BackTable / ENT / Podcast / Transcript #88

Podcast Transcript: 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. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Patient Presentation of Sialolithasis

(2) Physical Exam Techniques to Assess Salivary Stones

(3) Stone Removal During Sialadenitis

(4) Comparing Sialolithotomy, Sialendoscopy & Sialodochoplasty

(5) Setting up for In-office Sialolithotomy

(6) Candidacy for In-Office Sialolithotomy

(7) Addressing Stubborn Stones

(8) Post-Procedural Care Following In-Office Sialolithotomy

(9) Planning for Successful In-Office Sialolithotomy

Earn CME

Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs. Follow the button below to claim your credits on CMEfy.

Stay Up To Date

Follow:

Subscribe:

[Dr. Gopi Shah]
This week on The BackTable Podcast.

[Dr. Ashley Agan]
These are so fun, though. Yes, there's potential for complications, but these are some of my happiest patients and it is so rewarding to be able to have a patient come into the office and if you can just fix it in the office and then they walk out and they're like, all right, and you see them back and they're like, "Yes, it's better. You're awesome. Thank you." You're like, "Yes." It's a win and it feels good. Then you never really see them again because I assume-

[Dr. Gopi Shah]
They're good.

[Dr. Ashley Agan]
-they're off living their best life and doing well. It's different than some of your other patients that, you're managing long-term and they can be really fun, especially when you're taking out a big five-centimeter dinosaur fossil.

[Dr. Gopi Shah]
Hello everyone, and welcome to the BackTable ENT Podcast, where we discuss all things ENT. We bring you the best and brightest in our field with the hope that you can take something from our show to your practice. Now a quick word from our sponsor. Cook Medical's otolaryngology head and neck surgery clinical specialty strives to provide otolaryngologists with minimally invasive solutions to address unmet needs. Our areas of focus include head and neck, otology, and laryngology, with products ranging from a full suite of interventional sialendoscopy products and the Doppler blood flow monitoring system to the Biodesign otologic repair graft and the Hercules 100 transnasal esophageal balloon. For more information, visit cookmedical.com/otolaryngology. Now back to the show. My name is Gopi Shah. I'm a pediatric ENT, and I'm here with, I always say you're going to introduce yourself and then I'm always like, my partner in crime, Ashley Agan, I never let you introduce yourself properly. I love it.

[Dr. Ashley Agan]
I love being your partner in crime. I always get so excited. I'm Ashley Agan. I'm a general ENT, and I'm here today with my bestie, Gopi Shah, Sunday morning, just talking about stones today.

[Dr. Gopi Shah]
Yes, so we're going to talk about the in-office management of stones. For our listeners, we had an amazing in-depth Sialendoscopy podcast, episode 25, with Dr. David Cognetti. And just to kind of do a little offshoot, I thought it would be fun to talk about in-office management. You see patients in your office where you manage if it's right there or something you need to do in the office. You do that pretty frequently, yes?

[Dr. Ashley Agan]
Yes, it's not infrequent that patients come in with a salivary stone and possibly there is an in-office type of procedure that could help that's worth discussing sometimes. So it's nice to have that in your back pocket to be able to offer to patients.

(1) Patient Presentation of Sialolithasis

[Dr. Gopi Shah]
So before we kind of get into the nuts and bolts of the actual management in the office, and I know we did a very in-depth discussion with Dr. Cognetti, just for a quick review, how do these patients usually present to you and what are some of the questions that you ask every time that's always on your checklist of stuff?

[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.

[Dr. Gopi Shah]
Usually, you said they have a CT. Is an ultrasound common as well when they come to you or do you usually have something that you can look at more with the anatomy?

[Dr. Ashley Agan]
Yes, that's a good question. CT is way more common, but I think ultrasound is helpful. Sometimes, if I'm seeing the patient first and I have that suspicion, I may get an ultrasound because it does allow you to see perhaps, a dilated duct behind the stone. You're able to see the anatomy of the salivary glands and, the shadow of the stone. If you can't get a CT for some reason or maybe, the patient is really worried about their radiation exposure and they would prefer an ultrasound, I think ultrasound is great at looking at salivary gland pathology.

[Dr. Gopi Shah]
I know we're kind of talking about the gland and the duct. Would you say that we're talking about pretty much the submandibular gland and submandibular duct, yes? Or is it common that you see parotid stones?

[Dr. Ashley Agan]
Yes, there's some parotid stones that'll come in too. I would say as far as being able to do things in the office, it's far more common that that's in the submandibular gland and duct. I have maybe seen a handful of patients that have a stone that's literally right at the distal parotid duct where it's almost in the mouth. Like if it's right there, I think that's reasonable to, go after that in the office if they would like it. A lot of times the parotid ones will present maybe a little out of reach - those we start talking about sialendoscopy more to be able to kind of see and get back there better. It just depends. I would say you're right. Most of them, the vast majority are submandibular.

(2) Physical Exam Techniques to Assess Salivary Stones

[Dr. Gopi Shah]
Okay. Tell me about your exam. What are you looking for? Is there any specific tips or tricks about the palpation that you do?

[Dr. Ashley Agan]
I'm always wearing my loupes with a headlight so that I can really examine the punctum and be able to see if saliva is kind of flowing out from there. So a lot of times I will, if you're looking in the floor of the mouth, I'll dry up the mucosa with a piece of gauze so that it's easier to see if you're able to get saliva to flow, right? I'll have the patient push their tongue to the roof of their mouth because that kind of brings everything up. Then I will massage the gland in question first to see if anything comes out. Sometimes you can still get some normal salivary flow from a side that has a stone because sometimes the stone has gotten so big that it dilates the duct a little bit and you can get some saliva to kind of squeak around it.

Sometimes it might look cloudy or milky or yellow because maybe there is some chronic infection going on. Sometimes there's nothing that comes out and then sometimes, you do that and then the stone, if it's moving within the duct, sometimes it'll just like come right up to the, to that distal duct, at the punctum and it kind of just sits right up there for you and you're like, "Oh, hello, like there you are, that's it." Then I'll do the other side too just kind of, as a comparison to see what the salivary flow is on that side. And I'll do the parotids as well. I usually do all four just as a part of my kind of normal routine looking around.

Then I always palpate. So I'll do a bimanual palpation where there's one finger in the floor of the mouth and the other hand is on the outside, kind of pushing the gland up towards you. For most stones, you should be able to feel it, unless it's very small. If it's only, one or two millimeters, you might not feel it, but it's usually palpable. Even the ones that are stuck back at the hilum of the gland, in that very proximal duct, if you push the gland up towards you and you slide your finger all the way back, usually you can feel that stone. I think that's helpful for me in assessing the likelihood of being able to take it out transoral.

If it's kind of fixed at a certain spot and I can feel it really well and access it, then I feel a lot more confident about being able to get it out through the mouth. If it's really far back and really big, that may not be possible. If it's moving around, that obviously makes it a lot more challenging. It kind of helps me get a lay of the land and assess what we're dealing with, what the possibilities are. The other thing is just assessing how well the patient can tolerate you having your hands in their mouth. Because some people immediately are gagging and, it's just their gag reflex is too sensitive or they just can't really tolerate it. That's probably not going to be a great office procedure candidate.

[Dr. Gopi Shah]
I feel like the position of the inferior, like the lower teeth, if they're facing towards the tongue like you just don't have enough room, I feel like to—

[Dr. Ashley Agan]
Yes.

[Dr. Gopi Shah]
That can make the exam and even finding the punctum difficult.

[Dr. Ashley Agan]
Yes, or mandibular tori.

[Dr. Gopi Shah]
Oh, yes.

[Dr. Ashley Agan]
That can really make it challenging. I remember a patient, she was probably in her 80s, who had really prominent mandibular tori and was really trying to avoid going to the operating room. We were able to get it done, but it was a lot more challenging than my other patients. So, yes, that's a really good exam consideration of just being able to like-- With mandibular tori, that's going to make it hard whether they're in the office or in the OR because it's just kind of this fixed—

[Dr. Gopi Shah]
The same anatomy. It's not going anywhere.

[Dr. Ashley Agan]
Yes.

[Dr. Gopi Shah]
It's just there. Can't shave those down. Okay. So, if the ideal stone is going to be the one that's not moving around, that's not that proximal if you will, that's a little more distal, closer to the duct, that's pretty consistent when you feel it and you can feel it pretty good and it's going to feel hard between your hands, not like fullness or, it's going to feel hard.

[Dr. Ashley Agan]
It's obvious. Yes. I would say in the chip shots, the ones that are really easy are the ones that are right there at the punctum and you can almost-- It's almost like you see it already. It's like it just needs like just a little, the duct just needs to be open just a little bit and it's going to slide out on its own. It's almost, the body is delivering it to you. Those are the easy, easy ones. Most of them might be in that, distal third of the duct so that they're accessible, they're palpable, they're not really sliding around on you. Those are going to be easier to go after.

[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.

(3) Stone Removal During Sialadenitis

[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 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 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.

[Dr. Gopi Shah]
Yes. I think it's a great point. I think for anything we do, right? I think that's sort of not like the conservative, maximal medical management is always an option and patients are usually happy with a little extra time to kind of understand the disease process and what's going on and, feeling like they've tried some other things as well. Like you said, if you can avoid something or avoid a procedure, I feel like you're never going to.

[Dr. Ashley Agan]
Yes. There's nothing without complications. What I do, if we decide some sort of non-procedural management, I do follow them closely. If we're just going to do antibiotics and wait and watch, then I make sure that they come back and see me probably within three or four weeks so we can kind of see how things are going. I give them strict kind of ER precautions of like, if this gets bad, then don't sit on it. if we need to do IV antibiotics or something worse than, let me know because sometimes it can be like a situation where that stone is just kind of not allowing any sort of egress. of that infection, and we need to remove the stone for things to finally kind of get better.

[Dr. Gopi Shah]
Yes, that's a good point as well. For your antibiotics, what do you usually like to prescribe for somebody that has no allergies?

[Dr. Ashley Agan]
Yes, I usually do Augmentin if there's no allergies, and clindamycin if they're allergic to penicillins.

[Dr. Gopi Shah]
Do you think it matters, 7 days, 10 days?

[Dr. Ashley Agan]
I will usually do 10 days of Augmentin.

(4) Comparing Sialolithotomy, Sialendoscopy & Sialodochoplasty

[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.

[Dr. Gopi Shah]
Check out episode 25, and we'll try to get Dr. Dave Cognetti back on the show. Follow up.

(5) Setting up for In-office Sialolithotomy

[Dr. Ashley Agan]
Yes, so if we're back to this patient that is like, "All right, I'm here. Let's do this in the office. I don't mind. I'm going to be able to hold still. I'm going to be able to tolerate the feeling of things or whatnot, right?"

[Dr. Gopi Shah]
Is your chair upright, flat? I lay them down flat.

[Dr. Gopi Shah]
You lay them flat. Okay. Do you do a shoulder roll?

[Dr. Ashley Agan]
When you're at the dentist, you're laying all the way back, and I sit in a chair, like at the head. I will have them turn their head towards me. I'm usually on the right side of the patient, regardless of where the stone is. I think that's just because I'm right-handed. For me, it makes sense with my right-hand coming into the mouth from that side. I don't know. I'm usually, patients laid back, and I'm sitting in a chair at the head. Then I'll have my assistant on the other side with suction or being able to hand me things.

[Dr. Gopi Shah]
Do you numb them up with anything? I know we had this conversation in episode 25, which I keep referring to. I remember when I was a PGY-4, and I injected the floor of the mouth to try to numb everything up. All of a sudden, we couldn't feel anything or find the papilla. I didn't know. Do you ever do gel?

[Dr. Ashley Agan]
You're having a flashback.

[Dr. Gopi Shah]
A major flashback. A major flashback. I didn't know. Do you ever do hurricane spray on top, or gels or anything, or is that distort as well?

[Dr. Ashley Agan]
I might put a little bit of hurricane spray on some gauze and then put that in the floor of the mouth over it. I feel like if you just spray the floor of the mouth, it just goes everywhere, right? I'm trying to just anesthetize that spot. I don't know if that does anything, to be honest, because the lidocaine stings anyway, especially if you have someone that might be a little bit squeamish with needles, it does kind of take that edge off as far as feeling the poke of the needle. You do have to inject local, but you inject very small amounts so that you don't distort things, right?

Since I'm not cannulating the duct, that's less important than when you're thinking about sialendoscopy in the OR. And I'm just trying to put just a little bit of local right on top of that stone where I'm going to make that incision. I have to make sure that I'm not injecting so much that suddenly I can't feel the stone anymore because that's problematic. That's going to make it really hard.

[Dr. Gopi Shah]
I recall that problem very well, actually. I still remember it. Oh, my God. Yes.

[Dr. Ashley Agan]
I'll use like a little 1cc syringe with like a little half-inch 30-gauge needle, just a little tiny. I'll just poke right on top of the stone and do just a little dollop, a little tiny bit of local. I'll use like 1% lidocaine, with epi. Then I will have the patient push their tongue up to the roof of their mouth. I will let them know, I want you to do your best because they're going to be like moving their tongue the whole time because people, you have a hard time. Like, your tongue just moves around sometimes, right? Especially when someone's telling you to stop moving your tongue.

[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 like a Brown-Adson or, maybe a small hemostat, like a little mosquito to kind of grab the 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.

[Dr. Gopi Shah]
They're in your office, you sit them back or have them laying down wherever they're comfortable to suck on a lemon candy or something. Then you feel it and then you can milk it out. Is that kind of what?

[Dr. Ashley Agan]
Well, if I've successfully made a sialolithotomy if the duct is open and you're massaging the gland, it should come out. If it's not, then you haven't opened up the duct yet. Sometimes there's a little more tissue there than you think there's going to be because you feel it and you're like, it's just right there, especially if it's in kind of that middle third of the duct, it may be a little deeper. After you've injected a little bit of local, that's going to make it a little thicker too.

[Dr. Gopi Shah]
That little space.

[Dr. Ashley Agan]
Yes. It may be a little deeper than you think. I think the key is being able to grab the stone and stabilize and be like, okay, this is where it is. Because if not, then you're blindly poking around, and it's easy to just of like, it's because it's so small, it's easy to just kind of be poking around it.

[Dr. Gopi Shah]
Yes. Do you feel like there's a certain size incision length that if it's smaller than this, nothing's going to come out? Can you ever go too long or too-?

[Dr. Ashley Agan]
After the stone is out and you, you've massaged everything out, you've done a little bit of minor irrigation through there, you're going to do the sialodochoplasty part where you're formalizing that opening. The bigger it is, the easier. it is for that part, and so I tend to err on the side of larger because it's probably going to stenose down. My preference would be to open it up at least a centimeter, even if the stone is only five millimeters or something like that. Because I feel like it gives me space to work because it's a lot harder to formalize an opening that's only half a centimeter. You're going to end up ripping the mucosa. It's hard.

[Dr. Gopi Shah]
It's going to look like dog meat.

[Dr. Ashley Agan]
Yes.

It's not necessary. From a physiology standpoint, the saliva just needs to flow into the mouth, at least from when I think about it. I haven't had any patients that have noted any difference of the saliva coming out through this new opening versus how it used to come out all the way, through the punctum at the end. I don't think it matters. I would just make like a nice opening and if it's a little bit bigger than the punctum, if they develop another stone, maybe it'll pass easily on its own. It always kind of stenoses down, so I've never had it be so big that food's going to fall into it or anything weird like that. Even with really large stones.

(6) Candidacy for In-Office Sialolithotomy

[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. Gopi Shah]
Do you irrigate after, let's say the stone comes out, are you washing anything out? How much saline? What do you use?

[Dr. Ashley Agan]
I'll usually do a little bit of irrigation. Nothing crazy.

[Dr. Gopi Shah]
Because they're awake.

[Dr. Ashley Agan]
Yes, you can't drown them.

[Dr. Gopi Shah]
You're not getting the wood bald.

[Dr. Ashley Agan]
I will use my little disposable ear suctions, usually like a size three or five, real small. I'll kind of use some saline bullets and do a little flush, flush, flush with-- basically, you're using drops like it's a very small volume and then I'll use my little ear suctioning, kind of suction in the lumen of the duct to make sure that we've gotten everything. Sometimes I'll use the suction to just gently probe in there as well and see if there's anything else, because when that metal touches a stone, I don't know, I feel like that's not as common.

Usually, I'm just kind of like suctioning and then you see that flow of saliva, that backlog of saliva that needs to come out and then you're like, "Okay, this is good." That's a positive sign for me to kind of see all that flowing out and sometimes it comes out under pressure as soon as that stone is out of the way. It's like, whoosh, and you're like, "All right, nice."

[Dr. Gopi Shah]
Do you ever use, in the OR we irrigate sometimes with Kenalog or steroid. Do you do that in the office? Is that necessary?

[Dr. Ashley Agan]
Not usually. For just a simple stone, I usually don't. I have done that for patients who we're suspecting have some sort of chronic cell adenitis without stone, maybe some sort of autoimmune or something that's causing some sort of ductal stenosis or something weird like that. I might offer that as an option, but if it's a stone then I'm usually like, "We just need to take the stone out and just let it heal."

[Dr. Gopi Shah]
Then you do formal sialodochoplasty?

[Dr. Ashley Agan]
Yes, almost always as well, we'll throw some sutures. I will use a 4-0 Chromic suture. I have some little like Castro Viejo needle drivers that work well for just sewing in the mouth with a patient who's awake to do each side of that opening to basically sew that mucosa of the duct to the oral mucosa so that it's kind of created a formal new opening.

[Dr. Gopi Shah]
Do you think it matters though, let's say at that point the patient is just done and you're not going to get a suture in, can you watch him or do you feel like-- I feel like the sialodochoplasty is controversial of whether you have to, don't have to. I don't know, I'm just asking.

[Dr. Ashley Agan]
No, that's a good question. I try to get in at least one suture.

I guess it depends on the size of the incision as well. If it's bigger, I'm a little less worried about it completely stenosing and scarring together but I'm still worried. I'm always worried.

[Dr. Gopi Shah]
They're difficult, patients and if there are complications, they're not easy ones to manage being sutures and things like that. A recurrent stone happens, that's not uncommon and even that, having to manage that again and something that's already been manipulated is not easy.

[Dr. Ashley Agan]
For sure. Because you're basically changing the anatomy of the duct kind of forever. I really try hard to make sure that I'm at least getting a suture on each side just to try to hold that open, but you're right, sometimes that's probably the hardest part is being able to do that, especially in the awake patient because depending on how long it took to get the stone out, now they're still sitting there with their mouth open and they're getting a little antsy and their tongue's moving around.

[Dr. Gopi Shah]
Yes, maybe your local is in the-- you know what I mean? Because we're making a tiny bleb on top of the stone, but where you're putting your sutures may be beyond the borders of that stone too, so they may be feeling more.

[Dr. Ashley Agan]
Yes, sometimes you might have to come back and do a little bit, if they're like, "oh," I'm feeling that you might come back and put a little bit more local around your sialolithotomy. I think the other thing that can be really tricky, especially if there's bleeding.

[Dr. Gopi Shah]
Yes, I was going to say.

[Dr. Ashley Agan]
Sometimes it's hard to tell what is the lumen of the duct and what's just the soft tissue in the floor of mouth. I mean, the loupes are extremely helpful, I feel like you kind of have Superman vision when you have your loops on. I don't know if I could do it without loupes to be able to know exactly what tissue you're trying to sew to what, but yes, that can be really challenging. I don't know, if you're not sure and you get a little disoriented and it's bleeding, it might be better to just not—

[Dr. Gopi Shah]
Just call it. Leave it.

[Dr. Ashley Agan]
Because you might make it worse if you're sewing tissue to other tissue, that's not what you think you're doing.

[Dr. Gopi Shah]
It's like the stay sutures on a trach. We label them for a reason because you can very easily close that opening.

[Dr. Ashley Agan]
It can get really tricky and speaking of bleeding, we talked about patient selection. Another discussion to be had, patients who are on blood thinners. Again, if it's that tiny stone that's already at the punctum and you just kind of need to make a little nick to open things up and it comes out easily, you may not need to come off of your blood thinner for that but everything else, I'll usually say, "Hey, we need to see if it's safe for you to come off your blood thinner for this, because that's going to make it a lot easier for me."

[Dr. Gopi Shah]
Avoid the potential floor-of-mouth hematoma.

[Dr. Ashley Agan]
It's going to be easier for me and better for you, better outcomes for you if I can see what I'm doing. Usually, they're like, "Okay, yes that sounds good, I want you to be able to see what you're doing."

(7) Addressing Stubborn Stones

[Dr. Gopi Shah]
That's important. Let's say the procedure goes and the stone comes out or let's say, do you feel like you ever have situations where maybe the stone doesn't come out, but you've made a big opening, you got some milk out, milky saliva out. Do you feel successful in those as well? At least if anything, they can still massage the gland and continue to express and if it's small enough, it may still come out.

How do you feel about that?

[Dr. Ashley Agan]
Let's see. If I haven't gotten the stone out, no, I don't feel successful at all.

[Dr. Gopi Shah]
Isn't the glass always half full?

[Dr. Ashley Agan]
I haven't had this, knock on wood. I have not had this happen yet where we have to abort and end without getting the stone out but if that happened, then I would probably have that discussion about, we may need to go to the operating room to do this. Depending on what the reason was for not being able to get it. If it's small, sure, there's a chance that maybe it's just too wiggly. Maybe it was moving and it went back into the gland and once they massage it a little bit it might slip out. That's certainly possible.

I've had that happen with patients in the operating room where we do sialendoscopy. We can't reach the stone. We do a little bit of sialolithotomy, sialodochoplasty just at the punctum just to make it a little bit bigger because we dilate it a little bit with the scope. Then later the patient tells me, "Oh, yes. Afterward, I felt the stone come out. I massaged it and it came out." Sure, I think that happens and that's great if that happens, but going into it the goal is to be able to take the stone out and to be able to be, "yes, high-five," and then secondarily to make sure that things heal so that there's no complications afterward.

[Dr. Gopi Shah]
I feel we, in terms of size, you're always, oh, it's so big or this and that but the small ones, one to two-millimeter they're a pain and they're tricky and sometimes they lead to more problems than you're hoping. Because I've had that happen where you're chasing a small stone. It's causing symptoms. You go to OR. You do sialendoscopy. You don't see anything. You feel you're right as proximal as you physically can be and then there's you've opened up the potential for strictures or “hey, we're still asymptomatic.” Those small ones are real.

[Dr. Ashley Agan]
I totally agree. The small ones are way harder than the big ones. The biggest stone I ever removed was huge. I think, I actually drew a picture.

[Dr. Gopi Shah]
It was a dinosaur stone. I was like, "Is this dinosaur tooth? A shark tooth?"

[Dr. Ashley Agan]
It looked like a shark tooth.

[Dr. Gopi Shah]
It's the five centimeters plus. It was amazing. But that's ridiculous. You could feel it. It was big. It was there. Stones, the hard part is usually being able to isolate it and find it and grab it and so, the smaller it is the more evasive it is.

[Dr. Ashley Agan]
It is.

[Dr. Gopi Shah]
The more likelihood of potentially causing harm in your attempt to get it. Those are certainly the harder ones. It's like, I'm going to need you to just deal with this for about 10 more years, so we can triple the size of this and then that way.

(8) Post-Procedural Care Following In-Office Sialolithotomy

[Dr. Gopi Shah]
Oh, man. Let's get into post-op care. Do you do antibiotics or do you have them doing mouthwashes? What do you like them to do when you see them?

[Dr. Ashley Agan]
When I first started doing them I was really crazy about Peridex rinse and post-procedure antibiotics and I've really moved away from that. I think it's one of those things. The stone is the pathology and once you remove that you just let the body heal and get back to normal.

Unless there was some infection that was discovered after the stone was gone, it's like, “oh, there's a lot of pus here” or “that seems to be actively infected.” Then sure, I think, antibiotics make sense but I don't just routinely do antibiotics just because we did the procedure because I don't really think it makes a difference. At least, I haven't seen that it makes any difference and typically, they feel so much better once the stone is gone.

[Dr. Gopi Shah]
That's good to know because I'm one of those automatic, okay. I'm worried about sialadenitis. I did something but that's good to know that you don't have to do it always.

[Dr. Ashley Agan]
I tell them to make sure and massage the gland and encourage saliva to flow out and through that new opening if it's uncomfortable. If it has been recently infected maybe they can put a little heat on it or something like that. I don't give them any strict diet restrictions, yadda yadda. I let them. I basically say, you can eat what you want to eat. However, you have an incision in the floor of your mouth.

If you're eating something acidic or sour it might burn because it's just like when you have a cut in your mouth that might sting and burn. You might try to stay away from that and I do have them just rinse their mouth out with water for the first week after they eat with the idea being that just trying to keep things clean and they can brush their teeth as long as they brush their teeth like a normal person.

We usually tell them as long as the toothbrush is on your teeth and not on the floor of your mouth where your sutures are I think you're going to be fine. I've never had anybody disrupt anything with brushing their teeth or doing normal oral care. What else? I tell them that they have sutures in the floor of their mouth and that they will dissolve on their own and to just try to leave them alone and that when they dissolve away they might break off. You might see the knot or part of the suture in your mouth and just can just spit that out. That's okay.

[Dr. Gopi Shah]
Do you see them back?

[Dr. Ashley Agan]
Yes, and I usually like to see them back in a week or two. I like to see how things are healing up and make sure that it's not closing off and stenosing. It usually heals pretty quickly and pretty nice. It's amazing how well their mouth—

It's so amazing how well the mouth can heal and as far as pain, usually Tylenol or Motrin is fine. Again, most of them were having pain because of the obstruction of the stone and once that's gone they feel so good and they're so happy that they can eat without having pain. I hardly ever have those patients complain of bad pain from their procedure.

[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.

(9) Planning for Successful In-Office Sialolithotomy

[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.

[Dr. Gopi Shah]
We're talking about salivary stones, but that's with anything we do. Even the ear tube, the kid that maybe, do they really need ear tube, so they're always on antibiotics? Now, they have a big perf, or now, there's cholesteatoma. There's always something, right?

[Dr. Ashley Agan]
Yes, 100%.

[Dr. Gopi Shah]
There's always something potentially but anyways. Any final pearls? Anything that I'm missing?

[Dr. Ashley Agan]
This is great and really comprehensive. We talked about it for way longer than I thought we were going to be able to. I thought it was going to be really short, but I guess I have a lot to say about it. These are so fun though. Yes, there's potential for complications, but these are some of my happiest patients and it is so rewarding to be able to have a patient come into the office, and if you can just fix it in the office and then they walk out and they're like, "All right." You see them back and they're like, "Yes, it's better. You're awesome. Thank you." You're like, "Yes." It's a win and it feels good. Then you never really see them again because I assume-

[Dr. Gopi Shah]
They're good.

[Dr. Ashley Agan]
-they're off living their best life and doing well. It's different than some of your other patients that you're managing long-term, but it's nice and they can be really fun, especially when you're taking out a big 5-centimeter dinosaur fossil.

[Dr. Gopi Shah]
I was like, "What are you sending me?" Maybe that will be the picture on this podcast.

[Dr. Ashley Agan]
Yes, and I was so proud of that one. That one was really fun to do.

[Dr. Gopi Shah]
It'll be a headshot of the stone, the massive one from clinic. It was absurd y'all. Oh my God. I was like, "What is this?"

[Dr. Ashley Agan]
Yes, they're so fun. Even with any size of them, you take them out and you're just like, "all right, nice. Got it." Then patients generally get better, so the vast majority of patients do really well. I think doing it in the office can be a nice thing to add to your tool set and to be able to offer that to patients so they don't have to go to the OR. Be NPO, get there two hours early, get checked in, get in their gown, talk to the anesthesiologist and –

Then you do the procedure in, I don't know, 20 minutes, and then it's like then-- so they've spent their whole day at the hospital, whereas they could potentially just come into your clinic for an hour and be done with it. Think about it and I think having loops is huge. I don't think I could do it without having loupes. I think having another set of hands, being able to have an assistant there to help you with suctioning or things like that, just setting yourself up for success, start with the easier ones, and then go from there.

I'm happy to be a resource for people who are interested or want to know more.

[Dr. Gopi Shah]
That's awesome. Well, thank you so much, Ash.

[Dr. Ashley Agan]
Thank you, Gopi.

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.