1. Definition Sialolithiasis is the mechanical obstruction of salivary flow caused by the formation of salivary calculi (sialoliths) within the ductal system or glandular tissue of major or minor salivary glands. A sialolith develops around an organic nidus, which gradually enlarges through deposition of inorganic and organic materials. Characteristics of Sialoliths Growth rate: approximately 1 mm/year May occur as single or multiple stones Shape: round, oval, or elongated Color: yellowish-white Size: usually 1–10 mm in length 2. Composition A. Inorganic Components Calcium phosphate salts Hydroxyapatite Octacalcium phosphate B. Organic Components (Nidus) Desquamated epithelial cells Bacteria Products of bacterial decomposition Glycoproteins Mucopolysaccharides C. Foreign Bodies Acting as Nidus Toothbrush bristles Fingernails Wood splinters Hair Grass blades Fish bones 3. Etiology and Pathogenesis The exact cause is unknown; however, three major prerequisites are believed to be responsible: 1. Salivary Stagnation A neurohumoral disturbance causing reduced salivary flow and stagnation. 2. Presence of a Nidus An organic matrix acts as the center for stone formation. 3. Precipitation of Salivary Salts Metabolic changes favor precipitation of calcium and phosphate salts around the nidus, especially in the presence of inflammation. Clinical Significance Sialolithiasis is: A cause of chronic recurrent sialadenitis A consequence of chronic recurrent sialadenitis A frequent cause of acute suppurative sialadenitis 4. Why is the Submandibular Gland Most Commonly Affected? Approximately 80% of sialoliths occur in the submandibular gland. Reasons A. Alkaline Saliva pH = 6.8 to 7.1 More alkaline than parotid saliva B. Higher Calcium and Phosphate Concentration Greater concentration of apatite salts C. Increased Salt Precipitation Relative alkalinity and altered calcium-phosphate ratio promote crystallization. D. Mucin-Rich Secretions Saliva is more viscous, encouraging stagnation. E. Anatomical Factors of Wharton's Duct Longer duct Tortuous course Non-dependent drainage Saliva flows against gravity These factors increase salivary stasis and stone formation. 5. Risk Factors Conditions Causing Reduced Salivary Flow Dehydration Anorexia Fasting Drugs Antihistamines Antipsychotics Antidepressants Antihypertensives Anticholinergics Diuretics Other Risk Factors Radiotherapy Tobacco smoking Sjögren syndrome Hypercalcaemia Gout (uric acid accumulation) 6. Clinical Features Epidemiology Male : Female = 2 : 1 Peak age = 30–50 years Submandibular gland involvement ≈ 80% MEAL TIME SYNDROME (Classic Feature) Symptoms Moderate to severe pain during meals Swelling during and after eating Symptoms worsen when salivary secretion increases Mechanism Stone obstructs salivary flow → Increased intraductal pressure → Pain and swelling Characteristics Recurrent swelling with meals Gradual reduction during rest Repeated episodes until complete obstruction develops Other Clinical Features Stone Extrusion Occasionally patients spontaneously expel small calculi. Tenderness Point tenderness over: Hilum of gland Wharton's duct Secondary Infection Produces: Fever Tenseness Tenderness Trismus Reduced or absent salivary flow Salivary Changes Presence of: Gelatinous Cloudy Mucopurulent material Mixed with otherwise clear saliva. Advanced Disease Acute Suppurative Sialadenitis Severe exacerbations Pus discharge from duct opening Systemic manifestations Local Findings Inflamed ductal mucosa Floor of mouth swelling Redness Tenderness along Wharton's duct Gland Examination Enlarged Tender Tense Palpation causes pain and pus discharge 7. Diagnosis Clinical Examination Bimanual Palpation Most important method. Findings: Stone palpable along duct Hard mass in floor of mouth Milking Test Inability to express saliva from duct opening suggests obstruction. 8. Radiographic Features Conventional Radiographs Mandibular occlusal view Lateral view Lateral oblique mandibular view AP view Sialography Identifies exact location of stone Ultrasonography (USG) Non-invasive Detects stones >2 mm CT Scan Useful for: Gland enlargement Chronic disease Other Investigations Scintigraphy MRI 9. Complications 1. Acute Suppurative Sialadenitis Bacterial infection of obstructed gland. 2. Chronic Suppurative Sialadenitis 3. Sialoangiectasis Dilatation of salivary ducts due to prolonged obstruction. 4. Mucocele Occurs due to salivary retention. 5. Glandular Atrophy Complete obstruction may cause irreversible gland destruction. 10. Treatment of Sialolithiasis A. Conservative Management 1. Local Measures Warm compresses Salivary gland massage Sialogogues 2. Stimulate Salivary Flow Sour foods Lemon drops Hyperhydration Purpose: Facilitate spontaneous expulsion of stone 3. Acute Infection Control Antibiotics Analgesics Good oral hygiene 4. Drainage of Abscess When pus collection is present. 5. Definitive Surgery Performed after acute inflammation subsides. B. Surgical Management Stone Within Duct ➡️ Intraoral sialolithotomy Stone Within Gland ➡️ Removal of gland (sialadenectomy), especially when irreversible glandular or ductal changes are present. 11. Sialodochoplasty Definition Surgical repair of salivary duct by: Widening ductal opening Shortening duct Purpose Prevents: Restenosis Re-narrowing of duct Technique Duct may be sutured open Stent may be placed for 7–10 days to maintain patency during healing 12. Removal of Parotid Gland Calculi Possible Locations Papilla Submucous part of duct Extraglandular duct (outside buccinator) Intraglandular duct A. Papillary and Submucosal Stones Procedure Slitting of papilla Small incision into duct Gentle gland pressure This allows saliva to flush out the stone. B. Extraglandular Duct Stones Procedure Intraoral incision in cheek Y-shaped incision around papilla Blunt dissection through buccinator Identification and isolation of Stensen's duct Longitudinal duct incision Stone removal Closure Surrounding tissues sutured Duct left open C. Intraglandular Duct Stones Treatment Extraoral approach Similar to parotidectomy procedure Used when stone lies posteriorly in glandular duct system 13. Removal of Submandibular Gland Calculi Most Common Location Extraglandular portion of Wharton's duct. A. Anterior Submandibular Duct Calculi Definition Located anterior to the second mandibular molar. Surgical Steps Place suture posterior to stone to prevent displacement. Place traction sutures anterior and posterior to calculus. Make incision along duct. Identify Wharton's duct. Mobilize duct. Longitudinal incision over stone. Remove calculus. Important Point The duct incision is not sutured to avoid postoperative stricture. Postoperative Care Increased fluid intake Lemon drops Sialogogues to maintain duct patency B. Posterior Submandibular Duct Calculi Surgical Steps Pass lacrimal probe through duct. Mucosal incision opposite premolar region. Trace duct posteriorly. Identify and protect lingual nerve. Apply pressure on gland to elevate duct. Longitudinal duct incision. Remove calculus. Close mucosa, leaving duct open. C. Intraglandular Submandibular Calculi Asymptomatic Stone Observe if: Small stone Normal gland function Normal sialography Symptomatic Stone Indications for sialadenectomy: Recurrent infection Impaired gland function Abnormal glandular architecture ➡️ Submandibular gland removal (sialadenectomy) is the treatment of choice. make it as a ppt with required diagrams

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