Stones of salivary gland - Sialolithiasis is an uncommon presentation in ED, but keeping high suspicion index while treating the cheek swelling patients will solve the problem.

1. ENT Case Presentation
Runal Shah
PGY-2
Masters in Emergency Medicine
KDAH

2.  45/ Female, walks to A&E Triage at 10.45pm on
Sunday
 Complaints – sudden onset pain, swelling of right
cheek for 2 hours.
 A, B, C, D – all correct
 Vitals
◦ T- Afebrile
◦ P- 84/min
◦ R- 16/min
◦ BP- 120/70 mmHg
◦ SpO2- 97% on room air
 Pain Score – 5/10

3.  So, what is the problem we are dealing with ??
 What should be done ?
 Consider resources and act wisely !
 Triage category ???

4.  Interventions –
◦ IV access – scalp vein
◦ Inj Dynapar 75mg in 20ml NS iv
 Investigate –
◦ CBC
◦ Imaging – CT scan / USG soft parts ??

5.  S – Pain and swelling of the right cheek, for
approx 2 hours, following dinner, No fever,
similar complaints in the past
 A – no allergies
 M – no meds on routine basis
 L – dinner at 8.30pm
 E – none

6.  Secondary survey –
 HEENT –
 Inspection –
◦ vague swelling of right cheek, comparable increase in
size as to left cheek
◦ asymmetry of face !
◦ Oral mucosa healthy, no purulent discharge.
 Palpation –
◦ mild tenderness over right cheek
◦ on per-oral palpation no stones palpable
 Rest of the systems – unremarkable

7.  Reassessment
 Pain score 1/10 – discomfort only
 Swelling was same
 Discussed with pt regarding need of imaging for
the same to rule out sialolithiasis
 USG soft parts –
◦ right parotid gland duct stone of 1.7mm !
◦ No obvious inflammatory changes within right parotid
gland
 CBC
◦ 13.2 / 40 / 7800 / 2,90,000

8.  Disposition
 Explained the condition to the patient,
discharged with ENT follow up in OPD.
 On discharge Rx
◦ Tab Voveran-SR 75mg 1—0—0 x 3 days
◦ Tab Pantocid 40mg 1—0—0 x 3 days, 30min before
breakfast
◦ Warm compresses over right cheek

9.  Concrements (stones) formed in the salivary
gland parenchyma or duct due to increased
viscosity or stasis.
 1% population
 M > F
 Age group : 30-50
 Submandibular gland (80-90%) >> Sublingual >
Parotid
Case Discussion – Sialolithiasis

10.  Differentials :
1) Infections –
 Bacterial
(Staphylococcus,
Strep Viridans,
Pneumococcus, H
influenza)
 Viral – Mumps
2) Inflammation
3) Granulamtous
4) Neoplastic
 Commonly forms around an organic nidus.

11.  Clinical presentation
 Pain, swelling, tenderness overlying the gland,
Purulent discharge from the duct
 Difficult to differentiate between parotitis and
sialolithiasis clinically as they may co-exist or
may be causative of each other !!
 Features favoring Sialolithiasis :
◦ Typically Unilateral
◦ Pain, swelling aggravated post meals

12.  Management in ED
 Diagnosis is clinical
 Per-oral palpation with gland massage may
reveal stone or purulent discharge
 Imaging –
◦ X-ray
◦ USG
◦ CT
◦ MRI
◦ Sialography
 Pain relief by NSAIDs

13. Ultrasound appearance
Small High Frequency probes (Vascular probe)

14. Disposition
 If palpable stone is removed in ED – f/up with
ENT in 3-4 days
 If not, ENT f/up within 24 hours
 Discharge treatment –
1) Hydration
2) Moist heat
3) Massage
4) Analgesics
5) Sialogogues (Lemon
drops)
6) Antibiotics

15. Thank You…
 Ref :
◦ Rosen 8/e
◦ Tintinalli 7/e
◦ http://radiopaedia.org/articles/sialolithiasis