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Salivary gland stones

Salivary gland stones
Literature review current through: Jan 2024.
This topic last updated: Oct 17, 2022.

INTRODUCTION — Stones or calculi in the salivary glands or ducts are common. The presentation, evaluation, and treatment of salivary gland stones will be reviewed here.

The evaluation of salivary gland swelling and suppurative parotitis are discussed separately:

(See "Salivary gland swelling: Evaluation and diagnostic approach".)

(See "Suppurative parotitis in adults".)

TERMINOLOGY

Sialolithiasis – Stones within the salivary glands or the salivary gland ducts.

Sialoadenitis – Inflammation of a salivary gland, usually associated with swelling. (See "Salivary gland swelling: Evaluation and diagnostic approach" and "Salivary gland swelling: Evaluation and diagnostic approach", section on 'Definitions'.)

Acute sialoadenitis may be caused by primary infection (viral or acute bacterial sialadenitis) or secondary infection.

Chronic sialoadenitis is characterized by repeated episodes of inflammation resulting in progressive loss of salivary gland function.

ANATOMY — Salivary glands stones usually occur in the major salivary glands (parotid, submandibular, and sublingual (figure 1)) and occasionally in the minor salivary glands. The anatomy of the glands and ducts affects where stones are likely to lodge and also affects the choice of therapies. (See 'Management' below.)

Parotid glands and Stensen's duct – The parotid glands are located on the sides of the face anterior to the external auditory canal, superior to the angle of the mandible, and inferior to the zygomatic arch. Most of the parotid gland is superficial to the masseter muscle. Stensen's duct arises from the anterior border of the parotid gland and is 4 to 7 cm long and 2 to 3 mm in diameter, narrowing to 1.2 mm at an isthmus. The os of Stensen’s gland is 0.5 mm in diameter and is opposite the upper second molar (figure 1).

Submandibular glands and Wharton's duct – The submandibular glands lie beneath the floor of the mouth. Wharton's duct arises from the medial surface and is approximately 5 cm long and 1.5 mm in diameter. The os of Wharton’s duct is 0.5 mm diameter and located on the floor of the mouth near the frenulum of the tongue (figure 1).

Sublingual glands – The sublingual glands are located below the mucous membrane of the floor of the mouth. They are drained by multiple small ducts that empty either into Wharton's duct or directly into the floor of the mouth (figure 1).

Minor salivary glands – The minor salivary glands are exocrine tissue located in the buccal, labial, lingual, and palatal mucosa that drain directly into the mouth.

PATHOGENESIS — The precise pathogenesis of stone formation is not known, but relative stagnation of salivary flow and elevated salivary calcium concentration are thought to be important contributors. Salivary stones are composed largely of calcium phosphate and hydroxyapatite with smaller amounts of magnesium, potassium, and ammonium [1]. Inflammation of the salivary gland or duct and localized injury often contribute; bacterial biofilms involving the salivary ducts may also be involved, and bacteria may even serve as a nidus for sialolith formation [2].

The submandibular gland may be more prone to stone formation because the duct is long, the flow of saliva is slow and against gravity, and the saliva is more alkaline with a high mucin and calcium content [3].

EPIDEMIOLOGY AND RISK FACTORS — Although a 1 percent incidence is noted in autopsy studies [1], clinically symptomatic stones are much less frequently noted. A population-based study in England found a lifetime prevalence of symptomatic sialolithiasis of 0.45 percent [4].

Men develop more stones than women, and the majority of cases occur in individuals between the ages of 30 and 60 years. Stones rarely occur in children.

Seventy-five percent of salivary stones are single and approximately 3 percent are bilateral [5,6]. Stones occur equally on the right and left sides.

Risk factors associated with salivary gland stones include [1,7,8]:

Hypovolemia

Diuretics

Anticholinergic medications

Trauma

Gout

Smoking

History of nephrolithiasis

Chronic periodontal disease

An association between hypercalcemia and salivary gland stones has been reported but appears to be weak [9].

CLINICAL FEATURES

Location — Most (80 to 90 percent) salivary gland stones occur in the submandibular glands, 6 to 20 percent occur in the parotid glands, and 1 to 2 percent occur in the sublingual or minor salivary glands (figure 2) [1,10,11]. Submandibular stones tend to be larger than stones in other glands and are most often located in the duct. Parotid stones tend to be smaller than submandibular stones, are more often multiple, and 50 percent of the time are located within the gland itself.

Symptoms — Sialolithiasis typically presents with pain and swelling in the involved gland; these symptoms are usually aggravated by eating or by anticipation of eating. Stones can also present as painless swelling or may be noted incidentally on physical examination or on radiographs (such as dental radiographs). Approximately 33 percent of patients with submandibular sialolithiasis present with painless swelling and 10 percent with pain but not swelling [12].

Patients may have episodic swelling and discomfort or may have more persistent symptoms. A stone that causes intermittent obstruction may cause symptomatic episodes separated by days to weeks.

Worsening pain, erythema, and/or fever may indicate secondary infection. (See 'Complications' below.)

Physical examination

Salivary gland and duct examination

Submandibular gland – Have the patient close his or her mouth slightly to relax the musculature on the floor of the mouth [1]. Palpate the course of Wharton's duct along the floor of the mouth in a posterior to anterior direction (figure 1). A stone may be felt within Wharton's duct or seen at its orifice near the frenulum of the tongue (picture 1).

Parotid gland – Palpate the buccal mucosa around the opening of Stensen's duct, which is adjacent to the second upper molar (figure 1). Also palpate the face along the duct's route by starting at the attachment of the earlobe and palpating forward in the direction of the jaw-line with one hand on the outside and one hand inside the mouth. A stone may be felt within Stensen's duct or seen at the orifice.

Pertinent examination findings

A functioning gland is typically spongy and elastic.

Compression of a salivary gland should cause clear saliva to flow from the associated duct. If it does not, a stone may be obstructing the duct. Purulent discharge at the orifice raises concern for acute bacterial sialadenitis (picture 2). (See 'Acute bacterial sialadenitis' below.)

When a salivary gland stone is present, the gland may be quite tender, particularly in the presence of associated infection. (See 'Complications' below.)

Stones are typically rock hard and small; they may be smooth or irregular. They are most commonly felt within the ductal system.

Salivary gland tumors are firm and nontender. They are palpable in the parenchyma of the gland.

Complications

Secondary infection – Sialolithiasis can lead to secondary infection as a result of ductal obstruction and salivary stasis; this is a particular problem in older adults [13]. While these infections are often minor and respond rapidly to antibiotics, a small number progress to extensive cellulitis and abscess formation with the potential to compromise the airway. (See 'Primary care management' below.)

Chronic sialadenitis – Recurrent episodes of sialolithiasis may result in chronic sialadenitis and dysfunction. Chronic submandibular sialadenitis can result in a significant drop salivary flow, since the submandibular glands contribute 70 percent of the oral salivary flow [14]. The drop in salivary flow rarely has any clinical consequences. Most salivary gland function recovers if the obstruction is relieved and the gland and duct remain intact [15]. However, once a gland has atrophied (figure 2) from chronic obstruction, function is not regained.

DIAGNOSIS

Clinical diagnosis — Sialolithiasis is a clinical diagnosis based on a characteristic history and physical examination. There is typically sudden onset of swelling and pain in the affected gland associated with eating or anticipation of eating. A stone may be seen at the opening of the affected salivary gland duct (picture 1) or palpated along the course of the duct. (See 'Clinical features' above.)

Indications for imaging — Imaging can provide details about the location of a stone and can be helpful if the diagnosis is unclear or if there is concern about a salivary gland tumor. Imaging can also be helpful when a complication, such as an abscess, is suspected. Solid lesions are concerning for salivary gland neoplasm, both benign and malignant, or lymphoma. Cystic lesions are more consistent with benign causes such as lymphoepithelial cysts, commonly seen in human immunodeficiency virus (HIV) disease and Warthin tumor (a rare benign salivary gland tumor). (See 'Differential diagnosis' below and "Salivary gland tumors: Epidemiology, diagnosis, evaluation, and staging".)

There are a number of available imaging modalities, each with advantages and disadvantages:

Computed tomography – High-resolution noncontrast computed tomography (CT) scanning is the imaging modality of choice for the evaluation of salivary stones [16]. Most stones contain enough calcium to be visible with noncontrast imaging. Fine cuts must be requested so that the stone or stones are not missed.

CT scans have a high sensitivity for salivary stone detection; a retrospective cohort study reported a sensitivity of 98 percent and a specificity of 88 percent using sialoendoscopy as the reference standard [17]. Excellent assessment of the entire gland is available and sensitivity for the identification of parotid tumors approaches 100 percent [18].

Ultrasound – Ultrasound can be used to diagnose salivary gland stones. Although more than 90 percent of stones 2 mm in diameter or larger can be detected by ultrasound [19,20], ultrasound may more accurately detect submandibular and parotid gland sialolithiasis compared with stones in other locations [21]. Advantages of ultrasound include its noninvasive nature, relatively low cost, and lack of radiation exposure. Disadvantages include the need for an experienced operator and low sensitivity for detecting salivary gland neoplasms or stone related complications, such as strictures.

Magnetic resonance sialography – Magnetic resonance sialography is a noninvasive alternative to conventional sialography. It does not require intraductal contrast. Studies of magnetic resonance sialography suggest that it may have superior sensitivity compared with ultrasound [22] and a lower procedural failure rate than conventional sialography [23].

Standard magnetic resonance imaging (MRI) does not visualize stones well [1], so it is not an appropriate choice for evaluation of possible salivary gland stones.

Conventional sialography – Conventional sialography for the diagnosis of sialolithiasis has been largely supplanted by high-resolution CT scanning or ultrasound [16]. In conventional sialography, the duct is cannulated and a radiopaque dye is injected, followed by plain films. Sialography is contraindicated in patients with acute sialadenitis or contrast allergy [22,23].

DIFFERENTIAL DIAGNOSIS — A number of other disease processes may affect the salivary glands and must be distinguished from sialolithiasis (table 1). These include infections, inflammatory conditions, and masses, including neoplasms.

Viral sialadenitis — Viral parotitis due to mumps virus is characterized by acute pain and swelling of one or both parotid glands. It is a common cause of parotid gland swelling [24]. Infection is frequently accompanied by a nonspecific prodrome consisting of low-grade fever, malaise, headache, myalgias, and anorexia. These symptoms are generally followed within 48 hours by the development of parotitis. (See "Mumps" and "Salivary gland swelling: Evaluation and diagnostic approach", section on 'Viral sialadenitis'.)

Other less common viral etiologies of sialadenitis include coxsackie viruses A and B, echovirus, parainfluenza virus, influenza A, and Epstein-Barr virus.

Acute bacterial sialadenitis — Acute bacterial sialadenitis (suppurative sialadenitis) in the absence of sialolithiasis typically affects older adults, and malnourished or postoperative patients [13]. The parotid gland is most commonly involved. Acute bacterial sialadenitis is characterized by sudden onset of very firm and tender swelling over the involved gland. Purulent drainage can often be expressed from the affected duct orifice (picture 2 and movie 1). Fever and chills are usually present, generally with fairly marked systemic toxicity. (See "Salivary gland swelling: Evaluation and diagnostic approach", section on 'Infectious causes'.)

Staphylococcus aureus is the most frequent microbiologic isolate, but Streptococcus pneumonia, Streptococcus viridans, Haemophilus influenzae, and Bacteroides species have also been isolated. Broad-spectrum antimicrobial therapy should be initiated. Prompt surgical drainage and decompression is required if an abscess develops. (See "Suppurative parotitis in adults".)

Chronic bacterial sialadenitis — Chronic bacterial sialadenitis is a low-grade chronic infection that can eventually lead to destruction of the salivary gland. It may occur more commonly in patients with decreased salivary secretion and increased mucus content in their saliva [5]. Other predisposing factors include stones, strictures, and trauma. Patients with chronic bacterial sialadenitis generally have intermittent exacerbations of acute sialadenitis.

Human immunodeficiency virus — Patients with human immunodeficiency virus (HIV) infection are prone to the development of lymphoepithelial cysts within the parotid gland; cysts can also occur in other major salivary glands [25,26]. These may become superinfected. Parotid swelling in HIV infection is typically diffuse and symmetric. Asymmetric swelling is more characteristic of a parotid tumor. Imaging is necessary if the diagnosis is uncertain. (See "Salivary gland swelling: Evaluation and diagnostic approach", section on 'HIV related' and 'Salivary gland tumors' below and 'Indications for imaging' above.)

Sjögren's disease — Sjögren's disease is a chronic inflammatory disorder characterized primarily by diminished lacrimal and salivary gland secretions resulting in symptoms of dry eyes and dry mouth, the so-called "sicca complex." Sjögren's disease may present with a gradual swelling of the parotid or submandibular glands, typically bilaterally. Autoimmune sialoadenitis eventually causes parenchymal destruction and dilation of the intraglandular ducts [27]. (See "Clinical manifestations of Sjögren's disease: Exocrine gland disease".)

Sarcoidosis — Extrapulmonary sarcoidosis affects the parotid glands in a small number of cases and may be associated with uveitis and facial paralysis (Heerfordt's syndrome). The presentation is characterized by bilateral painless parotid enlargement due to granulomatous infiltration. (See "Salivary gland swelling: Evaluation and diagnostic approach", section on 'Granulomatous sialadenitis (noninfectious)' and "Overview of extrapulmonary manifestations of sarcoidosis".)

Salivary gland tumors — Salivary gland tumors should be considered in patients with a focal salivary gland mass or subacute, asymmetric, painless enlargement of a single salivary gland. Examination findings may include facial nerve dysfunction, firmness on palpation, and lack of mobility. Imaging is indicated if a salivary gland tumor is suspected. (See 'Indications for imaging' above and "Salivary gland tumors: Epidemiology, diagnosis, evaluation, and staging".)

Other

Radiation sialadenitis – Irradiation of a salivary gland by radioactive iodine or external beam radiation may cause acute, painful swelling [6]. Patients may also experience burning, dry mouth with diminished ability to taste. (See "Salivary gland swelling: Evaluation and diagnostic approach", section on 'Inflammatory causes'.)

Malnutrition – Sialadenosis is the noninflammatory, non-neoplastic enlargement of a salivary gland, typically the parotid [6]. It may be seen in malnourished patients; associated conditions include anorexia nervosa, bulimia, beriberi, pellagra, diabetes, and alcoholic cirrhosis. Histologic evaluation reveals acinar hypertrophy without an inflammatory infiltrate. (See "Salivary gland swelling: Evaluation and diagnostic approach", section on 'Sialosis due to metabolic causes' and "Salivary gland swelling: Evaluation and diagnostic approach", section on 'Acute sialadenosis of bulimia nervosa'.)

Reaction to intravenous contrast – Rarely, swelling of the salivary glands can occur after the injection of intravenous iodine-based contrast for radiologic studies [28]. (See "Salivary gland swelling: Evaluation and diagnostic approach", section on 'Inflammatory causes'.)

MANAGEMENT

Primary care management — Conservative management is the mainstay of treatment in the majority of patients presenting to a primary care clinician. Patients should be instructed to keep well hydrated, apply moist heat to the involved area, massage the gland, and "milk" the duct (figure 3).

Nonpharmacologic agents that promote salivary flow (eg, tart, hard candies such as lemon drops) may be helpful and should be used throughout the day as often as tolerated by the patient.

If possible, patients should discontinue medications with anticholinergic effects that reduce salivary flow, such as diphenhydramine and amitriptyline.

Moderate pain can generally be controlled with nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen; NSAIDs may also help reduce inflammation. Patients with severe pain may require opioid analgesics.

If secondary infection is suspected because of increasing pain, fever, or purulent drainage from the duct, antistaphylococcal antibiotics such as dicloxacillin 500 mg four times a day or cephalexin 500 mg four times a day should be administered for 7 to 10 days. If there is not an improvement in the pain, fever, or purulent drainage within five to seven days, a culture of any duct discharge should be obtained and the antibiotic coverage broadened by substituting amoxicillin/clavulanate or clindamycin until culture results are available. In addition to broadening antimicrobial coverage, we also obtain imaging with ultrasound or computed tomography (CT) with contrast if there are signs suggestive of an abscess, such as fluctuance with overlying erythema and warmth.

After resolution of the acute episode, risk factors (eg, smoking, hypovolemia, anticholinergic medication use, etc) should be identified and modified to prevent future episodes [8]. (See 'Epidemiology and risk factors' above.)

Indications for referral

Suspected salivary gland tumor — If the history or physical examination are more suggestive of a neoplasm (eg, parotid rather than submandibular location, indolent onset, painless swelling, not aggravated by eating or anticipation of eating) patients should be referred promptly to an otolaryngologist.

Failure to improve with conservative management — Patients who have persistent symptoms and/or obstruction lasting more than a few days should be referred to an otolaryngologist. The severity of symptoms determines how soon the patient should be seen.

Patients with salivary gland infection that worsens or does not improve with antibiotic therapy require urgent referral as they are at risk for the development of salivary gland abscess. Submandibular gland infection can spread to the floor of the mouth, potentially leading to airway compromise.

Recurrent symptoms — Patients with recurrent episodes of sialolithiasis should be referred for specialist management because they are at risk for chronic sialadenitis and loss of salivary gland function.

Specialist management — Most salivary gland stones that do not improve with primary care management can be managed by the otolaryngologist using minimally invasive techniques. Occasionally, open surgical extraction of the stone is necessary (eg, proximal stones, larger stones). In rare cases, it may be necessary to excise the affected salivary gland (sialoadenectomy).

Sialoendoscopy — For salivary stones that do not resolve with conservative management, minimally-invasive approaches are highly successful. In particular, sialoendoscopy is widely used [29,30]. Operative sialoendoscopes have a working channel through which miniaturized tools can be introduced. These include wire baskets and forceps for extracting stones and micro drills and laser fibers for fragmenting larger stones. Sialoendoscopy can be carried out with local or general anesthesia. In a systematic review, the overall success rate of sialoendoscopy (for a variety of indications, including obstructive stones, stenosis, and sialadenitis) was 86 percent [31].

Good prognostic factors for successful removal of salivary stones via sialoendoscopy include small size, mobility, roundness, and distal location in the main salivary duct [32]. Size is the most important predictor of success; stones less than 3 mm in the parotid and 4 mm in the submandibular gland are easily removed without fragmentation, while removal of larger stones is technically more difficult [33]. However, an open intraoral approach assisted by sialoendoscopy allows retrieval of proximal stones larger than 10 mm in over 80 percent of cases [34,35].

For stones larger than 4 mm, a combined approach using sialoendoscopy and laser assisted lithotripsy can be used. In a case series of almost 400 patients undergoing this combined approach, 90 percent of patients had no recurrent symptoms at two or more years after the procedure [36]. The remaining 10 percent had minor post-prandial symptoms but did not require intervention.

Sialoendoscopy may be utilized to visualize the ductal anatomy as well as to remove small stones that are beyond the reach of traditional transoral surgical procedures. Sialoendoscopy may also be used diagnostically, to detect small stones not detected by imaging, and to differentiate a stone from a polyp or mucous plug.

Sialoendoscopy may be used after traditional transoral calculus removal to check for the presence of residual stone fragments.

Other minimally invasive techniques — The availability of other minimally invasive interventions depends on the specific practice setting.

Extracorporeal lithotripsy – For patients in whom a simple transoral surgical approach is not possible (typically stones in the proximal ducts or in the salivary glands themselves) or fails, extracorporeal lithotripsy appears to be effective for stones that are intraductal and less than 7 mm [29]. However, extracorporeal lithotripsy for salivary stones is not approved by the US Food and Drug Administration (FDA).

Laser lithotripsy – Laser lithotripsy (available in some locations in the United States) is an alternative to extracorporeal lithotripsy and can be performed via endoscopy (see 'Sialoendoscopy' above). Laser lithotripsy allows fragmentation of the stone prior to endoscopic removal [37].

Wire basket retrieval – Removal of stones with a wire basket extractor under fluoroscopic guidance is an alternative to invasive surgery and sialadenectomy in some cases [38]. This technique is used less frequently with the availability of other minimally invasive techniques.

Surgical intervention — If minimally invasive interventions are not successful, the salivary stone can be removed surgically.

Submandibular stones – Submandibular stones can be removed via a transoral approach approximately 50 percent of the time [12]. Stones that are palpable within the mouth are generally amenable to this procedure. Transoral submandibular stone removal may be complicated by trauma to the duct and associated sublingual glands, which can lead to formation of a retention cyst on the floor of the mouth (ie, ranula).

Proximal stones are more challenging to remove transorally, although technically achievable [39]. The increased dissection required through a limited exposure may lead to a greater risk of trauma to surrounding nerves. Multiple procedures may be required when the initial attempt is unsuccessful. Growing experience with combining sialoendoscopic and open intraoral techniques has led to improved success rates in removing proximal stones [34,40].

Transcervical excision of the submandibular gland (sialoadenectomy) is typically reserved for cases where transoral or minimally invasive approaches have been unsuccessful or for a patient who would not tolerate a potential second procedure. Transcervical excision is a more difficult procedure and risks injury to the lingual and hypoglossal nerves [41].

Parotid stones – Parotid stones generally are not approachable transorally unless they are near the orifice of Stensen’s duct. Other open or minimally invasive approaches usually are necessary.

Parotidectomy is typically a last resort, reserved for patients who have failed less invasive approaches and whose symptoms warrant the additional risk to the auriculotemporal nerve (a branch of cranial nerve V) and facial nerve during dissection (picture 3) [42].

Complications – Evidence from series of patients undergoing sialadenectomy for chronic sialadenitis suggests that facial nerve injuries are common. As an example, one series found that facial nerve injury occurred in 29 percent of parotidectomies and 12 percent of submandibular gland excisions performed for chronic sialadenitis [43]. The lingual and hypoglossal nerves are close to the submandibular gland. The risk of injury to these nerves is increased in the setting of scarring and inflammation from chronic sialadenitis.

Recurrence – In patients who have undergone transoral surgical stone removal, recurrence has been reported in 18 percent of cases [1].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Parotitis (The Basics)")

SUMMARY AND RECOMMENDATIONS

Salivary gland anatomy – Salivary gland stones primarily are found in the three major salivary glands: parotid, submandibular, and sublingual (figure 1). (See 'Anatomy' above.)

Risk factors – Dehydration, diuretics, anticholinergic medications, and trauma predispose to the formation of stones. (See 'Pathogenesis' above and 'Epidemiology and risk factors' above.)

Clinical presentation

Eighty to 90 percent of stones arise from the submandibular glands (figure 1), most often occurring as single stones within Wharton's duct. (See 'Location' above.)

Sialolithiasis typically presents with pain and swelling with eating or anticipation of eating. Painless swelling or pain without swelling are less common. Symptoms may be episodic with intermittent obstruction. (See 'Symptoms' above.)

Evaluation and diagnosis

Examination for submandibular stones includes posterior to anterior palpation of the floor of the mouth and inspection of the opening of Wharton's duct (near the frenulum of the tongue). Examination for parotid stones includes palpation of the buccal mucosa and inspection and palpation of Stenson's duct (adjacent to the second upper molar). Stones are typically rock hard and small; they may be smooth or irregular. (See 'Physical examination' above.)

Sialolithiasis is a clinical diagnosis based on the characteristic history of swelling and pain associated with eating or anticipation of eating and a small rock hard mass palpable in the salivary gland or duct or visible at the os (picture 1). (See 'Diagnosis' above and 'Symptoms' above and 'Physical examination' above.)

Imaging can be helpful if the diagnosis is unclear or if there is concern for a salivary gland tumor or abscess. (See 'Indications for imaging' above.)

Differential diagnosis – The differential diagnosis of salivary gland stones includes infection (viral or bacterial sialadenitis, human immunodeficiency virus [HIV]), Sjögren's disease, sarcoidosis, and malnutrition (table 1). Acute bacterial sialadenitis should be considered with purulent drainage and systemic symptoms. Malignant tumors of the salivary gland should be considered when there is failure of swelling to respond to treatment, involvement of minor salivary gland tumors, facial nerve dysfunction, or a firm fixed mass. (See 'Differential diagnosis' above.)

Management

Conservative management is the mainstay of treatment in primary care; patients should be instructed to keep well hydrated, apply moist heat to the involved area, massage the gland, "milk" the duct, and suck on tart, hard candies to promote salivary flow. Pain should be managed with nonsteroidal antiinflammatory drugs (NSAIDs) or occasionally opioid analgesics. Anticholinergic medications should be discontinued when possible. Patients with severe or persistent symptoms should be referred for specialist management. (See 'Primary care management' above.)

Suspected secondary infection should be treated with an antistaphylococcal antibiotic (dicloxacillin 500 mg four times a day or cephalexin 500 mg four times a day for 7 to 10 days). Infection that worsens or fails to improve requires urgent referral. (See 'Primary care management' above.)

Most salivary gland stones that do not improve with conservative management can be treated by the otolaryngologist using minimally invasive techniques, particularly sialoendoscopy. Larger or more proximally located stones may require open surgical procedures. Sialadenectomy is reserved for patients with recurrent stones or failed minimally invasive procedures. (See 'Specialist management' above.)

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Topic 6854 Version 37.0

References

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