Stones may also be symptomatic or asymptomatic.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

Sialolithiasis is the presence of stones within the salivary glands or the salivary gland ducts.The exact pathogenesis of sialolithiasis not fully understood but the relative stagnation of salivary flow and calcium concentration may be important. 75 percent of sialolithiasis cases are single. 3 percent of stones are bilateral and most of them are located in parotid glands. Stone formation is 80 to 90 percent in the submandibular gland, 6 to 20 percent in the parotid glands and 1 to 2 percent in the sublingual or minor salivary glands. Sialoadenitis is inflammation of a salivary gland. Acute sialoadenitis may be caused by viral or bacterial infection. Chronic sialoadenitis is caused by repeated episodes of inflammation. On gross pathology, hard yellow -white spherical depositions usually less than 1 cm are seen. On microscopic pathology, dilated ducts with squamous metaplasia or calculi are usually present.

• Presence of stones within the salivary glands or the salivary gland ducts.

• The exact pathogenesis of sialolithiasis not fully understood but the relative stagnation of salivary flow and calcium concentration may be important.

• Component of salivary stones include: ^[2]
  • Calcium phosphate
  • Hydroxyapatite
  • Magnesium
  • Ammonium
  • Potassium

• Parotid, submandibular, sublingual glands and minor salivary glands are prone to the development of stones.^[3][4]

• Parotid glands and stensen ducts are located anterior to the external auditory canal.

• Submandibular glands and wharton ducts are located beneath the floor of the mouth.

• Sublingual glands are located beneath the mucous membrane of the floor of the mouth.

• 75 percent of sialolithiasis cases are single

• 3 percent of stones are bilateral and most of them are located in parotid glands.

• Submandibular stones are the largest ones and are often located in the wharton ducts.

• Parotid stones are the smaller than submandibular stones, and they are more located within the glands and they are more multiple.

• Stone formation is 80 to 90 percent in the submandibular glands, 6 to 20 percent in the parotid glands, 1 to 2 percent occur in the sublingual or minor salivary glands.^[5]

• Stones occur equally on the right and left sides.

• Sjögrens^[6]
• Medications such as anticholinergics^[6]

• On gross pathology, hard yellow -white spherical depositions usually less than 1 cm in diameter is characteristic finding of sialolithiasis.^[6]

• On microscopic histopathological analysis,
  • Dilated ducts with squamous metaplasia or calculi
  • Chronic inflammation
  • Destruction of acini
  • Fibrosis in sialadenitis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

The exact etiology of sialolithiasis is not well understood, but relative stagnation of salivary flow and calcium concentration may be important.

• Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no life-threatening causes of sialolithiasis.

The exact etiology of sialolithiasis is not well understood, but it is thought that the more alkaline, viscous saliva with relative stagnation of salivary flow and calcium concentration may be important.^[1]

Submandibular glands are more prone to sialolithiasis because of long and sinuous position of Wharton’s duct.^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mehrian Jafarizade, M.D [2]

Sialolithiasis must be differentiated from other diseases that cause swelling in salivary glands, such as acute bacterial sialadenitis, chronic bacterial sialadenitis, viral sialadenitis, human immunodeficiency virus, radiation, and systemic diseases such as, sarcoidosis, and sjögren’s syndrome.

Sialolithiasis must be differentiated from other diseases that cause swelling in salivary glands, such as acute bacterial sialadenitis, chronic bacterial sialadenitis, viral sialadenitis, human immunodeficiency virus, radiation, and systemic diseases such as, sarcoidosis, and sjögren’s syndrome.^{[1][2][3][4][5][6][7][8]}

Diseases	Symptoms and sign							Laboratory Findings		Other Findings
	Onset	Unilateral/Bilateral	Pain	Swelling	Tenderness	Purulent discharge	Common site of involvement	ESR	Leukocytosis
Sialolithiasis	Acute	Unilateral	+	+	+	–	Submandibular gland	↑/NL	↑/NL	Radio-opaque in X-ray
Acute bacterial sialadenitis	Acute	Unilateral	+	+	+	+	Parotid	↑	↑	Other sign of infection may be present
Chronic bacterial sialadenitis	Chronic	Unilateral	+	+	–	+/-	Parotid	↑	↑	Other sign of infection may be present
Viral sialadenitis	Acute	Bilateral	+	+	+	–	Parotid	↑	↑	Coryza symptoms
Human immunodeficiency virus	Acute	Bilateral	+	+	–	–	Parotid	NL	NL	Other systemic findings of HIV/ check ELISA
Radiation sialadenitis	Acute	Unilateral	+	+	+	–	Depends on the treatment field	NL	NL	History of radiation in the salivary gland site
Salivary gland tumors	Subacute	Unilateral	–	+	–	–	Parotid	↑/NL	↑/NL	Advance age
Sarcoidosis	Gradual	Bilateral	–	+	–	–	Parotid	↑	↑	Systemic findings in other organs
Sjögren’s syndrome	Gradual	Bilateral	+/-	+	–	–	Parotid or submandibular glands	↑/NL	↑/NL	Dry eye/dry mouth
Malnutrition	Gradual	Bilateral	+/-	+	–	–	Parotid	NL	NL	Systemic findings in other organs

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

The incidence of sialolithiasis is approximately 100 per 100,000 individuals in autopsy studies worldwide. The prevalence of sialolithiasis is approximately 450 per 100,000 individuals worldwide. Sialolithiasis commonly affects individuals between the ages of 30 and 60 years. There is no racial predilection to sialolithiasis. Men are more commonly affected by sialolithiasis than women.

• The incidence of sialolithiasis is approximately 100 per 100,000 individuals in autopsy studies worldwide^[1]

• The prevalence of sialolithiasis is approximately 450 per 100,000 individuals worldwide.^[2]

• Sialolithiasis commonly affects individuals between the ages of 30 and 60 years.^[3]
• Sialolithiasis is rare in children.^[4]

• There is no racial predilection to sialolithiasis.^[5]

• Men are more commonly affected by sialolitithiasis than women. The men to women ratio is approximately twice.^[6]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Mahda Alihashemi M.D. [2]

Common risk factors in the development of sialolithiasis include dehydration, duiretics, local trauma, sjögrens.

Common risk factors in the development of sialolithisis include:^[1]

• Dehydration
• Diuretics
• Local trauma
• Sjögrens
• Gout
• Anticholinergic medications
• Smoking
• History of nephrolithiasis
• Chronic periodontal disease
• Head and neck radiotherapy^[2]

• Less common risk factors in the development of sialolithiasis include:
  • Hypercalcemia^[3]
  • Being elderly^[4]
  • Renal impairment^[5]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

If left untreated, patients with sialolithiasis may progress to develop secondary infection and chronic sialadenitis. Common complications of sialolithiasis include infection and recurrence. Prognosis is generally good.

• If left untreated, patients with sialolithiasis may progress to develop secondary infection and chronic sialadenitis and gland atrophy.^[1]

• Common complications of sialolithiasis include:^[2]
  • Infection
  • Recurrence
  • Sialadenitis ( inflammation of salivary gland)
  • Abscess

• Prognosis is generally good but very small number of patients with secondary infection may develop cellulitis, abscess and compromised airway.

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