Case Report of Sialolithiasis (2008)

Editor: I recently saw an 87-year-old African American woman with past medical history of rheumatoid arthritis on prednisone, iron, and potassium complaining of facial swelling over one or two days. She denied any history of diabetes mellitus, nausea and vomiting, headache, tooth extraction, trauma, or similar past episodes. She does admit to subman dibular swelling with pain, fever (up to 101°F at home), and anterior neck fullness. This started a “couple of days ago,” and her son was worried enough to bring her to the ED. Upon arrival, she was in mild distress, hypertensive at 151/84 mm Hg, heart rate was 94 bpm, temperature was 101.8°F, and nonhypoxic at 98% on room air. She was sitting upright in mild distress. Her airway was obscured by her protruding tongue (see photograph), but she denied any trouble breathing. Breath sounds were equal, and her blood pressure was mildly elevated. Her pharynx could not be visualized secondary to current habitus. Her tongue was elevated and protruding with a firm intralingular base. Her neck was warm, swollen, and firm. The patient's only other complaint was 2+ pitting edema of both ankles, which she stated was a chronic problem. The patient's chemistries, CBC, and coagulation studies were normal. ENT evaluated the patient, and agreed with a presumed diagnosis of Ludwig's angina from the physical exam. Anesthesia nasal-intubated the patient, clindamycin and metronidazole were given, and she was transported to the ICU. The next day, a CT scan read by the attending radiologist revealed sialolithiasis of the submandibular gland, which excluded the diagnosis of Ludwig's angina. Sialolithiasis are salivary gland stones, and are found in about one percent of the population. Up to 95 percent of the stones are located in the submandibular glands. In patients with mild to moderate disease, stones can be confirmed by palpation or purulent discharge from the glandular duct with massage. This method also can be therapeutic if the obstruction is milked out of the duct at the time of diagnosis. Plain films and CT scans can be used to confirm ductal stones and obstructions. (Textbook of Family Practice. W.B. Saunders Co., 2002: 468.) Stone formation is thought to arise from precipitation of crystalline material around an organic source, like bacteria or epithelial cells. (Otolaryngology: Head & Neck Surgery. Mosby, 2004: 1307; 4123.) Because one theory on formation is around an organic and possibly bacterial source, antibiotics to cover penicillinase-resistant organisms should be given. Symptomatic relief can be achieved by moist heat applied to the affected area, and the judicial use of sialogogues. The most common sialogogues used are usually citric, which helps promote salivary production. Spaces in the peripharyngeal area can be invaded by external bacteria leading to various infections, including peritonsillar abscess, Ludwig's angina, retropharyngeal abscess, Lemierre's syndrome, osteomyelitis, uvulitits, lymphadenitis, and parotitis, to just name a few. The mainstay of treatment is antibiotics and airway management, not incision and drainage. Surgical management may be reserved for severe cases and cases not responding to antibiotics. All cases should have an emergent ENT consult. If conservative and symptomatic treatment fails or obvious active infection is present, stone removal is a viable option. There are many different methods to remove a salivary gland stone, the preferred being transoral stone removal under local anesthesia. This method is preferred over more invasive attempts because it has a higher chance of preserving the gland and causes less scarring of the ductal system. (Arch Otolaryngol Head Neck Surg 2001;127:432.) Some of the more novel approaches that are coming to the forefront are extracorporeal shock wave lithotripsy (ESWL) (Brit Dent J 2002:193:89) and interventional radiological approaches using stone retrieval catheters. (Dentomaxillofac Radiol 1996;25:242.) Some of the newer approaches, like the use of retrieval catheters, might soon become the preferred method of stone removal because they are not surgical and cause less postoperative damage to the ductal system.FigureLife-threatening diseases need to be considered and treated early in the evaluation of a patient. Even if the final diagnosis does not match the initial diagnosis, the presumed life threat needs to be treated. This patient presented with many of the symptoms of Ludwig's angina, which is potentially fatal. The final diagnosis is not considered a life-threatening disease, but the real possibility of airway obstruction made it a possibly devastating disease. The patient refused surgery to remove the obstructions, and left the hospital on oral antibiotics and ENT follow-up. Scott Goldstein, DO Philadelphia, PA