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Salivary Stones: Patient Workup for In-Office Management
Julia Casazza • Oct 25, 2023 • 36 hits
While salivary stones inflict pain and increase risk for sialadenitis, select stones can be addressed in clinic. The decision to remove a stone in clinic relies on physical exam findings, comorbid conditions, and patient willingness to sit through an awake procedure. Dr. Ashley Agan, BackTable ENT host and general otolaryngologist in Dallas, Texas, discusses her considerations for in-office stone removal.
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
• Salivary stones can cause pain during salivation that persists up to sixty minutes after eating. Alternatively, asymptomatic (often smaller) stones can be found on imaging ordered for other purposes.
• Physical examination of the patient with salivary stones should assess stone location and mobility to determine eligibility for in-office removal. Stones suitable for in-office removal are immobile and located in the distal third of a salivary duct.
• Stones should be removed in the operating room if the patient wants to avoid awake procedures or if the stone is located in the proximal portion of the salivary duct.
Table of Contents
(1) Patient Presentation for Salivary Stones
(2) Evaluating Salivary Stones: The Physical Exam
(3) Candidacy for In-Office Management of Salivary Stones
Patient Presentation for Salivary Stones
Usually, patients with salivary stones see an internist or emergency medicine clinician before coming to an otolaryngologist. Patients may report a history of pain that starts with eating and persists 30-60 minutes after mealtime. They may have a history of sialadenitis requiring antibiotics. Alternatively, stones may be an incidental finding on imaging that patients want treated before symptoms arise.
[Dr. Ashley Agan]
So most of the time, patients have been seen by their primary care doctor or in the ER and someone has already made the diagnosis that they have a stone. That's probably maybe 80% of the time, 80 to 90%. So most of the time, someone's gotten a CT and there's a stone there. The chief complaint on my schedule will say “sialolithiasis” or “salivary stone” or something like that. The important things that I'm asking them about are what kind of issues is this stone actually causing.
Patients will say that when they eat, sometimes they'll get some pain and swelling of the gland that persists during their meal and maybe lasts 30 minutes to an hour afterward and will kind of slowly go down on its own. Sometimes there will be a history of a really bad sialadenitis that had to be treated with antibiotics. Maybe that was the first thing that made them notice that there was something going on there. Sometimes it's incidental. Sometimes I have patients who got a scan for something else, completely different and there happens to be a stone there. When I say, "Do you have pain when you eat? Have you ever had a salivary gland infection? Do you know anything? It's like, "Nope, nope, nope."
I think it's really important to know that salivary stones are a pretty benign disease. They're not going to turn into cancer. They can certainly cause a lot of symptoms. They can cause, people to have recurrent infections. They can cause pain when you eat, but if they aren't causing symptoms and a patient is really trying to avoid surgical intervention, that's pretty reasonable to have that discussion. Sometimes patients just want it out because there's a concern that maybe someday it will cause symptoms, which I think is reasonable as well but that's where that shared decision-making comes in.
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Evaluating Salivary Stones: The Physical Exam
A focused physical exam provides all the information needed for removal of a straightforward salivary stone. During her examination, Dr. Agan wears loupes and a headlight. To begin, she asks the patient to raise their tongue to the roof of the mouth. She then dries the floor of the mouth using gauze. She massages all major salivary glands to assess salivary flow and bimanually palpates these glands to determine stone location. Stones most suitable for in-office removal are immobile and located at the distal third of the duct. For context, submandibular stones are located in the distal most portion of Wharton’s duct over 90% of the time. While CT or ultrasound provides greater detail regarding gland anatomy, it is not always necessary. In fact, Dr. Agan will offer same-day in-office stone removal to patients with a classic physical exam and accessible stone.
[Dr. Gopi Shah]
What about the patient that doesn't come in with any imaging, they have the classic history of when they eat, after they eat, they have swelling and pain and, you do your exam and you feel a stone. Do you have to get an ultrasound or imaging or can you-- Let's say it's that classic where maybe it's not crowning if you're not seeing it, but like you can feel it. Can you offer something right away? Do you have to, if you feel like, hey, the history fits, the physical fits, I'm pretty sure that's what it is.
[Dr. Ashley Agan]
Right. If I am 99% sure that that's it, I will talk to the patient about just, going straight to a sialolithotomy, sialodochoplasty, just removing the stone through the floor of the mouth. I've had patients who have, a high deductible plan and they know it's going to cost them a lot of money to get a CT and it may not change what we do. They're just twisting my arm to be like, can't we just, it's right there. Like, can we just do this? I think it's reasonable. The big thing that I talk to patients about is because we don't have the CT ahead of time, there may be surprises, right? So, I may not be able to get it out. There may be other stones behind it. So ultimately, we may need to get some sort of imaging or, a CT or an ultrasound beforehand.
I think an ultrasound is a good alternative to CT. I like having something before I go into any procedure. That would be my preference, is to have a CT going into it. The other thing about CT sometimes is dental artifact. If they have a bunch of dental work that is creating artifact on the CT, sometimes the CT won't show the stone. So sometimes it's not even helpful. I think it's one of those things that you talk about and you want to be as prepared as possible before you're doing any sort of procedure. Also, if you're physical, you can also trust your history and your physical exam and sometimes you can make the patient better that day and never have to do, the imaging workup and you're done.
It's one of those things that we talk about and, it's an option. I don't think it's a crazy thing to consider doing that, especially with the real small ones that are about to kind of come out on their own. You take it out in the clinic real quick. You show the patient. Oh, look, there it is. They're like, "That little thing? That's what's been causing me all this pain and agony when I eat." They're so they're really happy patients. It's really nice to be able to help them on the spot and make them feel better like that day. I think, having a little bit more information is not a bad thing.
Candidacy for In-Office Management of Salivary Stones
Not all patients are well suited to in-office stone removal. Patient desires, stone location, or medical conditions can all warrant a trip to the OR. Individuals with a strong gag reflex or hesitancy to undergo an awake procedure might require general anesthesia. When stones are located further back in the mouth, difficult visualization and risk of lingual nerve injury necessitate a surgical setting. Patients on blood thinners should stop their medication before undergoing any stone removal.
[Dr. Gopi Shah]
Are there landmarks in the mouth that you use to say, "Hey, this is just too posterior?" Because we have to worry about the lingual nerve the further back we go, right? It's more superficial, so do you have landmarks?
[Dr. Ashley Agan]
If it's really far back if I'm palpating and almost my entire hand is in their mouth, to be able to feel the stone way in the back, that's just not going to be a good candidate to do in the office. Because you need to be able to see what you're doing and so usually I'll tell them, "eh, you're just not going to be a good candidate to do in the office." I'll make sure we have imaging on those patients, CT scan would be nice to kind of know if the stone is in the duct or if it's more in the gland to kind of have that discussion of the likelihood of being able to take the stone out without taking the whole gland, but when it's really far back there, you do have to have that discussion of, "wait, you might just have to lose your whole gland."
People are very sensitive about having an incision on the neck and the risks that go along with that and so even though it can be a lot more technically challenging to take it out through the mouth when you're dealing with a stone that's super posterior, I think in a patient's mind it's like, "Oh, but it's coming out through the mouth. there won't be an incision out here." It doesn't mean it's impossible to take out through the mouth, but it means that for me and my hands, I don't want to try to do this in the office.
[Dr. Gopi Shah]
We might be going to the OR for that.
[Dr. Ashley Agan]
Even when it's in the middle third, that can be really challenging in the office. My preference for the ones in the office would be the ones that are right at that distal third where they're already almost out and you're just kind of helping them come out. Those are the nice chip shots. Even in the middle third, they can be challenging.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
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
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