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SIALOLITHI

ASIS
Mutia Auliany

Pembimbing :
DR. drg. Corputty Johan
,E.M.,Sp.BM

INTRODUCTION

Sialoliths are calcified structures that develop within the


salivary gland or the ductal system.

Men > women

Rare in children

75% - single

3% - bilateral

GLAND WISE DISTRIBUTION


80-92% - submandibular gland.
6-20% - parotid.
1-2% - sublingual and the minor salivary
glands.

Submandibular larger & intraductal

Parotid multiple, within the gland

SUBMANDIBULAR GLAND OCCURENCE

Abundant calcium concentration


Alkaline Ph

Anatomic factors

Whartons

duct - longest
- two sharp curves
- small punctum

Composit
ion

Organic substances

INORGANIC

CHEMICAL COMPOSITION

Chemical composition
Microcrystalline apatite (Ca5[PO4]3OH) or
Whitlockite (Ca3[PO4])
Brushite and weddellite

RECENT DISCOVERIES

Scanning electron microscopy has demonstrated


oval, elongated shapes,

suggesting the presence of bacilli in sialoliths.

A recent polymerase chain reaction study found


bacterial DNA, mainly belonging to the Streptococcus
genus

ARCH OTOLARYNGOL HEAD NECK


SURG/VOL 129, SEP 2003

PATHOGENESIS
Multifactorial

event

Secretory disturbances & precipitation inflammatory


process

Specific changes in structure of organic molecules


supportive frame formation

Metabolic disturbances alkalinity & precipitation

MICROLITHS

Concrements detectable only microscopically

Contain

calcium and phosphorus


hydroxyl apatite
organic secretory material
necrotic cellular residues

Generated - autophagocytosis of organelles that are

rich in calcium.

Dyschylia - Disturbed salivary secretion &


change in the composition

Accumulation of organic substances &


mineralisation of organic matrix
Accumulation of calcium
Increase in pH

Decreases the solubility of calcium phosphates

PROGRESSION

Secretory disturbances
Microlith formation

viscous secretions
ductal obstruction

Coaction of factors + participation of bacteria


sialoliths

Dyschylia & increasing microlith formation


ascent
of bacteria
lead to a focal obstructive atrophy of
the acinar cells
secretory disturbances
Journal of Oral Science, Vol.
45, No. 4, , 2003

OTHER FACTORS

Infection

Salivary dysfunction

Ductal anamolies

Foreign bodies

Ductal epithelium metaplasia

SYMPTOMS

Pain, swelling & discomfort

Pain - meal time severe with sour or acidic


food

Unusual taste

Associated with infection fever , purulent


discharge & lymphadenopathy

S&S :
When

saliva cannot exit a blocked


duct, it backs up into the gland,
causing :
1. swelling
2. pain
* particularly after eating. (1-2 hours)

S&S
Dull

pain from time to time over the


affected gland.
Infection of the gland may occur.
Dry mouth.

S&S
Tenderness

in the affected
salivary gland.

Difficulty

opening the mouth or


swallowing.

If

there is only partial obstruction


of the affected salivary duct,
then symptoms may be minimal
or absent (asymptomatic).

CHARACTERISTICS

The annual growth rate - 1 mm peryear

Shape - round or irregular

Size - 2 mm to 2 cm

GIANT SIALOLITH

72 mm in length and weighing 45.8 g

The ability of a calculus to grow and become a giant


sialolith depends mainly on the reaction of the affected
duct.

Rai and Burman. Giant Submandibular Sialolith. J Oral


Maxillofac Surg 2009.

TREATMENT MODALITIES

Newer treatment modalities - extracorporeal shortwave lithotripsy and sialoendoscopy are effective
alternatives to conventional surgical excision for
smaller sialoliths.

However, for giant sialoliths, transoral sialolithotomy


with sialodochoplasty or sialadenectomy remains the
mainstay of management.

HISTOLOGIC FEATURES

Stratified & mineralized with metaplastic excretory


duct cells

Concentric laminated structures

Acini infiltrated by lymphocytes

Dialatation of duct

Epithelium exfoliation

DIAGNOSIS

History

Clinical examination
Bi-manual palpation

Imaging

BIMANUAL

IMAGING

Imagin
g

Conventional radiography

Intra oral radiographs


IOPA , Occlusal radiographs

Extra oral radiographs


Panaromic , PA skull projection

Intraglandular and small stones can be missed.

20% of sialolithsare radiolucent

Sialography

"Gold Standard

Retrograde infusion of oil or water based contrast


& the architecture of the salivary duct system is
visualized radio graphically .

LIMITATIONS

Ultrasonography

Non invasive, alternative method

Stones > 2mm detected as echo-dense


spots with a characteristic acoustic shadow.

MR Sialography

Non invasive

Acute infections

Canulation not possible

COMPUTED TOMOGRAPHY

Posterior of the duct

Hilum of the gland

Substance of the gland

Radiation exposure

Non invasive & do not require contrast media

SIALOENDOSCOPY

Minimally invasive

Diagnostic & therapeutic

Small endoscope light at end of flexible cannula

Differential diagnosis

Phleboliths radiolucent center

Dystrophic calcification of lymph nodes


Cauliflower shaped

Palatine tonsiliths- multiple & punctate

Haemangiomas with calcifications

TREATMENT

ARCH OTOLARYNGOL HEAD NECK SURG/VOL

129, SEP 2003

paediatric patients

Relatively small and distal

Bimanual careful palpation is mandatory to diagnostic approach for


children suspicious of sialolithiasis.

These findings also suggest that intra-oral approach is effective


treatment procedure for most of sialolithiasis in children.

May;71(5)

Int J Pediatr Otorhinolaryngol 2007

Conclusion

Sialolithiasis is the main cause of unilateral diffuse parotid


or submandibular gland swelling.

Mechanical obstruction of the salivary duct, causing


repetitive swelling during meals, & often complicated by
bacterial infections.

Common in submandibular gland , 10 20% are


radiolucent

Newer minimally invasive diagnostic & therapeutic


modalities