Salivary Gland Stone Disease

Sialolithiasis affects approximately 1.2% of the general population, with submandibular gland involvement in 80-90% of cases (longer Wharton duct, more viscous mucus-rich saliva, retrograde upward course), parotid gland in 5-15%, and sublingual or minor glands rarely. Pathogenesis involves saliva stasis, microbial colonization, mineralization around organic nucleus (mucus, cellular debris, bacteria), and progressive crystal deposition forming calcium phosphate or calcium carbonate stones.

Risk factors include male gender, age 30-60 years, dehydration, diuretic use, anticholinergic medications, hyperparathyroidism, gout, smoking, gastric surgery, autoimmune sialadenitis, prior radiation to head and neck, and ductal anatomical abnormalities. Clinical features include episodic prandial salivary gland swelling and pain (mealtime syndrome), tender enlarged gland, palpable stone in floor of mouth or duct opening, pus expression on duct massage, recurrent acute sialadenitis, and chronic obstructive sialadenitis with gland atrophy.

Diagnosis includes clinical examination with bimanual palpation, ultrasonography (first-line, 90% sensitivity), CT (highest sensitivity for radiopaque stones), MR sialography (radiation-free option), and sialendoscopy (gold standard, both diagnostic and therapeutic). Modern management has shifted from gland excision to gland-preserving techniques including sialendoscopy with stone retrieval (basket extraction, intracorporeal lithotripsy with holmium laser or pneumatic), extracorporeal shockwave lithotripsy (ESWL) for non-palpable parotid stones, combined transoral and endoscopic approach (CISA) for distal submandibular stones, and gland excision reserved for failed conservative management.