The incidence of salivary calculus is more frequent insubmandibular gland compared to parotid gland with an approximate ratio of 8:2.
1 Parotid sialoliths are usually unilateral,and occur mainly in the ductal system.2 Sialoliths usually measure from 1 mm to less than 1 cm insize. Parotid sialoliths are smaller and lessradioopaque than submandibular stones.3 The growth of sialolithpartly depends on the ability of the affected salivary duct to dilate.4Previous histologic studies have demonstrated that diameter of the Stenson’s ductvaries from 0.
5mm to 1.4mm.5 Thedimension of sialoliths believed to annually increase by about 1 to 1.5 mm.6 Pain and swelling ofthe duct during meals which lasts for about less than 2hrs is the main symptomof salivary calculus.
7 Ifthe duct in which the calculus is located is able to dilate and allow the normal flow of saliva then the calculus maygrow in size without causing symptoms for long periods.8Thesialolith formation of in the parotid duct has been attributed to slow salivaryflow, salivary stagnation, and intricate metabolic events. An analysis by Zhu P et al has shown that thesialoliths may be of round, oval, or irregularshape, with the majority being oval similar to the sialolith in ourcase. In their study on 15 patients withparotid sialoliths revealed maximum sizebeing 10mm.9 Larger salivary calculi are usually found in the bodyof salivary glands and are rarely been described being in the salivary ducts 10Themainstay of investigation is ultrasound as it is non invasive and can also visualizestrictures. The size, site and mobility of the calculus, the ductal patencyas well as procedure availability dictate the type of management.
11,12Conservativeapproach for the management of small sialolith isadvising the patient to increase water intake,application of warm moist heat and massaging the gland in conjunction withsialogogues. Also helps to move the smallcalculi out through ductal orifices.13 Conventionally, calculi inthe distal section of the parotid duct near the punctum are removed through an intraoral approach and those in the posterior third of the duct and hilum have to be retrieved through an extra-oral approach.
1The smaller stones measuring less than 5 mm and lying freely in the duct lumencan be retrieved through sialendoscopy. Throughlithotripsy, larger stones up to 8mm can be fragmented and then can be retrievedendoscopically. The surgical method is the option if calculi is attached to theduct wall or is of diameter of more than8-10 mm.14Asthe calculi size appeared big measuring about 1mm in diameter, we suggestedsurgical removal of calculi. However, the patient was apprehensive aboutundergoing the procedure and opted to wait without any treatment. Usually, in such cases, the patient may develop recurrent sialadenitiscompelling them to undergo removal of calculi.
This did not happen in ourpatient. Hence she could afford to wait for ayear without any intervention. ConclusionSialolithiasisis a common disease affecting the salivary glands which are more common in elderly patients. Most of the cases, based onthe location and size are indicated for surgical removal.
However, if thecalculi are located in the distal portionof the duct and patient is relatively asymptomatic with normal salivation, thenthere is a high chance for self-exfoliation of calculi. Hence, attemptsshould be directed towards increasing the salivary flow to promote lavage ofstone. However, the patient should beunder periodic check up to prevent any untoward complications.