What I learn today: Sialolithiasis

Sialolithiasis: the formations of stones within the salivary gland or duct in which drains the salivary gland. Salivary duct stone formations are the accumulation of calcium and phosphate crystals. 

There are three salivary glands(the parotid, the sublingual or the submandibular gland) all of which functions include saliva secretions, which is what helps to moisten and digest the food that we eat.  

Parotid glands: lie basically in front of the ears or just behind the jawline. 

Submandibular and Sublingual glands: sit deep within the floor of the mouth.

The chemical composition of the stones also varies from one gland to another. Submandibular gland stones tend to have higher concentrations of calcium, which explains why 85% of submandibular stones are visible on x-ray, whereas only 15% of parotid duct stones are visible.

Sypmtoms:

• Since chewing promotes release of saliva, symptoms tend to increase during meals. A palpable lump or visible swelling in the area of the gland is often noted.
• In some instances the patient may have difficulty opening the mouth or swallowing.

Cause:

• The saliva helps break down starches and when the water of our saliva is decreased, the calcium and phosphate in the saliva can cause formation of a stone. Stones are much more likely to develop when the water content of saliva is decreased. Thereby a person who is dehydrated is at much higher risk of stone formation. 
• Any disorder that thickens saliva can predispose to stone formation. These disorders include autoimmune attack of the saliva gland, such as seen with sicca syndrome, Sjogren's syndrome, lupus, and other autoimmune connective tissue disorders. Drying medications are also frequent causes and include antidepressants, antihistamines, diuretics, etc. Dehydration also plays a prominent role, particularly in older individuals.

Effects:

• The long-term effects are very much determined by whether or not chronic bacterial infection sets into the gland because of the obstruction. Stones that pass spontaneously will create little, if any, difficulty. Should they, however, injure the lining of the duct, then a narrowing of the duct can occur which prevents good salivary flow from the gland, with either induction of additional stone formation or gland infection. Stones can occur in the duct and cause a complete obstruction. If the gland does not become infected, then it may involute and stop making saliva. Sometimes the stone may wear a hole in the duct and extrude into the tissue. In that location it may get walled off or spread the infection into the soft tissue. Should the gland not drain well and not respond to conservative treatment, such as hydration, gland massage, and saliva stimulants, it may become chronically symptomatic. For those individuals who develop a bacterial infection and the gland is incapable of effectively draining, chronic and recurrent bacterial salivary gland infection can result. The longer the infection continues, the more scarring there is in and about the gland and the greater difficulty exists in removing it should it be necessary.

• Surgical removal of the stone sitting at the duct opening may lead to complete scarring of the duct opening, with subsequent failure of the gland to further drain. This could lead to additional stone formation, infection, and/or gland involution. Should the entire submandibular gland, duct, and the offending stone need to be removed, the complications are related to the adjacent structures. For example, just on the outside surface of the submandibular gland is a small branch of the facial nerve that stimulates lower lip movement. If this nerve is injured, then lower lip paralysis can result. Two other nerves sit underneath the saliva gland. One is the hypoglossal nerve, which controls that side of the tongue. Above the hypoglossal nerve is the lingual nerve, which supplies sensation to the front part of the tongue. If these nerves are injured, there is paralysis and loss of sensation respectively. The main difficulty arising from removal of the parotid gland is injury to the facial nerve. The facial nerve controls the muscles in the face and thus injury to the main trunk of the nerve results in complete facial paralysis. Interruption of specific branches will cause paralysis in that part of the face innervated by that particular nerve branch. Since the damaged glands are usually not very functional, no significant mouth dryness usually results.

Prevention:

• In the individual suffering from thickened saliva, regardless of its mechanism, adequate hydration using six to eight glasses of water per day and sucking on sour drops will help maintain a good flow of saliva.
• For those who have successfully recovered from a previous stone or who suffer from autoimmune attack on the saliva gland, massaging the gland forward after meals helps clear any thickened, saliva from the gland itself.

Treatments:

• For small stones, hydration, moist heat, NSAIDs(ex: aspirin, ibuprofen, and naproxen) occasionally, and having the patient take any food or beverage that is bitter and/or sour. Sucking on citrus fruits, such as a lemon or orange, may increase salivation and promote spontaneous expulsion of the stone.
• Some stones may be massaged out by a specialist.
• An ENT or maxillofacial surgeon may canulate the duct to remove the stone (sialotomy).
• A surgeon may make a small incision near the stone to remove it.
• Sialendoscopy: The salivary glands are located around the mouth and the throat. These glands may at times be blocked, usually because of stones. Sialendoscopy involves the use of a flexible tube (endoscope) to enter a salivary gland and to visualise and remove the stone.
• To prevent infection while the stone is lodged in the duct, sometimes antibiotics are used. In some cases when stones continually reoccur the offending salivary duct is removed.

Sources: 

http://www.merckmanuals.com/home/sec08/ch111/ch111a.html

http://www.associatedcontent.com/article/2599605/sialolithiasis_causes_symptoms_and.html

http://www.drlouryent.com/Pages/PatientServices/1059.html

Lesson Learned:

So, drink water...DRINK LOTS OF WATER! It is needed by our body to function well 'coz Dehydration or lack of water is what causes most illnesses.


Update 05/19/11: Dr. Esperanza's advise:  Observe for 1 week with soft diet: increase in spicy, salt and citrus fruits + water + warm compress + massage on the affected area. Take pain reliever only when cannot tolerate the pain. Followed her instructions very well. The swelling eventually subsides! but have to continue eating sour oranges and drinking more than 2 liters a day for the next few days to make sure the stone is totally dissolved.