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In-Office Salivary Stone Removal

Author Julia Casazza covers In-Office Salivary Stone Removal on BackTable ENT

Julia Casazza • Oct 29, 2023 • 198 hits

In-office salivary stone removal is straightforward, but requires appropriate patient selection and procedural preparation. While sialadenitis increases bleeding risk, stone removal during infection is acceptable for a subset of patients. Are you interested in bringing the removal of salivary gland stones to your practice? Read on.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• Sialodochoplasty is enlargement of the salivary duct opening. It minimizes the risk of ductal stenosis following sialolith removal.

• If, during a clinic salivary stone removal, a sialolith slides proximally so that it is no longer easily graspable for sialolithotomy, increased salivary flow will push the stone distally. Stimulate salivary flow by instructing the patient to suck on a sour candy or lemon wedge.

• The removal of a salivary stone during an episode of sialadenitis confers an increased risk of bleeding and post-procedural pain. However, it may be considered for otherwise healthy patients with easily-accessible stones. These patients will need to take antibiotics following their procedure.

• Ideally, patients with sialadenitis should complete a course of antibiotics (ten days’ worth of amoxicillin-clavulanic acid or clindamycin) before undergoing any sort of stone removal.

In-Office Salivary Stone Removal

Table of Contents

(1) The In-Office Salivary Stone Removal Procedure

(2) Salivary Stone Removal During Sialadenitis

The In-Office Salivary Stone Removal Procedure

In-office salivary stone removal is a straightforward procedure requiring only local anesthetic and a few surgical instruments. Start by placing a benzocaine-sprayed gauze on the patient’s floor of mouth to reduce injection-associated pain. Then inject a small amount of 1% lidocaine with epinephrine directly on top of the stone. Pay attention to not obscure the stone by injecting too much local anesthesia. Grab the stone with a pair of forceps, and then perform a sialolithotomy by incising (with an 11 blade) directly on top of the stone. Use forceps to spread the opening and milk out the stone. Finally, perform sialodochoplasty by incising to enlarge the duct opening to 1 cm. Suture the opening to the floor of the mouth. Irrigate with a small amount of saline to assist in hemostasis. If during the procedure the salivary stone slides further back in the duct, salivary stimulation using sour candies can assist in moving the salivary stone forward.

[Dr. Gopi Shah]
Yes.

[Dr. Ashley Agan]
I'll just give them something. I'm just like, push your tongue to the roof of your mouth. What that tends to do is it keeps their tongue from wiggling around. It also kind of brings the floor of the mouth up towards you.

[Dr. Gopi Shah]
I like that trick.

[Dr. Ashley Agan]
Then I will use a Brown-Adson or, maybe a small hemostat, like a little mosquito to kind of grab the salivary stone so that it's, through the mucosa gently, just so that you know where it is. Because you feel it with your finger, but then as soon as you're not feeling it with your finger when you look, usually it's hard to see. Again, unless it's right there at the punctum, you're like, it's, somewhere in there. By feeling it and grabbing it, it lets you see exactly where it is, right? Then I'll take an 11 blade and I'll just go right down on top of the stone until I can feel it, because you'll feel yourself hit the stone with the tip of the blade. Then I'll just make a small little incision right on the top of the stone. Then I'll keep holding the stone and I'll take either some, like a Codman or a mosquito with my other hand, and kind of spread that area.

A lot of times the stone will just kind of pop out followed by, the egress of, the saliva and, all the air pus or whatever's behind it will kind of like all start shooting out. It's nice to have a handle on the stone because if it slips, then it kind of just, you might just lose it in their mouth, especially when it's small. They may swallow it. So, be prepared for that. Also, if it's very small, it's easy for your assistant to get it up in the suction too. So be careful of that. I like to be able to grab it so that I can show the patient, here's what it is. Does that make sense up to that point?

[Dr. Gopi Shah]
Absolutely. Have you ever had a time where you thought you were grabbing it and cut down and it's not the stone? Then what do you do?

[Dr. Ashley Agan]
Yes. You're poking with your 11 blade and you're not feeling it and you're like, "Huh, where'd it go?" I've had times where maybe it slides back. I will have the patients eat a lemon drop or a lemon wedge or sour candy or something, and that'll kind of push it back up. I've tried that trick before and it works pretty well to bring it back towards the front.

Listen to the Full Podcast

In-Office Management of Salivary Stones with Dr. Ashley Agan on the BackTable ENT Podcast)
Ep 88 In-Office Management of Salivary Stones with Dr. Ashley Agan
00:00 / 01:04

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Salivary Stone Removal During Sialadenitis

The decision to remove a salivary stone during a sialadenitis episode requires careful consideration. Dr. Agan typically recommends patients with infection take ten days’ worth of amoxicillin-clavulanic acid (or clindamycin if allergic to penicillin) and return for removal in two weeks. By counseling on the nature of salivary disease, particularly the relationship between inflammation and increased bleeding, patients can better understand why waiting on removal is prudent. If an otherwise-healthy patient desires salivary stone removal during an active infection, weigh risks and benefits before proceeding. If the patient is unlikely to return to clinic and the stone is ideally situated for an office procedure, salivary stone removal (followed by a ten-day course of antibiotics) may be appropriate.


[Dr. Gopi Shah]
What about you mentioned, you're going to express the gland to see if you can get anything out of the duct and, sometimes you get saliva. Sometimes you don't. What about the patient? You feel a salivary stone and you get milky turbid-looking fluid or pus. Do you cool it down and then address it? Or do you address it that day? What are your thoughts on that when it's sort of maybe on the not quite infected unless there's maybe it is it's about to pus or, maybe it's kind of inflamed? The gland is hard, but you feel a stone.

[Dr. Ashley Agan]
I think that I wouldn't necessarily say that that's a contraindication to doing a sialolithotomy that day but when things are infected and there's more inflammation, you have to be prepared that there might be more bleeding and that it may not be, as clean and nice and easy as it is when it's cooled down. My preference would be to, send them home on some antibiotics and maybe cool things down, get some imaging in the meantime if they haven't had it, and then maybe come back, in a week or two and kind of schedule it that way, which typically, our billing team prefers for us to give them a week or two for preauthorization and things like that.

Sometimes that is kind of the perfect sequence of events to kind of like see, assess, have a plan, come back, and do the intervention. Sometimes patients have driven four or five hours to see me and it just doesn't make sense to send them home on antibiotics and make them drive all the way back for something that potentially could be taken care of that day. So again, it's one of those gray areas where we talk about it. Depending on if I think it's really going to be difficult, like if it's a little more posterior and, maybe they're having a lot of pain with it too and worse, there's a lot of pus coming out, like I might just say like, you know what, like let's just start with some antibiotics. Especially if it's their first time.

Sometimes that salivary stone has been there for a while and this is the first episode of sialolithiasis that they've ever had. Maybe just treat it, especially if they're like maybe older and more frail and maybe they're on, more than one blood thinner and it's going to be a little less straightforward, a little more challenging, a little more risky, these types of things. You might be able to say, “hey, let's treat this infection.” This is the acute thing that's happening right now. Maybe this stone has been there for a while and hasn't been causing you issues and let's see what happens. Maybe the stone will continue to cause you recurrent infections henceforth or maybe, you were a little dehydrated or you, who knows, like for whatever reason, you had an episode of a salivary gland infection and once we treat it, maybe that will be the end. It's hard to know. Again, depending on the patient, I think it's a reason you could argue either way.

Podcast Contributors

Dr. Ashley Agan discusses In-Office Management of Salivary Stones on the BackTable 88 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Dr. Gopi Shah discusses In-Office Management of Salivary Stones on the BackTable 88 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, February 7). Ep. 88 – In-Office Management of Salivary Stones [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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