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BackTable / ENT / Podcast / Episode #88

In-Office Management of Salivary Stones

with Dr. Ashley Agan

In this episode of BackTable ENT, Dr. Shah and Dr. Agan talk about in-office management of salivary stones and tips for sialolithotomy.

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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

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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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.

Synopsis

First, Dr. Agan discusses the typical patient presentation of sialolithiasis, or salivary gland stones. Sialolithiasis patients have swelling and pain in their salivary gland when eating. Sialadenitis, or inflammation of the gland, may come first, but it is also possible for sialolithiasis to be discovered on incidental imaging. In either scenario, salivary stones are benign, and the most common gland affected is the submandibular gland. Dr. Agan usually gets CT imaging and uses ultrasound as an alternative if the patient prefers. Next, she discusses her physical examination of the gland. She uses her loupes and a headlight during bimanual palpation to find the stone in the gland. She observes saliva flow as well and assesses how comfortable a patient is with oral manipulation in order to gauge their candidacy for an in-office procedure. The ideal stone for an in-office sialolithotomy is a hard stone close to the punctum. For infected stones that elicit pus and inflammation, she sends patients home Augmentin or clindamycin for 10 days before performing the sialolithotomy.

Next, Dr. Agan discusses her in-office procedure for sialolithotomy. With the patient in supine position, she uses hurricane spray on gauze and puts the gauze on the floor of mouth before injecting local lidocaine at her incision site, which is directly on top of the stone. She uses an 11 blade and keeps holding stone while taking it out to avoid losing it in the mouth. She notes that posterior stones are not good for in-office procedures, as it is close to important landmarks, such as the lingual nerve. After she removes the stone, she uses a small volume of saline irrigation to flush out the duct. Then, if the patient is able to tolerate it, she performs a sialodochoplasty, a procedure in which she sutures to create a new formal opening from the gland to the oral cavity. She notes that this procedure may require more lidocaine injection and surgeons will have to distinguish between lumen of duct and normal oral tissue.

Finally, she covers her postoperative care regimen. She does not prescribe routine antibiotics unless there was an infection discovered during the procedure. She has no diet restrictions for her patients, but notes that acidic or sour foods may make the incision burn. She recommends Tylenol or Motrin for pain and follows up with her patients in 1-2 weeks after the procedure.

Resources

BackTable ENT Ep. 25 Sialendoscopy with Dr. David Cognetti:
https://www.backtable.com/shows/ent/podcasts/25/sialendoscopy

Transcript Preview

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.

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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In-Office Salivary Stone Removal

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Salivary Stones: Patient Workup for In-Office Management

Rock Solid: Procedural Considerations for In-Office Sialolithiasis Treatment

Rock Solid: Procedural Considerations for In-Office Sialolithiasis Treatment

Topics

Sialendoscopy Procedure Prep

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