SALIVARY GLAND DISEASES 0030-6665/99 $8.00 + .

OO

SIALOLITHIASIS
Mark F. Williams, MD

Sialolithiasis is one of the most common problems that afflict the sal-
ivary glands and is a major cause of salivary gland dysfunction. Autopsy
studies have reported the incidence to be 1% of the population.35Many
cases remain asymptomatic. This article describes the pathophysiology
and clinical features of sialolithiasis. Pertinent diagnostic studies and gen-
eral recommendations for management are discussed. Some mention is
given to new technologies that may become useful in the future for treat-
ment of patients with sialolithiasis.

PATHOPHYSIOLOGY

The exact cause of calculi formation is unclear. Chronic sialadenitis

is known to cause intraductal and intraglandular concretions, which can
promote stone formation. Conversely, the presence of calculi clearly
causes chronic sialadenitis. Which of these processes is the instigating
causative factor is unknown. It is clear that the genesis of calculi lies in
relative stagnation of a calcium rich saliva.12Partial obstruction appears
to be important. Completely obstructed glands, although they do have
salivary stagnation, do not have an increase in stone formation. In com-
pletely obstructed glands, the calcium secretory granules in the acini be-
come depleted and this saliva is less 1ith0genic.I~

From the Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of
Medicine, Baltimore, Maryland
~~~ ~ ~~~~

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

VOLUME 32 NUMBER 5 * OCTOBER 1999 819

820 WILLIAMS

Salivary glands are known to contain small concretions called mi-

croliths in the intraglandular ducts. These do not, however, appear to be
related to formation of stones. Microliths may be related to the establish-
ment of chronic sialadenitis by causing micro~bstruction.'~ For stone for-
mation, it is likely that intermittent stasis produces a change in the mucoid
element of saliva, which forms a gel. This gel provides the framework for
deposition of salts and organic substances creating a ~ t 0 n e . IIt~also has
been postulated that an unknown metabolic phenomenon can increase
the salivary bicarbonate content, which alters calcium phosphate solubil-
ity and leads to precipitation of calcium and phosphorus ions.5Calculi are
laminated in morphology. The laminations are irregular, which may be
attributable to the fact that salivary calculi formation is intermittent in
nature.16 Urinary calculi tend to be laminated more uniformly, as these
stones may be formed in a more continual fashion. Light and electron
microscopy studies have not shown evidence of bacterial organisms or
foreign bodies as the nidus for sialolith formation.'j
The composition of salivary stones is predominately calcium phos-
phate and carbonate in the form of hydroxyapatite with small amounts
of magnesium, potassium, and ammonium. This mixture is distributed
evenly throughout.16The organic matrix is composed of various carbo-
hydrates and amino acids. Parotid stones tend to be less dense and less
calcium rich. Most likely this is related to the serous nature of the secre-
tions from the parotid parenchyma, in contrast to the more mucinous
secretions from the submandibular gland.
Stone formation is not associated with systemic abnormalities of cal-
cium metabolism. Electrolytes and parathyroid hormone studies in pa-
tients with sialolithiasishave not demonstrated abnormalities. Gout is the
only systemic illness known to predispose to salivary stone formation."
In gout the stones are made up predominately of uric acid. One study has
suggested a relationship between sialolithiasis and nephrolithiasis, re-
porting an association in up to 10% of patientsz7 Other studies have
shown a lower rate.4 Many common medications are known to cause a
decrease in saliva formation. These medications include antihistamines,
antidepressants, hypertensives, diuretics and antipsychotic medications.
No obvious link between these medications and salivary stone formation
has been reported in the literature.
The natural history of sialolithiasisis to cause relative or total obstruc-
tion of salivary outflow, and to lead to bacterial ascent into the paren-
chyma of the gland. Acute and chronic inflammation commonly ensue
and the acini of the gland will become damaged. The gland will manifest
a histologic pattern of chronic inflammation. The patient can, over time,
become refractory to medical management. Long-term obstruction in the
absence of infection can lead to atrophy of the gland with resultant loss
of secretory function and ultimately fibrosis. Intraductal stones also may
 SIALOLITHIASIS 821

promote inflammation and scarring of the duct with stricture formation.

Strictures and stenosis of the duct can lead to recurrent salivary outflow
problems.

CLINICAL FEATURES OF SIALOLITHIASIS

Calculi may form in any of the salivary glands of the head and neck.
The submandibular gland is the most common site by far (80% to 92%).
The parotid gland (6%to 20%), and sublingual glands and minor glands
(1%to 2%) follow at a lower rate of occurrence. 2 5 3 3 3 4 Minor salivary
glands, when involved, are usually in the buccal mucosa or upper lip,
forming a firm nodule that may mimic Minor glands drain di-
rectly into the oral cavity. The likely mechanism of stone formation in the
minor glands is mechanical trauma with mucus extravastion, which
serves as a nidus for stone formation. The submandibular gland forms
the largest stones. A stone of 55 mm in length is reported as the largest.33
Salivary stones are single in 70% to 80% and multiple in the remaining
portion, with approximately 5%of patients having three or more
Parotid stones are usually smaller and more often multiple. With regard
to stone location, parotid stones are found to be in the hilum or paren-
chyma of the gland at least half of the time? Submandibular stones most
commonly are found in the duct (75%to 85%).2,27 Submandibular stones
close to the hilum of the gland tend to be larger before they become symp-
tomatic. Patients with multiple stones may have stones located in different
positions along the duct and gland. Stones in the hilum of the subman-
dibular gland tend to be oval, where as stones in the duct tend to be
elongated. The surface may be smooth or irregular.
Factors that tend to favor submandibular versus parotid gland stone
formation are: 1) longer and larger caliber duct with slower flow rates;
2) flow of saliva against gravity; 3) more alkaline saliva; and 4) high mucin
and calcium content of saliva.&These features, unique to the submandib-
ular gland, explain the overwhelming preponderance of stones found in
the submandibular gland. Bilateral and multiple glandular sialolithiasis
are uncommon, occurring in less than 3% of cases.2sRight-sided and left-
sided involvement is equal in 0ccurrence.2~
Demographically, sialolithiasis shows a male preponderan~e.2~ All
ages may be afflicted, although patients in their third to sixth decade rep-
resent the majority of cases. Sialolithiasis in children is rare. Stones in
patients as young as 16 months have been noted. Children presenting with
sialolithiasishave an average age of around 10-years-old.There is a strong
male preponderance in children with stones.8
Sialolithiasis presents with painful swelling (59%),painless swelling
(29%),and pain only (12%).10Patients wiIl be afflicted with a recurrent
822 WILLIAMS

salivary colic and spasmodic pains upon eating. The patient may have
repeated infections as well as abscess formation. Salivary stones also may
be discovered incidentally on dental radiographs or during routine ex-
amination. Obviously, not all patients with stones will be symptomatic.
This depends on the relative obstruction of salivary outflow. Of patients
presenting with a salivary gland disorder, a third will prove to have si-
alolithiasis.=
Careful history and physical examination are the mainstays for the
diagnosis of this disorder. Bimanual palpation of the floor of mouth in a
posterior to anterior direction will reveal a palpable stone in a large num-
ber of patients who have submandibular stones. Having the patient close
the mouth slightly to relax the floor of mouth musculature will aid in the
detection of these stones. Bimanual palpation of the submandibulargland
itself also can be informative. If the gland is spongy and elastic, it may
not be significantly compromised in terms of atrophy and fibrosis. If the
gland is uniformly firm and hard, however, this suggests a nonfunctional
or hypofunctionalgland. Approximately one quarter of symptomaticsub-
mandibular glands that harbor stones are hypofunctional or nonfunc-
ti0na1.~~ For the parotid gland, careful intraoral palpation around Sten-
sen’s duct orifice can reveal a stone. Also, facial palpation along the duct,
which lies lateral to the masseter in the anterior-posterior direction im-
mediately opposite the attachment of the ear lobe to the facial skin may
be fruitful? Parotid stones in the hilar or ductal position, however, are
often nonpalpable.
Occasionally,a stone is not palpable and the gland is fibrotic with the
clinical appearance of a tumor. In this setting, a fine needle aspiration
biopsy (FNA) may be performed for diagnosis. Interpretation of a fine
needle aspiration in the setting of distinguishing sialadenitis from sialo-
lithiasis can be problematic. Ductal metaplasia can mimic low-grade mu-
coepidermoid carcinoma on FNA. If no stone fragments are present in the
FNA, the diagnosis of sialolithiasismay be missed and a more worrisome
diagnosis may be suggested. It has been recommended that if FNA shows
a low-grade mucoepidermoid carcinoma of the submandibular gland,
subsequent work-up for a stone is re~omrnended.3~

RADIOLOGIC EVALUATION OF SlALOLlTHlASlS

Imaging studies are very useful for diagnosing sialolithiasisin situ-

ations where no stone can be seen or palpated. The use of plain radio-
graphs in this setting is well-established. Submandibular gland calculi are
radiopaque anywhere from 80% to 94.7%.21,27,34 Standard extraoral radi-
ographs, such as a facial or mandibular series, are less diagnostic than
intraoral radiographs or occlusal views (Fig. 1). Stones in the superior
 SIALOLITHIASIS 823

Figure 1. Right anterior submandibular duct stones (arrows)visualized on submentalocclusal

radiograph.

gland or proximal Wharton’s duct may be hard to visualize on plain lat-

eral projection radiographs because the stone may be superimposed on
the teeth or mandible. Often, an anteroposterior view with the mouth
open will allow visualization of superior hilar stones (Fig. 2). It is rec-
ommended that this view be used for work-up prior to proceeding with
the sialography. It is very uncommon for patients to have a combination
of radiopaque and radiolucent Thus, if a radiopaque stone is
found, the concern of an additional radiolucent stone is not substantial.
Other calcifications in the area, which may confuse the diagnoses, are:
1. Phleboliths or calcifications of intravascular thrombi either in a
hemangioma or in the lingual veins.
2. Calcified cervical lymphadenopathy, which may have occurred in
relation to tuberculous infection.
3. Arterial atherosclerosis of the lingual artery demonstrating calci-
fications along the floor of
To further differentiate these situations as extraductal, CT scanning or
sialography may be helpful.
Parotid stones are more likely to be radiolucent (40%); the addition
of high quality intrabuccal plain films, however, can show up to 70% of
parotid stones.34,40 Xeroradiography has been proposed in the past as su-
perior to plain radiography; this modality, however, is generally unavail-
able at this time.I3
824 WILLIAMS

Figure 2. Open mouth AP radiograph, showing left superior hilar submandibular stone (arrow).

Sialography also has been a mainstay in the evaluation of patients

with sialolithiasis. Sialography is performed by cannulating either Whar-
ton’s duct or Stensen’s duct and slowly injecting radiopaque dye into the
intraductal system. The duct and gland undergo retrograde filling of the
dye. Plain radiographs are taken either in the usual manner or with digital
subtraction to lessen the interference of surrounding bony structures. Si-
alography is useful also for other cause of obstructive sialadenitis, such
as stricture. Sialograms are reported to be up to 100%effective in detecting
ductal and intraglandular calculi.36
Contraindications to sialography are acute infection and significant
contrast allergy. Sialography is not indicated when a radiopaque stone is
situated in the oral portion of the submandibular duct. A stone in this
position is easily accessiblefor transoral removal and the injection of intra-
ductal contrast may displace the stone posteriorly. Sialography for sub-
mandibular gland disorders can help determine the position of more dis-
tal duct stones as they relate to the bend that the duct takes around the
mylohyoid muscle. Also, the sialogram can provide information regard-
ing the condition of the gland. If the intraparenchymal ducts are dilated
 SIALOLITHLASIS 825

grossly with the smaller ducts not filling in the face of a good sialogram,
the gland should be suspected of being nonfun~tional.3~ The sialogram is
extremely helpful for detection of parotid stones as they are less likely to
be radiopaque. The position of parotid stones in the duct, with relation to
the masseter, is very important information for choosing the mode of ther-
apy.
Ultrasound widely is reported as being a very helpful, but over-
looked, technology in this area. It is considered inexpensive, noninvasive,
and widely available. As many as 90% of all stones, greater than 2 mm
in size, can be detected as an echodense spot on an ultrasound." The
ultrasound also can show the location of the stone, as in sialography. U1-
trasound may come to the forefront of work-up in patients with acute
sialadenitis where sialography would be contraindicated. A further ad-
vantage of ultrasound evaluation is that it is unnecessary to cannulate the
salivary duct ostium, which may be technically difficult depending on the
patient's anatomy and expertise of the radiology staff. CT scanning is an
expensive, albeit highly diagnostic, modality for the detection of sialo-
lithiasis. Most stones contain enough calcium to be visible on CT scans
(Fig. 3>.aCare must be taken to obtain fine cuts so multiple stones are not
missed. Axial and coronal reconstructionsmay be helpful in assessing for
multiple stones.
Scintigraphy uses technetium-99m pertechnetate which is selectively
concentrated and secreted by the salivary glands. Some authors have rec-
ommended that preop scintigraphy be obtained to determine how func-
tional the gland is and thus determine the treatment." In obstructed
glands, however, there may be a marked decrease in pertechnetate uptake
that does not correlate well with functional recovery after stone removal.
Thus, the use of preoperative scintigraphy to aid in deciding whether or
not to proceed with sialadenectomy versus transoral excision is not alto-
gether advisable. Additionally, because there is no evidence that an
atrophic nonfunctional gland will remain symptomatic after stone re-
moval, proceeding to submandibular sialadenectomy as opposed to trans-
oral excision on the basis of preoperative scintigraphy probably is not
warranted.
MR imaging scanning will not visualize stones. There is active inves-
tigation using MR imaging to visualize the parotid and submandibular
ducts, as in sialography. In MR imaging sialography, the contrast medium
is the saliva in the duct. This study can be performed with conventional
MR imaging equipment. There are some problems at present with visu-
alization of the small ducts because of the high signal to noise ratio. This
technology produces a sialogram that does not require cannulation of the
duct. Studies are ongoing regarding MR imaging sialogram and this ul-
timately may be an alternative to formal sialogram.11,26
 Figure 3. CT scan showing right anterior floor of mouth submandibularstone (arrow).

MANAGEMENT OF SlALOLlTHlASlS

Patients presenting with sialolithiasis certainly may benefit from a

trial of a conservative management, especially if the stone is small. The
patient should be well-hydrated, and the clinician should use local heat,
massage the gland, as well as use sialagogues to promote saliva produc-
tion and possibly flush the stones out of the duct. In any gland with swell-
ing and sialolithiasis, infection should be assumed. Antistaphyloccocol
antibiotics are administered. In many patients the condition will resolve
with conservative therapy alone. Also, patients may be relatively asymp-
tomatic with infrequent bouts of sialadenitis relating to their stones. These
patients may elect not to have any surgical intervention and leave their
stones in place. If this is the treatment plan, the patient needs to be cog-
nizant of the need for early use of antibiotics, should symptoms reoccur.
They also should be aware that the stone may increase in size over time
and become more symptomatic.
The anatomy of the salivary gland and duct is very pertinent to de-
termining the mode of therapy for sialadenitis. The Stensen’s duct is 7 cm
 SIALOLITHIASIS 827

long and lies on the lateral surface of the masseter muscle. It makes a turn
medially at the front edge of the masseter and penetrates the buccinator
muscle. The orifice is in the buccal vestibule just opposite the maxillary
second molar. At the point where the duct penetrates the buccinator mus-
cle, there is an isthmus with the duct narrowing down to 1.2 mm. The
ostium is narrowed to typically 0.5 mm. The submandibularor Wharton's
duct is 5 cm long and originates on the lower edge of the mylohyoid
muscle. It bends sharply around the edge of this muscle and runs medial
to the sublingual glands and extends to a papilla in the anterior floor of
mouth. The diameter of the submandibular duct is constant at 1.5 mm.
There is no narrowing at its sharp bend at the mylohyoid. The ostium is
also the narrowest portion of the duct at 0.5 mL. Both ducts are able to
undergo considerable distention without macroscopic or microscopic de-
ra11gement.4~Thus, small stones less than 2 mm in size can be expected to
pass with some help by dilation of the punctum. The sublingual gland
has an anterior and posterior segment. The anterior segment drains into
Bartholin's duct, which usually opens into the floor of mouth, but can
open occasionally into the very anterior submandibular duct. The poste-
rior sublingual glands drain into multiple ducts in the floor of mouth, as
well as the ducts of Rivinus, which may enter into the submandibular
duct in the posterior floor of the
Submandibular stones are treated surgically either through a trans-
oral sialolithotomy approach or through complete sialadenectomy
through an extraoral approach. The most appropriate mode of treatment
is primarily dependent on the location of the stone. Radiograph or sialo-
gram information can be quite helpful in planning treatment for these
patients. Anterior submandibular stones are palpable and amenable to a
transoral procedure. Most surgeons feel that if the stone can be palpated
in the mouth it can be removed through a transoral approach. If the stone
is visualized on a central true occlusal technique film it also is amenable
to transoral excision. Another rule of thumb is, if the stone is no further
than 2 cm from the punctum as demonstrated by finger palpation or pal-
pating the stone by ductal probe, t+e stone may be removed through a
transoral approach. Approximately 50% of submandibular stones are in
this anterior position.'O For very anterior stones, a centimeter or less from
the punctum, fileting the submandibular duct is considered the best ap-
proach. This can be done under a topical and local anesthetic. A lingual
nerve regional block may be used also. The lingual nerve block will an-
esthetize the anterior two thirds of the tongue and the floor of the mouth,
as well as the gingiva of the lingual surface of the mandible. The technique
is to inject submucosally on the lingual surface of the mandible halfway
between the edge of the mandible and the tongue at the retromolar tri-
gone. With the patient appropriately anesthetized, a lacrimal punctum
dilator can be used to identify the ostium of Wharton's duct in the floor
828 WILLIAMS

of mouth. A pair of tooth forceps are helpful for stabilizing the duct while
probing. A punctal dilator (double zero lacrimal duct probe) is used to
probe and dilate the duct. The stone usually will be palpable with the tip
of the lacrimal probe. A scalpel may be used at this point to cut down on
the lacrimal probe, thus bivalving the duct. Alternatively, the probe may
be removed and the duct may be opened with one tang of an iris scissor
intraductally and one in the floor of mouth. After opening the duct, the
stone can be identified readily and milked forward, grasped, and re-
moved. The gland should be milked to remove any other debris in the
more posterior portion of the duct. The duct is not closed after opening
in this manner. In one report, the stone migrated posteriorly on manipu-
lation and was able to be removed with a #2 embolectomy catheter. The
catheter was passed distally and inflated, allowing the stone to be ad-
vanced forward and removed. There is also evidence that an embolectomy
catheter may allow transoral removal of stones that are around the edge
of the mylohyoid as well as Mar stones?
Stones in a slightly more posterior position, between 1 and 2 cm from
the punctum, may be amenable to a modification of this transoral ap-
proach where the stone is cut down on directly. This can be done under
local anesthesia. Care must be taken to be cognizant of the lingual nerve
being deep, but in close association with the duct posteriorly. The lingual
veins are medial and the lingual glands are lateral to the duct. After cut-
ting down on the stone, the stone can be grasped with forceps. No wound
closure is required. Some patients may fistulize in a more posterior posi-
tion, which is not harmful.
Deeper submandibular stones, such as around the knee of the my-
lohyoid and at the hilum generally are removed through sialadenectomy.
Some surgeons feel that removing these stones can be done safely, how-
ever, through a transoral appr0ach.3~ Transoral removal of these more dis-
tal stones usually requires a general anesthetic. The floor of mouth is
opened just opposite the first premolar, the submandibular duct is dis-
sected out, and the lingual nerve is identified. The lingual nerve is noted
to enter the surgical field from this approach at the lingual aspect of the
third molar. The lingual nerve is retracted and protected, whereas the floor
of mouth is opened in a posterior fashion. The duct is retracted anteriorly
and the mylohyoid can be identified. The stone in this more distal position
can be palpated in the duct. The duct is opened at the position of the stone
and the stone is removed. The sialodochotomy then is reapproximated
and the floor of mouth is closed loosely. Between 15%and 18%of stones
will be in this more posterior position.’O Oral and maxillofacial surgeons
will perform a complete sialoadenectomy for submandibular stones from
0.7% to 19.5% of the time. Otolaryngologists-head and neck surgeons,
general surgeons, and plastic surgeons will perform a complete siaload-
enectomy from 24% to 73%of the It is clear that the oral and max-
 SIALOLITHIASIS 829

illofacial surgeons are more comfortable with a transoral approach. The

advantage to approaching these stones in a transoral fashion is that a
functional gland may be preserved. Because complications of transoral
excision appear to be very low, morbidity of an external approach may be
avoided.
Parotid stone management is more problematic. The segment that is
approachable through an intraoral incision onto the Stensen’s duct orifice
represents a very small 1.5-cm portion of the 7-cm duct (Fig. 4). The duct
lateral to the masseter is unapproachable intraorally. To complicate mat-
ters, opening the Stensen‘s duct to allow removal and milking of stones
can be complicated by subsequent stenosis of the duct. Stenosis is uncom-
mon in the submandibular gland. Careful evaluation either by sialogra-
phy or ultrasonography is helpful in determining the number and posi-
tion of stones which is vital for choosing the appropriate management.
One case report does discuss a novel extraoral approach where the stone
is cut down directly on through a facial incision to access stones between
the hilum of the gland and the anterior bend of the duct at the masseter?
This procedure can be performed in patients where the stone is greater
than 1.5 cm from the Stensen’s orifice, where the duct turns to go lateral
to the masseter. In this approach, a line depicting the Stensen’s duct is

Figure 4. lntraoral examination, revealing stone at left Stensen’s duct (arrow),which is ame-
nable to intraoral removal.
830 WILLIAMS

drawn on the face horizontal from the earlobe attachment to a point where
an intraductal probe has been placed through Stensen's duct. The position
of the stone is estimated by the use of the preoperative study. A 2-cm
incision is made along this line. The duct is identified, opened, and the
stone removed. Care in dissection is necessary to avoid injury to the buccal
branch of the facial nerve, which accompanies the duct. The duct then is
reconstructed carefully and the wound is closed. This approach obviously
has the advantage of being less significant surgery than a parotidectomy.
This approach does not appear to be used widely and is only useful in
stones that are extrahilar and lateral to the masseter muscle.
Parotidectomy remains the mainstay of surgical management for the
majority of stones which are intragranular and hilar in location. The pro-
cedure is well-known to otolaryngologists-head and neck surgeons and
frequently is performed. In the face of chronic inflammatory sialadenitis,
the procedure can be somewhat tedious, but generally good results can
be expected. Certainly, parotidectomy is reserved for patients whose
symptoms do not resolve with conservative therapy and remain signifi-
cantly troubled by recurrent pain and swelling.

SEQUELAE AND COMPLICATIONS OF SlALOLlTHlASlS

Ninety percent of saliva is produced by the three paired major sali-

vary glands: parotid, submandibular,and sublingual. Ten percent of saliva
volume is from the minor salivary glands. The minor salivary glands pro-
duce 70%of the mucus secreted in saliva. Normal salivary flow is from
0.5 to 1.5 liters per day. The submandibular gland is the largest single
contributor to baseline salivary flow, producing approximately 70%of the
resting f l o ~After
. ~ destruction of a salivary gland from chronic sialad-
enitis or removal of a salivary gland, patients may have a significant drop
in the baseline salivary flow rates. A recent report has demonstrated that
a significant number of patients (57%)complained of subjective xerosto-
mia after excision of a submandibular gland.9 This certainly speaks for
attempting to perform transoral excisions for submandibularsialolithiasis
when possible. Even glands that are severely compromised from sialoli-
thiasis will have return of function 75%of the time after stone removal?
There is experimental evidence of signhcant acini regeneration after re-
moval of ductal
Recurrence of sialolithiasisin patients who have undergone transoral
excision approaches 18%.25 Sialolithiasisalso has been shown to recur even
in patients that underwent complete submandibularsialoadenectomy.Re-
currence has been reported to occur in up to 2.7%of these cases.'O It is
unclear whether this represents oversight and retention of intraductal
stones at the time of surgery or true recurrence with new stone formation.
A stone that presents in a delayed fashion after the surgery may be con-
 SIALOLITHIASIS 831

sidered to have arisen de novo in the residual Wharton’s duct. Clearly

after excising the gland and leaving the proximal duct in place, any saliva
that drains into the duct from the sublingual glands would tend to be
stagnant, which may predispose to stone formation. During surgery, care-
ful milking of the duct needs to be performed to remove all undetected
calculi, In patients undergoing transoral submandibular stone excision,
recurrence of sialolithiasisin the same gland can occur. This may represent
inability to determine whether or not multiple stones were present at the
time of the procedure with stones left behind. There is no significant in-
formation regarding recurrence of parotid stones following parotidec-
tomy. This would, however, be expected to be fairly low.
Sialoadenectomy of either major salivary gland does carry some risk
of injury to the facial nerve. Submandibular gland excision carries a 0%
to 8% risk of permanent marginal mandibular nerve palsy.’O Smith et a1
report that by using the low nonidentification approach, no permanent
marginal mandibular nerve palsy occurred, but 36% of nerves had tem-
porary dy~function.~~ This is likely because of stretching that may occur
in using a lower approach to the submandibular gland. Superficialparot-
idectomy also has anywhere from a 0% to 3.9% permanent facial nerve
dysfunction rate.29The risk of dysfunction may be increased with surgery
in a sigruficantly inflamed gland. Other neural injuries such as lingual
nerve and hypoglossal nerve dysfunction are uncommon in submandib-
ular excisi0n.2~Risk of unacceptable scar, hematoma, and wound infection
also applies for any open surgical approach. Because of these risks, sia-
loadenectomy needs to be considered in patients that are significantly
symptomatic and fail less invasive therapy.
There does appear to be some controversy about management of the
oral portion of Wharton’s duct during submandibular gland excision.
Some surgeons recommend total excision of the duct to prevent residual
formation of a stone in the duct remnant. This technique also can be sup-
ported by some authors finding significant residual Wharton’s duct in-
flammation in up to 5% of postoperative patient~.~ This inflammation
tends to resolve uniformly within 1year of the surgery, however, without
requiring any intervention. A consideration in favor of leaving the resid-
ual Wharton’s duct is the potential for retention cyst formation in the
remaining sublingual gland. This may occur from obstruction of the ducts
of Rivinus, which drain the posterior sublingual gland. One report shows
floor of mouth cyst formation in up to 6% of patients. Some patients that
underwent complete Wharton’s duct excision later required sublingual
gland excision?

FUTURE DIRECTIONS
FOR SlALOLlTHlASlSTREATMENT

Extracorporal lithotripsy (ECL) is a new modality that was intro-

duced in the early 1980s and has revolutionized the treatment of urinary
832 WILLIAMS

tract stones. In 1989, lithotripsy first was used to successfully treat a pa-
rotid stone.19Since this time, multiple reports have entered the literature
using this modality in mainstream treatment of sialolithiasis.
There are three types of lithotripters that have been used for urinary
lithiasis: 1) hydroelectric, 2) electromagnetic, and 3) piezoelectric. The hy-
droelectric and electromagnetic lithotriptershave problems with inability
to focus into small anatomic areas, as well as causing collateral injury to
adjacent tissues. The piezoelectric lithotripter, which was introduced in
1986, produces a narrow spot size and lends itself to salivary stone treat-
ment. In vitro and clinical studies using piezoelectric ECL have proven
its safety.' Salivary stone lithotripsy requires a gland to be functional and
produce saliva in order for the stone fragments to be cleared from the
duct. Some authors require a positive "gum-test" before performing ECL.
The patient chews a sour gum and swelling is noted in the affected sali-
vary gland. The patient would not be a candidate for lithotripsy if this
test was negative.%ECL can be performed without the need for local or
general anesthesia. The cost of three ECL treatments is approximately
equivalent to one day of hospitalization on a regular nursing unit.' Most
reports are from Europe. This modality does not seem to have translated
in a widespread fashion to the United States.
The efficacy of ECL in early studies is very encouraging. ECL appears
to be most effective for treatment of parotid stones. By using three out-
patient treatments for parotid stones, 50% of patients may be rendered
free of calculi, with the remaining 26% free of symptomatology,but having
small fragments left in the ductal system.20Although ECL can fragment
all stones regardless of composition, ECL appears to be more efficacious
for use in the parotid. In Ottaviani's series, all patients in a series of 16
patients with parotid stones were relieved of their symptoms?1 This is
quite significant, given the fact that standard alternative therapy is parot-
idectomy. Longer follow-up is needed to see if these patients remain
asymptomatic.Ottaviani et a1recommend that after failure of conservative
therapy, lithotripsy be used for all parotid stones prior to surgical inter-
vention?'
Extracorporal lithotripsy for submandibular stones is a little less en-
couraging. If submandibular stones are readily amenable to transoral ex-
cision, this probably is performed best. Hilar stones and intraglandular
stones in the submandibular gland tend to be large. If they are less than
7 mm in size, they may be amenable to treatment with lithotripsy. A lower
stone-free rate after lithotripsy is seen in the submandibular gland as op-
posed to the p a r ~ t i d . 'Thus,
~ , ~ ~it is recommended that patients with prox-
imal and hilar stones, which are not amenableto intraoral removal, should
undergo a trial of lithotripsy, and if this should fail, then proceed with
sialadenectomy.
Also, introduction of very slim endoscopes will allow the Wharton's
and Stensen's ducts to be approached endoscopically. Stones potentially
 SIALOLITHIASIS 833

can be diagnosed and treated endo~copically.4~ This technology may allow

also treatment of stones in the parotid duct that are lateral to the masseter.
Oral surgeonsare exploring rigid endoscopy techniques for stone removal
using standard temporomandibular arthroscopy equipment.3O
Sialolithiasis represents a significant cause of salivary gland disor-
ders. New modalities for diagnosis and therapy are being sought actively.

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Address reprint requests to
Mark F. Williams, MD
Johns Hopkins Bayview Medical Center
Department of Otolaryngology
ASW 595A
4940 Eastern Avenue
Baltimore, MD 21224