Sialolithiasis

• Formation of calcified stones (sialoliths) within the salivary ducts or gland parenchyma

• Most commonly affects the submandibular gland (up to 80–90%) because of its more alkaline saliva and high mucin content

• Can cause recurrent pain and swelling, particularly during meals when salivary flow increases

Clinical Presentation

• Pain and swelling of the affected gland, often triggered by chewing or mealtime

• Palpable lump under the jaw or in the cheek if the stone is near the duct orifice

• Possible discharge of pus or foul-tasting fluid if infection (sialadenitis) co-exists

• Reduced salivary flow or dryness in the mouth if the gland is significantly obstructed

Risk Factors

• Dehydration or reduced fluid intake

• Medications that decrease salivary flow (e.g. anticholinergics, diuretics)

• Poor oral hygiene

• Trauma or scarring within the salivary duct

• Chronic or recurrent infections of the salivary glands

Diagnosis

• Usually clinical (palpation of the duct or submandibular area, expression of saliva)

• Imaging if diagnosis is uncertain or stone is not easily palpable

  • Ultrasound often first-line to identify stone location and size

  • CT scan for better anatomical detail if large, recurrent, or complicated stones are suspected

Management

• Conservative

  • Milk the affected salivary duct to expel the stone

  • Warm compresses to the gland to encourage increased blood flow and salivary secretion

  • Suck on sour or hard candy (lemon drops) to stimulate salivary flow and aid stone passage

  • Adequate hydration to maintain salivary gland function

  • Analgesia with NSAIDs (e.g. ibuprofen 400 mg TDS as needed) to relieve pain and inflammation

• If Infected (Sialadenitis)

  • First-line antibiotics: Flucloxacillin 500 mg QID for 10 days if bacterial infection is suspected

  • Consider alternative antibiotics if penicillin-allergic or if MRSA is possible

  • If patient cannot swallow or is dehydrated, refer urgently to ED for IV antibiotics (e.g. IV flucloxacillin)

• Refractory or Recurrent Cases

  • Refer to ENT for sialoendoscopy or surgical removal of the stone if it does not pass spontaneously

  • Surgical intervention may be needed if the stone is large, impacted, or causing persistent obstruction

  • Imaging (e.g. CT) helps localise the stone and guide further management

• Preventive Advice

  • Good oral hygiene, including regular dental checks

  • Maintain adequate hydration to promote continuous salivary flow

  • Prompt treatment of any dental infections

  • Address medications that reduce saliva production if feasible

Notes:

• Most stones occur in the submandibular gland, presenting with pain and swelling exacerbated by meals

• Conservative measures (duct milking, hydration, sour lozenges) often succeed for small stones

• Antibiotics are required if signs of infection or sialadenitis

• ENT referral for persistent, recurrent, or complicated stones

• Early detection and intervention reduce the risk of chronic infection or irreversible gland damage