SIALOLITHIASIS

VI UGBOKO FMCDS FWACS

INTRODUCTION
Sialolithiasis refers to non-cancerous stones (calcium-rich crystallized minerals known as salivary calculi or sialoliths) in a salivary gland or duct. Sialolithiasis accounts for more than 50% of diseases of the large salivary glands and is thus the most common cause of acute and chronic infections.

 More than 80% occur in the submandibular gland or its duct 6% in the parotid gland 2% in the sublingual gland or minor salivary glands Most salivary stones are single; however multiple stones may be present.

 There are three pairs of major salivary glands: (i) the parotid glands, (ii) the sublingual glands, (iii) the submandibular glands. In addition to these major glands, there are hundreds of minor salivary glands that are scattered throughout the mouth and throat.

DUCTS
Parotid duct
located by maxillary bone 2nd upper molar) Stensens duct PAROTID GLAND

Submandibular Duct located on end of

sublingual ridge to fill submandibular Whartons duct SUBMAXILLARY

Sublingual duct (several small) located alongside

submandibular duct to

SUBLINGUAL GLAND

Sialolithiasis
Sialolithiasis results in a mechanical obstuction of the salivary duct Is the major cause of unilateral diffuse parotid or submandibular gland swelling2

Sialolithiasis Incidence
It is estimated that it affects 12 in 1000 of the adult population. Escudier & McGurk 1:15-20 000 Marchal & Dulgurerov 1:10-20 000 Males are affected twice as much as females Sialolithiasis remains the most frequent reason for submandibular gland resection

Sialolithiasis
The exact pathogenesis of sialolithiasis remains unknown. Thought to form via.
an initial organic nidus that progressively grows by deposition of layers of inorganic and organic substances.
Salivary stagnation Epithelial injury along the duct resulting in sialolith formation, which acts as a nidus for further stone formation Precipitation of calcium salts

Pathogenesis ...........
Traditional theories suggest that the formation occurs in two phases: a central core and a layered periphery. The central core is formed by the precipitation of salts, which are bound by certain organic substances. The second phase consists of the layered deposition of organic and non organic material. Submandibular stones are thought to form around a nidus of mucous, parotid stones are thought to form most often around a nidus of inflammatory cells or a foreign body.

Pathogenesis ...........
Another theory has proposed that an unknown metabolic phenomenon can increase the saliva bicarbonate content, which alters calcium phosphate solubility and leads to precipitation of calcium and phosphate ions.

Pathogenesis ...........
A retrograde theory for sialolithiasis has also been proposed. Aliments, substances or bacteria within the oral cavity might migrate into the salivary ducts and become the nidus for further calcification

Sialolithiasis
May eventually obstruct flow of saliva from the gland to the oral cavity. Acute ductal obstruction may occur at meal time when saliva producing is at its maximum, the resultant swelling is sudden and can be painful.

Sialolithiasis
Gradually reduction of the swelling can result but it recurs repeatedly when flow is stimulated. This process may continue until complete obstruction and/or infection occurs.

Etiology
Water hardness likelihood? Maybe. Hypercalcemiain rats only Xerostomic medicines - anti-histamines, antihypertensives and anti-psychotics Tobacco smoking, positive correlation Smoking has an increased cytotoxic effect on saliva, decreases PMN phagocytic ability and reduces salivary proteins

Etiology
Gout is the only systemic disease known to cause salivary calculi and these are composed of uric acid.

Stone Composition
Organic; often predominate in the center
Glycoproteins Mucopolysaccarides Bacteria! Cellular debris

Inorganic; often in the periphery

Calcium carbonates & calcium phosphates in the form of hydroxyapatite

Parotid (PG) vs. Submandibular Gland (SMG).

Most authorities agree obstructive phenomemnon such as mucous plugs and sialoliths are most commonly found in the SMG
Escudier et al Lustmann et al Rice

Others note that parotid glands are most commonly affected

Reasons sialolithiasis may occur more often in the SMG

Saliva more alkaline Higher concentration of calcium and phosphate in the saliva Higher mucus content Longer duct Anti-gravity flow

Other characteristics:
Despite a similar chemical make-up, 80-90% of SMG calculi are radio-opaque 50-80% of parotid calculi are radiolucent 30% of SMG stones are multiple 60% of Parotid stones are multiple

Other characteristics:
Submandibular stones are 82% inorganic and 18% organic material parotid stones are composed of 49% inorganic and 51% organic material

Clinical presentation
Painful swelling (60%) Painless swelling (30%) Pain only (12%)
Sometimes described as recurrent salivary colic and spasmodic pains upon eating

Clinical History
History of swellings / change over time? Trismus? Pain? Variation with meals? Bilateral? Dry mouth? Dry eyes? Recent exposure to sick contacts (mumps)? Radiation history? Current medications?

Exam: Inspection
Asymmetry (glands, face, neck) Diffuse or focal enlargement Erythema extra-orally Trismus Medial displacement of structures intraorally? Examine external auditory canal (EAC) Cranial nerve testing

Exam: Palpation
Palpate for cervical lymphadenopathy Bimanual palpation of floor of mouth in a posterior to anterior direction
Have patient close mouth slightly & relax oral musculature to aid in detection Examine for duct purulence

Bimanual palpation of the gland (firm or spongy/elastic).

Diagnostics: Plain occlusal film

Effective for intraductal stones, while. intraglandular, radiolucent or small stones may be missed.

Diagnostic approaches
CT Scan: large stones or small CT slices done also used for inflammatory disorders Ultrasound: operator dependent, can detect small stones (>2mm), inexpensive, non-invasive Although US has proven value, sialoliths smaller than 23 mm may be overlooked because an acoustic shadow may be absent

Ultrasound of smg stone

Diagnostic approaches: Sialography

Consists of opacification of the ducts by a retrograde injection of a water-soluble dye. Provides image of stones and duct morphological structure May be therapeutic, but success of therapeutic sialography never documented

Sialography continued
Disadvantages:
irradiation dose pain with procedure Possible perforation infection dye reaction push stone further contraindicated in active infection.

Sialography continued
Digital sialography and digital subtraction sialography are the favored techniques for help in the detection of sialolithiasis of the submandibular duct. Even nonradiopaque sialoliths are detectable with this technique.

Sialography continued
Another advantage of digital sialography and digital subtraction sialography is the ability to make small adjustments in the positioning of the patients head during imaging, thus ensuring more accurate positioning and collimation. Motion artifacts, however, are a severe problem with digital subtraction sialographic images

Diagnostic approach: Radionuclide Studies

Useful to image the parenchyma T99 is an artificial radioactive element (atomic #43, atomic weight 99) that is used as a tracer in imaging studies. T99 is a radioisotope that decays and emits a gamma ray. Half life of 6 hours. Helman & Fox 1987, found that Technitium-99 shares the Na-K-Cl transport system on the basement membrane of the parotid acinar cells

Diagnostic Approaches: Radionuclide Studies

Some say T99 is useful preoperatively to determine if gland is functional. However, no evidence to suggest gland wont recover function after stone removed. Not advised for pre-op decision making!

Diagnostic Approach: MR Sialography

T2 weighted fast spin echo slides in sagittal and axial planes. Volumetric reconstruction allows visualization of ducts ADV: No dye, no irradiation, no pain DIS: Cost, possible artifact

Diagnostic approach: Diagnostic Sialendoscopy

Is an image-guided technique for the evaluation and treatment of patients with obstructive disease of the parotid salivary glands Allows complete exploration of the ductal system, direct visualization of duct pathology Success rate of >95% Disadvantage: technically challenging, trauma could result in stenosis, perforation

Sialolithiasis Treatment
None: antibiotics and anti-inflammatories, hoping for spontaneous stone passage. Stone excision:
Lithotripsy Interventional sialendoscopy Simple removal (20% recurrence)

Gland excision

Sialolithiasis Treatment
If patients DO defer treatment, they need to know: Stones will likely enlarge over time Seek treatment early if infection develops Salivary gland massage and hyper-hydration when symptoms develop.

Stone excision
External lithotripsy
Stones are fragmented and expected to pass spontaneously The remaining stone may be the ideal nidus for recurrence

Interventional Sialendoscopy
Can retrieve stones, may also use laser to fragment stones and retrieve.

Transoral vs. Extraoral Removal

Some say:
if a stone can be palpated thru the mouth, it can be removed trans-orally (TO) Or if it can be visualized on a true central occlusal radiograph, it can be removed TO. Finally, if it is no further than 2cm from the punctum, it can be removed TO.

Posterior Stones
Deeper submandibular stones (~15-20% of stones) may best be removed via sialadenectomy. Some surgeons say can still remove transorally, but should be done via general anesthetic. Floor of mouth (FOM) opened opposite the first premolar, duct dissected out, lingual nerve identified. Duct opened & stone removed, FOM approximated.

Submandibular Sialoliths: Transoral Advantages

Preserves a functional gland Avoids neck scar Possibly less time from work No overnight stay in hospital Avoids risk to CN 7 & 12

Gland excision
After SMG excision, 3% cases have recurrence via:
Retention of stones in intraductal portion or new formation in residual Wharton's duct

No data regarding recurrence after parotidectomy

Gland excision indicated

Very posterior stones Intra-glandular stones Significantly symptomatic patients Failed transoral approach

Future !!
Alpha-blocker........ Guerre and associates (2010) evaluated the safety and effectiveness of alfuzosin, an alpha-blocker, in patients with ductal stenosis, allergic pseudoparotitis or sialolithiasis after lithotripsy Still experimental and investigational for the treatment of sialolithiasis because their effectiveness for this indication has not been established.