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:
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:
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
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.
