4.06 Sialolithiasis (Salivary Duct Stones)
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agk's Library of Common Simple Emergencies

Presentation
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Patients of any age may develop salivary duct 
stones. The vast majority of such stones occur 
in Wharton's duct from the submaxillary gland. 
The patient will be alarmed by the rapid 
swelling beneath his jaw that suddenly appears 
while he is eating. The swelling may be painful 
but is not hot or red and usually subsides 
within two hours. This swelling may only be 
intermittent and may not occur with every meal. 
Infection can occur and will be accompanied by 
increased pain, exquisite tenderness, erythema 
and fever. Under these circumstances pus can 
sometimes be expressed from the opening of the 
duct when the gland is pressed open.

What to do:
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- Bimanually palpate the course of the salivary 
   duct, feeling for stones.
- When a small superficial stone can be felt, 
   anesthetize the tissue beneath the duct and 
   ampule with a small amount of lidocaine 1% 
   with epinephrine. If available, a punctum 
   dilator can be used to widen the orifice of 
   the duct. Then milk the gland and duct with 
   your fingers to express the stone(s).
- If the stone cannot be palpated, try to 
   locate it with x-rays. Standard x-rays of 
   the mandible are likely to demonstrate only 
   large stones. Dental x-ray film shot at 
   right angles to the floor of the mouth is 
   much more likely to demonstrate small stones 
   in Wharton's duct. Place film between cheek 
   and gum to visualize Stenson's duct.
- When a stone cannot be demonstrated or cannot 
   be manually expressed, the patient should be 
   referred for contrast sialography and/or 
   surgical removal of the stone. Often 
   sialography will show whether an obstruction 
   is due to stenosis, a stone, or a tumor.
- Begin treatment of any infection with 
   cefalexin or dicloxacillin 500mg po tid x 10 
   days after obtaining cultures.

What not to do:
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Do not attempt to dilate a salivary duct if 
mumps is suspected. Acute, persistent pain and 
swelling of the parotid gland along with 
inflammation of the papilla of Stenson's duct, 
fever, lymphocytosis, hyperamylasemia and 
malaise should alert the examiner to the 
probability of mumps.

Discussion
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Salivary duct stones are generally composed of 
calcium carbonate and calcium phosphate. Uric 
acid stones may form in patients with gout. 
Although the majority form in Wharton's duct in 
the floor of the mouth, approximately 10% occur 
in Stenson's duct in the cheek, and 5% in the 
sublingual ducts. Depending on the location and 
the size of the stone the presenting symptoms 
will vary. As a rule, the onset of swelling 
will be sudden and associated with salivation 
during a meal.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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