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BackTable / ENT / Article
Rock Solid: Procedural Considerations for In-Office Sialolithiasis Treatment
Julia Casazza • Oct 25, 2023 • 39 hits
With a quick in-office procedure, otolaryngologists can relieve the pain and recurrent infections associated with sialolithiasis (salivary stones). How does in-office removal differ from that performed in the OR? What are the potential complications of the procedure? And how do you ensure a patient is right for the procedure? Dr. Ashley Agan, BackTable ENT host and general otolaryngologist in Dallas, Texas, answers all these questions and discusses her approach to salivary stones.
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
• Sialolithotomy is the removal of a sialolith (salivary stone) through an incision.
• Sialendoscopy facilitates visualization of difficult-to-reach stones and use of tools to access these stones. It is most often used in the operating room rather than the clinic.
• Risks associated with salivary stone removal include bleeding, damage to surrounding structures (including the lingual nerve in select cases), and ductal stenosis. Sialodochoplasty enlarges the ductal opening to mitigate risk of ductal stenosis.
• Floor-of-mouth and cheek pain both have extensive differential diagnoses. Otolaryngologists should carefully rule out other causes of pain before proceeding with removal of a salivary stone.
Table of Contents
(1) Techniques for Stone Removal: Sialolithotomy, Sialodochoplasty & Sialoendoscopy
(2) Planning for a Successful Sialolithiasis Procedure
(3) Post-Procedural Considerations for In-Office Sialolithiasis Treatment
Techniques for Stone Removal: Sialolithotomy, Sialodochoplasty & Sialoendoscopy
Both in-office and OR sialolithiasis treatment largely rely on the same surgical principles. Sialolithotomy refers to the ductal incision and removal of stone. Sialodochoplasty refers to the formalization (and enlargement) of that ductal opening. Sialendoscopy is the use of endoscopic instruments to visualize the ductal system and associated stones. During sialendoscopy cases, tools such as baskets and forceps may assist in stone removal. While all three techniques can be employed in-office, many healthcare systems provide sialendoscopy resources only in the operating room.
[Dr. Gopi Shah]
So let's say you do have the candidate. So the person that has this mandibular, the stone, maybe it's not right at the duct, but you can feel it pretty well, and it's not moving around on you, and you can feel it, and you have the imaging that you need, the stone is the stone, then what? How do you kind of set them up?
[Dr. Ashley Agan]
Let's say they're like, "Let's do it. I want to get it out. Let's take care of the problem. I need to move past this." If it is kind of the right size and location to consider just taking it out in the office, I will typically use-- I'll do sialolithotomy. I don't have sialendoscopy scopes in my clinic, and so if we're doing anything in the office, that's what I'm referring to is doing sialolithotomy, so opening the duct, sialodochoplasty to kind of formalize that opening.
If they really want sialendoscopy, because, if it's borderline and maybe it is a little further back, or if they just are like, “I'm squeamish about the idea of an office procedure,” then we might lean more towards sialendoscopy and talking about that. Depending on the size and location, again, it still may end up being a sialolithotomy in the OR, if we can't get it with the scope. If we're going to the OR, I do tend to almost always tell them that we'll at least try to do what we can with sialendoscopy. That's another podcast. We're not going to talk about that today
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Planning for a Successful Sialolithiasis Procedure
In-office salivary stone removal is generally well tolerated. As with any procedure, the risk of bleeding and damage to surrounding structures exists. Furthermore, any time a duct is manipulated, stenosis could occur, but performing sialodochoplasty can mitigate this risk. Perhaps most importantly, stone removal will not improve the patient’s symptoms if another pathology accounts for his pain. For this reason, careful examination and history-taking (with evaluation of other painful conditions such as temporomandibular joint dysfunction) should play a large role in the decision-making process for stone removal.
[Dr. Gopi Shah]
Any other major complications? We talked about sutures. We talked about stones can back. We talked about maybe not finding the stone. What else could not go wrong per se but what else do we need to think about, be prepared for?
[Dr. Ashley Agan]
Again, any time you're manipulating the duct, the punctum there's the risk of creating just a complete stenosis of that duct. The structures are really small and once you open the duct sometimes it can just and like we said, if there's bleeding sometimes it can all look the same. I would just make sure that your patients are aware of the possibility of things being worse. If I have a patient that's really not having symptoms and it's a small stone and I'm not super confident that we're going to be able to get it easily then we just have that conversation and say, "Hey, we could make things worse if we go in there and incise it up and try to saw it open. It could completely stenose off and you could have some infection related to that and that's really hard to treat."
I think patient selection is huge with this. Whether you're doing it in the office or the OR, or wherever your setting is, make sure that you have the right procedure for the right patient and that they're aware of those potential complications of either stricture and stenosis and recurrence. I think the other thing too is there are other conditions that can cause pain in that area.
I did have a patient one time who the patient did have a stone and we were able to easily remove it in the clinic and the patient continued to have pain. Even though there wasn't another stone that we presumed that there was chronic sialolithiasis going on because it was still in the same area and questionable, maybe a stone in the gland, but again, hard to see because it's an artifact on the CT. Took the gland out, and the patient just continued to have some pain, and then it ended up being TMJ jaw, from clenching and grinding related stress, so I felt silly for not going into that, but we were so focused on the stone, and the patient felt confident.
He was like, "oh, this is the same pain and it's there." I don't know. I think maybe just making sure that the pain is from the stone, which sounds silly, but I think we get excited, we're like, "oh, there's a stone. Let's take out the stone." Just having a clear idea of making sure that the pain is coming from where you think it is. Typically, patients who have salivary stones will have pain with eating. If it's truly causing an obstruction, they'll have pain every time they salivate, so usually when they're about to eat.
[Dr. Gopi Shah]
I think that's a great point because especially facial pain, neck pain, I think the history, like you said, the specific to stones and eating is probably very key, very important. I'm also glad we brought back the patient that has a stone but may be completely asymptomatic, and watching them as well because what we do, especially, interventions aren't without potential complications and risks, and that's always the worst is, I think I can make this better, but then somehow we're not and we're worse. That's the worst feeling to have.
[Dr. Ashley Agan]
You feel terrible when a patient has a complication that is worse than their disease process was when they came to you.
Post-Procedural Considerations for In-Office Sialolithiasis Treatment
After an in-office salivary stone removal, patients proceed with their usual activities. While sour foods may sting in the area sutured, patients can consume a normal diet. Prophylactic antibiotics are not indicated, but amoxicillin-clavulanic acid should be prescribed if concomitant sialadenitis is present. Regular massage of the affected gland helps stimulate salivary flow and minimize pain. If pain occurs, it can be managed using over-the-counter analgesics such as Tylenol or Motrin. Following the procedure, Dr. Agan sees her patients once for a two week post-procedural check, with instructions to return if the problem recurs.
[Dr. Gopi Shah]
Have you ever had any persistent post-op swelling? Have you ever had to do oral steroids for anything like that before? I would imagine that that should resolve. A little bit to be expected and then.
[Dr. Ashley Agan]
I can't think of a time when I've had any issues like that. There might be a little bit of bruising of the mucosa and things like that. Sometimes I tell them, if you look underneath your tongue, if you look where the procedure was it might look a little bruised or pus will run different from the other side until things heal up.
[Dr. Gopi Shah]
Then do you follow these patients long-term? Stones can sometimes come back. Do you expect them to come back if the symptoms represent themselves or do you ever see them back in six months or is there a reason for it? I don't know.
[Dr. Ashley Agan]
After I see them at that two-week mark or so, if things are looking good I let them go and I tell them, "This could happen again. You know where to find me. You know if we need to address it we will." I don't make them come back and see me on any sort of regular basis. No.
Podcast Contributors
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
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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