Salivary stones

Salivary stones

Salivary stones are understood to mean all concretions of calcareous origin which are located in the salivary canalicular system and which can be detected either by clinical examination or by additional examinations.

The formation and migration of stones in the excretory ducts of the salivary glands results in mechanical and infectious manifestations.

Approximately 1.3% of the population has one or more salivary stones. The location is submandibular in 76% of cases and parotid in 22% of cases.

1. Definition: This is the formation of stones in the excretory ducts of the GS, they can be rounded or irregular, of variable size and location.
2. Epidemiology :

The most common after mumps.

It is observed between the ages of 30 and 40 and affects men twice as often as women.

Frequent in the submaxillary gland with 76% of cases and 22% in the parotid gland.

They are often limited to one gland and can appear as part of a general pathology.

3. Etiopathogenesis:
   • Anatomical hypothesis: Wharton’s canal is longer, its ostium is also narrower, submandibular saliva flows from the bottom to the top, promotes salivary stasis and therefore lithiasis.
   • Physicochemical hypothesis: Submandibular saliva, due to its richness in mucus, is twice as thick, which also promotes stone formation.
   • Hypothesis related to diagnostic errors: the arrival of sialoscopy has made it possible to highlight many parotid stones that often go unnoticed.
4. Clinical forms of lithiasis:
   1. Submaxillary or submandibular lithiasis:

The discovery of submandibular lithiasis may be fortuitous, or most often linked to mechanical or even infectious accidents.

• Clinic:
  • Mechanical accidents:

They are punctuated by meals and are often related to stones embedded in the distal part of the submandibular canal. These accidents are of two types.

• Salivary hernia (Garel’s hernia): This is a swelling that appears suddenly during meals, under the basilar edge of the mandible, in front of the angle.

At the end of the meal, the swelling disappears and the patient feels saliva flow in the mouth.

• Salivary colic (Morestin): involves total retention of saliva and spasm of the duct, causing intense pain that occurs suddenly and is located in the floor of the

the mouth, tongue and radiating towards the ear, on palpation, the gland is firm and painful.

• Rapid disappearance of pain and swelling after a brief drooling.
• The initial course may be favorable (rare spontaneous expulsion or disengagement), but in the absence of treatment, it can lead to the occurrence of infectious accidents.
• Infectious accidents:

They often follow mechanical manifestations but can be inaugural. They constitute the adverse and serious effects of salivary stones.

• Warton Channel Sialodochite (Whartonite) :

It begins with pain in the floor radiating towards the ear, the salivary ridge is swollen, red, painful, the ostium is turgid and oozes pus.

-Medical-surgical therapy combining antibiotic therapy and stone removal is the rule.

• Pericanal abscess of the floor of the mouth (Periwhartonitis) or phlegmon of the floor of the mouth:

The pain is more intense than in whartonitis, as is the functional impairment. Local signs worsen, with swelling of the entire floor of the mouth, which raises the tongue and hinders swallowing. General signs are more pronounced than in whartonitis.

Suppuration of the canal confirms its salivary origin.

Spontaneous evolution within a few days towards fistulization in the mouth, sometimes with evacuation of the stone.

• Acute submandibulitis:

• In the acute form of submandibulitis, the submandibular region is the site of painful inflammatory swelling. This is associated with discomfort when chewing and swallowing, pus in the ostium, and sometimes cutaneous fistulization. The general signs are classically associated.
• Conversely, in chronic forms there is glandular induration, with an absence of general signs.
• Positive diagnosis:

It is based on the discovery of the calculation by bidigital palpation of the floor allowing the feeling of a hard body located on the path of the canal.

Imaging can confirm the existence, location and number of stones, by:

• Standard X-ray :

• An occlusal film will allow the floor of the mouth to be explored.
• A dental panoramic (projection problem with the mandibular horizontal branch).

• Ultrasound that can visualize the stone with a characteristic shadow cone effect.
• Sialography : never as a first-line procedure, allows posterior lithiasis to be highlighted and shows the state of canalicular sclerosis.

She shows indirect signs of lithiasis:

• Canal dilation upstream of the canal.
• Destruction of the excretory system.
• Differential diagnosis:

The radiological discovery of a high laterocervical radiopaque image gives rise to discussion

• a calcified lymph node (tuberculosis).
• a foreign body: residual dental fragment; dislocated tooth; intramandibular odontoma.
• Treatment :

It is essentially surgical and most often consists of the removal of the stone.

In the event of a collection, drainage may also be carried out.

Sometimes, spontaneous expulsion of a small stone under pressure can occur; this avoids surgery.

• Non-invasive treatments for salivary stones:

 Medical treatment (symptomatic) :

• Analgesics, anti-inflammatories, antispasmodics (Spasfon®).
• Antibiotics in case of infection (penicillin, macrolide).

 Sialendoscopy: diagnostic and therapeutic method, allowing stones to be removed regardless of their position (indicated for stones < 4mm in diameter).

 Extracorporeal lithotry: allows the fragmentation of stones using electromagnetic shock waves without glandular lesions.

• Invasive or surgical treatment:

The indication depends on the location of the stones;

Calculi located in the anterior third of the Wharton ⇒ extraction by intraoral route.

Calculi located in the middle third: the indications are divided between the intraoral route and the cutaneous route.

Posterior third stones and intraparenchymal stones require a submandibulectomy via the cutaneous route with, if necessary, recourse to a complementary oral route.

Two rare but possible post-surgical complications are: Paresis of the labiomental nerve

Paresis of the lingual nerve.

2. Parotid lithiasis:

• Less common, in the majority of cases, these are small, slightly calcified stones.
• Infectious accidents are more frequent than mechanical accidents.
• X-ray examinations can reveal these stones.
  • Infectious accidents:

• In the canal: sialodochite or stenonite:
  • Manifests as cheek pain radiating to the ear; moderate general signs.
  • The orifice of the Steno canal is gaping, red, swollen, and oozing pus.
  • Palpation allows the dilated canal to be perceived as a hard cord and sometimes the stone itself in the form of a hard core, painful to palpation.
• Upstream of the canal: sialadenitis or parotitis:
  • Combining several local signs: pre-auricular swelling, moderately painful, skin redness with induration on palpation, sometimes discharge of pus from the ostium and satellite ADP.
  • General signs with fever, headaches, anorexia may also be present.
• Cellular tissue damage: This is masseteric or genian cellulitis complicating stenonitis, characterized by sharp, stabbing pain associated with trismus and increased fever.

Induration of the canal with turgor of the ostium allowing pus to flow out.

• Mechanical accidents: Hernia and salivary colic are less frequent.
• Positive diagnosis

Unless the stone is in the process of being expelled from the ostium, radiology is essential.

Standard radiography is of little help.

Ultrasound: canal dilation around and around the obstacle with cessation of evacuation.

The scanner: locates the stone, specifies its size and allows us to see any possible ductal dilation upstream of the stone.

Sialendoscopy: interesting for diagnosis and therapy (small and poorly calcified stones).

• Treatment :

Unlike submandibular lithiasis, all medical treatment options must be exhausted before resigning to surgery.

Spontaneous expulsion or expulsion aided by medical treatment is frequent depending on (the size). Medical treatment is the same as for submandibular lithiasis.

Sténon duct lavages with penicillin particularly promote the migration and then expulsion of parotid stones (small, rounded, slightly calcified).

Surgical treatment consists of excision of the lithiasis:

• The intraoral route is difficult and only suitable for very anterior stones by incision of the canal, which will eventually be possible and sufficient
• For other locations, consider superficial parotidectomy. And sometimes a total parotidectomy is necessary if the stone is located in the deep lobe.

3. Sublingual lithiasis:

Exceptionally, it presents as submandibular lithiasis but with more external inflammatory signs.

Occlusal radiography and sialography (when possible) show small stones located between Wharton’s canal and the external table of the horizontal ramus.

Local infectious complications may lead to sublingualectomy.

4. Lithiasis of the accessory salivary glands:

It is uncommon and occurs in the elderly at the retrocommissural level as well as at the level of the upper lip. In general, the patient describes the presence of a painful , tense and hot intraoral swelling . The latter quickly fistulizes in the mouth and thus allows the expulsion of the stone.

Conclusion

Salivary stones are very common pathologies that can be discovered accidentally or following mechanical or infectious episodes.

Further targeted examinations can confirm the clinical diagnosis, locate the salivary stone and adopt the best treatment.

Salivary stones

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Salivary stones