Introduction to Sialolithiasis
For a long time, sialolithiasis (synonyms: calculous sialadenitis, sialolithiasis) was considered a rare pathology. Hippocrates already described such conditions, erroneously associating them with gout. It was not until 1930 that L.P. Lazarevich substantiated stone formation as a distinct nosological entity.
Today, it is recognized as the most common disorder of the salivary glands. The vast majority of calculi form within the submandibular salivary gland system, due to the anatomical and physiological features of their excretory ducts. The most crucial predisposing factor for the development of sialolithiasis is chronic sialadenitis, primarily affecting the ducts themselves.
Ductal sialadenitis as a precursor to stone formation
Chronic ductal sialadenitis, or sialodochitis, predominantly affects middle-aged and elderly individuals. The disease develops against the background of congenital defects—ectasias (dilatations) and strictures (stenoses) of the excretory ducts.
The pathogenesis is directly linked to a decrease in the body's overall reactivity and hyposalivation. Retention of secretions occurs in the dilated areas of the ducts. Over time, inflammation joins this stasis.
Clinical picture of sialodochitis:
- Main marker: glandular swelling occurs directly during meals.
- Patients note a sudden release of a large amount of saliva with a brackish taste into the oral cavity.
- The gland itself is usually not enlarged, but palpation reveals an expanded duct.
In later stages, when secretory function begins to decline, precisely the stasis of saliva and inflammation create ideal conditions for the crystallization of salts and the formation of a salivary stone (transition into sialolithiasis).
Other forms of chronic sialadenitis
In addition to the ductal form, inflammation can localize in other structures of the gland, forming parenchymatous or interstitial sialadenitis.
1. Chronic parenchymatous sialadenitis Occurs in patients of any age. It is based on congenital spherical dilations of the ducts leading to saliva retention and infection.
- The disease proceeds with spring-autumn exacerbations resembling mumps.
- Accompanied by pain, gland enlargement, and the discharge of pus and fibrinous clots from the duct.
- The frequency of exacerbations can reach 6–8 times a year.
- Important: in children, the first episode is often confused with epidemic mumps, however, this pathology is completely non-contagious.
2. Chronic interstitial sialadenitis Develops in elderly individuals against the background of systemic somatic diseases (diabetes mellitus, gastritis, prostatitis). Initially, a non-inflammatory change (sialadenosis) occurs, which later becomes complicated by interstitial inflammation.
- Parotid glands are affected more frequently.
- Swelling is uniform, soft, and painless.
- The disease proceeds covertly, the function of the gland remains normal for a long time, and the pathology is detected incidentally.
Diagnostic criteria
Making an accurate diagnosis is based on clinical manifestations, secretion cytology, and radiological data.
- Cytological examination: in parenchymatous and ductal sialadenitis, many inflammatory cells (and columnar epithelial cells in sialodochitis) are found in secretion smears. In the interstitial form, inflammatory cells are rare.
- Sialography (radiopaque examination):
- In parenchymatous involvement, round cavities 1–5 mm in diameter are visible.
- In ductal involvement, an uneven alternation of strictures and significant dilations of ducts of various calibers is revealed.
- In interstitial involvement, narrowing of small ducts is characteristic, which may not be detected at all on the radiograph.
Principles of treatment and prevention
During the exacerbation period, therapy is similar to the treatment of acute inflammation. In the remission stage, treatment aims to compensate for underlying background diseases and improve salivation.
Complex therapy regimen:
- Drug stimulation: potassium iodide solution (oral), injections of pyrogenal and galantamine, procaine blocks.
- Sanation of ducts: intraductal administration of antibiotics and proteolytic enzymes (trypsin, chymotrypsin), compresses with dimethyl sulfoxide.
- Stimulation of regeneration: administration of vegetable oils (sea buckthorn, rosehip) into the ducts, intramuscularly — ribonuclease.
- Physiotherapy: electrophoresis or galvanization with ascorbic acid, procaine.
The effectiveness of treatment is assessed by the duration of remission. If there are no exacerbations for 3 years or more, clinical recovery is stated. Patients with congenital changes of the glands are subject to mandatory clinical follow-up.
Briefly: answers to topical questions
What is the chemical composition of calculi in sialolithiasis?
Salivary stones are organomineral aggregates in which organic matter predominates.
- The organic part accounts for 75–90% of the total mass of the calculus; alanine and glutamic acid predominate in its amino acid profile.
- The stone core can be formed by actinomycetes, an accumulation of leukocytes, or foreign bodies.
- The shell has a layered (lamellar) structure and contains spherical bodies.
What surgical treatment methods are used for sialolithiasis?
In sialolithiasis, methods of calculus removal, lithotripsy, duct plasty, and gland extirpation are used.
- Intraoral stone removal is used for localization in the anterior, middle, and distal parts of the parotid duct (including the Afanasyev-Starodubtsev method).
- Extraoral stone removal is indicated for localization in the posterior part of the parotid duct.
- Extracorporeal shock wave lithotripsy — crushing of the stone using shock waves.
- Plastic surgery — creation of a new duct orifice posterior to the site of cicatricial stricture.
- Salivary gland extirpation — removal of the organ, indicated for frequent recurrences or the impossibility of surgical stone removal.
What clinical stages are distinguished in the course of sialolithiasis?
In the clinical course of sialolithiasis, three stages of development are distinguished according to I.F. Romacheva's classification.
- Initial stage — the period of stone formation, which proceeds asymptomatically without impaired salivation and pronounced inflammation.
- Clinically manifest stage — characterized by the appearance of first symptoms when saliva outflow is impaired during meals.
- Late stage — differs in that the clinical signs of chronic sialadenitis come to the forefront.
Class and exam questions
In which salivary gland do stones most commonly form?
In 90–95% of cases, sialolithiasis affects the submandibular salivary glands.
Why is parenchymatous sialadenitis in children often misdiagnosed?
The first exacerbation of the disease is very similar to epidemic mumps. The main difference is that parenchymatous sialadenitis is non-contagious and has a seasonal character.
What is the main clinical sign of ductal sialadenitis?
A specific symptom is swelling of the salivary gland directly during a meal, after which a large amount of saliva with a brackish taste is abruptly released into the oral cavity.
How is the treatment success of chronic sialadenitis evaluated?
The remission period serves as the criterion. The absence of exacerbations for more than 3 years is considered recovery, from 1 to 3 years is considered improvement, and less than 1 year is considered an "unchanged" state.
What else to study on this topic
- Complications of chronic sialadenitis: risk of developing Sjögren's syndrome
- Technique of sialography and reading sialograms
- Association of interstitial sialadenitis with background somatic pathologies
- Intraductal drug administration: technique and indications
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