> Table of Contents > Salivary Gland Calculi/Sialadenitis
Salivary Gland Calculi/Sialadenitis
Jason E. Cohn, DO, MS
Mark Weitzel, DO
Seth Zwillenberg, MD
image BASICS
DESCRIPTION
  • Inflammation and/or infection involving one or more salivary gland
  • Sialolithiasis is the cause of ˜90% of all obstructive salivary gland diseases.
  • Salivary obstruction is usually characterized by a painful swelling of the affected gland when eating, known as “mealtime syndrome.”
  • The submandibular gland is more commonly affected (80-90% of cases) by sialolithiasis and infection than the parotid gland. Submandibular stones occur more commonly due to higher mucinous content of saliva, longer course of Wharton duct, slow salivary flow, and saliva flow against gravity.
  • Can be acute or chronic
    • Types: infectious, obstructive (sialolithiasis), and autoimmune
EPIDEMIOLOGY
Incidence
  • Predominant age: Peak incidence is 30 to 60 years.
  • Most common in debilitated and dehydrated patients
  • 49% men and 51% women, average age 47.5 years; 82% submandibular stones and 18% parotid stones, 44% had a positive smoking history, and 20% of patients were taking diuretics.
Prevalence
  • Salivary calculi can be found in 1.2% of the adult population.
  • Only 5% of all cases occur in the pediatric population.
  • In those with sialographic evidence of benign intraductal obstruction, the obstruction is caused by salivary calculi in >73% of cases.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Decreased salivary outflow from anticholinergics, dehydration, or radiation is thought to allow bacterial infection of salivary glands.
  • Salivary calculi form by deposition of calcium phosphate. Predisposing factors include salivary stasis, retrograde bacterial contamination from the oral cavity, increased alkalinity of saliva, and physical trauma to salivary duct or gland.
  • Gout is a well-known systemic disease known to be associated with salivary stone development. In gout, sialoliths are composed of uric acid.
  • Sialadenitis occurs by recurrent inflammatory reactions that result in progressive acinar destruction with fibrous replacement and sialectasis.
  • Bacterial sialadenitis: Staphylococcus aureus, Streptococcus viridans, Streptococcus pyogenes, Haemophilus influenzae, Escherichia coli, Pseudomonas aeruginosa, and group B streptococci (neonates and prepubescent children)
  • Viral sialadenitis: mumps, cytomegalovirus (CMV), Epstein-Barr virus (EBV), HIV, and enteroviruses
Pediatric Considerations
The two most common causes of sialadenitis in children are mumps and idiopathic juvenile recurrent parotitis.
Genetics
Polygenic cause, with several loci under investigation
RISK FACTORS
  • Dehydration
  • Anticholinergic use
  • Antihistamine use
  • Diuretic use
  • Poor oral hygiene
  • Malnutrition
  • Head/neck radiation
  • Tuberculosis (TB)
  • HIV
  • Failure to immunize (mumps)
  • Gout
  • Diabetes mellitus
  • Hypothyroidism
  • Renal failure
  • Duct strictures
  • Previous intraoral procedures
GENERAL PREVENTION
  • Adequate hydration
  • Maintain proper oral care and hygiene.
  • Avoid antihistamines, anticholinergics, and other causes of xerostomia, especially if other risk factors are present.
COMMONLY ASSOCIATED CONDITIONS
  • Postoperative dehydration
  • Radiation-induced xerostomia
  • Drug-induced xerostomia
  • Sjögren syndrome
  • Hypercalcemia
image DIAGNOSIS
PHYSICAL EXAM
  • Palpate all salivary glands, floor of mouth, tongue, and neck to assess symmetry, tenderness, induration, edema, presence of stones, and lymphadenopathy.
  • Examine duct openings for purulent discharge and saliva.
  • Palpate gland gently to express purulent material.
  • Examine eyes for interstitial keratitis.
  • Note lingual papillary atrophy and/or loss of tooth enamel.
Pediatric Considerations
Stones in children are traditionally smaller in size, within the duct distally, and present with a shorter symptom duration.
DIFFERENTIAL DIAGNOSIS
  • Acute bacterial parotitis
  • Chronic bacterial parotitis
  • Idiopathic juvenile recurrent parotitis
  • Dental abscess
  • Mumps
  • TB
  • HIV (in pediatric populations)
  • EBV, CMV, enteroviruses
  • Tularemia
  • Cystic fibrosis
  • Lupus
  • Sjögren syndrome
  • Alcoholism
  • Bulimia
  • Hypothyroidism
  • Pleomorphic adenoma
  • Lymphoma
  • Sarcoidosis
  • Collagen vascular disease
  • Metal poisoning
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • CBC, electrolytes
  • Culture and sensitivity of any expressed pus
  • CT scan with IV contrast is the preferred imaging modality.
  • Ultrasound can localize abscesses as well as stones. Stones appear hyperechoic with posterior shadowing (1)[B].
  • Sonopalpation (concurrent ultrasound with transoral palpation) proved to have a sensitivity and specificity of 96.6% and 90% in finding a calculi (2)[B].
  • Minor salivary gland biopsy.
Follow-Up Tests & Special Considerations
  • If autoimmune process is suspected, consider ordering appropriate labs, such as autoantibody titers: Sjögren syndrome A (SS-A) and Sjögren syndrome B (SS-B), rheumatoid factor (RF), and antinuclear antibodies (ANAs). Erythrocyte sedimentation rate (ESR) may also be conducted.
  • Consider serial CT scans with contrast to evaluate disease resolution.
  • Ultrasound can identify indicators of persistent obstruction in patients undergoing sialolithotomy (1)[B].
Diagnostic Procedures/Other
  • Sialography to evaluate sialolithiasis and other obstructive lesions
  • Sialendoscopy to find and remove sialoliths. In one study, sialendoscopy confirmed 221 (79%) parotid and 812 (93%) submandibular stones (3)[A].
  • One study revealed that sonography, cone beam CT and sialendoscopy all had excellent specificity and positive predictive value in diagnosing stones. However, sialendoscopy was superior in sensitivity and negative predictive value (4)[B].
  • When sialendoscopy fails, a novel ultrasoundguided needle localization approach has been proposed (5)[B].
  • Technetium 99m pertechnetate scintigraphy showed decreased gland excretion and decreased uptake in patients with sialolithiasis (6)[B].
Test Interpretation
In chronic sialadenitis, loss of acini, fibrosis, and periductal lymphocytosis are evident; degree indicates chronicity.
P.935

image TREATMENT
GENERAL MEASURES
  • Maintain hydration.
  • Apply warm compresses with massage.
  • Maintain good oral hygiene.
  • Antibiotics if indicated by diagnosis
MEDICATION
First Line
  • Antistaphylococcal penicillins (nafcillin, dicloxacillin) are indicated in areas where methicillin-resistant Staphylococcus aureus (MRSA) is not predominant.
  • Penicillin-allergic: Use clindamycin 300 mg PO q8h
  • Gram negative: third-generation cephalosporin or fluoroquinolone
  • Anaerobic: metronidazole or clindamycin
  • Antibiotic coverage should be narrowed once culture and sensitivity are available.
  • Continue antibiotic therapy for 10 to 14 days.
Second Line
  • 1st-generation cephalosporin (cephalexin or cefazolin) or clindamycin is also indicated for empiric coverage.
  • If MRSA than Vancomycin.
ISSUES FOR REFERRAL
In the case of poor dentition and dental abscess, refer patient to a dentist.
ADDITIONAL THERAPIES
In the case of chronic sialadenitis with strictures, consider sialostent placement.
SURGERY/OTHER PROCEDURES
  • Submandibular stones found in the anterior floor of the mouth can be excised intraorally (sialodochoplasty), whereas those in the hilum require gland excision. Parotid stones usually require parotidectomy (7)[A].
  • Good results in patient symptom relief, quality of life and safety have been reported in sialadenitis and sialolithiasis using sialendoscopy (7,8,9,10)[A]. However, one study revealed a complication rate of 3.23%. Complications include strictures, ranulas, and lingual nerve injury (11)[C].
  • Incision and drainage of parotid abscess is indicated after failing 3 to 5 days of medical management.
  • Sialoliths and stenoses can be successfully treated by radiologically or fluoroscopically controlled or sialendoscopically based methods in ˜80% of cases. Extracorporeal shock wave lithotripsy (ESWL) is successful in up to 50% of cases.
  • Transoral duct slitting is an important method for extraparenchymal submandibular stones, with a success rate of 90%.
  • Recent evidence shows that larger stones can be successfully and safely treated with holmium: YAG laser lithotripsy (12, 13)[B].
Pediatric Considerations
The most effective diagnostic and therapeutic modality for children with sialadenitis is sialendoscopy with stone retrieval (14)[B].
COMPLEMENTARY & ALTERNATIVE MEDICINE
Consider lemon drops or other sialogogues to promote salivation. In one study, postoperative use of sialogogues nearly halved rates of sialadenitis (15)[C].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Parotid abscess
  • Sepsis
  • Inability to tolerate PO intake
  • Airway, breathing, circulation
  • Check vital signs, with particular attention to blood pressure, as patient may be septic secondary to abscess formation.
  • Evaluate airway patency.
Nursing
Responsibilities may include ensuring excellent oral hygiene and avoiding administration of drugs that cause decreased production or flow of saliva.
Discharge Criteria
  • Exclude abscess or sepsis.
  • Ensure ability to tolerate PO intake.
  • Stable vital signs
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Provide regular follow-up visits for patients with chronic sialadenitis.
  • Avoid prescribing medications that cause xerostomia.
Patient Monitoring
Continue to monitor patients with chronic sialadenitis, as decreased salivary gland function due to fibrosis and loss of acini can lead to acute exacerbations.
DIET
  • Avoid sialogogues during acute attacks.
  • Maintain adequate hydration on an outpatient basis.
PATIENT EDUCATION
  • Educate patients on maintaining excellent oral hygiene.
  • Educate patients on maintaining good hydration.
PROGNOSIS
  • Generally excellent, with acute symptoms resolving in about a week with appropriate treatment
  • Patients with autoimmune etiology may have prolonged course due to systemic involvement.
REFERENCES
1. Joshi AS, Lohia S. Ultrasound indicators of persistent obstruction after submandibular sialolithotomy. Otolaryngol Head Neck Surg. 2013;149(6):873-877.
2. Patel NJ, Hashemi S, Joshi AS. Sonopalpation: a novel application of ultrasound for detection of submandibular calculi. Otolaryngol Head Neck Surg. 2014;151(5):770-775.
3. Zenk J, Koch M, Klintworth N, et al. Sialendoscopy in the diagnosis and treatment of sialolithiasis: a study of more than 1000 patients. Otolaryngol Head Neck Surg. 2012;147(5):858-863.
4. Schwarz D, Kabbasch C, Scheer M, et al. Comparative analysis of sialendoscopy, sonography, and CBCT in the detection of sialolithiasis. Laryngoscope. 2015;125(5):1098-1101.
5. Joshi AS, Sood AJ. Ultrasound-guided needle localization during open parotid sialolithotomy. Otolaryngol Head Neck Surg. 2014;151(1): 59-64.
6. Wu CB, Xi H, Zhou Q, et al. The diagnostic value of technetium 99m pertechnetate salivary gland scintigraphy in patients with certain salivary gland diseases. J Oral Maxillofac Surg. 2015;73(3):443-450.
7. Wilson KF, Meier JD, Ward PD. Salivary gland disorders. Am Fam Physician. 2014;89(11): 882-888.
8. Atienza G, López-Cedrún JL. Management of obstructive salivary disorders by sialendoscopy: a systematic review. Br J Oral Maxillofac Surg. 2015;53(6):507-519.
9. Gillespie MB, O'Connell BP, Rawl JW, et al. Clinical and quality-of-life outcomes following gland-preserving surgery for chronic sialadenitis. Laryngoscope. 2014;125(6):1340-1344.
10. Meier BA, Holst R, Schousboe LP. Patientperceived benefit of sialendoscopy as measured by Glasgow Benefit Inventory. Laryngoscope. 2015;125(8):1874-1878.
11. Nahlieli O. Complications of sialendoscopy: personal experience, literature analysis, and suggestions. J Oral Maxillofac Surg. 2015;73(1): 75-80.
12. Sionis S, Caria RA, Trucas M, et al. Sialendoscopy with and without holmium: YAG laser-assisted lithotripsy in the management of obstructive sialadenitis of major salivary glands. Br J Oral Maxillofac Surg. 2014;52(1):58-62.
13. Phillips J, Withrow K. Outcomes of holmium laser-assisted lithotripsy with sialendoscopy in treatment of sialolithiasis. Otolaryngol Head Neck Surg. 2014;150(6):962-967.
14. Francis CL, Larsen CG. Pediatric sialadenitis. Otolaryngol Clin North Am. 2014;47(5):763-778.
15. Nakada K, Ishibashi T, Takei T, et al. Does lemon candy decrease salivary gland damage after radioiodine therapy for thyroid cancer? J Nucl Med. 2005;46(2):261-266.
Additional Reading
&NA;
Koch M, Zenk J, Iro H. Algorithms for treatment of salivary gland obstructions. Otolaryngol Clin North Am. 2009;42(6):1173-1192.
Codes
&NA;
ICD10
  • K11.5 Sialolithiasis
  • K11.20 Sialoadenitis, unspecified
  • K11.21 Acute sialoadenitis
Clinical Pearls
&NA;
  • Sialadenitis occurs mainly in debilitated patients who lack ability to control hydration.
  • Sialadenitis is associated with conditions that predispose patient to xerostomia.
  • Mainstay of treatment is hydration, good oral hygiene, sialogogues, and possible surgical excision.
  • Many cases are now being successfully and safely treated with sialendoscopy.